key: cord-260253-kd9fw7fh authors: lei, shaoqing; xia, zhong-yuan; xia, zhengyuan title: author's reply date: 2020-05-18 journal: eclinicalmedicine doi: 10.1016/j.eclinm.2020.100386 sha: doc_id: 260253 cord_uid: kd9fw7fh nan we thank tuech et al. and dr. ross for their letters in response to our recent study [1] . at the very beginning of the epidemic, we encountered some patients who had no symptoms before surgery but quickly developed covid-19 pneumonia after surgery. during the period of the research, the participating hospitals performed approximately 15,000 elective surgeries. our focus was to report those we believe and confident that the surgeries were performed during incubation period. thus, any infection long after surgery (say, 10 to 14 days after surgery) or those who contacted with confirmed cases of covid-19 after surgery (such as the 3 excluded patients) were excluded. additionally, we cannot exclude the possibility that there may be someone who got infected and performed surgery but maintained asymptomatic, despite this might be rare. therefore, the rate of 0.22% etc. as the authors estimated could only be the rate of unintentional surgery that activated latent infection. as for the number of patients in each group (surgical difficulties), we have presented the details of types of surgery and grading of surgical difficulty in table 1 and table 2 in our published article [1] . we appreciate the authors' suggestion of providing detailed rates of infection and mortality etc. for all surgical patients at that time. however, this was not the scope of our original study, and also exact detailed information couldn't be provided due to the lack of additional ethical approval at this point. we advise that strict protective procedures be followed [2, 3] as asymptomatic covid-19 is also contagious. none. clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection safety and efficacy of different anesthetic regimens for parturients with covid-19 undergoing cesarean delivery: a case series of 17 patients chinese society of anesthesiology, chinese association of anesthesiologists. perioperative management of patients infected with the novel coronavirus: recommendation from the joint task force of the chinese society of anesthesiology and the chinese association of anesthesiologists key: cord-263773-b8zbgaor authors: novara, giacomo; giannarini, gianluca; de nunzio, cosimo; porpiglia, francesco; ficarra, vincenzo title: risk of sars-cov-2 diffusion when performing minimally invasive surgery during the covid-19 pandemic date: 2020-04-13 journal: eur urol doi: 10.1016/j.eururo.2020.04.015 sha: doc_id: 263773 cord_uid: b8zbgaor nan there has been widespread diffusion of pure laparoscopic and robotic approaches for the vast majority of urological surgeries. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and the disease it causes, coronavirus disease 2019 , are significantly affecting urological practice in countries that the pandemic has hit more severely. specifically, recommendations have been suggested to guide reorganization of urological surgeries [1] . some surgical procedures that should still be performed during the covid-19 pandemic have been identified, such as radical cystectomy for muscle-invasive or very highrisk non-muscle-invasive bladder cancer; postchemotherapy retroperitoneal lymph node dissection; radical nephrectomy for ct3 tumors; nephroureterectomy for upper tract urothelial cancers; and adrenalectomy for specific adrenal cancers. it is also likely that some other surgical procedures (eg, radical prostatectomy for high-risk prostate cancer and partial nephrectomy for ct1b renal tumors) will be performed in centers located in areas not severely hit by the pandemic where the resources available are sufficient [2] . with this in mind, we read with enormous interest the paper by zheng et al [3] . based on the high prevalence of sars-cov-2 in stools [4] , some reports on the presence of other viruses in although, to the best of our knowledge, cases of this type of transmission have not been reported so far, this issue must be evaluated with particular caution for urologists still allowed to perform minimally invasive procedures during the covid-19 pandemic. first, the need to use appropriate personal protective equipment should be reinforced. second, nasopharyngeal samples should be considered for all patients undergoing such procedures, especially as covid-19 positivity could have a possible impact on their postoperative course. third, special care must be taken intraoperatively to reduce smoke formation (eg, lowering electrocautery power settings, using bipolar electrocautery, using electrocautery or ultrasonic scalpels parsimoniously to reduce surgical smoke, more extensive use of sutures and clips) or smoke dispersal in the operating room. this is especially important when removing trocars at the end of a procedure, when making a skin incision for specimen retrieval, and in the rare j o u r n a l p r e -p r o o f cases of conversion to open surgery. before such steps, generous use of suction to remove smoke and aerosol should be recommended. in parallel, care must be taken to limit smoke dispersal or spillage from trocars (eg, lowering the pneumoperitoneum pressure). finally, pressure-barrier insufflator systems that maintain a forced-gas pressure barrier at the proximal end of the trocar might be of benefit [5] . unfortunately, even urologists who have the privilege of being able to continue performing minimally invasive surgery must rethink details of their activities to minimize the risks for patients and health care workers. the authors have nothing to disclose. considerations in the triage of urologic surgeries during the covid-19 pandemic urology practice during covid-19 pandemic press minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes benchtop evaluation of pressure barrier insufflator and standard insufflator systems key: cord-032781-85hrb0vc authors: chen, herbert title: featured papers in the october issue date: 2020-09-28 journal: am j surg doi: 10.1016/j.amjsurg.2020.09.001 sha: doc_id: 32781 cord_uid: 85hrb0vc nan in the october issue of the american journal of surgery (ajs,) we feature the manuscripts listed below: delving deeper into disparity: the impact of health literacy on the surgical care of breast cancer patients. portelli tremont and colleagues summarize the current knowledge regarding health literacy in breast cancer. they identify future directions for research and potential intervention in breast surgical oncology 1 with an editorial from lauren theiss and dan chu. 2 . post-thyroidectomy emergency room visits and readmissions: assessment from the collaborative endocrine surgery quality improvement program (cesqip). taye and colleagues analyze independent factors associated with post-thyroidectomy emergency room visits and hospital readmissions. 3 there is an editorial from toni beninato and amanda m. laird. 4 surgeon experience and opioid prescribing. santosa and colleagues evaluate the effects of surgeon characteristics such as surgeon experience on differences in opioid prescribing after surgery. 5 they demonstrate that surgeon characteristics such as cumulative years of practice contribute to differences in prescribing behavior, with an editorial from willemijn sch€ afer and jonah stulberg. 6 significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: a nsqip analysis. chang and colleagues perform a review of the nsqip database to examine the impact of a diverting loop ileostomy (dli) in high-risk patients. they found that significant thirty-day morbidity exists with a dli among high-risk colectomy patients with minimal benefit in anastomotic leak rates. 7 there is an editorial from drew gunnells and greg kennedy 8 robotic intraperitoneal onlay versus totally extraperitoneal (tep) retromuscular mesh ventral hernia repair: a propensity score matching analysis of short-term outcomes. kudsi and colleagues present data suggesting that robotic tep-rm repair has better early postoperative outcomes for ventral hernias, suggesting that it may be preferable over robotic ipom repair. 9 ajita prabhu provides an invited commentary. 10 eight "my thoughts/my surgical practice" articles. we are highlighting these eight thought-provoking editorials: covid 19: surgery & the question of race, 11 reforming our general surgery residency program at an urban level 1 trauma center during the covid-19 pandemic: towards maintaining resident safety and wellbeing, 12 covid-19 and surgical training in italy: residents and young consultants perspectives from the battlefield, 13 the volume of recyclable polyethylene terephthalate plastic in operating rooms, 14 immersive virtual reality in surgery and medical education: diving into the future, 15 educational benefits of an acute care surgery rotation during the medical student surgical clerkship, 16 do we know our patients' goals? evaluating preoperative discussions in emergency surgery 17 and general surgery trainee perception of early specialization programs. 18 delving deeper into disparity: the impact of health literacy on the surgical care of breast cancer patients invited commentary on "delving deeper into disparity: the impact of health literacy on the surgical care of breast cancer patients post-thyroidectomy emergency room visits and readmissions: assessment from the collaborative endocrine surgery quality improvement program (cesqip) shedding new light on old complications: cesqip and understanding postthyroidectomy outcomes surgeon experience and opioid prescribing addressing (over)prescribing of opioids in surgery significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: a nsqip analysis proximal diversion after colectomy: the debate continues robotic intraperitoneal onlay versus totally extraperitoneal (tep) retromuscular mesh ventral hernia repair: a propensity score matching analysis of short-term outcomes rip ipom? not so fast covid 19: surgery & the question of race reforming our general surgery residency program at an urban level 1 trauma center during the covid-19 pandemic: towards maintaining resident safety and wellbeing covid-19 and surgical training in italy: residents and young consultants perspectives from the battlefield the volume of recyclable polyethylene terephthalate plastic in operating rooms e a one-month prospective audit immersive virtual reality in surgery and medical education: diving into the future educational benefits of an acute care surgery rotation during the medical student surgical clerkship do we know our patients' goals? evaluating preoperative discussions in emergency surgery general surgery trainee perception of early specialization programs key: cord-270382-z966wufy authors: sultania, mahesh; muduly, dillip; imaduddin, mohammed; kar, madhabananda title: oral cancer surgery and covid pandemic – metronomic therapy shows a promising role while awaiting surgery date: 2020-05-22 journal: oral oncol doi: 10.1016/j.oraloncology.2020.104814 sha: doc_id: 270382 cord_uid: z966wufy • metronomic therapy is a good option for locally advanced oral cancers in covid-19 pandemic time. • in the present situation there is a need for a therapy that ensure patients remain operable while awaiting surgery. • metronomic therapy is easily deliverable, minimally toxic, home based and cost effective. to the editor, the covid-19 pandemic has adversely affected the whole world along with the indian subcontinent and has shown a major impact on the health system and the economy of the country. india went into lockdown on 25th march 2020 and only essential services are still available for the general population. majority of the hospitals faces the challenge of caring for critical covid-19 patients which has resulted in diversion of critical hospital resources, care of non covid-19 patients with medical and surgical emergencies and protection of the health care workers. worldwide there has been a drop in number of elective surgeries and mostly surgeons are operating on patients with life threatening emergencies and postponing majority of the elective surgeries. a report from wuhan, china of elective surgery in incubation period of covid-19 for 34 asymptomatic patients resulted in 44% icu admission and 20% mortality [1] . there is confusion among the surgical disciplines and many questions coming up on what are the steps forward. the challenges faced by the surgeons includes the triaging of the patients and making guidelines to handle patients waiting for surgery, judicious use of personal protective equipment and other hospital resources, and protection of the health care providers from aerosol derived infection. there is also a high risk of infection to the patients by asymptomatic health care workers. during this covid pandemic, as oral cancer surgery is a high aerosol generating procedure, worldwide there is a difference of opinion regarding elective oral cancer surgery. in early april 2020, prof hanna, president of the american head and neck society suggests deferment of major surgery for oral cancer in patients who test positive for covid-19 unless it is a lifesaving measure, to consider surgery in patients who test negative if delay would negatively impact their prognosis and to use nonsurgical therapy in neoadjuvant setting in order to buy time before cancer surgery [2] . chaves et al suggest emergency international guidelines for treatment of head and neck cancer patients and say not to defer cancer treatment in sars-cov-2 negative patients unless there are significant clinical reasons that suggest otherwise [3] . deo et al has made an attempt to give guidelines which will help the cancer surgeons in india to make critical surgical decisions. they suggest neoadjuvant chemotherapy/oral metronomic therapy in locally advanced oral cancers or to defer surgery until progression [4] dr. varghese explains about the situation in the state of kerala in india and the clearance by state government to perform rt pcr for covid19 among all patients undergoing cancer surgeries, which is yet not a practice in other parts of india [5] . our institute is situated in eastern part of the country -state of odisha. we are facing many challenges like resource constraints, majority of the population being from low socioeconomic status without health insurance, patients present in locally advanced stage and waiting list of surgery is 2 to 3 months with a risk of tumor progression and no covid testing for surgical patients if not from containment zone. at this time of covid pandemic we have decreased the number of admissions and elective cancer surgeries significantly (in view of judicious use of resources and government guidelines) and hoping to start all operation theatres by the month of june. the services of allied disciplines (medical oncology and radiotherapy) have also been adversely affected. in the present situation there is a need for a therapy that would prevent progression of the tumour, effect its regression, and ensure that patients remain operable while awaiting surgery. metronomic therapy is one of the options for patient with locally advanced tumor who have been planned for elective oral cancer surgery which is easily deliverable, minimally toxic, home based and cost effective [6] . it exerts its anti-cancer activity by inhibiting tumor angiogenesis, stimulating anticancer immune response and inducing tumor dormancy. the protocol is of prescribing oral methotrexate 15 mg/m 2 once a week and oral celecoxib 200 mg twice daily. assessment is done at 4 and 8 weeks with clinical examination, complete blood count and imaging. the advantage of using methotrexate and celecoxib in a metronomic scheduling is its easy availability, well-known pharmacodynamic profile, and safety, excellent tolerance, minimal toxicity and affordability (usd 10 per month). we have an experience of 23 patients with locally advanced t4a tumors receiving metronomic therapy for at least 8 weeks before covid pandemic. there was no grade iii or iv toxicity. after 8 weeks, clinically complete response was seen in 2 patients -one with carcinoma lip ct4an0m0 and another with carcinoma of central arch ct4an0m0. fig. 1 according to response evaluation criteria in solid tumors (recist 1.1), stable disease was seen in 30.5% (07 patients), partial response in 56.5% (13 patients) and disease progressed in 13% (3 patients). we were able to offer surgery to 87% of the patients (20 pts) post metronomic therapy. in the covid pandemic time, the metronomic therapy is helping us to get over the phase and keep the patients still operable. low cost, home based oral metronomic chemotherapy seems to be a viable option in managing advanced oral cancer in the present covid pandemic time. clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection how fragile we are emergency changes in international guidelines on treatment for head and neck cancer patients during the covid-19 pandemic guiding principles for cancer surgery during the covid-19 pandemic covid19 pandemic; a practicing head and neck surgeon's perspective of an institutional model oral metronomic scheduling of anticancer therapy-based treatment compared to existing standard of care in locally advanced oral squamous cell cancers: a matched-pair analysis the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-275833-c3zamfix authors: mcelligott, helen; toale, conor; moloney, michael a.; kavanagh, eamon g. title: hybrid-cerab (covered endovascular reconstruction of the aortic bifurcation) procedure is preferable to aorto-bi-femoral bypass for limb-threatening aortoiliac occlusive disease during the covid-19 crisis. date: 2020-09-02 journal: j vasc surg cases innov tech doi: 10.1016/j.jvscit.2020.08.019 sha: doc_id: 275833 cord_uid: c3zamfix the covid-19 pandemic is disrupting the provision of acute vascular surgery across the globe. limited evidence regarding the impact of nosocomial infection on patient outcomes, as well as concerns regarding critical care capacity, will likely impact upon surgical decision making. endovascular therapy offers a way by which peri-operative risk can be reduced for vascular patients, while also reducing the impact of acute surgery on intensive care unit capacity. this case reports the management of a patient with complex aorto-iliac occlusive disease via a hybrid endovascular approach in light of the above constraints, with a successful outcome. the covid-19 pandemic has significantly impacted the provision of emergency surgery. early 3 data has highlighted the risks of morbidity and mortality in the event of sars-cov2 infection in 4 the post-operative period 1 . furthermore, critical care bed and overall hospital capacity will likely 5 continue to impact upon vascular surgery services. minimally invasive techniques offer a way of 6 mitigating against these constraints while providing quality care with acceptable outcomes for 7 patients 2, 3 . we report a case of a patient with acute-on-chronic tasc-ii (trans-atlantic inter-8 society consensus ii) d aorto-iliac occlusive disease managed by covered endovascular 9 reconstruction of the aortic bifurcation (cerab) as an alternative to open surgery in the era of 10 covid-19. the patient provided written informed consent for their case details to be published. 11 12 case report 13 14 a 57-year-old gentleman presented to a tertiary level care unit with a 3-week history of left foot 15 and calf pain at rest and a 4-day history of forefoot paraesthesia. the patient denied right sided 16 symptoms. a history of hypertension, hyperlipidaemia and obesity was noted. the patient was an 17 active smoker. he was taking rivaroxaban for a recently diagnosed left below-knee deep venous 18 thrombosis, based on a duplex scan reporting an isolated tibial vein that failed to compress 19 normally. this in retrospect was likely an incorrect diagnosis which lead to delayed referral. on 20 examination, the left foot was pale, with a sensory deficit noted over the lateral foot. there was 21 no tissue loss or ulceration, no motor deficit, and he had minimal calf tenderness. lower limb 22 pulses, including femoral pulses, were absent. a diagnosis of limb threatening acute on chronic 23 j o u r n a l p r e -p r o o f 5 lower limb ischemia was made, and unfractionated heparin infusion commenced. left sided toe 1 waveforms were absent, while ankle-brachial pressure indices (abpi) and toe-brachial indices 2 on the right were 0.64 and 0.81 respectively. computed-tomography angiography (cta) 3 revealed extensive mural thrombus in the infrarenal aorta with greater than 50% stenosis ( figure 4 1). aneurysmal dilatation of the right common iliac measuring up to 2.9 cm was observed, with 5 extensive thrombus occluding more than 80% of the lumen proximally. there was complete distance. open surgery with aorto-femoral bypass remains the gold standard for the management 1 of tasc-ii d aortoiliac occlusive disease 4 . patency rates of 75-80% at 10 years have yet to be 2 matched by endovascular techniques 5, 6 . however, several studies have reported successful 3 endovascular management of extensive aortoiliac disease in selected patients 7 . endovascular 4 management carries a lower risk of peri-operative morbidity, at the expense of a higher re-5 intervention rate and lower primary patency 8 . technical success rates of 95.1% have been 6 recorded, with major complication rates of 1.9% and a short median hospital length of stay 7 observed 9 . loss of primary patency after endovascular repair can often be managed by 8 percutaneous techniques, with subsequent secondary patency rates of 80% to 98% reported in the 9 literature 7 . while these studies demonstrate the safety and efficacy of an endovascular approach 10 in severe disease, in this age group an open approach to tasc ii d disease would normally be 11 favoured in our institution given the higher long-term rates of primary patency 7 .this case 12 highlights the importance of proficiency in endovascular techniques in order to provide an 13 individualised approach to patient care. 14 15 the coronavirus pandemic has impacted on the management of vascular disease. early data has 16 highlighted the impact of sars-cov2 infection on post-operative outcomes, with mortality rates 17 as high as 40% in covid-19-positive patients undergoing vascular surgery reported 10 . the 18 vascular society for great britain and ireland has emphasised the importance of reducing 19 inpatient length of stay and critical care bed dependency in a letter to members 11 . endovascular 20 techniques are highlighted as a way by which this may be achieved in order to deliver acute care 21 to patients requiring surgery while recognising of the above complexities 11 . in a recent the covd-19 pandemic has impacted significantly on the delivery of acute-care vascular 6 surgery. concerns regarding post-operative mortality in the event of sars-cov2 infection, 7 critical care bed capacity and inpatient length of stay will undoubtedly lead to a re-imagining of 8 the role of endovascular therapy in the management of complex aorto-iliac occlusive disease. 9 this case demonstrates the management of a tasc-ii d lesion with a hybrid endovascular 10 approach, negating the need for a critical care bed and resulting in a successful outcome. 11 j o u r n a l p r e -p r o o f clinical characteristics and outcomes 2 of patients undergoing surgeries during the incubation period of covid-19 infection percutaneous treatment of transatlantic inter-society consensus class c and d aorto-iliac journal of vascular surgery global vascular 8 guidelines on the management of chronic limb-threatening ischemia consensus for the management of peripheral arterial disease (tasc ii) clinical and anatomical considerations for surgery in aortoiliac disease and 14 results of surgical treatment minimally invasive management of severe aortoiliac acute limb 8 ischemia in patients with covid-19 pneumonia covid-19 virus and vascular surgery covid-19 virus and vascular surgery the global impact of covid-19 on 15 vascular surgical services 3-d reconstruction of lower limb ct angiography demonstrating abdominal aorta thrombosis, right common iliac aneurysmal degeneration and left common iliac artery occlusion, left external iliac occlusion and re-canalisation of the left common femoral artery via the left inferior epigastric artery intra-operative digital subtraction angiogram showing (a) a diagnostic angiogram demonstrating a right common iliac artery aneurysm and occlusion of the left common iliac artery, and (b) the completion angiogram post-endovascular recanalization key: cord-033829-56ka60bc authors: lau, joseph w.y. title: editor’s perspective november 2020 date: 2020-10-16 journal: int j surg doi: 10.1016/j.ijsu.2020.10.002 sha: doc_id: 33829 cord_uid: 56ka60bc nan editor's perspective november 2020 in the october 2020 issue of editor's perspective, i focused on the major advances in fibre-optic endoscopic surgery, a branch of minimally invasive surgery which marks the major developments of surgery 3.0. rapid developments in rigid endoscopic surgery, together with interventional and fibreoptic endoscopic surgeries form the foundation-stones of surgery 3.0, which rapidly became accepted by clinicians and patients in many routine over conventional open surgical procedures because of the advantages of minimal-invasiveness. rigid endoscopic surgery has developed in almost every specialties of surgery, including general surgery, neurosurgery, cardio-thoracic surgery, urology, paediatric surgery, plastic surgery, orthopedic surgery, otorhinolaryngology and emergency surgery. even within the specialty of general surgery, rigid endoscopic surgery has developed rapidly in its subspecialties including hepatico-pancreato-biliary, upper and lower gastrointestinal, and endocrine surgery. again, like fibre-optic endoscopic surgery, the approach as used in rigid-endoscopic surgery can be made through (i) a natural human orifice like the mouth, anus, urethral opening or vagina, or (2) through a small incision to access into a cavity like in thoracoscopic, laparoscopic or arthroscopic surgeries. there are limitations to the use of rigid compared with fibre-optic endoscopic instruments because rigid scopes cannot negotiate through a curvature. however, rigid instruments have the merits of ease in removing large foreign bodies and in crushing large urinary bladder stones. the best developments in rigid endoscopic surgeries are in thoracic surgery using video assisted thoracoscopic surgery (vats), laparoscopic surgery with its further developments, and arthroscopic surgery. i shall talk more about these developments in the future issues of editor's perspective. in this november 2020 issue of international journal of surgery, there are 6 systematic reviews with meta-analyses. the first article is a systematic review and bayesian network meta-analysis comparing "the efficacy and prognosis of different strategies for intrahepatic recurrent hepatocellular carcinoma". the study concluded that salvage liver transplantation and repeat hepatectomy gave better long-term survival outcomes than radiofrequency ablation, stereotactic body radiation therapy and transarterial chemoembolization. another systematic review and network meta-analysis of randomized clinical trials on "mesh position for hernia prophylaxis after midline laparotomy "concluded that onlay and retrorectus mesh augmentation to be more effective than preperitoneal or intraperitoneal mesh augmentation. the third article is a systematic review and meta-analysis on 22 randomized trials looking at the "effect of acute normovolemic hemodilution on coronary artery bypass grafting". the study concluded that acute normovolemic hemodilution reduced the number and rate of transfusion of allogenic red blood cell units and estimated blood loss in patients undergoing coronary artery bypass grafting. the fourth article on "robotic surgery for gastric cancer in the west" concluded that robotic gastrectomy had comparable short-term outcomes as open and laparoscopic approaches. however, long-term outcomes require further studies. the fifth article comparing "the efficacy and safety of thoracic endovascular aortic repair (tevar) versus open repair or optimal medical therapy for acute type b aortic dissection" concluded that tevar produced better 30 days/in-hospital mortality than open surgery and better long-term mortality than optimal medical therapy. finally, the sixth article compared "clinical efficacy of surgical versus conservative treatment for multiple rib fractures" concluded that surgical treatment resulted in faster recovery, with a lower risk of complications and better prognosis than conservative treatment. there are two randomized comparative studies. the first study which compared "side-to-end vs end-toend techniques for colorectal anastomosis" concluded that end-to-end anastomosis yielded better results in the subgroup of patients with tumors in the low-mid rectum. the second study compared trans-abdominal preperitoneal repair (tapp) for adult inguinal hernia with or without tacker mesh fixation showed without tacker mesh fixation to be better. in this november 2020 issue, there is a qualitative study on facilitators and barriers on implementation of the who trauma checklist, an interesting article for trauma and emergency surgeons. another very interesting article to read is the cross-sectional study which concluded that there is still a significant gender based disparity in leadership positions and academic ranks in the united states of america. this article calls for "institution level measures to embrace support, mentorship, and sponsorship for women to achieve overall parity in general surgery". there are 3 prospective studies. the first study was conducted to determine the "outcomes of a new slowly resorbable biosynthetic mesh (phasix tm ) in potentially contaminated incisional hernias." the second study aimed to compare between the "p-possum and apache-ii scores in predicting outcomes of perforation peritonitis". the third study highlighted "sarcopenia management for promoting surgical outcomes in esophageal cancers". of seven retrospective studies, the first is a retrospective study on prospectively collected data to look at the impact of microscopic resection margins on survival outcomes for colorectal liver metastases. the second article compared oblique lateral interbody fusion combined with percutaneous pedicle screw fixation versus traditional posterior transforaminal or transpedicular approach debridement and pedicle screws fixation for treatment of a single segment lumbar tuberculosis. the third article looked at the impact of choledochotomy techniques during laparoscopic common bile duct exploration on short-and long-term clinical outcomes. the fourth article determined the oncologic outcomes of earlyonset rectal cancer in patients aged 40 years or less compared with older patients. the fifth article determined whether laparoscopic surgery to be safe and effective for management of patients with colorectal cancer liver metastases in a population-based analysis in ontario, canada. the sixth article looked at the "mechanisms of recurrent laryngeal nerve injury near the nerve entry point in thyroid surgery". finally, there is a population-based cohort study on "primary tumour removal on prognosis in patients with stage iv breast cancer". there are two experiential research articles. the first article is on the "expression of a human complement-regulatory protein on protection of xenograft cells from systemic complement activation". the second study is on the "effects of endothelin receptor blockade and cox inhibition on intestinal ischemia/reperfusion injury in a rat model". as usual, there are a lot of invited commentaries/commentaries/letters to editor in the november 2020 issue. of particular interests are the 3 letters to editor which are worthy of special mentioning. this letter is recommended to surgeons who are actively managing covid-19 patients. the remaining two letters are technical notes with one letter on the use of "root of helix inter tragus notch incision (rhitni) for temporomandibular open surgery"; and the other letter on "cortical bone incarcerating a guidewire within a tibial intramedullary nail as the editor-in-chief of the journal, i am delighted to see more and more high-quality research articles submitted to us for publication. i welcome suggestions and comments on how the academician of the chinese academy of sciences key: cord-104463-btr5h70l authors: ertan, saridogan; grigoris, grimbizis title: covid-19 pandemic and gynaecological endoscopic surgery date: 2020-05-07 journal: nan doi: nan sha: doc_id: 104463 cord_uid: btr5h70l nan healthcare services have cancelled elective operations and minimised hospital attendances for face-to-face consultations. laparoscopic surgery was quickly flagged up as a potential area where the risk of transmission might be higher in patients with the covid-19 infection (royal college of surgeons, 2020) . this has naturally caused some disquiet amongst surgeons. national and international bodies have published recommendations to advise how to organise services and what precautions to take for gynaecological surgery to limit transmission and protect healthcare professionals, whilst providing the essential care to patients (british society for gynaecological endoscopy, 2020, european society for gynaecological endoscopy, 2020, royal college of obstetricians and gynaecologists, british society for gynaecological endoscopy and british gynaecological cancer society, 2020). all of these recommendations recognised the scarcity of evidence or data specific to coronavirus infection in relation to abdominal surgery. in this issue of facts, views and vision, the article by mallick et al. (2020) summarises what is known in relation to gynaecological laparoscopic surgery and highlights the unknowns. the authors emphasise that there is a theoretical but unproven risk of transmission during laparoscopic procedures because the viral rna is present in the blood of 1-15% of the patients and that presence of artificial pneumoperitoneum is likely to generate aerosol due to escape of co 2 which may contain the virus within droplets of blood or the surgical smoke. a more recent review of covid-19 patients showed that, in fact, the viral rna in blood is found in almost all (96.8%) of patients included in the publications before 23 february 2020 (rodrigues-morales et al., 2020). the virus which is causing the current pandemic is severe acute respiratory syndrome coronavirus-2 (sars-cov-2) which is a member of the β coronaviruses (covs). covs are rna viruses and commonly cause upper respiratory infections in humans. novel coronaviruses sars-cov and mers-cov, which emerged in 2002 and 2012 respectively, caused severe lower respiratory tract infections. viral rna of both these types were found in the plasma during the acute phase, but the live mers-cov was not isolated (chang et al., 2020) . hence, it is unclear if the viral particles in the blood have the capacity to infect other people. sars-cov-2 rna was detected in the blood of most cases but the viral rna load was found to be very low (chang et al., 2020) . this raises further questions as to whether there is a real risk of transmission of infection from exposure to blood either in the form of air droplets or surgical smoke during surgery. mallick et al. (2020) extrapolate that there may be possible transmission due to exposure to surgical smoke from hepatitis b (hbv), human immunodeficiency virus (hiv) and human papilloma virus (hpv). they do, however, admit that this risk remains mostly theoretical and controversial. there are no documented cases of hbv or hiv transmission from the surgical smoke. there are four cases of hpv transmission; hpv positive laryngeal papillomatosis or oropharyngeal squamous cancer were reported in healthcare professionals who had no risk factors other than repetitive exposure to surgical smoke in the literature (liu et al., 2019) . whilst the overall risk remains low, the possibility of transmission from surgical smoke may be related to the specific transmission route of the facts views vis obgyn, 2020, 12 (1): 1-3 editorial virus in general; blood borne viruses may not be able to infect but an orogenital virus such as hpv can. if this is true, then there is a chance that sars-cov-2 may have the potential to infect the respiratory tract from the surgical smoke, if full live viral particles are present in it. another important aspect of laparoscopic surgery is the escape of surgical smoke to the theatre environment. there has been a lot of debate over this point and this is used by some to justify open surgery over laparoscopy. surgical smoke is produced during both open and laparoscopic surgery. in fact, laparoscopy may offer an advantage over open surgery on this issue; the smoke is collected in a confined space, and as long as the smoke is evacuated safely, escape to the theatre environment may be much less compared to open operations. during open procedures, smoke inevitably dissipates into the theatre environment in an uncontrolled manner, even when effective suction devices are used. whilst there is uncertainty about the transmission through surgical smoke or the escaping co 2 during laparoscopic surgery, what is clearer is that the virus is more likely to infect healthcare professionals during intubation or extubation for general anaesthesia (anaesthetic team), or during procedures involving the upper respiratory tract (such as ear-nose-throat surgeons). hence, general anaesthesia appears to be the dominant risk factor when a gynaecological operation is needed and the recommendations from various organisations recognised the need for personal protective equipment for theatre personnel. avoiding general anaesthesia when possible is probably a sensible step in reducing the risk of transmission. whilst this might be impossible for laparoscopic surgery, certain emergency gynaecological procedures such as ruptured ectopic pregnancy or ovarian torsion can probably be performed via minilaparotomy under regional anaesthesia, in the absence of other risk factors such as obesity. most hysteroscopic procedures can also be performed without general anaesthesia, either as office procedures or under sedation without intubation, minimising the hazard to the operating team. the esge recommendations on endoscopic surgery (european society for gynaecological endoscopy, 2020), also published in this issue, highlight the importance of screening for sars-cov-2 before gynaecological procedures, when possible. there may not be enough time to screen women for the virus in emergency situations, but when there is time this seems to be a very logical approach. however, we need to recognise the limitations of currently available tests. although the reverse transcriptase -polymerase chain reaction (rt-pcr) tests appear to be 100% specific, false negative rates of 47-70% have been reported from oropharyngeal and nasopharyngeal swabs (alhazzani et al., 2020) . hence a single negative test does not rule out the infection. some hospitals combined rt-pcr testing with further imaging (chest x-ray or ct) to enhance the detection rates, but imaging is less likely to be useful in asymptomatic patients, or those with mild symptoms. it is likely that the sensitivity of rt-pcr tests will gradually improve and continuing to use it in combination with screening for symptoms and imaging looks like a sensible approach. in conclusion, we are left with many unknowns as regards to the risk of covid-19 transmission during gynaecological endoscopic surgery. the initial covid-19 specific publications have mostly originated from china, but more reports are now being disseminated from the rest of the world. thus, as more data accrue and our knowledge of the impact and behaviour of this novel virus becomes greater, recommendations may need to be revised. however, we probably will not have the answers to most of the questions that have been raised about gynaecological endoscopic surgery during the course of the pandemic and it is quite likely that our understanding will be enhanced after the outbreak is over. meanwhile, it looks sensible to take reasonable precautions, including theuse of appropriate personal protective equipment and taking precautions to reduce exposure to escaping co 2 or surgical smoke during the pandemic. ertan saridogan, editor, facts, views and vision, university college london hospitals grigoris grimbizis, president, esge, aristotle university of thessaloniki clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis bsge and bgcsguidance-for management of abnormal uterine bleeding in the evolving coronavirus (covid-19) pandemic updated intercollegiate general surgery guidance on covid-19 world health organization surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) joint rcog bsge statement on gynaecological laparoscopic procedures and covid-19 coronavirus disease 2019: coronaviruses and blood safety esge recommendations on gynaecological laparoscopic surgery during covid-19 outbreak. 2020. facts views vis obgyn covid-19 pandemic and and gynaecological laparoscopic surgery: knowns and unknowns facts views vis obgyn awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynaecologists key: cord-032067-eemlg0px authors: masket, samuel title: same day bilateral cataract surgery—who benefits? date: 2020-09-18 journal: ophthalmology doi: 10.1016/j.ophtha.2020.08.017 sha: doc_id: 32067 cord_uid: eemlg0px nan there was a time when decision making in health care followed a simple credo: if the treatment process was good for the patient, it was good for the doctor and good for the healthcare industry. that was a different day; times have changed. we are presently in an era when concerns about costs and convenience of healthcare delivery and third-party profit margins may, and sometimes do, seemingly exceed the interests of the individual patient. to my sense, routine simultaneous same-day bilateral cataract surgery (sdbcs) is emblematic of that shifting paradigm. is the patient the true beneficiary of sdbcs; if not, who is? what are the risks of sdbcs to the patient? certainly, the most significant concern is that of bilateral potentially blinding complications such as endophthalmitis or toxic anterior segment syndrome. 1 the proponents of sdbcs indicate that given current surgical techniques, use of prophylactic intracameral antibiotics and undergoing second eye surgery with a new sterile prep and drape, a new fully sterilized instrument set, and separate batches of disposable products from disparate lots should reduce risks to infinitesimally small numbers; they also indicate that the world's literature has but few cases of bilateral infection after surgery. 2 although the latter is true, there is a concern that complications of sdbcs could be underreported because there is a potential disincentive bias to publish severe postoperative complications. although potentially devastating complications can be mitigated to small numbers, they are severely life changing for the individual and his/her family and potentially avoidable with surgery on separate days. regarding risk reduction, should the surgeon also consider using sclerocorneal tunnel incisions for sdbcs, given earlier reports of increased rates of infection with temporally oriented clear corneal incision surgery? 3, 4 is the surgeon at greater medico-legal risk with sdbcs? although rare major complications are sobering and cause for sizeable concern among many eye surgeons, there are less severe risks that should be entertained. given improved intraocular lens (iol) prediction formulae and intraoperative aberrometry, significantly wrong power iol is fortunately less likely than in the past, but always a concern when the optical outcome in the first eye cannot be evaluated before second eye surgery. moreover, even in the best of circumstances, accuracy of optical outcomes of cataract surgery cannot compete with that of lasik, allowing the latter to be performed bilaterally on a routine basis. another condition that does not seem to be mentioned by the proponents of sdbcs is pseudophakic dysphotopsia or self-reported patient observations of undesired optical imagery after surgery. somewhat surprisingly, the incidence of dysphotopsia, in some form, has been reported to be as high as 49%, and it has been suggested that dysphotopsia is the leading cause of dissatisfaction after otherwise uncomplicated contemporary cataract surgery. 5 most typically, dysphotopsia is noted on the first postoperative day and may be disconcerting to the patient. considering negative dysphotopsia, the incidence has been reported at 19% immediately after surgery. 6 although the majority of cases with negative dysphotopsia resolve over time and are nondebilitating, occasional cases require secondary surgery. 7, 8 same-day bilateral cataract surgery exposes patients to the risk of bilateral symptomatic dysphotopsia, whereas nonimmediate second eye surgery allows the patient and the surgeon the opportunity to evaluate undesired optical side effects of surgery and consider an alternative iol or surgical approach for the second eye; this is particularly true for multifocal dysphotopsia associated with diffractive optic iols. what are the purported patient benefits? it is reported that sdbcs offers a more rapid visual outcome and stabilization in cases with high ametropia, fewer visits for postoperative care, less time away from work, reduced travel time for surgery and postoperative visits, and less dependence on others for supportive care. 9 a randomized clinical trial compared sdbcs with a waiting period of 2 months between procedures. 10 in that investigation, patients who had delayed second eye surgery had greater difficulty with daily life activities and binocular contrast sensitivity compared with the immediate same-day bilateral surgery group during their waiting period; as would be anticipated, at 4 months after the second surgery there were no differences between the 2 groups with regard to responses to a standardized questionnaire. 10 the findings of that study are not surprising when the comparison is between a 2-month hiatus between first and second eye surgeries versus sdbcs. however, the visual adaptive advantages of the latter are true only if there is a prolonged time period between surgeries, and although time for adaptation to pseudophakia is shortened by sdbcs, the risks remain. however, save for 1 postoperative visit, the proposed benefits of sdbcs virtually disappear if second eye surgery is performed perhaps 2 days after the first. in that scenario, the patient has first eye surgery on day 1 followed by a postoperative visit and second eye surgery on day 3. given that strategy, the concerns about prolonged visual recovery, anisometropia, and extra postoperative visits are all but eliminated. so then, who benefits most from sdbcs? although third-party reimbursement strategies vary across countries and healthcare delivery systems, in the united states, physicians and surgery centers are reimbursed just 50% for second eye surgery performed on the same calendar day under traditional fee-for-service medicare; this creates a significant financial disincentive for sdbcs. 11 under that scenario, societal healthcare costs savings can be substantial. a 2014 cost-minimization analysis study revealed that sdbcs could provide more than $500 million annual savings to medicare and an additional societal savings of approximately $250 million could be garnered from the viewpoint of lost wages, travel time, and so forth associated with nonimmediate sequential surgery. 12 it is interesting to note that in capitated healthcare systems in the united states and in countries with comprehensive national health services, sdbcs is practiced to a far greater extent than in the united states. a study from finland suggests that compared with sequential bilateral cataract surgery, simultaneous bilateral cataract surgery provided comparable clinical outcomes with substantial savings in health care and nonehealthcareerelated costs. 13 it would appear that surgeons benefit from increased surgical time efficiency and reduced office visits for postoperative care, but in some settings, the united states in particular, surgeons are financially penalized for sdbcs, leaving the bulk of the benefit to third-party payers. all of that said, sdbcs may be beneficial to patients under certain circumstances. patients who must travel great distances for surgery, those who require general anesthesia, and those with very limited social support systems are among those where risks may be outstripped by potential gain. recent release of an optically adjustable iol in the united states (rxsight, aliso viejo, ca) presents another potential avenue for sdbcs. because the optical correction of the iol is adjustable postoperatively, and patients require several weeks waiting time while wearing special goggles between surgery and adjustment, it would be logical to offer surgery for both eyes in the same setting. finally, how does the current coronavirus disease 2019 pandemic affect the decision to perform or not to perform sdbcs. no doubt, patients would prefer to reduce the likelihood of exposure to the virus by visiting surgery centers and physicians' offices as infrequently as possible, and sdbcs offers the chance to have bilateral surgery with 1 rather than 2 exposures. however, given the generally elective nature of cataract surgery, it is hard to fathom an emergency situation where bilateral cataract surgery would be mandated. what about the backlog of elective procedures created by the pandemic? likewise, why would the surgeon be willing to accept financial compromise and why should the patient accept the added risks, however small, of sdbcs, when surgery could be performed sequentially, just days apart as described above? at present, at least with regard to surgery in the united states under traditional medicare, it appears as though the surgeon is financially compromised and the patient put at greater risk, whereas the third-party payer is the ultimate beneficiary of sdbcs. bilateral same-day cataract surgery should routinely be offered to patients e no bilateral endophthalmitis after simultaneous bilateral cataract surgery cohort study of 27 cases of endophthalmitis at a single institution is there a relationship between clear corneal cataract incisions and endophthalmitis? dysphotopsia in phakic and pseudophakic patients: incidence and relation to intraocular lens type effect of active evaluation on the detection of negative dysphotopsia after sequential cataract surgery: discrepancy between incidences of unsolicited and solicited complaints negative dysphotopsia: long-term study and possible explanation for transient symptoms surgical management of negative dysphotopsia bilateral same day cataract surgery should routinely be offered to patients e yes benefit to patients of bilateral same-day cataract extraction: randomized clinical study prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the us a cost-minimization analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the payer, patient, and societal perspectives in the united states :1003e1008. footnotes and financial disclosures financial disclosure(s): the author has no proprietary or commercial interest in any materials discussed in this article number key: cord-253567-a7qg8546 authors: friedman, danielle t.; martin, matthew j. title: comment on: should bariatric surgery be offered to prisoners? date: 2020-08-11 journal: surg obes relat dis doi: 10.1016/j.soard.2020.08.001 sha: doc_id: 253567 cord_uid: a7qg8546 nan the authors of this opinion piece raise the thought-provoking argument that in order to ensure equity in healthcare for imprisoned persons, and to provide optimal treatment for prisoners with obesity and its health-related comorbidities, access to bariatric surgery should be provided for qualifying individuals within the prison system. 4 they propose that candidates might be identified during routine health care within the penal system and referred to a bariatric program, the logistics of which would vary based upon the resources available within an individual prison and the affiliated bariatric surgery program. some may rely on consultation with outside psychiatrists and dieticians, for which telehealth could play a vital role, while other facilities may offer services from in-house staff, supported by such existing recommendations as the federal bureau of prisons nutrition management after bariatric surgery guidelines. in the era of covid-19, with many essential clinical encounters being transitioned to telehealth media, the suggestion that bariatric appointments could occur digitally across prison walls is hardly farfetched. the authors acknowledge that the correctional system is generally underfunded and understaffed, but suggest that some of the cost to the taxpayer may be offset by the resolution of obesity-related comorbidities and therefore reducing the significant costs associated with their treatment. most importantly, the authors point out that incarcerated individuals are disproportionately affected by obesity and its comorbidities. what's more, incarceration may provide their first access to adequate healthcare. this underlines the critical argument for bariatric surgery in an imprisoned population, despite its challenges: providing these patients access to the most effective treatment for obesity and its comorbidities could help to correct dramatic racial and socioeconomic healthcare disparities impacting prisoners. as noted in a 2017 lancet study, "incarceration has become common for poor men from ethnic minorities," j o u r n a l p r e -p r o o f especially non-hispanic black men. 6 this is the same population that suffers the highest rates of obesity, and is simultaneously significantly less likely to receive surgical treatment for obesity compared to higher-income, privately-insured, white patients. 2 the ability to reach out to this vulnerable and underserved population while in a controlled and healthcare-supported environment might provide a unique opportunity for positive intervention with potential lifelong health benefits. 7 what's more, since bariatric surgery is known to be the most effective treatment for obesity, principles of justice and equity would demand that incarcerated patients with obesity have equal access to optimal treatment of their chronic disease. unfortunately, the incarcerated population is also likely to suffer worsened health outcomes upon release from prison, including fewer with a primary care physician and more with preventable hospitalizations. a strong relationship with a bariatric surgery program, and its oversight of long-term follow-up, might offset this to some degree, although high rates of non-insurance or under-insurance on release might complicate subsequent access. despite the promise of this proposal and the above arguments in favor of bariatric surgery in the prison population, there are numerous concerns, obstacles, and counterarguments that must be considered. these can be roughly broken down into medical and non-medical. the nonmedical arguments against this proposal center around the legal, moral/ethical, and political obstacles that wound have to be overcome. the courts have clearly upheld the right of prisoners to "reasonably adequate" medical care under the eight amendment to the constitution, but there is no universal right to non-urgent or elective surgery. 8 although bariatric surgery is widely recognized as the gold standard for patients with obesity and metabolic disease, it would still fall under the category of "elective" as defined by insurers and the prison medical systems. despite the authors' arguments that prisoners should have the same access and options as non-prisoners, j o u r n a l p r e -p r o o f there clearly is legal, moral, and ethical precedent that many rights are altered or forfeited during incarceration. 8 these include freedom of travel, association, voting, employment, holding office, etc. there is also significant precedent in restricting access to bariatric surgery among certain populations due to situations factors and potential adverse impacts on the individual and affiliated group. for example, active duty u.s. military service members are currently barred from undergoing bariatric surgery even if they clearly meet qualifications, due to the perceived impact on their readiness and deployability which could adversely affect the system. these same arguments can certainly be made and readily justified for the prison population. in addition, one could readily see the moral, political, and social justice issues in a situation where a prisoner convicted of murder is able to receive taxpayer-funded bariatric surgery, while equally qualified family members of the victim are unable to afford the same opportunity due to insurance and access reasons. unfortunately, the solution to many of these equity and justice issues related to medicine and surgery, namely universal single-payor healthcare coverage, continues to be an uphill political battle. of equal concern and controversy are the numerous medical and healthcare minefields that would have to be successfully navigated to ensure acceptable preparation for surgery, performance of the procedure, and short and long-term postoperative care. although the prison population may seem ideal for bariatric surgical intervention due to the high prevalence of obesity and obesity-related disease, it is also a population with a much higher prevalence of negative factors such as major psychiatric illness, behavioral disorders, drug and alcohol abuse, low health literacy, and non-compliance. 5, 6 thus any program would have to have an extremely careful preoperative evaluation process and maintain highly selective criteria, or alternatively be exposed to a higher rate of postoperative complications and failure rates similar to what was seen j o u r n a l p r e -p r o o f with the medicare patient population. 9 additional concerns regarding the role of the autonomy of prisoners to give informed consent and the impact of coercion or secondary gain on their decision for bariatric surgery require careful consideration. although the authors argue that the preoperative and postoperative nutritional evaluation, counseling, and management could be handled by the prison system and their available pool of dieticians, we feel that this is unproven and highly suspect given our own encounters with numerous prison medical systems. in an analysis by the marshall project (www.themarshallproject.org/), numerous and widespread instances of inadequate nutritional programs were identified. this included reports of inmates "eating toothpaste and toilet paper" to supplement what was described as "starvation rations". multiple other series have demonstrated huge disparities in nutritional delivery throughout our nation's patchwork system of federal, state, local, and private prisons and jails. u.s. prisoners are six times more likely to get foodborne illnesses and have filed numerous lawsuits related to substandard nutritional programs. most correctional facilities now utilize outside contractors who deliver pre-packaged meals rather than in-house kitchens. these meals have been largely found to be high in sodium and carbohydrates, and with less options for variation in content and amounts to meet the needs of prisoners with specific dietary needs or restrictions. in addition to being a major obstacle that would have to be addressed before initiating a prisoner bariatric surgery program on any kind of scale, the optimizing of prison nutrition may be a potentially high-yield target for improving health and outcomes and even avoiding the need for bariatric surgery in select populations. finally, the critical issues of postoperative care, close medical/nutritional monitoring, and follow-up has been only superficially addressed in this piece. one only needs to perform a brief internet search to identify numerous stories and investigations of a prison medical system that is j o u r n a l p r e -p r o o f understaffed, undertrained, and overwhelmed with just meeting the day to day routine and urgent healthcare needs of the prison population. thus, the postoperative care and monitoring would need to either be done in the prison setting by existing personnel, by hiring new prison personnel, or by frequent transport of the patient to the hospital or clinic and any other ancillary visits that are required. this again would require significant infrastructure, coordination, training, and of course adequate funding and monitoring to ensure even a bare minimum level of success. for these reasons we also remain somewhat skeptical about the prediction that such a program would be cost-neutral or even cost-effective. the existing data on the overall cost effectiveness of bariatric surgery in non-prison populations is contradictory, highly dependent on the patient population, and at a minimum becomes cost-neutral or negative only after a number of years. there is significant evidence to suspect that these same cost savings may not be seen in this population or may be entirely overshadowed by the increased administrative and logistical requirements that such a program would entail. we congratulate the authors for writing this timely, topical, and controversial piece advocating for improved bariatric surgical access in a highly specialized and vulnerable population. given the numerous complex considerations, logistics, and potential second and third order effects of such a program, the question remains regarding the best way to proceed. we agree with the authors that this proposal certainly has merit and is worth pursuing, with the caveat that careful attention is paid to all of the concerns raised above. a small and focused pilot study at a location where the bariatric program is able to partner with a willing prison medical and administrative team would be the ideal start, and could provide critical experiences and data to guide future similar efforts or program expansion. j o u r n a l p r e -p r o o f socioeconomic and racial disparities in bariatric surgery socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis racial disparities in mortality in patients undergoing bariatric surgery in the u should bariatric surgery be offered to prisoners? medical problems of state and federal prisoners and jail inmates mass incarceration, public health, and widening inequality in the usa bariatric surgery among vulnerable populations the authors have no financial dislosures or relevant conflicts of interest related to this workthe opinions presented in this work are solely those of the authors, and do not represent the opinions or policy of jacobi medical center, albert einstein college of medicine, scripps mercy hospital, or any affiliated organizations. key: cord-270214-5bjow148 authors: tan, winson jianhong; foo, fung joon; sivarajah, sharmini su; li, leonard ho ming; koh, frederick h; chew, min hoe title: safe colorectal surgery in the covid-19 era – a singapore experience date: 2020-04-30 journal: ann coloproctol doi: 10.3393/ac.2020.04.21 sha: doc_id: 270214 cord_uid: 5bjow148 nan the covid-19 pandemic crisis has had a staggering impact worldwide. confirmed cases have increased exponentially and the number of infected individuals has since exceeded a million [1] . it is however important to realize that with limitations in testing, true infection rates may in fact be much higher [2] . in addition, presymptomatic transmission of infected individuals has been documented in china and lately confirmed in singapore [3] [4] [5] . our local data suggests that this can occur in 6.4% of patients but has been reported to be as high as 30% in other studies [6, 7] . safe surgery has emerged as a topic of immense interest. as colorectal surgery accounts for a significant proportion of general surgery workload [8] , the covid-19 pandemic thus has immense implications for many general and colorectal surgeons. in this current juncture of the pandemic with dangers of viral transmission, surgeons need to achieve a balance between surgical safety and judicious consumption of personal protective equipment (ppe). while deferment of nonurgent cases may be an initial strategy, this approach is impractical in the long run. the co-vid-19 pandemic will likely have a protracted course and the resultant backlog of cases from indiscriminate deferment may overwhelm surgical capacity in the near future and compromise clinical care [9] . this is particular pertinent for common and timesensitive pathologies like colorectal cancer. in singapore, covid-19 management has been one of prompt contact tracing and isolation to prevent transmission. curtailment of travel as well as safe distancing measures at work and so-cial areas have all been imposed. nonetheless, there have been a large number of imported cases with resultant community spread. in the authors' hospital, there have been 290 (latest figures as of 23/4/20) positive covids to date. while there has been a gradual reduction of elective workload over the last 2 months since the onset of the disease outbreak in singapore, there continues to be a reasonable volume of cases performed. in this article, we share our colorectal unit's workflow ( fig. 1 ) and recommendations (table 1) for safe practice in the covid-19 era. workflow for patients undergoing elective colorectal procedures in the covid-19 era: our workflow for evaluating patients scheduled for procedures (endoscopy or surgery) is illustrated in fig. 1 . preprocedure risk stratification is done for all patients at 3 stages. at the initial anesthetist assessment 1-2 weeks preoperatively a chest x-ray or computed tomography thorax for cancer cases will be obtained to assess for consolidative changes in the lungs. three days prior to the surgery date, our admission team will contact the patient to obtain a travel declaration and to inquire if there are new flu-like symptoms. on day of admission, this process is repeated with a formal declaration form signed by the patient. patients who have any travel history within 14 days, or has contact with any member of the public who is positive for covid-19 or on home quarantine, or has new onset of flu-like symptoms will be advised on postponement of procedure. the procedure would be postponed by 2 to 4 weeks to allow infected patients who may be within the incubation period of coivd-19 to declare themselves. if there is clinical urgency, the procedure may proceed with precautions taken as per a presumed covid-19 positive patient ( fig. 1 ). clinical urgency refers to cases which necessitate intervention within 2 weeks. these include colorectal cancer cases with impending obstruction or with overt bleeding resulting in significant transfusion requirements. postoperatively, such patients will undergo covid-19 testing and will be nursed in isolation until their test results clear them from covid-19 infection. at the current moment, universal covid-19 testing for all pa-tients undergoing surgery is not performed. we only perform testing for patients who meet the suspect case definition stipulated by the ministry of health, singapore. as of 16 april 2020, the case definition is as follows: (1) a person with clinical signs and symptoms suggestive of community-acquired pneumonia or community-acquired severe respiratory infection with breathlessness. (2) a person with an acute respiratory illness of any degree of minimize port incisions to prevent leakage consider use of smoke evacuation system pneumoperitoneum to be safely evacuated using filtration system or suction device prior to specimen extraction or port removal emr, endoscopic mucosal resection; esd, endoscopic submucosal dissection. severity (e.g., symptoms of cough, sore throat, runny nose, anosmia), with or without fever, who, within 14 days before onset of illness had: (a) travelled abroad (outside singapore); (b) close contact with a case of covid-19 infection. endoscopy carries an increased risk of covid-19 infection from droplets inhalation, conjunctival contact and fomite contamination. upper gastrointestinal (gi) endoscopy is recognized to be a high risk aerosol-generating procedure (agp) [10] . however, it is important to highlight that colonoscopy may also pose significant risks. the 2019-ncov has been consistently isolated in stool samples and fecal oral transmission is recognized [11] [12] [13] . it remains unknown if gas insufflation during colonoscopy may be considered an agp. in our unit, we adopt the same ppe measures for colonoscopy as for a gastroduodenoscopy. a summary of our ppe recommendations for endoscopy is summarized in table 1 . there is scant evidence regarding the risks of virus transmission of minimally invasive surgery (mis) or open surgery. however, data does indicate that laparoscopy can lead to aerosolization of blood borne viruses, although it remains unknown if this applies to covid-19 [14, 15] . as such, while we still perform mis procedures, surgeons are recommended to adopt the necessary ppe precautions. (table 1) filtration systems applied to trocars for smoke evacuation and safe evacuation of pneumoperitoneum may be considered but the efficacy of such measures remains unknown. the risks of transanal mis procedures (tatme -transanal total mesorectal excision, tamis-transanal minimally invasive sur-gery) remains unknown in the covid-19 era. however, the 2019-ncov has been demonstrated in stool samples, and with the strong potential risks while evacuating air per-anally, these procedures should be performed with extreme caution in the current climate [11] [12] [13] 16] . smoke from electrocautery during open surgery can harbor virus particles [17] . unlike mis, the exposure of the surgeon to smoke inhalation is likely higher in open surgery which raises the possibility of covid-19 transmission. measures to mitigate risks of transmission should thus be adopted. these, together with our proposed ppe for open surgery, are summarized in table 1 . most operating room (ors) have an average of 15-40 air exchanges per hour. to ensure clean air in the or, 14-18 minutes is thus required [18] . in our institution, an intubation-extubation protocol has been in practice since the covid-19 outbreak. in this protocol, a 5-minute pause has been mandated during intubation and extubation, with only the anesthetists and assistant in or wearing full ppe. this ensures at least 2 gas exchanges of the or, and enhances safety in the scenario that surgeons are operating on an undiagnosed covid-19 case. to address the concerns of laparoscopy, an additional 15 minutes has been factored in, which commences on evacuation of the pneumoperitoneum. this allows a complete 20 minutes of air exchange on completion of surgery and extubation [19] . for covid-19 cases, surgery is performed in a dedicated negative pressure or. in the negative pressure or, the induction and scrub room is maintained at a pressure of -2.5 pascals relative to the exterior to prevent dissemination of aerosolized virus particles. fig. 2 illustrates the setup of our negative pressure or. the covid-19 pandemic is likely to run a protracted course table 2 [10, [20] [21] [22] [23] . while the measures we have in place have allowed safe colorectal surgery, there are several modifications that may have to be considered in view of increasing community transmission and recognition of presymptomatic transmission. one suggestion is that routine bowel preparation may be considered to reduce fecal load during bowel surgery. secondly, the appropriate ppe in this era needs to be reviewed and perhaps all or staff should be in n95 respirators for all colorectal procedures until there is more evidence regarding transmission risk during surgery. the difficulty, however, is having the availability of resources and its pragmatic allocation. thirdly, universal preoperative covid-19 testing may seem to be intuitively better and replace clinical stratification but the issues of false negatives and limited covid-19 testing capacity may hamper widespread implementation. we urge the colorectal fraternity to share their workflows and protocols to ensure safe practice among our community amidst this uncertain era. all elective cases to be postponed all elective procedures to be delayed patients with time-sensitive diagnosis to proceed with evaluation strongly consider postponing elective, nonurgent procedures only emergency procedures to be performed no diagnostic work to be done na surgery all elective cases to be postponed surgical care limited to those whose needs are imminently life threatening na largely confined to emergency surgery stoma formation to be considered rather than anastomosis tiered approach for cancer cases sages, society of american gastrointestinal and endoscopic surgeons; eaes, european association of endoscopic surgery; asge, american society for gastrointestinal endoscopy; aga, american gastroenterological association; acg, american college of gastroenterology; aasld, american association for the study of liver diseases; na, not applicable. john hopkins coronavirus resource centre johns hopkins university & medicine; c2020 substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2) a cov-id-19 transmission within a family cluster by presymptomatic infectors in china potential presymptomatic transmission of sars-cov-2 presymptomatic transmission of sars-cov-2 -singapore asymptomatic and presymptomatic sars-cov-2 infections in residents of a long-term care skilled nursing facility estimation of the asymptomatic ratio of novel coronavirus infections (covid-19) colorectal surgery as a specialty the possible impact of covid-19 on colorectal surgery in italy esge and esgena position statement on gastrointestinal endoscopy and the covid-19 pandemic characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention evidence for gastrointestinal infection of sars-cov-2 enteric involvement of coronaviruses: is faecal-oral transmission of sars-cov-2 possible? surgical smoke and infection control surgical smoke may be a biohazard to surgeons performing laparoscopic surgery covid-19: gastrointestinal manifestations and potential fecal-oral transmission awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists centers for disease control and prevention a call to arms: a perspective of safe general surgery in singapore during the covid-19 pandemic sages and eaes recommendations regarding surgical response to covid-19 crisis sages covid-19 guidelines for triage of colorectal cancer patients american college of surgeons gastroenterology professional society guidance on endoscopic procedures during the covid-19 pandemic intercollegiate general surgery guidance on covid-19 update the royal college of surgeons of edinburgh; c2020 key: cord-274782-yymo9i6r authors: şahbat, yavuz; buyuktopcu, omer; topkar, osman mert; erol, bulent title: management of orthopedic oncology patients during coronavirus pandemic date: 2020-07-02 journal: j surg oncol doi: 10.1002/jso.26092 sha: doc_id: 274782 cord_uid: yymo9i6r the new measures implemented in hospitals also altered the operation of orthopedics and traumatology departments. the main purpose of this article is to discuss how orthopedic oncology clinics should be organized during the pandemic and to present the process management scheme for patients requiring orthopedic surgery, including trauma surgery, from diagnosis to treatment, together with our experiences. instead of thinking about the global emergence of the epidemic, it is time to act decisively. at first glance, the coronavirus disease 2019 (covid‐19) pandemic and orthopedics may seem to be unrelated disciplines, but the provision of healthcare services to patients who require them proves that these two fields are parts of the same whole. our experiences in treating neutropenic, lymphocytopenic, and chemotherapy patients seem to have proven beneficial during this process. we operated on 10 biopsy patients, 15 primary bone sarcomas, 9 soft tissue sarcomas, and 82 trauma patients within this time frame. only three patients were suspected to have covid‐19 before admission. the early identification, strict isolation, and effective treatment of these patients prevented any nosocomial infections and disease‐related comorbidities. this success is the result of the multidisciplinary cooperation of the ministry of health, our hospital, and our clinic. the novel coronavirus was first reported as a zoonotic agent in hand hygiene with soap and water or by alcohol based hand rub, avoiding touching eyes, nose and mouth, wearing face masks, and practicing respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the tissue, maintaining social distance (minimum of 1 m). 3 all health workers have to use personal protective equipment (ppe) during procedures of covid-19 suspected or diagnosed patients. in addition to these measures, people who had been in close contact with newly diagnosed cases, including medical personnel, were traced and put under a 14-day house quarantine. the consensus opinion issued by the turkish society of orthopedics and traumatology (totbid) indicated that authorized clinics in public hospitals should continue trauma and tumor surgeries. 4 the new measures implemented in hospitals also altered the operation of orthopedics and traumatology departments. the main purpose of this article is to discuss how orthopedic oncology clinics should be organized during the pandemic and to present the process management scheme for patients requiring orthopedic surgery, including trauma surgery, from diagnosis to treatment, together with our experiences. instead of thinking about the global emergence of the epidemic, it is time to act decisively. we searched for the keywords "coronavirus" and "hospital management scheme" in the pubmed advanced search engine. we determined the statements published by the turkish ministry of health and totbid as the bases of the patient management scheme. we obtained data from the hospital information system regarding all oncologic orthopedics and trauma surgery patients operated on and followed between 11 march 2020, the date of the first confirmed case of coronavirus in turkey, and 11 may 2020. as per the world health organization's pathogen screening system, patients were questioned regarding their symptoms and their contacts. the patients who were operated previously or who have been followed conservatively were continued following in outpatients clinics with precautions for coronavirus. all preoperative patients were questioned and examined for signs and symptoms related to covid-19. besides routine pre during this process, we contacted patients with benign bone lesions and soft tissue masses that required surgery and postponed their operations. we continued to perform the surgeries of patients with primary bone sarcomas, metastatic lesions with impending or eventuated pathological fractures, and malignant soft tissue masses, after taking the adequate precautions for health care workers from getting infected. we recommended and performed biopsies for patients whose medical history and physical and radiological examinations indicated a high risk of malignancy. the 10 patients who required biopsy (four males and six females, aged 7-84 years) were scheduled for outpatient surgery. they were asked to come to the hospital in the morning ready for surgery and were sent home after the nerve block or general anesthesia wore off. the patients were not hospitalized overnight. this outpatient surgery approach allowed the patients to remain in the hospital for less than 24 hours and helped avoid nosocomial infections. one patient with soft tissue sarcoma who was being followed for surgical wound care was determined to have a fever, cough, fatigue, and pancytopenia in the preadmission screening. the blood test results of this patient were as follows: hemoglobin, 6.8 g/dl; white blood cells, 0.1 × 10 3 /µl; platelets, 65 × 10 3 /µl; lymphocytes, 0.1 × 10 3 /µl; procalcitonin, 1.43 µg/l; c-reactive protein, 220 mg/l; d-dimer, 1.74 mg/l; ferritin, 2023 µg/l; and fibrinogen, 752 mg/dl. the ct scan results of the patient revealed ground-glass opacities in both lungs and the patient was tested for covid-19 by real time rt-pcr, which came back negative (figure 4 ). in the meantime, the patient was isolated and treated (plaquenil + azithromycin) in a different ward as per the recommendation of the infectious diseases department. all medical staff were screened for fever the morning of the operation. all staff were also screened for fever during entry to and exit from the hospital. only healthcare workers were allowed in the clinic to reduce the risk of nosocomial infections originating from other people. all medical staff were provided with online covid-10 training in accordance with the directives of the ministry of health. all patients were screened for fever twice a day and lymphocyte counts were evaluated daily. parallel to the measures taken by the medical staff, certain rules were introduced for the patients. the patient's relatives were provided with information on covid-19 before the patient being admitted to the clinic. wearing masks was made mandatory and daily fever screenings were implemented. we evaluated all patients that were scheduled for biopsy and surgery both preoperatively and postoperatively at weekly orthopedic oncology committee meetings that included a pediatric oncologist, a medical oncologist, a radiation oncologist, a radiologist, an orthopedic surgeon, and a pathologist. to reduce contact, we reduced the number of physicians on the committee from three specialists per branch to one. a seating plan was organized in which the members of the committee would be at least 1.5 m apart. also use of mask was encouraged during those meetings. we thus ensured that the treatment of orthopedic oncology patients that required a multidisciplinary approach would not be disrupted. the patients were operated by an experienced surgical team. entrance to and exit from the operating room were kept to minimum. the operating room ventilation system should minimize the presence of airborne pathogens. the ventilation system in our operating room provided at least 20 air changes per hour. we reduced the amount of equipment in the operating room and only kept the essentials for the surgical procedure. we minimized the number of people in the operating room, especially during the intubation or extubation of the patient. we applied tranexamic acid to every patient unless contraindicated to reduce complications related to perioperative and postoperative bleeding ( figure 5 ). visitors were not allowed after the operation. we administered standard postoperative antibiotic and anticoagulant prophylaxis since there is no evidence suggesting the preferred postoperative in our clinic, we primarily decided to reduce all forms of contact. we halted general orthopedic and nonurgent specialty outpatient services (foot and ankle surgery, sports surgery, deformity surgery, arthroplasty, hand and wrist surgery, pediatric orthopedic surgery). we aimed to reduce both the healthcare workers' contact with patients and the patients' contact with other patients while coming to and from the hospital. we reduced the number of actively working outpatient clinics from seven to two, where we followed up only early postoperative patients, patients followed for conservative treatments or casts, and tumor patients. we created a separate outpatient service for tumor patients and prevented any contact with other patients during follow-ups. we determined early postoperative patients who were operated on before the covid-19 outbreak through the hospital information system and used teleconferencing for consultations. we only called in patients who were deemed necessary to come into the hospital for assessment. during teleconference conour patients were asked to arrive in the morning ready for surgery and were sent back home after nerve block or general anesthesia wore off. the patients were not hospitalized overnight. the outpatient surgery approach allowed the patients to remain in the hospital for less than 24 hours and helped avoid nosocomial infections. 5 considering the possibility that the fight against the covid-19 outbreak may be long-term, it is crucial to ensure the safety of healthcare workers and the rational use of medical resources. for this reason, like all healthcare workers, the orthopedic team was instructed to regularly wash their hands and to wear surgical masks during clinical practice. the infectious diseases clinic and ward were isolated and separated as a follow-up and treatment zone for patients with covid-19. two healthcare workers who worked in the orthopedics clinic had recently returned from abroad and were put under 14 days of home quarantine. four staff working in the outpatient clinic during the outbreak presented with fever and flu-like symptoms and tested positive by real time rt-pcr. they were subsequently put under 14 days of home quarantine and were treated at home as per the suggestion of the infectious diseases clinic. these six workers returned to active duty after two consecutive real time rt-pcr test results came back negative. one employee of the hospital had lymphocytopenia (lymphocyte count of <500) due to using immunosuppressive drugs for multiple sclerosis and was removed from active duty and quarantined. healthcare workers' safety is one of the key goals. 5, 14 one of the key strategies here is to reduce the number of surgeries and elective operations in the entire hospital. 15 at first glance, the covid-19 pandemic and orthopedics may seem to be unrelated disciplines, but the provision of healthcare services to patients who require them proves that these two fields are parts of the same whole. our orthopedics and traumatology clinic was this success is the result of the multidisciplinary cooperation of the ministry of health, our hospital, and our clinic. novel coronavirus (2019-ncov) situation report-8 clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study rational use of personal protective equipment (ppe) for coronavirus disease (covid-19): interim guidance guidelines of covid-19 precausions novel coronavirus and orthopaedic surgery orthopaedic surgical selection and inpatient paradigms during the coronavirus covid-19 pandemic incidence, risk factors, and clinical implications of pneumonia following total hip and knee arthroplasty epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study current concepts review resuming elective orthopaedic surgery during the covid-19 pandemic survey of covid-19 disease among orthopaedic surgeons in wuhan, people's republic of china what we do when a covid-19 patient needs an operation: operating room preparation and guidance misguided drug advice for covid-19 characteristics and early prognosis of covid-19 infection in fracture patients minimally invasive surgery and the novel coronavirus outbreak orthopedic oncology: what's new in 2019? management of orthopedic oncology patients during coronavirus pandemic the authors did not receive any outside funding for their research or preparation of this work. data sharing not applicable to this article as no datasets were generated or analyzed during the current study. key: cord-032915-r6qguo8q authors: paul, saptarshi title: the dilemma faced by a budding cardiothoracic surgeon in india—a first hand account date: 2020-09-30 journal: indian j thorac cardiovasc surg doi: 10.1007/s12055-020-01045-5 sha: doc_id: 32915 cord_uid: r6qguo8q cardiothoracic surgery is undoubtedly one of the most glamorous and exciting surgical fields on earth. the field requires passionate and hardworking youngsters who are always willing to learn. bright young surgeons should know what is going to be on their platter once they have decided to take the plunge into cardiac surgery. this article is a fruit of my 3 years of residency experience and my ongoing stint as an assistant professor. in this article, i have tried to make young surgeons aware of what they will face during their residency tenure and also to attend to some of their worries prior to selecting cardiac surgery as a career option. cardiothoracic surgery was, unlike many of my peers, my choice of a career even before i entered post graduate studies. back in 2009, as an undergraduate student, i had participated in a special examination in cardiology, consisting of multiple choice questions and three cardiac case presentations. i trumped it. since then, matters related to the heart always found a very inquisitive student in me. coming to cardiothoracic surgery, admission was fairly smooth; though, it actually involved a lot of conflicts with friends and family. i am sure many of the budding cardiac surgeons might face the same. sad to say, but one of the most beautiful and intricate surgical specialties on earth is being neglected based on hearsay and rumours. my aim, here, is to encourage the young surgeons to join this profession. and i shall execute it by a simple counter the rumour method. rumour 1: cardiac surgery needs too much of an investment on the family front with very little returns; family life needs to be sacrificed. truth: which surgical branch does not? the learning curve is indeed tougher than the other surgical streams, but any surgical stream for that matter would not give returns with a suboptimal investment. a. considering the number of surgeons mushrooming up in other specialties, a young surgeon needs to be extraordinary to survive the race and be a worthy contender. contrary to that, in cardiac surgery, the learning curve deters people from joining, so the competition is less. as stated by burt et al., increasing years of surgeon experience is associated with improved operative efficiency and long-term survival in valvular cardiac surgery [1] . a prolonged learning curve leads to a slow reduction in operative timings, which in turn has a detrimental effect on the prognosis of the patient [2] . and now, the pertinent question: does family life need to be sacrificed? it might be safe to assume that the sheer magnitude of work and its finer intricacies are best understood by the surgeon and by no second person, unless the latter is properly trained. so the onus is on the surgeon to enter a detailed discussion with his family members, explaining the nature of the work, and the importance of staying back in the hospital on some occasions. hours can be erratic, and late nights and next mornings are commonplace. rumour 2: cardiac surgery is a dying specialty. truth: not at all. in fact, i was advised by a consultant neurosurgeon to go for cardiovascular and thoracic surgery, as the cardiologists' dominance had come a full circle by 2013-2014. newer ways of approach have been imbibed in some parts of the world wherein the interventional cardiologists and the cardiothoracic surgeons work in synchrony, the so-called heart team [3] . the management modality of ischaemic heart disease with multiple vessel occlusions, as it stands now, is an option between quick relief from symptoms, with the risk of disease relapse, in the form of stenting (percutaneous coronary intervention), or in the form of coronary artery bypass grafting. catheter-based techniques have succeeded in grabbing a major slice of the pie. however, the age-old debate continues with respect to the superiority of percutaneous coronary intervention (pci) versus coronary artery bypass grafting (cabg). cabg is by no means obsolete, as proved time and again by trials such as syntax (synergy between percutaneous coronary intervention with taxus drug-eluting stent and cardiac surgery, 2009) which concluded that cabg demonstrated fewer major adverse cardiac and cerebrovascular events compared with pci [4] . in 2018, 5-year data from the syntax trial and other similar randomized studies (11 randomized trials involving 11,518 patients) comparing pci with cabg for complex coronary artery disease were assembled and meta-analysed. all-cause mortality was found to be significantly higher in pci compared with cabg [5] . as of 2019, the syntaxes (synergy between percutaneous coronary intervention with taxus and cardiac surgery extended survival) trial, which is a 10-year follow-up study of the syntax trial, has shown that patients with threevessel disease had a survival advantage with cabg versus pci at 10 years. also, all-cause death at maximum available follow-up was 18% more in pci compared with cabg [6] . so as we follow the patients longer, the benefit of the surgery gets larger. even the latest generation of drug-eluting stents may impair coronary vasomotion, trigger neoatherosclerosis and hamper surgical attempts to treat failed stented segments [6] . bioabsorbable vascular scaffold (bvs) had been specifically developed to reduce late adverse events after coronary stenting, such as device thrombosis, but, the evidence shows that in select patients they are non-inferior with a trend toward being inferior [7] . a multitude of case reports have been published over the past 5 years that imply the unreliability of the bvs, leading to restenosis and severe symptoms after one and a half years on an average, after the stoppage of dual antiplatelet therapy [8] [9] [10] . hence, the demand for bvs has gone down drastically. now my message for the trainees, do not stop at traditional open surgeries only. that's just the tip of the iceberg. as more and more centres adopt minimally invasive surgeries as standard, the trainees should aim to have adequate exposure in minimally invasive direct coronary artery bypass (midcab), endoscopic atraumatic coronary artery bypass (endo acab), total endoscopic coronary artery bypass (tecab) etc. there are transcatheter aortic valve implantation (tavi), transcatheter mitral valve repair (tmvr), transcatheter mitral valve replacement (tmvr), robotic surgeries, surgeries for heart failure and arrhythmias and transplants. however, it should be mentioned in this context that there is no information about the long-term results of minimally access surgeries, unlike the tried and tested median sternotomy approaches. though these are very popular in countries like india, we are still not aware of the reoperation rate, e.g., after mitral valve repair through mini thoracotomies. we know today, for sure, that off-pump coronary artery bypass grafting (opcab) has not sustained the test of time (10 years) against on-pump surgery, though as a short-term solution it might look good against pci. and paediatric cardiac surgery is a different story altogether. the playground is open! rumour 3: the subject is very difficult. truth: indeed it is, but albeit a mesmerizing one. it takes time to understand and imbibe the concepts, but once they are thoroughly incorporated in your system, one cannot stop exclaiming about how beautiful it is. and it has a fascinating history that documents the risks and failures that the great stalwarts of the subject had to face, in order to shape it into a safe and convenient management modality, as it is now. for the young aspirants, i would advise them to be confident about their anatomy, as that is half the battle won. the initial experience is difficult, but as you go deeper you would find that a bit of concentration and passion would help you go a long way. the heart needs passionate people to know how beautiful it really is. what do you need to learn? well, a lot of surgical skills and handling techniques. during the learning curve, things need to be learnt that are considered to be the domain of anaesthesiologists; viz., drug doses, inotrope administration, ventilator settings, extubation techniques, reading electrocardiograms and pulseoximeter wave forms etc. truth: this is a critical topic. so i would like to break it up into segments. (a) the mortality may be higher on paper compared with other surgical fields if the numbers are considered. the young surgeons might get to hear time to time from their peers in other specialties about the heightened mortality rates in cardiac surgery. but they should be aware that no two surgical field is the same, and hence, a fair comparison is impossible. let us examine a case in point. in neurosurgery, for example, the patients who undergo extensive surgeries for intracranial bleeds or a large tumour may have devastating post operative sequelae with a low glasgow coma scale score (gcs), though they cannot be registered as mortalities. the knowhow about inotrope use, drug dosages, ventilator settings and extubation techniques helps. post cardiac surgery patients require intensive monitoring, judicious use of cardiovascular drugs, effective pain control, early mobilization and intensive respiratory therapy, for reduction in mortality. according to our institution protocol, the post-operative patients would entirely be managed by us, as there is no cardiac anaesthesiologist. this protocol, however, changes from institution to institution, when there are full time intensivists or cardiac anaesthesiologists. i implore all the young surgeons to observe the post operative management intently, as it has as much implications on the prognosis of the patient as the surgery itself. (b) how much is too much? a perseverant and tenacious attitude is essential, and this has to be exercised efficiently in extreme conditions of fatigue and frustration (sometimes), year after year. a clear head, reactive to the importance of a situation has to be nurtured, to safely tide over stormy post operative periods. the rush you get, when your patient walks home, comfortable, is beyond words. all the frustration and sleepless nights finally feel worth it. rumour 5: the surgeon's job is confined to the theatre. truth: that and much more. operating is only half the job done. for youngsters, the onus is on them to ensure that the operated patient has a safe post operative course. the trainees are required to spend the entire post operative period in the intensive care unit (icu) till the patient is extubated and even more. this helps them understand the progression of the patient. rumour 6: settlement takes time, when peers in non medical streams may be at their pinnacle of glory, we are just exiting the training programme. truth: hands on experience is a bit guarded than most of other specialties. that's understandable, as the handling of the heart takes years to master. and in cardiac surgery, it is always life or death. the settlement as a senior consultant takes time, but that again is also dependent on the individual's skills. after a decent settlement, the remuneration is right at par with other superspecialties and sometimes even more. frustration may creep in sometimes, when peers in non medical streams settle early and have a complete family by thirty. i believe that a select personality trait helps people be surgeons; and that trait shall help the youngsters hone their skills further. i had joined chemical engineering before joining medicine, and trust me that was not even half as exciting as this is. the daily adrenaline rush compensates a long way, for the loss of material pleasures. truth: perseverance, perseverance and perseverance! this is the keystone for gaining inroads into the department and into the heart of the chief. do not forget that they have gone through sufficient hardships to gain this position. i must say that, even though a government approved and monitored protocol-based training in india is still a few years away, a measured approach with an eagerness to operate gets its due reward. i was lucky to be in an institution where all of us residents received substantial hands on training. that might not be the case with everyone. be disciplined and persistent, and maintain a down to earth demeanour. never lose hope, never! to sign off, a few other points i would like to mention: 1. interpersonal relationship and leadership qualities are vital. you should be able to work in a team with your peers and lead a team in situations of duress, and a cordial relationship with the chief and nursing staff should be maintained at all costs. it is important to counsel the patient's family about a surgery that is a potential life saver, but could be fatal too. 2. immense patience is required to channelise the adrenaline, else ominous mistakes could occur on table. 3. do not let frustration get the better of you. talk to your parents and loved ones. family support is essential to tide through this time. it can be a jolly ride, when challenges become commonplace. dealing with the heart takes a lot of heart. challenges should not be a deterrent, as at the end of the day, do not we all love a bit of them? funding there has been no source of external funding. conflict of interest the author declares that there is no conflict of interest. influence of experience and the surgical learning curve on long-term patient outcomes in cardiac surgery surgical learning curves and operative efficiency: a cross-specialty observational study cabg in patients with three-vessel or lm cad: who finally won the battle of the titans? percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled syntax trial bioresorbable vascular scaffoldstime to vanish? managing bioabsorbable vascular scaffold failure: combined scaffold restenosis and late-acquired coronary aneurysm treated with self-expandable stent neoatherosclerosis as the cause of late failure of a bioresorbable vascular scaffold very late bioresorbable vascular scaffold thrombosis following discontinuation of antiplatelet therapy publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations ethical committee approval not required.informed consent not required.human and animal rights statement not required. key: cord-007547-gdsoc93j authors: gillies, m.a.; wijeysundera, d.n.; harrison, e.m. title: counting the cost of cancelled surgery: a system wide approach is needed date: 2018-09-07 journal: br j anaesth doi: 10.1016/j.bja.2018.08.002 sha: doc_id: 7547 cord_uid: gdsoc93j nan outcomes. interestingly, rcts targeting intraoperative bp thresholds have found no differences in 30 day 9 or 90 day mortality. 10 in summary, wesselink and colleagues 2 have presented a robust, well-organised systematic review of the disparate studies on the association between intraoperative hypotension and adverse postoperative outcomes. because of large variations in study populations, definitions of hypotension, surgical procedures, outcome measurements, and analytic methodology, we are still unable to definitively point to intraoperative hypotension as the culprit of adverse outcomes. nonetheless, the review reveals multiple avenues for future research that may bring us closer to making sense of hypotension. we may not know how to define hypotension, let us hope we recognise it when we see it. discussed an overview, contents, and the proposed narrative before composing the manuscript: j.x.c.k., w.s.b. wrote the first draft: j.x.c.k. edited the first and subsequent drafts: r.b.g., w.s.b. the authors declare that they have no conflicts of interest. cancellation on the day of surgery is a major issue in the uk nhs and other healthcare systems. a recent prospective epidemiological study over a 1 week period in nhs hospitals suggested a cancellation rate of between 10% and 14% and that only one-third of these were because of clinical reasons. this editorial explores the implications of the findings of this study and how clinicians, managers, and healthcare commissioners might reduce this problem. as the uk nhs entered its 70th year, figures from the first quarter of 2018 showed that 25 475 operations were cancelled in nhs england on the day of surgery. this is the highest quarterly figure recorded since records began in 1994. at the start of this year, nhs england recommended that all hospitals cancel elective surgery for the month of january. as a consequence, government targets to treat 92% of patients within 18 weeks were missed for the second year running. 1 winter bed pressures and a failure to discharge patients awaiting social care packages from acute beds are routinely blamed for cancelled surgery. recent data from the royal college of surgeons of england and the king's fund suggest that not only is this problem increasing year on year, 1 but that increased hospital occupancy extends all year round as hospitals attempt to reschedule cancelled admissions. 2 bed pressures, particularly over winter months, are not the sole reason for cancelled surgery. other issues can be implicated, including failure of adequate preoperative assessment, staff shortages, access to operating theatres, equipment shortages, and critical care capacity. cancellation on the day of surgery is costly for patients and healthcare providers. in addition, it can have profound consequences on patients' health and experience, extending their period of pain or debilitation and even worsening long-term outcomes in surgery for cancer or cardiovascular disease. estimates quantify cancelled surgery in the uk at 1.3% of all hospital admissions. the cost in lost operating theatre time is as high as £400 million per year. hence, detailed information on the reasons for cancelled surgery and strategies to reduce this is of great interest to healthcare providers, clinicians, and the public. in this issue of the british journal of anaesthesia, wong and colleagues 3 present a prospective observational study exploring the reasons for cancellation on the day of surgery in 245 nhs hospitals across the uk. theirs was a planned sub-study of the second sprint national anaesthesia project: epidemiology of critical care provision after surgery study (snap-2: epiccs). this prospective, observational, cross-sectional study into critical care provision for adult surgery was conducted over one week in 2017. of 15 000 patient episodes, 10% of patients enrolled had been previously cancelled for the same procedure. moreover, 13.9% of patients attending for inpatient surgery on the week of the study had their surgery postponed. the investigators used statistical modelling to identify factors associated with postponement of surgery at patient and hospital levels. although non-clinical factors such as hospital bed capacity and operating theatre capacity were highlighted, clinical reasons were responsible for 33% of historical cancellations and 28% of contemporaneous cancellations. patients who required postoperative critical care were at higher risk of being cancelled, while those undergoing obstetric surgery, emergency surgery, or cancer surgery were at reduced risk. hospital factors associated with a risk of cancellation were the presence of an emergency department and enhanced ward care areas. this study increases our understanding of what seems to be an intractable problem in nhs institutions and beyond. this was a large study involving more than 90% of uk hospitals. however, in common with many epidemiological studies, there are limitations. the study period was a single week in march, and thus may not be representative of conditions throughout the year, particularly in winter months when hospital occupancy and cancellation rates are known to be higher. 2 there was limited granularity in the clinical reasons for cancellation (e.g. was it because of poor preparation or unexpected deterioration in patient health). in 14% of historical cancellations and 57% of contemporaneous cancellations, no reason was identified at all. finally, the uk has a unique healthcare structure and the results of this study may not be applicable to an international audience. despite these, what relevant information from this study can be learned and applied by those delivering surgical care to minimise the risk of cancellation? provision of acute hospital beds clearly remains an issue, particularly at times of peak demand. tied in with this issue is access to long-term care beds, rehabilitation beds, and availability of home care support packages, preventing discharge. this is also a major issue in other healthcare systems including north america; for example in ontario, hospital overcrowding and occupancy of more than 100% has also become the norm. 4 in this study, the presence of an emergency department was strongly associated with risk of cancellation. unsurprisingly, the co-provision of acute and emergency services in nhs hospitals may result in emergency admissions being prioritised over admission for elective procedures, thus resulting in cancelled surgery. this may be compounded in the presence of competing government targets, for example simultaneous delivery of the emergency department 4-h wait target and the 18-week maximum waiting time for elective treatment. this and the time-critical nature of cancer surgery may explain the finding that cancer surgery was less prone to cancellation. in the uk, these patients are prioritised by clinicians and hospital managers, and are thus less likely to be postponed. data from canada suggest that this approach does not impact adversely on other nonprioritised surgery (e.g. elective major joint replacement). 5 to apply the findings of this study to a broader setting than the uk, one must first consider the funding model for each system, for example whether institutions receive a fixed amount of money to deliver surgical care to a population or where funding is based on activity. in the latter, institutions would be incentivised to hire more staff and open more beds to accommodate additional activity at times of peak demand. reducing or even stopping elective operating completely in winter months is unlikely to be a long-term solution to this problem, as many hospitals report capacity issues beyond the traditional winter months and the postponed surgery must be accommodated at another time in the year. 2 there are advantages to creating virtually or physically separate elective operating centres, or at least ensuring ring-fenced beds within an acute hospital. this approach can not only reduce cancellations, but also the length of stay and postoperative complications. 6 this may also prove a strong argument for the creation of cancer treatment centres, where prompt access to surgical treatment may be only one of several advantages, for example more seamless preparation for and delivery of preoperative and postoperative chemotherapy or radiotherapy. access to operating theatres is another area where improvements might result in reduced rates of cancellation. the investigators found that obstetric and emergency surgery were less prone to cancellation. this might be explained by appropriate clinical prioritisation of these patients. however, obstetric and emergency cases also tend to have dedicated operating theatres that can improve throughput and reduce cancellation. interestingly, even during the severe acute respiratory syndrome (sars) crisis in 2003, emergency care in toronto hospitals was largely preserved, while elective cases were reduced, consistent with the vulnerability of elective surgery to competing hospital pressures. 7 ensuring that there is adequate dedicated operating theatre capacity for emergency general surgery and orthopaedic trauma to minimise delay in treatment is strongly linked with outcome, and might also minimise cancellation and delay for other patients undergoing elective surgery. inadequate critical care provision has long been cited as a reason for postponed surgery and inferior patient outcomes after high-risk surgery. in this study, the requirement for postoperative critical care was associated with an increased risk of cancellation. although admission to critical care is recommended for many types of high-risk surgery, data from epidemiological studies do not support routine admission to critical care after elective surgery, 8,9 except in the highest risk groups. 10 although the uk is thought to have fewer critical care beds per capita than other developed countries, international definitions of critical care beds are not standardised. research within the uk suggests that per capita critical care provision is not linked with improved outcome. 11 patients selected for direct postoperative admission to a critical care area are likely to have more co-morbidities 10 and this may also explain the increased risk of cancellation seen in this study. it is also known that there is a wide variation in icu admission practice after surgery, much of which is at hospital level. even without clear evidence that critical care improves postoperative outcomes, there is a need to better standardise criteria for postoperative critical care admission across hospitals. 12 enhanced care wards have been suggested as an alternative to critical care for patients undergoing major surgery, however, this study did not suggest that their presence reduced the rate of cancellation. although it is tempting to attribute many of the reasons for cancelled surgery to hospital factors, government policy, or healthcare delivery, we must acknowledge the finding that up to a third of cancellations in this study were for clinical reasons. 3 while we do not know if this was because of unexpected clinical deterioration, intercurrent illness, or inadequate preoperative preparation, we must consider the possibility that better preoperative assessment, risk stratification, and optimisation of pre-existing medical conditions might reduce the risk of cancellation on the day of surgery. with admission on the day of surgery now the norm, there is limited time for additional investigations or treatments for unexpected issues that arise on the day of surgery. anaesthesia-led preoperative evaluation clinics have been shown to significantly reduce rates of last minute cancellations. 13 these are clinics that in some way assessdin person or by phonedalmost all elective surgical cases. such clinics have a broader role than specialised preoperative cardiopulmonary exercise testing clinics. comprehensive preoperative assessment, with involvement of other specialties and assessment of functional capacity, is critical to minimising cancellations on the day of surgery. if such clinics help reduce costly lastminute cancellations, hospitals may be incentivised to fund them. this is recognised as a goal of perioperative medicine delivery and the role of interventions to improve physical, nutritional, and psychological condition before surgery has been identified as an area in which more research is required. 14 in conclusion, this study highlights the scale of the problem of surgical cancellation along with its implications for patients and optimal use of resources. it also offers us insights into associations with clinical and healthcare delivery factors. the problem of cancelled surgery is complex, and the results of this study underscore the need for clinicians and healthcare providers to work together to develop systems that ensure that there is adequate bed and operating theatre capacity for elective surgery. the 'systems' here must extend beyond the acute care hospital to encompass long-term care beds and home nursing care provision. they must also encompass optimal patient preparation and accurate assessment of risk so that costly and finite resources, such as critical care and operating theatre capacity, can be utilised effectively. sugammadex, a modified cyclodextrin molecule, encapsulates rocuronium and other aminosteroid neuromuscular blocking agents (nmbas) to provide rapid and reliable reversal of neuromuscular block. in comparison to the standard reversal agent, neostigmine, the quality and speed of reversal are impressive, reversing moderate block around 17 times faster 1 and with fewer episodes of partial reversal in recovery. 2, 3 in addition, it can provide reversal from deep blockade, 3,4 a feature not possible with neostigmine. arguably, sugammadex is the ideal reversal agent whenever an aminosteroid nmba is used, as it can potentially speed recovery and improve turnaround time in surgical lists. 5 sugammadex has also been proposed as an agent to treat rocuronium-induced anaphylaxis, with isolated case reports in the literature suggesting an almost immediate reversal of the anaphylaxis cascade when sugammadex was administered. 6, 7 the main barrier to the use of sugammadex, in the majority of countries, is cost. it is up to 20 times more expensive than neostigmine at a dose of 2e4 mg kg à1 (for reversal of moderate block), and clearly even more expensive with the 16 mg kg à1 dose (for reversal of profound block). in japan, however, the national healthcare insurance system subsidises patient care, and the cost of drugs seems only a minor consideration for anaesthetists. here, sugammadex is used routinely, and an estimated 10% of the population received sugammadex during an 8 yr period from 2010 to 2018. 8 another concern around the use of sugammadex is the risk of hypersensitivity. indeed, sugammadex was only approved for use in the united states in 2015 (compared with 2008 in europe and australia) because of concerns about hypersensitivity. it is ironic that, as sugammadex was approved by the us food and drug administration (fda), the body of evidence of hypersensitivity to the drug in clinical settings seems to be strengthening: in japan, sugammadex is now the leading cause of perioperative anaphylaxis. 8 two papers in this issue of the british journal of anaesthesia report investigations of sugammadex hypersensitivity. 9,10 these clinical trials undertaken before fda approval and funded by the manufacturer of sugammadex were presumably done with a view to allaying concerns about the incidence of hypersensitivity, whereas they may have had the opposite effect. both trials involved giving sugammadex at doses of either 4 or 16 mg kg à1 , or placebo, repeated twice at weekly intervals, to healthy non-anaesthetised subjects. the aim was to establish the rate of hypersensitivity and to determine whether hypersensitivity became more likely after repeated administrations. they also sought to determine the underlying mechanism of hypersensitivity, and specifically whether this was an immunoglobulin (ig)e-or igg-mediated process. after completion of data collection in the first study, 9 over 62,000 fewer operations performed this winter, following necessary cancellations the king's fund. an nhs winter that never seems to end cancelled operations in the uk e a 7 day cohort study of planned adult inpatient surgery in 245 nhs hospitals the globe and mail. hospital overcrowding has become the norm in ontario, figures show the ontario wait time strategy, no evidence of an adverse impact on other surgeries a national review of adult elective orthopaedic services in england: getting it right first time. london: british orthopaedic association effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome the authors declare that they have no conflicts of interest. key: cord-253318-nlk8pjv2 authors: roberti, fabio; arsenault, katie title: minimally invasive lumbar decompression and removal of symptomatic heterotopic bone formation after spinal fusion with rhbmp-2 date: 2020-05-06 journal: world neurosurg doi: 10.1016/j.wneu.2020.04.235 sha: doc_id: 253318 cord_uid: nlk8pjv2 abstract we present a case of symptomatic heterotopic bone formation following revision of posterolateral lumbar fusion/instrumentation and “off-label” use of recombinant human bone morphogenetic protein-2 (rhbmp-2), treated successfully with the use of a minimally invasive tubular approach. the use of recombinant human bone morphogenetic protein-2 (rhbmp-2) as an osteoinductive factor in spine surgery has been approved by the us food and drug administration for singlelevel anterior lumbar fusion with tapered cages in skeletally mature patients (1) . due to its proven effectiveness in increasing postoperative fusion rates (2, 3) , the "off-label" use of these proteins has gained wide spread popularity among spine surgeons dealing with various spinal conditions (4, 5, 6, 7, 8, 9) and a published review of administrative data found that 85% of rhbmp-2 utilized in spinal surgery fell under the "off-label" definition (10) . notwithstanding the proven benefits, several studies regarding complications associated with the use of rhbmp-2 have been so far published. increased rates of infection, postoperative seromas and hematomas, delayed wound healing, dysphagia and neck swelling, retrograde ejaculation, symptomatic radiculitis, vertebral osteolysis, cage subsidence as well as heterotopic bone formation have all been reported following the use of rhbmp-2 in spine surgery (11, 12, 13, 14, 15, 16, 17, 18) . we report a case of symptomatic heterotopic bone formation following lumbar spinal revision surgery and posterolateral fusion with rhbmp-2, successfully treated using a minimally invasive tubular approach and provide documentation of the technical aspect of the procedure. a 65-year-old obese female underwent an open lumbar laminectomy with instrumented allograft postero-lateral fusion using iliac bone graft, local bone, calcium phosphate augmentation and pedicle screws instrumentation at l4-l5 at an outside institution, with clinical improvement. three years after the initial surgery, she experienced recurrent low back pain and was diagnosed with pseudo-arthrosis and hardware failure (fractured left l5 pedicle screw) that prompted a revision surgery with fractured hardware removal and extension of the instrumented fusion to s1, bilaterally. at the time of the revision surgery rhbmp-2 was utilized "off-label" to promote a successful postoperative postero-lateral arthrodesis. both initial and revision procedures were performed at the same hospital and by the same surgeon. three years after the revision surgery she started experiencing recurrent episodes of severe l5 and s1 left radiculopathy and medical management and lumbar steroids injections failed to reduce the severity of the symptoms. this is when we first saw the patient. a clinical examination confirmed the presence of radicular signs and symptoms with no neurological deficits or significant back pain. lumbar x-rays and ct scan were performed and revealed the presence of new broken hardware on the left side (fractured s1 pedicle screws) as well as significant heterotopic bone formation mainly involving the left l5-s1 lateral recess, leading to severe stenosis and nerve root compression (fig 1-2-3) . despite the findings of broken hardware, there were no signs of mechanical instability at a flexion-extension x-ray and the ct documented the presence of a solid joint arthrodesis, especially on the right (fig 4-5-6a-6b ). an mri was also performed which confirmed the diagnosis of severe lateral recess stenosis at l5-s1 due to heterotopic bone formation (fig 7) . clinically she had only minimal axial low back pain, no radiological signs of mechanical instability, with most of the symptoms being radicular in nature. she was severely obese with a bmi of 40.10 with history of hyperlipedimia, htn and cad. after discussing the surgical options with the patient we elected to explore the fusion, remove the broken instrumentation and decompress the involved nerve roots by removing the heterotopic bone formation using a minimally invasive tubular approach. open surgery with complete revision of instrumentation and redo arthrodesis was also discussed. in light of the absence of significant low back pain, the predominance of radicular symptoms, the absence of mechanical instability and the presence of bilateral facet arthrodesis, as well as the history of previous lumbar surgeries and associated medical comorbidities, we felt a minimally invasive approach was an appropriate option to be selected in this case and the patients concurred with this informed decision. the patient was positioned on a standard prone position on a wilson frame. metrx tubular system and antero-posterior (ap) and lateral intraoperative fluoroscopy guidance were utilized. a 3 cm incision was made over the ap x-ray projection of the l5-s1 broken screws on the left side and the fascia was open approx. 3-4 cm lateral to the midline, as guided by the x-rays. an xtube expandable tubular retractor was utilized to expose the l5-s1 hardware. the rod was exposed and any surrounding newly formed bone was carefully drilled away. the rod was then cut using a carbide drill bit and removed. the lower broken screw (s1) was then utilized as landmark to start our microscopic dissection (fig 8) . the borders of the previous laminectomy were the identified, epidural scarring removed and the dura and nerve roots displaced by the presence of the heterotopic bone formation identified. the traversing nerve root was decompressed below the area involved by the ectopic bone formation and the exiting nerve root was isolated and decompressed above it (fig 9-10-11) once the nerve roots and the lateral dura were identified the heterotopic bone was removed by gentle drilling and use of kerrison rongeurs until complete decompression was achieved ( fig 12) . after hemostasis was achieved and any dural leak ruled out, the remaining loosened hardware (s1 screw head that was kept in place as landmark) was removed. the xtube was removed and the fascia and would closed using standard techniques. the procedure lasted approx. 90 minutes and blood loss was minimal (<50 cc). in light of the absence of significant low back or radiological signs of mechanical instability, the documented solid arthrodesis on the contralateral side, as well as the presence of retained fractured screws within the l5 and s1 pedicles, we elected not to place supplemental instrumentation. a postoperative ct confirmed good neural decompression (fig 13) and the patient was discharged home on postoperative day 1. the radicular symptoms resolved and no recurrent symptoms or complications were recorded at a 1-3 and 6 month follow up. at the most recent clinical follow up (7 years after the minimally invasive surgery) the patient still remains pain free without any significant recurrent radicular symptoms or axial back pain and has been able to resume recreational sport activities. in light of the ongoing covid 19 pandemic and following institutional protocols and policies while dealing with this event, long term follow up radiological examinations were not obtained. heterotopic (or ectopic) bone formation is a known complication associated with the of rhbmp-2 during spinal fusion surgery (19, 20, 21) and due to its possible compressive nature this condition may lead to recurrent or worsening symptoms in the postoperative period. depending on size, symptoms and location of the ectopic bone formation surgical treatment may be needed, posing sometimes a technical challenge especially in patients who already underwent revision surgery of that carry multiple medical comorbidities. in such patients the use of minimally invasive decompressive techniques may be beneficial in tailoring the treatment to the symptomatic condition while minimizing possible adverse effects sometimes associated with open revision surgery. minimally invasive spine surgery (miss) techniques are nowadays utilized by many surgeons as an alternative or adjunct to open spine surgery in the treatment of various degenerative pathologies involving the cervical, thoracic and lumbosacral spine (22, 23, 24, 25) as well as trauma related and tumoral conditions (26, 27) . centers and surgeons familiar with these novel techniques have also expanded the use and indications of this lesser invasive techniques to deformity correction surgery and revision surgery as well (28, 29, 30) . in our practice we too have expanded the use of miss techniques as we live in a community were many patients are seen in consultation in their 7 th and 8 th decade of life. spine surgery in the elderly may be at time challenging as multiple comorbidities, osteopenia/osteoporosis, as well as history of multiple previous spine surgeries need to be carefully considered while selecting the most effective and safe surgical (or non-surgical) approach. revision spine surgery may also prove challenging as several factors may contribute to render some of these procedures more complicated than others. lack or paucity of information related to previous surgeries, diagnostic limitation of radiological studies available (e.g. patients with spinal cord stimulators or non-mri compatible implanted devices) and post-surgical anatomical changes and fibrosis do in fact play an important role during the preoperative and operative decision making process in such patients. anatomical landmarks may difficult to recognize during revision surgery as post-operative changes, associated deformity and epidural fibrosis may all render the surgeon's evaluation of the operative field at times challenging. this is especially true in miss where the anatomical exposure is usually limited to the surgical area of interest and in such cases an optimal use of preoperative and intraoperative imaging plays a very important role in facilitating the surgeon during the various steps of the selected approach. miss offer many benefits in this cohort of patients (elderly, revision surgery, multiple comorbidities) as limited tissue dissection, minimal blood loss, shorter surgery time, faster and easier mobilization, lesser and shorter need for postoperative narcotics are all in favor of the use of such techniques when deemed feasible and appropriate. in the presented case it is unclear when the hardware failed/re-fractured as the patient did not complain of significant low back pain at the time of our initial evaluation. it is indeed possible that the hardware failure happened before the arthrodesis was complete and solid and before the ectopic bone formation became symptomatic. also we were unable to directly confirm what dose of rhbmp-2 was utilized at the time of the revision surgery, therefore cannot comment on this specific issue as cofactor for the onset of the heterotopic bone formation. review of previous operative reports revealed that the initial postero-lateral fusion was performed with the use of iliac crest and local bone autograft as well as calcium phosphate allograft augmentation. in light of the recurrence of radicular symptoms and evidence of fractured hardware at l5, the patient underwent a revision surgery with "exploration of fusion, removal of l5 instrumentation, bilateral transverse process fusion with local bone graft and "off label" use of bmp", as well as left tlif at l5-s1 with peek allograft and l4-s1 bilateral pedicle screw instrumentation.". according to the operative report there was no presence of heterotopic bone formation at l5-s1 at that time of the revision surgery and the bmp sponges were "morcellized and placed in smaller pieces, combined with the local bone graft, into both posterolateral gutters". the amount of bmp utilized was not recorded. the colleague also commented that the "fixation of the l5 screw on the left side was extremely good and had sustained a fatigue fracture at its base, indicating a solid anchorage in the l5 pedicle" therefore such fractured screw was not retrieved at that time. in light of the documented absence of heterotopic bone formation at the time of the revision surgery, the addition of calcium phosphonate to promote the arthrodesis during the initial lumbar fusion does not appear to have played a role in the genesis of the ectopic bone formation in this case, and it appears that this condition is to be associated to the use of rhbmp-2, as previously described (11) . in the presented case an open procedure of revision/decompression/lysis of adhesions could have certainly been utilized but in light of the patient's expectations, the absence of significant low back pain and radiological instability, as well as the presence of numerous medical comorbidities, we chose a minimally invasive approach, which proved to be successful in providing a long lasting relief of the preoperative symptoms. although the treatment of heterotopic bone formation associate with the use of rhbmp-2 may be challenging, the use of a minimally invasive tubular decompression may facilitate a tailored and safe approach to this condition and should be kept in the armamentarium of spine surgeons, as one of the many valid techniques to be considered and discussed with these patients. in the presented case we found the use of minimally invasive techniques to be of benefit for the removal of heterotopic bone formation following lumbar spine fusion with rhbmp-2. this approach remains consistent with the concept that minimally invasive surgery should not equal lesser effective surgery and that final recommendation on the technique to be adopted should be tailored on a case-by-case scenario, keeping in mind patient's expectations, safety issues and goals to be achieved. anterior lumbar interbody fusion using rhbmp-2 with tapered interbody cages is infuse bone graft superior to autograft bone? an integrated analysis of clinical trials using the lt-cage lumbar tapered fusion device guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. part 16: bone graft extenders and substitutes as an adjunct for lumbar fusion fusion rates of lateral lumbar interbody fusion using recombinant human bone morphogenetic protein radiographic and ct evaluation of recombinant human bone morphogenetic protein-2-assisted cervical spinal interbody fusion.clin spine surg minimally invasive reduction of thoracolumbar burst fracture using monoaxial percutaneous pedicle screws: surgical technique and report of radiological outcome the misdef2 algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery minimally invasive removal or revision of lumbar spinal fixation use of recombinant human bone morphogenetic protein-2 to achieve posterolateral lumbar spine fusion in humans: a prospective, randomized clinical pilot trial: 2002 volvo award in clinical studies off-label use of bone morphogenetic proteins in the united states using administrative data complications associated with the use of the recombinant human bone morphogenetic proteins for posterior interbody fusions of the lumbar spine fineberg sj et al clinical sequelae after rhbmp-2 use in a minimally invasive transforaminal lumbar interbody fusion complications with the use of bone morphogenetic protein 2 (bmp-2) in spine surgery symptomatic ectopic bone formation after off-label use of recombinant human bone morphogenetic protein-2 in transforaminal lumbar interbody fusion intraoperative computed tomography navigational assistance for transforaminal endoscopic decompression of heterotopic foraminal bone formation after oblique lumbar interbody fusion bone morphogenetic protein usage in anterior lumbar interbody fusion: what else can go wrong? world neurosurg complications associated with bone morphogenetic protein in the lumbar spine promoting fusion in minimally invasive lumbar interbody stabilization with low-dose bone morphogenic protein-2--but what is the cost? heterotopic ossification associated with recombinant human bone morphogenetic protein-2 (infuse) in posterolateral lumbar spine fusion: a case report.spine (phila pa 1976) ectopic bone formation in titanium mesh loaded with bone morphogenetic protein and coated with calcium phosphate pseudo-pedicle heterotopic ossification from use of recombinant human bone morphogenetic protein 2 (rhbmp-2) in transforaminal lumbar interbody fusion cages clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation. neurosurg focus minimally invasive transforaminal lumbar interbody fusion: one surgeon's learning curve removal of ossified ligamentum flavum via a minimally invasive surgical approach the use of a "double-triple barrel" technique during minimally invasive multilevel tubular laminectomy. a technical note comparison of transforaminal lumbar interbody fusion outcomes in patients receiving rhbmp-2 versus autograft minimally invasive resection of spinal hemangioblastoma: feasibility and clinical results in a series of 18 patients correction of marked sagittal deformity with circumferential minimally invasive surgery using oblique lateral interbody fusion in adult spinal deformity bone morphogenetic protein in adult spinal deformity surgery: a meta-analysis bone morphogenetic proteins in anterior cervical fusion: a systematic review and meta-analysis. world neurosurg rhbmp-2 (recombinant human bone morphogenetic protein-2) fabio roberti: conceptualization, methodology, writing-original draft preparation, validation, writing-reviewing and editing. key: cord-262556-gpnp06je authors: behrens, estuardo; poggi, luis; aparicio, sergio; martínez duartez, pedro; rodríguez, nelson; zundel, natan; ramos cardoso, almino; camacho, diego; lópez-corvalá, juan antonio; vilas-bôas, marcos leão; laynez, jorge title: covid-19: ifso lac recommendations for the resumption of elective bariatric surgery date: 2020-08-22 journal: obes surg doi: 10.1007/s11695-020-04910-9 sha: doc_id: 262556 cord_uid: gpnp06je background: covid-19 pandemic varies greatly and has different dynamics in every country, city, and hospital in latin america. obesity increases the risk of sars-cov-2 infection, and it is one of the independent risk factors for the most severe cases of covid-19. currently, the most effective treatment against obesity available is bariatric and metabolic surgery (bms), which further resolves or improves other independent risk factors like diabetes and hypertension. objective: provide recommendations for the resumption of elective bms during covid-19 pandemic. method: this document was created by the ifso-lac executive board and a task force. based on data collected from a survey distributed to all ifso-lac members that obtained 540 responses, current evidence available, and consensus reached by other scientific societies. results: the resumption of elective bms must be a priority maybe similar to oncological surgery, when hospitals reach phase i or ii, treating obesity patients in a non-covid area, avoiding inadvertent intrahospital contagion from healthcare provider, patients, and relatives. same bms indication and types of procedures as before the pandemic. discard the presence of sars-cov-2 within 72 h prior to surgery. continues laparoscopic approach. the entire team use n95 mask. minimum hospital stays. implement remote visits for the follow-up. conclusion: resumption of elective bms is crucial because it is not only a weight loss operation but also resolves or improves comorbidities and appears to be an immune restorative procedure of obese patients in the medium term, offering them the same probability of contracting covid-19 as the regular population. on december 2019, wuhan, china, reported an outbreak of the coronavirus sars-cov-2 (covid19) , an rna virus that affects the respiratory system and has a high fatality rate especially in adults over the age of 60 and patients suffering obesity and its comorbidities [1] [2] [3] . health systems throughout the world have been stunned by the most serious pandemic so far in the twenty-first century. italy [4] and spain [5] have entered a state of disarray and their hospitals have collapsed, despite their infrastructure typical of developed countries. the virus is known to have a diameter of 0.06-0.14 μm and is transmitted by [6] [7] [8] : 1 direct contact: respiratory droplets larger than 54 μm propelled into the air up to 2 m from hands or fomites with secretions, and come into contact with mucous membranes of the mouth, nose, or eyes. 2 aerial or aerosol transmission: not detected in the sars-cov-2 outbreak in china, but it could occur during invasive medical procedures in the respiratory tract and upper digestive tract. there is no evidence of fecal transmission, but the virus has been identified in stools and the peritoneal fluid [9] . in the transmission dynamics of asymptomatic cases, it is estimated to occur in 48 to 62% of the cases, 1 to 3 days before the onset of symptoms, suggesting a high transmission rate even in the asymptomatic period before symptoms appear. 3 hand contact with the mouth, eyes or nose: the virus can potentially remain viable on surfaces like plastic or steel for several days. sars-cov-2 is highly sensitive to common antiseptics, ultraviolet radiation, and sunlight. for the time being, the use of face masks, face shields, social distancing, and frequent handwashing are the most effective practices to prevent virus spread. latin america, as the rest of the world, has been affected by the pandemic. analyzing the mortality rate per million inhabitants in latin america (la), compared to the usa and europe ( fig. 1) , we find the former has a lower rate than the latter. this is probably because la is still at a very early phase of the pandemic or because isolation and contention measures were promptly implemented, avoiding new or severe cases to supersede the capacity of the health systems, which would have prevented infected patients from receiving adequate treatment. an important element to take into consideration is the specific phase of the epidemic in each region or city, as well as hospital units. around the globe, more than 2.8 million people die each year due to complications derived from obesity and metabolic syndrome [10] [11] [12] [13] [14] [15] . recent studies have shown that obesity (bmi higher than 30) is one of the independent risk factors that affects the development of the severe forms of the sars-cov-2 infection, in the same way as cardiovascular disease, type 2 diabetes, hypertension, chronic lung disease, cancer, and chronic kidney disease. [16] [17] [18] [19] [20] [21] [22] [23] therefore, patients with obesity must avoid getting infected with covid-19 at all costs, adopting the strictest possible preventive measures and resolving their underlying conditions. currently, the most effective treatment against obesity available is bariatric and metabolic surgery, which further resolves or improves the related comorbidities that are the same risk factors in developing a severe case of sars-cov-2. [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] consequently, we must balance the risk of the disease against the advantages of resuming bariatric and metabolic surgeries as soon as possible. although this type of interventions can by no means be categorized as emergency surgeries, their postponement causes deterioration of the patient, advances obesity disease and the comorbid conditions that endanger patients' life, and increases the direct and indirect costs of patients' medical treatment [34] [35] [36] [37] [38] [39] . deficiencies in the immune system of morbidly obese individuals is a well-known condition, include elevated levels of eosinophils, monocyte cd14, and monocyte cd14+/cd16+ subsets, with depression of monocyte and neutrophil cd62l. these abnormal levels reverse rapidly with bariatric surgery because it is not only a weight loss operation but also appears to be an immune restorative procedure. [22, 40, 41] covid-19 pandemic varies greatly and has different dynamics in every country, city, and hospital in latin america, and special conditions that distinguish it from the rest of the world. therefore, it demands recommendations, guidelines, and protocols for the resumption of elective bariatric surgery specific for the region. these were jointly formulated by the executive board of ifso lac and a task force especially commissioned to this end. the resulting document is based on data collected from a survey distributed to all members of ifso lac that obtained 540 responses, current evidence readily available, and consensus reached by other scientific societies around the globe [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] . the resumption of elective bariatric and metabolic activities must be a priority maybe similar to oncological surgery. bariatric surgeries should be resumed when hospitals reach phase i or ii as described in the spanish association of surgeons classification (appendix 1), with preferably less than 15% of its hospitalization deriving from covid-19positive patients. in other words, when the capacity of the health system admits pathologies other than covid-19, but also ensures sufficient resources in the event of a second pandemic wave. consider the local prevalence of covid-19. it is recommended that elective bariatric surgery be performed in medical facilities with the necessary infrastructure to treat obesity patients in a non-covid area. the hospital must provide at least three areas, ideally with independent circulation amongst them: -non-covid area for patients not suspected of having the infection, without symptoms, and with no history of having been in close contact with a person at risk. the hospital must also offer exclusive non-covid operating rooms as far as possible from operating rooms for positive patients (ideally with negative pressure). avoid inadvertent intrahospital contagion (closing the back door): according to the "closing the back door" recommendations from the society of american gastrointestinal and endoscopic surgeons (sages), the european association for endoscopic surgery (eaes), and the spanish association of surgery (aec, for its acronym in spanish), the following minimum measures must be taken in the care of patients with obesity and other associated conditions for the prevention of unsuspected transmissions from asymptomatic patients in a non-covid area: & healthcare provider -negative to the symptoms and epidemiological questionnaire in table 1 . -daily response to the sanitary questionnaire (clinical and epidemiological) regarding the appearance of new atypical symptoms in the preoperative, hospitalization, and postoperative phases (table 1) . patient selection in the context of this pandemic will include all of those for whom bariatric or metabolic surgery has been indicated based on current scientific publications applicable to the specific region, and observing the following exclusion criteria: patient decompensation of associated conditions, high-risk patients over the age of 60, those who need immunosuppressant drugs or suffer chronic lung diseases (chronic obstructive pulmonary disease (copd) or asthma), and bariatric revisional surgery for insufficient weight loss. the patients should be encouraged to try to lose weight before the surgery. preparation protocols for patients with obesity and metabolic syndrome should not be modified from the ones indicated before the pandemic, but should be adjusted to include: -clinical survey: conducted by the anesthesiologist or internist 48 to 72 h previous to the surgery and should inquire about the symptoms that help determine the presence of the disease (table 1 ). -epidemiological survey: conducted in parallel with the survey mentioned above, to discard close contact with confirmed covid-19-positive patients in the past 21 days, recent travel abroad to countries with a high viral load in the past 15 days, or hospitalization in other medical institutions (table 1 ). -laboratory: include microbiology to discard the presence of sars-cov-2 (rt-pcr and igm/igg serological tests depending on the availability and politics of each country), whose results must be no older than 72 h. -imaging: chest radiography performed during the same preanesthetic or clinic consultation and, in cases of uncertainty, thoracic computed tomography (ct), or ultrasound in three quadrants. once this last study has been performed, the patient must return home and observe self-isolation up until the day programmed for surgery. on this day, the symptoms and contact questionnaire (table 1 ) must be responded again. any clinical, epidemiological, laboratory, or imaging suspicion of sars-cov-2 infection is criteria to postpone surgery until it is discarded, or the patient has met the criteria of healing, at which time the same assessment cycle must be completed. an informed consent must be duly subscribed, specifically indicating that, in the context of the pandemic, the risks associated with the procedure might be higher. likewise, there is a risk-small but present, nonetheless-to be infected with the sars-cov-2 virus during in-patient care. -non-covid operating rooms must be available, with detailed circulation routes for persons not suspected of having the infection. -the number of professionals involved in the surgery should be kept to a minimum, and the team should be led by the most experienced surgeon in order to minimize risks, complications, and exposure time in the operating room. -the number of staff members entering or leaving the operating room must be reduced as much as possible. assuming that the patient is by no means suspicious of having a sars-cov-2 infection, all personnel entering the sterile field of the operating room should observe the same protection measures as in normal conditions. however, the use of disposable equipment and clothing, face masks (even double piece), and safety glasses is recommended. the use of n95-rated masks is recommended in procedures that generate aerosols (table 2) and when the medical personnel is over the age of 60 or has any of the high-risk factors for covid-19. if your institution has the necessary supplies, we suggest that the entire team use n95, which can even be reused. the laparoscopic approach continues to be the best recommendation, under conditions that prevent pneumoperitoneum and smoke leakage. port incisions for laparoscopy must be as small as possible and allow stability but prevent leaks. if the insufflation port must be relocated, it should first be closed before removing the tube and the new port should not be opened until the insufflator tube is connected. the insufflator should be turned on before the new port valve is opened to prevent gas and smoke from back-flowing into the insufflator. a filter should be used for safe gas insufflation, and intra-abdominal pressure must remain low (10-15 mmhg). an ultrafiltration system or water trap should be used for gas evacuation and, if the insufflator has a smoke evacuation option, it should be used (appendix figs. 2 and 3) . complete evacuation of the pneumoperitoneum must be performed prior to removal of surgical specimens or completing fascial closures. recuperation will take place in the non-covid area. postoperative hospital stays should be kept to a minimum and, during hospitalization, the use of postoperative accelerated recovery protocols is recommended. patients that require intensive monitoring should be admitted to an icu prepared to this effect for non-covid patients (table 2) conclusions although obesity and its comorbidities have long been considered the most severe pandemic in mankind's history, only recently it has been listed as a high-risk condition associated with high mortality rates in the context of the covid-19 pandemic. it might be possible that timely resumption of elective surgery for the treatment of obesity could enhance the immune systems of these patients in the medium term, offering them the same probability of contracting the disease as the regular population. in view of the constant changes in the scientific evidence generated by this disease, these recommendations constitute a suggestion and by no means should replace the medical criteria of the attending physician. moreover, they are susceptible to revisions at any given time and vary according to the realities of each region. conflict of interest the authors declare that they have no conflict of interest. ethical approval statement this article does not contain any studies with human participants or animals performed by any of the authors. informed consent does not apply. dynamic scale of the different evolutionary phases of the hospitals during the pandemic and how it affects the surgical activity. clinical characteristics of coronavirus disease 2019 in china clinical features of patients infected with 2019 novel coronavirus in wuhan clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study coronavirus disease (covid-19) situation report in italy disponible en: https:// covid19.isciii.es. royal decree 463/2020, of march 14, which decrees the state of alarm for the management of health crisis caused by covid-19 clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72,314 cases from the chinese center for disease control and prevention clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients from wuhan, china sars cov2 is present in peritoneal fluid in covid 19 patients body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents predictors of health-related quality of life in 500 severely obese patients association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis using the edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity prospective studies collaboration. body-mass index and cause-specific mortality in 900.000 adults: collaborative analyses of 57 prospective studies closed system water trap for the evacuation of smoke and aerosols obes surg high prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (sars-cov-2) requiring invasive mechanical ventilation obesity in patients younger than 60 years is a risk factor for covid-19 hospital admission [published online ahead of print presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city obesity could shift severe covid-19 disease to younger ages obesity and covid-19 severity in a designated hospital in shenzhen factors associated with hospitalization and critical illness among 4,103 patients with covid-19 disease in new york city influenza and obesity: its odd relationship and the lessons for covid-19 pandemic groups at higher risk for severe illness surgical treatment of obesity and diabetes asmbs position statement on long-term survival benefit after metabolic and bariatric surgery metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations indications for surgery for obesity and weight-related diseases: position statements from the international federation for the surgery of obesity and metabolic disorders (ifso) consenso de cirugía metabólica en argentina (consensus of metabolic surgery in argentina) long-term effects of bariatric surgery on type ii diabetes, hypertension and hyperlipidemia: a meta-analysis and meta-regression study with 5-year follow-up the effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis long-term follow-up after bariatric surgery: a systematic review bariatric surgery in class i obesity: a position statement from the international federation for the surgery of obesity and metabolic disorders (ifso) bariatric surgery: the indications in metabolic disease obesity surgery score (oss) for prioritization in the bariatric surgery waiting list: a need of public health systems and a literature review bariatric surgery waiting lists in spain what is the impact on the healthcare system if access to bariatric surgery is delayed? surg obes relat dis reduced survival in bariatric surgery candidates delayed or denied by lack of insurance approval cause of death in patients awaiting bariatric surgery natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric surgery effect of surgicallyinduced weight loss on leukocyte indicators of chronic inflammation in morbid obesity effect of surgery-induced weight loss on immune function medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid-19 pandemic clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection eclinicalmedicine. 2020:100331 strategy for the practice of digestive and oncological surgery during the covid-19 epidemic precautions for operating room team members during the covid-19 pandemic [published online ahead of print joint statement roadmap for resuming elective surgery after covid-19 pandemic 41720update por american college of surgeons, american society of anesthesiologists, association of perioperative registered nurses recomendaciones del colegio americano de cirugía (recommendations of the american college of surgeons -acs recomendaciones de la sociedad americana de cirujanos gastrointestinales y endoscopistas (recommendations of the society of american gastrointestinal and endoscopic surgeons) surgical services protocol from hospital universitario virgen del rocio de sevilla (spain) and surgical services from hospital de pavia (italy) surgical care protocol during the covid-19 pandemic bariatric and metabolic surgery during and after the covid-19 pandemic: dss recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments we thank gustavo romero-velez m.d. for his help and support for this manuscript submission. appendix 3 key: cord-257824-qz6yxuph authors: fuertes, víctor; monclús, enrique; agulló, alberto title: current impact of covid-19 pandemic on spanish plastic surgery departments: a multi-center report date: 2020-05-19 journal: eur j plast surg doi: 10.1007/s00238-020-01686-0 sha: doc_id: 257824 cord_uid: qz6yxuph background: after its initial description in china, covid-19 is hitting nations across the world, with spain as the third country in number of deaths, after the usa and italy. similarly to what is happening in other countries, an important reduction in available operating rooms is affecting our departments. in this study, we aim to know how covid-19 pandemic is affecting the delivery of plastic surgery services in spain. methods: a questionnaire addressing some of our concerns about how the coronavirus crisis might severelyimpact our specialty has been sent to the heads of the divisions of plastic surgery of several hospitals across spain. results: a total of 12 plastic surgery departments from different hospitals across the country agreed to participate in the survey. most plastic surgery teams will need to maintain 50–80% of their staff in order to be able to offer emergency and undelayable oncological procedures. the total amount of procedures currently being performed ranged from 0 to 44% of the figures before the coronavirus outbreak, except for one department, with elective surgery mainly affected. microsurgical cases have been massively discontinued during this crisis. conclusions: plastic surgery delivery in the spanish health system is being severely impacted as a collateral damage from this pandemic. most of the elective surgery is currently stopped. our departments seem to be vulnerable regarding their capacity to keep offering emergency care. level of evidence: not ratable (multi-center survey) after its initial description and spreading in the province of wuhan, china, covid-19 is hitting nations across the world, with the center of the crisis now located in europe and the usa. the situation has already been declared a public health emergency of international concern by the world health organization (who). to date, spain is the third country in the world, after the usa and italy, with regard to the number of deaths caused by covid-19 virus (who). a cumulative figure of 208,389 positive cases and 21,717 deaths have been reported by april 22, 2020 (ministry of health, spain). our center is a third level hospital with an estimated capacity of 1400 hundred beds. our department attends to a regional population of approximately a million and a half patients and includes a burn unit and a pediatric clinic. similarly to what is happening in the north of italy [1] , and according to our hospital guidelines, we have adopted several new measures. most of our outpatient clinics have been postponed. all elective, non-urgent, and non-cancer procedures have been stopped in an effort to anticipate the need of relocating nurses and anesthesiologists to tackle covid-19 situations. consequently, we have reduced the number of attending surgeons and residents working on a daily basis to the minimum required. the goal is to keep the department functioning, while avoiding infections between the team members. emergency surgeries during the on-call shifts will continue. we should not underestimate how these necessary measures, and the associated reduction in effective or time, will affect not only plastic and reconstructive surgery (prs) departments but other medical and surgical specialties as well. in this study, we aim to discover how covid-19 pandemic is affecting the delivery of prs services in spain. a questionnaire addressing some of our main concerns as to how the coronavirus crisis might severely impact the delivery of prs has been sent to the heads of the divisions of prs in several hospitals across spain. only departments in third-level hospitals with over 650 beds were considered. in an effort to achieve a realistic picture as to how this pandemic is affecting departments in the entire country, we have contacted hospitals from all the regions, including those less affected by the outbreak. the survey was sent to the selected departments on march 30, 2020. the questions (q) included in this multi-center survey are presented in table 1 . the hospital name from which each set of data is coming from has been kept confidential. when responding to questions regarding data submission before the crisis started, an average figure of january and february inputs is recommended. for answers about the present data, the first 2 weeks of april (during the peak of the pandemic) will be considered. the questionnaire was sent to 16 prs departments from different hospitals across the country. a total of 12 departments (75%) agreed to participate in the survey and answered by email. those departments include hospitals from a wide range of locations, where the outbreak has been evolving differently. thus, we believe a representative sample has been obtained. all the detailed information with the complete answers from each department is included in table 2 . each question row is identified as q and a number/letter representing their order in the questionnaire. highlights are summarized in the following paragraphs. eight people out of 179 (4.5%) of the staff members from the units consulted in our study have been tested positive for coronavirus. when asking about the percentage of the team members that a department would need to be working in order to maintain their on-call system running as usual, the most common answers were between 50 and 80% of the entire team. two of the institutions consulted, stated that they might be able to continue their on-call activity while maintaining active only 20% and 30% of their respective teams. in two of the centers we have contacted, the staff has been properly trained on the medical management of covid-19 patients. one of those departments specified that the training consisted of a 3-h duration course. according to the hospital guidelines, members of that group have joined internal medicine teams to assist them on covid-19 monographic wards. in table 1 questionnaire. ppe, personal protective equipment q1 a b please specify your team members, including consultants and residents. how many colleagues have been tested positive for covid-19/are isolated due to have been in contact with a positive patient amongst the surgical team, including residents? q2 what is the percentage of your team members that you estimate you will need to keep the emergency calls and the most basic surgical procedures (oncological cases excluding those that you can delay at least 2 weeks) running? *please consider as the limit for maintaining your current emergency call flow either the need to transform in-hospital duties to on-call duties or the increase in the on-call days per month in double or more per consultant. q3 a b did any of the team members receive any specific education on covid-19 patient medical management? did any of them have already been re-located and currently providing medical care to coronavirus patients? please specify the number of residents and consultants and if these positions have been randomly assigned or are voluntary. what was the total amount of surgical procedures, excluding those done under local anesthetic, performed by week in your department? how many cases are you currently operating? please differentiate elective and urgent surgeries as well as inpatient and day-care cases q5 similarly, reduction in the number of oncological surgical procedures q6 a b are you actually seeing patients in your clinics other than immediate surgical follow-ups and oncological new cases? what was the total amount of patients seen in your clinics per week before the onset of coronavirus and today? q7 are your elective micro cases (such as dieps) still taking place? in case that your department includes pediatric population, are you still operating elective cases such as cleft lip and palate, congenital hand anomalies or microtia? q8 have you implemented a specific protocol in your burn unit? (in case you have it at your facility). please explain the four main changes q9 does your team have access to ppe*-ffp3 (n95) masks/goggles/face screens-when performing surgeries close to the patient airways or other types or surgeries in positive patients? q10 did you ever experience any restrictions in the surgical ward of your hospital regarding supply of normal surgical gowns, masks and gloves? a drastic reduction in surgical capacity has occurred. nonurgent or activity has notably dropped in all but one of the hospitals answering our survey. the total amount of procedures currently being performed ranged from 0 to 44% of the figures before the coronavirus outbreak (fig. 1a, b) ; except for one hospital, that was declared to maintain the same surgical activity (100%). the decrease in the total amount of daycare procedures (as compared to in-hospital surgeries) is highly variable between the centers analyzed in this article. only two departments provided accurate data regarding the number of urgent procedures before and after the crisis. in one of them, urgent cases have been reduced by 50%. at the second one, urgent surgeries are now 15% of what they used to be before the outbreak of coronavirus. the vast majority of respondents indicated that the available operating time is now mainly occupied in treating cancer cases. consequently, they do not expect a decrease in the amount of non-delayable oncological procedures during the crisis. nonetheless, consistent data about this question has not been obtained and solid conclusions are not possible. nine departments have sent their total number of consults before and after this crisis. prs clinics have diminished their in-person activity by 85%. elective microsurgical cases have been uniformly discontinued during this crisis. one department has delayed not only microsurgical breast reconstruction but also implantbased cases. five of the prs divisions included in the study declared to have a burn unit. in four of these units, substantial changes have been implemented. some of the more prevalent measures include screening protocols for coronavirus among patients and workers, increasing hygiene measures, reducing the number of visitors per patient, directing burn patients who tested positive to other units and trying to apply day-care/ delay surgeries whenever this is possible. one unit does not have a specific protocol. all the departments have access to adequate personal protective equipment (ppe) when performing surgeries in positive patients. five out of the 12 institutions checked have experienced restrictions in accessing basic surgical gowns, masks, and gloves. another center clarified that reusable gowns are becoming scarce, and thus, fabric ones are being worn. in an effort to save as much units as possible, most of our hospitals are monitoring the number of surgical masks received per person. incidence of covid-19 among plastic surgeons is expected to be considerably lower as compared to positive cases in colleagues from other specialties acting in the first line of defense against the pandemic (emergency wards, internal medicine, or intensive care units). nevertheless, testing asymptomatic members of our teams is not common yet. prs teams in the spanish public health system tend to be small when compared to other surgical specialties. we found an average size of 10 consultants/5 residents per team in the departments participating in this study, with the biggest one counting up to 17 consultants. consequently, even short reductions in our groups could easily cause unsustainable increases in the number of shifts per consultant. this might pose a challenge against the delivery of emergency surgeries and cancer care to our community if this pandemic lasts for a prolonged period long time according to our analysis, reductions of about 20-50% in the total number of consultants per team may lead to this situation. some centers (such as the one stating that keeping only 20% of its staff would be enough) are maybe more resistant to this situation as they do not have a burn unit, nor they attend to trauma patients. most of the plastic surgeons working at the institutions included in this study have not been relocated to frontline departments directly attending to pandemic cases. on the other hand, hospitals have generally provided education on updated surgical protocols for the current scenario. overall, non-urgent surgical activity in our departments represents about one-third (29%) of the total number of cases that we used to have before the onset of coronavirus. only one of the institutions we have contacted maintains its usual activity. this is probably related to the geographical location of this center, in a region where the pandemic is considerably milder compared to other places. analyzing how the approach to day-care surgery is different amid the departments may lead to interesting conclusions. while some departments have stopped most of their day-care procedures and operate only more severe, inpatient cases; others try to do as many cases as they can in a day-care approach, minimizing admissions. these two alternative options are most likely related to the availability of beds and the severity of the outbreak in each hospital. it has been difficult to obtain data from urgent cases only. it will be interesting to know if urgent cases have actually been reduced. nhs hospitals in england have also been told to suspend all non-urgent elective surgery for at least 3 months from april 15 as a measure to deal with the covid-19 pandemic [2] . as previously stated, the reduction in surgical activity seems to have mainly impacted elective reconstructive surgery. departments are currently using all their resources to perform cancer-related surgeries that cannot be delayed. however, further analysis needs to be conducted in order to confirm that access to oncological surgeries is not being significantly affected. if the current situation keeps worsening, the delay in diagnosis and management of cancer patients could be catastrophic. our hospital guidance for the pandemic, similar to those used in other institutions, has established three possible levels of alert. they will be applied depending on the severity of this continuously evolving crisis. we are currently in the phase 2 scenario. in the last step (phase 3), ventilators might become hardly available, and life-saving surgeries are the only procedures performed [3] . some general surgery departments in china [4] adopted guidelines recommending multidisciplinary approaches and encouraging them to use non-surgical anti-tumor therapies as the first choice for the management of gastrointestinal malignancies. by doing so, even oncological surgeries were reduced to those that are unavoidable. some of these surgeries can include the absence of therapeutic alternatives to surgery for tumor control, intestinal obstructions not amenable to stenting, or gastrointestinal bleeds not controlled by embolization. a uniform and steep decrease in prs clinics have taken place in all the hospitals in this article. as a general rule, only oncological new consults (mainly melanomas and other cutaneous malignancies) and immediate follow-ups are being received in our hospitals. all the other cases are usually delayed or managed with telemedicine. microsurgery has become a secondary option. it is only performed when other surgical approaches are not feasible, such as for trauma patient's coverage and head and neck cancer reconstructions. according to the paper by andrea et al. [5] , solid organ transplants have been reduced to only the most urgent cases during the covid-19 outbreak in the epidemic area of the north of italy. similarly, elective micro cases such as immediate or delayed dieps have been temporarily suspended in spain. unfortunately, this population of patients consumes longer or times, occupies more resources at the reanimation units, and stays longer periods of time in our facilities. additionally, patients with an active or former cancer have shown a significantly higher risk of severe events if infected by covid-19. a paper by liang et al. [6] , from the hospital of guangzhou, demonstrated a rr of 3.56 (95% ci 1.65-7.69) for severe events in oncological patients with wuhan pneumonia. according to the experience of two similar teams in china [7, 8] , several institutions across the world [9] (including ours) have applied a protocol to optimize burn units. this will ultimately help to reduce the exposure of such a sensitive group of chronically ill patients and their health care providers. some of the embraced measures encompass: -interviewing all the patients about any symptoms suggesting a possible case of coronavirus and checking their temperature before nursing them either at the ward or in our clinics. similar measures have been applied in the other spanish units consulted for this article. these measures have been taken as a strategy to attempt to keep our burn units free of covid-19. by doing so, health care will remain available for burn patients during the pandemic. however, if the burden of the pandemic becomes overwhelming, burn units will always be amenable to be transformed into polytrauma/surgical/ covid-19 intensive care units [9] . access to ppe seems to be guaranteed country-wide if performing surgeries in positive patients; but generalized testing of patients before surgery and other important measures, still need to be implemented. an article by wang et al. [10] , from shanghai ninth people's hospital, highlighted the measures that allow them to perform over 4000 surgical procedures without any health care professional or patient resulting infected: -telehealth clinics -triage workflow: infra-red fever measure and thorough symptoms/travel history survey to all patients attended in the hospital; chest ct scan and pcr test for patients being admitted. suspicious patients were sent to quarantine for 2 weeks. confirmed positive cases were sent to centralized institutions for surgery -environmental control measures: maximizing hygiene measures, using rapid sequence induction for general anesthesia patients and disinfecting all the ors with uv lights for at least 30 min -staff protection measures: ppe for surgeries on negative patients included ffp2 (n95) masks, disposable waterproof protective suits, and goggles/facial screens. isolation screens were added when performing emergency cases and during long procedures our hospital has divided the facilities into two separate parts: a covid-19 area (corresponding to a general hospital) and a covid-19-free one (at the trauma center). both buildings admit surgical and non-surgical patients of all specialties, depending solely on their condition as positive/negative for coronavirus. similarly, we have divided the surgical ward of the hospital in two parts, covid-19 positive and covid-19 negative, with different patient's entry and exit circuits. some institutions have temporarily experienced a lack of basic surgical protection equipment. limitations of the present study may include its descriptive nature and the fact that participating in the questionnaire was voluntary. prs services delivered in the spanish health system are being severely impacted as a consequence of the pandemic. in an effort to continue operating new cancer cases in these under-resourced circumstances, most of elective surgery is currently ceased. an increase in the waiting list (in days per week of the crisis) is expected to happen. not only surgical cases are not being performed but also the new consults are being canceled, and will eventually compound. we anticipate the need of a follow-up report about this issue once the burden of coronavirus disease has receded. our departments seem to be very vulnerable regarding their capacity to keep offering emergency care. losing a small number of staff members will represent a big proportion of the team, potentially compromising the normal function of the units. authors' contributions all authors contributed to the study conception and design. material preparation, data collection, and analysis were performed by fuertes vand monclús e. the first draft of the manuscript was written by fuertes v and all authors commented on previous versions of the manuscript. fuertes v, monclús e, and agulló a read and approved the final manuscript. data availability the data that support the findings of this study are available from the corresponding author, upon reasonable request, but will not identify the specific departments from which they were generated. conflict of interest víctor fuertes, enrique monclús and alberto agulló declare that they have no conflict of interest. ethical approval the local ethics committee has confirmed that no ethical approval is required for studies that involve questionnarie surveys. consent to participate participants in the survey consented for publication of the results. consent for publication upon submission, all authors consent to the publication of the manuscript in the european journal of plastic surgery. covid-19 pandemic: perspectives on an unfolding crisis covid-19: all non-urgent elective surgery is suspended for at least three months in england covid-19: pandemic surgery guidance treatment strategy for gastrointestinal tumor under the outbreak of novel coronavirus pneumonia in china coronavirus disease 2019 and transplantation: a view from the inside cancer patients in sars-cov-2 infection: a nationwide analysis in china recommendations for the regulation of medical practices of burn treatment during the outbreak of the coronavirus disease management strategies for the burn ward during covid-19 pandemic burn center function during the covid-19 pandemic: an international multi-center report of strategy and experience our experiences on plastic and reconstructive surgery procedures during covid-19 pandemic from shanghai ninth people's hospital publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-265014-ic5drg5l authors: serebrakian, arman t.; ortiz, ricardo; christensen, joani m.; pickrell, brent b.; irwin, timothy j.; karinja, sarah j.; broyles, justin m.; liao, eric c.; eberlin, kyle r.; helliwell, lydia a. title: webinar during covid-19 improves knowledge of changes to the plastic surgery residency application process date: 2020-09-29 journal: plast reconstr surg glob open doi: 10.1097/gox.0000000000003247 sha: doc_id: 265014 cord_uid: ic5drg5l background: the covid-19 pandemic has significantly impacted residency application process for all specialties, including plastic surgery residency. almost all plastic surgery residency programs have suspended visiting sub-internship rotations. this study quantifies the impact of a webinar through an analysis of poll questions and a post-webinar survey sent to all registered participants. methods: a dedicated webinar was organized and held by the harvard plastic surgery residency training program. all attendees were asked several poll questions during the webinar. the 192 participants were also sent a post-webinar survey. results: the response rate was 68.2% (n = 131). respondents were more confident about matching into a plastic surgery residency program at the end of the webinar compared with before the webinar (p < 0.001). respondents who did not have a plastic surgery residency program at their home institution were less confident at the start of the webinar (p = 0.009). in addition, respondents who had not taken time off for research or for other endeavors during or after medical school were less confident about their chances to match at the start of the webinar (p = 0.034). conclusions: an online webinar program increased confidence levels of medical students interested in applying for residency positions in plastic surgery. residency programs should consider webinars as a method to inform and assist medical students during the upcoming application season. the covid-19 pandemic has created unique challenges for this year's plastic surgery residency applicants. medical students who would typically spend 1-3 months completing visiting sub-internships at institutions other than their home medical school are unable to pursue these opportunities, thereby foregoing a traditionally important part of the recruitment process in our specialty. for residency programs, the sub-internship experience and in-person interview days normally provide a way to get to know candidates on a personal level. 1, 2 with the ongoing pause to both visiting sub-internships and in-person interviews, residency programs and medical students applying for plastic surgery residency positions (as well as all other specialties) are now forced to adapt and optimize the online resources available to maximize the recruitment process. given the competitiveness of the plastic surgery match, the sub-internship rotation experience provides a means for mutual assessment on behalf of the applicant as well as the residency program. students can spend up to 4 weeks or more on service at an outside institution. these away rotations allow students to get to know a program firsthand versus relying solely on the interview process or word of mouth. additionally, residency program directors and staff members can interact directly with the sub-interns for a much longer period than possible during an interview day. 3 finally, residents within programs can assess a student's potential and gauge whether there would be a mutually beneficial fit. because of the covid-19 pandemic, many medical schools and residency programs across the united states have announced the temporary cessation of visiting subinternship rotations during the summer and fall of 2020. as such, medical students will be left without these important experiences during the residency match process. anecdotally, we noticed an increase in queries on online forums and email correspondences from medical students since the start of the pandemic, with a large number of questions focused on how to best adapt to the current unprecedented situation. in may 2020, our residency program organized and held a dedicated webinar for medical students interested in applying for plastic surgery residency positions during the covid-19 pandemic. we performed a survey study of webinar participants, aiming to determine how a webinar may affect student perceptions about the residency application process during covid-19 and what specific groups of students may benefit most. we hypothesized that a webinar would provide information and increase the confidence of medical students in their ability to match into plastic surgery during the covid-19 pandemic, especially those students without a plastic surgery residency program affiliated with their medical school. any medical student or current resident physician interested in plastic surgery was eligible to sign up. foreign medical graduates were eligible to participate. registration for the webinar was provided free of cost. the webinar was promoted through the official host residency program social media platforms. all faculty and resident webinar hosts were also encouraged to share posts announcing the webinar event. interested attendees were instructed to send an email from their medical school email account indicating their interest to join the webinar. after an email was received by our program, a registration weblink was sent to each interested student that opened a zoom webinar registration form. subsequently, a weblink for the meeting was sent to those who completed the registration process. demographic information was collected from the registration form. it included current year in medical school or residency training, name of medical school, and whether or not one was applying for plastic surgery residency training this fall/winter 2020. because there are 2 formal tracks for plastic surgery training (independent and integrated), participants were also asked whether they would be applying for an integrated or independent position. additional demographic information was collected at the start of the webinar, including how attendees had been informed about the webinar event and whether or not their home medical school had a plastic surgery training program. several poll questions were posed throughout the webinar, including attendees' confidence levels in their ability to match into plastic surgery during the covid-19 era both at the beginning and at the end of the webinar, and what specific topics were most concerning about the residency application process ( table 2) . within the webinar, discussions were held addressing specific concerns about this year's application cycle according to questions applicants had posed during the registration process. these included how covid-19 and this year's lack of sub-internship season will impact the plastic surgery residency application process, how to optimize one's application strengths given the covid-19 pandemic, changes to the usual interview procedures, and the ways through which students can show interest in a program, given the social climate surrounding the pandemic. the aamc recommendations for virtual interviews were presented to the attendees as well. (see pdf, supplemental digital content 2, which displays the aamc virtual interview tips for medical school interviewers document. http://links.lww.com/prsgo/b508.) a post-webinar survey was emailed to all webinar attendees. it included questions about the status of plastic surgery interest groups at their medical school, whether the attendee had already completed a plastic surgery clinical rotation, and the perceived level of importance of several portions of the application process (sub-internships, personal statements, letters of recommendation, and interviews) ( table 3 ). the survey was sent again to nonrespondents approximately 48 hours after the original survey. all data were collected anonymously. data were analyzed with stata, version 13.0 (statacorp, college station, tex.). categorical variables were described using frequencies and percentages. likertscale data were treated as ordinal variables. paired likertscale data were compared using the wilcoxon signed rank test. associations between likert scale data and demographic variables, such as associations between webinar usefulness and having a home program, were tested for using the wilcoxon rank sum test. associations between categorical variables were analyzed using a chi-square or fisher's exact test. statistical significance was set at p < 0.05. an estimated 192 respondents participated in the webinar and were sent a post-webinar survey. a total of 131 survey responses (response rate: 68.2%) were received. there were 75 women (57.3%), 55 men (42%), and 1 non-binary (0.8%) respondent. actively enrolled medical students comprised 75.6% of respondents, with an additional 12.2% who were taking dedication research time, pursuing a secondary degree program (ie, mph, mba, mpp, etc), or taking time for other pursuits outside medical school at the time of the webinar. the remaining participants were either taking additional time off after medical school or were already in an unspecified residency program. geographically the us respondents were most commonly from the northeast (33.6%) and south (23.7%), and 15.6% were international participants. table 1 highlights demographic information. most respondents (74.6%) were planning to apply to a plastic surgery residency program during the upcoming 2020-21 application cycle, with a majority (96.8%) applying to an integrated plastic surgery residency program. a total of 63.1% of respondents had already completed at least one clinical rotation on a plastic surgery service before the start of the webinar. of those respondents who had already completed a plastic surgery clinical rotation, 33.7% had been on rotation for 2 weeks or less, 41.9% for 3-4 weeks, 11.6% for 5-8 weeks, and 12.8% had completed greater than 8 weeks on a plastic surgery rotation (fig. 1) . a total of 38.2% of respondents did not have a plastic surgery residency training program at their home institution. of the remaining respondents, 42.3% had only an integrated program at their home institution, 3.8% had only an independent program, and 15.3% had both integrated and independent residency programs at their home institution. most commonly, respondents (46.6%) were active members of their home institution's plastic surgery interest group for medical students. when asked about taking dedicated time for other pursuits (research, secondary degrees, etc) during or after medical school, 32.6% confirmed they had done so. of those individuals, a majority (57.1%) had taken 1 year for additional pursuits outside medical school, 26.2% had taken 2 years, and 16 .7% had taken more than 2 years. of the 44 respondents who had taken time for additional pursuits during or after medical school, 75% did so to pursue formal research activities while 15.9% pursued a separate secondary degree program. when asked about the importance of various aspects of the residency application process (assessed using a likert scale with answers ranging from "essential" to "not important"), letters of recommendation were thought to be most essential (86.6%), followed by interviews (77.3%), sub-internships (66.4%), and personal statements (22%). overall, respondents were more confident about matching into a plastic surgery residency program at the end of the webinar compared with at the beginning (p < 0.001; figure 2 ). respondents who did not have a plastic surgery residency program at their home institution were less confident at the start of the webinar (p = 0.009). in addition, respondents who had not taken time off for research or other endeavors during or after medical school were less confident at the start of the webinar (p = 0.034). no associations were found between gender, the status of a home residency program, international location, presence and/or membership in a plastic surgery interest group, prior plastic surgery rotations completed, and time off during or after medical school and changes in confidence levels after the webinar. participants were most likely to be informed about the webinar through instagram (31.3%), as seen in figure 3 . the second most common forum through which applicants heard about the webinar was through an online openaccess spreadsheet that circulates among medical students interested in plastic surgery (14.8%). respondents most commonly follow social media accounts of plastic surgery programs weekly (32.8%) and at least 63% of respondents interact with social media accounts of programs on a weekly (or more frequently) basis. social media accounts of residency programs were most often reported as moderately important for applicants trying to get to know programs. when asked about the topic most concerning to them, participants most often responded citing lack of sub-internship rotations (35.2%), followed by inability to express interest to programs (14.2%) and virtual interviews (14.2%), obtaining letters of recommendation (11.9%), learning about programs (6.3%), finding mentors (5.1%), and finding research opportunities (4.6%) (fig. 4) . overall feedback from participants was overwhelmingly positive, with over 75% of respondents finding the webinar either "extremely useful" or "quite useful." future suggestions for webinar topics, in order of popularity, included topics on how to succeed during a virtual interview, how to learn about residency programs virtually, social media as a plastic surgery residency applicant, mentorship, strategies to get involved in research, learning more about the harvard program specifically, and applying as an independent resident candidate. the covid-19 pandemic has resulted in the cessation of visiting sub-internships for medical students interested in plastic surgery during this upcoming application cycle. our program held an online hour-long webinar to answer questions, provide insights, and lend advice about some of the expected changes to the residency application process as a result of the pandemic. poll surveys during and after the webinar were conducted by the authors and were sent to all participants. we hypothesized that changes to the application process due to the covid-19 pandemic negatively affected medical student confidence levels toward matching into a plastic surgery residency training program. results from our study indicate that an educational 1-hour webinar hosted by a plastic surgery residency program increases self-reported confidence levels for students interesting in matching into plastic surgery. our results also show that students without a home program and those who had not taken time off for research or other endeavors were less confident about their ability to match into plastic surgery at the beginning of the webinar. since confidence levels are internally defined for each individual, our self-reported assessment of confidence levels reflects an important outcome that we sought to measure. webinars are effective tools in medical education. 4,5 they are an effective method for transmitting knowledge to a vast audience and have become exponentially more popular during the current pandemic. 5, 6 previously published studies regarding online webinars hosted by residency programs have also shown effective results. fereydooni et al. showed that a national webinar hosted by recently matched students improves medical students' understanding of the application process for integrated vascular surgery programs. 6 another study by sura and colleagues described a webinar developed and hosted by a radiation oncology program that received positive feedback in assisting medical students during the application process. 7 we also found similar results with a significant increase in confidence levels. in addition, over 75% of respondents described the webinar as either "extremely useful" or "quite useful." the plastic surgery match continues to be among the most competitive specialties in the national residency match program (nrmp). successful applicants match at an average rate of 85.7% and have among the highest usmle board score averages across all specialties. 8 medical students interested in matching into plastic surgery have traditionally relied heavily on visiting rotations and sub-internships. 2, 9, 10 performing 3 or more rotations at outside institutions has become the norm in recent years for integrated applicants. 3 incurring a significant cost burden has also become commonplace, with 1 recent study finding plastic surgery applicants spent an average of $3591 per applicant on visiting rotations. 10 in the same study, 91.1% of the applicants believed an away rotation made them more competitive, and program directors surveyed stated a strong away rotation performance as the most important residency selection criterion. among the most recent intern year class, 67% participated in a rotation at the institution where they matched. 3 with the widespread changes in the residency application process this year due to the covid-19 pandemic, different aspects of the residency application may be weighted more than during previous application cycles. when asked regarding the importance of several elements of the plastic surgery residency application process in our study, a majority of survey respondents believed that letters of recommendation, interviews, and sub-internships were "essential." this is in accordance with prior studies, which have shown that applicants generally consider interviews, away rotations, and personal experiences with residents as the most important elements when evaluating a residency program. 11 another study by rogers and colleagues found that quality interactions, both with faculty and with residents, are the most important factors an applicant considers when ranking a program. 12 interestingly, only 22% of respondents in our study believed personal statements were "essential" to the overall application process. personal statements have previously been shown to have very little correlation with applicants matching into highly competitive surgical residency programs. 13 one study from the scott and white general surgery residency program found little interrater reliability and a lack of objective criteria with regards to evaluation of personal statements. 14 in our experience, during the plastic surgery application process applicants are advised to write personal statements that are generic descriptions of themselves and to describe the reasons for choosing plastic surgery as a career. however, no formal studies have been performed evaluating the exact value of the personal statement in the plastic surgery rank process. in fact, survey studies of plastic surgery program directors evaluating resident selection protocols in both the integrated and independent pathways did not even include personal statements as an option for evaluating and selecting candidates. 2, 15 it is our opinion this may change during the 2020-2021 cycle with more emphasis placed on personal statements, given the lack of other more objective evaluation methods, such as sub-internship rotations. educating medical students regarding these potential changes may be beneficial. social media continues to gain traction in the plastic surgery community and has become a significant method for medical students to learn about and connect with residency programs. [16] [17] [18] instagram was the most common platform through which participants learned about our webinar. furthermore, at least 63% of survey respondents stated they interact with social media accounts of plastic surgery residency programs on a weekly basis or more frequently, and only 9.2% of respondents stated they did not believe social media was important in getting to know a residency program. further bolstering the fact that social media accounts continue to play a large role in the residency application process, the covid-19 pandemic's effect on away rotations leaves medical students with fewer in-person opportunities to experience programs outside their home institutions. we believe that residency program social media accounts will continue to develop and will play more vital roles during the recruitment process from both the programs' and applicants' perspectives. importantly, applicant social media accounts are not currently part of the residency application process. without further official society guidelines, these accounts should not be considered an additional evaluative tool. there were several limitations to this study. like all survey studies, response rates were limited, and we did not capture all webinar participants' responses. furthermore, we were not able to capture any long-term observations regarding the efficacy of our webinar on the knowledge and confidence of medical students over time. our study represents the experience of one residency program. future studies examining multi-institutional experiences with webinars, or pooling data from multiple webinar experiences, would be useful in strengthening the findings of this study. finally, our webinar was intended for an audience of participants interested in applying to plastic surgery residency programs within the united states; however, approximately 15.6% of survey respondents were from international backgrounds. there were no international graduates or experts on our webinar panel. this study showed that a webinar program increased confidence levels of medical students interested in applying for residency positions in plastic surgery and should be considered by residency programs as a means to educate medical students. as away rotation sub-internships will not take place for the foreseeable future, online platforms, including various forms of social media, will play a larger role in the plastic surgery application process. plastic surgeons are often rapid adopters of novel approaches, and as plastic surgery educators, we are similarly adaptive to the rapidly evolving challenges this pandemic has presented, using newer tools to provide guidance to potential applicants. swings and roundabouts: paradoxes of the away rotation resident selection protocols in plastic surgery: a national survey of plastic surgery program directors away rotations in plastic and reconstructive surgery: a survey of program directors webinar-based contouring education for residents webinars for continuing education in oral and maxillofacial surgery: the austrian experience a national post-match webinar panel improves knowledge and preparedness of medical students interested in vascular surgery training applying for radiation oncology residency: webinar-based medical student mentorship outreach charting outcomes in the match for us allopathic seniors the plastic surgery match: predicting success and improving the process away rotations and matching in integrated plastic surgery residency: applicant and program director perspectives residency characteristics that matter most to plastic surgery applicants: a multi-institutional analysis and review of the literature integrated plastic surgery residency applicant survey: characteristics of successful applicants and feedback about the interview process characteristics of highly ranked applicants to general surgery residency programs is the evaluation of the personal statement a reliable component of the general surgery residency application? resident selection protocols in plastic surgery: a national survey of plastic surgery independent program directors insta-grated plastic surgery residencies: the rise of social media use by trainees and responsible guidelines for use harnessing social media to advance research in plastic surgery the impact of social media on plastic surgery residency applicants key: cord-011234-awbubjy4 authors: acevedo, edwin; mazzei, michael; zhao, huaqing; lu, xiaoning; edwards, michael a. title: outcomes in conventional laparoscopic versus robotic-assisted revisional bariatric surgery: a retrospective, case–controlled study of the mbsaqip database date: 2019-06-17 journal: surg endosc doi: 10.1007/s00464-019-06917-5 sha: doc_id: 11234 cord_uid: awbubjy4 introduction: revisional bariatric surgery is being increasingly performed and is associated with higher operative risks. optimal techniques to minimize complications remain controversial. here, we report a retrospective review of the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) participant user files (puf) database, comparing outcomes between revision rbs and lbs. methods: the 2015 and 2016 mbsaqip puf database was retrospectively reviewed. revision cases were identified using the revision/conversion flag. selected cases were further stratified by surgical approach. subgroup analysis of sleeve gastrectomy and gastric bypass cases was performed. case–controlled matching (1:1) was performed of the rbs and lbs cohorts, including gastric bypass and sleeve gastrectomy cohorts separately. cases and controls were match by demographics, asa classification, and preoperative comorbidities. results: 26,404 revision cases were identified (93.3% lbs, 6.7% rbs). 85.6% were female and 67% white. mean age and bmi were 48 years and 40.9 kg/m(2). 1144 matched rbs and lbs cases were identified. rbs was associated with longer operative duration (p < 0.0001), los (p = 0.0002) and a higher rate of icu admissions (1.3% vs 0.5%, p = 0.05). aggregate bleeding and leak rates were higher in the rbs cohort. in both gastric bypass and sleeve gastrectomy cohorts, the robotic-assisted surgery remain associated with longer operative duration (p < 0.0001). in gastric bypass, rates of aggregate leak and bleeding were higher with robotic surgery, while transfusion was higher with laparoscopy. for sleeve gastrectomy cases, reoperation, readmission, intervention, sepsis, organ space ssi, and transfusion were higher with robotic surgery. conclusion: in this matched cohort analysis of revision bariatric surgery, both approaches were overall safe. rbs was associated with longer operative duration and higher rates of some complications. complications were higher in the robotic sleeve cohort. robotic is likely less cost-effective with no clear patient safety benefit, particularly for sleeve gastrectomy cases. all of which contribute to increased healthcare-related costs. this high rate of weight recidivism following bariatric surgery is also consistent with the reported twofold increase in revisional bariatric procedures in recent literature [12, 13] . the optimal treatment modality for weight recidivism post-bariatric surgery remains controversial. most practitioners agree that early recognition and intervention for weight recidivism post-bariatric surgery is important in containing obesity-related healthcare costs in this cohort of patients [3, 4, 14] ; however, standardized practice guidelines for managing these patients are lacking. the spectrum of treatment recommendation includes behavior modification [7, 10] , medication [10] , endoscopic bariatric therapy [15] , and revisional bariatric surgery [1-7, 9, 12, 16-20] , with varying results. revisional bariatric surgery is often recommended for those with inadequate weight loss or significant weight regain, as well as persistence comorbid conditions following primary bariatric surgery [1, 4, 9] . other reasons for revisional or conversional bariatric surgery vary and are related to physiologic and anatomic complications associated with the index surgical procedure [1, 2, 6, 7] . outcomes following revision or conversion bariatric surgery are not similar to outcomes following primary bariatric surgery [3, 4, 18, 19] . while some small cohorts and meta-analyses have reported no difference in complication rates between primary and revisional bariatric cases [6, 7, 18, 19] , others have reported that weight loss is less and complication rates are higher in revisional bariatric surgery [14, 17, 20] . the optimal surgical approach also remains a point of controversy. as technical approaches to surgical weight loss continue to evolve, the robotic platform continues to be increasing used; however, the role, safety, and cost-effectiveness of this platform remain unclear for both primary and revisional bariatric surgery. there are limited published studies on revisional or conversional robotic bariatric surgery [5, 16, 17] . most are small retrospective cohorts, limiting our understanding of outcomes following robotic revisional bariatric surgery. we present the largest retrospective cohort analysis of revisional bariatric surgery comparing conventional laparoscopic and the roboticassisted techniques. we performed a retrospective analysis of the 2015 and 2016 metabolic and bariatric surgery accreditation and quality improvement program participant use file (mbsaqip puf) database for this study. we compared outcomes in revision or conversion metabolic and bariatric surgery performed with conventional laparoscopic or robotic-assisted techniques. the mbsaqip accredits bariatric surgical facilities in the united states, who are then required to report bariatric surgical outcomes to the mbsaqip puf. the mbsa-qip puf serves as a file registry that contains prospective, risk-adjusted data based on preoperative, intraoperative, and post-operative variables specific to bariatric surgery. data is collected by trained metabolic and bariatric surgery (mbs) clinical reviewers at each bariatric center and audited similar by the national surgical quality improvement program (nsqip). de-identified data is reported on patient characteristics, operative details, and intraoperative and perioperative outcomes. as our study utilized deidentified data from a national clinical database, neither institutional review board (irb) approval nor consent was required. there are 355,675 bariatric cases in the combined 2015 and 2016 mbsaqip puf. we first excluded cases without the revision/conversion flag in the database. this excluded all primary mbs procedures. we then excluded cases by surgical approach, including only revision cases performed by either conventional laparoscopic or robotic-assisted techniques. from this cohort, we identified patients who had a revision/conversion bariatric operation using current procedure terminology (cpt) codes for laparoscopic gastric proximal gastric bypass (43,644), laparoscopic distal gastric bypass (43,645), laparoscopic sleeve gastrectomy (43,775), laparoscopic gastric band (43,770), and laparoscopic duodenal switch (43,659). our case selection algorithm resulted in exclusion of primary bariatric cases, all cases not performed by conventional laparoscopic or robotic-assisted techniques, revision cases that were not a revision/conversion to another bariatric procedure, as well as cases in our final study cohort with missing data points. in order to control for possible confounding variables, we performed 1:1 case-control matching of the entire cohort. cases and controls were matched by patient demographics (age, gender, race/ethnicity, and body mass index (bmi) closest to surgery), asa classification and preoperative comorbid conditions (history of myocardial infarction (mi), hypertension requiring medication, hyperlipidemia, renal insufficiency, need for dialysis, venous thrombosis requiring therapy, history of pulmonary embolism (pe), ambulation status, functional dependence, diabetes mellitus, steroid and immunosuppressant use, smoking status within 1 year of surgery, obstructive sleep apnea (osa), chronic obstructive pulmonary disease (copd), and oxygen dependence) ( table 1) . procedure-specific subgroup analyses were also performed, comparing case-control matched roboticassisted versus conventional laparoscopic sleeve gastrectomy (sg) cases and robotic-assisted versus conventional laparoscopic roux-en-y gastric bypass (rnygb) cases. thirty primary outcomes variables were assessed, including operative time, hospital length of stay, conversion rate, discharge status, 30-day icu admission, reoperation, readmission, intervention, or mortality, death likely related to bariatric surgery, drain present at 30-days, renal failure, progressive renal insufficiency, cardiopulmonary resuscitation (cpr), coma > 24 h, stroke, myocardial infarction, venous thrombosis requiring therapy, pulmonary emboli, transfusion, pneumonia, on ventilator > 48 h, unplanned intubation, peripheral nerve injury, urinary tract infection (uti), sepsis, septic shock, superficial soft tissue infection (ssi), deep ssi, and organ space ssi. seven aggregate complications were also assessed, including aggregate leak-as previously described by berger et al. [21] , bleeding, renal failure, cardiovascular and pulmonary complications, venous thromboembolic events and surgical site infection. aggregate methodology is reported in table 2 . primary and aggregate outcomes were analyzed for the entire unmatched cohort and case-control matched cohorts. pearson's chi squared test for categorical variables (i.e., gender, race, asa class, and preoperative comorbidities) and an independent two sample t test and mann-whitney test for normally and non-normally distributed continuous variables perioperative and aggregate outcomes for the entire unmatched conventional laparoscopic and robotic-assisted cohorts are described in table 4 . operative duration (min) (121.7 ± 67.5 vs. 177.4 ± 79.4, p < 0.0001) and hospital length of stay (days) (2.2 ± 3.1 vs. 2.4 ± 3.1, p = 0.01) were significantly longer in the robotic-assisted cohort. 30-day reoperation (4.3% vs. 3.2%, p = 0.01), readmission (8.5% vs. 6.6%, p = 0.0024), and intervention (4.4% vs. 3.1%, p = 0.003) were also significantly higher in the robotic-assisted cohort. perioperative complications were similar between the two cohorts, except for a higher rate of intraoperative or post-operative transfusion (1.5% vs. 0.9%, p = 0.04) in the conventional laparoscopic cohort. aggregate complications were also similar between the cohorts, except for a significantly higher rate of leak (1.7% vs. 0.9%, p = 0.003) in the robotic-assisted cohort. aggregate bleeding trended toward being significantly higher in the conventional laparoscopic cohort (p = 0.05). there was no mortality difference between the two cohorts (0.2% vs. 0.23%, p = 0.8). perioperative and aggregate outcomes following matched cohort analysis of all included bariatric procedures are described in table 5 . after 1:1 case-control matching for patient demographics and preoperative comorbidities (table 1) , 2288 cases and controls were identified. operative duration (min) (119.5 ± 64.1 vs. 173.7 ± 78.9, p < 0.0001) and hospital length of stay (days) (1.9 ± 1.8 vs. 2.3 ± 2.2, p = 0.0002) remained significantly longer in the robotic-assisted cohort. 30-day outcomes were similar between the two cohorts, except for a higher rate of unplanned icu admission in the robotic-assisted cohort (1.3% vs. 0.5%, p = 0.05). all perioperative complications were also similar between the two cohorts, including intraoperative or post-operative transfusion with 72-h, which was significantly higher for the conventional laparoscopic cohort in the unmatched cohort analysis (p = 0.04 vs. 1.0). aggregate bleeding (1.0% vs. 0.4%, p = 0.07) and leak (1.3% vs. 0.6%, p = 0.09) remained higher in the roboticassisted cohort, trending toward statistical significance. all other aggregate complications were similar between the two cohorts ( table 5 ). subgroup analyses of sg and rnygb cohorts were then performed. perioperative and aggregate outcomes for the unmatched revision sg and rnygb cohorts are detailed in table 6 . in the unmatched rnygb cohort (n = 7901), 9.2% were performed robotically. in comparison with conventional laparoscopic cases, robotic-assisted cases were associated with significantly longer operative duration (195.4 ± 73.1 min vs. 154.9 ± 73.2 min, p < 0.0001) and higher rates of conversion (1.8% vs. 0.8%, p = 0.008) and aggregate bleeding (1.8% vs. 0.9%, p = 0.02). in contrast, the conventional laparoscopic cohort had significantly higher rates of transfusion requirement (2.1% vs. 0.8%, p = 0.02), aggregate leak (1.1% vs. 0.9%, p = 0.04), and pulmonary complications (1.4% vs. 0.6%, p = 0.05). mortality, morbidity, 30-day adverse outcomes, and other complications were not significantly different in the unmatched revision robotic and laparoscopic bypass cohorts. in the unmatched sleeve gastrectomy cohort (n = 11,525), 5.9% progressive renal insufficiency peri-operative and aggregate outcomes for procedurespecific matched cohorts are detailed in table 7 . following 1:1 case-control matching, 668 revisional gastric bypass (338 robotic-assisted and 338 conventional laparoscopic) and 778 revisional sleeve gastrectomy (389 robotic-assisted and 389 conventional laparoscopic) cases were compared. in the matched revisional gastric bypass cohort, outcomes were preserved and similar to the unmatched analysis. roboticassisted rnygb was associated with longer operative duration (186.6 ± 68.0 vs. 151.4 ± 67.6, p < 0.0001) and conventional laparoscopy was associated with fivefold higher rate of transfusion requirement (2.9% vs. 0.6%, p = 0.02). all other outcome measures were similar between the two surgical approaches for gastric bypass cases. in matched sleeve gastrectomy cohort analysis, robotic-assisted surgery remains associated with significantly longer operative duration (143.8 ± 56.6 min vs. 106.9 ± 47.4 min, p < 0.0001) and a higher rate of post-operative sepsis (1.0% vs. 0%, p = 0.04). however, post-operative length of stay and outcome measures that were significantly different in unmatched analysis, were similar among the two surgical approaches in matched sleeve gastrectomy cases. as the number of total bariatric procedure performed annually continues to increase, it is expected that a concomitant increase will be seen in the total number of complications, cases with weight recidivism, and other post-operative morbidities that may require the need for revisional/conversional bariatric procedures [6, 7, 10, 22] . this is a challenging cohort. in a recent systematic review of re-operative bariatric surgery, mortality was estimated to be 2%, which is significantly higher than the 0.1-1.1% reported for primary bariatric procedures [2] . in a case-matched analysis comparing primary and revisional laparoscopic roux-en-y gastric bypass (lrygb), the revisional cohort was found to have significantly longer length of stay (3.8 vs. 2.4, p = 0.02), conversion to laparotomy (10.8% vs. 0%, p = 0.01), and 30-day morbidity (27% vs. 8.1%, p = 0.02) [3] . a meta-analysis comparing bariatric reoperations after adjustable gastric banding (abg) found that conversion to sleeve gastrectomy had the lowest long-term complication rates (2.6%), while conversion to rygb had the highest short-term and long-term complication rate at 10.7% and 22.0%, respectively [4] . the current literature suggests that revisional bariatric surgery is associated with higher rates of mortality and morbidity and outcomes may be related to the primary and re-operative operation performed. however, there have been limited studies evaluating outcomes in revisional bariatric surgery comparing conventional laparoscopic-and robotic-assisted surgical approaches [5, 16, 17] . this study represents the largest case-controlled retrospective review of the mbsaqip puf database comparing perioperative outcomes in laparoscopic-and robotic-assisted revisional/ conversional bariatric surgery. our case-control matched analysis of 2288 revisional bariatric cases revealed longer operative duration and hospital length of stay, and higher rates of icu admission, aggregate leak and bleeding complications in the robotic-assisted bariatric surgery compared to conventional laparoscopy. this is in contrast with other studies. buchs et al. performed a comparison of 60 consecutive revisional bariatric procedures performed laparoscopically, open, or robotic-assisted [16] . they found that while operative duration was significantly longer in the robotic-assisted cohort, there were less complications and a shorter hospital stay when the robotic platform was used. in another small series (n = 32) evaluating robotic-assisted revisional roux-en-y gastric bypass, the authors concluded that their complications and perioperative outcomes were similar to the published results on conventional laparoscopic revisional bariatric surgery [5] . there remained some similarities and differences between the findings in our study and prior studies. in overall and procedure-specific match analysis, robotic-assisted surgery was associated with significantly longer operative duration, which is consistent with the published literature. while outcomes between robotic-assisted and conventional laparoscopic revisional gastric bypass were statistically similar, robotic-assisted surgery was associated with higher rates of aggregate bleeding (fivefold higher) and aggregate leak (2.5-fold higher). in our matched analysis of robotic and laparoscopic sleeve gastrectomy, most outcomes were statistically similar, as with the gastric bypass cohorts. however, robotic-assisted revisional sleeve gastrectomy was associated with higher rates of conversion (twofold higher), 30-day reoperation (3.3-fold higher), 30-day readmission (1.5-fold higher), 30-day intervention (2.5-fold higher), anticoagulation for presumed for confirmed vte (twofold higher), transfusion requirement (fourfold higher), organ space ssi (sixfold higher), aggregate leak (1.25-fold higher), aggregate venous thromboembolism (1.9-fold higher), and aggregate ssi (1.8-fold higher). much of the higher complication rates observed in the robotic-assisted cohorts were not statistically different. this may be a reflection of the smaller sample size compared after our procedure-specific case-control matching. while unclear, this suggests that the robotic-assisted platform is associated with higher rates of adverse outcomes in sleeve gastrectomy revisional cases compared to gastric bypass revisional cases. the reasons for our findings remain unclear. our study represents the largest case-controlled matched study comparing these two surgical platforms for revision/ conversion bariatric surgery. we show that while most peri-operative outcomes are similar after controlling for confounders, operative duration remains significantly higher in both robotic-assisted gastric bypass and sleeve gastrectomy. while the robotic platform was overall safe for both revisional gastric bypass and sleeve gastrectomy cases, we also showed that while most complications were statistically similar in matched gastric bypass (robotic vs. laparoscopic) and matched sleeve gastrectomy (robotic vs. laparoscopic) cohorts, robotic revisional metabolic and bariatric surgery was associated with non-significantly higher rates of some complications. these complications rates were overall higher in the sleeve gastrectomy cohort compared to the gastric bypass cohort. giving these findings, the robotic platform seems overall safe, but is likely less cost-effective, and value added for patient safety remains unclear for revisional metabolic and bariatric surgical procedures, and particularly for revisional sleeve gastrectomy cases. our study has a number of limitations that should be highlighted. first, this study is limited to peri-operative outcomes only, so long-term outcomes cannot be assessed. second, the database does not provide the details about the initial bariatric operation performed for cases designated as revision/conversion. as the primary bariatric operation may impact the level of difficulty of a revision/conversion bariatric procedure, the lack of detail about the initial bariatric operation performed is a possible confounding variable our study could not account for. third, the dataset does not provide details about anastomotic techniques and surgeon experience, which are variables previously shown to impact outcomes following metabolic and bariatric surgery [23, 24] . the level of surgeon experience is not accounted for in this database, including where surgeons are on the laparoscopic or robotic learning curve. it is also unclear if anastomotic techniques varied by surgical approach. for instance, were more robotic anastomosis hand-sewn and laparoscopic stapled? it is also unclear what primary bariatric procedures were converted to what revisional procedures. were more difficult conversion cases performed using the robotic platform versus conventional laparoscopy. these nuances could not be illicit from the mbsaqip database, and may be confounding variables not accounted for in our study. lastly, this is a retrospective analysis and is therefore susceptible to biases associated with retrospective analyses of clinical databases. taking into consideration the above outlined study limitations, the findings of this case-control matched analysis comparing these two surgical approaches for revision/conversion metabolic and bariatric surgery show that using the robotic platform is overall safe, but is associated with longer operative times and a higher rate of some perioperative outcome measures. it has been shown that prolonged operative duration is associated with increased complications. in a recent meta-analysis, the authors found that the likelihood of complications approximately doubles with operative time thresholds exceeding 2 [25] . moreover, perioperative complications [26] , hospital length of stay [27, 28] , 30-day adverse outcomes, such as reoperation, readmission, and intervention [29] have all been reported to be associated with increased costs. therefore, outcome measures that were higher in the robotic-assisted gastric bypass (operative duration, aggregate bleeding and aggregate leak) and robotic-assisted sleeve gastrectomy cohorts (operative duration and rates of conversion, 30-day reoperation, 30-day readmission, 30-day intervention, anticoagulation for presumed or confirmed vte, transfusion requirement, organ space ssi, aggregate leak, aggregate venous thromboembolism and aggregate ssi), can serve as proxies for higher cost associated with robotic-assisted metabolic and bariatric surgery. while revisional cases have been reported to be a safe and effective way to treat patients who have significant weight recidivism and relapse of comorbid conditions post-bariatric surgery [6, 7, 18, 19] , there are no clear patient benefits to utilizing robotic assistance for these cases. because of the large initial investment, consumables, annual maintenance, and other reusable equipment also associated with the robotic platforms [30, 31] , health systems must be cognizant of the fact that some peri-operative outcomes may favor the use of conventional laparoscopy over the roboticassisted approach for revisional bariatric procedures. these differences can contribute to higher healthcare expenditures with little effect on patient safety outcomes when the robotic platform is utilized in this patient cohort. conventional laparoscopic and robotic-assisted revision/ conversion metabolic and bariatric procedures are both safe and effective surgical approaches. however, we found that robotic-assisted revision/conversion gastric bypass and sleeve gastrectomy is associated with longer operative times. robotic-assisted and conventional laparoscopic gastric bypass were similar in outcomes, except a non-significantly higher rate of aggregate leak and bleeding. outcomes between robotic-assisted and conventional laparoscopic sleeve gastrectomy were also statistically similar; however, the robotic-assisted cohort had numerous 30-day adverse outcomes, complications, and aggregate complications that were higher. these findings suggest less cost-effectiveness and no clear patient safety benefit with use of the robotic platform, particularly for revisional sleeve gastrectomy cases. larger revisional cohorts are needed to validate our finding, given the limited sample size included in our analysis following our procedure-specific matching. reoperations after bariatric surgery in 26 years of follow-up of the swedish obese subjects study re-operative bariatric surgery: a systematic review of the reasons for surgery, medical and weight loss outcomes, relevant behavioral factors case-matched analysis comparing outcomes of revisional versus primary laparoscopic roux-en-y gastric bypass re-operations after secondary bariatric surgery: a systematic review outcomes of robotassisted roux-en-y gastric bypass as a reoperative 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high cost after bariatric surgery: a single institution review cost of bariatric surgery and factors associated with increased cost: an analysis of national inpatient sample cost of bariatric surgery and factors associated with increased cost: an analysis of national inpatient sample healthcare utilization and outcomes after bariatric surgery robot-assisted surgery compared with open surgery and laparoscopic surgery: clinical effectiveness and economic analyses. canadian agency for drugs and technologies in health robotic versus laparoscopic roux-en-y gastric bypass in obese adults ages 18 to 65 years: a systematic review and economic analysis disclosures drs. edwin acevedo, jr., michael mazzei, huaqing zhao, michael a. edwards, and mr. xiaoning lu have no conflicts of interests or financial ties to disclose. key: cord-258402-9s57thvn authors: dabas, vineet; bhatia, nishant; goel, akash; yadav, vedpal; bajaj, vineet; kumar, vinod title: management of orthopaedic accidental emergencies amidst covid-19 pandemic: our experience in preparing to live with corona date: 2020-09-10 journal: indian j orthop doi: 10.1007/s43465-020-00252-x sha: doc_id: 258402 cord_uid: 9s57thvn introduction: with increasing prevalence of coronavirus cases (including among health care providers), the current advice for orthopaedic surgeons is to favor non-operative management of most injuries and reduce face-to-face follow-up. we present our experience in managing the patients at government-run non-covid-19 trauma center in delhi in an algorithmic form. our standard operating protocols were mainly based on recommendations of indian orthopaedic association and targeted to provide healthcare at a minimum risk to the treating team as well as other patients admitted to the hospital. methodology: we describe the inflow, in-hospital management and outflow of patients at our facility during the lockdown period and in the following unlock period (from 23 march to 8 july 2020). those patients who had absolute indications for surgery were offered surgery, while conservative treatment was more favored in those with relative indications. we also highlight the changes incorporated in ot settings as well as in rehabilitative and follow-up period. results: following the described protocol helped us maintain a balance between the safety of patients and our front line workers which was evident by very low covid-19-positive rate in admitted patients (4.22%) and health care providers (16.67%) in the above-mentioned time period. conclusions: we need to be prepared to cohabitate with this deadly novel coronavirus and adapt our surgical practices according to the need of the hour by minimizing surgical indications and strengthening the training in conservative principles. the first reports of coronavirus (covid-19) outbreak came from wuhan city of china in the month of december 2019 [1] . it was declared as a global pandemic by world health organization (who) on 11 march 2020 [2] . as of 25 july 2020, 15,296,926 cases and 628,903 deaths have been reported worldwide [3] . in india, the first case of covid-19 was reported on 30 january 2020, and the number has reached 1,287,945 as on 25 july 2020, with 30,601 deaths [4] . the most effective strategies against covid-19 include preventing exposure and staying indoors. keeping this in mind, the government of india (goi) declared a nationwide lockdown on 23 march 2020 for a period of 3 weeks which was extended further to 3rd may. the lockdown was still further extended till 17th may but this time with ease of some restrictions. thereafter, unlock procedure was started in many states and over the time period, several states have reopened various public facilities with adequate precautions. the goi has designated the 733 districts of india into red, orange and green zones according to varying levels of restriction aimed at containing the virus [5] . restrictions are being imposed/withdrawn depending upon the rate of increase/decrease in number of active cases across various states [6] . we are still far away from the pandemic being over and now is the time that we start implementing our exit strategies and prepare ourselves to coexist with this deadly disease. with increasing prevalence of cases in delhi hospitals with affected healthcare workers, the current advice is to take pragmatic decisions and favor non-operative management of most injuries and reduce face-to-face follow-up [7] . in orthopedic surgical procedures, power tools, such as electrocautery, bone saws, reamers and drills, are commonly used that have shown to produce aerosols [8] . it is now well documented that virus transmission can happen through blood aerosols infecting the health care professionals [9] . we present our experience in managing patients with acute trauma presenting to the government-run trauma center in delhi. keeping in mind the future challenges in the post-lockdown period when a sudden surge of orthopaedic emergencies is expected again, we highlight the algorithmic approach adopted by our institute and expect it to be useful in the coming time when uncertainty regarding the end of this pandemic will still persist and we will be expected to coexist with the virus around. the study collected data from the period 23 march to 8 july 2020 at government-run trauma center in delhi. the standard operating procedures (sops) were implemented which were based upon the recommendations of icmr, ministry of health and family welfare, goi and indian orthopaedic association (ioa) [10] , and targeted to provide optimum healthcare at a minimum risk to the treating team as well as other patients admitted to the hospital. sanitization of the facility spraying of the surfaces and mopping of the floors were done with 1% hypochlorite solution every 12 h in areas including wards, icu, offices, gas plant, doctors' duty rooms, entrances and exits, etc. for the emergency ward where patients were received, deep cleaning and sanitization was done every 6 h and on sos basis (in cases of spills, etc.). fomites and workstation cleaning were carried out every 3-4 h with 0.5-1% hypochlorite. strict measures were taken to avoid any unnecessary fomites like papers, forms, boxes, etc. on counters. receiving the patients in emergency separate corridors for entry and exit of patients and health care workers (hcw) were designated so as to avoid risking the work force which is probably the most important resource needed at present times. the emergency wards were designated into isolation and non-isolation zones. whenever possible, all hcws in the emergency were advised to wear full ppe (personal protective equipment), kits (hazmat suits and face shields included) while receiving, examining and resuscitating patients. in these times of crisis, shortage of adequate equipment is not an unexpected event. hence, the minimum protective items that were made absolutely necessary before receiving any patient were n95 mask, face shield, head cap, examination gloves, shoe covers and a surgical gown. all the patients were screened with an infrared thermometer and history pertaining to covid-19 symptoms like fever, dry cough, difficulty in breathing, contact with a known positive case, travel, etc. was elicited. if there was any positive history, the patient was sent to isolation zone and was assumed to be a suspect, while patients with no history of covid-19 like symptoms were shifted to non-isolation zones. ct scans were ordered only when deemed absolutely necessary like in cervicodorsal spine. the imaging rooms were sanitized frequently as per the recommendations of cddc [11] . among the patients shifted to isolation zone (covid-19 suspects), those requiring non-operative treatment were managed with fluids, analgesics, closed reduction and splintage in plasters, etc. as required for the particular injury. the threshold for the need of operative intervention was kept very high in such patients. these patients were discharged at the earliest and referred to dedicated covid-19 hospitals for further testing and management of their covid-19-like symptoms. suspected covid-19 patients who were stable but had a clear-cut need for surgery, like femoral neck fractures, closed displaced intra-articular fractures, irreducible long bone fractures, etc. were given primary treatment in the form of fluids, temporary stabilization with splints, plasters and dressings. they were referred to dedicated covid-19 centers for surgical management in ambulances with hcw in ppe and maintaining special precautions like social distancing, coughing and sneezing etiquettes. patients who were hemodynamically unstable or required a limb/life-saving surgery (whether covid-19 suspect or not), for instance, grade three open fractures, vascular injury, compartment syndrome, mangled extremity, pelvic injuries requiring fixation, implant-related sepsis (in those who were previously treated at our facility) were considered to be covid-19-positive and shifted to isolation zone. they were managed with full covid-19 precautions as discussed further. among the non-covid-19 suspects, who were shifted to non-isolation zone, those who could be managed conservatively were given adequate primary treatment like fluids, analgesics and splintage and were discharged at the earliest so as to minimize the risk of infection transmission to them as well as health care workers. all attempts were made to manage the patients non-operatively. those patients who had absolute indications for surgery were offered surgery, while the relative indications for surgery in a particular injury were considered as low priority. this policy was used as our center was one of the few non-covid-19 centers having the facility to perform fracture fixations requiring c-arm, and thus there was a need to give preference to the absolute indications. this usefulness of this policy became more evident once the lockdown started lifting and patients coming to our center increased. the remaining patients were broadly divided into three categories: 1. patients needing non-operative treatment. 2. patients needing operative treatment but a delay of a couple of days do not adversely affect the outcome for the patient. 3. patients requiring urgent surgery where a delay could adversely affect the outcome. for the first two categories of patients, all the necessary preoperative investigations and their covid-19 samples (throat and nasopharyngeal swab rt-pcr) were sent at the earliest. the surgeries were performed after receiving the covid-19 reports. this also gave time to observe the patients at hospital for any signs of covid-19 infection. the patients with injuries like proximal femur fractures, intra-articular fractures and unstable spine injuries with partial neurological deficit were given priority in the ot list. overall, patients, in whom conservative management or delayed primary surgery would hamper earning of livelihood, were considered for surgical management. for the third category of patients, they were considered covid-19-positive, and were operated taking all the precautions as per the guidelines for personnel protection. the rt-pcr test for covid-19 was sent the very next morning for these patients. this was done so that if the patient comes to be positive for covid-19, the team involved in the surgery could be quarantined as their exposure to aerosols would be high. once the rapid test for covid-19 became available to us, all these patients were tested using the rapid test kit before shifting them to ot. segregation in the wards the preoperative wards were divided into 'covid report awaited' and 'covid report negative' rooms. adequate distancing was maintained between beds and full measures were taken to maintain social distancing among attendants as well as health care workers. proper measures were taken to ensure hand hygiene, use of masks by patients and their attendants, avoiding social gatherings at times of eating, coughing and sneezing etiquettes, etc. all patients and their attendants were required to wear triple-layered surgical masks. patients who tested positive for sars-cov 2 were transferred to dedicated covid-19 facility, to which our center is affiliated. proper measures were taken to ensure the safety of the accompanying healthcare worker to avoid transmission. those who tested negative were shifted to 'covid report negative' rooms and prepped up for surgery as soon as possible. figure 1 is a flow chart depicting the sop adopted by our facility during the covid-19 pandemic. theater settings one operating room out of the two available to us was dedicated for patients needing emergency surgery (where covid-19 status was unknown). even when the testing was available, everyone was alert to the possibility of the test being false negative and precautions were carried out even in these patients. proper donning and doffing areas were designated for equipping ppe kits. anesthetic induction and use of orthopaedic power tools are aerosol generating procedures and require negative pressure maintenance in ots [12] . minimum number of personnel were allowed inside the ot at any given time. all theater staff were advised to wear enhanced ppe that consists of ffp3mask (filtering face piece and the number denotes level of protection), full face shield, head cover, double pair of gloves, full sleeve waterproof gown and shoes. all staff were trained to do donning and doffing in the designated areas provided. general anesthesia (ga) involving intubation has shown to increase the production of aerosols leading to an increased risk of infection to the healthcare workers [9] . the aim was to do most of the procedures under regional block, but this was not possible for all procedures. if ga was administered, then it was carried out with minimal number of staff. the same was applied when the patient was extubated [13] . recovery of the patient was done in theater, and once stable, he/she was shifted directly to post-operative ward. another important aspect in ot setting was careful management of waste. all the wastes pertaining to covid-19 patients (suspects/positives) were discarded in dedicated yellow bags, be it plastic/ cotton/latex or human waste. changes in surgical practices cautery use was minimized. an assistant was handed the task to constantly operate the suction machine. syringe wash was used along with suction instead of direct and pulsed lavage. operating time and blood loss were tried to be kept minimal. objective was to achieve quick and adequate fixation. hammering of implants was carried out only after covering the field with absorbent linen. whenever it was possible, a senior and experienced surgeon would perform most cases so as to reduce the operating time, blood loss and execute quick exposure and fixation. drains were avoided. every precaution was taken to prevent any kind of spillage. the post-operative stay of the patient was tried to be kept to minimum required. after observing the patients for 1-2 days, they were discharged mostly on oral analgesics and antibiotics; however, if intravenous drugs/frequent dressings, etc. were needed, duration of stay was extended. follow-up visits were restricted to suture removal days. a separate floor was designated to run the follow-up opd. most of the complaints and apprehensions of the patients were attended telephonically. during the postoperative stay, the patients were told about what exercises they needed to do and at what time in sessions conducted by our physiotherapist with adequate social distancing. the patients who were covid-19-positive (including those who tested positive after emergency surgery) were shifted to our covid-19-dedicated facility for the further management of their illness after they were deemed stable for transportation. stay of such patients was tried to be kept as small as possible. to carry out this protocol effectively, while keeping the exposure of the healthcare workers to minimum, we divided our team of doctors into two units. each unit worked at a time in divided shifts for 15 days followed by a quarantine period of 15 days. the other unit joined after the 1st unit had finished 15 days of its work. this division of the work force into units was done on the premise that if even one patient with covid-19 infection was operated or admitted in the ward for a significant duration, the team coming in contact would need to be quarantined else they would place the nonexposed staff at risk. with two teams, it would be possible to replace the quarantined team. a total of 794 patients presented to the center who were managed as in-patient and out-patient as shown in table 1 . five (3.5%) out of 142 admitted patients were tested positive in the pre-operative period and only one (0.7%) patient was positive in the post-operative period. fifteen (1.89%) patients with open fractures required emergency surgery before covid-19 sampling could be done. one patient with fracture of lumbar spine with partial neurological deficit (including bladder and bowel involvement) was planned for early decompression and stabilization of the spine, who was detected as covid-19-positive later. all the members of the operative team (including the anesthetist and the paramedical staff) were quarantined for a week in the post-op period and were tested negative after 7 days. table 2 shows the covid-19 positivity rate among hcws with an overall rate of 16.67%, the source of infection, however, could not be validated in them. out of total 17 covid-19-positive individuals, seven (41.2%) were asymptomatic, 10 (58.8%) were mildly symptomatic, and none were seriously ill requiring intensive care. most of these infections were during the first week of lockdown and more than 50% of the workers were of the same category, sharing a common room. this practice of sharing room by multiple workers was discontinued after the initial spike. the present study discusses the management principles of orthopedic trauma during covid-19 pandemic in delhi. patients having emergent conditions like grade three open fractures, mangled extremities, vascular injury, polytrauma or compartment syndrome need to be considered as covid-19-positive (or suspects) and should be managed on urgent basis (with enhanced ppes) with appropriate resuscitation and operative intervention. enhanced ppes and special considerations like separate isolated wards, on table intubation and extubation, minimal use of orthopaedic power tools, reducing the operating time and blood loss, aiming for quick and adequate fixation instead of aggressive and rigid fixation are some extremely important measures that we need to adopt in these times of crisis when the infection is rampant in our health care force leading to compromised patient care and increased stress on our already overburdened medical system. so far in india and other south asian countries, we do not have specific and detailed guidelines for management of orthopaedic accidental injuries. the ioa and boa have published some extensive guidelines; however, the experience and consensus regarding those are remotely available. hence, the experience we are sharing here may be of value in enhancing the acceptability of such guidelines especially in the burdened government set-up with minimal facilities and when there was no clarity about resolution of this pandemic. we were able to operate the negative patients within 48 h of their test reporting. during the surgery of these negative patients, we did not believe it was absolutely necessary to wear full ppe although the choice was left to individuals getting scrubbed in the surgery. spending long duration in full ppe hampers the proficiency of the chief operating surgeon but operating the patient within 48 h of negative report without hazmat suits (which are not available at most places) definitely allowed us to pull off the best possible surgical outcome. operative management of fractures provides early rehabilitation and highest level of function to the patient with minimal residual disability; however, during this pandemic and in the near future, we have to be very careful in such an approach as the patients with covid-19 infection (which may be undetected) are known to have higher complication rates when operated under anesthesia. hence, there is an urgent need to shift back to conservative principles of fracture management and keep the threshold for operative intervention at a higher level. this will ensure the safety of the frontline task force, as was evident from our experience and control the cross-spread of infection to patients coming to the hospital. these changes need to be adopted till efficacious and safe vaccine and targeted drugs for treatment and prevention become available in market. recently, rapid antigen test (rat) from nasopharyngeal swab has been made widely available at all government facilities. although the test is useful in screening the patients coming to the casualty, keeping in mind the massive exposure while performing a surgery, we still recommend an rt-pcr test before taking up a patient for surgery as the sensitivity of rapid test is low (30-45%) [14] [15] [16] . from the point of view of the infrastructure, the lack of single isolation rooms in our facility was one of the main hurdles. initially, during the lockdown, the admissions were less and we could keep the patients on alternate beds. but this could not be maintained once the admission rate increased. another issue was the availability of a single ot complex, making it impossible to maintain a separate facility for covid-19-positive/status unknown patients. proper planning and execution of policies to de-stress our health system and improve patient care without risking the health of its frontline task force is one long mile that this nation needs to cover to survive this and any future pandemics. we believe that we were able to manage our facility well with whatever limited resources we had by following the most important lesson for orthopaedic surgeons is that effective and necessary treatment of patients should be provided while ensuring safety of the health care workers during this pandemic. we need to be prepared to cohabitate with this deadly novel coronavirus and adapt our surgical practices according to the need of the hour. minimizing surgical indications, strengthening the training in conservative principles and following protocols indigenized for workplaces can provide optimum patient care with personal safety. authors' contributions vd: conceptualization, methodology, validation, supervision, writing-original draft, writing-review and editing. nb: methodology, data curation, writing-original draft. ag: data curation, writing-review and editing. vy: conceptualization, methodology, writing-review and editing. vb: conceptualization, methodology, writing-review and editing. vk: validation, supervision, writing-review and editing. funding no funds were received in support of this work. data availability data generated during and/or analyzed during the current study are not publicly available due to confidentiality reasons but are available from the corresponding author on reasonable request. conflict of interest the authors declare that they have no competing interests. ethical standard statement this article does not contain any studies with human or animal subjects performed by the any of the authors. informed consent for this type of study informed consent is not required. comment from china: hope and lessons for covid-19 control. the lancet infectious diseases novel coronavirus covid-19: current evidence and evolving strategies pdf?sfvrs n=4da7b 586_2. accessed full list of red, yellow, green zone districts for lockdown 3 coronavirus: ghaziabad dm extends lockdown restrictions till british orthopaedic association. management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. london: british orthopaedic association characterization of aerosols produced during surgical procedures in hospitals aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review indian orthopaedic association. covid-19 ioa guidelines minimising aerosol generation during orthopaedic surgical procedures-current practice to protect theatre staff during covid-19 pandemic covid-19: infection prevention and control (ipc) low performance of rapid antigen detection test as frontline testing for covid-19 diagnosis rapid point-of-care testing for sars-cov-2 in a community screening setting shows low sensitivity evaluation of rapid antigen test for detection of sars-cov-2 virus key: cord-272061-r4a4cvug authors: rossella, elia; giuseppe, giudice; michele, maruccia title: plastic surgery in the time of coronavirus in italy. can we really say “thanks god we are plastic surgeons?” date: 2020-09-04 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.08.081 sha: doc_id: 272061 cord_uid: r4a4cvug nan we reviewed the data of all the patients admitted to our plastic surgery unit, which is located in a covid hospital, from our institution digital databases from the 1 st to the 31 st of march 2020 and we compared those data with the ones of the previous 5 years. in accordance with the circulars of the ministry of health, the ordinary hospitalization and outpatient activities have all been remodulated in order to meet the potential increase in hospitalization needs and to limit patient the anxiety and the fear of contagion have led many to do-it-yourself for the sanitization of environments and the hygiene of hands and clothes. quite for this reason, ten patients were admitted to our burn center this month alone. the 67% of the patients were treated for burns caused by denatured alcohol, while in the 33% of the cases, the injury was caused by the improper use of corrosive substances, awkwardly used for the artisanal realization of disinfectants. the total number is 22% higher than the five years before. not even the prison system has remained foreign to the previous observations, with reference to patients who had needed recovery and treatment in a plastic surgery department. riots in italian prisons hit the headlines after the italian government decision to discontinue visiting from relatives. maxillofacial trauma admitted to the selected departments raised from the last 5 years of 35%. the plastic surgery community continues to work and to fight the same universal battle with the same sense of responsibility. responsibility to be part of the cure and not part of the disease 2 . for instance, dedicated plastic surgery teams comprising attending physicians and residents have been established in our center. they do not come into contact with each other and alternate on a weekly basis. we should be role models for good hand hygiene and enforce strict compliance to minimize disease spread and not add to the general hysteria 3 . covid-19 and italy: what next? the lancet am i part of the cure or am i part of the disease? keeping coronavirus out when a doctor comes home novel coronavirus and orthopaedic surgery: early experiences from singapore key: cord-264631-rsmcos7j authors: bregman, dana e; cook, tracey; thorne, charles title: estimated national and regional impact of covid-19 on elective case volume in aesthetic plastic surgery date: 2020-07-30 journal: aesthet surg j doi: 10.1093/asj/sjaa225 sha: doc_id: 264631 cord_uid: rsmcos7j background: in efforts to help alleviate the strain placed on healthcare during the covid-19 pandemic, the american society of plastic surgery (asps) recommended suspending elective procedures on march 19, 2020. when this suspension was enacted, it was unknown when cases would resume. objectives: this analysis aims to estimate the regional economic impact of the pandemic specifically with regards to elective, aesthetic surgical procedures. as knowledge regarding the effects of the pandemic has grown, the authors then evaluated the accuracy of our projected estimates when compared to actual events. methods: using the asps 2018 plastic surgery statistics report, regional case volume and surgeons’ fees were obtained for the top five aesthetic procedures. models developed by the institute for health metrics and evaluation (ihme) were used to estimate the anticipated duration of suspension by using the date that no ventilators would be required to for covid-19 patients. this duration was used to calculate the volume of cases that would not occur. results: these estimates predict up to 1.3 billion fewer dollars will be collected in surgeons’ fees, representing a 20% loss compared to 2018. the south atlantic region is predicted to have the greatest number of or days lost; however, the mountain and pacific regions are estimated to have the greatest loss in case volume and surgeons’ fees. conclusions: the cumulative impact of the pandemic on life, society, and the economy is tremendous. this analysis may help guide surgeons’ responses during and after the crisis. a c c e p t e d m a n u s c r i p t as the covid-19 pandemic began to escalate in the united states, the authors sought to predict the economic impact of the crisis on elective, aesthetic surgical procedures. this study endeavors to both present estimations that were made prospectively using predictive models available as of march 2020 and assess the relevance and accuracy of these predictions with the benefit of hindsight in the months since that time. the first 30 days of the pandemic in the united states were overwhelming and frightening for both the population in general and healthcare providers in particular. the most significant consequence of the pandemic has been loss of life. by the end of march 2020, more than 120,000 people worldwide and 24,000 people in the us had died of covid-19. i as of june 27, 2020, almost 500,000 people worldwide and over 125,000 people in the us had died of in the early days of the pandemic in the us, the institute for health metrics and evaluation (ihme) at the university of washington predicted that more than 80,000 americans would die in the next 4 months. iii with the advantage of hindsight, we can appreciate that the scale of the pandemic exceeded our worst expectations. compounding the loss of life are the myriad ways in which society and the economy have been affected. almost ten million americans filed for unemployment in the last two weeks of march, iv and the us government took extraordinary steps to help staunch the economic hemorrhage. v in this context, any consideration of how this would affect the practice of plastic surgery may seem insensitive. the following analysis should not convey that the authors believe the economic impact to plastic surgery is as important as the morbidity and mortality caused by this disease. this analysis sought to clarify the horizon beyond the storm in the early days of the pandemic. initial estimations employed predictions made in the final days of march 2020. at that moment, it was unknown when practices would reopen and elective surgery would resume. while we have the advantage of hindsight to evaluate the accuracy of early predictions, we are facing renewed uncertainty. assessing retrospectively the accuracy of our predictions made with incomplete information may be instructive as we try to imagine an uncertain future. a c c e p t e d m a n u s c r i p t the impact of the pandemic has varied and will continue to vary between states, hospital systems, practitioners, and over time. the centers for medicare & medicaid services (cms) released guidance on 3/18/2020 recommending that low and intermediate acuity surgeries be postponed (table 1) ; vi within the next two days, dr. lynn jeffers, current american society of plastic surgeons (asps) president and dr charles thorne, then president of the american society for aesthetic plastic surgery (asaps), issued similar guidance. vii the duration of this restriction was initially unknown. on april 19, cms released recommendations viii in concordance with the white house"s guidelines on reopening. ix both phases i and ii of reopening guidelines state that elective surgeries may resume provided certain criteria are met. in actuality, the resumption of surgery has occurred differently in each state and county. despite the diversity of reopening plans nationwide, guidance on recommended changes to the informed consent process was released by asps x and asaps. xi these documents elaborate the additional risks of surgery imposed by covid-19 as well as requirements for covid-19 testing prior to surgery. it remains unknown when or whether elective surgeries will resume at a pace similar to that experienced prior to the pandemic. in many locales, hospitals began resuming elective cases with urgent and oncologic surgery, however this varied widely by region, xii and by operating room setting (eg, hospital-based versus private office). based on models accessed march 27, 2020 that predicted state-specific illness due to covid-19, as well as annual cost data for cosmetic procedures, we generated predictions of the economic impact of these surgical restrictions nationally and by region on the five most frequently performed cosmetic procedures in each locale. a critique formulated with the knowledge gained in the three months since these estimates were developed informs the confidence one can place in models of dynamic phenomena. a c c e p t e d m a n u s c r i p t methods data on surgical volume and surgeons" fees for elective, aesthetic cases were derived from the 2018 plastic surgery statistics report published by asps xiii ; these data are based on survey responses from society members with estimates of regional and national volume extrapolated from these responses to the cohort of board certified plastic surgeons nationwide. within this report, states are divided into five regions: (1) table 2 . xv estimates of economic impact reflect the volume of the five most commonly performed cosmetic procedures within each region in 2018 using the national average physician fee (table 3) . additional information on cost per procedure such as operating room fees vary regionally and by length of procedure and is not included in this analysis. estimates of duration of covid-19 impact were based on state-specific figures and predictive models from ihme data as of march 27, 2020. xvi data provided by this model include state-specific forecasts of mean and range of uncertainty for the daily number of patients with covid-19 requiring hospital beds, icu beds, and invasive ventilation. in additional, the model provides estimations of daily hospital and icu admissions, mortality, and number of icu and non-icu beds required beyond the capacity of the state. the following values from the ihme model were collected and entered into a database: the mean, upper, and lower bounds of the 95% confidence interval that were used to estimate the mean, earliest, and latest dates for which the model predicts there will be fewer than 0.5 patients requiring hospitalization, invasive ventilation, and icu beds. for states that had reported cases prior to 3/27/2020, the actual dates when the first patients required hospitalization, icu beds, or ventilator support were known. a c c e p t e d m a n u s c r i p t the duration of suspension of elective cases was estimated in several ways for each state: the number of days from 3/19/2020 (per asps guidance) to the respective predicted dates when a mean of <0.5 patients would require hospital beds, icu beds, and invasive ventilation. consequently, calculations of "or days lost", are for all days including weekdays and weekends. the mean number of days affected for all states in a region was calculated and used for estimations of impact on surgical volume and economic loss on a regional basis. it was initially unknown which measure of predicted hospital burden (ie, hospital bed occupancy, icu bed occupancy, or ventilator use) would most inform when the health system in a particular region would be ready to resume elective surgical procedures. however, the authors postulate that the period during which patients require invasive ventilation reflects the most acute degree of illness burden placed on the healthcare system and provides information on state-specific effects. therefore, the predicted date by which the model as of 3/27/20 showed <0.5 patients would require invasive ventilation was used to project the date by which elective, cosmetic cases would resume to a pace similar to prior to the pandemic. additional information on whether and when states have resumed elective cases was collected for each state (when available) and the ihme model incorporates data regarding regional hospital resources, state-wide information on infections and deaths from covid-19, and observations on the spread of the disease to predict when and to what degree states would most likely have patients requiring hospitalization, critical care, and invasive ventilation. this model relies on several assumptions regarding most likely progression of the virus and death rates based on the data available from china, italy, south korea, and the us. the number of or days lost, as estimated from 3/19/2020 to when invasive ventilators were estimated to no longer be required was determined for each state ( figure 2 ). the national average days a c c e p t e d m a n u s c r i p t lost using this estimation is 94.38 (range, 43-119; sd, 21.24). for comparison, estimates of duration of covid19 impact were also calculated for each state on the predicted duration when hospital beds and icu beds would be required. nationally, mean duration from 3/19/2020 to when the last hospital bed would be required is 105.3 (range, 53-126; sd, 20.77); the mean duration from 3/19/2020 to when the last icu bed would be required is 96.18 (range, 44-119; sd, 21.15) ( figure 3) . these values are also calculated per region, demonstrating that region three (south atlantic) has the greatest number of estimated lost days using the duration from 3/19/20 to when invasive ventilators are estimated to no longer be required. region 1 (new england and middle atlantic) has the fewest estimated or days lost ( figure 4 ). several states have since announced when elective cases may resume following the initiation of restrictions. data were available for 31 states; the mean duration from 3/19/2020 to when elective surgeries were stated to resume is 42.65 (range, 32-70; sd, 9.84). estimates of impact on regional case volume assume that the duration of restrictions on elective, cosmetic cases extends from 3/19/20 to the estimated date when patients no longer require invasive ventilation derived from the ihme model. when considering the five most commonly performed cosmetic procedures performed in each region in the year 2018, these figures predict an estimated 286,327 of these cases will not be performed (range, 173,299-304,324 ). this will result in an approximate loss of 1.2 billion dollars (range, 0.7-1.3 billion dollars) in surgeons" fees, based on national rates of reimbursement for 2018. the region expected to have the greatest loss in case volume and revenue is region 5 (mountain and pacific), reflecting the greater volume of cosmetic cases performed in this region relative to other regions ( figure 5 ). the contributions of individual procedures to the overall economic impact on a regional basis is displayed in figure 6 . in two regions, region 5 (mountain and pacific) and region 2 (east north central and west north central), the plurality of the total economic impact is due to loss a c c e p t e d m a n u s c r i p t of breast augmentation procedures. the mean, minimum, and maximum estimates for anticipated or days lost were used to predict the cumulative impact on case volume and surgeons" fees collected for the top five most common procedures in each region ( figure 7 ). it is impossible to know what precisely lies ahead in this time of uncertainty. of greatest concern is the enormous and ongoing loss of life due to the pandemic. this analysis makes no claims as to the relative importance of the concerns of cosmetic plastic surgery. rather, these predictions are a dispassionate estimation of how surgical volume may be differentially affected based on regional variations in covid-19 cases and surgical volume. in the early days of the pandemic, it was unknown when elective cases would resume. states are now reopening, but some states that had resumed elective surgeries, such as texas, have had to scale back due to increases in covid-19 cases burdening the local healthcare system. xix in 2018, a total of 16.5 billion dollars was spent on cosmetic procedures, both surgical and minimally invasive, in the united states. xx nationally, the top five most commonly performed surgical cosmetic procedures in 2018 were abdominoplasty, blepharoplasty, breast augmentation, liposuction, and rhinoplasty. the total surgeons" fees derived from these procedures in 2018 was approximately five billion dollars. this analysis demonstrates that the current pandemic will result in an approximately 20% decrease in collected fees. this does not approach the total economic impact. the cost involved in taking a patient to the operating room involves numerous factors with a wide degree of variation influenced by regional differences, type of care setting, devices utilized and patient mix. in 2018, authors childers et al created the first standardized estimates of operating room cost. xxi it was estimated that for the state of california, the mean cost of an operating room was approximately $36 per minute. this estimate does not reflect the total cost charged to a surgical patient, as it does not include anesthesia, blood products, pathologic tests and fees for implants. however, we can utilize a c c e p t e d m a n u s c r i p t this as a benchmark to attempt to estimate the effects of the surgical suspension has had in regards to operating room fees. using these estimates, an hour of operating room costs is estimated to be $2,160. assuming the majority of elective cases take anywhere from 1 to 4 hours, it is evident that the overall economic losses incurred by restrictions on surgeries are far greater than those due to lost surgeons" fees alone. there are additional reasons why the aforementioned underestimates the overall economic impact: only the top five procedures in each region are included in this analysis; there is no discussion of minimally invasive procedures; office based surgery will likely resume prior to hospital based surgery for those same procedures; patients may be unwilling to undergo procedures in a hospital based setting for longer than the duration of or closure; and patients may suffer economic losses during this time that preclude spending on non-essential costs such as elective surgeries. there are also factors that may result in surgeons recouping some of the anticipated lost income: surgeons may elect to perform procedures in private ors at dates earlier than those employed in this analysis; surgeons may perform non-invasive or office-based procedures on a timeline that is wholly different from estimates based on ventilator need; and there may be a period after the restrictions are lifted when surgeons are performing procedures at a rate higher than that predicted from historical averages because of a "back log" of cases. in addition to variations in the data relating to surgeons" and patients" behavior, there are innumerable variables influencing the duration and severity of this pandemic. predictions from the ihme model on 3/27/20 undergird these estimates of the economic impact of the pandemic. there are significant limitations to this model including: limited foundational data based on publicly available information from wuhan, china, the veracity of which cannot be assured; assumptions regarding social distancing and the impact thereof on the spread of the virus; the manner with which the virus will spread differently in the context of a metropolitan versus rural area, or a long term care facility versus an ambulatory population; and the manner with which different municipalities will enact mandatory or voluntary guidance on interventions to mitigate the spread of the virus (eg, requiring face covering) in the face of location-specific a c c e p t e d m a n u s c r i p t epidemiology data. additional variables including local politics, accuracy and availability of data, and population compliance to local mandates, complicate our ability to account for the limitations inherent to the model, or predict the direction in which these limitations may skew the model. however, the preceding analysis is anchored by the most robust predictive data available early in the pandemic regarding impact on hospital operations. the authors do not believe that the appropriate response to such uncertainty is to avoid attempts to estimate the impact of the virus. rather, it is valuable to assess the conclusions derived from these models as well as interrogate the accuracy of their predictions retrospectively. understanding the reliability of these predictive models in a retrospective manner informs one"s assessment of their future utility as the pandemic evolves. comparing estimates of duration of restrictions on surgery based on anticipated duration of ventilator use to actual duration from 3/19/2020 to when some states announced the resumption of elective surgeries demonstrates a large discrepancy; the former predicts 94.38 days whereas the latter is 42.65 days. it is critical to recognize the following: the duration of restrictions based on states" announcing resumption of surgeries is calculated on incomplete information (31 of 50 states); although elective surgeries may resume, many hospital systems are resuming cases in a staggered manner that prioritizes tier 1b, 2a, and 2b cases; and individual hospital systems may resume cases in an idiosyncratic manner not accounted for in these estimates. of all surgical subspecialties, elective plastic surgery may be one of the most affected by the current crisis. all practitioners underwent dramatic, immediate changes to their practice. those who operate for primarily reconstructive indications have generally been permitted to resume surgery prior to those performing cosmetic cases. one may also consider whether there are distinct levels of risk to each procedure given nasopharyngeal carriage of the virus. it is reasonable to hypothesize that rhinoplasty may have greater inherent risk compared to abdominoplasty (given that all other variables are equal) due to the anatomic site of surgery. however, patients undergoing elective surgery are required to undergo covid-19 testing prior to their procedure, which may mitigate a c c e p t e d m a n u s c r i p t potential increased risk based on surgical site. the authors further anticipate that all cosmetic, elective cases will be deferred until the risk of surgery is perceived to be minimal regardless of anatomic location. finally, procedures requiring general anesthesia require intubation, a process that generates potentially infectious aerosolized material and occurs regardless of surgical site. prior scholarship on the impact of economic downturns on aesthetic plastic surgery has shown that since consumers directly pay for procedures, the application of market economic analysis is appropriate, in contrast to other surgical procedures financed by health insurance. in 2010, gordon et al investigated this premise by comparing the volume of four common cosmetic procedures to trends of the three major us stock market indices; the dow jones, nasdaq and s&p 500 funds. as anticipated, the study confirmed a direct correlation between the majority of their cosmetic procedures and the three major market indices. procedures such as total joint replacements and elective lumbar and cervical spine surgery were not influenced by the economic downturns in the 2000s. xxii,xxiii,xxiv,xxv the recent restriction of elective surgeries was entirely unique, and the relevance of these historical findings to the current situation is yet unknown. however, given this and other works by krieger et al in regards to cosmetic surgery during times of recession, xxvi it may be prudent to maintain a broad-based practice including reconstructive surgery, aesthetic surgery, and minimally invasive procedures in order to maintain control over one"s practice during this time of uncertainty. these data suggest that there will be significant regional variation in economic impact due to covid-19. many variables contribute to these regional discrepancies, only some of which are considered in the figures provided herein. the total population in each region varies between 51,557, 675 and 77,993,663. 17 there are likely also regional differences in average annual income, interest in cosmetic surgery, and proximity to a plastic surgeon; these differences exist apart from the differential impact the pandemic has on each state. on january 20, 2020, the first confirmed case of sars-cov2 was reported in washington state. xxvii within two weeks, cases were identified in six states (wa, ca, il, az, ma, wi). by march 18, cases were present in all 50 states. new york a c c e p t e d m a n u s c r i p t emerged as an early epicenter and struggled to care for the thousands who had fallen ill and required hospitalization. case incidences were predicted to peak and wane at different times, with the mean predicted date on which patients no longer require ventilators ranging from 5/31 -7/3. areas of the country in which the predicted date of peak case volume is closer to the date when surgeries were restricted nationally per cms guidance (3/19/2020) are predicted to have a shorter duration of case restriction, as the national prohibition on surgeries aligns with their predicted time course. states that experienced peak case incidence later than 3/19/2020 were estimated to have a longer duration of impact as their time to case volume decrease lagged behind the respectively later date of peak cases. region 1 (new england and middle atlantic), which saw the majority of cases early in the pandemic, was predicted to have the earliest resolution of ventilator requirement. region 3 (south atlantic) was predicted to have patients requiring ventilators until 7/3. although states on the east and west coasts were the first to be significantly affected by the pandemic, restrictions on cosmetic surgery reflect the national guidance that recommended suspending procedures beginning 3/19/2020. data are also provided with respect to estimated or days lost based on the duration for which ventilator, icu beds, and hospital beds are required by state. it is possible that these estimations do not accurately reflect the period during which elective surgeries are suspended. additional limitations on availability of personal protective equipment (ppe) may inspire hospitals to have a staged reinstatement of elective surgical cases with priority placed on semi-elective procedures that were delayed due to the pandemic. states may officially reinstate elective cases earlier than the duration during which icu beds and ventilators are required; however, the authors believe that full reinstatement of elective, cosmetic cases will lag behind as surgical priority is given to cases such as oncologic extirpations. the authors therefore elect to rely on estimations that are more conservative. it is likely that elective cases will resume while some number of patients are predicted to still require critical care and ventilation. however, the delayed fashion with which cosmetic cases are permitted by individual hospitals relative a c c e p t e d m a n u s c r i p t to the stated date when elective surgeries resume; as well as the limited or time available given the backlog of cases that need to be performed, will likely result in full reinstatement of cosmetic cases being delayed longer than suggested by states" published date of elective case resumption. although some states have resumed elective surgeries at dates earlier than those provided by the aforementioned estimations, it is possible that early resumption of elective cases will be followed by reimposed restrictions, as seen in texas. recent findings suggest that when hong kong relaxed restrictions on social interaction after having apparently controlled the virus, the number of new cases rapidly increased. xxviii however, as testing becomes more widely available, it is possible that social distancing restrictions could be limited to regions with continued viral transmission. furthermore, testing for antibodies against the virus could identify patients and healthcare providers who have recovered from the virus and are at a theoretically reduced risk of illness. it is important to note that knowledge of the risk of reinfection and the prevalence of asymptomatic viral carriers remains limited. xxix the ihme models of the impact of the pandemic by state were a valuable resource for estimating the trajectory of the pandemic in its early days. despite this, the actual course of the virus throughout the us deviated from these predictions in several states. overall, elective surgical cases have resumed prior to the date estimated by the predicted requirement for invasive ventilation in each state. the resumption of cases has not meant that operating rooms are functioning at full pre-pandemic capacity. furthermore, the reopening of some states has been met with increasing numbers of covid patients and consequently some states have had to reverse course. the financial impact with respect to anticipated loss of surgeons" fees does not capture the total economic impact of the pandemic or of the loss in elective cases as it does not include operating room fees or hospital costs. a c c e p t e d m a n u s c r i p t a 3,000% jump in jobless claims has devastated the us job market it"s a wreck": 3.3 million file unemployment claims as economy comes apart. the new york times centers for medicare & medicaid services. non-emergent, elective medical services, and treatment recommendations centers for medicare & medicaid services. centers for medicare & medicaid services (cms) recommendations re-opening facilities to provide non-emergent non-covid-19 healthcare: phase i american society of plastic surgeons the aesthetic society. covid-19 informed consent agreement state resumption of elective surgery orders, guidance, and resources national clearinghouse of plastic surgery procedural statistics census bureau quickfacts: united states accessed april 7, 2020. xvi. institute for health metrics and evaluation american college of surgeons. state resumption of elective surgery orders, guidance, and resources champagne sr. gov. greg abbott pauses texas" reopening, bans elective surgeries in four counties to preserve bed space for coronavirus patients. the texas tribune national clearinghouse of plastic surgery procedural statistics understanding costs of care in the operating room cosmetic surgery volume and its correlation with the major us stock market indices impact of the economic downturn on total joint replacement demand in the united states impact of the economic downturn on elective lumbar spine surgery in the united states: a national trend analysis impact of the economic downturn on elective cervical spine surgery in the united states: a national trend analysis cosmetic surgery in times of recession: macroeconomics for plastic surgeons a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t key: cord-266842-fr7kj186 authors: mckechnie, tyler; levin, marc; zhou, kelvin; freedman, benjamin; palter, vanessa; grantcharov, teodor p. title: virtual surgical training during covid-19: operating room simulation platforms accessible from home date: 2020-05-01 journal: ann surg doi: 10.1097/sla.0000000000003999 sha: doc_id: 266842 cord_uid: fr7kj186 nan the past several decades, there remain a number of options for the maintenance of intraoperative knowledge beyond textbook-learning that are easily accessible from home. computer-and phone-based technologies provide access to intraoperative video recordings, virtual reality (vr) operating room simulations, and other interactive surgical platforms. such applications are widely available and have the potential to satisfy and supplement the learning needs of surgical trainees as defined by surgical education governing bodies. 2 moreover, surgical simulation has the potential to increase objective technical proficiency in the operating room, decrease intraoperative errors, and decrease operative time. 3 the aim of the present article is to provide an overview of the available computerand phone-based platforms accessible at home for surgical trainees who currently have limited surgical exposure given the ongoing covid-19 pandemic. such a review may allow surgical trainees as well as surgical education governing bodies to initiate and create at-home surgical curricula during the covid-19 pandemic. exponential growth of computer processing power over recent decades has fueled a parallel expansion of computer-based surgical platforms. currently, over 20 computer-based platforms, ranging over nine surgical specialties, are available on the internet and are accessible from home. fifteen computer-based platforms are freely accessible, one platform (incision academy) is offering a four-week free trial during the covid-19 pandemic, and seven platforms require paid accounts. subscribe. 4 it has been demonstrated that residents with an active subscription to score portal score higher on their american board of surgery qualifying examination. 5 the journal of medical insight (jomi) is a peer-reviewed surgical video journal that offers annotated intraoperative videos along with supporting primary literature, organized neatly into "chapters". each chapter pertains to a specific step of the selected procedure, as well as offers an opportunity for self-assessment. access to this platform costs $50 per month or $500 per year for surgical residents. two platforms focus solely on general surgery and six have content pertaining mostly to general surgery while also having additional modules focused on other surgical specialties. incision academy is a european-based online platform that presents live intraoperative video. it details the steps of a given operation, provides primary literature evidence, allows for interactive anatomy learning relevant to the operation, and has a section for self-assessment. they have released a free four-week trial in light of the covid-19 pandemic. websurg is an online platform that publishes multimedia general surgery, as well as gynecology, content monthly. it is produced by the institute for research into cancer of the digestive system (ircad, france) and is supported by medtronic© and karl storz©. over 2,000 sequenced and subtitled intraoperative videos in seven languages are currently available. this platform also offers free live webinars and conference broadcasts. users must register a free online account for full access. teach me surgery has a large general surgery section as well as sections available for other surgical specialties. this is a free platform that organizes over 400 peer-reviewed articles, has over 1,000 interactive clinical images, and allows for self-assessment. similarly, surgery squad caters to general surgery, ophthalmology, and obstetrical procedures. it is an interactive, virtual reality platform that allows the user to progress through the key steps of an operation. copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. ensure material consolidation. touch surgery has been validated by 19 independent peerreviewed publications. for example, touch surgery laparoscopy and intramedullary femoral nail simulations were able to significantly distinguish between expert surgeons and novices (p<0.001, p<0.001). 8, 9 additionally, studies have reported that users find the surgical simulations to be realistic. 8, 9 level ex developed four free interactive animated phone applications entitled cardio amidst the covid-19 public health crisis, that has infected more than one million people in over 180 countries, the educational needs of surgical trainees should not be neglected. promoting remote learning platforms such as those highlighted in the present review and integrating them into formal curriculum can expand educational opportunities beyond the walls of the hospital. such measures may mitigate the diminished surgical skill among surgical trainees that is foreseeable in hospitals across the word. copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. covid-19: elective case triage guidelines for surgical care the role and validity of surgical simulation surgical simulation in 2013: why is it still not the standard in surgical training? what can score web portal usage analytics tell us about how surgical residents learn? subscription to the surgical council on resident education web portal and qualifying examination performance creation, implementation, and assessment of a general thoracic surgery simulation course in rwanda telemedicine for retinal care in developing nations: the orbis cyber-sight programme validating touch surgery™: a cognitive task simulation and rehearsal app for intramedullary femoral nailing validation of the mobile serious game application touch surgery™ for cognitive training and assessment of laparoscopic cholecystectomy wolters kluwer health, inc. unauthorized reproduction of this article is prohibited key: cord-035258-nff6gfik authors: tanner, tristan george; colvin, mai o. title: pulmonary complications of cardiac surgery date: 2020-11-11 journal: lung doi: 10.1007/s00408-020-00405-7 sha: doc_id: 35258 cord_uid: nff6gfik cardiothoracic surgery posits an arrangement of large, significant hemodynamic, and physiologic alterations upon the human body, which predisposes a patient to develop pathology. the care of these patients in the postoperative realm requires an astute physician with deep understanding of the cardiopulmonary system, who is able to address subtle developing problems promptly, before the patient suffers further sequelae. in this review, we describe the presentation and management of an assortment of important complications which occur in the pulmonary system. in addition, we aim to shed better light upon how the physiology of a patient responds to the condition of cardiothoracic surgery. cardiac surgery is a high-risk field requiring specialized teams to manage patients in the perioperative and postoperative environment. the pulmonary system, exquisitely related in both spatial proximity and synergistic function, requires close attention and support during cardiac surgery's acute stress. pulmonary complications are common in patients who undergo cardiac surgery with outcomes such as pneumonia, pulmonary embolism, ventilation longer than 24 h, and pleural effusions necessitating drainage being reportable to the society of thoracic surgeons [1] . pulmonary complications after cardiac surgery result in prolonged hospital stay and increase in healthcare cost [2] . patients prone to complications tend to have limited homeostatic reserve associated with chronic heart failure, pulmonary illness, multiple comorbidities, older age, or have completed more invasive and longer duration surgeries [3, 4] . as the field continues to advance medical acumen, we seek to protect the pulmonary system better. cardiac surgery commonly uses cardiopulmonary bypass (cpb), which provides advanced physiologic support with an extracorporeal circulatory device. depending on the type of cardiac surgery, the lungs experience up to several hours of relative ischemia during bypass. under normal physiology, blood is delivered to the lungs by both pulmonary and bronchial arterial systems which share collateral circulation. during bypass, perfusion is solely provided to the bronchial system, placing the lungs in a relative state of ischemia. upon cessation of bypass, reperfusion of the lungs occurs after reinstatement of pulmonary arterial flow. in addition, bronchial arterial flow on bypass paradoxically decreases, contributing to worsening low flow ischemia, which normalizes after pulmonary arterial clamping ends [5] . this environment generates ischemia-reperfusion injury with a proinflammatory/proapoptotic state, characterized by reduced microvascular permeability, increased arteriolar resistance with pulmonary hypertension, and pulmonary edema with impaired gas exchange. these physiological changes generate an overall predisposition to develop pulmonary complications [6] . several changes in intraoperative care have been studied aiming to alleviate pulmonary ischemia/reperfusion. bronchial arterial flow during bypass is continuous. adding pulsatile flow to the extracorporeal output did not improve pulmonary outcomes, but parallel continuous pulmonary arterial cold perfusate infusion attenuated pulmonary ischemia-reperfusion injury [7, 8] . this may preferentially benefit patients with pulmonary conditions like copd [9] , but this practice is not standard of care and would require further study. ischemia-reperfusion injury affects the intravascular compartment adjacent to pulmonary microcirculation, causing no-reflow phenomenon. no reflow was initially coined in coronary vasculature during atheroembolism. with diminished flow and concurrent ischemia to local endothelial and interstitial tissue, cells of the vessel wall swell and protrude into the lumen, obstructing flow [10] . activated neutrophils and platelets also likely trap red blood cells to obstruct microcirculation, causing persistent vascular insufficiency after reperfusion [3, 4] . other strategies to limit lung injury during cpb are being studied and remain active areas of research. some suggested strategies include introducing prophylactic steroids to reduce the inflammatory cascade associated with cpb [11] , biocompatible circuits to mimic endothelial surface [12] , and leukocyte filters to preferentially remove activated leukocytes [13] . continuous heparin infusion is maintained during cpb, with activated clotting time (act) kept within therapeutic range to offset thrombosis within the extracorporeal circuit. a primary reason for using heparin is that it is rapidly reversed with protamine sulfate, an alkaline polypeptide which reacts with the acidic heparin to generate neutral inert salt. on occasion, protamine-heparin complexes can induce nonimmunogenic anaphylaxis (anaphylactoid reactions, with classic complement activation and degranulation of mast cells), which is less severe with lower protamine dose and slower infusion rate [14] . series report this complication in 0.06-10.7% of patients, with clinically significant pulmonary reactions to protamine, including wheezing/bronchospasm, pulmonary hypertension, and noncardiogenic pulmonary edema, with worsening mortality [15] . this protamine reaction likely exists on a spectrum. it more commonly presents subclinically with small decreases in systemic arterial pressure and increased pulmonary artery pressure noted by the operative team after use. these minor reactions, even when isolated and adjusted for preoperative and intraoperative risk factors, were associated with increased inpatient mortality [16] . management of the protamine reaction is supportive, although patients with severe anaphylaxis are sometimes re-heparinized and temporarily placed back on cpb [17] . managing multifactorial coagulopathy is a large component of bypass care during cardiac surgery, and venous thromboembolic disease associated with the venous access cannula (and embolization into the pulmonary circulation) is a rare, catastrophic complication during cardiac surgery. the circulation during cardiac surgery is in a focally static state with endothelial injury, fulfilling virchow's triad. williams et al. [18] compiled 48 cases of acute intracardiac thrombosis and pulmonary embolism after cpb. common features among these cases included congestive heart failure (50%), platelet transfusion (37.5%), cpb duration > 3 h (37.5%), and aortic injury (27.1%). thrombolytic therapy was only used in 5 out of 48 cases but efficacy was unclear, given frequent use of the antifibrinolytic protamine sulfate therapy (77.1% of cases). intracardiac thrombosis with pulmonary embolism can present with profound refractory hypotension and biventricular failure during or after separation from bypass. one case presented with cardiac arrest after protamine administration. 64.6% of cases were diagnosed with transesophageal echocardiography. treatment has typically been to reestablish cpb (54.2%) and perform thrombectomy (31.3%). this generally required additional mechanical support devices, culminating in an 85.4% mortality rate. cardiac surgery is invasive and frequently requires therapeutic anticoagulation during cpb, which commonly requires allogeneic blood transfusion [19] . an estimated 10-15% of the collective blood donor supply is utilized during cardiac surgery. with restrictive transfusion strategy, over 50% of the patients receive perioperative transfusion [20, 21] . while the chance of clinically significant microbial contamination is equal to being struck by lightning, transfusion-related acute lung injury (trali) is the primary adverse event and most common cause of death from blood transfusion worldwide [22] . trali is defined as acute onset of hypoxia and bilateral pulmonary infiltrates after allogeneic blood transfusion that is difficult to distinguish from alternative causes of acute lung injury. the condition is more prominent in cardiac surgery patients than in other transfused groups in the inpatient setting [23] . this condition, mediated by donor antibodies directed against host leukocytes, is thought to unfold in a "two hit" manner. the first hit involves systemic inflammatory activation in the host, activating endothelial cells within the lung to induce neutrophil sequestration. the second hit involves preformed donor alloantibodies reacting with these neutrophils to induce an inflammatory cascade that injures the pulmonary interface [23, 24] . cpb is associated with neutrophil activation and inflammatory response, which may prime the environment for trali to occur [25] . treatment is discontinuation of the inciting transfusion and supportive care. reduction in the frequency and amount of blood products transfused is beneficial, but even small sub 10-20 cc volumes of plasma have been shown to induce trali [23] . use of a restrictive transfusion threshold for moderate-to high-risk cardiac surgery patients, even when controlled for chronic pulmonary disease, shows equivalent cardiac outcomes while allowing us to transfuse less patients and avoid this complication [21] (table 1) . atelectasis is a common cause of hypoxemia and impaired gas exchange after cardiac surgery. atelectasis is seen in 30-72% of postoperative chest radiographs after cardiac surgery and is a major contributor to the postoperative respiratory dysfunction [26, 27] . nearly all patients with general anesthesia develop atelectasis while spontaneously breathing and after muscle paralytics are administered, regardless of the use of intravenous or inhalational anesthetics [40] . in an animal study, cardiopulmonary bypass produced large atelectasis with a corresponding increase in intrapulmonary shunt and decrease in pao 2 [41] . in the same study, animals who had sternotomy without cpb only had minor atelectasis in comparison. in another study using computed tomography (ct) scans to assess the degree of atelectasis in patients who underwent cabg and mvr, the area of atelectasis was considerably larger than previously seen if the patient underwent additional abdominal and lower extremity surgery on the first day after operation [42] . the amount of atelectasis and shunt was similar in patients who had undergone mvr or cabg open surgeries [42] . other postoperative factors worsening atelectasis include diaphragmatic dysfunction due to phrenic nerve injury, inadequate pain control, and immobilization. treatment of atelectasis includes frequent chest physiotherapy, incentive spirometry, encouraging pulmonary hygiene, as well as noninvasive ventilation and high-flow nasal cannula [43, 44] . postoperative pleural effusions in cardiac surgery can have a broad range of etiologies and should be approached with care and heightened attention. thorough clinical history and pleural fluid analysis is often required to delineate the origin. timing is a key component of an effusion's etiology. early effusions (the initial 15 postoperative days) are typically hemorrhagic, neutrophil predominant, and associated with operative trauma. later effusions tend to be lymphocyte predominant and autoimmune in etiology [45] . after cabg, effusions are associated with low bmi, female gender, history of atrial fibrillation, history of heart failure, concurrent valve replacement, and history of anticoagulation [45] . postoperative pleural effusion is the second most common cause of readmission in a cabg patient (22.5% of patients), and the need for thoracentesis is a poor prognostic sign [45, 46] . a benign, self-resolving pleural effusion can often present after harvesting the left internal thoracic artery [47] , but harvesting of the internal mammary artery does not share the same association [45] . pleural effusions after cardiac surgery also often represent a limited or complete presentation of postpericardiotomy syndrome. postpericardiotomy syndrome is a spectrum of pathology following cardiac surgery in approximately 15% of cases [47] . while traditionally defined as pericarditis following cardiac surgery, it has evolved to define a (likely) autoimmune response to both pleural and pericardial interfaces after direct damage or entry of blood into the pericardium [45] . in fact, isolated intraoperative pleural incision predicts development of this complication, with hazard ratio of 4.31 on one series [48] . the clinical presentation usually includes 2 of the following: fever without an infectious source, pleuritic chest pain, new pleural effusion, pericardial friction rub, or persistent pericardial effusion several weeks after surgery. over 80% of postcardiotomy syndrome cases have pleural involvement and development of effusion [48, 49] , and a late atypical presentation can be with an isolated pleural effusion [49] . the pleural fluid is typically exudative, 75% showing > 10,000 erythrocytes and lymphocytes > 50% [50] . the syndrome was also shown to produce similar clinical presentation and fluid qualities, regardless of whether a patient was post-cardiac surgery or post-pacemaker placement [50] . postcardiotomy syndrome-related effusions have strong predilection for the left hemithorax; 83% are left-side predominant, 67% are unilateral (> 95% unilateral and left sided), and 38% of the effusions are noted to fill greater than ½ of the affected hemithorax [50, 51] . treatment of the syndrome is typically with nsaids and colchicine, and therapeutic thoracentesis should be promptly offered to those with moderate and large effusions. therapeutic thoracentesis significantly affects physical recovery rate through 30 days mean walking distance, which is associated with reduced postoperative cardiovascular events [52] [53] [54] . as discussed earlier, cardiac surgery is commonly associated with postoperative blood loss, often collected in the pericardial and pleural systems. acute-retained blood manifests with hemothorax and gross blood drainage through thoracostomy tube, which is prone to coagulate within the chest cavity or the chest tube lumen and make the situation less amenable to nonoperative drainage. subacute-retained blood presents as pleural effusion, with drainage appearing more as liquefied blood-containing pleural fluid than frank blood. chronically retained blood can manifest with fibrothorax, an outcome of prolonged inflammatory states of the involved serous membranes, which eventually deposit dense adhesive fibrotic tissue [55, 56] . this continuum of complications is called retained blood syndrome, which negatively impacts hospital and 30-day mortality in cabg patients, prolongs icu stay, prolongs the duration of mechanical ventilation, and increases the incidence of stroke (particularly when intervention is required) [55, 57, 58] . risk factors for postoperative bleeding in cardiac surgery patients include advanced age, low body weight, nonelective surgery, cpb time over 150 min, high complexity of procedure, perioperative use of antiplatelet agents, and use of over 5 bypass grafts [58] . incidence has been estimated to be 13.8-22.7% [59] . concurrently with pleural effusions and retained blood products, there should always be concern for pulmonary infection, discussed next. the left and right phrenic nerves originate from c3, c4, and c5 within the cervical spine, moving caudally within the thorax alongside the great vessels (particularly the subclavian arteries) and pericardium bilaterally. eventually these nerves pierce the two diaphragmatic domes, relaying sensory and motor innervation. in addition, these nerves receive sensory innervation from the pericardium and the mediastinal portion of the parietal pleura. the phrenic nerves are key components to maintain successful independent respiratory function. surgical injury typically causes complete unilateral suspension of diaphragmatic function, commonly while the surgeon dissects near the internal thoracic artery [60] . in addition, prior studies have shown that phrenic nerve injury is associated with cold-induced injury during myocardial protection strategies [61, 62] . the incidence of phrenic nerve injury is unclear, with studies citing between 10 and 73%, likely owing to the sensitivity of diagnostic testing [1] . diaphragmatic dysfunction generates paradoxical diaphragmatic movement or grossly reduced diaphragmatic excursion, which can be visualized through liver and splenic windows with bedside ultrasonography. diaphragmatic atrophy is also noted with prolonged paralysis, depicted as a diaphragmatic thickness below 0.2 cm at end expiration. other ultrasound modalities used include diaphragmatic thickening and diaphragmatic excursion fraction to assess function [63] . management of diaphragmatic dysfunction typically requires supportive care, while addressing potential differential causes. many patients fully recover the nerve function over time [61] . debilitating cases of diaphragmatic paralysis with paradoxical diaphragmatic motion have been treated with early tracheostomy as it is felt to lessen the severity of pulmonary complications [61] . healthcare-associated infection is one of the leading causes of non-cardiac morbidity after cardiac surgery, with pneumonia being the most common, costly, and resource-intensive infectious complication [31, 64] . 2.4-20% of patients develop pneumonia after cardiac surgery, 33% of which occur after discharge [31, 32] . ventilator-associated pneumonia also becomes problematic in postoperative patients experiencing prolonged mechanical ventilation, complicating 35.2% of patients who remain intubated for over 48 h [64] . in a prospective cohort trial observed 5158 patients in 10 centers, ailawadi et al. worked to categorize postoperative pneumonia and clinical outcome [31] . risk factors isolated included known copd, older age, current steroid use, low hemoglobin level perioperatively, longer duration of surgery, and the involvement of lvad insertion or heart transplant. measures found which may protect against development of this complication include perioperative use of second-generation cephalosporins, under 24 h on the ventilator, avoiding the use of a nasogastric tube perioperatively, restrictive transfusion of packed rbcs, and use of few platelet transfusions. most common isolated organisms, in order of frequency, included pseudomonas, klebsiella, then enterobacter cloacae. finally, postoperative pneumonia showed a ninefold increase in mortality and 2 weeks increase in hospital length of stay [31] . chlorhexidine oral care has also been shown to reduce ventilator-associated pneumonia in postoperative patients, also beneficial when administered to preoperative patients as well [65] . in addition to preventative therapies, it is important to have standardized postoperative care to promote aggressive pulmonary toilet and mobilization. postoperative pneumonia is reduced when the head of bed is kept elevated. the patient should be given ample motivation to leave the bed for the chair (particularly during mealtime) and to ambulate (even in the post-anesthesia care unit). patients should be encouraged to perform frequent deep breathing and use incentive spirometry [66] . patient education throughout the process is key, allowing the patient and his/her loved ones to become actively involved in their recovery. the most significant postoperative pulmonary complication is acute respiratory distress syndrome (ards), which is predominantly proinflammatory injury to the alveolar interface, characterized by a constellation of diffuse endothelial injury, severe hypoxia, and pulmonary edema not predominantly of cardiogenic origin [67] . preoperative risk factors for ali/ards development include age > 60, history of copd, current or recent smoking, history of previous heart surgery, nyha iii/iv congestive heart failure, liver cirrhosis, and multiple recent transfusions. operative risk factors include low cardiac output syndrome, more than 3 u of packed rbcs (or massive transfusion), isolated valve surgery, and development of postoperative pneumonia [68, 69] . there is a multifactorial pathogenesis to this condition that overwhelms homeostasis in the pulmonary microcirculation. in addition to the previous conditions described thus far, which place injurious stress on the alveolar interface, additional stressors can include reduced respiratory function due to general anesthesia (causing impairment of vital and functional residual capacities) or other surgical factors (sternotomy, pleural dissection due to internal mammary utilization, cpb, and ischemia-reperfusion injury) [67] . although there is paucity of information on optimal perioperative mechanical ventilation in these patients, recent data show an improved complication profile with intraoperative lung protective ventilation. this bundle emphasized keeping tidal volume below 8 ml/kg ideal body weight, peep greater or equal to 5 cm h 2 o, and actively aiming to keep modified driving pressure (a surrogate for lung compliance, defined as peak inspiratory pressure minus peep) at a value lower than 16 cm h 2 o [70, 71] . open lung strategies during cpb, defined as the provision of low tidal volumes and high peep (typically 8), along with frequent use of recruitment maneuvers, did not improve postoperative pulmonary outcomes [72, 73] . cpb time, restrictive transfusion, careful sternotomy with preservation of pleural integrity, and fluid restriction have been other potentially helpful preventative interventions described [74] . mediastinal and pleural drains are routinely inserted following cardiac surgery to evacuate the postoperative bleeding, fluids, and air from the mediastinum or pleural cavities. these drains are usually removed when fluid output is minimal, accompanied by stable cardiac and respiratory status. recurrent pneumothorax with tension physiology following discontinuation of a thoracic cavity drain is a most significant and life-threatening complication. it occurs due to a one way communication between lung parenchyma and the pleural cavity leading to air entrapment in the pleural cavity. a large retrospective study looking at 8900 patients undergoing various cardiac surgical procedures showed that an overall incidence of recurrent pneumothorax after chest tube discontinuation to be approximately 1.4% [75] . patients should be clinically monitored closely for development of respiratory difficulty following chest tube removal. chest x-ray and/or bedside ultrasound are useful modalities to look for a pneumothorax. while routine use of the pulmonary artery catheter became less prevalent over the previous decades, it still holds a central role in the postoperative care of cardiac surgery patients. most of these catheters are placed in the operating room and remain in place to guide therapy during early recovery. complications involved with the pulmonary artery catheter are rare, but tend to be devastating. the most feared complication is rupture of the pulmonary artery, which can occur during or following catheter insertion. one series describes the incidence of pulmonary artery rupture at 0.031%. it presents with hemoptysis, acute pulmonary hypertension in 50% of patients, and carries a mortality rate of 70% [76] . ruptures with massive hemoptysis or signs of developing hemothorax typically require emergent thoracotomy. delayed hemoptysis following pulmonary artery catheter placement can be associated with catheter-associated pulmonary artery pseudoaneurysm, which start as a collection of blood between the tunica media and adventitia and progressively expands before rupturing [77] . treatment includes vessel ligation, wedge resection, lobectomy, embolization, stenting, and watchful waiting [77] . other complications to watch for carefully include pulmonary infarction (when the balloon of the catheter is inflated for a prolonged amount of time or the uninflated catheter tip migrates into distal branches of the pulmonary artery) and pulmonary embolism (when the catheter presents a foreign body nidus for inflammation and infection, accompanied by thrombosis) [78]. as the lungs are closely interdependent with the heart, adequate pulmonary support and monitoring are paramount in the care of a post-cardiac surgery patient. it is important that the cardiothoracic intensivist remains vigilant with regard to the unique pulmonary challenges faced in the cardiac surgery patient. unique stresses are posed, associated with cardiopulmonary bypass (along with the coagulopathy it generates), operative intervention in close proximity to the pleural surfaces and vasculature, frequent need for continued postoperative intubation, and the routine use of pulmonary artery catheterization. as surgical techniques advance to become more amenable with human physiology, postoperative care will evolve concurrently. it will be important for that evolution to address these complications and find unique and novel modalities of care to prevent them. conflict of interest the authors declare that they have no conflict of interest. current trends in preoperative, intraoperative, and postoperative care of the adult cardiac 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biocompatible cardiopulmonary bypass circuits and clinical outcome leukocyte depletion during cpb: effects on inflammation and lung function protamine dosage effects on complement activation and sonoclot coagulation analysis after cardiac surgery serious anaphylactic reactions due to protamine sulfate: a systematic literature review hemodynamic changes after protamine administration: association with mortality after coronary artery bypass surgery three cases of anaphylaxis to protamine: management of anticoagulation reversal acute intracardiac thrombosis and pulmonary thromboembolism after cardiopulmonary bypass: a systematic review of reported cases eacts/ eacta guidelines on patient blood management for adult cardiac surgery reoperation for bleeding in patients undergoing coronary artery bypass surgery six-month outcomes after restrictive or liberal transfusion for cardiac surgery patient blood management in cardiac surgery the incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of cardiac surgery patients: a prospective nested casecontrol study the role of neutrophils in the pathogenesis of transfusion-related acute lung injury neutrophil adhesion molecule expression during cardiopulmonary bypass with bubble and membrane oxygenators postoperative cardiac surgical care: an alternative approach radiographic pulmonary abnormalities after different types of cardiac surgery prevalence and clinical course of pleural effusions at 30 days after coronary artery and cardiac surgery electrophysiological evaluation of phrenic nerve injury during cardiac surgery-a prospective, controlled, clinical study phrenic nerve dysfunction after cardiac operations: electrophysiologic evaluation of risk factors pneumonia after cardiac surgery: experience of the national institutes of health/ canadian institutes of health research cardiothoracic surgical trials network the impact of nosocomial infections on patient outcomes following cardiac surgery prolonged ventilation post cardiac surgery-tips and pitfalls of the prediction game predictors of prolonged mechanical ventilation after open heart surgery prolonged mechanical ventilation after cardiac surgery: outcome and predictors incidence and predictors of ards after cardiac surgery prevalence of acute respiratory distress syndrome after cardiac surgery pulmonary dysfunction after cardiac surgery atelectasis and gas exchange impairment during enflurane/nitrous oxide anaesthesia influence of age on atelectasis formation and gas exchange impairment during general anaesthesia atelectasis and gas exchange after cardiac surgery continuous positive airway pressure versus noninvasive pressure support ventilation to treat atelectasis after cardiac surgery prophylactic respiratory physiotherapy after cardiac surgery: systematic review pleural effusions following cardiac surgery: prevalence, risk factors, and clinical features coronary artery bypass graft readmission rates and risk factors-a retrospective cohort study the post-pericardiotomy syndrome contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome clinical features associated with adverse events in patients with postpericardiotomy syndrome following cardiac surgery characteristics of pleural effusions in acute idiopathic pericarditis and post-cardiac injury syndrome pleural effusions in acute idiopathic pericarditis and postcardiac injury syndrome | ovid early, dedicated follow-up and treatment of pleural effusions enhance the recovery rate after open cardiac surgery: results from a randomized, clinical trial six-minute walk test as a prognostic tool in stable coronary heart disease: data from the heart and soul study outcome after procedures for retained blood syndrome in coronary surgery pneumothorax, chylothorax, hemothorax, and fibrothorax. in: murray & nadel's textbook of respiratory medicine, 6th edn active clearance of chest drainage catheters reduces retained blood impact of retained blood requiring reintervention on outcomes after cardiac surgery retained blood syndrome after cardiac surgery: a new look at an old problem phrenic nerve injury from ice slush placed during multi-cardiac valve repair/replacement phrenic nerve injury following cardiac surgery: a review diaphragm paralysis following cardiac surgery: role of phrenic nerve cold injury lung ultrasound for the diagnosis and management of acute respiratory failure ventilator-associated pneumonia after cardiac surgery: a meta-analysis and systematic review preoperative chlorhexidine mouthwash to reduce pneumonia after cardiac surgery: a systematic review and meta-analysis cough: reducing postoperative pulmonary complications with a multidisciplinary patient care program postoperative pulmonary complications adult respiratory distress syndrome following cardiac surgery risk factor analysis of postoperative acute respiratory distress syndrome in valvular heart surgery red blood cell accumulation in a rat model of pulmonary ischemia/reperfusion injury intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery | ovid effect of open-lung vs conventional perioperative ventilation strategies on postoperative pulmonary complications after on-pump cardiac surgery: the provecs randomized clinical trial a perioperative surgeon-controlled open-lung approach versus conventional protective ventilation with low positive end-expiratory pressure in cardiac surgery with cardiopulmonary bypass (provecs): study protocol for a randomized controlled trial protective invasive ventilation in cardiac surgery: a systematic review with a focus on acute lung injury in adult cardiac surgical patients post pull pneumothorax following cardiac surgery pulmonary artery rupture associated with the swan-ganz catheter pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment pulmonary artery catheterization key: cord-275266-e6omvo5x authors: kort, nanne p; zagra, luigi; barrena, enrique gomez; tandogan, reha n; thaler, martin; berstock, james r; karachalios, theofilos title: resuming hip and knee arthroplasty after covid-19: ethical implications for well-being, safety and the economy date: 2020-07-07 journal: hip int doi: 10.1177/1120700020941232 sha: doc_id: 275266 cord_uid: e6omvo5x reinstating elective hip and knee arthroplasty services presents significant challenges. we need to be honest about the scale of the obstacles ahead and realise that the health challenges and economic consequences of the covid-19 pandemic are potentially devastating. we must also prepare to make difficult ethical decisions about restarting elective hip and knee arthroplasty. these decisions should be based on the existing evidence-base, reliable data, the recommendations of experts, and regional circumstances. a survey on behalf of the european hip society and the european knee associates has shown a massive reduction in primary and revision hip and knee arthroplasty surgery across europe in response to the pandemic. 1 of the participating surgeons, more than 90% stated that their institutions no longer provided primary total joint arthroplasty. this reduction of arthroplasty services in europe will have a detrimental impact on our patients' pain, mobility, social life, and general health including cardiovascular well-being. [2] [3] [4] [5] [6] delaying the reintroduction of arthroplasty surgery will result in less favourable outcomes following surgery. due to the reallocation of resources for covid-19 patients, the ethical issue becomes: how long non-covid-19 patients scheduled for elective orthopaedic surgery should be excluded from medical care? elderly patients with multiple comorbidities scheduled for total hip arthroplasty (tha) or total knee arthroplasty (tka) are at a higher risk of succumbing if infected with covid-19 perioperatively, and may also require inpatient recovery in rehabilitation units or nursing homes further increasing the risk of transmission. total joint arthroplasty generates significant revenue for medical care centres, implant companies, and makes up a substantial portion of the daily income for arthroplasty surgeons. the projected value of the global overall joint market is $20.2 billion by 2025. 7, 8 these economic factors will influence the decision to re-start elective total joint resuming hip and knee arthroplasty after covid-19: ethical implications for well-being, safety and the economy arthroplasty during the covid-19 pandemic. thus, because our judgement will be affected by complex medical and economic factors, this article explores the five crucial ethical challenges to the resumption of tha and tka after the covid-19 pandemic in europe. there are a few different categories of postponed patients waiting for total joint replacement during the pandemic. 9 the first group, whose hip/knee disease severely affects their independence and well-being, are too concerned about disease transmission to seek medical attention. the second group of patients with joint conditions and risk factors for complications or death from covid-19 are eager to undergo surgery, possibly not realising the potential risks and possible adverse outcomes which we cannot fully evaluate due to a lack of evidence. a third group which possibly includes half of our patients have joint conditions that would benefit from surgery but are unsure about proceeding in current circumstances and request guidance from the surgeon. patient safety is of utmost importance in guiding an ethical re-opening of our total joint arthroplasty services. complications related to total hip and knee arthroplasties are well known to every surgeon, and adequately discussed at any informed consent procedure. however, the consent to elective surgery at the point when the pandemic is decreasing but cases are still being diagnosed requires a different kind of discussion. most hospitals have incorporated specifically informed consents to add to those required for surgery. this specific, informed consent (ic) for elective surgery in times of covid-19 requires further discussion with the patient about higher risk of virus transmission including from healthcare workers, the long incubation period (up to 14 days), the variable nature of the disease from mild to fatal, and discussions regarding ceilings of care and the potential need for ventilation. ic needs to clarify the patient's understanding of these factors, and the specific measures taken by hospitals and staff to mitigate against each. usually, those measures include prior testing of surgeon and staff, patient epidemiological interrogation and sars-cov2 testing (serology and/or pcr) before surgery (preferably 48-72 hours and no more than 7 days before surgery), and specific hospital pathways for non-covid patients where patients may be protected to some extent. 10, 11 of note, guidelines should be carefully tracked as consensus evolves along with the pandemic. of course, a pcr positive patient on an elective pathway should be postponed. a quarantine of 14 days is recommended until the pcr becomes negative. 10, 11 specific patient comorbidities are associated with a poor outcome following covid-19. 10, 11 among those, careful attention should be paid to severe cardiac conditions, diabetes, chronic lung disease, chronic kidney disease, immunocompromise, liver disease, severe obesity and age >65 years. also, the emerging risk of thromboembolism related to covid-19 means that consideration should be given to thromboprophylaxis regimes. 12 physical distancing, hand washing and use of masks must also be required at the hospital, and limiting the visits of relatives (1 single relative if required) is also part of this safety awareness. the demand for arthroplasty is likely to exceed available resources after the resumption of elective surgical procedures. this demand may be exacerbated by reduced theatre productivity because of precautions used for the safety and protection of the patient and surgical team, limited availability of beds in intensive care units and hospital wards and limitations set by hospital administrators or health authorities. unlike trauma cases, most patients needing arthroplasty are older and have associated comorbidities and therefore a higher risk of morbidity & mortality following covid-19 transmission. 13 this presents a dilemma for arthroplasty surgeons prioretising patients for arthroplasty surgery. most guidelines at the peak of the coronavirus pandemic focused on emergency procedures such as periprosthetic fractures and acute infection or reconstructive arthroplasty after sarcoma resection as priority surgery and advised the postponement of other nonurgent joint reconstruction. with the resumption of elective surgery, several other guidelines have been published. the american college of surgeons describe hip dislocation, knee dislocation, periprosthetic fracture, acute pain exacerbation in prior joint arthroplasty, inability to bear weight on the extremity, wound drainage, fever and concern about periprosthetic infection as priority indications for hip and knee arthroplasty surgery. 14 the international consensus group and the aahks research committee recommend priority surgery for impending fracture and exposed implants, in addition to the conditions outlined above. 15 the ments score (medically needed time-sensitive procedures score) takes procedural factors (overall procedure time, blood loss, need for intensive care unit, intubation probability); disease factors (viability of non-operative treatment, increased surgical difficulty and risk due to delaying the procedure) and patient factors (age, cardiopulmonary disease, diabetes, influenza-like symptoms and recent exposure to a known covid-19-positive person) into account. 16 this score can range from 21 to 105, with higher scores being associated with poorer perioperative patient outcomes, increased risk of sars-cov-2 transmission to the health care team and/or increased use of hospital resources. however, there is no threshold for safe elective surgery, and hospitals can adjust their thresholds depending on covid-19 prevalence in their region and available resources. the international consensus group (icm) and the aahks research committee recommend delaying elective surgery for patients over 75 years old with cardiopulmonary comorbidities, patients with morbid obesity, transplant patients undergoing immunosuppression and patients with active cancer. 8 esska guidelines advise giving priority treatment to younger patients (<60), requiring fewer than 3 days of hospitalisation and delaying elective surgery for patients with comorbidities. 17 the european hip society and esska-european knee associates are also working on joint recommendations on resuming elective hip and knee arthroplasty. although a variety of recommendations are available, the decision to select patients for arthroplasty ultimately rests on the shoulders of the surgeon. factors not mentioned in the guidelines are; severe deterioration in quality of life, inability to weight-bear, sustained absence from work, dependence on assistance with activities of daily living, severe disease and deformity. the surgeon should weigh the relative benefits and risks of surgery, taking into account patient and disease factors, availability of resources and public health concerns, before they decide to offer surgery. this selection process should be fair, compassionate and free from financial concerns. as orthopaedic surgeons, we should continue to treat our patients with honesty, compassion, skill and care. our aims should always be to 'cure and to care'. 18 if we rely solely on technique and neglect our ethics of service, we become a trade and not a profession. 19 the therapeutic alliance between doctor and patient should be based on understanding, confidence and cooperation and form the platform for a successful treatment. 20 this quotation from the ethical orthopaedics for efort (european federation of national associations of orthopaedics and traumatology) has even greater value in this particular time of covid-19. 21 postponing hip and knee arthroplasty may increase functional limitations and eventually result in loss of independence for many patients. this may also have an impact on a patient's ability to survive in isolation or in difficult social circumstances. on the other hand, we have to accept that hospitalisation for hip and knee arthroplasty represents greater risk than previously, particularly in older patients with comorbidities. at the time this paper was written, most european health systems were beginning to recover from the pandemic. if surgeries have been cancelled or postponed, waiting lists will grow, and there may also be limited availability for consultation services and face to face meetings with healthcare professionals. from a patient's perspective, communication plays a significant role. the individual patient's needs should be the focus of the doctor. 22 information is needed about treatment options while waiting for surgery, the risks of medication misuse, types of physical activity which could be beneficial for the individual patient, the evolving situation in the hospitals and the estimated time before intervention. this type of communication cannot be delegated to administrative staff at present. 23 we have all recognised the potential of telemedicine as a tool for remote communication and patient evaluation. the challenge is to align with our patients' expectations, and enable them to work with their surgeon. 24 shared decision making with full informed consent oriented explicitly to specific covid-risks and issues must be considered. some patients who are afraid spontaneously postpone surgery; they must be adequately informed about the risks and benefits of such a decision related to the specific covid-19 situation at the time, and of preventive measures, including the need for preoperative screening. a case-by-case evaluation is necessary, but this can be time-consuming for the surgeon. a similar situation is the interaction with relatives as they are not permitted in the hospital. ward rounds should incorporate remote communication, including daily phone calls with relatives of the hospitalised patients. 23, 25 rehabilitation time is also problematic due to the lack of facilities including at-home services while admissions for rehabilitation are restricted to the minimum even for the older population, if not suspended. therefore, careful ethical evaluation is required at an individual centre and for a specific patient, keeping in mind and discussing the pros and cons of early discharge. in this challenging time, when reinstating elective surgery in a risky scenario with limited resources, surgeons have the responsibility to follow a shared decision-making process with the patient that includes an understanding of the legal aspects of complications, and covid-19 specific, informed consent. at the same time, surgeons cannot ignore the most difficult cases in order to avoid any professional risk: this is probably the main ethical challenge in phase 2. the covid-19 pandemic constitutes an unprecedented challenge with very severe socio-economic consequences. 26 the proposal for a coronavirus response investment initiative was approved by the european parliament and the council and is in force as of 1 april. this approval will allow the use of eur 37 billion under the cohesion policy to address the consequences of the covid-19 crisis. also, the scope of the solidarity fund was broadened to include major public health crises. starting from 1 april, this allows the hardest hit member states to get access to the financial support of up to eur 800 million that has been made available in 2020. the global joint arthroplasty devices market is projected to exceed $20.2 billion by 2025, growing at a cagr of 4.6% over the forecast period, driven by technological advancement and higher preference for and adoption of minimally invasive surgeries worldwide. indeed, the demand for joint arthroplasty devices is expected to double within ten years, driven by robotically assisted operations, ageing populations, improvements in surgical and pain management techniques and moderate incremental innovations. 27 since 2000, the number of hip and knee arthroplasties has increased rapidly in most oecd countries. on average, hip arthroplasty rates increased by 30% between 2007 and 2017 and knee arthroplasty rates by 40%. this increase aligns with the rising incidence and prevalence of osteoarthritis caused by ageing populations and growing obesity rates in oecd countries. 28 without elective hip and knee arthroplasty procedures, our patients are at risk of increased pain and less mobility, and our health care institutions are at risk of insolvency. patient risks derived from the lack of elective hip and knee arthroplasties include less independence due to joint pain or even joint destruction, which may also impact the ability to survive in isolation or under difficult social circumstances. moreover, there is an increased risk of medication abuse by suffering patients. unfortunately, covid-19 has had a tremendously negative impact on economic growth in 2020. 29 hospitals are on the front line and vulnerable to this economic disruption as they face challenges and hits to their revenue from the cancellation of elective surgeries. most non-covid-related activity has been halted due to the urgent demands of infected patients. as a result, health care providers are experiencing a significant reduction in revenue, while at the same time seeing increased staff and supply costs. moreover, hospitals are unlikely to see ongoing contributions from non-operating income because their investment portfolios have been hurt, as well. even before the coronavirus outbreak, many health care providers were struggling financially. the orthopaedic industry has also been witnessing a loss of business with some companies facing financial problems before the pandemic. many orthopaedic companies have pro-actively planned for a worst-case scenario and reset their budgets to protect employees, customers and investors. the overall effect of the pandemic is impacting the production process of life science industries. hip and knee arthroplasty deferrals and late resumption of the procedures will lead to revenue declines. there is a boom expected in hip and knee arthroplasties in the second half of 2020 once these procedures can be restarted, and revenue will once again be generated from such surgeries. 30 an ethical discussion awaits us: how far do we allow the safety of patients and staff to prevail, and at what stage do we allow the economic side of this discussion to prevail? 31 above all, which is the safest, most effective way to treat our patients suffering from a joint disease at this time? the circumstances are different in every country, with a disparate impact of covid-19 on the population and on health care providers. we need to find the right balance between medical safety and economic security. in any case, the decision to treat must not be based on financial reasons. in both privately and publicly funded systems, the decisions about the form of treatment that is offered should be based on need and not on finance. 31 one thing is sure, with the downward trend in covid-19 cases and deaths, there has been more and more focus on its economic impact, with tremendous pressure to restart primary hip and knee arthroplasties across europe. at the same time, pressure from patients to be operated on soon is growing as they begin to feel safer about the path of the pandemic. in times of financial restraint, we know the problems caused when cost savings are achieved at the expense of patient care. 23 there must be a balance between the risks and safety for our patients/staff and the economic pressure to restart the arthroplasty business. in some countries, most arthroplasty surgeries are performed in public hospitals, while in other countries high volume arthroplasty surgeons work in private settings. sometimes a combination of both is the preferred choice for arthroplasty service in a distinct region. therefore, a general statement on a covid-19 pandemic related shift of arthroplasty patients from one institution to another to reduce waiting lists and to satisfy the overall demand for arthroplasty is difficult. there is also a high variation in costs and reimbursement for total joint arthroplasty between countries, 32 and therefore cross-country comparisons are difficult. total joint arthroplasty is a frequently performed elective surgery and part of social benefit policies in many european countries; there is thus a significant budget impact for hospitals or private doctors. 33 in recent years, countries with tax-based universal healthcare systems have experienced increasing attention from private healthcare providers. 1 however, the difference in the quality of care is reported to be equal between public, private non-profit hospitals and private for-profit hospitals. 34 following general social distancing principles, reallocation of treatment of elective patients into a private sector might reduce the risk of sars-cov-2 infection of elective patients, because public hospitals or academic centres are more often confronted with covid-19 patients. as well as potential additional costs for these patients or their health care providers, a patient shift to the private sector also might impair the education of the next generation of orthopaedic surgeons and science in general. it has already been reported that the covid-19 pandemic has had a significant impact on the education and training of young surgeons. 35 also, the pandemic is currently disrupting clinical trials all over the world. 36 before the pandemic, most clinical science was performed at public, academic centres. hence, a shift from elective joint arthroplasty patients from public hospitals into private hospitals would further disrupt clinical science and researchers and research questions might not be able to have direct contact with patients. from an ethical point of view, the overall goal in the covid-19 era is to provide protocols to safely perform hip and knee arthroplasty, irrespective of the set-up and environment. arthroplasty should be performed in an environment where resources, staff and supplies can guarantee the patient's safety. this can either be done in the private sector or public hospitals. there might also be a shift to ambulatory surgery centres, a public or private speciality hip and knee hospital, or fast track total joint arthroplasty in future. however, a transition during the pandemic will be challenging because all stakeholders will have to be convinced, and it has to be affordable for the patient. our primary duties as orthopaedic surgeons are to serve our patients and reduce the risk of a second peak of covid-19 cases even in times of long waiting lists and increasingly expensive procedures. the dutch hospitals' association, draws attention to the financial consequences of the covid-19 epidemic for hospitals. hospitals are confronted with higher costs and lower healthcare turnover. the care of covid-19 patients and the adjustments in the outpatient clinic at the start of regular care cost money. as a result of the downscaling of regular care, income fell by 47%. in march, april and may, this may amount to approximately 2.1 billion euros. in addition, hospitals face additional costs in providing care for covid-19 patients. for example, hospitals had to expand the number of ic beds, train or retrain other healthcare professionals, and continue to invest in digital care and purchase equipment and protective equipment. it is estimated that the extra expenditure in recent months is approximately 0.5 to 2 million euros per month per hospital and may rise to nearly 3 billion euros in the coming years. italy was the first country forced to face the covid-19 emergency after china. the emergency has put a strain on the health system, both for the rapidly increasing need for intensive care unit beds and for the growing number of patients suffering from less severe disease that needed to be treated in the hospitals. all elective procedures have been stopped during the pandemic, only infections, oncology cases and acute trauma were treated in a network system at regional level where a few hubs were identified for orthopaedic and trauma urgent cases while general hospitals were taking care of covid-19 patients. during the second half of april and may the situation was improving and elective surgery is slowly increasing. nevertheless the demand from health authorities is to operate on patients younger than 70 with few comorbidities that are on a priority list, and not more than 60-70% of the volume done in the same period of 2019. hospitals must remain ready for a rapid conversion to covid-19 care in case of a second wave. the first covid-19 patient was diagnosed in greece on the 26th of february 2020. a complete lockdown of the country was implemented on march 11th. as a result, all elective orthopaedic surgery was halted (both state and private sectors) and only musculoskeletal trauma, infection, and orthopaedic oncology were dealt with. on monday, may 4th a restart of surgical procedures was enacted at a level of 50% (predominantly musculoskeletal trauma) of hospital capacity, while taking strict preventive measures. despite satisfactory clinical and social management of the pandemic, there has been a serious impact on elective orthopaedic services with broad ethical and social implications. in a country with a yearly average of 20,000 primary and revision implant surgeries, a very small number of cases are now performed. waiting lists have increased and patients are now expected to endure symptomatic joint disease and resulting disability for an indeterminate length of time. implant providers have also seen revenue reduced to 20%, and despite the fact that their employees have been included in a partial unemployment scheme supported by low income state benefits, it is expected that job losses will be recorded at the level of 50%. comparing international data, austria is ranked among the top countries with respect to its population-based implantation rate of 210 per 100,000 for total hip arthroplasty (tha), and 202 per 100.000 for total knee arthroplasty (tka). austria was considered 1 of the hotspots for the covid-19 outbreak at the beginning of the pandemic in europe. hence, the countries lockdown was on march 14th, including some parts of the country being under quarantine and stopping all elective surgery on march 16th. however, after the covid-19 curve flattened, approximately 50% of elective arthroplasty volume was started at april 12th, followed by full resumption at may 11th. turkey 90,000 hip and knee arthroplasties are performed annually in turkey, with a market of 55 million euros in implant costs. this amounts to 1/6 of the entire orthopaedic implant/ consumables market of the country. with the identification of first covid-19 cases in 14 march 2020, select hospitals were designated to treat covid-19 patients, however all elective orthopedic surgeries were halted in other hospitals to provide a back-up for overflowing cases from covid-19 hospitals. this led to a 98% cessation of arthroplasty procedures until june 1st. with the down slope of the pandemic curve, elective surgery will start at 50% volume on june 1st, followed by full resumption on june 15th, 2020 if no surge in covid-19 cases occurs. currently (26 may 2020), spanish elective total joint replacement surgery is timidly opening. in late may, joint reconstructive surgery has been restricted in most tertiary hospitals to infections, particularly 2-stage revision surgery. hospitals have incorporated defined protocols to assess serology and sars-cov2 pcr in surgeons and staff, but also in every patient scheduled for any surgical intervention. furthermore, icu needs after surgery are planned, besides regular postoperative care, while spinal or epidural anaesthesia was already the standard for hip and knee procedures in many hospitals. although the number of operating rooms available for scheduled orthopaedic surgery lies at 50%, the number of available hospitalisation beds and icu beds is within the required limits, and low risk patients are already selected to start total knee and hip replacement this week. a careful monitoring of each institution is required, and the impact of the clockstop for elective joint replacement surgery will probably endure until the end of the summer. meanwhile, elderly patients with comorbidities are refusing to visit clinics. safety needs improving and patients need support to regain confidence in healthcare. in the uk, the national health service advised hospitals to postpone elective surgery on 17th march 2020 for 12 weeks to free up capacity for the increasing numbers of covid-19 patients being admitted to hospitals. it is estimated that there have been a total of 516,000 postponed surgeries, including 36,000 cancer procedures. private sector hospitals have been repurposed to help deliver urgent services, but planned joint replacement surgery has ceased throughout this period. measures such as social distancing and self-isolation have resulted in falling numbers of covid-19 cases in most parts of the uk, buying time to increase ventilator numbers and free up surge capacity within our hospitals during the first phase of our response to the pandemic. we are now entering the second phase where we are beginning to reintroduce elective surgery, including joint replacement. the reintroduction of elective joint replacement during the covid-19 pandemic poses greater organisational and ethical challenges than its cessation 12 weeks ago. frameworks for the safe reintroduction of orthopaedic surgery have been drawn up by nhs england, and the british orthopaedic association in mid may 2020. there is consensus that 2 very separate pathways are required; 1 for covid-negative planned elective work, and the other pathway for urgent or emergent care. we require planned-surgery candidate patients to isolate for 14 days and test negative on home covid swab kits within 72 hours of admission. currently strict isolation of all members of the household is required, however this will be challenging for most patients, and it may be similarly effective for just the individual concerned to isolate from other household members for 14 days. either way, there are concerns that not all patients will comply, risking an outbreak in within a covid-negative pathway. rules for the staff treating patients are currently being determined locally. it makes sense for staff to work exclusively within covid-free pathways for periods of time with an interval before alternating from urgent to elective (covid-free) pathways. teamworking will be required among arthroplasty surgeons to provide alternating periods of planned joint replacement and urgent revision surgery for periprosthetic fractures and prosthetic joint infection. provisions will need to be made for outbreaks within the covid negative pathways, with extreme vigilance and plans set out for immediate isolation of patients and staff with symptoms. the ethical tenant of 'achieving the most good' with limited theatre resources makes the reintroduction of nonurgent joint replacement an important milestone in the societal recovery from the pandemic. doing good must be balanced with doing the least harm. we thereby have a duty to mitigate risk for our patients, and so it may be prudent to establish our pathways and processes for low risk patients such as the young undergoing day case orthopaedic surgery, before the reintroduction of joint replacement for more frail patients. we have seen a downward trend in covid-19 cases and deaths yet the economic impact of covid-19 on health care institutions, the orthopaedic industry and health care providers continues to rise. these factors will eventually intersect, depending on which country you live in (figure 1 ). restarting hip and knee replacement at this moment of intersection (area b) is the challenge. if we start up hip and knee replacements earlier (area a), we may endanger patients and staff. if we start later (area c), we may jeopardise health care institutions in an already fragile health economy. the consent process must include making patients aware that despite efforts to minimise disease transmission, the risk of hospital-acquired covid-19 cannot be eliminated. patients will need to exercise their autonomy when deciding whether to come into hospital for planned surgery based on the most accurate advice we can give. ultimately, many of our joint replacement patients are elderly and comorbid, living in pain. some will even be enduring a quality of life 'worse than death,' and may wish to proceed despite the high risks of mortality from contracting covid-19 in the perioperative period. we will need a major catch up effort to avoid additional harm to our patients waiting in the backlog. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship and/or publication of this article. enrique gomez barrena https://orcid.org/0000-0003-1065-6137 disruption of joint arthroplasty services in europe during the covid-19 pandemic: an online survey within the european hip society (ehs) and the european knee associates (eka) the operation of the century: total hip replacement the effect of elective total hip replacement on health-related quality of life physical activity after total joint arthroplasty: a narrative review quality of life after total knee arthroplasty future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030 what are the costs of hip osteoarthritis in the year prior to a total hip arthroplasty? global joint replacement devices market $20.2 billion by 2025 clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection cdc centres for disease control and prevention. groups at higher risk for severe illness rapid risk assessment: coronavirus disease 2019 (covid-19) in the eu/eea and the uk-ninth update systematic assessment of venous thromboembolism in covid-19 patients receiving thromboprophylaxis: incidence and role of d-dimer as predictive factors clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study covid 19: elective case triage guidelines for surgical care resuming elective surgery during the covid-19 pandemic: guidelines developed by the international consensus group (icm) medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid-19 pandemic covid-19 -esska guidelines and recommendations for resuming elective surgery il bene, il male e la scienza: le dimensioni etiche dell'impresa scientifico-tecnologica ethics, advertising and the definition of a profession etica della cura medica ethical orthopaedics for efort ethical standards for orthopaedic surgeons changes of clinical activities in an orthopaedic institute in north italy during the spread of covid-19 pandemic: a seven-week observational analysis predicting dissatisfaction after total hip arthroplasty: a study of 850 patients reinstating elective orthopaedic surgery in the age of covid-19 report on the comprehensive economic policy response to the covid-19 pandemic global joint replacement devices market $20.2 billion by 2025 hip and knee replacement covid-19 outbreak: migration, effects on society, global environment and prevention economic recovery after the covid-19 pandemic: resuming elective orthopedic surgery and total joint arthroplasty elective reconstructive surgery during a pandemic: a moral dilemma quality differences between private for-profit, private non-profit and public hospitals in norway: a retrospective national register-based study of acute readmission rates following total hip and knee arthroplasties health service costs in europe: cost and reimbursement of primary hip arthroplasty in nine countries outsourcing day surgery to private for-profit hospitals: the price effects of competitive tendering covid-19 impact on young arthroplasty surgeons continuum clinical. covid-19 live updates: find the latest information from continuum on how covid-19 is impacting clinical trial enrollment and retention key: cord-286646-d3x0rekw authors: martin, allison n.; petroze, robin t. title: academic global surgery and covid-19: turning impediments into opportunities date: 2020-05-14 journal: am j surg doi: 10.1016/j.amjsurg.2020.05.022 sha: doc_id: 286646 cord_uid: d3x0rekw nan the covid-19 pandemic has revealed cracks in the united states (us) healthcare system, laying bare the vulnerabilities of our most at-risk patients. 1 stories of overwhelmed hospitals, critical resource limitations, and disparate outcomes in african americans affirm that the us healthcare system is both fallible and frail. surgeons working in low-and middle-income countries (lmics) are no strangers to similar public health challenges. our colleagues in lmic routinely confront complex medical and surgical issuesdperforated typhoid, traumatic fractures and prolonged labor complicationsdwith fewer resources. the burden of surgical disease disproportionately falls on the poorest countries where our surgical colleagues must also navigate the milieu of everpresent endemic diseases (i.e., malaria outbreaks, locust infestation), poverty, and food insecurity. fewer resources available in the so-called "developing world", however, do not stop development. rather, it stimulates innovation. case in pointdin the midst of the covid-19 pandemic, senegal, a west african country with nearly 16 million people but just 56 resuscitation beds has developed a covid-19 test that costs approximately $1 and has a turnaround time of 10 minutes. 2 this illustration suggests that it is not the resources you have but what you do with them. indeed, we likely have much to learn from a global perspective. the last ten years have seen the rise of global surgery as an academic pursuit. 3 academic medical centers, private citizens, and foundations have started to make financial investments to establish sustainability in the mission of academic global surgery, but the true inclusion of global surgery into the academic surgical core remains in its infancy. 4, 5 still, this burgeoning investment is grounded in a fundamental lesson of global surgery: surgical disease is a disease of poverty, and the most economically depressed populations have the greatest need for surgical care. understanding the specific social determinants of health that impact patients is fundamental to improving access to safe and timely surgical care around the globe. to be clear, vulnerable populations exist both globally and locally. as the covid-19 pandemic has shut borders and economies around the globe, many will look internally to protect our own, and the support of global surgery programs that rely on international travel exchanges may be in jeopardy. yet, a pandemic also highlights the true interdependence of health around the world, and the impediments to sustaining academic global surgery programs are perhaps also opportunities to better develop and maintain programs that incorporate the competencies of global surgery into a future of collaborative surgical education and innovation. poverty and access to surgical care are intrinsically linked to one another. the country where you were born, the financial situation you were born into, the rurality of your towndall of these factors impact ability to access healthcare and, by extension, essential surgical, obstetric, and trauma services. 6 as the pandemic and policies of strict social distancing spread around the globe, the most susceptible populations lay prey to diseases of poverty. there will no doubt be increased morbidity and mortality from non-covid related conditions, further exacerbating strain on global healthcare systems and economic dependence of the poorest countries on the wealthiest. 7 in rwanda, for example, necessary social distancing policies have eliminated options for public transit, such as motos, which are the primary transportation mode for individuals of all socioeconomic statuses. loss of transportation means lack of access to healthcare facilities. we are not immune in the united states as fewer elective surgeries and healthcare visits has led to impending financial devastation for many of our nations' safety-net hospitals and medicaid providers. not surprisingly, children, minorities, and other vulnerable populations are disproportionately represented in our medicaid community. 8 academic global surgical initiatives desire to engage colleagues in exploration of meaningful solutions to issues of access and quality. resources allocated for research and development of essential services for low-income settings have always been limited. certainly, funding for global surgery was a challenge before the covid-19 pandemic began. in today's new economic reality, academic departments and hospitals face challenging financial decisions to sustain themselves and their missions. as travel is canceled, we fear that global surgery programs will be first on the chopping block. we submit a call to action for surgeons to build on existing relationships and resources to engage global surgery in a more proactive-and perhaps creative-way during these challenging times. we posit that in the future, these efforts will be even more important, particularly to trainees. recent research has highlighted the lack of alignment between the availability of experiences and resources in global surgery and the high level of interest amongst students and trainees imbued with a commitment to global health equity. 9 competencies learned through global health engagement will inform how the next generation of trainees practices medicine, which will be of greater importance in the post-covid era (if such as era even exists). the current global public health crisis illustrates resource constraints, health inequities and structural disparities in healthcare systems worldwidedleaders of tomorrow need a global view, and so it is particularly important to incorporate an academic global surgery curriculum that includes principles of ethics, health economics, disparities, and varying clinical pathologies. moreover, building strong healthcare systems the american journal of surgery j o u r n a l h o m e p a g e : w w w . a m e r i c a n j o u rn a l o f s u r g e r y . c o m relies on the development of surgical services. and strong healthcare systems around the world are necessary to prevent and treat the next pandemic. additionally, what can we do moving forward to enhance access to resources for our colleagues around the globe? does our move to online teaching for students and trainees create an opportunity for a more global classroom that can include our colleagues in lmics, truly challenging academic departments to partner with an lmic training program through telehealth? innovators around the globe have worked to develop locally-sourced personal protective equipment and ventilators, for example. this highlights a renewed opportunity for global partnerships to address surgical problems through collaborative innovation. innovation to produce technology that can help fight the spread of covid-19, including low cost ventilators and locally-produced particulate-filtering masks, can be shared with colleagues in any country and can be adjusted to fit available resources. similarly, curriculums and inexpensive simulation that are developed for medical students and trainees in the us can be shared and adapted for trainees globally. the looming financial impact of the covid-19 pandemic on academic surgical departments and hospitals is profound and has significant long-term implications for many research and programmatic endeavors. let this be a call to action for the development of robust and sustainable academic global surgery initiatives rather than sweeping these fledgling programs under the table. a foundation in global health teaches perseverance, innovative thinking, and hope, which we could all use right now. let the unprecedented changes we are seeing be an opportunity to better integrate into the global and public health dialogue as surgeons, to drive collaborative innovation and teach our medical students and residents the fundamental interconnectedness of health around the planet. none. covid-19 and african americans communication and prevention are the key words global surgery 2030: evidence and solutions for achieving health, welfare, and economic development an academic career in global surgery: a position paper from the society of university surgeons committee on academic global surgery what is global surgery? identifying misconceptions among health professionals disparate outcomes of global emergency surgery -a matched comparison of patients in developed and under-developed healthcare settings poor countries need to think twice about social distancing streamlining medicaid enrollment during covid-19 public health emergency next generation of global surgeons: aligning interest with early access to global surgery education the authors would like to acknowledge dr. gilbert r upchurch, jr, md for his critical edits and contributions to this manuscript. key: cord-275272-qdg8sqpy authors: soares-júnior, josé maria; sorpreso, isabel c.e.; motta, eduardo vieira; utiyama, edivaldo massazo; baracat, edmund chada title: gynecology and women’s health care during the covid-19 pandemic: patient safety in surgery and prevention date: 2020-06-16 journal: clinics (sao paulo) doi: 10.6061/clinics/2020/e2063 sha: doc_id: 275272 cord_uid: qdg8sqpy nan in december 2019, the novel severe acute respiratory syndrome coronavirus emerged in wuhan, china. it has since spread around the world (1, 2) , leading the world health organization (who) to declare a global pandemic (3) . the disease caused by the virus, coronavirus disease (covid19) , has been detected in more than 2,400,000 people worldwide and has caused more than 160,000 deaths (3) (4) (5) . in brazil, the first confirmed case was announced february 26, 2020 in the city of são paulo. at the time of this article's publication there were more than 600,000 confirmed cases and more than 36,000 deaths in brazil (6, 7) . following the who declaration, the organization recommended the cancellation of elective surgeries in hospitals (5, 8) due to the concern that elective procedures may contribute to the dissemination of covid-19 and to optimize medical resources for emergency areas (9) (10) (11) . since then, safety protocols have been adopted for patients and health professionals to enable the continued execution of both elective and necessary surgical procedures during the pandemic (12) (13) (14) (15) (16) . however, women's needs for care due to gynecological disorders continue, as well as the need for special public health measures to avoid contagion during care. non-oncologic gynecological diagnoses are common and described as the main demand on women's health care in reference centers. in the reproductive period, non-inflammatory and inflammatory diseases of the lower genital tract, such as abnormal uterine bleeding and pelvic inflammatory disease, respectively, are common. in the postmenopausal period, urogenital dysfunctions and breast diseases are prevalent (17) . protocols for obstetric care and maternal and child health care during the pandemic have been described (18, 19) , but there are few guidelines for women's health care in relation to gynecological disorders (18) (19) (20) (21) (22) . in recent publications, we discussed the importance of systematization and organization of work processes, prioritizing activities, and implementing clinically relevant algorithms in each specialty (12) (13) (14) (15) (16) ; these measures should be oriented to patient safety and guide decision-making for appropriate surgical treatment, both of which are appropriate concerns for the gynecological field. another concern during this period of the covid-19 pandemic is the indefinite postponement of surgical treatment, which can aggravate the health and quality of life of women with hemorrhagic, pain, and/or genitourinary disorders (12) (13) (14) (15) (16) (17) . a gynecologist's decision is fundamental in the definition of elective procedures that may be postponed depending on the general and clinical status of the patient, the availability of access to clinical treatment in the unified health system, and the conditions and diagnoses to be elucidated that may or may not be expected (due to a delay in the time of diagnosis) for medical reasons. thus, the american college of surgeons proposed stratification of surgical cases according to the patient's clinical condition and the severity of the disease as low, intermediate, or high severity. stahel used the indications and waiting times to stratify the following for general surgical cases: emergency surgeries (o1h), urgent surgeries (o24h), elective urgent surgeries (o2 weeks), essential elective surgeries (o3 months), and non-essential elective surgeries (43 months) (9) (10) (11) . these guidelines could also be used for gynecological surgeries. in this context, based on a recent publication regarding patient safety in elective surgeries (9) (10) (11) , as well as on the law of access to treatment and laws related to women's health care (23, 24) , we propose the inclusion of gynecological surgery cases, stratified as follows ( figure 1 ): emergency (o1h): peritonitis by tubo-ovarian and/or pelvic abscess, necrotizing fasciitis in surgeries for pelvic and breast neoplasms; doi: 10.6061/clinics/2020/e2063 urgent (o24h): postoperative infections, acute inflammatory abdomen (adnexal tortoise, myoma tortoise, ovarian cysts), hemorrhagic conditions (ovarian cysts); elective urgent (o2 weeks): surgeries for neoplasms of the lower genital tract and breast previously diagnosed by pathological examination; essential elective (42 to o3 months): hysteroscopy for abnormal uterine bleeding (unknowledge causes, suspected malignancy, and menopausal transition), postmenopausal bleeding (suspected malignancy), cervical conization or looped electro excision procedure (to exclude neoplasm in the lower genital tract); non-essential/elective surgery: infertility procedures, family planning procedures (bilateral tubal ligation procedure). a patient may obtain gynecological care from providers offering daily reception and/or urgent and emergency care. it should be noted that provider locations may be far from those considered priority cases due to covid-19. this should also be considered when determining the condition severity and surgical risk of each patient. furthermore, the estimated length of postoperative hospitalization should be abbreviated, and preference should be given to minimally invasive surgeries. the cost (possibility of resources) and surgical indication should always be reassessed if there is a need and/or expected risk for prolonged ventilation in the postoperative period (25) (26) (27) (28) . there is no consensus in the literature regarding whether laparoscopy or laparotomy is superior under pandemic conditions. however, the principles of safety and testing whenever possible should be followed. in suspected or confirmed cases of covid-19, the preferred route should be the one that produces the lowest aerial dispersion of viral particles. in urgent/emergency cases or in surgical cases with possible intestinal involvement, laparotomy would be preferred (25) (26) (27) (28) . when evaluating surgical indications, a gynecologist's decision is made individually. the analysis of a clinical case is based on guidelines in addition to the gynecologist's experience. in the acute phase of the covid-19 outbreak, self-regulation has been observed; patients may voluntarily cancel scheduled elective consultations and procedures (9) (10) (11) . we must remember that reproductive planning is a right guaranteed by law. all contraceptive methods are considered safe for use, and eligibility criteria (use and safety) are maintained. access to contraceptive methods may be compromised due to several factors, including lack of access to a prescription that must be administered by a health professional. thus, behavioral and barrier methods should always be encouraged. furthermore, health professionals should give preference to the maintenance of long-term contraceptive methods or those previously used by the patient. longterm methods should be maintained, and the exchange time may be extended without prejudice to the patient's reproductive planning (25) (26) (27) (28) . the care of patients with non-surgical gynecological complaints should be postponed, and, when possible, these patients should be encouraged to make use of telemedicine services (9) (10) (11) . professionals in the operating room should be limited to the essential, and the use of complete footwear protection, waterproof aprons, surgical or n-95 masks, head protection, gloves, and eye protection (glasses or face shield) should be ensured. movement in and out of the operating room should be limited to what is strictly necessary (25) (26) (27) (28) . n-95 masks have been shown to be 95% effective in filtering particles larger than 300 nm. they should be effective in filtering sars-cov-2 particles range from 50 to 200 nm. good-quality conventional surgical masks can provide protection similar to that of n95 masks under general-purpose conditions (25) (26) (27) (28) . many gynecological procedures can be performed using a locoregional block (e.g., spinal anesthesia, epidural). as such, we can often opt for this type of anesthesia and avoid the orotracheal intubation necessary for general anesthetic procedures to safeguard the anesthesiology team (25) (26) (27) (28) . in addition to contagion by contact with surfaces and secretions due to manipulation of the patient, it is theoretically possible that aerosolization of viral particles through the use of cautery instruments and dissection (i.e., electrosurgical and ultrasonic scalpels) may be a source of transmission, especially in surgical times such as opening valves of trocars in endoscopic surgeries or extraction of parts, as in vaginal surgeries (25) (26) (27) (28) . despite the theoretical speculation for this type of transmission, one should be careful during these surgical times to avoid exposure of the team to viral aerosols. therefore, when using electrosurgical or ultrasonic elements, a lower power should be used to reduce smoke/steam production. providers should also maintain aspiration and perform dissection for shorter intervals. vacuum cleaners with closed systems and ultra-small particulate matter filtration are indicated and may minimize this problem (25) (26) (27) (28) . procedures in cervical pathology, such as laser vaporization, conization, and high frequency surgery, usually produce smoke and vapors. therefore, greater attention should be given to the protection of professionals, and the proper use of energy sources and smoke evacuation should be ensured to minimize contamination of the environment (25) (26) (27) (28) . in laparoscopic/robotic surgeries, direct deflation should be avoided and the least possible intraabdominal pressure should be used (e.g. 10-12mmhg). care should be taken during instrument exchanges and removal of surgical specimens (25) (26) (27) (28) . in this context, it is also important to avoid the spreading of liquid and/or blood droplets during instrument manipulation (25) (26) (27) (28) . in diagnostic hysteroscopy, contamination is theoretically possible via the use of distension means, especially gas. it is recommended to use liquid (saline) as a means of distension (25) (26) (27) (28) . in summary, non-surgical treatments should be used whenever possible to reduce the risk of horizontal transmission of sars-cov-2 to health professionals and the general population and, therefore, reduce the need for hospitalization. patients should be evaluated for possible viral infection, and universal screening should be considered for all surgical candidates and patients undergoing surgical procedures. urgent and emergency personnel should always be suspected of sars-cov-2 contamination, and appropriate safety procedures and equipment should be utilized by all health professionals. soares-júnior jm, sorpreso ice, motta ev, utiyama em and baracat ec conceived and planned the present idea. soares-júnior jm, sorpreso ice, motta ev and utiyama em revised the literature and developed the theory manuscript. soares-júnior jm, utiyama em and baracat ec took the lead in writing the manuscript. all of the authors provided critical feedback and helped shape the research, analysis and manuscript. who. rolling updates on coronavirus disease (covid-19). available from education: from disruption to recovery the covid-19 epidemic a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature coronavirus disease (covid-2019) situation reports coronavírus covid-19 coronavírus: ac¸ões em sp surgeon general urges providers to consider stopping all elective surgeries -hospitals push back. healthleaders open letter to vice admiral jerome m. adams, md, united states surgeon general how to risk-stratify elective surgery during the covid-19 pandemic? version 2 covid-19 update: guidance for triage of non-emergent surgical procedures the coronavirus (covid-19) epidemic and patient safety safety and efficacy of different anesthetic regimens 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and gynecologists. coronavirus aid, relief, and economic security (cares) act: what you need to know casa civil. subchefia para assuntos jurídicos. lei n o 9 dispõe sobre o primeiro tratamento de pacientes com neoplasia maligna comprovada e estabelece prazo para seu início. diário oficial da união preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore covid 19 pandemic and gynaecological laparoscopic surgery: knowns and unknowns. facts views vis obgyn rcog staffing options for obstetrics and gynaecology services during covid-19 pandemic joint rcog/ bsge statement on gynaecological laparoscopic procedures and covid-19 key: cord-273929-kpcmy9x8 authors: shah, jatin p. title: the impact of covid‐19 on head and neck surgery, education, and training date: 2020-04-25 journal: head neck doi: 10.1002/hed.26188 sha: doc_id: 273929 cord_uid: kpcmy9x8 nan the year 2020 began quietly, except for the news of a novel virus outbreak, felt to be a local problem in wuhan, china. in the united states, economy was booming and the world had great expectations of a wonderful 2020. what followed has stunned the world with a "never seen before," calamity; the covid-19 pandemic with over two and a half million individuals infected and nearly 200 000 lives lost so far. the havoc created by this global tragedy has impacted upon many lives in many ways. we need to quickly think and to plan, as to how our professional and personal lives will be conducted in the days, weeks, months, and years ahead. at the moment there is total chaos, in every part of the world, particularly in new york city. the day-to-day life is disrupted; regular patient care of diseases and cancers is in disarray, with the focus of medical care shifted to the management of patients with covid-19. surgery is limited to emergencies and cancer cases that cannot be postponed without a negative impact on their outcome. the great majority of hospital beds is occupied by covid-19 patients, and sudden makeshift hospitals are created to accommodate the surge. temporary morgues in refrigerated trucks are to be seen at every local hospital in new york city to "house" the over 14 000 patients who have died in the last 4 weeks. what comes next, and when this will end is unknown; our future and the future of the world are frightening in its uncertainty. with a fragile future, how do we conduct our day-to-day activities, and plan to retain our robust education and training programs, to educate and train the next generation of head and neck surgeons? the major onslaught of the first wave of cases and mortality from those exposed to the disease may slow down in the weeks to come, as observed in china, but life is unlikely to return to normal in the foreseeable future. "business as usual" will not work, since we do not know the impact of the aftermath of this pandemic, the risk of a rebound second cycle of splurge in the number of cases worldwide in the fall and winter, and the potential risk of annual outbreaks from covid-19. we have great expectations from our scientists that we will find a therapeutic solution for the treatment of covid-19, and great hopes that a vaccine would be developed in the future to prevent infection. we have to develop strategies to modify, devise, and reshape our current methods of education and training to sustain a robust training program and continue to support our current work force geared to educate and train succeeding generations of students and trainees. 1 the drastic changes that have affected our work and life during the past 2 months have taught us that remote communications, education, teaching, learning and training are possible and have to be incorporated in our current systems. human communication forever has been practiced on a one-to-one basis with the production of sounds/verbal speech and the ability to hear and interpret spoken words. science and technology permitted the transmission of spoken words to be heard at a distance with the introduction of the megaphone. advancing technology gave us the radio to hear people from remote distances, and television gave us the capability to see and hear people "live" from remote distances. the internet and development of social media made human communications a "norm" in the current generation. we can now communicate with not one but multiple individuals through multiple platforms and applications. the development of these technologies in remote communication can easily be applied to remote learning. the usual academic activities occupying good part of our working week involves lectures, grand rounds and tumor boards, case conferences, journal clubs, and other similar activities. all of these activities had required physical presence and an assembly of individuals, but we have come to realize that nearly all of these activities can be conducted remotely through the internet. live video lectures and grand rounds can be easily and effectively delivered through webex or zoom conferencing where hundreds of people are able to see/hear the speaker live with the ability to interact with two-way conversations. case conferences and tumor boards can be conducted quite effectively on these platforms with screen sharing. the need to be "physically present" is not essential for conducting most academic activities. even after the passing of the current pandemic, such activities may continue to be conducted on such platforms. this would be convenient and effective and can offer such activities to an even larger audience. we can imagine a future where every institution and academic center will have an open "online book," where every learning activity is available to the world. with easy access to the internet in every part of the world, remote learning has become a way of life in many domains of education and learning. this is vividly demonstrated by a plethora of online courses available from many universities around the world. in the specialty of otolaryngology, general surgery, and head and neck surgery, even operative surgery is possible to be learnt by watching expertly demonstrated surgical procedures performed by leading surgeons and surgical educators on the websites of the american college of surgeons, the american academy of otolaryngology head and neck surgery, the international federation of head and neck oncologic societies (ifhnos), and other similar organizations. remote learning in all domains of surgical education is feasible and available. testing and examinations have traditionally required the candidates to report to a designated location, where the examination in paper form is handed to the candidates to be completed in the designated time frame, while a proctor is supervising the candidates. that is no longer necessary. multiple-choice written examinations can be taken securely online, with defined time limits. many universities and colleges offer these examinations coordinated and conducted by commercial examination companies such as exam soft. offering such examinations online is less labor intensive, more cost effective, more practical, and may attract a larger number of students from remote locations to participate. traditionally, oral examinations are conducted "in person," where the candidate and the examiners meet in private and conduct face-to-face conversation with questions and answers. the purpose of this exercise is to assess the candidates' immediate assessment, judgment, and knowledge. however, with modern technology and two-way private video platforms, such an encounter can be effectively conducted remotely. the ifhnos has taken a lead on developing the first remote learning online fellowship program in head and neck surgery and oncology, which has been in existence for the past 6 years. 2 the global online fellowship (golf) program was introduced in 2014. it is a 2-year curriculum with seven written multiple-choice online examinations, a 1 month of observership, and an oral examination (www.ifhnos.net/global). nearly 400 candidates have registered from 48 countries during the past 6 years, and 244 have graduated. the goal of this program is to improve the knowledge base and judgment of surgeons in their own home environment, without displacing them, within their resources, in their institution or place of practice, and on their own patients. this program has been very successful and is received enthusiastically in all parts of the world. in the past, the oral examinations were conducted on-site in various locations in australasia, central asia, europe, and latin america. beginning this year, ifhnos plans to conduct the oral examinations online, either using webex, zoom, or a similar technological platform. medical consultations, conversations, and office visits in the private office or in clinics are the mainstay of practice in head and neck surgery, where follow-up visits form a large percentage of our office or clinic volume. with the risk of locoregional failure of up to 40% and the risk of developing multiple primaries approaching 35%, posttreatment follow-up or surveillance has been emphasized through decades. this takes a significant amount of investment of time, effort, and personnel on the part of the clinician, and an expense, in travel and investment of time away from work and home on the part of the patient. in the past, when surgery was the only treatment of mucosal cancers of the head and neck, the follow-up schedule recommended was very laborious. the common practice was once a month the first year, every other month the second year, every 3 months the third year, every 4 months the fourth year, and every 6 months thereafter. after discovery of a second primary or a recurrence patients were put back on the same schedule. in head and neck surgery, the stringent follow-up schedule was designed on the basis that nearly 80% of the patients who were to recur, would have recurred in the first 24 months, with a median time to recurrence of 9 months. however, with the combination of surgery and radiotherapy, the locoregional recurrence rates declined significantly, and the median time to recurrence was also prolonged. thus, the need to see the patients every month in the first year, or every 2 months in the second year, became less compelling. many have argued against such intensive physician/patient personal interactions and suggested less stringent follow-up schedules. multiple trials of close follow-up vs less stringent follow-up for similar-staged patients have been proposed, but rarely accepted or came to fruition (j. shah and l. harrison, personal communication, 1996) . the absolute benefit of detecting an asymptomatic recurrence or a new primary during routine follow-up examination is questioned, compared to the patient who reports for examination when the earliest symptoms develop suggesting a recurrence. although, there are no randomized trials to compare this, the probability of a major difference in outcome is unlikely. in addition, only a very small number of patients are found to have recurrence or a new primary which is totally asymptomatic during a routine follow-up examination. some institutions and practices have transitioned the follow-up care of low-risk patients to "survivorship clinics" run by physician assistants/advanced practice providers or nurse practitioners. this second level of care for low-risk patients will reduce the follow-up volume for the clinician, but will still not do away with the inconvenience of travel, and investment of time and cost of the service, on the part of the patient. it is in this arena that telemedicine will play an important role. many patients who are at low risk of recurrence can be followed by telemedicine on a video call. during that call, if the caregiver finds the need for a close physical examination, the patient may be asked to see his/her primary care physician, closer to home, and a clinical picture, intraoral photograph or a picture of larynx/pharynx done with a fiberoptic laryngoscope can be sent to the head and neck surgeon. imaging studies can be read and reviewed online and avoid the need for "physical presence" of patient and surgeon. this practice will require a culture change among head and neck surgeons and their trainees. we will have to train our residents/fellows in developing a work ethic of practicing telemedicine. the current methodology of payment is "procedure" based (current procedural terminology [cpt]). to adequately compensate the specialist for his time, talent, expertise, and opinion, a new methodology or codes will need to be developed from cpt to current expertise terminology. an entirely new payment schedule will be required dependent on the extent and length of consultation; mail review, telephone, video consultation, tumor board involving multiple physicians will all require redefinition. for many institutions, including our own, this already exists for the international patient and has been highlighted by the current covid outbreak. the events experienced in the past few weeks have put a significant strain on the practice of medicine in general, and head and neck surgery in particular. they have forced us to think and develop strategies for transition of our current practices in patient care, education, and training to innovative solutions and prioritize the levels of patient care. only recently, numerous guidelines have appeared in all media and means of communications to strategize the optimal use of operating room space and staff. conduct of safe surgery avoiding exposure to aerosolized viral transmission and prioritizing patients at high risk of an adverse outcome if surgery is not performed have been put into practice. routine and elective cancer surgery is being postponed. if the pandemic continues for several months, the current fellows in training will not have the volume of the required surgical cases to gain the experience necessary for completing the fellowship. one solution to address this problem is to extend their fellowship by 3 to 6 months. however, this may prove to be impractical due to a variety of reasons. these include commitments made to incoming fellows who will start their training on july 1, additional salary support, housing, and the fellows themselves may have made personal or professional commitments for their respective postfellowship careers. we will need to develop ongoing teleeducation much as is being done with the ifhnos golf program with similarly defined goals and expectations to be met before certification. another potential solution is to implement regular operative techniques, group discussions with faculty members with video demonstration of surgical techniques highlighting the finer details of operative procedures and the "dos" and "don'ts" in the operative procedure. experiencing the huge impact of the covid pandemic on the society and economy of the globe and the severe strain it has put on the health care systems have been a humbling experience. it has brought the realization that all medical and surgical training programs have a component of disaster management. we need a complete reassessment of man power needs. how many surgeons were lost during this pandemic? how many more senior surgeons have elected to take early retirement or were some lost to covid? what are the manpower needs for increasing remote evaluation? what new technology is needed? current platforms like zoom cannot handle the chaos. what are the privacy issues of remote consultation? we have many challenges to face, but with challenge comes opportunity. the challenge created by the covid-19 pandemic has brought reality to life and humility in our minds and has given us the appreciation of the "luxuries and comforts" in which we practiced, taught, and trained head and neck surgery. i have shared my thoughts for dealing with these difficult times and any such future calamity that may come to keep our education and training programs sustainable by embracing technology and alternative means to teach and train our younger generation. the author appreciates the input from dr murray brennan, director of the international center of memorial sloan kettering cancer center, in the preparation of this manuscript. jatin p. shah https://orcid.org/0000-0002-6444-6592 training of a head and neck surgeon global online fellowship how to cite this article: shah jp. the impact of covid-19 on head and neck surgery, education, and training key: cord-285354-bp2dozzg authors: costanzi, andrea; mari, giulio; confalonieri, marco; maggioni, dario; fingerhut, abe title: in response to: surgery in the covid-19 phase 2 italian scenario: lessons learned in northern italy spoke hospitals date: 2020-07-01 journal: j trauma acute care surg doi: 10.1097/ta.0000000000002838 sha: doc_id: 285354 cord_uid: bp2dozzg nan dysfunction on outcomes in severe isolated traumatic brain injury. j trauma acute care surg. 2020. doi: 10. 1097 w e read with interest the article "covid-19 outbreak in northern italy: viewpoint of the milan area surgical community," which reported the pandemic surge response of our colleagues within tertiary hospitals in lombardy. this was essentially the experience of "hub" centers. herein, we would like to relate what goes on in the peripheral or "spoke" areas. italy has entered phase 2 of the coronavirus disease 2019 (covid-19) pandemic after more than 210,000 infections and more than 29,000 deaths, as the peak of the outbreak was reached at the end of the first week of april. as surgeons operating in spoke hospitals, we have paved through the pandemic in an unusual and unexpected way, many of us having to turn from surgical specialists into coronavirus disease (covid) ward doctors. at a time when guidelines and recommendations were not yet available, we had to reshape our surgical units and the entire surgical path that patients had to follow. nonetheless, being a surgeon used to emergencies in peripheral hospitals was a valuable resource during the covid mass casualty incident because of our commitment to patients and acute care background. 1 our daily schedule changed dramatically when we were asked to cancel elective surgery to increase the hospital capacity in mechanical respirators and intensive care personnel for covid-19 patients. some of us were forced to transfer cancer patients to distant oncologic hubs, and others had the possibility of reorganizing their surgical activity on a hub and spoke basis. most of us were left with sporadic emergencies as we witnessed a reduction of them as well. now that our administrators are considering a gradual reopening of outpatient activity, non-covid wards, and elective surgery, we strongly believe that what we learned in phase 1 of the outbreak should guide us in phase 2. based on the immense battle we have just run in our spoke hospitals, we would like to share some considerations. 1. our manner of approaching the patient changed dramatically to a more holistic reality that brought us back to the beginning of our practice. surgery is part of medicine in a general sense; it stands again where it is supposed to stand, strong and sturdy. multidisciplinary assessment of patients has regained a central role. 2. the covid-19 pandemic will stay in the background for many months to come, and looking at the surgical patient, in primis as a potential covid patient, will influence our choices. outpatient and inpatient activities will have to be structured in separate flows of covid versus covid-free patients. to have covid-free hospitals or wards is illusory, but an anti-covid strategy able to provide adequate protection and isolate suspected patients is necessary and feasible. 2 of surgeons, our experience with teams composed of surgery, anesthesiology, and nursing personnel has been essential in the daily decision-making process to manage urgent and emergency surgery. when progressively reopening our activities, such multidisciplinary teams can lead the development and implementation of local guidelines, as we need to stratify priorities for elective surgery into essential and nonessential. 3,4 4. rationing of health care resources has never been so fundamental. at the peak of the outbreak, all postponable urgent surgical procedures needing intensive care unit postoperative assistance were postponed, and only emergency surgery was performed. spoke hospitals with reduced intensive care unit capacity were penalized and often failed to meet their mission of wide access to acute care surgery. 5. the hub and spoke model used to centralize oncologic surgery during phase 1 had severe limitations and must be replaced by other strategies to better take advantage of professional competences widely and unevenly dispersed in the regional health network and particularly in peripheral hospitals, which were underused. 6. minimally invasive surgery was considered a luxury in covid patients. one particular point that led us to curtail laparoscopic operations was the need for forced trendelenburg position that might have interfered with covid pneumonia. other than that, we modified our techniques (no inadvertent escape of pneumoperitoneum and need of filters) in accordance with others. 5, 6 as the father of asepsis joseph lister asked himself "if a man is not to take advantage of the opportunities that present themselves to him, what is he to do, or what is he good for?" it is not our intention to stop the process of human and professional growth that this pandemic has brought about. nevertheless, after this simplified view of "war-time medicine" that required our availability in spoke hospitals to turn into covid doctors, we feel that more planning is required to have the right specialists for covid patients and to manage a second wave of the pandemic not as unprepared as we did. as far as we are concerned, we now need to rapidly move back to the professional competence we as surgeons were trained for, to be able to manage clinical complexity as it is, but with the thought that "being a doctor will never be the same after the covid-19 pandemic." 5 the impact of non-neurological organ references covid-19 outbreak in northern italy: viewpoint of the milan area surgical community covid-19: joint statement: roadmap for resuming elective surgery after covid-19 pandemic minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy and the technology committee of the european association for endoscopic surgery. a low cost, safe and effective method for smoke evacuation in laparoscopic surgery for suspected coronavirus patients being a doctor will never be the same after the covid-19 pandemic laparoscopy at all costs? not now during covid-19 outbreak and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a hub tertiary teaching hos the authors declare no conflicts of interest. surgery in the coronavirus disease 2019 phase 2 italian scenario:lessons learned in northern italy spoke hospitals w e thank dr. costanzi and colleagues for their appreciation and interesting insights about our work. 1 we perfectly agree with them that coronavirus disease 2019 pandemic dramatically changed the health system organization and surgeons' duties.we would like anyway to make some points clear:• we strongly believe that surgeons used to deal with critical patients and committed in the care of acute patients played a key role in facing this pandemic event, which seems to be a mass casualty event. the attitude of surgeons in managing scenarios involving people with different injuries and their ability to prioritize treatment and resources are crucial and effective in the field and in planning the correct hospital strategy. previous experiences and training in these fields were of paramount importance and deserve attention for the future plans.• surgical critical care knowledge, one of the pillars of acute care surgery, revealed once more a mandatory background for surgeons. 2 • the surgeons' role is important in the "hub" hospitals and much more important in the "spoke" hospitals. in our opinion, their help is fundamental in the crisis unit too, of course together with hospital manager and directors, medical and emergency department, logistic, supply, and strategic staff.• we continue, during this pandemic event, to face different surgical scenarios, emergent, urgent, and elective (particularly cancer related), and we continue to use laparoscopy (in coronavirus disease patients too) when the laparoscopic technique is recommended and widely recognized. [3] [4] [5] • we fully agree in using adequate personal protective equipment and the precautions advised.• regarding patient positioning in severe acute respiratory syndrome coronavirus 2 patients, we never experienced any problem due to trendelenburg position when required. key: cord-278609-zxdd06ur authors: sarac, benjamin a.; schoenbrunner, anna r.; wilson, stelios c.; chiu, ernest s.; janis, jeffrey e. title: the impact of covid-19-based suspension of surgeries on plastic surgery practices: a survey of acaps members date: 2020-08-03 journal: plast reconstr surg glob open doi: 10.1097/gox.0000000000003119 sha: doc_id: 278609 cord_uid: zxdd06ur the coronavirus disease 2019 (covid-19) pandemic led to a drastic decline in the number of elective surgeries performed in the united states. many national societies and local governments provided recommendations for surgeons to initially suspend and progressively resume elective surgery. the authors used a survey to the american council of academic plastic surgeons (acaps) to assess the effect on plastic surgeons. methods: an electronic survey questionnaire was distributed to 532 members of acaps. data on individual and plastic surgery practice demographics, covid-19 prevention measures, and procedures or services that were being performed or delayed were collected and analyzed. results: an estimated 161 members (30.2%) completed the survey. changes in hospital policy were cited as the most common reason (89%) for determining which procedures were currently offered. results vary by specialty. notably, <10% of respondents who normally offered aesthetic procedures currently offered any procedures during the survey. subspecialty-specific results and prevention measures when seeing clinic patients are further summarized and discussed. conclusions: plastic surgeons have seen a drastic decrease in the variety of procedures and services they are allowed to offer during the covid-19 pandemic. to help plan a return to normalcy, surgeons should create and implement plans to protect patients and staff from coronavirus transmission, assure financial solvency, and consider the effects of delayed surgeries on both the physical and mental health of their patients. in doing so, surgeons and their patients will be better prepared in the event of a resurgence of the virus. the coronavirus disease 2019 (covid-19) pandemic led to a drastic decrease in the number of elective surgeries performed in the united states. the american college of surgeons (acs) was the first group to recommend postponing elective surgeries, 1 followed by other national organizations, as well as states and individual institutions. 2 specifically, the centers for medicare and medicaid services (cms) initially detailed, 3 then later updated, a tiered system on the approach to which procedures should be postponed. 4 to further advise plastic surgeons who are not under direct state mandate, the american society of plastic surgeons (asps) added additional advice to provide specialty-specific guidance. 5 as the authors previously reported, the guidance stemming from multiple organizations at various political levels created a challenge for plastic and reconstructive surgeons to best decide how to conduct their individual practices. 2 although the number of elective surgeries being performed has decreased, colleagues in china have shown that appropriate increases will follow adequate disease control. 6 anticipating this resumption, asps released a detailed statement on april 21, 2020, to help guide plastic surgeons through the uncertain future. 7 despite the plethora of guidelines, little is known about how plastic surgeons have been affected by these changes. to help guide surgeons toward a safe return to normalcy, it is necessary first to examine and then disseminate information on what plastic surgery colleagues around the country are doing to decrease the risk of covid-19 transmission and ppe utilization. further, as the numbers of covid-19 cases rise, the need for this information becomes more relevant, as further cessations in elective surgery may result. the authors conducted a survey assessing individual provider's practice changes as related to the procedures and services offered. quantitative data on changes in plastic surgery practices due to the covid-19 health crisis are presented below to guide the reader and public health officials if cessations in elective surgery are again recommended. an electronic survey questionnaire with branching logic and a maximum of 63 questions was distributed to 532 members of the american council of academic plastic surgeons (acaps). an initial recruitment email was sent on april 8, 2020, with additional reminder emails on day 6 and 15 after the first email survey invitation was sent. the survey was closed 17 days after opening, at which point it went 48 consecutive hours without a response. participants were asked to provide demographic information about their practices. they were then asked if they normally offered services in aesthetic, breast reconstruction, pediatric/craniofacial, gender-affirming, general reconstruction, and/or hand surgery. based upon these answers, participants were directed to specific questions on whether or not they were currently offering specific procedures during the pandemic. the survey and research protocols were granted irb approval by the new york university school of medicine. in total, 161 members (30.2%) completed the survey. demographic information is shown in table 1 . each question was optional, and the number of responses to each question is shown in the table. the majority of respondents were from the south (n = 43, 29%), followed by the northeast (n = 38, 26%), midwest (n = 37, 25%), and west (n = 29, 20%). most participants reported working in an academic environment (123, 79%) and urban location (115, 74%). ninety-five percent (n = 147) reported that their institution prohibited elective surgery. an estimated 148 participants (92%) cited still seeing clinic patients, of which 125 (84%) reported both seeing patients in person and consulting them via telemedicine; the remaining 18 (12%) and 5 (4%) reported consulting patients solely via telemedicine and seeing them in person, respectively. preventative measures taken by the respondents during inperson visits are illustrated in figure 1 . the most answered reasons cited for determining which procedures are being offered during the covid-19 outbreak were hospital governance (89%), followed by patient (84%) and clinician staff safety (80%). responses to questions related to aesthetic surgery are shown in table 2 . no procedure was offered by more than 10% of respondents. responses related to breast reconstruction are shown in table 2 . fifty-eight (95%) respondents stated that they were adhering to asps breast reconstruction recommendations when not under direct state or institution policy. 8 results show that breast reconstruction continued through the pandemic; however, more respondents reported offering implant-based over autologous reconstruction. responses related to pediatric craniofacial surgery are shown in table 2 . results varied greatly, ranging from 66 (97%) respondents indicating offering surgery either currently or in a situation-specific manner for facial fracture repair to only 4 (7%) offering orthognathic surgery. forty-nine participants (32%) answered that they normally performed gender affirmation surgery. when asked about face, chest, and genital surgery, none reported that they are currently offering these procedures. only 4 (8%) responded that revision surgery was a situation-specific scenario. responses related to general reconstruction surgery are shown in table 2 . fifty-five participants (51%) indicated that they are offering breast reconstructive surgery during the pandemic. specifics of breast reconstruction are discussed above. in total, 45 (56%) and 85 (72%) responses related to hand surgery are shown in table 2 . fifteen (21%) respondents reported offering carpal tunnel release, whereas less than 10% reported offering trigger finger release or carpometacarpal (cmc) arthroplasty. repair of fractures, tendon lacerations, and replant of digits all exceeded rates of offering of 75%, with replant of the thumb was cited as the most common (97%). aesthetic and cosmetic procedures are generally considered elective and greatly outnumber the amount of reconstructive procedures performed each year. 9 as the authors reported previously, 4 of the 50 states in the united states specifically mention the cessation of cosmetic or aesthetic surgery in official state guidance, 2 as does the international society of aesthetic plastic surgery. 10 the drastic decrease in these procedures has likely caused a tremendous financial burden for cosmetic practices, though we are unable to quantify the exact burden at this time amid the pandemic. however, in their guidelines on resuming normal procedures, asps recommends creating a financial policy in the event of cancellations. 7 survey results showed that of the surgeons who normally offer aesthetic services, up to 8% are continuing to perform some of these procedures, which may be a result of the pandemic-caused financial strain. proceeding with such surgeries puts the patient and staff at risk for viral transmission, especially during endotracheal intubation and extubation. 11 in the event of repeated recommendations for the cessation of elective surgery, aesthetic procedures may still be offered in outpatient centers without overnight stays. multiple national societies released recommendations on the approach to breast cancer and reconstructive surgery during the covid-19 pandemic. for example, the society of surgical oncologists recommended making the decision to operate based on the histopathologic analysis of breast masses. 12 in addition, many of the state guidelines on elective surgery allow the continuation of procedures when there is a concern for a progression of metastasis or upon reliasing a need for staging. however, state guidelines lacked details on post-mastectomy reconstructive surgery, as none provide definitive details in state-issued guidance on elective surgery. 2 survey results showed that oncologic breast surgery continued during the covid-19 outbreak, which highlights a need for clear guidelines on breast reconstruction. asps and the plastic surgery foundation released a joint statement on the approach to breast reconstruction following oncologic surgery. 8 notably, the guidelines recommend delaying immediate autologous reconstruction, while considering immediate tissue expander or direct implants, and, as mentioned previously, survey results generally followed. if performed in the outpatient setting, breast reconstruction surgery may be safely continued while taking into account the specific operation and health of the patient. as seen in the survey results, the wide breadth of pediatric craniofacial operations necessitates the need for casespecific decision-making. the ao craniomaxillofacial (cmf) foundation released general and specific recommendations for maxillofacial surgeries during the covid-19 pandemic. 13 survey responses generally coincide with the ao cmf recommendations on maxillofacial procedures; however, the guidelines urge that if possible, closed reductions be performed over open procedures, which was not captured in the survey results. liu et al. detail their implementation of the ao cmf best practices from initial workup through surgery on a 21-year-old covid-19-positive male patient who sustained a gunshot wound to the neck and zygomatic region. 14 in their report, they show that while adhering to conservative measures, it can be safe to operate on the patient under such circumstances. their preventative cautions include full aerosol precautions during evaluation and operation, including utilization of powered air purifying respirators, and minimal irrigation and suctioning. as the authors have described elsewhere, the timing of pediatric craniofacial surgery can be crucial because it plays a role in both function and complication rates, and, thus, should be taken into consideration even during the covid-19 outbreak. 15 one such example is the timing of intervention for craniosynostosis, where the age of the patient for minimally invasive compared with open cranial vault remodeling can affect complication rates. as such, respondents more often answered situation-specific scenario than currently offering all pediatric craniofacial surgeries, with the exception of fracture repair, suggesting that timing is already on the minds of craniofacial surgeons. as states in the united states begin to resume elective surgery, there will likely be a higher than usual volume of these surgeries, and plastic surgeons should consult the asps guidelines 7 as well as the ao cmf foundation 13 recommendations to protect themselves and their staff due to the possible presence of a high number of viral particles on or near mucosal surfaces of the nose and throat. 16 whether or not pediatric craniofacial surgeries may continue in the event of further restrictions should be highly individualized to the patient, evaluating all risks and benefits of the procedure, including risks to surgeons and their associated staff when operating on high-risk areas of the body. although no respondents reported offering primary gender-affirming surgery, in a comments section at the end of the survey, one respondent noted that a patient of his/hers was scheduled for a gender affirmation surgery, which was ultimately cancelled owing to the covid-19 outbreak; the patient subsequently attempted suicide. suicide rates and suicidal ideation are known to be high among transgender adults, 17 and all surgeons should be aware that the current global health crisis may exacerbate underlying mental health conditions for all patients. 18 when planning gender affirmation surgery, providers should discuss the possibility of future cancellations in elective surgery to best formulate a supportive care plan in such an event. for non-breast cancer oncologic reconstruction, physicians are required to make individualized decisions, as the cms guidelines recommend that most cancers not be postponed, while some lower risk cancers may be postponed during the pandemic. 3 the ao cmf foundation provides more details on the approach to cancers of the head and neck, but lacks details on reconstruction. 13 however, head and neck reconstruction for advanced squamous cell carcinomas requires reconstruction in more than 50% of cases, again highlighting a need for clear reconstructive guidelines during the covid-19 pandemic. 19 as surgeries resume, evaluation of the immunologic status of the patient may be a priority, as many oncology patients may be immunocompromised and at a higher risk to covid-19 infection. for this reason, as cases continue to climb in the united states, the health of the patient becomes a top priority when evaluating reconstructive options. the cms guidelines listed few examples for each tier in their system, but they explicitly mentioned carpal tunnel release as tier 1a, suggesting this procedure be postponed. 3 despite this, survey results showed higher rates of offering carpal tunnel than cmc arthroplasty or trigger finger release. while overall volume for hand surgeons may be low, resumption of elective surgery should promote large increases in volume as some states, like ohio, initially reinstituted surgeries that do not require an overnight stay, before allowing full resumption. 20 however, many state guidelines, including ohio, again, initially permitted surgery if there was "threat of permanent dysfunction of an extremity or organ system," which is reflected in the survey responses for potentially debilitating hand injuries. 21 in the event of another round of cancellations in elective surgery, it becomes important to note that procedures that carry a high risk of permanent dysfunction or are amenable to outpatient repair may be allowed to continue. this survey was sent to members of the acaps. the majority of participants reported working in academic environments, thus not reaching the entire spectrum of all plastic and reconstructive surgeons. given the rapidly evolving nature of the pandemic, participants' answers may have changed during the open window for survey completion. answers are prone to responder bias, especially those assessing protective measures for themselves, ancillary staff, and patients. plastic surgeons have seen a drastic decrease in the variety of procedures and services they are allowed to offer during the covid-19 pandemic. those performing exclusively cosmetic, gender affirmation, or other routine elective procedures are affected more than their counterparts in craniofacial, reconstructive, and hand surgery. to help plan a return to normalcy, surgeons should create and implement plans to protect patients and staff from coronavirus transmission, assure financial solvency, and consider the effects of delayed surgeries on both the physical and mental health of their patients. in doing so, surgeons and their patients will be better prepared to weather the impact of a possible resurgence of the virus. covid-19: recommendations for management of elective surgical procedures coronavirus disease 2019 state guidelines on elective surgeryconsiderations for plastic and reconstructive surgeons cms adult elective surgery and procedures recommendations: limit all non-essential planned surgeries and procedures, including dental, until further notice non-emergent, elective medical services, and treatment recommendations asps guidance regarding elective and non-essential patient care our experiences on plastic and reconstructive surgery procedures during covid-19 pandemic from shanghai ninth people's hospital considerations for the resumption of elective surgery and visits asps statement on breast reconstruction in the face of covid-19 pandemic plastic surgery statistics report covid-19: recommendations for management of elective surgical procedures in aesthetic surgery covid-19 and risks posed to personnel during endotracheal intubation resource for management options of breast cancer during covid-19 ao cmf international task force recommendations on best practices for maxillofacial procedures during covid-19 pandemic considerations for management of craniomaxillofacial trauma in covid-19 patients considerations for pediatric craniofacial surgeons during the covid-19 outbreak sars-cov-2 viral load in upper respiratory specimens of infected patients suicidal thoughts and behaviors among transgender adults in relation to education, ethnicity, and income: a systematic review patients with mental health disorders in the covid-19 epidemic current reconstructive techniques following head and neck cancer resection using microvascular surgery governor dewine announces details of ohio's responsible restartohio plan director's order for the management of nonessential surgeries and procedures throughout ohio key: cord-293378-bi3lcj09 authors: teven, chad m.; song, david h. title: patient counseling in plastic surgery during coronavirus disease 2019 date: 2020-05-13 journal: plast reconstr surg glob open doi: 10.1097/gox.0000000000002924 sha: doc_id: 293378 cord_uid: bi3lcj09 nan an ongoing public health crisis. as of april 19, 749,666 cases and 35,012 deaths have been confirmed in the united states. 1 in response, hospitals have implemented significant changes to normal operating procedures to address anticipated needs of infected patients. one key example is cancellation of nontime-sensitive elective surgery. because the majority of plastic surgical procedures fall under this classification, the current pandemic has profound effects on plastic surgery. due to effective social distancing, recent models report reduced covid-19-related death estimates and flattening of the curve. 2 in response, hospitals have started preparing for a return to normal operations. several institutions, including ours, recently relaxed restrictions on surgery, permitting some elective procedures to proceed. it is, therefore, critical that both surgeons and patients understand additional risks present in the setting of the covid-19 pandemic. a recent report by bryan et al 3 highlighted several considerations for surgical patients during the pandemic (table 1) . first, there is a lack of evidence demonstrating how infected patients tolerate routine procedures, including physiologic response to surgery and anesthesia. second, patients have an unknown but presumably heightened risk of nosocomial severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection. third, changes in normal perioperative procedures, such as visitor restrictions or limited nursing staff, may impact care. finally, resource shortages may alter postoperative care, both in cases of successful surgery and when complications arise. 3 we agree on the importance of informing patients of these issues. however, there are risks specific to plastic surgery that must also be addressed (table 1) . first, there appears to be an increased risk of thromboembolic complications in covid-19-positive patients. 4 whether this translates to an increased risk of thrombosis in microvascular surgery or for procedures with a high relative risk of thromboembolism (eg, abdominoplasty) remains uncertain. second, many procedures are staged, such as prosthetic breast reconstruction and forehead flaps. due to unforeseen issues related to the pandemic, patients may experience atypically long delays to the second procedure. similarly, revision surgery may be delayed indefinitely if hospital resources become limited. third, although changes to the riskbenefit calculus for common procedures are expected, the degree of change remains unknown. for example, evidence regarding the safety of delaying versus performing nonelective, nonemergent surgery (eg, skin cancer resection) in patients at risk for severe covid-19 infection (eg, elderly and/or comorbidities) is limited. additional risks will certainly arise in specific cases and must be addressed accordingly. moving forward, we offer recommendations to facilitate appropriate care during the pandemic (table 2) . first, during the informed consent process, in addition to case-specific risks, benefits, and alternatives, implications of surgery during the pandemic must be discussed and documented accordingly. next, whenever 3 the use of advanced directives and living wills is encouraged, given the high degree of uncertainty surrounding surgery and covid-19. 3 finally, application of sound clinical judgment, shared decision-making, and a patient-centered approach will facilitate improved care, particularly where clinical evidence is lacking. 5 mayo clinic 5779 e. mayo blvd. phoenix, az 85054 e-mail: teven.chad@mayo.edu johns hopkins coronavirus resource center available at covid19.healthdata.org/united-states-of-america unknown unknowns: surgical consent during the covid-19 pandemic incidence of thrombotic complications in critically ill icu patients with covid-19 shared decision making: a model for clinical practice the authors have no financial interest to declare in relation to the content of this article. key: cord-275985-rj0o7lg2 authors: keller, deborah s.; grossman, rebecca c.; winter, des c. title: choosing the new normal for surgical education using alternative platforms date: 2020-08-30 journal: surgery (oxf) doi: 10.1016/j.mpsur.2020.07.017 sha: doc_id: 275985 cord_uid: rj0o7lg2 the traditional methods for surgical education and professional development are changing, from a variety of external factors. the covid-19 pandemic accelerated the pace innovative alternative tools are introduced into clinical practice, creating a new normal for teaching and training. in this new normal is the challenge to create durable changes for the future of surgical education. social media (some), a tool that uses electronic communications and applications to allow users create and share information in dynamic ways, can meet this challenge. some is reshaping how we communicate and learn, and offers great benefits for effective, individualized surgical education. the limits for some appear endless, and elements have already help establish digital surgery to help improve the precision and outcomes of surgery. as we work to define the new normal in surgical education and professional development, some digital surgery will be critical for continued growth and progress. the term 'the new normal' gained popularity from technology investor roger mcnamee, describing a time of substantial possibilities as long as one resists succumbing to urgency, and plays by novel rules created in response to the current environment. in a sense, the new normal is the new standard of baseline expectations or experiences. the term has since been used in a variety of other contexts to imply that something which was previously abnormal has become familiar. it is commonly now used to describe our personal and professional lives amidst the covid-19 pandemic, and can be applied to how we will return to surgical practice. the pandemic has impacted surgical education, and no one can say with certainty if there is an end in sight, or when to start measuring the consequences. new normals may emerge, in which novel systems and assumptions will replace others that are long established and taken for granted. currently, however, the new normal represents a challenge in how to create durable changes for the future of surgical education. the paradigm for surgical education is shifting from multiple external pressures. the traditionally used halstedian apprenticeship-style approach to teaching was challenged by duty-hour restrictions and limitations in time available for inperson mentorship and skills acquisition amid mounting administrative responsibilities. 1 the resulting time in the hospital can resemble shift work, with implications for adequate training exposure and professional development. the covid-19 pandemic invoked additional challenges by limiting the number of surgeons in-house, case volumes, and in-person learning opportunities while highlighting surgeon safety. our covidcoerced state has transitioned the question from, 'how do we ensure appropriate surgical training and professional development in the current environment?' to 'how do we maintain the integrity of surgical training while also protecting our trainees and simultaneously ensuring the sustainability of a critical workforce for our healthcare systems?'. 2 in the republic, plato wrote that 'necessity is the mother of invention'. the covid-19 pandemic has indeed created an abrupt need for new and innovative end-to-end training solutions, as well as a greater willingness for trainers and trainees to use novel technologies for surgical education. in this environment, surgeons and trainees need to pioneer alternative forms of surgical education in order to develop the same level of cognitive and technical skills. social media and digital learning tools may be the ideal alternative platforms to meet the changing needs in surgical training and professional development. surgical competence is a complex, multifactorial process that takes ample time and training to develop. the best way to achieve this is still up for debate. instead of asking how to teach surgical skills, the real question should be, how do trainees and surgeons learn surgical skills? the answer is that there is no single answer. learners respond differently to different methods of teaching, and acquire knowledge at different speeds and levels of repetition. but there are absolutes in the process. first, appropriate acquisition of knowledge, psychomotor skills and cognitive skills together form the basis for optimal training. the deliberate practice of tasks, combining repetition with tailored feedback, is crucial for surgeons learning new procedures and advancing their skill set with new techniques. 3 pre-training skills in a non-clinical setting can increase patient safety, maximize individualized learning and task mastery, and alleviate financial and external constraints associated with traditional teaching models. however, this skills acquisition should be individualized, as not all learners start at the same level of experience and knowledge. once in the operating room, proctoring and mentorship is necessary to safely implement new techniques into clinical practice and truly achieve competence. despite changes in the training environment, the same standards for quality and competency remain. learners need to be motivated and take the initiative to do pre-training, simulation and use alternative tools prior to the operating room and after cases to develop the same level of cognitive and technical skills. social media (some) and digital learning applications are ideal tools to meet these needs. having platforms available for learning outside of the traditional schema is invaluable for meeting the varied needs of individual learners. adding the compulsory limitations of physical distancing from covid-19, the use of these alternative platforms will become increasingly important and their inclusion in surgical training and professional development should become a part of the normal curriculum during these times and beyond. we live in an age of information abundance. the global accessibility of the internet has redefined how we access information. some is reshaping how we communicate that information online. 4 it is broadly defined as a tool that uses electronic communication, including websites and mobile applications, to enable users to create and share information. some permits internet users to interact in more dynamic ways through virtual communities. in general, some is widely accepted and extensively used. in 2020, there are nearly 4 billion #some users reported worldwide, with global penetration rates estimated at 71% in east asia, 69% in north america, and 67% in europe, and the usage rates are continuously growing. 4 there are multiple types of some platforms with different primary purposes, including social networking, disseminating knowledge and content, blogging, microblogging, wikis, video-sharing, collaboration sites, messaging, and virtual worlds. commonly used platforms for those applications include facebook, twitter, youtube, instagram, linkedin, whatsapp, and wechat. surgeons initially lagged behind other sectors in the use of some for professional purposes; however, the online surgical community has since flourished. 5 applications of some specific for surgical education include live dissemination of research from peer-reviewed journals, live tweeting at medical conferences, online journal clubs, transmission of news from professional societies and surgical departments, coordination of research collaborative groups, and consultations/general discussion to further medical learning. digital learning platforms are continuously developing to meet the changing needs of learners. twitter remains the most popular #some app for surgeons. twitter is a microblogging application where users post character-limited messages, known as tweets that may contain links, images, polls, or video clips. twitter provides immediate access to a constant feed of the most current research and news, as well as opinions of experts, surgical societies, organizations, and any reader. users can receive immediate feedback on the interactions with their tweets and quantify their impact. two key processes favour the use of twitter in creating global surgical communities over other social networks: 'connection', where individual nodes establish an unlimited number of bidirectional communication links, and 'contagion', where ideas are copied, disseminated and incorporated by connected nodes. 6 these posts from individual surgeons, surgical societies, and journals contribute to the digital transformation of surgical education and professional development on a global scale. certain aspects of some make it idyllic for surgeons and surgical education. as a learning tool, some uses connectivism, a contemporary education theory that embraces acquiring and maintaining knowledge flow through networking and connections made using technology. 7 in connectivism, media is the content and tool for cognitive engagement. this theory is intuitive for those that grew up with such technology, use online sources as the go-to source for learning, and are skilled at filtering the overabundance of material online. 8 the wide availability and convenience of some platforms and their content is another major factor. surgeons can access some on any device with internet access, anywhere, at any time. this flexibility is ideal for the demanding and unpredictable schedule of surgeons and trainees. furthermore, the information is up-todate, as results are published instantly and appear in real-time, with the ability to update in the same fashion. no textbook or traditional didactic classroom curriculum can compete with this immediacy. some can harness this convenience and immediacy to disseminate research papers, case studies, ideas, and thoughts more effectively than any other model. furthermore, some allows learners to personalize the educational experience to meet their needs. learners can select their preferred method or use multiple resources to acquire information, which allows better retention of knowledge than when presented through a single channel. there is the capability for self-directed learning, with simulation platforms, virtual technology, and visual media that allow trainees to gain learnerconstructed knowledge that can be interactive. the self-direction is critical for learners to achieve proficiency and shorten the learning curve based on their individual needs; they may not otherwise be proficient over a short period of practice. in addition, the interactive nature of some permits active learning and increased engagement over passive learning methods, such as live classroom lectures or independent reading. microblogs such as twitter may promote greater student-staff engagement by developing an ongoing academic conversation as an additional, or alternate, teaching intervention. as the vast majority of trainees have smartphones and have used twitter before, it was reported to be a user-friendly educational tool to supplement and enhance the experience of students on a medical school surgery clerkship. 9 a systematic review of 14 published studies on the impact of some as an educational tool for physicians and physicians-in-training found that some was associated with improved knowledge, and incorporating some tools promoted learner engagement, feedback, and collaboration and professional development. 10 the platform has also been shown to help students become more interactive and seek feedback from their mentors without resistance or hesitation. 11 this timely feedback can be essential for personal growth in surgery. the scale for communication on some is unprecedented. on social media platforms, there is a near limitless ability to connect and interact with other users. one of the most powerful ways some has affected surgical education is by harnessing this potential to create a forum for collaboration and consultation. 12 this provides a uniquely rich learning experience, where global real-time community discussions on any topic can occur at any time, including use of images and video. 12 participants can include renowned experts from all over the world, who are openly accessible. the resulting collective expertise of some users can ultimately influence patient care, and the learning experience of all involved. a prime example of this communication ability is a closed facebook group the robotic surgery collaborative, which allow surgeons to share de-identified cases, post informal polls, and exchange questions and experiences regarding particular techniques or practices (figure 1 ). this group has thousands of members that are vetted before being able to access the site, and generates numerous online discussions daily among surgeons worldwide. users have integrated this site into their workflow to post questions, photos or videos of their techniques for feedback, learning or discussion. the ability of some to reach a wider audience and have the participants widely accessible provides an unparalleled opportunity for networking with subject matter experts and thought leaders. 5 these principles have thrust some into the role as a disruptive technology for collaborative research and mentorship. in this vein, some uniquely facilitates communication, exposure and development of relationships that would not have otherwise been possible for academic and professional development. international collaboratives such as pelvex (@pelvex) and glob-alsurg (@globalsurg) have relied on some platforms for recruiting investigators, participating centers and streamlined data entry and analysis, with great success. this ability was exemplified by the covidsurg (@covidsurg) collaborative that came together at an unprecedented pace at the onset of the covid epidemic to collect, analyse, and disseminate data on how the pandemic affected surgical care. for research, the some content can also be personalized for the user in every experience. adjuncts such as hashtags (#metadata tags) on microblog platforms can be used both as a guided search tool and to create a research repository, which filters content for specific topics or research, reducing the overwhelming noise inherent to internet-based platforms. 13 current widely used hashtags that exemplify this ability include #colorectalsurgery, #colorectalresearch, #crstrials, and #some4surgery. 5, 6, 13 for mentorship, some breaks down barriers of time, space and academic position; everyone has a seat at the table. this communication model allows trainees to identify mentors and role models to engage and sponsor them, especially in underrepresented and minority groups. 14, 15 these defining characteristics of some have challenged conventional disparities in access to surgical education. essentially, anyone with internet capabilities can participate on some platforms at nominal costs. this could reduce issues with disparity and connectivity of educational tools in low-income countries and rural areas. the intersurgeon collaboration (www. intersurgeon.org) is an example of using a some-based platform to lower the barriers to information access and facilitate global surgical partnerships between surgeons across and between high-income and low/middle-income countries for exchange of knowledge and expertise. while currently linking urologists and neurosurgeons, the success of the dynamic social model will undoubtedly spur expansion across other surgical specialties. some is revolutionizing how we read, engage with, and disseminate surgical research, forcing traditional channels onto some platforms to retain learners. the traditional methods relied on in-person conferences, textbooks and published papers to disseminate research and information. this model can hinder advancing science from limitations in time, money, and access. research needed to transform from this passive model, where information is restricted and communication in silos, to a more engaged active model. recognizing the need for this shift, the vast majority of textbooks, surgical societies, departments of surgery, and journals are now accessible online. conferences cancelled live gatherings as a consequence of the pandemic, but learning continued via streaming sessions and interactive webinars. while the social and networking opportunities are not the same, the time and money saved, as well as the greater accessibility, are major benefits. as a result, journals and surgical societies are expanding their some presence, to facebook, instagram and twitter to meet the changing demands of learners. the number of subscribers reading paper journals is dwindling, and the use of alternative platforms continues to grow, where a paper can be offered in forms ranging from a digital link to a visual abstract, increasing its reach. the prestige of work has traditionally been evaluated by citation number, impact factor and journal subscribers. to stay current, the impact of research can now be measured using alternative metrics ('altmetrics') such as impressions, downloads, likes, shares, retweets and mentions across social media platforms. research has demonstrated that the size of a journal's twitter following is strongly associated with traditional metrics, such as impact factor and citations, showing the correlation between scientific and social media impact. 16 there are universal gaps in surgical education and practice improvement from cost restrictions, lack of institutional support, and lack of time. with these current educational restrictions, some could be argued as a necessity for surgical education and the delivery of academic work. 12 while some platforms have a powerful impact on education in normal circumstances, its fundamental virtual state has solidified some as essential during the covid pandemic. some can bridge and enhance gaps in training from any internal or external restrictions encountered. some tools commonly used for surgical education are detailed below, and the technologies continue to grow. podcasts are prerecorded audio files available to download or stream to a computer or smart phone. examples of surgical podcasts include those produced by the british journal of surgery, the royal college of surgeons of england, and behind the knife. these are a useful way of staying up to date on surgical topics, with the advantage that trainees can listen while for example commuting, enabling their learning to be supplemented in a time-efficient manner. webinars are interactive online mini conferences where a speaker or group delivers a presentation or journal club via live video stream to an audience who engage by watching, asking questions, responding to polls and other interactive elements. they are commonly held by surgical societies, training groups and medical device companies, with a wide selection of topics, and options for playback after the live streaming event. they allow surgeons an opportunity to select content that best matches their interests and learning needs. member-only online communities provide physicians with a free platform to collaborate and discuss clinical scenarios using text, images, videos, and live streaming content. they are most commonly found on facebook, e.g. the robotic surgery collaboration, the international bariatric club and the international hernia collaboration. such platforms are increasingly used for cooperative education, to get expert input on case presentations, and to disseminate clinical information, all with the goals of furthering surgeon education and optimizing patient care. online platforms can provide high-quality, innovative content from subject-matter expert surgeons in scheduled and continuously available formats across surgery service lines, as well as online case libraries. an example of this platform is the ais channel (www.aischannel.com). software application developed specifically for use on small, wireless devices, like smartphones and tablets, that can provide cognitive skills training through simulation apps, such as ilappsurgeryã�, touch surgeryã� and think like a surgeonã�. these mobile apps offer real-time, easy access to comprehensive models by procedure for an effective new model of surgical training. these adaptive some tools use videos, three-dimensional animations and keynote lectures in a dynamic format that allows deliberate practice, repetition, and interval learning as 'pre-training' for surgery, as well as to help work toward expertise when out of the operating room. video-based review is an increasingly utilized technique for knowledge acquisition, operating room preparation and performance improvement. video-based review uses objective assessment tools to evaluate both global and procedure-specific skills from cases performed for trainees and surgeons in practice alike. in this format, the learner can compare their current technical skill against both their own performance and an expert's performance for objective clinical skills assessment and a standard to model their technique after. particular merit may be seen in minimally invasive surgery, where instant skills assessment can be performed objectively in the operating room, and procedures are easily recorded for post-procedure performance review. while video-based coaching may increase technical performance of surgical trainees, there is a need to standardize video-based coaching tools. currently there is a wide variety of video-based review tools (outside of watching one's own), that range from curated journal youtube channels (colorectal disease), expert surgeon self-maintained sites (dr mark soliman), surgical society repositories (sages, american college of surgeons), and subscription services with expert video catalogues (websurg, giblib). curated on-demand learning content and end-to-end some-based surgical tools enable subscribers to access material on any device. these include live peer-to-peer discussions, video recording, cataloging and expert feedback for telementoring and coaching. an example of a community is the c-sats service (https://www.csats.com). virtual reality (vr) uses technology to create and place the user inside a simulated environment, with which they are able to interact. vr has revolutionized simulation for learning and training outside of the operating room. user-friendly immersive environments, such as oculus rift, have been used to simulate anatomy lessons, procedures, and the or experience in an accessible, effective, and affordable fashion. augmented reality (ar) differs from the vr experience by augmenting and overlaying information in the actual environment rather than transporting the surgeon into a virtual world. using just headset or heads-up display systems can combine imaging to create a three-dimensional model that surgeons can see, manipulate and even overlay on the physical anatomy in the operating room, guiding them in a three-dimensional space. ar can also provide an unrivaled telementoring experience, allowing the expert to see what the surgeon is seeing in real-time, providing guidance during the procedure to increase the case precision, surgeon competence and patient safety. certain systems can also record video during the case, mining the data for personalized annotated assessment post-procedure and, with the assistance of machine learning, automated recommendations to refine the precision and safety of the procedure. an example of this advanced ar system is proximiearã� (www.proximie.com), which allows learners to virtually 'scrub in' on any device for the live collaborative experience or the post-procedural review, allowing surgeons and trainees to prepare, perform, and work towards mastery in a safe environment (figure 2 ). given the capabilities of ar, this platform will likely have input in training proficiency, credentialing, and privileging for surgeons. despite the growing recognition of some as an integral tool for surgical education, there are downsides. some platforms lack rigorous peer review. evidence-based management is typically not provided and unsafe recommendations often go uncontested. the application and liability remains the responsibility of the user. information on some can be presented bypassing traditional privacy protections and other regulatory firewalls. users should ensure they obtain appropriate patient and institutional permissions, and use caution to maintain patient confidentiality and personal accountability. conflicts of interest must always be declared. issues of informed consent and patient privacy still need to be refined, and ensuring some use abides with all institutional and patient obligations remains the responsibility of the surgeon. digital surgery is the product of the marriage between some and technological solutions for surgical education. it is the convergence of surgical technology and real-time data and intelligence, which may increase the precision and outcomes of surgery. digital surgery is hailed as the next disruptive technology in surgery, following waves of disruption from laparoscopic and robotic surgery. while these inflections were based on technical improvement, digital surgery has roots in data. there is tremendous power from the data produced during surgery. details on confidence, efficiency, economy of motion, and competency can be gathered from each procedure performed. by compiling volumes of procedural data and linking that data to artificial intelligence models, patterns can be recognized, expert steps acknowledged, and standards defined for safe surgery and surgical mastery. though key aspects are already in place from the expansion of some, digital surgery offers great potential to impact on the way surgeries are performed, reducing variability in the surgical process and outcomes. the prospects for surgical education and development with digital surgery are innumerable; they include improvements in surgical quality and patient outcomes while reducing cost and inefficiencies, delivering more personalized surgical care, and increasing access to care while reducing disparities between populations. seeing the potential, stakeholders across all sectors are working to accelerate the development of digital surgery. as we work to define the new normal in surgical education and professional development, digital surgery will be critical for continued growth and progress. while these some principles and applications were useful for supporting surgical education pre-covid, they have become essential since the pandemic. elective surgery ceased nearly completely, surgeons were redeployed outside of their usual practice, and trainees were effectively barred from being physically present in the hospital, patient room and operating suite. surgeons needed innovative methods to deliver safe, effective surgical care and training. given the immediate need, some solutions were implemented more quickly than ever before to ensure surgeons and trainees had access to learning materials and remote expertise. with the successful application of some during this time of necessity, it should be incorporated into the curriculum for surgical training and professional development in the 'new normal' phase. there will be a continued need to minimize live exposure and healthcare resources while seamlessly providing high-quality care and training outside of the or. some has proven it can seamlessly and successfully provide these tenets, and should have solidified its place in surgical education. a figure 2 augmented reality system. example of the proximiear system used across multiple social media platforms that allows surgeons to virtually scrub in and receive critical performance feedback. cognitive skills training in digital era: a paradigm shift in surgical education using the tatme model covid-19 -considerations and implications for surgical learners acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice available online at: social media -statistics & facts breaking international barriers: #color-ectalsurgery is #globalsurgery new technology supporting informal learning is your residency program ready for generation y evaluating the use of twitter to enhance the educational experience of a medical school surgery clerkship social media use in medical education: a systematic review introduction of case-based learning aided by whatsapp messenger in pathology teaching for medical students social media is a necessary component of surgery practice colorectalresearch: introducing a disruptive technology for academic surgery in the social media age social media and advancement of women physicians social media as a means of networking and mentorship: role for women in cardiothoracic surgery medical journals, impact and social media: an ecological study of the twittersphere key: cord-294849-qgr0e0gt authors: diaz, adrian; sarac, benjamin a.; schoenbrunner, anna r.; janis, jeffrey e.; pawlik, timothy m. title: elective surgery in the time of covid-19 date: 2020-04-16 journal: am j surg doi: 10.1016/j.amjsurg.2020.04.014 sha: doc_id: 294849 cord_uid: qgr0e0gt the covid-19 pandemic has placed a significant strain on the united states health care system, and frontline healthcare workers are rapidly altering their professional responsibilities to help meet hospital needs. in an effort to decrease disease transmission and conserve personal protective equipment (ppe), surgeons have witnessed one of the most dramatic changes in their practices with rapidly decreasing numbers of elective surgeries. the sars-cov-2 pandemic has placed a significant strain on the united states health care system, and frontline healthcare workers are rapidly altering their professional responsibilities to help meet hospital needs. in an effort to decrease disease transmission and conserve personal protective equipment (ppe), and as a result of widespread recommendations, surgeons have witnessed one of the most dramatic changes in their practices with rapidly decreasing numbers of elective surgeries. general surgeons, in particular, are uniquely affected due to the wide variety of procedures they perform, many of which are conducted routinely in the outpatient setting. interpreting the meaning of "elective" and balancing this definition with the health of the patient can become a challenge for even the most experienced surgeons. fortunately, many groups, ranging from hospital boards to national societies, have weighed in on how to approach elective procedures. however, with so many federal and state orders, along with numerous societal recommendations, surgeons and hospital leadership are left with little guidance on how to interpret quickly evolving and sometimes conflicting information. as such we herein provide a brief review of publicly available federal, state, and general surgery society statements on elective surgery during the covid-19 outbreak. we conclude by providing a framework ( fig. 1 ) for interpreting these legislative orders and societal guidelines amidst turbulent times and rapidly evolving information. as the coronavirus outbreak was well into its evolution during march of 2020, concerns about conserving resources and ppe led to calls for delaying non-urgent services. as such, on march 18 the centers for medicare and medicaid services (cms) announced that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed. the announcement by cms came as a recommendation that provided hospitals and clinicians specific examples to guide whether or not to postpone a given surgery. 1 individual states have also contributed to the conversation on elective surgery. at the time of writing, 33 states (66%) have issued guidance in the form of either a mandate or recommendation on limiting elective surgeries. 2 at the time of our final review (march 24th 5:00pm edt) announcement dates ranged from march 15th to march 23rd. ten of the 33 states listed an end date ranging from april 13th to june 19th. of note, the direction provided by states varies. specifically, some states such as massachusetts have defined nonessential, elective invasive procedures as procedures that are scheduled in advance because the procedure does not involve a medical emergency and provide a list of examples. 3 other states, such as alaska, have acknowledged the difficulty of applying a blanket statement to define "elective surgery" for state-wide guidelines, and have chosen to keep their guidance brief while urging individual hospital systems to create their own frameworks. 4 the result of such vague guidance has been a concern among general surgeons who, in turn, are required to interpret and apply medical recommendations often published by non-medical or non-surgical professionals. similar to cms, nearly all states that provided a statement on elective surgery did so only as guidelines or recommendations. one exception was maryland that stated, "the secretary is authorized and ordered to take actions to control, restrict, and regulate the use of health care facilities for the performance of elective medical procedures …". violation of maryland's order is punishable up to one year imprisonment or a fine up to $5000 or both. 5 in an effort to help clarify the ambiguity surrounding federal and state guidelines relative to elective surgery, several professional societies have put out their own guidelines, often providing disease specific guidance. for instance, the american college of surgeons provides subspecialty specific guidelines ranging from cancer surgery to neurosurgery and urology. 6 some of these guidelines issue overarching principles such as considering nonoperative management whenever clinically appropriate, whereas other guidelines provide disease specific consideration, as in the case of emergency general surgery. considerations for cancer surgery, in particular, have been debated due to balancing the elective nature of most the american journal of surgery operations with the risk of disease progression. as such, the society of surgical oncologist has developed disease-site specific management resources that takes into account cancer stage. 7 as the covid-19 outbreak quickly spreads across the country, surgeons and hospital leaders are left trying to consume, interpret, and implement ever-changing recommendations for elective surgery. making well informed decisions will necessitate surgeon leaders to establish multi-disciplinary teams that can absorb information in real-time and provide the best local recommendations while being sensitive to national priorities (fig. 1) . first, hospital leadership and surgery department chairs should assure that their respective departments are in compliance with both federal and state recommendations when available. although much of the existing legislation lacks detail on enforceability, the ultimate price may come in the form of public opinion. surgeons may not want to find themselves explaining to their community why they continued to perform elective operations while their collogues struggled to find ppe. surgical department chairs should also convene content experts including, but not limited to surgeons, nurses, administrators, resource managers, and ethicists. expert panels should be tasked with establishing and updating elective surgery guidelines. experts should consider and balance national, state, and local resources and priorities. for example, there are areas in the country that have been largely unaffected by the pandemic. in this instance, leaders in less affected areas must weigh the utilization of ppe for elective procedures against the demand for goods and services in other, heavily affected parts of the country. additionally, special consideration should be given to the tradeoff of resource utilization between surgery and non-operative management. for example, in the management of acute appendicitis one may elect nonoperative management to free up resources. however, unintended consequences may include utilization of hospital beds and resources for intravenous antibiotic administration. in these instances, one must consider local capacity relative to the trajectory of the covid-19 disease burden to guide recommendations. as both capacity and disease burden evolve, so too will recommendations. beyond the walls of large medical centers, leaders of free standing ambulatory and outpatient surgery centers should also be sensitive to developing concerns. understandably, these surgical centers may be hesitant to postpone elective surgery as they are dependent on these services as a source of revenue. 8 furthermore, the american college of surgeons guidelines have suggested that some lower acuity surgery may be performed at ambulatory surgical centers. 9 however, leaders of these free standing centers should work closely with their local departments of public health to anticipate future needs and resources allocation. in addition, ambulatory centers may be necessary to address overflow problems at the main hospital due to the covid-19 surge. 10 cutting back on elective procedures at ambulatory centers may be crucial to slowing the spread of sars-cov-2, as well as make capacity, staff, and equipment available to address covid-19 as the outbreak spreads. it is incumbent on hospital leadership and department/division leaders to adapt their policies to the dynamic local environmenttaking into account current and projected ppe, staffing, beds, and equipment needs. a hospital may be compliant based on state and national guidelines while following society recommendations; however, these guidelines may be inappropriate for a strained hospital system. surgeon leaders need to synthesize national, state and local data to make the best decisions for their patients locally, while being sensitive to the broader national implications. dr. janis receives royalties from thieme publishing, otherwise the authors have no conflicts of interest pertaining to the work herein. dr. diaz receives funding from the university of michigan institute for healthcare policy and innovation clinician scholars program and salary support from the veterans affairs office of academic affiliations during the time of this study. this does not necessarily represent the views of the united states government or department of veterans affairs. fig. 1 . framework for evaluating guidelines for elective surgery during sars-cov-2 pandemic notes. framework for establishing elective surgery guidelines during the sars-cov-2 pandemic e as this is a rapidly evolving situation, stakeholders should repeatedly cycle through a-d as new information becomes available. a. leaders should review and evaluate national, state, local, and society guidelines so that their surgeons and institutions are compliant. b. leaders should leverage content experts within their institution such as disease content experts (e.g. surgeon), nurses, administrators, ethicist, and supply chain managers to help inform local guidelines and recommendations. c. all stakeholders should evaluate current and projected resources including workforce, ppe, and medical equipment (e.g. ventilators) and weigh availability versus disease burden d. stakeholders should consider their patients immediate needs while being sensitive to national needs. non-essential medical, surgical, and dental procedures during covid-19 response the commonwealth of massachusetts. elective procedures order covid-19 health mandate directive and order regarding various healthcare matters covid-19: elective case triage guidelines for surgical care society of surgical oncology statement from the ambulatory surgery center association regarding elective surgery and covid-19 covid-19: guidance for triage of non-emergent surgical procedures. american college of surgeons the nation's 5,000 outpatient surgery centers could help with the covid-19 overflow key: cord-006563-qmigctkp authors: nan title: the abstracts of the 26th congress of esctaic, timisoara, romania, september 22–24 2016 date: 2017-03-07 journal: j clin monit comput doi: 10.1007/s10877-017-9991-4 sha: doc_id: 6563 cord_uid: qmigctkp nan ultrasound guided nerve blocks: what makes us happy? emergency county hospital cluj-napoca, orthopaedic and traumatology clinic cluj-napoca, romania since 1994 when first described by s. kapral et al., for the supraclavicular approach of the brachial plexus, the ultrasound (us) guidance in regional anaesthesia became the choice for many of those who are practicing peripheral nerve blocks and who can afford this method. in many ways this change of paradigm in regional anaesthesia moved for the better our practice, and most important, changed patient's perioperative period pattern and probably his outcome. abrahams et al. (2009) brought the data that confirmed the superiority of us in performing nerve blocks as compared with the traditional methods, but did not conclude regarding complications because the lack of sufficient data. a more recent analysis (lewis 2015) on 2844 participants (32 rct) showed that us in peripheral nerve blockade improved the quality of block (both sensory and motor), reduced the incidence of complications and also the need to shift to general anaesthesia. beside, in their study, us use shortened the performance time while the combination with neurostimulation prolonged it. a real good thing that happened with us was the increased interest of young doctors in regional anaesthesia because of the clear benefits of this method. the us introduced a new "screen" in our everyday life, a "screen" that helps to see anatomical structures, the needle paths and the local anaesthetic distribution, meanwhile reducing the chance of intravascular "placement" of the blocks and injury of the pleura or the nerve itself. since patient safety is direct related to the total dose of local anesthesia (la) administered (barrington; kluger 2013) the use of us reduces the needed local anaesthetic volume thus reducing the risk of toxicity due to its systemic absorption, but not in case of intravascular injection (sites 2012). there are many debates regarding the right dose for peripheral nerve blocks, because the total volume depends on the practitioner's skills in regional anaesthesia, on the nerve size to be blocked, on the need of duration for the block and others factors (o′donnell 2014). beside the advantage offered by the use of us regarding the precision of the method and its accuracy, one has to add the patient's satisfaction, due to less sufferance and pain, both during the anesthesia and surgery performances. we, anesthesiologists, have also the right to look for our own professional satisfaction, since us is a method which somehow expels monotony from our daily activity. a message to your patient: if he/she is too anxious before surgery, there would be more pain in the postoperative period gabriel m. gurman ben gurion university of the negev, beer sheva, israel the acute postoperative pain produces a long list of untoward effects, from the reduced respiratory ability to the increase in the sympathetic activity, and above all psychological problems, sleepiness, confusion, agitation and delay in recovery. this is the reason why in the last decades a lot of clinical studies have been performed with the aim of reducing the magnitude of the postoperative pain, all of them directed to those factors which might influence the pain after surgery, such as: presence of preoperative chronic pain, anesthesia technique, or the need for an acute pain service. the promoter of the management of postoperative pain was john bonica, who in the last decade of the twentieth century published the list of factors which could influence the magnitude of the postoperative pain: site, duration and nature of surgery; use of pre-emptive analgesia; quality of intra-operative analgesia; quality of postoperative care. but he was also the first to bring into the clinician's attention the fact that the physiological and the psychological pattern of the surgical patient plays a very important role in establishing the intensity of postoperative pain. his recommendation was clear: pay a special attention to the preoperative psychological preparation of the patient. since then a lot of clinical studies tried to solve the problem of the preoperative anxiety, in order to reduce to a minimum its influence on the postoperative pain. currently, there is a general consensus that there are two types of preoperative anxiety: *the state anxiety (sa): a transitory emotional state, that varies in intensity over the time. *trait anxiety (ta): a personality disposition, that remains relatively stable over the time. in the year of 1983 ke scott described the differences between the two types. only sa could be influenced by premedication, which has no effect on ta. being a part of patient personality, ta's influence on postoperative pain is very difficult to control. on the contrary the sa, considered a temporary state, is much easier influenced and could also be highly predictive for the magnitude of the postoperative pain. but more recently, in 2014, nm petrovic described the so called d personality (letter d stands for distress), which includes those patients with a clear tendency towards negative affectivity, irritability, social inhibition and lack of self assurance. for some authors, the d personality is part of the ta, but it seems that those patients belonging to this specific category are at very high risk to develop severe postoperative pain. all the relevant clinical studies (katz 1997 (katz , 2000 (katz , 2001 ; kepf 1997; southerland 2014) lead to the same conclusion: preventive measures regarding the preoperative anxiety seem to help! the list of proposals to be taken into consideration includes: a careful psychological evaluation and preparation of the surgical patient, a good preoperative sedation and even the use of antidepressants before surgery in specific cases. in conclusion, it is the anesthesiologist's task, among many others, to recognize the importance of the preoperative anxiety, to identify those patients in high risk from this point of vu and prepare the anxious patient accordingly. placement is facilitated by use of ultrasound guidance. the objective pursued with this presentation is to bring awareness to the challenge of managing postoperative pain for this repair, to discuss our experience with te and pvb, and to also talk about the adjunct medications which we commonly use to supplement these techniques. pectus excavatum is the most common chest wall deformity. repair of this defect depends upon the respiratory, cardiac symptoms, or pain experienced by the patient. it is accomplished via placement of an intrathoracic bar. this in turn provides immediate correction of the defect, but typically results in significant postoperative pain. traditional approach has made use of te as the gold standard for pain control during thoracic procedures. placement is usually at the t5-t6 level or immediately below it. continuous infusions using a combination of local anesthetic with or without opioids are usually initiated. te may be used alone or in combination with pca. disadvantages of thoracic epidural are the risk of spinal hematoma, cord ischemia, epidural abscess, and profound hypotension due to subsequent sympathectomy. enter ultrasound-guided placement of bilateral pvb with continuous infusion of local anesthetic as an alternative. currently there is no consensus as to what the best technique is for pain control, but using regional anesthesia with a multimodal pain management approach may represent the best option. current studies contain data with relatively small groups of patients. future studies will need to compare existing techniques head to head with larger patient populations to determine their efficacy. regional anesthesia and ambulatory surgery: the role of continuous infusion devices in postoperative pain management in pediatrics ralph j beltran department of anesthesiology and pain medicine, nationwide children's hospital, columbus, columbus, oh, usa continuous infusions of local anesthetic delivered via peripheral nerve block catheters (pnb) for postoperative pain management in adult patients has become more prevalent. mirroring this trend, our institution adopted the idea of providing these services to our pediatric patient population. incorporating the use of pnb in the setting of ambulatory surgery for the pediatric population presents its own unique challenges. the purpose of this presentation is to describe the elements involved in rolling out an ambulatory peripheral nerve block catheter program, describe our institutional evolution in regional anesthesia, and to briefly address evidence based-research in support of regional anesthesia use in this setting. placement of pnbs in the pediatric population typically involves an in-depth conversation with parents regarding risks, benefits, and alternatives. but this conversation initiates what is a partnership between parents and physicians. the process begins with the selection of the patient for placement of pnb. at the center of the selection process is the ability to communicate with the family via telephone upon discharge to monitor the effectiveness of the block, and diagnose any potential complications. the necessary elements to establish an ambulatory pnb program includes the availability of experts in regional anesthesia around the clock, ultrasound technology, and availability of catheter supplies and infusion devices. in our institution, utilization of regional anesthesia began primarily with services geared toward arthroscopic procedures of knee and shoulder using single shot techniques. this step was followed by placement of continuous infusion catheters to patients who were originally scheduled for admission, and ultimately progressed to include ambulatory patients. the program was successfully initiated in october 2012. an initial query reflecting the first 2 years of activity showed that 78 patients benefitted from the program. the majority of patients received lower extremity catheters. no major complications occurred, including screening for skin infections, bleeding and local anesthetic toxicity. locoregional blocks in maxillo-facial surgery. advises for the anesthesiologist federico fiocca maxillo-facial surgery has been associated with intense pain, that is often difficult to assess and treat and is frequently affected by concerns regarding airway obstruction and oxygen desaturation. moreover, this is associated with difficult feeding and swallowing in the post-operatory period, thus leading to possible poor outcomes. pain control has been historically obtained by the use of intravenous and oral medication, on the other side, regional blocks have been widely used in the last several years in pain therapy, but only recently became a commonly utilized approach in pediatric care. the maxillary nerve, the second branch of the trigeminal nerve, innervates the face from the alveolar process and palate to the floor of the orbit. in oral and maxillofacial surgery, branches of the maxillary nerve are blocked to provide analgesia during and after the surgical procedure. for lip surgery infraorbital block is widely used. its indications include not only post-operatory pain relief in cleft lip repair, but can include also nasal surgery (i.e. septo-rhinoplasty, endoscopic sinus surgery). classic techniques in the performance of infraorbital block include intraoral and extraoral approaches. understanding not only the location but the course of the infraorbital foramen in fundamental in order to have optimum performance and to ensure maximum safety. for palate surgery the block of the palatine nerves with an intraoral approach are a relative common block to provide intra and postoperatory analgesia in cleft palate repair. moreover, block of the maxillary nerve, that has been used in the last several years in pain therapy, has recently become a commonly utilized approach in pediatric care with a suprazygomatic approach. in 2010 a new approach for peri-operative analgesia of cleft palate repair in infants has been proposed, permitting the reduction of intra and post-operatively opioids use with no complications. with this approach the needle is inserted perpendicular to the skin to reach the greater wing of the sphenoid, and then redirected in anteriorly and caudally direction to the pterygopalatine fossa. moreover, recently a study involving ultrasound guidance in performing this block has been presented. medical apps: potentials and risks for the anesthesiologist m. czaplik since almost everyone is attended by his smartphone always and everywhere, it is a faithful companion with nearly inexhaustible knowledge and potentialities. as one of the most important components it is part of the digitally connected world. it seems natural that smartphones therefore are used to access information especially in time-critical situations or where precise up-to-date information are urgently requested. since apps are more comfortable and faster than using google or scientific databases to find information-especially while using tablet pcs or smartphones-the usage of medical apps has grown dramatically. as a "new technology for the sake of the physician" medical devices and apps can support routine clinical tasks for all medical specialists e.g. by calculating drug doses, assisting patient education, getting access to drug databases, accessing medical record on the move and receiving clinical decision support. not only physicians but also patients are using medical apps everincreasing to gather more information about their illnesses or adverse effects of drugs, to measure their heart rate, to analyze their physical activity and much more. although they are convenient and handy, mobile medical apps must be accurate and reliable to avoid relevant risks for the users: health care professionals and patients. several studies have stated that various apps are crucial or even potentially dangerous in clinical use. patients who are using an app for skin cancer detecting lean on its reliability. for technically skilled persons it is not surprising that sensitivity of these apps which are using unclear ambient light und the ordinary build-in camera of the phone is low, but by far not for all potential users. further apps undertake drug doses calculations. this is practical, particularly for children's medicine or to convert opioid equivalences. however, a wrong opioid dosage conversion can lead to life threatening harm. for the decision whether to use an app or not, it should be taken into account that most app developers have little or no formal medical competence. lastly the physician should balance risks of harm against anticipated benefits for the respective clinical field of application. in order to be make that possible, it is necessary to identify potential risks including diverse risk types concerning software, hardware, sensors, display, user interface, network issues etc. a relatively easy framework to evaluate potential risks by an app will be introduced. it considers the probability of an event occurring that could lead to harm, the severity of the consecutive harm and the likelihood of a clinical error being detected. a few examples out of hundreds apps that are useful for the anesthesiologist in the field of emergency care, operation theatre and intensive care unit will be presented. potentials and all types of risks will be identified for each, leading to a risk category a to d aiming in sensitization of the sophisticated modern anesthetist to circumspectly using the next "discovered" app for clinical purposes. the global economic and financial crisis is having crucial impact on european healthcare systems (1) . pressures in health come from the requirements of an ageing population, the introduction of expensive medical technologies and greater community expectations for access to health services. however, it is evident that public hospitals could provide better care by being more efficient and reducing wasteful spending. operating theatre (ot) services represents a significant proportion of hospital costs. in 2011-12, approximately 210,000 patients in new south wales (nsw) had elective surgery accounting for 45% of all public admissions. this is estimated to cost approximately $1.3 billion each year or about 17% of nsw health's inpatient services budget. ot costs averaged more than half total episode costs in a study of australian general surgery cases. (2) increasing the ot productivity is a wise strategy to reduce costs. one of the key methods is proper ot management and optimization of the whole process involved in the treatment of the surgical patient. the goals for ot management are: improving productivity and efficiency while maintaining high quality of care at all times. improving efficiency means shorter case durations, rational scheduling of various types of surgery, and minimizing nonoperative time by reorganizing ot tasks. information technology (it) can support decision making to manage ot efficiency. hereinafter an example of it implementation in an operating theater. in 2005 in view of the newly created operating room block (orb) in gb morgagni l pierantoni hospital in forlì, a project aimed to develop a data recording system of the surgical process of every patient within the orb was started. the primary goal was to create a practical and easy data processing tool to give ot managers the information basis to increase operating theaters efficiency and patient safety. the developed data analysis tool is embedded in an oracle business intelligence environment, which processes data to simple and understandable performance tachometers and tables. the system is divided in the tree profile types manager, anesthesiologist and surgeon. every profile includes subcategories where operators can access more detailed data analyses. the implementation of the project enabled a slow but constant raw utilization increase, a reduction of the number of unscheduled procedures and overtime events (3). however it by itself cannot make the miracle and human element has to be considered. humans have a natural reluctance to change and evidence-based methods to overcome these barriers have to be used (4) . moreover, education and leadership can compensate for the cognitive biases affecting every decision maker. the it gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. (ae-copd). the aim in the ards patient is to avoid hypercapnia and respiratory acidosis in a ventilation strategy consisting of very low tidal volumes. in the ae-copd patients ecco2r may avoid intubation or facilitate extubation and potentially improve outcome. in 2009, terragni et al. (1) presented a ventilation model of low vt (4 ml/kg of pbw) for severe ards patients using a modified renal replacement system coupled with a vv-ecco2r device (decap) which allowed safe and efficient management of acidosis resulting from vt reduction. the decap/decapsmart ecco2r device is a modified renal replacement circuit, incorporating a neonatal polypropylene membrane lung (0.3 m 2 ), coupled in series with a polysulfone hemofilter (1.35 m 2 ). the blood flow into the membrane is aided by a nonocclusive roller pump (maximum 450 ml/min), whereby co 2 is eliminated by diffusion against a concentration gradient, created by sweep gas flow of 6-8 l min of o 2 . kluge et al. 2012 (2) was able to show in his clinical trial that the use of extracorporeal carbon dioxide removal with the ila-system in patients with ae-copd allowed avoiding intubation and invasive mechanical ventilation without changes in mortality. in the prospective randomized xtravent-study published 2013, bein et al. (3) were using the same system to reduce vt to 3 ml/kg pbw in patients with moderate ards. the primary outcome, the 28and 60-days ventilator-free days, was not different in both groups. the prototype of this pumpless av-ecco 2 r device used in both studies is the ila (novalung, xenios). it consists of a single-use, high-molecular-weight heparin-coated, very low resistance and highly efficient poly(4-methyl-1-pentene) membrane (1.3 m 2 ). blood is drained via the femoral artery and returned via the femoral vein (15to 21-french catheters). the more advanced ila-activve platform consists of a centrifugal pump and four different oxygenators that can be used depending on the type of gas exchange disturbance. the blood flow can be regulated between 500 ml and 7 l/min. the currently running pilot and feasibility "supernova" study will use three different devices (hemolung, ila-activve, hls set advanced 5.0) for the low-flow extracorporeal co2 removal in patients with moderate ards to enhance lung protective ventilation. the rest trial is the first multicenter clinical study to determine whether vv-ecco2r (hemolung) and lower tidal volume mechanical ventilation improves outcome and is cost-effective. the ultra-low flow pumpdriven ecco 2 r device exclusively used in this trial (hemolung ras, alung technologies) uses a 15.5 french dual lumen catheter inserted in either the femoral or jugular vein, and provides removal of up to 50% of basal co 2 production at flows of 400-500 ml/min. previous studies have shown that the use of partial ecco 2 r facilitates lung protective ventilation, is easily implemented, and found to be safe and effective. whether it improves outcome remains to be determined. universities of medicine and pharmacy, târgu mureş and cluj napoca, romania the use of simulation in the medical teaching process is attractive for all the people involved. patients, trainees, trainers, researchers, administrators, industry, they all may benefit from the development of this tool and they already set up high levels of expectation. it is very clear that simulation provides an opportunity for teaching but it is not yet consistently proved if other expected benefits from simulation use are real. we may agree that opportunity alone is a strong argument to use simulation to train for catastrophic rare events like malignant hyperthermia or emergency cricothyroidotomy, but is that the case for routine care as well? while some organisations advocate for offering certificates to simulation programs, others warn about the danger of using simulation alone as a teaching tool and prohibit this practice. simulation is not a cheap tool and the real benefits of using it need to be demonstrated to the managers before we can expect them to agree with such an expensive investment. the very well-known argument "we may lose more money than a simulator's price in a malpractice suit" may not work, as nobody demonstrated that using simulation for training prevents malpractice accusations. in the long road from just "doing things" to "doing the right things right" medical simulation is just at the beginning. we should aim for both high efficiency and high effectiveness even if it might sound unrealistic. researchers and educators will first need to establish how to measure the expected effects. only by routinely measuring the results of medical simulation use we will be able to improve it, just like in any other aspect of life. utilizing simulation in the operating room environment for fiberoptic intubations to perform the fiberoptic intubation safely, calmly, and with confidence, it was elected to recreate the airway and perform a simulation prior to intubation. the airway was simulated using common tubing from the or of approximate size, shape, and angles of pediatric larynx, trachea, and bronchi. the passage contained landmarks marked with different colors to serve as checkpoints. several studies have been conducted in order to specifically evaluate the efficacy of bronchoscopy simulation (1). the literature has been conflicting in outcomes. a study at penn state hershey medical center found extreme standard deviations in skills when learning nasal endoscopy on a fiberoptic simulation (2) . another study found that using a simulator could advance resident skills to levels similar to that of attendings (1). proper use and training with the simulation equipment is paramount in creating a realistic environment (1). simulation has been proven useful in the education of specific skill sets during anesthesiology residency. most simulation training involves the fabrication of the operating room setting removing the learner from the operating room. this report describes the use of a bronchoscopy simulator, in the or environment, used directly prior to actual patient care. this report describes the use of a bronchoscopy simulator, in the or environment, used directly prior to actual patient care. pulse oximetry imaging-practical feasibility introduction photoplethysmography imaging (ppgi) [2] may bring two essential advantages for the icu: (1) non-contact, hence applicable to wounded skin regions. (2) spatial resolved vital parameter monitoring. this work analyzes the physical limitation of spatial resolved monitoring of s p o 2 with monte carlo simulation (mcs). material and methods ppgi makes use of a camera and an illumination array in front of the subject (fig. 1, left) . among other parameters, s p o 2 can be calculated space-resolved by defining virtual sensors (vs) with defined spacing. the signal-to-noise ratio (snr) of the vs depends on the spacing. this represents the physical limitation of pulse oximetry imaging (poi) that was investigated with mcs. our skin mc phantom divides the skin into the anatomical/functional layers and includes discrete, dynamic blood vessels [3] . results mcs was performed with a centrically photon injection up to 4 billion photons. we found a relationship between the number of photons, the vs size and the resulting s p o 2 error, see fig. 1 (right) . limited by the fda requirements of accuracy, the theoretical minimum vs area is 0.1 mm, depending on the sampling rate and the illumination intensity. ben gurion university of the negev, beer sheva, israel some years ago there was mirza (2008) who wrote: ''the extent of the surgical invasiveness may relate to the risk of immediate complications, time required for postoperative recovery and, perhaps, longterm functional outcome". apparently this very true statement referred to the surgeon activity and might have nothing in common with the anesthesiologist's task in the operating room. specific studies in this domain prove that this assumption is far from being correct. but before we will discuss very briefly the impact anesthesia may have on the extent of surgical trauma, a short glance on its pathophysiological pathways could be worthwhile. the well known axis related to the body fight for restoring posttrauma tissue functions includes the afferent impulses sent by the inflammation place to hypothalamus, which relays anti-inflammatory messages to the site of the inflammation in order to reduce the mediators release by immunocytes. this process is regulated by three neurohormonal mechanisms: the receptor kinases releasing insulin; the guanine nucleotide-binding acting through prostaglandins; the ligand-gated ion channels for glucocorticoids. the final result of all of the above is the activation of the adrenergic system, producing hyperglycemia, increase in total body expenditure and a higher energy demand. the hormonal response to trauma is a biphasic one. in the immediate postoperative period there is an increase in the secretion of corticotrophin-releasing factor (crf), acth and, of course, cortisol. but starting with the 2nd postoperative day, there would be a decrease in crf and acth secretion while, due to the so called "the acthcortisol paradox", cortisol secretion rate remains high. from the clinical point of vu all of the above have some very important side effects: homeostasis imbalance, slow recovery, predisposition to infections, longer hospitalization and, very often, aggravation of preexistent co-morbidity. the surgeon's task is clear and evident: he/she is supposed to have a gentle approach to the tissues, avoiding unnecessary blood loss and shortening the procedure duration as much as possible. beside, the place of minimal invasive surgery is totally accepted (wickham, 1987) , since this kind of procedure was shown to reduce the tissue trauma and the postoperative complications rate, all for a fig. 1 relation between the s p o 2 standard deviation and the poi pixel size or image sharpness not so significant price represented by a possible longer surgical procedure. the anesthesiologist task becomes evident. he/she may influence the magnitude of the negative effects of surgical trauma by using some techniques, such as: free-stress anesthesia (use of opiates, neurogenic blockade), a right level of depth of pharmacological hypnosis and analgesia and a correct and efficient prevention of postoperative pain. unfortunately neither older proposals, such the use of spectral edge frequency (sef, gurman 1994), nor the well known bis (sebel 2009) did prove to be useful in all cases, since there are some patients for which the measurement of the depth of general anesthesia becomes a difficult task. but on the other side, a combined general-regional anesthesia, followed by a successful and continuous postoperative analgesia could significantly reduce the magnitude of the untoward side effects of surgical trauma. but before everything we do need a universal method of quantifying surgical trauma. biro p*, sermeus l, jankovic r, savić n, onuţu ah, ionescu d, godoroja d, gurman gm *institute of anesthesiology, university hospital zurich, zurich, switzerland besides the patients' underlying disease and morbidity, for investigations of postoperative outcome it is important to have information about the magnitude and invasiveness of the involved surgery. unfortunately, there is a lack of simple and universal denominator for the magnitude of surgical invasiveness and there is no assessment tool that encompasses both, spatial as well as temporal aspects of an intervention, as well as qualitative distinction between different organs and tissues. a versatile tool to assess the invasiveness of surgery-as the "preliminary universal surgical invasiveness score" (pusis) is intended to be-would necessarily encompass all possible stressing effects of the intervention on the targeted organs/tissues as well as on the whole body. the result should be expressed in a numerical value and applicable on any kind of surgery. for this scope pusis has been proposed (1). this purely observational evaluation system has been created according plausible considerations and experience, but has not yet been validated. this circumstance is the reason why it has the term "preliminary" in its name. therefore a 3-phased plan for introduction of this new scoring system has been drawn: (1) this recent pilot study is a first step to prove the feasibility of pusis on a limited number of routine elective surgical cases, (2) a "delphi exercise" with a group of experienced surgeons and anesthesiologists to discuss and (re)-evaluate the components of pusis in the light of the results from this pilot study, and finally (3) a prospective multi-center validation study on a large number of cases which will obtain the final version of the scoring system. in the 1st phase, the multicenter pilot study, pusis values from all 80 surgeries ranged from 8 to 36. the lowest median pusis value of 11.5 was found for laparoscopic chole-cystectomy, the highest was 24.5 for open thoracic surgery. as extremes we found the lowest score at 8 in laparoscopic cholecystectomy and the highest score at 36 in a total hip replacement. the durations (mean±sd) of surgery ranged from 37± 15 min for laparoscopic cholecystectomy to 162±45 min for laparoscopic sleeve gastrectomy. we can conclude, that pusis promises to become a first step in introducing of a useful, simply obtainable, universal assessment tool for quantification of magnitude and stressing capacity of individual surgical operations. potential benefits of having a finally validated and approved usis are manifold in the context of decision making, outcome research and evaluation of surgical performance. laparoscopic and robotic surgical procedures present a particular challenge for both surgeons and anesthesiologists. pneumoperitoneum improves the surgical space and facilitates the surgical procedure by allowing the surgeon a better field of vision. however, high pneumoperitoneum pressures (12-15 mmhg) that improve surgical exposure are associated with greater physiologic derangements such as hypotension and tachycardia and increase postoperative shoulder pain. the hemodynamic effects of high-pressure pneumoperitoneum can be attenuated by decreasing the insufflation pressures (to 8-10 mmhg), but such maneuvers may worsen surgical exposure. one way to address both surgical need for better exposure and anesthesiologist need for maintenance of hemodynamic stability is to achieve a profound level of neuromuscular block of the abdominal musculature, thereby allowing better surgical exposure at lower intraabdominal pressures. however, at the end of the surgical procedure, recovery from such an intense block can be significantly prolonged, and pharmacologic reversal with traditional cholinesterase inhibitors is contraindicated. with the introduction of sugammadex, the surgical and anesthetic goals could be achieved by establishing intraoperative profound neuromuscular block with an aminosteroid nmba that would maximize surgical exposure at low intra-abdominal pressure (8-10 mmhg), followed by rapid (\5 min) and complete neuromuscular reversal with sugammadex. the literature on the actual benefits of such an approach, however, remains divided. this review will present the scientific evidence for the role of deep neuromuscular block in improving surgical exposure, decreasing intraoperative hemodynamic instability, and improving postoperative analgesia and recovery. high flow nasal oxygen cannula (hfnc), high flow nasal oxygen therapy (hfnc) and trans-nasal humidified rapid insufflation ventilatory exchange (thrive) are three terms used to describe the same oxygen delivery system. the circuit comprises an air/oxygen blender, an active humidifier, a heated circuit, and a single patient use nasal cannula. the system delivers adequately heated and humidified oxygen at up to 60 l/min of flow, coming close to matching peak inspiratory flow rates. this rate of oxygen delivery is considered to have a number of physiological effects: reduction of anatomical dead space, a peep effect, a high and relatively constant fraction of inspired oxygen, and good humidification. originally the device was developed for paediatric and neonatal icu practice, and much of the early experience comes from this field; but over the past 5 years it has been gaining popularity in adult practice as an innovative respiratory support for patients with modest respiratory failure. more recently it has made the jump into the operating theatre and is now being increasingly used during anaesthetic induction to extend the time before desaturation in the apneic patient, ie to prolong the safe apnea time. the precise mechanism by which hfno has its effect is incompletely understood, but four main areas exist. the difference between the inspiratory peak flow of patients and delivered flow is small and fio 2 remains relatively constant. • because gas is generally warmed to 37°c and completely humidified, mucociliary functions remain good and little discomfort is reported. it is very well tolerated by patients (roca et al. 2010 ) and the modest levels of support allow respiratory rates to reduce, improving mechanical function of the lungs. it has provided a useful support within the icu, both in reducing need for primary intubation and as a tool to reduce the need for re-intubation (hernandez et al., 2016)a useful review is available here (nishimura, 2015) . last year a french study of respiratory failure patients randomised to hfno vs niv vs standard face mask oxygen showed a survival benefit of hfno (frat et al., 2015) . the increase in lung volumes has been demonstrated by impedance plethysmography in post-cardiac surgical patients (corley et al., 2011) . this group described the benefit to be particularly marked in the obese, although this has not been widely reported. the most exciting recent findings relate to the use of hfno to both pre-oxygenate and then to extend oxygenation following induction and paralysis in the patient with the difficult airway. in a series of 25 patients undergoing hypopharyngeal or laryngeal surgery, median apnoeic periods of 14 min without desaturation were achieved, with a rate of pco2 rise of around 0.15 kpa/minute (patel and nouraei, 2015) . the authors describes this application of hfno as a therapy that 'could change the nature of difficult intubations from a hurried stopstart, potentially traumatic undertaking, to a smooth event undertaken within an extended safe apnoeic window'. the lecture will focus particularly on this role of hfno. intranasal administration is an attractive option for drug delivery. available devices vary in accuracy of delivery, dose reproducibility, costs and ease of use. we present an evaluation of a new generation nasal delivery device for systemic and direct nose-to-brain delivery-sipnose. we used the device to administer 3 mg intranasal midazolam (5 mg/ml) as a part of premedication before induction of general anaesthesia. we recorded bi-spectral index value (bis) to monitor sedation, the time until minimum recorded bis, the sedation score evaluated by the attending anaesthesiologist, presence of the bitter taste reported by the patient and physician feedback. we compared the results with intranasal administration of same midazolam dose using a standard commercial device. the concentration of midazolam in the blood was determined for both groups. the study population consisted in 8 asa i&ii patients for each group. mean bis value was 74.50± 3.196 in sipnose group vs 87.25±1.840 in commercial pump group, p= 0.0019. the time until minimum bis value recording was 5.875± 1.619 s for sipnose group versus 10.00±1.464 s in the commercial pump group (p=0.039). subjective assessment performed by the attending anaesthesiologist found sipnose effective in 100% times, versus 12.5% for the standard commercial pump. bitter taste was reported by 75% of patients from standard pomp group and by 12.5 of patients from sipnose group. physician feedback was excellent in 100% for the sipnose group and only in 25% from standard pomp group. midazolam blood concentration was 0.821±0.4 ng/ml in the sipnose group and 1.39±1.73 ng/ml for the standard commercial device group. we found sipnose to be more effective, with a much more reproducible effect than the standard commercial pump delivery. sipnose delivery results in lower blood concentrations than the nasal pump delivery, although efficiency in brain activity was higher. also patient and physician feedback were better for the sipnose device. note: the study was supported by sipnose ltd. assisted by a simple software, the perioperative management of chronic medication improves patient safety and easies the physician activity adrian belîi, roman ciubara, iana burmistr, andrei leontiev nicolae testemitanu state university of medicine and pharmacy, chisinau, republic of moldova today, the surgical patient becomes more and more elder, with more comorbidities. the patient benefits from more extensive surgeries that require constant perioperative monitoring of vital signs. according to internal data of st vincent hospital, france (2012), in this context it is worth to mention that 74% of hospitalized patients take chronic medication; in every second case the anesthesiologist it the first doctor that analyzes in details these medications; 16% of patients practice self-medication, and in 30% of cases the name, dosage, administration regimen cannot be mentioned from various reasons. but chronic medication of the patients can interfere with the anesthesia, surgery, postoperative care or with the range of risks and complications, afferent to the perioperative period. it has become quite difficult for the anesthesiologist, a multi-tasking specialist by definition, to keep in active memory all the existent recommendations (and keep them up to date), regarding perioperative management of a large spectrum of drugs. thus, own research have revealed that the rate of drug management errors was 28.5% regarding antihypertensives, 50.0% regarding antidepressants, 40.4% regarding anticoagulants and antiagregants, 15.4% regarding oral anti-diabetic medication (personal data). in order to diminish the probability of errors and afferent iatrogenic consequences, a soft based on an excel (microsoft) platform was elaborated, designed to assist the anesthesiologist in the perioperative management of chronic medication of the patient. the theoretical base of the recommendations given by the soft were made from official current recommendations of european national medical societies regarding the subject. the software gives individualized recommendations in written and graphical form in an ergonomic and easy perceivable way. the anesthesiologist enters patient's general data, comorbidities and corresponding chronic medication. the output data: a printable sheet, which includes individualized written and graphical recommendations concerning perioperative management of selected drugs. as a resultless errors and perioperative complications. nuclear, biological and chemical warfare: a healthcare provider's perspective ahsan syed nationwide children's hospital, columbus, ohio, usa every victim needs a thorough examination to evaluate for all kinds of injury and not just the obvious. the injured are considered to have extensive and or unrecognized trauma that needs to be treated. in any such incident life or death is often determined within the first few minutes of its occurrence. in order to deal with such unfortunate incidents, we must prepare for them at all levels, from pre incident planning and training to incident management and post incident follow up. triage is the most important mission of any disaster medical response. patients sustaining major injuries who have the greatest chance of survival with the least expenditure of time, equipment, supplies, and personnel must be managed first. triage entails doing the greatest good for the greatest number of people. triage will separate ambulatory from the non-ambulatory and expectant. in the event of a chemical and/or biological incident, decontamination reduces the threat of contamination related injury to health service support personnel. resource allocation takes center stage when the number of victims outgrows the available resources. nuclear and radiological incident results in massive immediate casualties and then prolonged effects of radiation. the immediate damage from the nuclear disaster is from the blast itself causing structural damage along with heat and light that cause burns and retinal damage respectively. radiation is by far the most important cause of immediate and late destruction. harm from radiation depends on a multitude of factors including dose, quality, fraction of body irradiated along with genetic, demographic and other factors. acute radiation syndrome develops with a radiation dose of 2 gy or more and is characterized by gi, hematological, dermal and cns/cvs effects. depending upon the radiation dose and quality it may lead to resolution of symptoms in a few weeks or may progress to multi system failure and death caused by infections, diarrhea, bone marrow dysfunction, seizures and autonomic instability. only supportive care consisting of fluids, antibiotics, blood products, tpn and cytokines can be employed. in the us, remm (radiation emergency medical treatment) and ritm (radiation injury treatment network) are set up to help healthcare providers learn and manage radiological and nuclear emergencies. bioterrorism incident can happen quietly without any explosion or warning and pose a significant threat of morbidity and mortality. these agents gain entry via skin, gi tract and lungs. early detection and diagnosis is the key to their management. epidemiologic clues to their use are non-specific. it is important to emphasize on respiratory isolation of the patient and employ standard precautions until the agent is known. biological agents can be physically decontaminated by flooding with water and adsorbents or chemically by soap and water along with oxidation and acid-base hydrolysis. it's important to provide a safe and secure area where the patients are treated as that area will have contaminated casualty and family members around and could also be a target for terrorists. anthrax spores can survive even in the arctic, infection spreads by eating infected meat or by inhalation, incubation period of 1-6 days followed by fever, fatigue and cough, treated by antibiotics and immunoprophylaxis. smallpox is spread by variola virus, has an incubation period of about 12 days and manifests with uri symptoms and progresses to macules and papules to virus filled vesicles. smallpox is highly contagious and requires droplet and airborne precautions. it has a live virus vaccine that can also be given within 3 days of exposure. botulism spores are common in soil and water and the toxin is produced in anaerobic conditions. botulism manifests as muscular weakness, fatigue, trouble speaking and weakness of arms and chest muscles. antitoxin is available and antibiotics can be used for wound botulism. botulism has a low risk to the healthcare providers. chemical warfare constitutes manmade agents with pathophysiological effects designed to kill, injure or incapacitate the troops or the civilians in a war or a terror attack. an increased incidence of symptoms consistent with nerve, vesicant, blood, or respiratory agent exposure should raise immediate suspicion of poisoning. there are two kinds of agents, persistent and non-persistent. persistent agents have low volatility and are used to deny terrain and include vesicants and nerve agents and are among the most common. non-persistent agents are highly volatile and lethal and include pulmonary toxicants and cyanide. decontamination and the use of ppe are imperative in any such event. the possibility of combined use of chemical and biological warfare agents should also be considered. there are antidotes available for use before and after nerve agent attack. the management of specific agents depends upon the agent used and mostly includes symptomatic therapy. chemical agents pose special considerations when taking care for them in the operating room, including pulmonary shunt resulting from pulmonary edema and enhanced effects of succinylcholine to reduced efficacy of non-depolarizing muscle relaxants. it's important to know your hospital in terms of location of decontamination equipment, agent detection equipment, ppe and emergency supplies. knowing how the operating rooms and emergency rooms are ventilated and how can they be separated to prevent the major difficulties in providing anesthesia in mass casualties-how to prevent them by practical exercise? anaesth italian red cross army (reserve) mass casualties demand very often the immediate intervention of the anesthesiologist in charge with the emergency assistance on the spot and the rapid evacuation of the surviving victims to the closed medical facilities. on the 12th november 2003 in nassirya, iraq, a suicide bombe attack waslaunched against the animal house barracks where the italian contingentoperated as part of a multinational security unit. the assault killed 19 soldiers and wounded more than 30 people. since 1993 (in somalia) the italian army has been involved in peacekeeping operations; this time, in irak, they suffered the largest number of victims in one single attack. dramatic events such as a terrorist attack are almost impossible to prevent, but a few considerations and special measures may help to improve possible responses to major incidents. back to that day in nassirya, the horror following the event was hard to deal with. once the scene was secure, the first step was to rescue as many as people as possible. hostile surroundings and lack of communication in the field did not help. a review considering main difficulties encountered in the field is listed here, in order to suggest a permanent search for correct responses to major incidents in the future, through changes and improved organization of the pre-hospital aid. a. triage is one of the first measures to be taken. in our case it was inaccurate and incomplete because of hostile surroundings which did not permit a quick and exact assessment of every victim. b. emergency entrances, once opened, were not cleared immediately, so rescue teams were unable to reach the first aid station readily.patients were not labeled with priority care tags, so medics wasted time assisting unsalvageable or dead people. c. lack of communication (area was secluded) did not allow passing essential information on the patient's condition (such as necessity of specialized investigations and care, e.g. ct, mri, neuro-or vascular surgery).there was no detailed map of health facilities in the area, so the medical team did not possess the necessary information to make the evacuation quicker and more efficient. in spite of all of the above, most patients did however receive immediate and proper care, notwithstanding the adverse circumstances. this quick glance regarding the difficulties encountered on the field offers some lessons to be learned: 1. a detailed map of health facilities on the ground is vital in case of a major incident occurs. 2. a turnover of a key professional specialists is necessary to ensure frequent periods of rest and guarantee efficiency. 3. adaptability and ability to face this kind of special conditions on the field should be used as selected criteria including surgeons and anesthesiologists in the special rescue teams. 4. field drills are to be periodically organized,as well as periodical assessment of the psychological and physical fitness of the team members. in this kind of circumstances, nobody could assure a 100% success, but a better organization and a successful learning curve could, in any similar case, improve the results on the field. mass casualty incident management supported by augmented reality and telemedicine m. ohligs, a. follmann, r. rossaint, m. czaplik section medical technology, department of anesthesiology, university hospital aachen, germany the major problem in mass casualty incident is organization and the dissemination of information as soon as the first paramedics have arrived. with 5th generation networks and new mobile devices like smartphones, tablets, headsets and especially smart glasses, a new area of possibilities could help to extremely speed up the information flow. the particular time challenges require to originate a new workflow, which is developed within the project audime. one objective of the project is to exploit the opportunities of telemedicine, bringing medical expertise inside the situation in seconds. in the project audime the information exchange is realized by pivotal rabbitmq messenger service. information is evaluated, merged and stored by the information integration layer (iil), which is controlled by a server. every device is able to communicate with the server, other devices directly or complete device groups. thus the iil is able to push new inserted information to the appropriate experts instantly. subsequently, the telemedicine platform for the external leading tele emergency doctor is able to show patients lists with live-updated-statistics including triage results, shortly taken photos and a map overview. furthermore, the user interface (ui) enables the doctor to initiate a call to start a tele consultation as well as a direct video connection recorded by the smart glasses of the paramedic. as a consequence, not only the directives, findings and sampler data is directly documented as well as the view of a patient monitor is transferred, but also the tele doctor is able to realize the situation from the viewpoint of the paramedic by video stream. results initial results were taken by joining a real mass casualty incident practice. to test the ui intuitiveness, the participants were only shortly introduced into the system before the practice was started. since area-covering 5g networks are not available in these days, an independent wlan infrastructure was installed. due to serious, discontinuous voice channel problems the video possibility was not tested in this primary test. one part of the test was an individual medical treatment with support of a tele emergency doctor. with support of a sophisticated telemedicine ui, the paramedics reached in middle a 23/25 score in correctness of taken actions without the support of video. moreover, the support of the leading tele emergency doctor by choosing the triage of the patient showed nearly the same grade of correctness compared to an experienced paramedic, and a much higher grade than using the prior algorithm or compared to a normal paramedic. to improve the management in a mass casualty incident, the project audime explores new methods based on new algorithms and technologies. unlike expected the use of an algorithm for classifying patients performed worse in a real-world test setting. however, the teleconsultation by a remote tele doctor worked well and was rated as helpful. hampered by various voice connection problems and without the video stream, the leading tele emergency doctor performed excellent in supporting paramedics. the partly high time delays while operating were basically influenced through extreme distortion in the audio connection. another problem was the used headset whose microphone was not to the side of the mouth, leading to understanding issues when casualties screamed in the background. finally, the first test shows that the adoption of the leading tele emergency doctor may be the key of improving the treatment of patients in a mass casualty incident, with having a clear information overview. further studies should be created by using a better audio connection and to examine if a video connection which gives the doctor the possibility to experience the situation from the viewpoint of the paramedic could improve the results further. persistent postsurgical pain: risk factors and prevention when does acute pain become chronic? epigenetics of chronic pain after thoracic surgery chronic pain after surgery or injury predictors of chronic pain following surgery. whatdo we know? the acute to chronic pain transition. can chronic pain be prevented? chronic postsurgical pain: prevention and management a novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery chronic postsurgical pain quality of postoperative pain management in american vs european institutions chronic postsurgical pain in europe audit office of new south wales. operating theatre efficiency for elective surgery nsw.2013. the audit office of nsw how to change practice photoelectric plethysmography of the fingers and toes in man remote pulse oximetry imaging-fundamentals and applications photonische sensorkonzepte für ein mobiles gesundheitsmonitoring proposal for a surrogate surgical invasiveness score (sis) to obtain a "post hoc" quantification of surgical stress and tissue trauma in the context of postoperative outcome assessments resp care key: cord-297362-mhtvrn0c authors: wu, xian-rui; zhang, yun-feng; lan, nan; zhang, zhong-tao; wang, xi-shan; shen, bo; lan, ping; kiran, ravi p. title: practice patterns of colorectal surgery during the covid-19 pandemic date: 2020-11-05 journal: dis colon rectum doi: 10.1097/dcr.0000000000001840 sha: doc_id: 297362 cord_uid: mhtvrn0c nan the study conceived by the key researchers (x.r.w., b.s., p. l., r.p.k.) mainly consisted of 4 domains: surgeon's expertise and setting, practice patterns of colorectal surgery, factors associated with decision making for colorectal surgery, and safety and protection concerns of patients and health care providers. the study was programmed to a mobile application with a questionnaire. the study was first conducted among members of the chinese society of colorectal surgery of china medical association. the members were allowed to distribute the questionnaire to others as indicated. all participants answered the questionnaire using the mobile communication application wechat from april 24, 2020 to april 25, 2020. descriptive statistics were computed for all variables. these included frequencies for categorical factors. a p value less than 0.05 was considered statistically significant. a total of 363 respondents completed the questionnaire, including 249 (68.6%) colorectal surgeons and 114 (31.4%) general surgeons performing at least 1 colorectal surgery per week. of all the respondents, 158 (43.5%) were chief surgeons, a rank equivalent to full professor. the surgical volume was reduced during the pandemic. one-hundred eighty-four (50.7%) surgeons reported that they operated on ≥7 cases on average per week before the covid-19 pandemic compared with 31 (8.5%) respondents reporting the same number after the pandemic (p < 0.001). two-hundred nine respondents (57.6%) reported that at least 25% of their elective surgeries were canceled or postponed, whereas only 50 (13.8%) reported that at least 25% of their emergent surgeries were canceled or postponed (p < 0.001). patient concern about the risk for co-vid-19 infection was the most common reason leading to the cancellation or postponing of both elective (n = 219, 60.3%) and emergent surgeries (n = 207, 57.0%). a total of 313 (86.2%) surgeons agreed that diverting all resources to patients who had covid-19 adversely influenced the care of other patients. sixtyseven (18.5%) respondents believed that at least 25% of their patients with elective surgery being canceled or postponed had a deteriorated disease condition. onehundred fifteen (31.7%) surgeons experienced a higher percentage of emergent cases after the covid-19 pandemic than before the pandemic (supplementary table 1 http://links.lww.com/dcr/b403). the concern of the safety and protection of health care providers (n = 316, 87.1%) and timing of surgery (n = 257, 70.8%) were 2 main factors affecting decision making in colorectal surgery. the majority of respondents felt that the best timing for surgery during the covid-19 pandemic should be determined based on the discretion of the treating surgeons (n = 286, 78.8%) or by government or institutional mandates (n = 251, 69.1%). colorectal cancer was the main indication for elective or emergent colorectal surgery during the pandemic as reported by 237 (65.3%) surgeons. in general, there was a high agreement on the criteria for emergent colorectal surgery. the main indications for emergent colorectal surgery were bowel obstruction (n = 284, 78.2%) and bowel perforation (n = 237, 65.3%). approximately 50% of respondents considered gi tract bleeding (n = 172, 47.4%) and perianal abscess (n = 157, 43.3%) as a surgical emergency (supplementary table 2 http://links.lww.com/dcr/b404). surgeons with adequate or somewhat adequate personal protective equipment (ppe) supply (285/304, 93.8%) were more likely to report that they could provide adequate or somewhat adequate care to patients undergoing colorectal surgery than their counterparts without adequate ppe (27/50, 54.0%; p < 0.001). three-quarters of respondents (n = 273) voiced that more patients could safely have had elective surgery during the covid-19 pandemic if the ppe availability had been maximized (78.2%, n = 284), if there was better planning and triage of resources (n = 316, 87.1%), and if greater testing of patients and hospital personnel (n = 269, 74.1%) was available. the majority of surgeons (n = 354, 97.5%) felt it was necessary to screen patients undergoing surgery for covid-19, of whom 90.4% (n = 320) felt that all patients should be tested, whereas the remaining (n = 34, 9.6%) agreed with screening with other strategies (supplementary table 3 http://links.lww.com/dcr/b405). it is clear that this rapidly evolving covid-19 pandemic has exerted a broad threat to global health systems, in particular, to surgery-related departments, because preparing for the pandemic and caring for surgical patients are equally important to them. 8 the actual impact of the pandemic goes far beyond the viral infection itself and the associated complications; rather, it also profoundly affects patients who are not infected. 9 competition for limited operating capacity led to elective noncancer procedures being largely canceled or postponed. 10 consistent with this reality, this study showed that the percentage of surgeons who operated on at least 7 cases per week previous to the pandemic dropped significantly after the covid-19 pandemic began, with emergent colorectal surgeries being less likely to be affected than elective cases. most respondents reported that the majority of operations were canceled by patients, their main concern relating to the risk of covid-19 infection. colorectal cancer has been one of the most common disease entities that colorectal surgeons in china deal with even in normal times. 11 this fact was reflected by the results of our survey which demonstrated that most surgeons reported colorectal cancer as the main indication for colorectal surgery during the covid-19 pandemic. most respondents in the study voiced their concerns about a compromise of the care of patients with colorectal disease from the diversion of health care resources. as a result, a high percentage of participating surgeons felt that more patients could safely have had elective surgery during the covid-19 pandemic. the right strategy might be to discuss this on a case-by-case basis, because resources, such as ppe supply, need to be maximized to allow the delivery of safe and effective care to surgical patients and minimize the infection risks for medical personnel. hospitals designated to the care for covid-19-infected patients may be better able to focus on the covid priority to contain the spread of the virus. in agreement with expert opinion from review articles, the vast majority of surgeons from this study felt that it was necessary to screen patients for covid-19 infection before they were admitted. the findings of the current study have clinical merits. we must acknowledge that the pendulum of covid-19 pandemic is likely to swing back and forth again several times before it reaches equilibrium. 12 therefore, it is critical that we come together as a surgical community to efficiently disseminate high-quality information based on existing experience and data. the results of this study may represent an opportunity for other countries to develop guidelines for the government, professional societies, and hospitals to decrease the potentially devastating effects of the health care crisis on other groups of patients. in the midst of the covid-19 pandemic, the risks and benefits between the protection of patients and health care providers and the adverse outcomes resulting from delayed surgery need to be balanced. in particular, strict and consistent criteria for "emergent" colorectal surgery should be established that could help to simplify surgeons' decisions to operate or not in their practice during the difficult times. there are several limitations to our study. one of the main messages from this survey is that the covid-19 pandemic leads to a reduction of workload in colorectal surgery. however, it is unclear which specific type of colo-rectal surgery has been compromised the most. since the severity of covid-19 pandemic was different among the cities across the country, it is reasonable to think that the practice patterns of colorectal surgery might not be the same. unfortunately, data regarding which city or institution the surgeons are from is not available in this survey. in conclusion, the covid-19 pandemic clearly influenced the care of patients with colorectal disease. elective colorectal surgeries were more likely to be affected than emergent cases. china medical treatment expert group for covid-19. clinical characteristics of coronavirus disease 2019 in china enteric involvement in hospitalised patients with covid-19 outside wuhan epidemiology, virology, and clinical features of severe acute respiratory syndrome -coronavirus-2 (sars-cov-2; coronavirus disease-19) effects of covid-19 pandemic in daily life clinical course and mortality risk of severe covid-19 asian critical care clinical trials group. intensive care management of coronavirus disease 2019 (covid-19): challenges and recommendations global guidance for surgical care during the covid-19 pandemic surgery during the cov-id-19 pandemic: a comprehensive overview and perioperative care covid-19: disease, management, treatment, and social impact the impact of the covid-19 pandemic on cancer patients cancer statistics in china laparoscopy at all costs? not now during covid-19 outbreak and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a hub tertiary teaching hospital in northern lombardy the authors thank all surgeons participating in the questionnaire. key: cord-298082-zzztzi8i authors: vannini, francesca; mazzotti, antonio; stefanini, niccolò; faldini, cesare title: coronavirus disease 2019 pandemic: should we delay cartilage regenerative procedures and accept the consequences, or can we find a new normality? date: 2020-08-07 journal: int orthop doi: 10.1007/s00264-020-04741-4 sha: doc_id: 298082 cord_uid: zzztzi8i the covid-19 pandemic changed elective surgery routine. during the initial spread of the novel coronavirus, elective surgery has been stopped and only emergency and trauma and oncologic procedures were allowed. following the decrease of the contagion curve, elective surgery is slowly being recovered. the hospitals should create a pre-hospitalization path to identify possible infected patient and further postpone surgery. in this setting, cartilage repair surgery should not be neglected, because this could potentially lead to an increase of patients needing major joint replacement surgery. the covid-19 pandemic, caused by the novel coronavirus (sars-cov-2), had a strong negative impact on international communities. emergency departments and icus have been under a major stress and in orthopaedic surgery, only emergencies and trauma-related or oncologic procedures were allowed [1] . orthopaedic departments underwent a strong limitation, since elective surgery represents approximately 47% of orthopaedic expenditures. with the virus spread being progressively controlled in italy, the healthcare system is heading towards a progressive return to normal activity. there are several key aspects to be considered to return to elective procedures in a safe environment. in a large orthopaedic facility, such as the rizzoli institute, with an emergency department, the maintenance of a specific pathway is mandatory to treat potentially infected patients: trauma patients for whom surgery is mandatory, who are isolated until the swab, executed at the time of the admission, whose results are negative. if positive, the isolation is maintained in a dedicated department and surgery is performed in a dedicated operating room, with assigned access, staff and instrumentation. while resuming elective procedures, preference has been given to traditionally considered "major" surgery, such as spinal procedures or primary and revision large joint replacements. cartilage regenerative procedures and even orthobiologics were among the suspended procedures; still, a delay in treatment of arthritis-promoting lesions could result in an increased number of patients who will need joint replacement in the future, with potential long-term influence on quality of life [2] . to effectively and safely return to cartilage repair surgery, the entire course of treatment should be structured to either avoid risk of infection or make it of the lowest possible impact for the hospital itself, in order to make it feasible. patients scheduled for a cartilage procedure should visit the outpatient clinic and undergo a nasopharyngeal swab 48 hours before hospitalization [3] . the majority of cartilage treatment may be performed in day surgery, with minor risks of disease transmission. with regard to the inpatients, only the first patient scheduled as inpatient will be hospitalized in the standard orthopaedic department the night before surgery. all the other patients will enter the hospital in the early morning of surgery. patients who have a positive result to the nasopharyngeal swab for covid-19 will be postponed and immediately reported to the hygiene department. a functional isolation of the patients has been created by washable and removable dividing walls between inpatient beds (each room has 2 beds), and in day surgery. no permission for family and friends' visit has been given. indications to day surgery procedures have been extended, in order to reduce hospitalization time. patients affected by injuries such as ankle impingement, osteochondral lesion of the knee and the ankle and oa with bone marrow lesions or symptomatic bone marrow oedema could be easily treated in day surgery, as well as all the orthobiologic procedures, such as bmac injections, needing a surgical procedure; injuries involving larger joint such as hip osteonecrosis and knee or ankle oa, requiring osteotomy procedures, such tibial or femoral osteotomy + cartilage addressing, or ankle joint reconstruction + cartilage addressing, may be scheduled for one night in-hospital stay. even in the case of patients with negative swab, all the medical and nursing staff involved in the surgery should adopt the correct personal protective equipment (ppe) such as disposable caps, safety goggles, surgical masks, protective clothing, disposable gloves and shoe covers. the first follow-up of cartilage repair procedure, usually at one month, is mandatory, to evaluate possible early complications and should not be telematic. outpatient visits therefore are organized in full respect of social distancing and infection spread-avoiding rules: body temperature is checked at the entrance, all the patients should wear personal protective equipment such as masks and sanitizing gel is disposable at the entrance of every room. further follow-up may be telematic, depending from patient's conditions and the pandemic spread situation, with a mandatory mri at six months. cartilage lesions are considered a "minor" pathology in orthopaedic pantheon. nonetheless, young and active patients are frequently interested, with major impact in quality of life [4, 5] . due to the nature of the surgeries, with very limited hospitalization or day surgery being required, by using the appropriate care, the risk of disease transmission is very low. furthermore, young and active patients are less prone to develop a severe form of illness, while they may have a worsening of their joint conditions, if procedures are delayed too long. for these reasons, we should consider cartilage regenerative procedures and orthobiologics, safe and feasible procedures, in this early reopening stage. the covid-19 outbreak in italy: perspectives from an orthopaedic hospital the epidemiology of osteoarthritis covid-19: nasal and oropharyngeal swab surgical treatment for early osteoarthritis. part i: cartilage repair procedures what parameters affect knee function in patients with untreated cartilage defects: baseline data from the german cartilage registry publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-028285-n4dommet authors: weilongorska, natasha l.; ekwobi, chidi c. title: covid-19: what are the challenges for nhs surgery? date: 2020-07-02 journal: curr probl surg doi: 10.1016/j.cpsurg.2020.100856 sha: doc_id: 28285 cord_uid: n4dommet nan in december, 2019 while covid-19 was unfolding in china, surgeons in the uk were enjoying some of their last few months of normality. by april, 2020 all national health service (nhs) trusts in the uk had halted their non-urgent elective operating, 1 and much of the surgical community had been redistributed to roles far from their specialized career trajectories. the first uk identified case of covid-19 was recorded in february, 2020. 2 by the march 11, 2020, the world health organisation (who) had declared a global pandemic. 3 it became rapidly apparent that despite the nhs being a highly revered healthcare system, it was sorely underprepared. with some of the lowest ratios in europe of beds per population (2.5 per 1000) and doctors per population (2.8 per 1000), combined with the lack of experience of recent epidemics (severe acute respiratory syndrome-1, middle eastern respiratory syndrome, ebola), which were successfully contained by other continents, covid-19 presented an emergent humanitarian crisis for the uk. the risk of nosocomial infection to the surgical workforce through both direct contact with surfaces, droplet or aerosol spray, or through intraoperative generation of fomites have led to abrupt changes in surgical practice during this unprecedented period. in the face of covid-19, the risk profile of surgery to both patients and the operative team has dramatically increased. routine procedural activities such as open suctioning, smoke generation (monopolar, bipolar diathermy, laser), and the opening of pressurised cavities or orifices, are now considered high-risk. 4 to mitigate these risks, surgical services (across all surgical specialities) have made pandemic-response changes to their practice as guided by their specialist organizations, the department of health, public health england and input from the royal surgical colleges. as part of the immediate nhs response to the pandemic, surgical services were restructured to enable redistribution of resources. surgical patients were grouped (obligatory inpatients, nonoperative, inpatient management, day case surgery, and outpatients), with guidance offered on the management of each category. 5 key recommendations included consultant led decisionmaking, daily review of inpatient status, and extension of imaging (whenever required) to include chest screening. all operative scheduling should be consultant sanctioned, when an emphasis on conservative management where feasible. decisionmaking for acute surgical presentations, namely between operative and non-operative management, or modifications to routine surgical strategies (such as open techniques versus laparoscopy, or other adjustments to surgical approach), have been informed by speciality guidance, but, ultimately, are the responsibility of the on-call or lead consultant. most departments have initiated multiple consultant decisionmaking for acute admissions, in response to the pandemic. with there being a short interval from the time of the first covid-19 case presentation, to the development of a global pandemic, validated management algorithms to support changes in operative strategies are lacking. 6 the royal surgical colleges stipulated that maintaining emergency surgical capacity, including major trauma provision, was the primary aim during the covid-19 pandemic. 7 nhs surgical organizations have worked in collaboration with the international community to pool knowledge and adopt recommended practices from countries earlier exposed to the pandemic. internationally, grading systems have been adopted to denote the services available at each stage, depending on a hospital's pandemic burden. in some examples, these are quantified by number of cases, 8 whereas the nhs guidance is based on low, medium, high, or very high prevalence due to nationwide variation in hospital capacity. 9 some specialities have adopted a 2-tier consultant-on-call arrangement to aid emergency work load, as well as providing contingency cover for unpredictable changes in professional fitness to practice, or isolation requirements. 10 similarly, a prioritization system for cancer surgery has been implemented throughout the nhs (levels 1a -3), to provide uniform understanding of oncological urgency (table 2) . 11, 12 operations proceed based on their assigned prioritization level, often in conjunction with daily prioritization meetings that enable multiple speciality discussions to ensure an agreed case order. ultimately, the reduction in capacity has, for some patients, led to delays in cancer treatment and rescheduling of cases. the nhs 2-week wait standards (for review of new or suspected cancer diagnoses) has been maintained, with an acceptance that first contact may be via telephone clinic. 13 oncological management (whether medical or surgical) requires careful consideration between (1) safety and availability of treatment in the current climate, versus (2) the risk of metastasis. surgeons have been required to liaise closely with oncologists, their mdt, and adopt a service-limited, less invasive approach. the key components of nhs preoperative patient screening for covid-19 are: structured questionnaires with temperature monitoring, viral real-time polymerase chain reaction (rt pcr) for sars-cov-2, and chest imaging. the aim of screening is to prevent pandemic spread and minimize the risk to patients and staff. on the other hand, covid-19 screening investigations are performed only in response to risks identified through questionnaires, patient temperature, or clinical presentation. not all surgical patients are screened by all possible modalities. patients can be categorized as confirmed covid-19 positive, suspected covid-19 (includes any patient with or without symptoms who has not been screened), and covid-19 negative (following robust screening). as hospitals are high-risk environments, a patient's status may change during an inpatient admission. attention should be paid to possible symptoms, accepting that multiple viral screening swabs may become necessary. increasingly, surgical patients are tracked down 1 of 2 pathways: covid-19 positive (includes confirmed and suspected patients) or likely covid-19 negative, recognizing that absolute certainty about status is not possible. segregation of patients based on viral status occurs throughout nhs surgical pathways; however, complete separation of patients to different hospital sites has generally not been possible. accordingly, hospital sites are deemed high-risk areas for potential transmission of covid-19. as part of the exit strategy, independent hospitals have been recruited in the effort to return to elective operating. as these institutions have not housed acute covid-19 positive patients, they are viewed as "covid-free", "covid-light", or "covid-cold" zones. the use of a traffic light system has been adopted in many nhs trusts for clinical areas, including oprating rooms. using this system, red denotes areas with confirmed covid-19 cases, amber for suspected cases when results are not yet available, and green for patients where covid-19 is not suspected. strategies employed to increase safety within the operating suite are discussed in more detail in the section on surgical process. all nhs patients are questionnaire screened to identify risk of covid-19 prior to surgery. questions determine the presence of symptoms, history of exposure, isolation status, temperature status, presence of high-risk factors (eg, key workers) and vulnerable patient features. in the case of acute or unplanned surgical admissions, preoperative screening questions are completed on admission. patients may have symptoms, as part of their surgical pathology, that could be associated with covid-19. low-grade pyrexia is particularly troublesome and should be monitored carefully for signs of progression. in true emergency operating, screening may be impractical and therefore cases have had to be managed as suspected covid-19. for scheduled cases (planned trauma or elective operating), where delays to operating may be possible, screening occurs prior to admission. the aim is to determine covid-19 status prior to surgery and, if possible, to delay operating until the patient can be managed through a covid-19 negative pathway. screening questionnaires are performed by phone and, if the patient is deemed low risk, a provisional date for surgery is given with enough time for viral swabs to be performed and reported. any case in which there is a suspicion of covid-19 infection or the presence of risk factors, will be referred to the lead consultant for discussion. all patients are re-screened by questionnaire and temperature check on the day of surgery as part of the admission and pre-operative assessment. patient screening tools are essential for minimizing pandemic spread; however, they are not uniform across all nhs hospitals, rely on patient reporting, and are not formally validated. the gold standard for testing for covid-19 is pharyngeal swab rt-pcr for sars-cov-2 which detects viral rna in situ. routine testing involves nasopharyngeal and oropharyngeal swab, with sampling of the tonsillar region. performing swabs is therefore difficult in some groups, which may affect the sensitivity of the test, making screening less reliable and unsuitable for patient directed hometesting. location of viral expression appears to change with disease progression, impacting site detectability, and further complicating screening. 14 covid-19 has been detected in blood, urine, peritoneal fluid, and stool; however, transmission from these modalities is thought to be low. [15] [16] [17] faecal viral rt-pcr for sars-cov-2 may remain positive for a longer duration than other modalities, 18 particularly in children, which has implications for endoscopic, general surgery, urology, and paediatric procedures. in the advent of covid-19, the uk government's pandemic strategy differed from the strict measures of testing, tracing, and isolation recommended by the who. 19 the decision not to perform widespread testing and contact tracing was highly scrutinized and led to significant implications for the healthcare workforce. 20 compared to many countries, the uk's facility for covid-19 rt-pcr testing has been very limited. in response to public outrage, the government pledged to prioritize increasing the capacity of viral testing. unlike most countries, routine patient testing for all hospital admissions is not yet conceivable. revisions to the uk testing and tracing strategies seem to have missed the metaphorical "boat". 21 limitations in screening capacity, unsatisfactory delays to result reporting (initially up to 72 hours), 22 and a high false negative rate (up to 20%) 23, 24 have complicated preoperative screening. the prolonged incubation period of covid-19 (up to 14 days) has also been problematic. 25 the triad of asymptomatic carriers, non-specific symptoms, and absence of routine viral screening, reaped havoc to surgical workflow in the early weeks of the pandemic. subsequently, all aerosol generating procedures (agp) required full personal protective equipment (ppe), regardless of the rt-pcr result. in response to these challenges, the royal college of surgeons released a consensus statement in april, 2020 detailing the screening pathway prior to elective surgery. 26 patients require isolation (with shielding) for 14 days prior to surgery, to be asymptomatic for the preceding 7 days, and have a negative rt-pcr pharyngeal swab within 48 hours of surgery. international guidance recommends dual testing for preoperative surgical patients who have no history of exposure or symptoms. 27 accordingly, patients with 2 consecutive negative results may be managed as covid-19 negative in the operative setting. 28 many nhs trusts do not yet have this system in place; however, with the uk government warning of a prolonged emergence from the pandemic, effective pathways will need to be followed to combat the backlog of surgical cases safely. chest imaging has been shown to have a key diagnostic role in covid-19 and is the final modality of screening employed for some surgical patients. 29 the british society for thoracic imaging released guidance supporting the use of computerised tomography (ct) and chest radiographs (cxr) to identify features of covid-19 infection. 30 screening of the chest is not routine for all surgical patients; however, ct chest is indicated in patients requiring intensive care postoperatively. 26 extending imaging to include the chest (either ct or cxr) is recommended in acute abdominal presentations, 26 and may be considered in other surgical presentations. again, radiological signs vary with the course of disease and, therefore, imaging findings can be open to interpretation. a covid-19 diagnostic algorithm has been developed to aid decisionmaking. 31 the increased imaging demand has been matched by an expanded capacity for hot reporting. acute staffing changes, required to maintain these requirements, may be problematic as normal nhs workflow returns. ultimately, there are many complexities regarding screening for covid-19. the unique risks of upper airway viral titers, in relation to anaesthesia and agp, require careful consideration of all surgical cases. variable carriage of viral load, progression of disease signs and symptoms, and problematic investigation sensitivities all complicate the picture. accordingly, surgeons are required to review the whole patient panel of results, which includes screening questionnaires, swabs, supporting blood tests, and any imaging performed, with a low threshold for repeat investigations. developments in rt-pcr for sars-cov-2 testing within the nhs include decentralization of processing (enabling quicker turnover locally) and use of quicker detection systems. 32 ideally, rapid and reliable point of care testing for covid-19 would be available with a low false negative rate; however, due to the characteristics of the virus, it is unlikely that this will be realized. focus should instead be on how to improve investigation effectiveness, processing time, and reliability of reporting. the protection and preservation of the surgical workforce was listed as the second priority in the "guidance for surgeons working during the covid-19 pandemic". 33 the widespread impact on staffing numbers has been dramatic due to isolation requirements, sickness, and redeployment. surgical services have required adequate staffing, with the potential to adjust to changing disease prevalence, despite a depleted workforce. accordingly, staff flexibility and resilience have been crucial. most scheduls include the provision of standby staff; residing at home, these personnel are readied for work and can be called in to cover shortfalls in staffing levels and/or sickness. the main aims are to minimize the exposure of the surgical workforce, enable adequate rest, and have escalation plans in place, if required. redeployment strategies implemented at the local level vary hugely between nhs trusts. professionals across the board have faced redeployment, often to unfamiliar roles. some of the 10,000 nhs returners who responded to the national 'bring staff back' initiative will have returned to the surgical workforce. 34 these individuals require additional training and support as part of their re-introduction to practice. since the advent of covid-19, the operating rooms environment is a very different workplace. the general dynamic in operating rooms is less relaxed due to a multitude of challenges. staff numbers are minimized for safety and their roles are more clearly defined. operative cases are required to be consultant led. ppe is uncomfortable, impairs staff recognition, renders spoken communication difficult, and largely eliminates non-verbal communication from facial expressions. unfamiliarity of staff with safety protocols can lead to inefficiencies and staff anxiety. as staff are assigned to a specific section of the operative suite, in keeping with their designated roles (operating room, anesthetic room, or corridor), there is increased segregation of staff and less interaction. with experience, there is an improvement in staff confidence and efficiency with covid-19 safety protocols. over time, individuals adapt to the cultural change involved in daily operating rooms turnover. 35 post-procedural debriefs are crucial to staff development, as well as providing a platform to acknowledge any physical or psychological difficulties associated with current processes. staff requiring quarantine on account of their personal health requirements have been assigned low risk or contact-free activities. changes to the on-call arrangements of the surgical specialities vary throughout the nhs, depending on staffing, services demand, and local policy. some departments have maintained their pre-covid-19 shift system, whereas others have required restructuring. cross cover, doubling of staff cover, and contingency scheduls are strategies employed in nhs trusts. 36 on account of occupational changes to working hours and roles, remuneration may be required in some incidences. during the covid-19 pandemic, there have been many changes to practice. for some individuals, this has been overwhelming and frequent guideline updates have been difficult to interpret. dissemination of information to all members of the surgical team has been implemented largely by senior clinical staff. using a communication task-force has been suggested as a strategy to reduce duplication of work and to keep team members informed. 37 gaps in knowledge lead to increased staff anxiety. the use of daily trust-wide email updates has been employed by most nhs organizations to inform staff of updates within their own workplace. in the surgical setting, covid-19 transmission can occur through droplet, aerosol, and contact spread. ppe is required to mitigate against each of these routes. uk guidelines on ppe requirements have been subject to multiple changes and have been the source of controversy. in the early phase of the nhs covid-19 experience, discussions about ppe dominated workforce concerns and the national media. conflicting information, variance in local ppe recommendations, and restricted availability of required equipment led to significant workforce anxiety. extensive workforce training has been required to ensure nhs staff are safely and appropriately using ppe. ffp3 mask or respirator fit-testing, as well as simulation training in donning and doffing ppe are now part of mandatory training for all patient facing personnel in the nhs. full ppe (fluid resistant gown, double gloving, visor or goggles, fit-tested ffp3 mask or respirator, disposable hat, shoe covers) should be worn in the operating rooms for any suspected or positive covid-19 case, for agp 38 (table 3) , and for procedures for which the risk is unknown. despite initial discrepancies in the recommended ppe requirements, guidance released by the royal surgical colleges and affiliated speciality organisations on march 27, 2020 reclassified laparotomy, laparoscopy, and endoscopy as high-risk procedures 39 . updates detailing ppe requirements for surgery and re-classifying agp were released by public health england [40] [41] [42] but did not answer the supply chain concerns. later guidance, in response to acknowledged ppe shortages, suggested a reduction in intraoperative protection, 43 surgical ward staff also require access to ppe. routine procedural tasks such as replacing feeding tubes, as well as general care of tracheostomies and general stomas, are all associated with higher risk of transmission. covid-19 safety protocols suggest that these skilled aspects of patient care should be performed by experienced staff. 45 the use of heat and moisture filters for tracheostomies has also increased safety. nasogastric and nasojejunal tube insertion frequently induces aerosol generation by local irritation-induced cough or sneeze response. 46,47 likewise, chest physiotherapy can be considered from a similar stance. routine care for covid-19 positive patients with an active cough, also requires full ppe. accordingly, the ppe requirement of the wider surgical team of healthcare professionals has been underestimated. supply of appropriate ppe has been a problem throughout the nhs, with severe shortages 48 compounded by a high case burden over a short period. 49 in april, a survey of uk surgeons and surgical trainees demonstrated that more than one half had experienced shortages of ppe over the preceding month, and approximately one third felt ppe was still inadequate and unsafe. 50 a survey of otorhinolaryngology surgeons revealed that 20% of trusts did not have the required ppe available and 95% of respondents felt the supply would run out during the crisis. 51 furthermore, concerns about trust rationing, self-funded ppe, and reports of emotional blackmail or gagging surfaced. 52,53 reuse protocols and cleaning of visors is now commonplace in the nhs. across the surgical community, there are also concerns that uk guidance does not meet internationally reported standards. 54, 55 inconsistencies in guidance, combined with difficulties in patient screening, have undoubtedly resulted in higher expenditure of ppe than necessary. in most nhs trusts, a range of ffp3 masks were initially available to staff. with depletion of stocks, many healthcare workers have had to repeat fit-testing with alternative masks or respirators as certain models have become unavailable. a worrying gender imbalance in the suitability of ppe has surfaced. 56 the majority of ppe has been designed to fit an average man. 57 masks and respirators are of particular concern, often being unsuitable, and resulting in high proportions of failed fit-tests in the female workforce. given that 77% of the nhs workforce are women, many have been unable to work in high-risk areas, putting further strain on the system. 58 the wearing of full ppe is generally not a pleasant experience for most healthcare workers and can have a significant impact on morale. 59 goggles, ffp3 masks, and respirators all have a significant impact on skin. constant use can lead to abrasions, dermatitis, and pressure areas 60 which may necessitate the alternating of roles or days off work. 61 wearing full ppe during operations is hot and restrictive. in certain specialist operating rooms, additional requirements, such as high ambient temperatures for burns surgery or radiation protection in orthopaedic procedures, exacerbate the unpleasantness. operative discomfort may increase the risk of technical error. ppe can also interfere with important operative aids such as operating microscope, loupes, or headlights . 62 the impact of ppe on surgical efficiency is dramatic. case duration is prolonged due to donning, doffing, down-time (to allow for air changes following intubation and extubation), surgical factors, and cleaning. 4 with process familiarity there is upskilling, leading to improvements in procedural duration, but this does not match standard operating times. 63 as elective operating recommences, adjustment of scheduling times will be necessary. regardless of the backlog of cases, surgical centers will need to accept reduced efficiency as a trade-off for increased safety. on account of the unavailability of covid-19 testing in the uk, personnel testing for covid-19 has been exceptionally limited. it is recognised that healthcare workers are at higher risk of exposure, could be asymptomatic carriers, and may unknowingly be the source of hospital-acquired infection in patients. nhs trusts have had to adopt a rough risk analysis of patients on admission (instead of routine testing), despite the fact that approximately 80% of people who test positive for covid 19 are either asymptomatic, or experience only non-specific symptoms. 64 consequently, unscreened staff are frequently exposed to untested members of the public, providing potential for viral transmission to either party. without adequate testing solutions available, the nhs has faced a dramatic rise in absenteeism. in line with the uk government's isolation recommendations, individuals have been instructed to completely self-isolate for 14 days in the presence of symptoms, and 7 days following close contact with a symptomatic person. a high proportion of nhs staff have had to self-isolate either due to personal or close-contact symptoms. in practice, without access to testing, an enormous number of households have had to self-impose cautionary isolation due to the presence of a symptomatic individual. in families with young children this has been particularly problematic. many staff had to take multiple absences without clarity on whether they had suffered from covid-19. not only has this been incredibly frustrating for those involved but has also put pressure on the rest of the workforce. a survey by the royal college of physicians in april, 2020, found that more than 20% of respondents were isolating either with symptoms, or due to contact with a member of the household with symptoms. only 31% had access to testing. 65 the nhs employee absence rates for 2020 have not yet been released, but these are expected to be the highest in recorded history, 66 with a huge impact on the total cost of covid-19. later, testing was offered for symptomatic staff (following sanction by the trust microbiology or infectious diseases teams), in an attempt to return a proportion of the isolating workforce. as the emphasis on viral testing has increased nationally, and availability of tests has expanded, staff displaying symptoms now warrant screening. against the backdrop of a national data vacuum, small data samples arising from isolated nhs trusts, which have adopted routine testing for all symptomatic staff, 67,68 unsurprisingly demonstrate the highest proportion of nhs workers testing positive for covid-19 were those working in patient facing roles. in the absence of a proficient immunity test, multiple rt-pcr sars-cov2 viral swabs may be necessary per individual healthcare worker. the lack of routine screening for asymptomatic staff has important social implications for healthcare workers and their families. with covid-19 status unknown, as we move out of lockdown, nhs staff will be unable to be in contact with vulnerable individuals. the government has now pledged that with increased testing capacity, screening will be available regularly to asymptomatic staff 34 but a program for this has not yet been rolled out. compulsory weekly viral screening for everyone may be the most robust strategy moving forward. 69, 70 the covid-19 pandemic has seen lower levels of training. from march 16, 2020, all courses, conferences, examinations, and other surgical education-based activities requiring physical attendance were cancelled. 71 planned rotations in april, 2020 were suspended by health education england to minimise disruption. across all surgical specialities, the training curriculums are competency based. it is recognised that the covid-19 pandemic has been hugely disruptive to training and individualized placement objectives may not have been met. although the annual review of competency progression (arcp) process will allow some concessions, based on the covid-19 pandemic, surgical trainees will still be required to meet the same standards in order to complete their training. accordingly, senior trainees may be more adversely affected and in some circumstances additional time may be required to meet these competencies. postponement of the final speciality examinations will, for some unfortunate candidates, result in extended training. for those trainees redeployed on account of covid-19, alternative duties may provide unique experiences, but in most cases, will lack direct surgical experience. the joint committee on surgical training (jcst) has emphasised that redeployed trainees will not be disadvantaged; however, it is recognized that the curriculum requirements will need to be achieved in future placements. the role of the who surgical safety checklist (developed in june, 2008 and mandated into routine nhs practice in january, 2009), 75 has been largely omitted from recommended covid-19 guidelines, but has nevertheless played an intrinsic role during the pandemic. as is standard in surgical practice, meetings are held at the beginning of operative lists to disseminate case based information, using the who checklist as a guide. these meetings are compulsory and are attended by all members of the team. during the pandemic, routine checklists have been expanded to include vital case-specific covid-19 information. all surgical cases require a discussion about the patient's covid-19 status, the degree of aerosol risk for each part of the procedure (induction of anaesthesia, extubation, and for all operative phases), with ppe requirement stated for each stage. important logistical considerations should also form part of the preoperative checklist, such as: wait-time for air changes following induction and termination of anesthesia, location of operating rooms donning and doffing areas, designated staff roles, and a detailed itinerary of the required (and potentially required) surgical instrumentation. 76 frequent, structured communications are key to safe practice and particularly important during the covid-19 pandemic. 77 workplace risk remains high; predictions expect heightened risk level to remain for months to years. accordingly, changes made to systems, staff handover, and general communications may become incorporated into routine nhs practice for the longer term, despite originally introduced as covid-19 related cultural changes. it should be assumed that the operating rooms environment and its contents are contaminated , 54 providing exposure for development of nosocomial covid-19 infection. furthermore, agp are highrisk for viral transmission to healthcare workers, and must be managed in concordance with stringent safety protocols. necessary adjustments to operating suite layout, staff working, and operating rooms flow have been implemented throughout the nhs surgical services to mitigate these risks. to ensure safety throughout the phases of a surgical procedure, modifications have been made to each component of the operative pathway. viewed as separate parts, these include preprocedure team meeting (who checklist), transfer, induction of anesthesia, operative steps, extubation, and transfer to recovery. wait times following instrumentation of the pharynx should be considered part of the anesthetic procedure. ventilation systems have been the subject of dispute. in the majority of nhs hospitals, operating rooms ventilation runs on positive pressure systems, with or without laminar flow. literature from other countries recommending negative pressure ventilation in the management of covid-19 cases, 78,79 initially generated concern. a consensus statement between the royal surgical colleges, affiliated organizations and public health england have approved that positive flow ventilation systems are considered safe for the management of covid-19 cases, 39 and that laminar flow is recommended. acute restructuring of nhs operating rooms ventilations systems has not been feasible during the pandemic, but safe ventilation management has been crucial. doors between the operating rooms and adjacent spaces should be kept closed to maintain effective airflow. 80 most nhs operating operating rooms have a degree of open plan design. the heightened requirement for ventilation and reduced contamination has changed the demands of the operating suite. 81 anesthetic rooms do not routinely have high frequency ventilation, and scrubbing up areas are usually confluent with the operating rooms space. transforming operating suites into covid-19 safe work spaces overnight, has been challenging. example operating rooms layouts are provided for our institution, prior to covid-19 (fig. 1) , and demonstrating the repurposing of workspace areas during the covid-19 pandemic (fig. 2) . under current circumstances, all parts of the patient's pathway (induction of anesthesia, the operating procedure and recovery), now occur in the main operating suite. in our institution, the absence of doors between the scrubbing up area and the main operating rooms has required scrubbing and donning to be performed in the repurposed, anesthetic room. access to operating rooms for the delivery of additional equipment should occur through the newly assigned "staff entrance and donning area". the lack of a designated storage space for equipment which is separate from the main operating rooms space has required "external runners" to deliver kit into operating rooms, through the clean donning area (which would have previously been the anesthetic room). equipment is passed from the "external runners" in the operating rooms corridor, to staff in full ppe stationed within the clean area. knocking on the operating rooms door signifies to the internal theatre team that the equipment is available. the "internal runner", when ready, opens the door for a minimal period, accepting the required equipment. pauses in operating, while this process is actioned, can prolong the procedural time. operations on children should be avoided due to the unique risks of asymptomatic carriers and difficulty of performing pediatric screening, examinations, and procedures. in exceptional circumstances, essential procedures can be performed. all children are managed as high-risk for covid-19 transmission. the surgical pathway for children has been modified for safety accordingly. generally, children are cannulated on the ward and accompanied by a parent or guardian to the operating rooms entrance, where staff in full ppe meet them. the patient is then anaesthetized without the parent present. in some parts of the uk, child services have been reduced in peripheral hospitals, favoring centralization of cases to designated pediatric hospitals, thereby maximizing expertise. the need to segregate suspected or confirmed covid-19 patients into designated operating rooms has spurred the use of traffic light systems to denote case status. ideally, completely separate operating suites, with isolated ventilation systems, should be used for suspected or positive covid-19 patients. all non-essential equipment should be removed from the operating rooms environment and essential apparatus should be covered with plastic wrapping. 82 a detail run through of all required equipment should be detailed in the team briefing and kept sterile in a clean area within theatres enabling swift access. unused items should be returned to stores without being contaminated. whenever possible, staff perform a dedicated role for the duration of an operation, thereby minimizing the number of people in the operating rooms, and reducing handovers. due to additional steps and segregation of areas within the operating suite, the staffing requirement overall is greater. 63 social distancing should be maintained, when practical, within the operating rooms environment. based on national guidance, local nhs trusts individualize their covid-19 response based on the existing infrastructure of individual hospital sites. structural layout, ppe availability, and disease prevalence are taken into consideration. all nhs trusts, but not all hospitals, have a critical care capacity. the total number of nhs critical care beds for combined adults and pediatric occupancy (under usual circumstances), totals 5,900 beds, 83 or 7.5 beds per 100,000 population. 84 this figure is lower than many european countries and posed an immediate concern in the advent of covid-19. halting elective operating and reassigning operating spaces has been the main contributor to nhs england's plan for an additional 30,000 critical care beds. 85 difficulties in the procurement of essential equipment, including ventilators (due to supply flow problems and a global shortage) has, in some cases, resulted in redistribution of operating equipment. in other locations, due to an expanded critical care bed requirement, areas with capacity for ventilation were identified, recruited, and converted. most commonly in nhs hospitals, these have been operating rooms, anesthetic rooms, and recovery areas, which has had an immediate effect on operative capacity. the consolidation of surgical cases (across all specialities) into the remaining operating rooms lists, has required daily multidisciplinary meetings to discuss prioritizations. operational adjustments to redirect elective surgeries to "covid-19-free" zones, has seen the reopening of some surgical areas and utilization of private sector establishments. block-buying of independent sector capacity has occurred on a national scale and is being managed by local nhs trusts. 85 during the covid-19 pandemic, across all specialities, modifications to the technical aspects of surgical practice have been implemented. within nhs practice, certain pandemic principles have emerged to reduce the risk profile of surgery (table 4 ). it is accepted that many surgical conditions may be managed conservatively. as a result, some patients who would have been transferred to specialist centers will have been managed locally. 86, 87 in the current climate, a trend is observed towards increased imaging to inform surgical decisionmaking. patients with acute general surgical conditions such as suspected appendicitis and cholecystitis, should either have open procedures (due to the unknown risk of laparoscopic surgery) or be managed conservatively. similarly, management of acute mastoiditis should now be medical with imaging support. 88 a detailed, collaborative, covid-19 response has redefined the trauma management standards during the pandemic. 89 increasingly, trauma cases that can be managed with local anesthetic procedures are performed whenever possible in the emergency department or trauma clinic setting to reduce the operating room burden. 9 the covidharem study has been announced to capture the impact on morbidity and mortality of differing approaches to the management of acute appendicitis during covid-19. 90 emergency surgery during this period has been complicated by later surgical presentations, most likely due to patient compliance with isolation or anxiety around entering a high-risk clinical area. reports demonstrating a relative increase in the number of bowel obstructions during the covid-19 pandemic are not surprising, making surgery more challenging and having a negative impact on patient outcomes. 91 given that conservative management is being considered for a larger cohort of patients, the use of surgical scoring systems may help stratify patients. 80 the avoidance of general anaesthesia (ga) is primarily due to the associated aerosol risk; however, there are also secondary advantages such as potential reduction in postoperative bed requirement and anesthesia related complications. the move away from ga has seen a reciprocal increase in use of regional anaesthesia. newer techniques such as "wide awake local anaesthetic no tourniquet" (walant) technique 92 have gained an overnight increase in popularity. walant has been recommended by the british society for surgery of the hand for routine practice during covid-19 and is increasingly being used for other anatomical regions. many standard operative devices such as laser, bone saws, high-speed drills, skin dermatome, harmonic scalpel, and other tissue-sealing devices have been evaluated as high aerosol risk and have been temporarily replaced with alternative techniques. in real terms this has meant a temporary return to more traditional surgical techniques. 72 settings of cautery devices should be as low as possible to reduce the generation of smoke and used with suction or intrinsic vacuum. 93, 94 there is an ongoing debate about the risks of open surgery versus laparoscopic surgery. the intercollegiate general surgery guidance advised against laparoscopic surgery due to the unquantified risk. 93, 95 insufflation of body cavities may be associated with aerosol generation due to escape of fluid with high pressure gas. more detailed guidance later suggested that laparoscopic techniques for cases with clear benefit, could be used over alternative techniques, with use of full ppe to mitigate against potential transmission. 96 prior to use, all equipment must be checked meticulously and operating room ventilation should be appropriate. adjustments to technique to maximize safety include careful introduction of trocars to minimize leak, aspiration of abdominal cavity insufflation prior to removal of trocars, and the use of air filters. a consensus on safety of laparoscopic surgery has not been reached. the association of laparoscopic surgeons of great britain and ireland has provided a series of safety recommendations for laparoscopic practice in cases where there is a clear benefit. 97 certain procedures involving the head and neck cannot eliminate exposure to agp. for these highrisk operations, procedural planning is key. an emphasis on clear stepwise processes increases safety. 98 tracheostomy placement and changes, whenever possible, should be delayed until patient is proven covid-19 negative. when necessary, strict protocols should be followed incorporating modifications to standard practice, such as advancement of the endotracheal tube below the incision level to mitigate aerosol generation. 63 in keeping with the "essential surgery only" approach, many complex surgeries are simply not being performed. surgical choices focusing on reduced operative time, low complication rates and minimizing the inpatient stay are favored. in the current climate, breast cancer patients are not being offered primary reconstructions. similarly, in the severely injured limb, early amputation should be considered over limb salvage and reconstruction, requiring multiple procedures. in gastrointestinal surgery, patients are more likely to be offered a temporary stoma formation to reduce the risk of anastomotic leak and longer inpatient stays. 4,99 surgical management of fragility fractures (the incidence of which remains high) are a priority, with acceptance that hemi-arthroplasty and sliding hip screw fixation in the current climate offer a beneficial reduction in operative time. 100 surgical techniques to reduce complexity and follow-up contact are preferential. examples include the use of absorbable sutures and percutaneous k-wires for fracture fixation. minimizing staffing numbers in the operating room also extends to the number of surgeons. operator requirements are dependent on the technical challenges of the procedure. in some operations, such as pediatric otolaryngology cases, a minimum of 2 surgeons are still recommended during the pandemic for safety reasons. 63 the uk's daily figures for covid-19 proven infections, hospital admissions, and deaths, appear to suggest that we are emerging from the peak. lockdown measures have been, to some extent loosened, without a detectible effect on these trends. with the most vulnerable groups of people still under strict isolation, and with no clear strategy for their safe emergence, we may be falsely reassured. recorded figures are valuable, but should be interpreted cautiously, taking into consideration the uk's screening challenges and the international variation in testing and recording practices. some of the surgical specialty organizations have released literature detailing the next phase of the pandemic response, encouraging a move towards resuming elective services. 104 the priority must be for safe return to surgical pathways and the readiness to do this will vary across nhs trusts. gradual resolution of elective surgery will be limited by a multitude of factors, many of which have been discussed in this manograph. prolonged procedure time will continue to have a dramatic effect, and it is unlikely that services will return to the pre-covid-19 level of turnover. should subsequent surges in covid-19 prevalence occur, there may be a similar regression in availability of surgical services. all surgical staff will continue to play a role in reducing the risk of transmission, thereby continuing to mitigate against the impact on patients and staff. surgical trainees, who have been flexible during the pandemic period, will need their training requirements planned into the next phase response. changes to working patterns and surgical schedules have been extremely disruptive and decisions will need to be made about how these will be readjusted. since january, 2020, the uk is no longer part of the european union, which could lead to major changes in workplace standards. it is unclear if the ewtd rules for safe working will be abolished. proposals to target the disruption to services, may encourage a move towards 7-day working. at the same time, covid-19 delivered rapid delivery of flexible working, previously unimagined in the nhs. it is likely that the nhs will be challenged to maintain more adaptable ways of working for some individuals. the effect of covid-19 on patients has been dramatic and very difficult to quantify. the covid-19 pandemic has brought a novel sense of risk around healthcare, with particular caution surrounding surgery. the psychological effects of social isolation, and the impact of media should not be underestimated. as we emerge from the peak, an emphasis on high quality research is now needed to generate data on critical deficiencies in knowledge, and to help inform decisionmaking in surgical care. early data suggest that covid-19 has a detrimental effect on surgical outcomes. the overall mortality rate, in the presence of covid-19 infection prior to, or following surgery, is higher than would be expected. 105, 106 this is highly concerning for patients, surgeons, and healthcare providers. robust research is required into the impact of covid-19 on surgical outcomes. one quarter of the uk population are deemed high-risk. 107 patients' vulnerability factors will influence their level of anxiety around attendance to healthcare institutions and treatment decisions. delays to cancer operartions, on account of service availability, oncological prioritization, or patient choice will have magnified the stress and uncertainty experienced by cancer patients and their families. increasingly, data are emerging suggesting there may be patterns in susceptibility to covid-19. broadly, these could be grouped into potentially-modifiable and non-modifiable factors [107] [108] [109] [110] [111] (table 5 ). although some of the literature is speculative, these potential links are the cause of significant anxiety and require expedient scientific investigation. the increased risk of covid-19-relatedmortality is particularly problematic for cancer patients requiring treatment. ultimately, in some cases, the presence of risk factors will complicate treatment discussions and decisions. clearly, trends in susceptibility affect patients and staff alike. looking forward, possible implications include the need for differential management of patients or staff based on the presence of risk factors, increased preoperative or occupational screening, and potentially, public health initiatives to address modifiable risks. this raises the question: as the largest employer in the uk, should be the nhs be more responsible for addressing the health of its workforce? if so, covid-19 could result in an infrastructural shift towards greater emphasis on occupational health and well-being. interestingly, in the uk healthcare workers have not been shown to have higher death rates when compared to the general population. 112 healthcare workers from black, asian and minority ethnic (bame) groups, have been shown to have a significantly increased risk of mortality when compared to white healthcare workers. 113 furthermore, national data suggests that black, pakistani and bangladeshi individuals are at increased risk of mortality from covid-19. 108 although the data are striking, they are unlikely to represent ethnicity factors alone. essential research investigating the link between ethnicity and risk of mortality, as well as other contributory factors, should be a national priority. as the uk moves into the next phase of covid-19, a focus on understanding and managing vulnerability factors will be key. globally, an estimated 37.6% of cancer surgeries and 81% of benign operations will be delayed on account of the pandemic. 114 many patients will have accepted alternative treatment pathways on account of covid-19, with unknown effect on outcomes. pathways designed to aid decisionmaking between surgeon and patient do have a role, but are not validated. 105 the nhs safeguards patient care by delivering treatment pathways within a series of strict timelines. cancer waiting times include standards for the time to diagnosis (31 days) and time to treatment (31 days from treatment decision, 62 days from initial referral). clearly, in the current climate these may be more difficult to maintain; however, cancer care will be most protected. the management of benign conditions will inevitably suffer delays. the maximum duration for treatment of non-urgent conditions should be 18 weeks. any breach of these standard waits results in a fine for the nhs trust. currently, most patient pathways have been frozen (on account of the exceptional circumstances), therefore not incurring these penalties. how suspensions to pathways, prolonged wait times for operations and, patients' expectations will be managed, has not yet been publicized. an emphasis on cancer management and other time-dependant operations will be the primary focus as services resume. the cancellation of some operations may have already led to harm, or may require adjustment to planned surgical interventions due to disease progression. rapid resolution of transplant, cardiothoracic, and vascular surgery services will be necessary to reduce the secondary morbidity and mortality associated with covid-19. transplant services in the uk have been dramatically affected by covid-19. live donations were held due to the relative risks to both patients. the complex infrastructure required for rapid organ retrieval, matching, and transplantation could not be maintained uniformly over the peak pandemic. pancreas, liver and kidney services have been particularly affected, with the majority of centers still closed. 115 the national reduction in transplantation and donor availability will have contributed to the number of potentially preventable deaths. 116, 117 non-urgent benign operations are likely to be suspended indefinitely until a strategy has been agreed for the urgent procedures. these patients are likely to be disappointed by prolonged waiting times. delays to surgery will in many cases result in progression of disease and an associated impact on the technical complexity of surgery. pediatric surgery is a particularly difficult area. in general, surgeries are only performed in children when they are clinically urgent. due to the challenges of performing adequate pharyngeal swabs in children and the frequent requirement for ga, all pediatric operations will need to be managed as high-risk cases. age dependent operations such as cleft lip and palate are generally performed within a narrow window, based on a delicate balance of risks. with ongoing uncertainty about the risks of surgery in the presence of covid-19 infection, pediatric surgeons will need to carefully consider the safe return to elective operating. outpatient cancer surveillance and imaging has largely been held. telemedicine clinics, which are reliant on patient reported signs and symptoms, are unlikely to have been a substitute for professional assessments. 118 as a consequence, we are likely to see a rise in cancer recurrence, presenting later. high-risk imaging for oncological surveillance will resume, but managing the backlog will be challenging. the longer imaging gap in some patients will mean later detection of oncological metastasis or recurrence. the government's decision to halt elective operating over the covid-19 pandemic peak was necessary, but has led to an accumulation of cases. it has been estimated that clearing the backlog of these operations will take an estimated 45 weeks, working at a 20% increase in productivity. 114 trusts invested in targeting these delayed procedures will however, be confronted with limited surgical capacity and reduced efficiency. an expansion of staff provision, operating room availability, and associated support services will be necessary. in practice, this translates into a systems approach to increased capacity, with as much emphasis on dressings clinics, physiotherapists, and radiographers as it has on surgeons and operating room staff. how this will be funded is not yet clear, but the uk is facing estimated costs of â£2 billion. 114 the use of independent sector hospital services will play a key role in the expansion of nhs surgical capacity. many patients will prefer to have procedures in covid-19 "light" or "cold" sites, which may be safer. the logistics of managing patients through additional sites, is problematic. information technology systems are different and are often not compatible with the parent nhs trust systems, leading to challenges with access to patient records and data protection. many hospitals have not yet confirmed their position on trainee access to alternative sites, which, if denied, could have an ongoing detrimental effect on training. on account of the many delays and unplanned changes to patient management decisions, the nhs will experience a unique wave of healthcare litigation. cases of clinical negligence may target nhs trusts or the individual. organizations such as the british medical association and the general medical council have provided guidance for members on practicing during the covid-19 pandemic; however, there is ongoing professional concern about the personal level of risk. returning nhs professionals may be particularly vulnerable. undoubtedly there will have been preventable harm and deaths suffered as a consequence of the covid-19 pandemic. surgical specialty organizations have adopted a key role in the dissemination of available evidence to aid safe practice and should be used as a guide for professionals. individuals should carefully discuss and document all patient management decisions influenced by the covid-19 pandemic. current indemnity arrangements will cover events incurred over the covid-19 period; however, the uk government has launched an additional covid-19 clinical negligence scheme for additional scope. 119 the coronavirus act 2020 covers the services outsourced to independent hospitals on account of covid-19. 120 other high-risk areas of potential litigation include the manufacture of equipment and pharmaceuticals. 121 use of telemedicine clinics has bridged an important gap in the availability of services, but the rapid development of virtual services, with temporary slackening on data protection standards, will have implications for patient confidentiality, with legal implications. 122 the rapid introduction of new systems are often associated with greater potential for error and breach of information standards. the development of increasingly data-safe systems will be paramount. covid-19 has resulted in a significant number of challenges for surgery in the uk. by detailing the unique nhs experience, as well as the evolving responses to the covid-19 pandemic, we offer a view into the current impact on surgical services. at the time of writing, the uk is thought to be emerging from peak prevalence. navigating a safe return to surgical pathways, as the pressure on the health system changes, will be a slow process and will generate further challenges. with many countries entering their pandemic experience later, a map of the nhs surgical challenges will likely inform expectations and practice. the consolidation of the challenges into the subgroups of surgical workforce, surgical patients, and surgical process has aimed to address the concerns of different nhs stakeholders, within a constantly evolving landscape. many uncertainties remain, and the effects of covid-19 on surgical practice are likely to be longstanding. the first weeks of the pandemic were an unsettling time for the nations as new ground was being navigated. the dynamic nature of the covid-19 pandemic has made the generation of this monograph both interesting and challenging. despite the devastating loss of life, healthcare disruption, and international anxiety, we must identify the wealth of lessons gleaned from the covid-19 pandemic and cultivate from them positive changes for our healthcare systems. the sharing of international experiences has been invaluable in tackling the covid-19 response. consensus statements have been crucial in guiding care decisions, but as we move forward an increased emphasis will be on evidence based medicine. the response of both the public and the international healthcare community in tackling covid-19 has been impressive. we will need continued vigor to manage the ongoing challenges facing surgery. table 2 . nhs prioritisation system in covid-19 pandemic 12 . emergency -operation needed within 24 hours urgent -operation needed with 72 hours surgery that can be deferred for up to 4 weeks surgery that can be delayed for up to 3 months surgery that can be delayed for more than 3 months table 3 . uk procedures classified as aerosol generating procedures covid-19: all non-urgent elective surgery is suspended for at least three months in england first cases of coronavirus disease 2019 (covid-19) in the who european region 4. 2nd-update-intercollegiate-general-surgery-guidance-on-covid-19-5-april covid-19 and emergency surgery presidents update 27_03_20 report from the american society for microbiology covid-19 international summit detection of sars-cov-2 in different types of clinical specimens novel coronavirus can be detected in urine, blood, anal swabs and oropharyngeal swabs samples. infectious diseases (except hiv/aids) fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia offline: covid-19 and the nhs--a national scandal covid-19: uk pledges to reintroduce contact tracing to fight virus 22. guidance-and-sop-covid-19-virus-testing-in-nhs-laboratories-v1.pdf. accessed correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases improved molecular diagnosis of covid-19 by the novel, highly sensitive and specific covid-19-rdrp/hel real-time reverse transcription-pcr assay validated in vitro and with clinical specimens updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan recommendations for surgery during the novel coronavirus (covid-19) epidemic sustainable response to the covid-19 pandemic in the operating theatre: we need more than just personal protective equipment clinical characteristics of coronavirus pneumonia 2019 (covid-19): an updated systematic review. infectious diseases (except hiv/aids) thoracic imaging in covid-19 infection the continuing evolution of covid-19 imaging pathways in the uk: a british society of thoracic imaging expert reference group update guidance for surgeons working during the covid-19 pandemic. the surgical royal colleges of the united kingdom and ireland social distancing: implications for the operating room in the face of covid-19 global guidance for surgical care during the covid-19 pandemic annotation: the covid-19 pandemic and clinical orthopaedic and trauma surgery covid-19 personal protective equipment (ppe). gov.uk. accessed covid-19 statements | asgbi -association of surgeons of gb. accessed recommended ppe for healthcare workers by secondary care inpatient clinical setting, nhs and independent sector covid-19 personal protective equipment (ppe). gov.uk. accessed reducing the risk of transmission of covid-19 in the hospital setting considerations for acute personal protective equipment (ppe) shortages. gov.uk. accessed entuk guidelines for changes in ent during covid-19 pandemic tracheostomy in the covid-19 era: global and multidisciplinary guidance. the lancet respiratory medicine aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. semple mg covid-19: government cannot say whether nhs will run out of protective gowns this weekend covid-19: 90% of cases will hit nhs over nine week period, chief medical officer warns covid-19: third of surgeons do not have adequate ppe, royal college warns covid-19: doctors are warned not to go public about ppe shortages surgical treatment for esophageal cancer during the outbreak of covid-19 sexism on the covid-19 frontline: -ppe is made for a 6ft 3in rugby player.â�� the guardian gender-in-the-nhs-2018.pdf. accessed covid-19 epidemic: skin protection for health care workers must not be ignored skin reactions to non-glove personal protective equipment: an emerging issue in the covid-19 pandemic personal protective equipment induced facial dermatoses in healthcare workers managing covid-19 cases operating during the covid-19 pandemic: how to reduce medical error. british journal of oral and maxillofacial surgery practical insights for paediatric otolaryngology surgical cases and performing microlaryngobronchoscopy during the covid-19 pandemic covid-19: four fifths of cases are asymptomatic, china figures indicate covid-19 and its impact on nhs workforce. rcp london first experience of covid-19 screening of health-care workers in england. the lancet. 2020;0(0) roll-out of sars-cov-2 testing for healthcare workers at a large nhs foundation trust in the united kingdom universal weekly testing as the uk covid-19 lockdown exit strategy. the lancet covid-19: pcr screening of asymptomatic healthcare workers at london hospital. the lancet 71. joint-policy-statement-on-covid-19.pdf. accessed immediate and long-term impact of the covid-19 pandemic on delivery of surgical services orthopaedic education during the covid-19 innovations in neurosurgical education during the covid-19 pandemic: is it time to reexamine our neurosurgical training models? decade of improved outcomes for patients thanks to surgical safety checklist surgical tracheostomies in covid-19 patients: important considerations and the -5tsâ�� of safety. british journal of oral and maxillofacial surgery preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore what we do when a covid-19 patient needs an operation: operating room preparation and guidance european society of trauma and emergency surgery (estes) recommendations for trauma and emergency surgery preparation during times of covid-19 infection cutting edge -the surgical blog from bjs. cutting edge managing covid-19 in surgical systems: annals of surgery nhs hospital bed numbers. the king's fund how is intensive care reimbursed? a review of eight european countries sbns :: covid. accessed pdf?utm_source =all+ent+uk+members+no+events+comms+24.03.20&utm_campaign=441cf7538a-email_campaign_2020_03_23_05_26_copy_01&utm_medium=email&utm_term=0_6 covid-19-boasts-combined-v1final.pdf. accessed association of surgeons of gb reduction in emergency surgery activity during covid-19 pandemic in three spanish hospitals wide awake hand surgery handbook v2.pdf intercollegiate general surgery guidance on covid-19 update. the royal college of surgeons of edinburgh safe management of surgical smoke in the age of covid-19 updated intercollegiate general surgery guidance on covid-19. royal college of surgeons laparoscopy in the covid-19 environment -alsgbi position statement a framework for open tracheostomy in covid-19 patients treatment strategy for gastrointestinal tumor under the outbreak of novel coronavirus pneumonia in china 100. c0086_specialty-guide-_fragility-fractures-and-coronavirus-v1-26-march.pdf. accessed recovery of surgical services during and after covid-19. royal college of surgeons acpgbi-considerations-on-resumption-of-elective-colorectal-surgery-during-covid-19-v28-4-20.pdf. accessed clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection. eclinicalmedicine covid-19: risk factors for severe disease and death covid-19) related deaths by ethnic group, england and wales -office for national statistics deaths involving covid-19 by local area and socioeconomic deprivation -office for national statistics clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. the lancet cancer patients and research during covid-19 pandemic: a systematic review of current evidence covid-19) related deaths by occupation, england and wales -office for national statistics exclusive: deaths of nhs staff from covid-19 analysed elective surgery cancellations due to the covid-19 pandemic: global predictive modelling to inform surgical recovery plans transplant centre closures and restrictions. odt clinical -nhs blood and transplant the covid-19 outbreak in italy: initial implications for organ transplantation programs telemedicine and plastic surgery: a review of its applications, limitations and legal pitfalls clinical negligence scheme for coronavirus. nhs resolution. accessed patient safety and litigation in the nhs post-covid-19 covid-19: can orthopaedic surgeons really work from home? accessed key: cord-290771-18dj37dj authors: tzeng, ching-wei d.; teshome, mediget; katz, matthew h. g.; weinberg, jeffrey s.; lai, stephen y.; antonoff, mara b.; bird, justin e.; shafer, aaron; davis, john w.; adelman, david m.; moon, bryan; reece, gregory; prabhu, sujit s.; desnyder, sarah m.; skibber, john m.; mehran, reza; schmeler, kathleen; roland, christina l.; tran cao, hop s.; aloia, thomas a.; caudle, abigail s.; swisher, stephen g.; vauthey, jean-nicolas title: cancer surgery scheduling during and after the covid-19 first wave: the md anderson cancer center experience date: 2020-05-18 journal: ann surg doi: 10.1097/sla.0000000000004092 sha: doc_id: 290771 cord_uid: 18dj37dj objective: to summarize the multi-specialty strategy and initial guidelines of a case review committee in triaging oncologic surgery procedures in a large comprehensive cancer center and to outline current steps moving forward after the initial wave. summary of background data: the impetus for strategic rescheduling of operations is multifactorial and includes our societal responsibility to minimize covid-19 exposure risk and propagation among patients, the healthcare workforce, and our community at large. strategic rescheduling is also driven by the need to preserve limited resources. as many states have already or are considering to re-open and relax stay-at-home orders, there remains a continued need for careful surgical scheduling because we must face the reality that we will need to co-exist with covid-19 for months, if not years. methods: the quality officers, chairs, and leadership of the 9 surgical departments in our division of surgery provide specialty-specific approaches to appropriately triage patients. results: we present the strategic approach for surgical rescheduling during and immediately after the covid-19 first wave for the 9 departments in the division of surgery at the university of texas md anderson cancer center in houston, texas. conclusions: cancer surgeons should continue to use their oncologic knowledge to determine the window of opportunity for each surgical procedure, based on tumor biology, preoperative treatment sequencing, and response to systemic therapy, to safely guide patients through this cautious recovery phase. t he initial onset of the coronavirus disease 2019 (covid19) pandemic forced cancer surgeons to make challenging decisions regarding the appropriate delay of potentially curative ''elective'' operations. however, ''elective'' cancer operations, whereas not ''emergent,'' have oncologic windows of opportunity that depend on tumor biology, treatment sequencing, and response to systemic therapy, and do not last indefinitely. there is a societal responsibility to balance the time pressures of individual oncologic surgical care against the societal goal of continued covid-19 mitigation strategies, especially in the context of varied regional economic re-openings which began april 24. herein, we present the strategic approach for surgical rescheduling during and immediately after the covid-19 first wave for the 9 departments in the division of surgery at the university of texas md anderson cancer center, in houston, texas. on march 4, 2020, our institution restricted employee travel and instituted intensive planning to reduce covid-19 spread in our region and prepare to care for any potential surge. each department within the division of surgery voluntarily evaluated scheduled operations and postponed them when oncologically reasonable. 1 rescheduling drastically cut the weekly operative volume from 460 operations during the week of march 8, to 258 the next week ( fig. 1) . by the week of april 19, only 90 operations were scheduled, marking an 80% drop in usual volume. downstream activity including clinic volume and inpatient census fell as well, allowing social distancing strategies inside the hospital. the department of surgical oncology inpatient rounding list for 36 faculty members typically includes 60 to 75 patients. on april 10, this list had 5 patients. as of april 30, we are back to 16 inpatients. as recommended by national societies, a multispecialty, interdisciplinary case review committee was created from 9 departmental quality officers and division of surgery leadership. 2 every afternoon, the case review committee evaluated all scheduled operations and provided recommendations to departmental quality officers who had reviewed their faculty's cases in the morning, regarding which operations should proceed as scheduled and which should be postponed. in performing this work, the committee balanced the competing requirements of patient safety and timely care, workforce protection and preservation, appropriate and limited exposure of trainees, limiting the need for transfusions, conserving personal protective equipment and critical care equipment, and preserving hospital ward and intensive care unit (icu) capacity. when the case review committee was created on march 24, covid-19 test kits were rare in the u.s., 3 and there were many unknowns in perioperative covid-19 risk, including the prevalence of covid-19 in our surgical patients (and visitors accompanying them) and in the workforce through community spread. there was an unknown postoperative mortality risk of operating unknowingly on a covid-19 patient. early case reports from china reported astoundingly high postoperative death rates of 20%, 4 compared to contemporary 90-day mortality expectations of <1% in our institution. healthcare providers have been exposed as well with notably agecorrelated hospitalization rates of 5%-20% and death rates of 0.1%-4% in providers with documented covid-19 infections. 5 the case review committee advised the individual surgeons on the potential consequences to the patient and hospital system across a spectrum of potential postoperative outcomes related to estimated transfusion needs, potential icu need, and total hospital stay, all of which could potentially limit hospital capacity while preparing for a potential surge similar to new york city and northern italy. 6 as we enter may, with texas re-opening for limited business, the case review committee continues to review cases and adapt to a limited re-opening of our operating rooms. as a cancer center with many immunocompromised and elderly patients, the institution created a ''moat'' to protect our uniquely vulnerable patients from excess hospital foot traffic. 7 based on early case reports, cancer patients with covid-19 used greater hospital resources including icu beds with higher mortality rates than the general population. 7 to protect all parties, the institution moved quickly to 5-person limits on meetings (with 6 feet distance) utilizing virtual platforms almost exclusively (including fellowship interviews), 8 and visitor restrictions culminating in a no-visitor policy on march 24, which will be continued indefinitely even as the state re-opens. finally, as the pandemic affected surrounding states, a mandatory 14-day home quarantine for all patients traveling to md anderson cancer center (mdacc) from outside texas was instituted, covid-19 testing in a nonclinic building for out-of-state patients upon arrival on campus. surgical trainees were no longer allowed to ''double scrub'' to limit exposure risk. 9 surgical departments moved toward rotational team-based care with ''active duty'' advanced practice providers, trainees, and faculty, with ''reserve duty'' counterparts encouraged and equipped to work remotely. enhanced recovery protocols safely reduced hospital stays. minimally invasive operations, with their known early discharge benefits, were part of this equation but with a balance taking into account avoiding longer (eg, robotic) operations which could be accomplished open or laparoscopically with less operating room utilization. after each department postponed elective cases and cases in which delay was oncologically appropriate, department quality officers, section chiefs, and chairpersons then developed internal guidelines for scheduling cases for the pre-peak period (april) and more importantly the post-peak period (may to summer). the department of neurosurgery established a review board composed of 3 senior faculty. 10 preference was given to patients requiring urgent interventions and patients who would benefit most from surgical intervention, particularly newly diagnosed patients without pathologic verification of disease, younger patients who were considered less likely to be negatively impacted by covid-19, and in-state patients who did not require a 14-day home quarantine. a separate faculty group reviewed all scheduled cases for oncologic necessity. this review group considered the aforementioned parameters and the status of systemic disease, prognosis, risk of neurologic deficit, possibility of nonsurgical treatment, and risk of progression to ''unresectable'' disease or development of an emergency situation during the initial wave. pituitary surgery was delayed in the early pre-peak period because of the increased risk associated with airway-related surgery. in addition, awake surgery was discouraged because of the theoretical risk of exposure for the anesthesia team and the staff assisting with intraoperative language assessments. most of the cranial operations that were approved were for large malignant gliomas or large metastases that caused mass effect and progressive symptoms and neurologic deficits, including unremitting seizures despite use of multiple anticonvulsants. patients with newly diagnosed intrinsic tumors or initial presentation with metastases were more commonly operated on than were patients with multiply recurrent tumors. spine procedures were approved if patients had progressive neurologic deficit, severe unremitting pain from tumor involvement and nerve compression, or significant canal compromise with impending neurologic catastrophic symptoms. as we re-open our operating room capacity, here are the priorities within neurosurgery. top priority patients remain those with large masses, progressive neurologic decline, severe pain, no nonsurgical options, or when diagnosis via surgery is required to initiate therapy. the next priority is posting previously deferred patients for whom no additional therapy was recommended but for whom surgery is required. in contrast, patients recommended to proceed with other nonsurgical therapy will be re-staged as indicated before re-scheduling. the third priority includes newly diagnosed patients with unbiopsied suspected malignant disease or those with diagnosis post-biopsy and requiring definitive resection. also in this third priority are new patients with benign disease with pain, debilitating symptoms, radiographic evidence of brain(stem) compression, midline shift, ventriculomegaly, and spinal cord compression. the fourth priority includes patients with recurrent disease for whom surgery is indicated for cytoreduction, to obtain a diagnosis figure 1. total surgical case volume by week during early covid-19 response, in which md anderson cancer center implemented goals to create a ''moat'' around hospitalized patients, to reduce workforce and visitor traffic, and to limit ''elective'' cases. for clinical trial enrollment or adjuvant treatment, and symptom relief from mass effect. the department of head and neck surgery developed treatment and management guidelines by disease sites based on urgency as related to patient health, safety of healthcare personnel, and curative intent. 11, 12 resection of tumors along mucosal surfaces of the upper aerodigestive tract increases the risk of aerosolization of covid-19 virus particles, especially from the oral cavity, oropharynx, nasopharynx, larynx/hypopharynx, and paranasal sinuses and skull base. 13 thus, the guidelines developed by the department emphasized surgical treatment of intermediate-stage or advanced disease for which nonsurgical options were not available and disease progression would significantly affect patient function or disease outcome. dental surgery and prosthodontic procedures performed in conjunction with head and neck operations or to prepare patients for adjuvant therapy were continued. salivary gland neoplasms and sarcomas were managed according to histologic grade: slow-growing low-grade and intermediate-grade disease was monitored, but high-grade carcinomas were resected. for salivary ductal carcinoma and carcinoma ex pleomorphic adenoma, neoadjuvant chemotherapy was considered. similarly, neoadjuvant chemotherapy was considered for high-grade soft tissue sarcomas, but osteosarcomas were resected. endocrine surgery proceeded for high-acuity situations, including progressive and biologically aggressive disease, such as anaplastic thyroid cancer and parathyroid carcinoma. ophthalmologic surgery proceeded for higher-grade malignancies (eg, retinoblastoma, melanoma, choroidal metastasis) and diseases threatening sight or life. the majority of thoracic oncology procedures, including resections of the lung parenchyma, airway, and esophagus, are considered aerosolizing procedures. 14 moreover, the preoperative tests for staging and quantifying pulmonary reserve (eg, bronchoscopy, endobronchial ultrasound, and pulmonary function tests) are also aerosolizing. this creates the dilemmas of whether or not to proceed with surgery in the absence of testing that might otherwise be considered standard of care. further complicating decision-making is that substantial proportions of patients with primary lung and esophageal malignancies have comorbidities that render them at high risk for worse outcomes if they, unknowingly, are infected with covid-19 perioperatively, including older age, smoking history, and concomitant cardiopulmonary disease. another important consideration is that most thoracic oncologic procedures are operations for which there is a low but realistic potential for significant blood loss and need for postoperative icu admission. the following approach was decided. during the time of the initial wave up to our predicted late april/early may texas peak, when few patients with covid-19 were in the hospital and the majority of our workforce remained healthy, resection proceeded for patients with non-small cell lung cancer with predominantly solid appearance, especially patients with tumor stage of t1c or greater or positive nodes, and patients who completed induction therapy for lung or esophageal cancer, patients with chest wall tumors of high malignant potential, and patients with symptomatic thoracic malignancies. during the initial wave, deferral of resection was strongly considered for patients with predominantly ground glass nodules; small, minimally invasive thymomas; small, node-negative lung cancers; and well-differentiated carcinoids. for many patients with pulmonary metastatic disease, surgery was delayed or interval systemic therapy was offered, depending on tumor histology, location, and size. for patients with early-stage lung cancer, stereotactic radiation therapy was considered, with the caveat that it was also important to reduce hospital traffic for radiation oncology as well. as we move beyond the first wave, repeat cross-sectional imaging can verify resectability and confirm lack of progression from previous clinical staging. as we slowly open up operative capacity, it will be of great importance to prioritize operative resources for nonsmall cell lung cancer and esophageal cancer. diseases like thymoma and slow-growing ground glass lung nodules will continue to be suitable to delay until we see more clearly beyond the first wave. because the department of surgical oncology and md anderson cancer center have traditionally favored neoadjuvant therapy for many solid tumors, we strategically initiated or continued this treatment sequencing when possible to postpone surgery to beyond the late april peak of covid-19 incidence in the houston area. each disease site group continues to formally review new patients to reach consensus regarding treatment plans even before patients take the risk of traveling to our institution. patients with localized disease with potential for cure (eg, stage ii colon cancer) and no indication for chemotherapy proceed to the operating room. patients needing extensive gastrointestinal surgery, such as whipple procedure for pancreatic adenocarcinoma, major hepatectomy for colorectal liver metastases, and retroperitoneal sarcomas, are carefully reviewed to balance the risks of delaying surgery versus excessive chemotherapy causing organ damage or performance status decline. however, with our extensive experience with neoadjuvant therapy, we are selectively extending neoadjuvant chemotherapy or chemoradiation, which pushes the surgery out another 2 months for many patients with gastrointestinal cancers, including cancers of the pancreas, stomach, and rectum, and liver metastases. specific guidelines regarding selection and prioritization for each disease site have been outlined by several institutions and surgical societies. [15] [16] [17] [18] patients with pre-invasive disease and patients with genetic syndromes such as breast cancer (brca) mutations or lynch syndrome who need risk-reduction surgery had their surgical procedures postponed beyond our late april peak. new patients with advanced ovarian cancer were triaged to neoadjuvant chemotherapy because data from phase iii trials show equivalent survival for surgery and neoadjuvant chemotherapy. 19 patients with grade 1 endometrial cancer without deep myometrial invasion and no evidence of metastatic disease are being treated with progestin therapy. 20 patients considered to require surgery even in the initial wave include those with stage ib cervical cancer who are candidates for radical hysterectomy with low risk of needing adjuvant radiotherapy, patients with grade 2-3 endometrioid endometrial cancer, and patients with type 2 histologies with no evidence of metastatic disease. a number of areas were considered ''gray areas'' and still require individual case review. ovarian cancer patients with significant radiographic and tumor marker response after 3-4 cycles of neoadjuvant chemotherapy are considered for interval cytoreductive surgery if they have good performance status. others are re-evaluated after additional chemotherapy. for patients with stage ia cervical cancer, patients who have had a conization with negative margins are generally having surgery postponed, and patients who have not had a conization are recommended to have outpatient cervical conization. for patients with stage ia2 cervical cancer with positive margins, we are considering immediate radical hysterectomy, but delayed radical hysterectomy is probably safe as well. patients with a solitary adnexal/pelvic mass are evaluated with imaging and tumor markers and discussed at a multi-disciplinary conference to decide on surgery versus close surveillance and delayed surgery. as of late april/early may, we are prioritizing patients with invasive cancers whose operations were delayed from april. specifically, previously delayed early stage, low grade endometrial cancers, and solitary pelvic masses are now being scheduled. additionally, advanced stage ovarian cancers that have received neoadjuvant chemotherapy and approaching their third or fourth cycle are being scheduled for their interval cytoreductive surgery if they have good response. during the first wave, newly diagnosed advanced ovarian cancers were almost exclusively being triaged to neoadjuvant chemotherapy. now, we will be assessing them for upfront cytoreduction based on our operating room capacity and hospital resource utilization. for urologic oncology, 3 tiers of triage for case selection were created: ''elective,'' ''move if possible,'' and ''urgent.'' this guidance was used to evaluate existing operations until may 11. 21 cases in the middle tier and the highest urgent tier are evaluated weekly taking into account current hospital covid-19 census and existing personal protective equipment (ppe) and related resources. the first (elective) tier included prostate cancer with low to favorable risk or patients already being treated with systemic therapy. second tier (moved if possible) included unfavorable to high risk patients, especially those already scheduled for resection. testis cancer was considered highest (urgent) tier if primary orchiectomy was required to start postoperative therapy or if resection of a residual mass with retroperitoneal lymphadenectomy was needed after neoadjuvant chemotherapy. for kidney cancer, elective tier patients include those with masses <4 cm and those needing cytoreductive nephrectomy to undergo systemic therapy. second tier kidney cancers included large masses without thrombus, those who are still <12 weeks from their final dose neoadjuvant chemotherapy, and those who can safely start chemotherapy to delay the need for surgery. finally, the urgent tier included patients with renal vein or vena cava thrombus or patients with high grade disease after chemotherapy or those not candidates for chemotherapy. for bladder cancer, operations which can wait include nonmuscle invasive cancer, muscle invasive cancer on chemotherapy, endoscopies for recurrence or while on chemotherapy, and diagnostic upper tract endoscopies. patients in the mid-tier who can be delayed include those needing transurethral resection if the diagnosis is already established or those whose tissue biopsy is not needed to start chemotherapy. the urgent tier includes radical cystectomy within a 12-week time limit after chemotherapy and transurethral resection for high-grade pt1 tumors to determine intravesicular therapy versus cystectomy. true emergencies continue to include stents for pyelonephritis and refractory hematuria. sarcomas are rare tumors that require multidisciplinary care best delivered at specialized sarcoma centers. operations (particularly for spine and pelvic sarcomas) often require tremendous resources involving many specialists, significant transfusion volumes, and prolonged stays in intensive care, inpatient units, and rehabilitation centers. the decisions regarding extensive operations continue to be carefully reviewed by faculty at a weekly conference and then by the chair and departmental quality officer. all elective, nonurgent orthopedic operations, including those for benign diseases were postponed until elective operations were allowed in texas on april 22. priority was given to stabilization of lower extremity fractures and impending fractures, when bracing and activity modifications would be ineffective. we recommended preoperative radiotherapy for radiosensitive sarcomas, impending pathologic fractures, and metastatic epidural spinal cord compression, whenever feasible. we continue to recommend utilizing novel devices to decrease/contain aerosolized particles (ie, osteotomes and gigli saws instead of high-speed drills and saws; intubation boxes; and clear plastic enclosures while using high speed drills and saws). departmental consensus guidelines were developed balancing timing of surgery with likely oncologic outcome and availability of systemic therapy and informed by national recommendations. 16, 22, 23 patients proceeded to surgery if delay was associated with adverse outcome and no alternative treatments were available. these diagnoses included triple negative and inflammatory breast cancer after neoadjuvant chemotherapy, soft tissue sarcomas, and tumors with progression despite chemotherapy. postponing surgery was recommended for benign diagnoses including atypia, prophylactic riskreduction, ductal carcinoma in situ, and early-stage estrogen receptor (er)-positive breast cancer treatable with neoadjuvant endocrine therapy. less clear-cut situations were discussed daily for departmental recommendation, such as er-negative, human epidermal growth factor receptor-positive disease after neoadjuvant chemotherapy, and er-positive breast cancers in premenopausal women or after neoadjuvant chemotherapy for advanced disease. looking ahead to the recovery phase, breast surgical cases represent a high volume with low likelihood for utilization of significant hospital resources and capacity. case prioritization for re-opening the operating room inversely followed the consensus guidelines for delay during the covid-19 pandemic surge. the first priority are patients with invasive cancer diagnoses where surgery was postponed from april, followed by patients with ductal carcinoma in situ. in the first month after the peak, we will continue to postpone surgery for benign conditions and prophylactic surgery. many reconstructions are performed quickly, with little or no hospital stay, transfusions, or intensive care, and relatively low ppe depletion. all non-emergent/urgent operations (e.g., delayed breast reconstruction, revisions, elective hernias, etc) were postponed starting in late march and continue to be delayed as the state cautiously re-opens. however, any immediate reconstruction that prevents/ reduces major functional deformity and/or minimizes risk of major medical complications is considered ''medically necessary,'' and is proceeding. many head and neck resections require free flap reconstruction and were not delayed. oncoplastic breast reconstruction after lumpectomy was permitted, as was placement of a tissue expander, implant, and/or acellular dermal matrix after mastectomy. however, contralateral symmetry procedures were delayed in march/april patients, but were allowed starting the week of april 27. immediate autologous flap reconstruction after mastectomy was not allowed in april, but was allowed starting may 1. autologous flap reconstructions elsewhere in the body were always permitted for coverage of exposed hardware, bone, and vital organs and structures. as we see beyond the first peak with improved clarity, the institution is allowing previously postponed reconstructions and revisions to be posted. by flattening the curve with social distancing and forming the ''moat'' around our cancer hospital, our ppe and testing kits are very annals of surgery volume 272, number 2, august 2020 cancer surgery scheduling slowly catching up as of late april/early may. preoperative covid-19 testing remains mandatory, but the unknown false negative rate remains a reality, given the reported high rates of asymptomatic covid-19 carriers. the prospect of contracting the virus in the weeks and months ahead, even on the downslope of the initial peak, or in a controlled plateau, or in secondary waves this year and next year, remains an impediment toward returning to pre-covid-19 hospital practices. no-visitor policies will continue until we can ensure visitors are covid-19-negative, thereby limiting family support for our postoperative patients, especially patients with greater needs (eg, pediatric, elderly, disabled, immunosuppressed). serologic testing is a priority of research teams here and across the world, but with an unknown promise of immunity even among previously infected patients. we currently allow usage of our limited supply of n95 masks for certain high-risk exposure situations (eg, head and neck surgery, intubations, etc), but this will remain a concern for the perioperative workforce involved in putatively ''low-moderate'' exposure risk scenarios (eg, abdominal surgery). we must face the reality that we will need to co-exist with covid-19 for months, if not years. our institution is likely similar to the majority of healthcare systems in the u.s. in that we are starting a cautious recovery process, slowly relaxing the restrictions detailed above in late april/early may. this recovery process includes daily assessment of the inpatient census (including suspected and confirmed covid-19 patients), updated city/state covid-19 incidence, optimizing testing and tracing capabilities, ppe burn rate, and workforce health/availability. through early mitigation strategies and cooperation within the texas medical center, we avoided overloaded hospitals, but ''business as usual'' seems like both a distant memory and a faraway dream as local and state governments tiptoe into re-openings. as we transition from surge planning (which has been laid out and is ready for any second wave) toward re-opening business and society in a country without universal testing and case tracking, 3 we propose a few practices that can help us move forward in the initial covid-19 recovery period (may -summer 2020). remote work to protect the workforce and virtual visits for preoperative and postoperative patients are current practice and will remain necessary until we have effective treatments, a vaccine, or herd immunity. the surgical timeout now incorporates covid-19 risks. universal precautions should be employed during any procedure that entails covid-19 aerosol risks. personnel not needed to intubate a patient should leave the room and spare themselves the exposure risk. ppe should be distributed to personnel at high risk for exposure for all cases. 24 testing having both diagnostic and confirmatory tests could inform surgeons as to when an acute infection has resolved, so that cancer therapy or surgery planning can be resumed. a preoperative covid-19 test to rule out infection has become as routine as a type and screen the day before surgery. increasing the sensitivity and reducing the result time will increase confidence in the result and allow for less disruption to normal morning start times. use of swab testing, serologic antibody testing, and even chest computed tomography could be the combination needed to inject confidence towards a return to normalcy. advanced care planning and documentation of goals of care should be required for all cancer patients. in the current and future covid-19 era, knowing a patient's wishes in case they develop covid-19 organ failure while undergoing cancer treatment is mandatory. operation timing can be more carefully planned rather than bending to arbitrary surgeon preferences, especially because most surgeons are no longer tethered to heavy clinic and operating block days. development of a collective strategy to prioritize previously delayed operations began on april 27. our regional hospital cases were centralized to our main campus to consolidate resources and for covid-19 testing. to balance hospital resources, operations can be distributed throughout the week (including weekends) to plan adequate but not excessive (to continue social distancing) daily staffing for the operating rooms, clinics, and inpatient wards. cancer surgeons can use their knowledge of tumor biology to schedule surgery appropriately for cancer patients at high risk for covid-19 infections and sequelae, whereas fulfilling the societal responsibility to reduce covid-19 dissemination. we hope that the early experience we have presented here will be useful to other cancer surgeons looking for disease-specific guidance for the remainder of this spring, for a potential second wave this summer or next year, and for future unforeseen crises that may strain our healthcare systems. operationalizing the operating room: ensuring appropriate surgical care in the era of covid-19 american college of surgeons. create a surgical review committee for covid-19-related surgical triage decision making as governments fumbled their coronavirus response, these four got it right. here's how clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection characteristics of health care personnel with covid-19 -united states a combined approach to priorities of surgical oncology during the covid-19 epidemic may 1. epub ahead of print cancer patients in sars-cov-2 infection: a nationwide analysis in china virtual interviews for surgical training program applicants during covid-19: lessons learned and recommendations blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the university of wisconsin experience letter: the coronavirus disease 2019 global pandemic: a neurosurgical treatment algorithm surgery treatment guidelines consortium. head and neck surgical oncology in the time of a pandemic: subsite-specific triage guidelines during the covid-19 pandemic changing practice patterns in head & neck oncologic surgery in the early covid-19 era safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic thoracic surgery outcomes research network inc. covid-19 guidance for triage of operations for thoracic malignancies: a consensus statement from thoracic surgery outcomes research network management of cancer surgery cases during the covid-19 pandemic: considerations covid-19: elective case triage guidelines for surgical care approaching surgical triage during the covid-19 pandemic surgical decision-making and prioritization for cancer patients at the onset of the covid-19 pandemic: a multidisciplinary approach neoadjuvant chemotherapy or primary surgery in stage iiic or iv ovarian cancer survival implications of time to surgical treatment of endometrial cancers urology practice during covid-19 pandemic covid-19 resources: disease-site specific management resources recommendations for prioritization, treatment, and triage of breast cancer patients during the covid-19 pandemic. the covid-19 pandemic breast cancer consortium personal protective equipment and covid-19 -a review for surgeons. ann surg. 2020. epub ahead of print the authors acknowledge and thank charles e. butler, md; kelly k. hunt, md; rosa hwang, md; karen h. lu, md; and neema navai, md; for helping create and review departmental guidelines. we thank yujiro nishioka, md, for technical editing. we thank stephanie deming, mls, for her scientific editorial review. key: cord-276676-lgt0rzob authors: moka, eleni; paladini, antonella; rekatsina, martina; urits, ivan; viswanath, omar; kaye, alan d.; yeam, cheng teng; varrassi, giustino title: best practice in cardiac anesthesia during the covid-19 pandemic: practical recommendations date: 2020-07-03 journal: best pract res clin anaesthesiol doi: 10.1016/j.bpa.2020.06.008 sha: doc_id: 276676 cord_uid: lgt0rzob the covid-19 outbreak has influenced the entire health care system, including cardiac surgery. in this review, the authors reveal practical aspects that are important during the covid-19 pandemic with regards to the safe delivery of cardiac anesthesia. timing for operations of the cardio-vascular system may be well programmed, in most cases. hence, the level of priorities must be defined for any single patient. the postponement of surgery may be convenient for most cases, if it is made in the best interest of the patient. the preanesthetic evaluation should keep attention to the respiratory history of the patient. cardiac anesthesia is always implying some respiratory monitoring; hence the existing clinical situation of the patient’s respiratory system should be clear. in case of emergency surgery, the patient should be treated as if they potentially have or are at risk for the virus. in the case of a covid-19 confirmed or suspected patient, attention must be made to preserve operating room and team integrity. the machineries are to be draped with plastic, in order to simplify the disinfection after the operation. perioperative management of suspected or confirmed covid-19 patients must strictly follow the most relevant international guidelines. this review article has synthesized the common aspect present in the most important of these. the outbreak of the novel coronavirus and coronavirus disease was labelled as a public health emergency of international concern, in january 2020 [1, 2] . in march 2020, the rapid and exponential increase in confirmed cases of infection and number of deaths globally obliged who to raise the alarm and declare covid-19 a pandemic, triggering upscaling of emergency response mechanisms worldwide. covid-19 control has been extremely critical and demanding, having unfolded serious challenges to disease prevention and public health protection [3, 4] . although common clinical manifestations are mostly respiratory, some patients may develop severe cardiovascular damage and are consequently at higher mortality risk [5] . patients with suspected or confirmed covid-19 infection, who undergo cardiac surgery procedures, represent numerous challenges for the cardiac anesthesia team. they necessitate an extremely careful approach during perioperative anesthetic care and may reflect higher risks of perioperative morbidity and mortality. it is emphasized that management of the infected covid-19 cardiovascular patients, as well as self-protection of involved personnel, are extremely challenging and of equal importance, mandating a meticulous handling in the perioperative setting [6, 7] . cardiac surgery and related anesthesia practice might not be in the frontline of covid-19 patients' care, but coronavirus expansion resulted in an important impact in this surgical and anesthesia subspecialty. indeed, the pandemic has already affected cardiac surgery units in multiple ways: limited number of available icu beds and ventilation sites, necessity to postpone or cancel elective and/or complex cardiac interventional procedures, patients developing covid-19 post cardiac surgery, coronavirus patients necessitating urgent cardiac operations, cardiac anesthetists' in-hospital transfer to staff and support icus in front of the pandemic, infected health care providers with consequent shortage of medical and nursing practitioners, restrictions in clinical meetings, and cancelation of training and continuing medical education [6, 8] . cardiac anesthesiologists have the responsibility to ensure that evidence-based anesthetic care, and only essential cardiac operations are provided to the general public. in this context, the wider burden of such procedures on the healthcare systems and health care workers needs to be minimized in the current coronavirus pandemic, by delaying elective cases, to sustain health care services [6, 8, 9] . based on the current understanding of covid-19 pathophysiology and the clinical characteristics of cardiovascular surgical patients, in this review, the authors highlight related anesthesia concerns and provide practical recommendations in reference to perioperative planning and management of patients undergoing cardiac surgery, along with a focus on disease control and prevention in the times of covid-19 outbreak. while a conclusion to proceed with or postpone a cardiovascular operation seemed easy in the low and medium escalation phase, continued escalation related to restricted icu capacity made such decision very difficult [6, 8] ; e.g. it is difficult to answer critical dilemmas such as offering surgery only to younger, or lower risk patients. cardiovascular surgical patients are usually characterized by a relatively progressive disease. the necessity for surgery for a given disease condition must be identified by an experienced surgeon, who will prioritize patients underlying problems and will recognize potential risks encountered delaying the operation, also taking into consideration the risks for health care providers. as such, moving on with a decision to postpone or perform a cardiac operation is not at all easy. indeed, it can be tricky and needs to be taken after careful evaluation of patient status and health care system capacity, rather than being exclusively based on covid-19 associated risks. in all cases, availability of medical staff (e.g., cardiac surgeon, cardiac anesthetist, icu bed, perfusionist), potential need for isolated icu bed, equipment (e.g., ventilators, pumps, extracorporeal membrane oxygenation, intra-aortic balloon pump, trans-esophageal echo), medical supplies, blood and blood products, should be balanced and taken into account prior to a definite conclusion. importantly, when such decisions are taken, both the decision process and the decision making should be well documented, for obvious medicolegal reasons [9 -11] . a knowledgeable decision-making process is emphasized and has to be based on a classification of planned interventions or/and operations in levels of priority (lop), such as (a) elective (lop i), (b) urgent (lop ii), (c) emergency (lop iii), and (d) salvage (lop iv), as per international guidelines. in a progressively escalating situation, as it has happened in most european countries, routine elective cardiac surgery (lop i) should be postponed as much as possible. on the contrary, operations at lop ii-iv, should be further evaluated on an individual basis, by the whole cardiac surgery team, keeping in mind that pci or endovascular interventions are preferable and should be selected if applicable. on the contrary, in-house urgent cases (lop ii), at risk for adverse cardiac events if going home instead of remaining hospitalized, might still undergo cardiac surgery at this time point, with the application of all precautions and protective measures, as per recent recommendations. the same rule applies for lop iii & iv interventions [6, 8, 10 -12] . however, one must seriously consider such patients exposure risk to a possible covid-19 infection, during hospitalization, and/or exposure of health care workers to patients with potential coronavirus infection. most covid-19 patients have mild or no symptoms and therefore, it might be difficult to identify them from the pool of in-hospital urgent cases. moreover, patients with acute coronary syndrome in case of severe coronary artery disease (e.g. severe lm trunk stenosis, severe triple vessel disease with high syntax score), who are not eligible candidates for conservative or interventional treatment may be operated on. this may be true also for younger patients with symptomatic severe aortic valve stenosis, left-sided endocarditis with a severe valve defect and/or large mobile vegetation, large ascending aortic aneurysm (>6 cm in diameter), and symptomatic severe mitral valve insufficiency. if the pandemic escalates into a crisis, characterized by an absolute shortage of icu beds and ventilation sites, cardiac procedures will need to be extremely limited to absolutely essential emergency surgeries, for example acute type a aortic dissection, acute heart failure due to severe coronary artery or valvular heart disease, and ventricular septal defect. under these circumstances, even such decisions obviously remain tough to be resolved, should be taken after examining available hospital resources and reserves, and must always be supported by an ethical and legal framework [8, 11, 12] . in all cases, postponing elective cardiac surgery does not necessarily translate into a delay in or a neglection of patient care. it is fully understandable, as well as a realistic assumption that cardiac surgery units are responsible for their patients' best outcome, but also equally responsible towards the health care workers and the wider health care service in a region or country. therefore, in an escalating pandemic, patients normally scheduled for elective cardiac procedures are best managed by delaying their care until a few weeks or even months later. this is probably in the patients' best interest, to avoid their exposure to the hospital environment, and to eliminate chances of an incidental covid-19 development in their postoperative course. it is already documented that acs patients, infected by coronavirus usually end up with a poor prognosis. therefore, developing covid-19 post cardiac surgery might be associated with higher mortality rates. however, cardiac patients, whose operations are postponed, should be regularly re -evaluated and strictly followed -up, before their underlying conditions evolve further, and they arrive at a point of needing a cardiac surgery of lop ii or higher. finally, the cardiac surgery team should not only take decisions on postponing elective operations but should also discuss and plan regarding the timing of surgery in the future, based on the rapidly evolving covid-19 circumstances, and the continuously evolving regulations and restrictions [11] [12] [13] [14] [15] . the coronavirus is highly contagious. its incubation period fluctuates between 4 and 6 days, although its latency period can extend up to 14 days. most infected patients usually present with mild, flu-like symptoms, including low fever, dry cough and fatigue, or can be even asymptomatic. the mean age of a covid-19 case is reported to be 49 years. worse outcomes are associated with geriatric populations and those with underlying diseases, such as obesity, cardiovascular comorbidities, pulmonary disorders, and/or diabetes. di erential diagnosis can appear extremely challenging, since common influenza is characterized by similar signs and symptoms. chest radiography or thoracic ct scan may be utilized, in identifying evidence of secondary pneumonia [4, 5, 14] . taking into consideration that invasive or at least minimally invasive cardiorespiratory monitoring is usually required in most cardiac surgery procedures, all patients proceeding to or must be treated as confirmed covid-19 cases, not only if the disease is suspected, but until a test result becomes available. additionally, in an escalating pandemic, candidates for elective or semi-elective cardiac operations may be best managed by delaying their care until a few weeks or even months later, or in the worst case postponed until covid-19 virus detection results are negative, at least twice, with a minimum of 24 hours between tests [6] [7] [8] [9] 13] . it is known that patients with acute coronary syndrome, who are infected with coronavirus, often have a poorer prognosis compared to the general population. therefore, developing covid-19 after cardiac surgery might contribute to a complicated postoperative course and be associated with higher morbidity and mortality rates [15, 16] . in the event of an emergency cardiac surgery operation, covid-19 status mandates immediate evaluation, in terms of patient recent epidemiologic and respiratory infection history, clinical manifestations, and laboratory and radiographic testing, including but not limited to temperature, respiratory pathogen testing, serum igg level, complete blood count, crp and procalcitonin levels, sars-cov-2 nucleic acid testing, and chest ct scanning. in case enough time is not available for a complete preoperative evaluation prior to surgery, preoperative hospitalization and preparation must strictly follow the already published guidelines for suspected/confirmed covid-19 cases. such patients should be admitted to an airborne isolation room (single room with negative pressure and frequent air exchange), with the quarantine necessity being evaluated and finally decided, according to sars-cov-2 nucleic acid testing and chest ct scanning examination results [17] . a multidisciplinary team consisting of cardiac surgeons, cardiac anesthesiologists, respiratory infectious disease experts, perfusionists, and nursing staff should be involved in coordinating such patients care. for healthcare personnel involved in suspected or confirmed coronavirus cases, level 3 infection control precautions (such as disposable hat, medical masks [n95 or above], powered air purifying respirators [papr], scrubs, disposable gloves, and disposable shoe covers) should be strictly applied throughout the whole perioperative period. personnel clinical observation and follow-up for signs and symptoms of covid-19 must not be forgotten and should be carried out closely after their clinical involvement in such patients care. in case of health care personnel exposure risks, an isolation period of at least 14 days is mandatory [6] [7] [8] 12] . keeping in mind the ease of in-hospital coronavirus contaminating capability and expansion, and that all health care workers are among those at high risk of infection, they must all routinely apply protective and preventive measures, with attention to details, to avoid any nosocomial spread to patients and healthcare nursing and medical personnel. indeed, precautions in the care of all patients and in the interaction between health care personnel are of paramount importance, to limit infection spread, as much as possible. it is highly recommended that all health care providers focus on their personal protective equipment. in this context, all should wear a n95 mask, surgical cap, gown, protective eye googles, shoe covers, double gloves, and paprs or protective full-face shield, during very contact with suspected or confirmed covid-19 cardiac surgery candidates [6] [7] [8] . a dedicated operating room for the suspected/confirmed cardiac surgery covid-19 patients must be readily available and in absolute isolation from the rest of operating theatres, with a warning sign posted outside and with predefined, dedicated preoperative and postoperative patient transportation pathways, which must be disinfected regularly. covid-19 or set up, workflow and organization are extremely critical. surgical devices and anesthetic equipment must be unique and dedicated only to the predefined covid-19 or, without any chance of being transferred to other operating sites. all non-essential surgical and anesthetic equipment needs to be removed outside this dedicated or. the operating room should also be converted to a negative pressure environment with airflow changes, with doors remaining shut at all times, to maintain an optimal negative pressure at all time points of the cardiac patient perioperative care [6, 7, [17] [18] [19] . coordination of and collaboration between healthcare practitioners, workflow of the covid-19 or (inclusive of, but not restrictive to routine universal infection prevention practices, donning and doffing personal protective equipment [ppe] , and decontamination after the procedures), and designated personnel must be planned on a daily basis, also evaluated and adapted to circumstances dynamic alterations. cardiac surgery is a complex operative procedure that cannot be completed successfully without a group of health care practitioners. such operations must involve a dedicated team, limited to the minimum number of nursing and medical personnel (cardiac surgeon, anesthesiologist, anesthesia nurse/technician, cpb technician, perfusionist, scrub and circulating nurse). all team members should be assigned and allocated to their roles prior to covid-19 patient entrance in the or. irrelevant staff should not enter the covid-19 or to minimize unnecessary traffic. staff management can take appropriate measures to separate workers/anesthetists/surgeons into groups, so that possible necessary quarantines can be applied to groups within each unit, rather than the unit as a whole, which could lead to the closure of the entire cardiac surgery service, something that is especially true for smaller cardiac surgery units [6-9, 13, 19] . all equipment and devices required, for endotracheal intubation, arterial and central venous cannulation, syringes, gauzes, surgical drapes, surgical instruments, sutures, material for cannulation prior to cardiopulmonary bypass (cpb), oxygenator and circuit for cpb, prosthetic grafts and valves must be checked for adequacy prior to surgery and be set and positioned properly and definitely prior to patients arrival in the or. the aim is to have as minimal as possible traffic in circulation across the covid -19 or. additionally, high-touch surfaces of devices like anesthesia machines/workstation, infusion pumps, cpb machine, cell-saver device, iabp, heat exchangers and computerized devices for documentation should be wrapped with plastic sheets, to facilitate cleaning and decontamination after the end of surgery and following patients transportation to icu, as per international general guidelines. strict measures and precautions for infection control should be implanted and must definitely be applied in the case of suspected/ confirmed covid-19 cardiac surgery patients [6] [7] [8] [9] . first, in reference to staffing management, and based on the potential complexity of a cardiac operation, two experienced cardiac anesthesiologists and a cardiac anesthesia nurse are necessary to be present inside the cardiac surgery or, directly being responsible for the patient anesthetic care. a third cardiac anesthesiologist should be readily available outside the or, serving as backup and consultant, in case it becomes necessary [6, 9] . or traffic should be limited to the minimum. only dedicated staff should be allocated for specimen collection and delivery (e.g. arterial blood samples analysis, act, thromboelastography, blood tests etc.). all healthcare providers involved should be covered by level iii protection and should wear in the following order: n95 mask, disposable surgical cap, disposable work uniform, disposable medical protective uniform, scrub, gown, anti-fog goggles, shoe covers, first layer disposable latex gloves, isolation gown, and full-face respiratory devices or powered air-purifying respirator (papr), if available. anesthesiologists must wear gloves before contacting the patient and eventually patient body fluids, such as blood, urine, mucus, or other potentially contaminated objects. in such case, vigilance is required to remove the outer gloves, followed by appropriate hand hygiene, with gloves repositioning being strongly advised afterwards. extreme care should be applied to avoid touching surfaces prior to contaminated gloves removal. also, contaminated, semi-contaminated, and clean zones should be clearly defined, and protective equipment must be removed consequently, and when necessary, according to the hospital guidelines and protocols [6, 8, 13, 17, 19] . a specific note must be given to surgeons and scrub nurses preparation in terms of personal protection. they should put the surgical mask and cap above ppe, then get scrubbed in and move on with putting on the surgical coat with double gloves. gloves should be long-sleeve and fixed to sterile coat with adhesive tape or drapes. regarding equipment and devices preparation, anesthesia machines, monitors, toe probes, us machines, blood gas analyzers, act machines, and disposable or supplies must be prepared well in advance. the waste anesthetic gas disposal system should be checked for proper working provisionally and must be equipped with the necessary filtering and sterilizing functionalities. the centralized waste anesthetic gas disposal system should be avoided, to prevent the spread of coronavirus among operating rooms, in case standard negative pressure in the or cannot be achieved. an independent (preferentially portable) negative pressure suction device should be readily available in each or. a video laryngoscope (disposable laryngoscopes whenever possible) is strongly recommended and advised to be utilized, if available, to improve the success rate of endotracheal intubation, thus reducing exposure time. video laryngoscope must also be used even in case of unplanned emergency circumstances for securing airway [6-8, 17, 18] . cardiac surgery patients must always wear a n95/surgical mask, and at all times, and should be transported to the or through a predesigned pathway. nasal oxygen supply /therapy can be offered underneath the surgical mask when needed. a venturi mask is advised to be avoided [7, 17] . in patients with severe cardiac and pulmonary dysfunction, intra-aortic balloon pump, or extracorporeal membrane oxygenation (ecmo) might be considered [6-8, 19, 20] . general rules and principles: current guidelines 1. all non-essential or unnecessary equipment and devices must be kept outside the covid-19 or, during anesthesia induction and endotracheal intubation (eti). all anesthesia induction and resuscitation equipment must be prepared and ready for use, prior to patient transfer in the or. anesthesia and intubation protocols for covid-19 cases must be strictly followed [6 -8, 18, 21 ]. 2. arterial and cv catheterization are recommended to be facilitated by ultrasound guidance, to improve success rates, reduce procedural times, and avoid multiple vessel punctures, that could contaminate surrounding personnel via blood [6, 7, 17, 22] . 3 . in general, regional anesthesia is preferred to ga in surgical procedures. however, in most cardiac surgery circumstances, a single ra technique cannot be applicable, although it may be combined to ga, based on the type of surgery, as an adjunct to a ga technique, for adequate perioperative pain management [6, 23, 24] 10. electrostatic heat and moisture exchange filters (hmef) must always be used in the anesthesia circuit throughout the intubation process, as its virus filtration efficiency reaches 99.9995%. for suspected patients, lower respiratory tract secretions should be collected through the ett, and specimens should be sent for examination as soon as possible [25] [26] [27] [28] . patients covid-19 patients may suffer from severe viral myocardial damage. elevated cardiac injury biomarkers are commonly found in covid-19 patients. among other manifestations, hypertension, heart failure (with a high incidence in elderly), hypoxia-induced myocardial damage (especially after myocardial infarction, unstable angina, or in patients with a pci history), and stunned myocardium have been reported. multiple explanations have been described, all related with a high expression of ace2 receptors in the heart, blood vessels, and lungs, possibly being responsible for the virus induced activation of the raas system. patients receiving ace inhibitors prior to surgery might be in higher risk for complications and worse outcome [5, [14] [15] [16] 29] . in reference to cardiovascular monitoring, that is necessary in the covid-19 cardiac surgery patients, minimally or advanced invasive hemodynamic monitoring (picco, flotrac, pulmonary artery catheterization) and toe are mostly recommended to guide fluid therapy and inotropic/vasoactive drugs usage. patients with acute mi might need iabp insertion, ventricular assist device, or ecmo mechanical circulatory support, and these devices should be applied with extreme caution to avoid transmission of infection. intraoperative toe is the routine technique of choice for lv function monitoring, volume status optimization, and valvular diseases evaluation, and may serve as a useful guide during cardiac anesthetic management. concise and comprehensive toe examination represents the primary modality for the evaluation of every cardiac disease and of a covid-19 induced cardiac dysfunction. rv dysfunction, can be a manifestation of covid-19 cases, after cpb, related to increased pulmonary vascular resistance and pulmonary edema, lv dysfunction, and related stress cardiomyopathy [6] [7] [8] . patients with sars, under mechanical ventilatory support, suffer a higher risk for developing pneumothorax, which contributes to increased mortality rates in this subgroup of patients. as such, it is recommended that pneumothorax is excluded by ct scanning during preoperative patient evaluation. a protective mechanical ventilation strategy must be applied in all suspected and confirmed cardiac surgery cases. pneumothorax should be suspected according to patient clinical picture (mostly decreased spo2 or sudden blood pressure decreases. lung ultrasound, as a basic part of pocus, can be useful for fast evaluation and diagnosis, and a chest tube should be placed if a pneumothorax is the final diagnosis. lung re-expansion should be verified prior to chest closure. lung ultrasound can also be useful in assessing the severity of pulmonary manifestations due to covid-19, by easily identifying presence of b-lines, air bronchogram, and pleural effusion, thus helping in selecting proper lung protective ventilating strategies [5, 14, 30] . critically ill covid-19 patients have a high incidence of acute kidney injury and severe acidbase imbalances, with electrolyte abnormalities commonly being encountered. continuous renal replacement therapy should be performed perioperatively when indicated. goal -directed fluid therapy is recommended to optimize fluid administration [5] [6] [7] [8] 31] . blood conservation strategies should be applied, as such patients' coagulation profile is usually not normal. coagulation status should be checked routinely via measurements of platelet counts/ function, prothrombin time (pt), partial thromboplastin time (ptt), international normalized ratio (inr), and thrombo-elastography. antifibrinolytics, preoperative hemodilution, autologous platelet-rich plasma technology, mild hypothermia or normothermia during cpb, and intraoperative blood salvage must be used, as in non-covid cases, to minimize blood transfusion requirements and transfusion-related acute lung injury. coagulation factor concentrates are preferred over blood products when possible to reduce potential trali, which can worsen the already existing lung manifestations related to covid-19 [6 -8] . major surgery and anesthesia produce well documented inflammatory and immune response in humans. in cardiac surgery procedures, extracorporeal circulation and cpb are further considered as an additional risk factor and the most important trigger for a massive perioperative inflammatory reaction, a problem that has been largely addressed in the past, because of its detrimental consequences and impact on perioperative morbidity and mortality. continuous blood exposure to non-endothelial surfaces (perfusion circuit) is responsible for a cascade of systemic inflammatory response, via activation of coagulation pathways, complement system, and production of tissue factor and cytokines, that can eventually result in ards, potentially being further complicated by blood transfusion, finally causing trali. the inflammatory response during cardiac surgery occurs due to not only cpb, but also surgical trauma, anesthesia, cardioplegia and myocardial ischemia, cardiac manipulation, heparin, and protamine. inflammatory response to cpb can be controlled and minimized by off-pump cardiac surgery, temperature maintenance and arrangement (32°-34°c for operations requiring up to 2 h of cpb), heparin coated-perfusion circuits, modified ultrafiltration, complement inhibitors, and glucocorticoids [32, 33] . current covid-19 therapies are mainly supportive. development of novel therapies and effective prevention are an urgent need, particularly for life-threatening severe acute ards and hyper-inflammatory syndrome (characterized by a fulminant and fatal hypercytokinemia with multi-organ failure). several cytokines are involved in the disease pathogenesis. likewise, some of these cytokines induce increased vascular permeability and leakage, pulmonary edema, air exchange dysfunction, ards, acute cardiac injury, and multi-organ failure. novel therapies such as interleukin (il) antagonists (dupilumab), jak2 inhibitor (fetratinib), interferon blockers and stem cell and mesenchymal cell therapies have been applied to neutralize cytokine storm and offered some improvement. in the cardiac surgery setting, extracorporeal circulation and cellsaver application might reduce the systemic cytokine load, could in part eliminate immune and inflammatory response, and as such, might be reasonable options as alternatives and might be considered for covid-19 patients during cardiac surgery [6 -8, 13, 20, 34] . at the end of each cardiac operation, specific attention must be given to patient transportation, medical waste management, or and equipment disinfection and patient and health care personnel follow up. a single dose of an antiemetic (e.g. 5-hydroxytryptamine receptor antagonist) should be administered to prevent postoperative nausea and vomiting (a common adverse effect due to high opioid doses that are provided intraoperatively), which may be responsible for an extensive coronavirus spread. prior to departure from or, all healthcare providers should take off the outer layer of their personal protective equipment, in the sequence guided by local hospital policy and international guidelines. the transportation of covid-19 patients should be performed by a personnel with ppe. this team should wear new personal protective equipment in the clean zone. in cases undergoing cardiovascular surgery, extubation should be planned in the or if possible and for the appropriate patients. patients to be admitted to the icu should be transferred in accordance with the infection prevention measures for covid-19. if the patient transported to icu is intubated, ventilation can be performed by a disposable ambu bag, or an hmefequipped portable ventilator should be used. the positive pressure ventilation should be stopped prior to disconnection from ventilator, while placing the patient to ambu bag or the portable ventilator. if the transported patient is extubated, a n95/should be applied to patient. regarding transportation, a pre-specified pathway must be followed, to transfer the patient to an airborne isolation intensive care unit room, specifically dedicated to covid-19 cases. personal protective equipment can be taken out only after leaving the isolation area. all disposable equipment and medical waste (breathing tubes, infusion tubing, disposable laryngoscopes, sutures, drapes etc.) should be discarded. these must be put in and sealed with double-layered medical waste bags and must be treated as highly contagious medical waste. anesthesia machine and their surfaces, other surfaces, equipment used in or, floor and operating table need to disinfect and decontaminate as per dictated procedures. it is advised they are wiped with 75% alcohol or chlorine-containing disinfectants. the inner circuit of the anesthesia machine should be removed and disinfected with 75% alcohol or hydrogen peroxide. mixed o 3 and h 2 o 2 atomized gases or pasteurization can also be applied. or negative pressure must be maintained for at least 30 minutes, after patient departure and transfer to icu. or ceiling filters of exhaust vent and or wall return vent must be definitely replaced. no operation should start in this or before or space has been thoroughly disinfected, as per the description provided above. plasma air purifiers can be used for air sterilization. alternatively, ultraviolet light can be used as well for one hour. the casing and monitor of ultrasound machines should be wiped with 75% alcohol. quaternary ammonium disinfectants should be avoided as they can damage the casing. however, ultrasound probes can be disinfected with quaternary ammonium or hydrogen peroxide. for disinfection of the toe probe, blood gas analyzer, and act machines, one should address to the manufacturer's instructions. reusable surgical instruments must be transferred to the nearest washstand (with a covid-19 warning sign above it) and decontaminated by personnel wearing ppe. reusable instruments disinfection via soaking must be carried out with a chlorine containing disinfectant for at least 30 minutes [6, 8, 11, 13, 17, 19] . postoperative care and intensive follow-up of covid-19 patients, necessitate establishment of a dedicated multidimensional cardiac covid-19 team, with a particular expertise in cardiac icu, mainly including, anesthesiologist, cardiovascular surgeons, respiratory medicine physicians, infectious diseases specialists, experienced nurses, physiotherapists, and social worker. team decisions should be taken jointly, as a multidisciplinary decision making among the covid-19 team can minimize specialty bias and prevent self-referral from interfering with the optimal patient care. in this context and to minimize/prevent infection, healthcare workers should follow the infection control policies and procedures already in place at their healthcare institutions. for the healthcare workers performing aerosol-generating procedures in patients with covid19 in the icu, it is advisable to use fitted respirator masks (i.e., n95 respirators, ffp2, or equivalent), in addition to other ppe (i.e., gloves, gown, and eye protection, such as safety goggles) as described in the infection prevention measures for covid-19. if possible, the shift of healthcare workers should be reduced to four hours. additionally, it is preferentially recommended that performing aerosolgenerating, nonaerosol-generating procedures in icu patients with covid-19 should be carried out in a negative-pressure room and a portable high-efficiency particulate air filter should be used in the room, if available. in patients who require endotracheal re-intubation, intubation should be performed by the healthcare worker who is the most experienced with airway management to minimize the number of attempts and risk for transmission and using videoguided laryngoscopy over direct laryngoscopy, if available. during icu follow-up of covid-19 patients, patients should be closely monitored for ards, systemic inflammatory response syndrome, and cytokine release syndrome. the preventive and treatment options (including antiviral treatment strategy which is subject to change) related to the diseases itself and subsequent serious clinical conditions (i.e., ards or shock) should be taken in accordance with the guideline recommendations [6, 8, 13, 19, 35, 36] . finally, one other big problem is the feeling of fear of health care providers to be diseased or contagious for their families. therefore, they may need enormous support against burn-out during the covid-19 pandemic. cardiac anesthesia provision presents with many challenges in the coronavirus era, as presented in table 1 . for the performance of cardiac operations in the covid-19 pandemic, it is important that a dedicated team decides on which cases to postpone for a later stage, based on an assessment of level of priority. the basic goal is to support the healthcare facilities and to protect patients from severe postoperative complications that contribute to high mortality rates, and health care workers from a potential contamination. the rest of operations that cannot be deferred should be performed with great caution, strictly following guidelines and health authorities' recommendations, that are readily available. personal protective equipment is the most crucial measure during pandemic, even if in this kind of working environment is challenging. support of health care cardiac anesthesia and surgery team is mandatory, taking into account that patients can only be treated if health care workers are healthy. the authors have no conflicts of interest to disclose. no funding was received for the completion of this manuscript. sars cov-2 is an appropriate name for the new coronavirus a pneumonia outbreak associated with a new coronavirus of probable bat origin who announces covid19 outbreak a pandemic world health organization. coronavirus disease (covid19) pandemic the current clinically relevant findings on covid-19 pandemic special article: chinese society of anaesthesiology expert consensus on anaesthetic management of cardiac surgical patients with suspected of confirmed coronavirus disease perioperative care provider's considerations in managing patients with covid -19 infection perioperative planning for cardiovascular operations in the covid -19 pandemic cardiac surgery in canada during the covid-19 pandemic: a guidance statement from the canadian society of cardiac surgeons american college of surgeons. covid-19 guidelines for triage of cardiac surgery patients ramping up the delivery of cardiac surgery during the covid-19 pandemic: a guidance statement from the canadian society of cardiac surgeons the society of thoracic surgeons covid-19 task force and the workforce for adult cardiac and vascular surgery. covid-19 guidance document: adult cardiac surgery during the covid-19 pandemic: a tiered patient triage guidance statement cardiac surgery in the time of the coronavirus novel coronavirus patients' clinical characteristics, discharge rate and fatality rate of meta-analysis covid-19 and cardiovascular disease covid -19 and the cardiovascular system practical recommendations for critical care and anaesthesiology teams caring for novel coronavirus (2019-ncov) patients recommendations for endotracheal intubation of covid-19 patients cardiovascular surgery in the covid 19 pandemic covid-19 and ecmo: the interplay between coagulation and inflammation-a narrative review anaesthesia and covid-19: infection control covid-19 / coronavirus outbreak: how to establish a central venous access by placing a central venous catheter regional anaesthesia and covid-19: first choice at last? regional anesthesia for cardiac surgery consensus guidelines for managing the airway in patients with covid-19 rational use of personal protective equipment for coronavirus disease 2019 (covid-19) recommendations for endotracheal intubation of covid-19 patients precautions for intubating patients with covid-19 the variety of cardiovascular presentations of covid-19 what we know so far: covid-19 current clinical knowledge and research covid-19 and kidney failure in the acute care setting: our experience from seattle the systemic inflammatory response to cardiac surgery: implications for the anesthesiologist inflammatory response and cardioprotection during open-heart surgery: the importance of anaesthetics extracorporeal oxygenation and coronavirus disease 2019 epidemic: is the membrane fail-safe to cross contamination? a case of postoperative covid-19 infection after cardiac surgery: lessons learned. the heart surgery forum ra preferable when applicable, combined with ga avoidance of aerosol generating processes (airway manipulation, face mask ventilation, suction awake eti -rapid sequence induction -video laryngoscope utilization -avoidance of circuit disconnection • cardiovascular considerations: hemodynamic monitoring, toe use, attention to possible rv dysfunction • respiratory considerations: protective mechanical ventilation strategy / lung ultrasound / pocus • renal dysfunction -role of renal replacement therapy postoperative care of suspected/confirmed cardiac surgery covid -19 patients • attention to patient transportation by personnel with ppe • antiemetics administration at end of surgery and prior to weaning • if possible, extubation in or -n95 mask applied to patient afterwards • proper disposable equipment and medical waste should be discarded as per guidelines and protocols key: cord-303631-u0rzxw7o authors: hart, andrew title: cover illustration: “lockdown” mural, bath street, glasgow, by the.rebel.bearunshackling plastic surgery from covid-19 date: 2020-06-14 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.05.082 sha: doc_id: 303631 cord_uid: u0rzxw7o nan colleagues who were doing so, and reduce activity during the exponentially rising phase of the epidemic. it is also right that as incidence plateaus and falls we now advocate the rapid restoration of broader healthcare, in order to limit further avoidable death and disability that can only worsen the health, economic, and moral impact of covid-19 upon our communities. in this advocacy we are promoting the care that we can deliver primarily against restricted healthcare provision, and less against that given by other specialties and services. the risks of providing normal treatments while covid-19 remains prevalent must be compassionately balanced against the undoubted risks of not providing those treatments. considerable supportive evidence exists for the positive impact of plastic and reconstructive surgery upon quality of life, patient reported outcomes, return to work, and longterm healthcare costs, but to most effectively advocate plastic surgery to policy makers focused upon the risks and resource requirements of covid-19, more, scientifically robust, data is urgently needed. national / international evidence of the impact of plastic surgery service disruption upon patient welfare is also required. the clearest immediate argument for rapid resumption of elective surgery is based on our role in cancer care. amongst evidence that cancer care is being compromised by both a public perception that healthcare services should be avoided, and by structural disruption of those services, is elegant modelling published on the 19th may 5 . this illustrates the considerable impact on 5-year survival for surgical cancers of treatment delays of only 3 / 6 months. a 6-month delay in delivering surgical cancer treatment results in 43% of the life years, and 59% of the resource adjusted life years, saved by treating covid-19 cases being lost to increased cancer mortality. the effect is greater for more aggressive cancers, and lesser for more indolent ones, but cumulative loss of years of life remains sizeable for common, low risk malignancies. cancer surgery must recommence urgently, with initial supranormal throughput if delays in delivering definitive surgical care are not to be perpetuated, and the increased mortality and healthcare cost made permanent. that will require novel solutions and facilities, overcoming difficulties around social distancing and patient education since symptom-screening and pcr-testing continue to have an undesirably high false negative rate. it also requires considered thought about major reconstruction, for which we urgently need specific safety data in covid infected patients (u.k. data currently being sought by the bapras microsurgical special interest group 6 ). it is unlikely that the 44.1% rate of icu admission and 20.5% risk of death recently shown for major surgery 7 will directly transfer to flap procedures, but the association between more severe peri-operative morbidity and increased mortality with more prolonged general anaesthesia, age, and identified patient factors may. where major reconstruction enables curative resection (as with chest wall sarcoma) the decision seems simple. reconstruction for limb salvage is not essential for curative intent resection, but merited as the one opportunity to preserve function and body image. the same argument can be extended to immediate breast reconstruction, but this is a more nuanced debate given the range of cancer subtypes, oncoplastic and reconstructive options, each with differing resource requirements and outcomes / complication profiles. the undoubted benefit of immediate reconstruction for a sizeable cohort of women is being considered against the greater apparent safety and lesser shortterm resource requirement of mastectomy and delayed reconstruction, and guidance from the association of breast surgery (u.k.) is under review. women will have to wait an extended period for delayed reconstruction in a time of greater healthcare stringencies, and delay carries harm in itself. it will be specifically addressed in the next issue, but the solution may be to develop capacity to provide equitable access to safe, effective reconstruction, with a low complication profile, in a governanced setting where the risk of operating during covid infection can be minimised, and detailed consent provided that includes known and unknown risks, along with the implications of awaiting delayed reconstruction. as plastic surgeons we deliver a continuum of outcomes from functional restitution that restores independent living or occupational capacity, through optimisation of holistic and psychological welfare (e.g. through breast reconstruction), to pain reduction and curative oncological surgery; treating neonates to centenarians. this generates a complex surgical prioritisation matrix for assessing plastic surgery service provision against service restriction while covid-19 remains prevalent. various bodies have produced prioritisation guidance, including the joint royal colleges 8 , and u.k. federation of surgical specialty associations (in preparation 9 ), but rationalisation may best be finalised at the local level in reflection of actual risks (covid-19 alert level 10 , local prevalence and epidemiology), healthcare capacity (anaesthetic and surgical consumables, bed occupancy, hdu / icu / theatre capacity, adjuvant therapy pro-vision), staffing levels (including that for all post-operative care, occupational and physiotherapy), and supply levels of ppe (reflecting anaesthetic guidance 11 ). prioritisation must reflect both the individual care needs of the patient and their individualised risk from receiving that care in the covid era, when outcomes may differ from historical ones due to altered structures and processes, with new known and unknown risks to account for. consent legally requires a new and detailed conversation specifically cogniscent of the impact of covid-19. this supports the benefit of separating care streams / facilities into those naive to covid status (e.g. for acute trauma), and those based around stringent measures to exclude covid infection during elective interventions. it also provides a framework within which ethically secure decisions can be made around the resumption of appropriate aesthetic surgery. given the different clinical picture for covid in the paediatric population, children's services will merit focused attention to ensure that key age-related windows of opportunity for intervention are not missed, in order to avoid permanent impacts upon growth trajectory, development, or lifelong functional outcomes. many of these complexities are being addressed in the bapras covid webinar series 12 , supported by jpras. the series also seeks positives from the current situation, including ways to provide better services in the longer term, and to enhance education and training. the use of webinars, social media, and virtual platforms for education and meetings has become universally accepted within a month, and now challenges the traditional models for professional associations and surgical education that relied upon physical presence. individual units, including the canniesburn unit, are providing webinar teaching that is freely open to participants from around the world, while others deliver virtual courses. we are witnessing the democratisation of education in a manner that facilitates international collaboration in ways that could also actually solve longstanding research or clinical problems, and provide previously unachievable levels of equity in access to expert opinion and high quality educational resources. professional associations should consider changing their meetings into social and networking events, with scientific presentations and education delivered online, since these may become the only reason to physically bring people together. without the restriction of travel, a shrinking pool of highly available international experts may come to dominate global educational output, but they, like those setting programmes, should take care to support the development of their successors, and provide space for dissent and evidence based argument in preference to eminence-based didactic instruction. jpras supports this global drive (for example through the icoplast journal club 13 that will feature the free-to-access editor's choice paper each month), and celebrates the millennial approach to consolidating our specialty, our international community, and the evidence base that will drive international consensus and strengthen plastic surgery's voice in these challenging times. world bank global poverty projection lockdown collateral damage: the impact on outcomes from cancer surgery of the covid-19 pandemic clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection federation of surgical specialty associations guidance on surgi aesthetic guidance on recommencing elective surgery key: cord-286523-4ip8er0h authors: grippaudo, francesca romana; migliano, emilia; redi, ugo; turriziani, gianmarco; marino, davide; d’ermo, giuseppe; ribuffo, diego title: the impact of covid-19 in plastic surgery departments: a comparative retrospective study in a covid-19 and in a non-covid-19 hospital date: 2020-08-26 journal: eur j plast surg doi: 10.1007/s00238-020-01725-w sha: doc_id: 286523 cord_uid: 4ip8er0h background: covid-19 is a new human-infecting coronavirus for which the world health organization declared a global pandemic. the first italian cases occurred in february 2020: since then, there has been an exponential increase in new cases, hospitalizations and intensive care assistance demand. this new and sudden scenario led to a forced national health system reorganization and review of welfare priorities. the aim of this study is to evaluate the effects of this pandemic on ordinary activities in two plastic surgery divisions in rome, hosted in a covid-19 and a non-covid-19 hospital. methods: the data of this comparative retrospective study was collected between 9 march and 9 april 2019 and the same period of 2020 from two plastic surgery units, one in a covid-19 hospital and second in a non-covid-19 hospital in rome, italy. the 2019–2020 data of the two hospitals was compared regarding the number of surgeries, post-operative dressings and first consultations performed. results: both units sustained a decrease in workload due to lockdown effects. statistically significant differences for day surgery procedures (p value = 0.0047) and first consultations (p value < 0.0001) were found between the covid-19 and non-covid-19 institutes, with a drastic trend limiting non-urgent access to covid-19 hospitals. conclusions: the long-term effects of healthcare reshuffling in the “covid-19 era” imply a delay in the diagnosis and treatment of skin cancer and cancellation of many reconstructive procedures. these findings pose a question on the future consequences of a long-term limitation in plastic surgery healthcare. level of evidence: level iii, risk/prognostic study. covid-19 is a new human-infecting betacoronavirus, first reported in wuhan (china) in december 2019 and rapidly spreading to all continents, causing a pandemic and a public health emergency. this virus is highly contagious with a human-to-human transmission and may present a benign course showing flu-like symptomatology (malaise, fever, cough) or a serious health hazard with severe acute respiratory syndrome (sars), acute cardiac injury and acute kidney injury [1, 2] , among other systemic effects described. contact frequency among individuals is known as one of the major elements affecting the spread of the disease. liu et al. estimate the basic reproduction number (r 0 ) of covid-19, a mathematical term that indicates how contagious a disease is, indicating the average number of people who will catch covid-19 from one single infected patient as 3.8 [3] . transmission from asymptomatic carriers has been demonstrated. italy has been highly affected by this pandemic since february 2020 [4] , with 173, 730 confirmed cases and 22, 586 deaths according to the data of 'istituto superiore di sanità' on 22 april 2020 [5] . in rome, the number of patients infected to date is 4257. the italian national health system is currently facing a challenge due to the high demand for intensive care assistance needed by 9-11% of covid-19 patients [6] and the lack of beds in intensive care units. therefore, remarkable efforts are spent to provide an efficacious reaction to the emergency, reorganizing the beds within the public health system hospitals to create new beds for covid-19 patients. italian hospitals have started to reduce elective activities to receive the high number of infected patients [7] , and in an endeavour to preserve normal activities, 'covid-19' and 'non-covid-19' hospitals were identified in the nhs hospital network. it only makes sense that today's focus is exclusively on the sars-cov-2, and the hospitals are primarily acting to defeat it. the coronavirus has deleted everything that can be felt superfluous and/or unnecessary. after the prime ministerial decree 09 march 2020 [8], the two leading italian plastic surgery organizations, sicpre (italian society of plastic, reconstructive and aesthetic surgery) [9] and aicpe [10] (association of aesthetic plastic surgery) provided recommendations to postpone any routine elective plastic surgery, with the exception of cancer or emergencies. most of the italian plastic surgery wards faced a reduction in beds and theatres to enable hospitals to free up healthcare staff to provide medical care for patients in other areas, given the need for a change in work organization to comply with limited outpatient clinic activities and reduced theatre availability for all hospitalization typologies and to cope with new pre-hospitalization modalities to screen up covid-19 positive patients among the ones scheduled for surgery. the aim of this comparative retrospective study is to ascertain the effects of the covid-19 pandemic on ordinary activities in two plastic surgery division in rome, italy, one in a covid-19 hospital and the other in a non-covid-19 hospital. this is a comparative retrospective study. data was collected from two plastic surgery divisions in rome, italy, of which policlinico umberto i (pu1) was set as a covid-19 hospital and san gallicano (isg) as a non-covid-19 hospital. pu1 plastic surgery department serves the faculty of medicine and dentistry at rome's sapienza university, italy, with a staff consisting of six consultants and eleven trainees. in 2019, the in-hospital ward had ten beds and five weekly theatres treating 500 patients; the day surgery ward had three beds and five weekly theatres treating 750 patients; 1610 outpatient clinic surgery operations were performed and 10. 500 outpatient consultations were carried out, of which 3.360 were referrals and 7.140 were dressing changes. isg plastic surgery department is located in a roman ircss, a biomedical institution of relevant national interest, which drives clinical assistance in strong relation to research activities. the staff is made up of nine consultants and one trainee. in 2019, the in-hospital ward had seven beds and five weekly theatres treating 341 patients; the day surgery ward had four beds and five weekly theatres treating 981 patients; 1.655 ambulatory surgery operations were performed and 9.151 outpatients received a consultation, of which 3.635 were referrals and 5.516 were dressing changes. the study analysed the data collected between 09 march (starting lockdown date in italy) and 09 april 2020 and the same period of 2019. outpatient, day surgery (ds) and inpatient (ip) medical charts were retrieved from both plastic surgery departments and the following data compared: both units sustained a decrease in workload due to the lockdown effects (fig. 1) . routine follow-up visits were suspended and replaced by phone calls where feasible, except for dressing change in recently discharged patients. only patients referred as urgent by the general practitioner were scheduled for consultation. pu1 in-patient ward capacity was reduced to 6 beds, to accomplish the 2-m social distance between beds; isg inpatient ward capacity was reduced to 4, thus accommodating one patient only in an originally double-bed room. theatre availability was reduced as well, in accordance with the work volume. outpatient clinic surgery was considerably reduced in both departments: 90% in pu1 and 80% in isg compared with the same period in 2019. in both hospitals, only melanoma was treated, excluding basal cell carcinoma and squamous cell carcinoma. in both units, visitors for day surgery patients were not allowed; for in-patients, only one visitor per room was allowed, after a thermoscan check negative for fever. all patients and visitors were required to wear a surgical mask during their permanence on the hospital grounds. consultant staff shift remained unchanged in pu1 to help in covid-19 patients care, and daily resident number was reduced to two; while in isg a restricted staff policy was adopted to limit exposures, limiting the staff on duty to two surgeons each day and resident on duty only when surgery was scheduled. from 4 march 4 2020 onwards, all patients requiring admission to both plastic surgery departments were screened 24 h prior to admission, by means of a telephone interview by a doctor from each unit, to triage a possible covid-19 infection that would contraindicate hospital admission and require treatment in the appropriate setting (table 1) . all patients in both hospitals also had to complete a preoperative health screening prior to admission, including one negative covid-19 test using the reverse transcription polymerase chain reaction on specimens from both upper respiratory tracts (nose and oropharyngeal samples), taken at least 48 h before scheduled surgery. all non-oncologic surgery was curtailed in both hospitals. when compared with the same period of 2019, 2020 witnessed a percentage decrease with regard to in-patient and outpatient procedures in both hospitals. in detail, pu1 faced a total in-patient surgery decrease of 62.90%, while at isg it amounted to 51.28%. figure 2 shows the specific variation by type of in-patient surgery and highlights the reduction in non-urgent procedures such as lipofilling, post-bariatric surgery or periorbital surgery and the increase in surgical oncology and trauma surgery. ambulatory surgery decreased by 90% at pu1 and by 80% at isg when compared with the same period in 2019. day surgery procedures decreased by 87.65% at pu1 and by 70.87% at isg. the average number of in-patient hospitalization days between 2019 and 2020 remained almost unchanged for pu1 (from 6.4 to 6.8 days) and for isg (from 2.8 to 2.5 days). overall, there is a clear decrease in welfare procedures in both hospitals, with statistically significant differences at chisquare test between the two institutes for day surgery procedures and first consultations ( table 2 ). the primary objective of this study was to ascertain if there was a qualitative and quantitative modification in the activities of plastic surgery departments caused by the covid-19 pandemic. the secondary end-point was to ascertain whether the nature of covid-19 hospital or non-covid-19 hospital the pandemic-based guidelines of state authorities in many countries stipulate that all elective procedures that could be safely delayed must be cancelled [11, 12] until the end of the pandemic, limiting the number of exposures for healthcare workers and reducing nosocomial transmission [13] . despite the national government decree, plastic surgery activities show different managements depending on the covid-19 or non-covid-19 nature of the host hospital. after this work, it is possible to ascertain that both plastic surgery departments enrolled in this study are facing an overall decrease in activities, with a substantial cut in plastic surgery cares, which normally include a wide spectrum of diseases. fig. 2 percentage change in in-patient procedures in isg and pu1, during the period 9 march-9 april 2020 and the period 9 march-9 april 2019. melanoma + sentinel lymph node biopsy (slnb) is the only increased surgery for isg, whereas skin cancer and post-traumatic surgeries are the increased procedures for pu1: post-traumatic surgery is doubled (+ 100%). in pu1, melanoma + slnb has not changed (0%). all other surgeries decreased in both hospitals (− 100% means that the procedure has not been performed) have you had shortness of breath or breathlessness over the past 15 days? have you had a loss of smell or taste , even for a short ɵme, over the past 15 days? have you had pinkeye or conjuncɵviɵs over the past 15 days? have you experienced over the last 15 days vomiɵng or diarrhea? in the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? in the past 14 days, have you been travelling outside italy? have you been tested for covid 19 ? are you in quaranɵne for covid-19? have you been diagnosed with covid-19? if yes, when? are you in contact with anyone who has been confirmed to be covid-19 posiɵve, or that are in quaranɵne for exposure to study data shows the effects of the consequence of cancellation of plastic surgery elective surgeries in both hospitals during the lockdown, when the operating theatre was available only for such urgent procedures as melanoma or melanoma and slnb removal or for post-traumatic reconstruction in pu1. these non-delayable procedures were unaffected in both hospitals, and this fact caused a relative increase in trauma surgeries and oncological figures compared with 2019. that is not due to a surge of patient population affected by these pathologies but reflects the drop in elective procedures. due to the reduced availability of operating theatres and the restricted hospital policy admission criteria, the limited numbers of staff on duty were sufficient in both hospital to cover all the activities. the data qualitative analysis showed a similar decrease in both units about in-patient and day surgery cases and a statistically significant difference in workload between the units concerning the outpatient surgery and the referrals. this reduction in health services had a higher impact in pu1, where some of the anaesthetist staff and intensive care beds were recruited for covid-19 patients. another reason for this difference is that patients requiring referrals or outpatient surgery are more apt to avoid covid-19 hospital for fear of nosocomial transmission and, accordingly, isg endured a lesser drop in these activities. procedures that are delayed until elective surgery because deemed safe include basal cell carcinoma removal, secondary breast reconstruction, post-bariatric surgery, regenerative medicine, hand surgery and electrochemotherapy for the treatment of cutaneous and non-cutaneous cancer. fuertes described the impact of covid-19 pandemic in spanish plastic surgery units on twelve plastic surgery unit across spain, investigating on different effects of the pandemic: team members schedule reduction, variation in type and number of surgical procedure, etc. [14] fuertes results are comparable to ours in respect to the drastic reduction in overall surgical procedures (in-patient and outpatient) and consults, with a prevalence of oncologic case and a postponement of elective surgical activity. in this report, one hospital only, geographically located in a mildly affected pandemic area, declared to have maintained its usual activities. staff policy reductions were applied also in spain, with effects on increase of shifts numbers per consultants. at present, 6 weeks after the lockdown began, there is no scheduled date yet to plan the return to full activities in both covid-19 and non-covid-19 hospitals, with the next national government guidelines expected on 19 may. as a result, some patients could be damaged because of an undetected worsening of a long-standing lesion while in waiting list for planned elective surgery. other surgical specialties are facing the same problem, due to the restriction in elective surgery procedures [15, 16] . emergency surgery addresses a broad spectrum of diseases of traumatic genesis or acute illness that need surgical treatment [17] . conversely, elective surgery does not mean optional surgery but identifies a procedure assigned to a pathology that is not life-threatening in the immediate term and yet can seriously harm the patient if postponed for a long time [18] . most of the procedures delayed by the plastic surgery units in this study are included in this definition. brücher et al. in a comprehensive article on pandemic surgery guidance described three surgical response phases depending on the epidemiological situation of covid-19: phase 1 with only few covid-19 patients, infection rate not in rapid increase and good availability of intensive care unit (icu) beds and ventilators; phase 2 with many covid-19 patients and limited capacity of hospital and icu resources; and phase 3 when all hospital resources are diverted to covid-19 healthcare and only life-saving operations are performed [19] . when this manuscript was drawn up, rome was in phase 2, although all of italy was declared a red zone with similar restrictions in access to healthcare. therefore, a possible bias of this study is that it can be better compared only in regions in the same phase of the pandemic, since regions in which the pandemic has had the highest numbers will be much worst and, conversely, in regions with less covid-19 patients the figures will be better. further studies are needed to evaluate the consequences of covid-19 induced healthcare limitations in this class of patients with non-urgent pathologies. this is a preliminary study that evaluates the current situation in italian plastic surgery units amid the covid-19 outbreak. the decrease in procedures has relevant economic implications not to be underestimated. we are now working on guidelines in the event of similar future scenarios since, to date, we are not able to predict the foreseeable events. covid-19-new insights on a rapidly changing epidemic clinical, laboratory and imaging features of covid-19: a systematic review and meta-analysis the reproductive number of covid-19 is higher compared to sars coronavirus covid-19: italy confirms 11 deaths as cases spread from north covid-19 and italy: what next? critical care utilization for the covid-19 outbreak in lombardy, italy: early experience and forecast during an emergency response global guidance for surgical care during the covid-19 pandemic elective surgery in the time of covid-19 minimising intrahospital transmission of covid-19: the role of social distancing agullo a current impact of covid-19 pandemic on spanish plastic surgery departments: a multi-center report safety recommendation for evaluation and surgery of the head and neck during the covid-19 pandemic maxillofacial trauma management during covid-19. multidisciplinary recommendations aast committee on severity assessment and patient outcomes. emergency general surgery: definition and estimated burden of disease how to risk-stratify elective surgery during the covid-19 pandemic? covid-19: pandemic surgery guidance publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements open access funding provided by università degli studi di roma la sapienza within the crui-care agreement.availability of data and material not applicable. authors' contributions francesca romana grippaudo conceived the presented idea, contributed to the interpretation of result and wrote the manuscript.ugo redi, gianmarco turriziani, davide marino and giuseppe d'ermo retrieved the data, contributed to the interpretation of result and designed the tables.emilia migliano and diego ribuffo contributed to the design and implementation of the study and supervised the work.all authors commented on the manuscript. code availability not applicable. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. key: cord-277803-7p1qu2rf authors: rubino, francesco; cohen, ricardo v; mingrone, geltrude; le roux, carel w; mechanick, jeffrey i; arterburn, david e; vidal, josep; alberti, george; amiel, stephanie a; batterham, rachel l; bornstein, stefan; chamseddine, ghassan; del prato, stefano; dixon, john b; eckel, robert h; hopkins, david; mcgowan, barbara m; pan, an; patel, ameet; pattou, françois; schauer, philip r; zimmet, paul z; cummings, david e title: bariatric and metabolic surgery during and after the covid-19 pandemic: dss recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery date: 2020-05-07 journal: lancet diabetes endocrinol doi: 10.1016/s2213-8587(20)30157-1 sha: doc_id: 277803 cord_uid: 7p1qu2rf the coronavirus disease 2019 pandemic is wreaking havoc on society, especially health-care systems, including disrupting bariatric and metabolic surgery. the current limitations on accessibility to non-urgent care undermine postoperative monitoring of patients who have undergone such operations. furthermore, like most elective surgery, new bariatric and metabolic procedures are being postponed worldwide during the pandemic. when the outbreak abates, a backlog of people seeking these operations will exist. hence, surgical candidates face prolonged delays of beneficial treatment. because of the progressive nature of obesity and diabetes, delaying surgery increases risks for morbidity and mortality, thus requiring strategies to mitigate harm. the risk of harm, however, varies among patients, depending on the type and severity of their comorbidities. a triaging strategy is therefore needed. the traditional weight-centric patient-selection criteria do not favour cases based on actual clinical needs. in this personal view, experts from the diabetes surgery summit consensus conference series provide guidance for the management of patients while surgery is delayed and for postoperative surveillance. we also offer a strategy to prioritise bariatric and metabolic surgery candidates on the basis of the diseases that are most likely to be ameliorated postoperatively. although our system will be particularly germane in the immediate future, it also provides a framework for long-term clinically meaningful prioritisation. bariatric surgery has been used for decades to treat patients with severe obesity. in 2016, global guidelines established through the diabetes surgery summit (dss), an international consensus conference series, formally recognised gastrointestinal surgery as a standard therapy for type 2 diabetes; this practice is known as metabolic surgery. 1 during the coronavirus disease 2019 (covid19) outbreak, under unprecedented pressure to free up inpatient capacity, and because of intraoperative risks for viral contagion among patients and staff, hospitals worldwide have been obliged to postpone most elective operations, including bariatric and metabolic surgery. increased hazards of severe covid-19 complications in patients with obesity, type 2 diabetes, or both, 2-5 further support the rationale for a pause in elective surgery during the peak of the pandemic. the return to normal services will be gradual, with surgeons competing for reduced capacity to address a backlog of elective procedures. hence, access to bariatric and metabolic surgery will continue to be constrained. given the uncertainty regarding the effects and duration of the covid-19 outbreak, combined with the progressive nature of obesity, diabetes, and related conditions, delaying bariatric and metabolic surgery could increase the risks for morbidity and mortality in surgical candidates. the risk of harm, however, is variable among individuals, depending on the type and severity of disease and their indications for bariatric and metabolic surgery. the traditional, weightcentric criteria for patient selection in bariatric surgery, which are still commonly used today, do not reflect severity of disease, 6 and they therefore cannot be used to prioritise treatment based on actual clinical needs. furthermore, physical distancing policies and continued lockdowns might limit adherence to lifestyle interventions, worsening metabolic deterioration among candidates for bariatric and metabolic surgery. additionally, reduced access to nonurgent care during the covid-19 pandemic might impede postoperative monitoring for potential surgical and nutritional complications. a clear and urgent need therefore exists for strategies to mitigate harm to patients during and after the covid-19 pandemic. these approaches should include non-surgical interventions to optimise metabolic and weight control in patients awaiting surgery, telemedicine protocols for postoperative surveillance, and use of appropriate criteria to triage surgical candidates during a foreseeable period of reduced capacity for elective surgery. to address these issues, the dss 1 organisers directed a group of international experts to assess the effect of the covid-19 pandemic on candidates for surgical treatment of obesity and type 2 diabetes. our specific aim was to develop criteria to help prioritise bariatric and metabolic surgery for when elective surgery is resumed and beyond. elective surgery refers to operations that can be planned and scheduled in advance. these procedures, however, are not optional, because they can have important, lifechanging implications. when access to elective surgery is reduced, doctors should prioritise patients with the greatest need or with a greater risk of harm from delayed treatment. in some health-care systems, elective surgery is categorised into urgent, semi-urgent, or non-urgent. 7, 8 urgent elective surgery is required within 30 days for conditions that might deteriorate quickly. semi-urgent conditions are those that, although not likely to deteriorate quickly, could reasonably cause severe pain or dysfunction or further harm if delayed beyond 3 months. non-urgent elective surgery is planned for conditions that are unlikely to cause substantial discomfort, dysfunction, or harm if treated within 1 year. although some complications from bariatric and metabolic operations can require emergency surgical treatment (eg, haemorrhage, leak, or intestinal obstruction), most bariatric and metabolic procedures represent genuine elective surgery. to date, however, no consensus exists for criteria to identify urgent, semi-urgent, or nonurgent indications in bariatric and metabolic surgery on the basis of the type and severity of patients' conditions. there are many reasons why most bariatric and metabolic operations should be suspended during the most intense phase of the covid-19 pandemic, including infection risks among patients and staff, factors inherent to the operations, and increased hazards of severe covid-19 complications among patients with obesity or type 2 diabetes. laparoscopic surgery involves aerosol-generating techniques such as carbon dioxide, pneumoperitoneum, electro cautery, and ultrasonic shearing. these techniques could easily increase the risk of viral contagion for staff, 9, 10 including with severe acute respiratory syndrome coronavirus 2 (sars-cov-2). upper gastrointestinal endoscopy (another aerosol-producing procedure) is also commonly done before bariatric and metabolic surgery. patients undergoing major surgery are at risk of lifethreatening inflammatory complications such as infection (including from viruses), the systemic inflammatory response syndrome, and sepsis. 11 although there is no conclusive evidence that laparoscopy or upper endoscopy can promote covid-19 transmission, postponing elective metabolic and bariatric interventions during the acute phase of the covid-19 outbreak seems sensible, except for urgent revisional surgery or emergency endoscopic interventions for complications (eg, haemorrhage, stoma stenosis, or leaks). despite the potential for a higher risk of contagion, the laparoscopic approach in bariatric and metabolic surgery is associated with substantial benefits compared with traditional open surgery, especially in patients with severe obesity. these benefits include lower rates of mortality and complications (including pulmonary and procedural), and shorter hospital stays. 12, 13 for these reasons, laparoscopic access should remain the preferred approach over open techniques when elective bariatric and metabolic surgery resumes. appropriate personal protective equipment should be used, however, given the increased risk of sars-cov-2 infection for staff. obesity increases the risk of complications from viral respiratory infections. during the 2009 influenza h1n1 pandemic in california, 91% of people who died had obesity, and higher bmi was associated with mortality. 14 in patients admitted to intensive care for sars-cov-2, class 2-3 obesity (bmi >35 kg/m²) is an independent risk factor for disease severity. 5 similarly, patients with diabetes have augmented risk for severe covid-19 and mortality. [2] [3] [4] [5] several mechanisms have been suggested to increase the risk of complications from viral infections in obesity and type 2 diabetes, including low-grade chronic inflammation with overproduction of proinflammatory cytokines, reduced natural killer cell number and activity, and impaired antigen-stimulation responses. [15] [16] [17] another factor that might have a role in the relationship between obesity, diabetes, and increased risk for complications is that sars-cov-2 enters host cells by binding to the angiotensinconverting-enzyme 2 (ace2) receptor. ace2 transforms angiotensin 2 to angiotensin, 14-20 thereby reducing vaso constriction, sodium retention, inflammation, and metabolic degeneration. 21 chronic hyperglycaemia down regulates ace2 expression, 22 and further reduction of ace2 during covid-19 infection could contribute to hyperinflammation and respiratory failure in patients with type 2 diabetes. 23 people with obesity are also prone to hypoventilation syndrome, cardiovascular disease, 24 heart failure, 25 and other conditions that could increase the risk of covid-19 mortality. when elective bariatric and metabolic surgery resumes, the pandemic will be contained, but sars-cov-2 will probably still circulate in the population. given the risks of severe complications from covid-19 in patients with obesity and type 2 diabetes, we recommend that covid-19 screening should be mandatory preoperatively for patients considering bariatric and metabolic surgery. class 2-3 obesity and type 2 diabetes, the most common indications for bariatric and metabolic surgery, are associated with reduced quality of life and increased morbidity and mortality. their ability to cause lifethreatening complications, however, varies depending on the severity or stage of disease and the burden of comorbidities. the degree of harm from delaying metabolic and bariatric surgery depends on each patient's condition, the surgical efficacy at different stages of disease, and the availability and effectiveness of nonsurgical therapies to control disease progression while awaiting surgery. understanding the prognostic factors of morbidity and mortality in obesity and type 2 diabetes can help to define criteria for surgical prioritisation. diabetes is a major cause of morbidity and death, including from cardiovascular, renal, neurological, and retinal complications. approximately two-thirds of people with diabetes die of cardiovascular disease, with a relative risk 1·8-2·6 times greater than in people without diabetes. 26 the biological progression of type 2 diabetes, characterised by declining β-cell function and continuing insulin resistance, is manifested clinically by deteriorations in multiple parameters, including hba 1c , fasting, and postprandial glucose levels. the uk prospective diabetes study 27 reported significant associations between hyperglycaemia and development of diabetes complications or death, and a 21% risk reduction for any diabetes-related endpoint with each 1% absolute hba 1c reduction. factors beyond hyperglycaemia can also influence type 2 diabetes prognosis. in the triad study, 28, 29 predictors of all-cause mortality at 4 years and 8 years of study follow-up included older age, male sex, non-hispanic white race, lower education and income, longer duration of diabetes, lower bmi, hypertension, macrovascular disease, retinopathy, nephropathy, and neuropathy. among the specific predictors of cardiovascular mortality were also treatment with insulin (with or without oral medication), higher ldl cholesterol, history of nephropathy, transient ischaemic attack, stroke, angina, myocardial infarction, coronary artery and peripheral vascular disease, and use of antihypertensive or cholesterol-lowering medications. obesity increases the risks of many other illnesses, including diabetes, hypertension, dyslipidaemia, liver disease, coronary artery and cerebrovascular disease, many cancers, cholelithiasis, infertility, psychosocial dys function, osteoarthritis, chronic kidney disease, and now also covid-19. together, these complications power fully reduce quality of life and exacerbate obesity-associated mortality. even before covid-19, obesity reduced life expectancy by 5-20 years. 30 notably, higher all-cause mortality is associated with obesity class 2 (bmi 35-39·9 kg/m²) and 3 (bmi ≥40 kg/m²), corresponding to candidates for bariatric surgery, but not with class 1 obesity (bmi 30-34·9 kg/m²). 31 obesity hypoventilation syndrome and obesity-associated heart failure substantially increase mortality. obesity hypoventilation syndrome represents the combination of obesity and chronic daytime hypercapnia. 32, 33 the prevalence of obesity hypoventilation syndrome is highest among patients with a bmi of more than 50 kg/m². 34 mortality from untreated obesity hypoventilation syndrome can be as high as 24% at 1·5-2 years after diagnosis. 35 obesity heart failure is associated with increased mortality, and for each 5-unit increase in bmi, heart failure-related mortality increases by 1·4 times. 36 since bmi alone does not reflect obesity-related mortality and morbidity, staging systems such as the king's obesity criteria 37 and edmonton obesity staging system (eoss) 38 have been developed to assess individual patients' risk on the basis of evidence of subclinical, established, or endstage comorbidities. 39 retrospective application of eoss to data from the national health and nutrition examination survey showed that patients in stages 2-4 of eoss have increased all-cause mortality compared with stages 0 or 1. this finding supports the idea that the presence, type, and severity of obesity-related complications, in addition to bmi, 39 should inform decision making about the prioritisation of treatment, especially surgery. non-alcoholic fatty liver disease is characterised by excess hepatic fat. its more aggressive form, non-alcoholic steatohepatitis, includes hepatocyte injury, inflammation, and fibrosis. [40] [41] [42] these two conditions affect 20-25% of the western population, with rates rising worldwide. 40,43 66% of patients with obesity and diabetes have non-alcoholic fatty liver disease or non-alcoholic steatohepatitis. 44, 45 non-alcoholic steatohepatitis can lead to cirrhosis (in 15-20% of cases), liver failure, or hepatocellular carcinoma. 46 beyond liver-related mortality, non-alcoholic steatohepatitis can substantially increase microvascular and macrovascular complications, and cardiovascular mortality in patients with obesity and type 2 diabetes. [40] [41] [42] [43] 47, 48 non-randomised trials suggest that roux-en-y gastric bypass resolves the histological features of non-alcoholic steatohepatitis in up to 80% of patients. 49, 50 randomised clinical trials and observational studies show that in patients with all classes of obesity, bariatric and metabolic surgery promotes greater long-term weight loss than the best available non-surgical interventions, regardless of the operation chosen. 47, [51] [52] [53] multiple obser vational studies also indicate that bariatric and metabolic surgery lowers long-term risk of all-cause mortality compared with matched non-surgical patients. [54] [55] [56] [57] [58] [59] data from eight observational studies involving a total of 635 642 patients suggest that bariatric and metabolic surgery is associated with a reduced risk of all types of cancer (odds ratio [or]=0·72; 95% ci 0·59-0·87) and obesity-associated cancer (or=0·55; 95% ci 0·31-0·96). [60] [61] [62] without exception, each of the 29 all-cause mortality studies published to date shows that patients who have bariatric and metabolic surgery live longer than matched nonsurgical controls. 54-59,63,64 concerning type 2 diabetes, at least 12 randomised controlled trials comparing bariatric and metabolic surgery with conventional diabetes therapies (ie, lifestyle plus medication) in patients with type 2 diabetes show that surgery is superior for control of hyperglycaemia, reduction of cardiovascular and overall mortality risk, improvement in quality of life, and reduction in risk of renal complications. 1, 65, 66 the safety of bariatric and metabolic surgery compares favourably with that of most elective operations, including hysterectomy, chole cystectomy, and knee replacement. surgical treatments for diabetes are highly cost-effective, with the cost per quality-adjusted lifeyear ranging between us$3200 and $13 000. 1, 65, 67 based on this evidence, dss guidelines, which have been formally endorsed by 56 worldwide medical or scientific organisations and recognised by payers worldwide, recommend the consideration of bariatric and metabolic surgery for appropriate candidates (including those with only class 1 obesity), who do not achieve adequate glycaemic control with medical therapy. 1 the delay of bariatric and metabolic surgery that is occurring due to covid-19 will augment the burden of disease among surgical candidates. this increase will particularly affect patients with type 2 diabetes, given that metabolic surgery causes remission of hyperglycaemia in most cases. 65 the likelihood of hyperglycaemia remission, however, depends upon how soon an operation is done during the natural history of diabetes. algorithms designed to predict surgical remission (eg, diarem-2, ad-diarem, diabetter, and abcd) [68] [69] [70] [71] consistently show that longstanding disease is one of the most powerful indicators of failure to achieve this benefit. 72 remission rates drop off notably after 10 years of diabetes. moreover, the sos study 73 reported substantially lower type 2 diabetes remission among patients with only 4 years of known disease than in those with 2 years of known disease. thus, delaying metabolic surgery reduces the chances of diabetes remission. delayed metabolic surgery might cause even greater harm to patients with type 2 diabetes who are at higher risk of microvascular and macrovascular complications and mortality, especially when medications and lifestyle interventions are not achieving adequate metabolic control. patients without diabetes but with severe respiratory (obesity hypoventilation syndrome), cardiac, or renal complications of obesity, and individuals for whom weight reduction is crucial to advancing time-sensitive and life-saving treatments (eg, organ transplants) also have greater risks of harm from delaying bariatric and metabolic surgery. patients with surgically remediable metabolic diseases, especially diabetes, incur more health-care costs per day than do those without these conditions. all studies that compared costs for 1-5 years between surgical and non-surgical patients found that pharmacy expenses decrease substantially after bariatric and metabolic surgery compared with matched non-surgical patients, [74] [75] [76] [77] 78 primarily due to lower diabetes medication costs. 69 hence, metabolic surgery decreases daily health-care costs, especially for patients requiring multidrug therapy. the longer surgery is delayed for these patients, the less costsaving it becomes. various non-surgical options can be used to mitigate the harm from delaying bariatric and metabolic surgery and to manage patients who have had surgery (panel 1). regarding the need to optimise glycaemic control in patients with type 2 diabetes, especially those with advanced microvascular or macrovascular complications, 79 we considered available evidence of pharmacological strategies that promote weight loss, such as glucagon-like peptide-1 receptor agonists (glp-1ra) or sodium/glucose cotransporter 2 (sglt-2) inhibitors, or both. 80 glp-1ras reduce hba 1c by about 1% 81 while promoting clinically relevant weight loss. 82 sglt-2 inhibitors, however, might be contraindicated with covid-19, because of concerns about potential subclinical vascular congestion and risk of acute metabolic decompensation associated with these drugs. 83 we also considered available data regarding the efficacy of dietary or pharmacological interventions for weight loss, 84, [85] [86] [87] [88] or both, as a strategy to achieve weight loss or weight maintenance in patients with multiple weightresponsive comorbidities who face prolonged waiting times for bariatric and metabolic surgery. regarding strategies to maximise surgical outcomes in patients who have already had surgery, our recommendations are based on results from studies investigating the efficacy of pharmacological approaches in people with persistent or recurrent type 2 diabetes after surgery. among these individuals, a recent study 89 showed that the glp-1ra liraglutide can reduce hba 1c by 1·2%, with up to 5% additional weight loss. we reviewed existing evidencebased recommendations for postoperative nutritional care 79 to define safe and pragmatic methods of virtual consultation by telemedicine (panel 1). even before the covid-19 pandemic, metabolic and bariatric surgery was underused for many reasons, including misconceptions and stigma about obesity and bariatric surgery. 90 such barriers might further penalise candidates for this surgery in times of limited resources. given the seriousness of the diseases that require metabolic and bariatric surgery, clinicians, hospital managers, and policy makers should ensure that these operations are not further delayed because of the widespread misconception that they are a last resort. 90 eventually, the covid-19 crisis will abate, and elective operations will resume, leaving an enormous backlog of patients who would benefit from bariatric and metabolic surgery. how should we prioritise whom to serve first with limited resources? at a broad level, the answer is simple. if patients are well enough to be safe surgical candidates, preference should be afforded to those with the greatest risk of morbidity and mortality from their disease, if it is probable that this risk can be reduced by surgery. this logic would apply, for instance, to many surgical candidates with poorly controlled type 2 diabetes or substantial metabolic, respiratory, or cardiovascular disease. traditional bmi-centric criteria for patient selection, however, tend to skew access to bariatric and metabolic surgery in the opposite direction. despite strong evidence that surgery achieves its greatest health benefits among patients with type 2 diabetes, a minority of those who have such operations have preoperative type 2 diabetes or cardiometabolic disease. 91 furthermore, in many publicly funded health-care systems (eg, uk national health service), candidates for bariatric and metabolic surgery are currently placed on a single elective surgery waiting list, regardless of their indication. priority is established largely on a first-come first-served basis, rather than on non-surgical options to mitigate harm from delaying surgery • glycaemic control should be optimised in patients awaiting metabolic surgery for type 2 diabetes, especially for those with advanced microvascular or macrovascular complications; this is desirable to prepare for surgery and also in case of severe acute respiratory syndrome coronavirus 2 infection • in patients who do not achieve glycaemic targets with lifestyle modifications and metformin, the addition of a glucagon-like peptide-1 receptor agonist (glp-1ra) or sodium/glucose cotransporter 2 (sglt-2) inhibitor, or both, can advance the combined goals of improving metabolic control and causing weight loss or limiting weight gain; use of sglt-2 inhibitors, however, is not recommended in the case of acute coronavirus disease 2019 (covid-19) infection because of concerns about potential subclinical vascular congestion and risk of acute metabolic decompensation associated with these drugs • for patients with multiple weight-responsive comorbidities who face prolonged waiting times for surgery, dietary or pharmacological interventions for weight control might become necessary • diets with higher protein content and lower glycaemic index can be effective and should be considered • among patients already taking weight-loss medications, efforts should be made to continue the drug(s) until surgery is scheduled, since rapid weight regain is predictable when they are discontinued • in countries where weight-loss medications (eg, phentermine, orlistat, glp-1ras, naltrexone-bupropion, and phenterminetopiramate) are accessible, clinicians could consider their use when weight loss or weight maintenance is important, such as for patients with multiple weight-responsive comorbidities • telemedicine strategies that are supervised by specialist bariatric and metabolic surgery providers should be used • in people with persistent or recurrent type 2 diabetes after surgery, weight-reducing diabetes medications (eg, glp-1ras) should be considered; weight maintenance should also be encouraged in patients with type 2 diabetes remission to mitigate risk of disease recurrence • there is insufficient evidence to justify deviations from current evidence-based recommendations for postoperative nutritional care in patients who have had bariatric and metabolic surgery • to minimise risk of nutrition-related complications, providers should engage with patients at the same intervals as in current guidelines • clinical signs (eg, weight, visual changes, rash, weakness, oedema or anasarca, and neuropsychiatric signs), and symptoms (eg, nausea, tingling, bowel-habit changes, and fatigue) of nutritional deficiency must be assessed during virtual clinic sessions • routine laboratory tests (eg, albumin, thiamine, b12, vitamin a, vitamin d, iron, and calcium) should not be deferred but obtained at standard intervals, particularly for patients who had operations with greater risk of nutrient malabsorption, such as long-limb diversionary procedures • urgent face-to-face meetings and laboratory tests are mandated when symptoms suggest severe biochemical deficiencies or surgical complications (eg, intestinal obstruction or acute cholecystitis) • misconceptions and stigma about obesity and bariatric and metabolic surgery might further penalise candidates for surgical treatment of obesity and diabetes in times of limited resources; clinicians, policy makers, and hospital managers should recognise the seriousness of the diseases that require metabolic and bariatric surgery and ensure that these operations are not further delayed • given the risks of severe complications from covid-19 in patients with obesity and type 2 diabetes, covid-19 screening should be mandatory preoperatively for patients considering bariatric and metabolic surgery • despite the potential higher risk of contagion for staff, the risk and benefit of a laparoscopic approach remain favourable for patients and should be preferred over the use of open techniques • appropriate personal protective equipment should be used as recommended by professional bodies and public health agencies to minimise risk for staff and operators clinical need. this approach is comparable to putting all colorectal surgery candidates on the same waiting list with similar priority, regardless of whether their diagnosis is cancer or benign neoplasia. a strong need therefore exists for clinically sound criteria to help prioritise access to surgery in times of pandemics with limited resources. these criteria can also inform future waiting list management and decision making about the structure of surgical services. the prioritisation of any elective operation should seek to facilitate access according to clinical need, maximise equity of access, and minimise the harm from delayed access. we have adapted previous categorisations of elective surgery 7 to define an objective prioritisation system reflecting these principles for bariatric and meta bolic operations (panel 2; figure) . given the factors contributing to morbidity and mortality in obesity and type 2 diabetes, surgical prioritisation should be based on disease-specific consider ations. for patients with type 2 diabetes, we suggest that surgery be prioritised for patients at increased risk of morbidity and mortality. this risk would be indicated by poor glycaemic control despite maximal medical therapy, use of insulin, previous cardiovascular disease, albuminuria and chronic kidney disease, non-alcoholic steatohepatitis, or multiple cardio metabolic comorbidities. 28 insulin use is a meaningful prioritisation criterion because it correlates with increased cardiovascular mortality 28 and reduced quality of life. 92 moreover, metabolic surgery reduces or abolishes the figure: examples of conditions that warrant expedited access to bariatric and metabolic surgery aha=american heart association. the severity of obesity-associated symptoms (eg, mobility issues or joint pain as a consequence of extremely high bmi, regardless of comorbidities) must also be considered when establishing priorities. equally important is the effect of obesity-related conditions that increase morbidity and mortality (eg, obesity hypo ventilation syndrome, chronic kidney disease, or severe obstructive sleep apnoea). 38 the availability of non-surgical options that slow disease progression (ie, pharmacological diabetes treatments achieving adequate glycaemic control) reduces need for prior itisation. expedited access to surgery should also be considered when bariatric and metabolic operations are used as adjuvant therapy to enable other time-sensitive treatments that are made unfeasible or unsafe by excess weight, poor metabolic control, or both (figure). many candidates for bariatric and metabolic surgery are at high risk of morbidity and mortality from comorbid conditions. for these patients, access to surgical treatment should be prioritised on the basis of disease-focused clinical needs, rather than primarily on bmi, to mitigate harm from delaying surgery. this approach is especially needed in periods in which access to surgery is reduced, as in the current covid-19 pandemic. societal crises often spur developments that provide benefits long after the storm passes. disease-oriented, medically meaningful strategies to triage patients seeking metabolic surgery after the covid-19 crisis should help prioritise patients in more urgent need, both now and long into the future. fr conceived the idea for this initiative. fr, rvc, gm, cwr, jim, dea, jv, and dec reviewed relevant medical literature and prepared the first draft of this report. ga, saa, rlb, sb, gc, sdp, jbd, rhe, dh, bmm, apan, apat, fp, prs, and pzz provided additional input in the appraisal of evidence and in manuscript preparation. all co-authors participated in the development of the recommendations and reviewed and approved this report. we did a rapid narrative literature review for this personal view. for references about the effect of viral infections including coronavirus disease 2019 (covid-19) on diabetes, obesity, and laparoscopic surgery, we searched pubmed for articles in english published between jan 1, 2002, and april 10, 2020. we used combinations of terms such as "sars", "h1n1", "coronavirus", "covid-19", "sars-cov-2", "diabetes", "obesity", "bmi" "laparoscopy", "endoscopy", "severe acute respiratory syndrome", "acute respiratory distress syndrome", and "co-morbidities". we also reviewed recent guidelines from professional organisations and public health agencies about elective surgery and the covid-19 pandemic. for evidence about the benefits of bariatric and metabolic surgery, the predicting factors of morbidity and mortality from type 2 diabetes, obesity, non-alcoholic fatty liver disease, and non-alcoholic steatohepatitis, and the classification of elective surgery, we reviewed recently published systematic reviews and consensus statements by major scientific societies and relevant individual articles cited in these documents. members of the expert panel were selected on the basis of their previous participation in the diabetes surgery summit series and their relevant expertise. additional experts were also invited to join the group and provide complementary expertise or ensure global representation, or both. a subgroup of the expert panel did a first appraisal of the evidence and draft recommendations, and they generated the first draft of the report, synthetising the literature review in response to each specific query. the entire expert group then engaged in online discussion to further appraise the evidence and refine the final consensus recommendations. 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mortality among patients with diabetes: the translating research into action for diabetes (triad) study years of life lost due to obesity morbidity and mortality associated with obesity prevalence and ethnicity of sleep-disordered breathing and obesity in children adiposity in relation to age as predictor of severity of sleep apnea in children with snoring obesity-associated hypoventilation in hospitalized patients: prevalence, effects, and outcome combining risk estimates from observational studies with different exposure cutpoints: a meta-analysis on body mass index and diabetes type 2 body mass index, abdominal fatness, and heart failure incidence and mortality: a systematic review and dose-response meta-analysos of prospective studies emerging concepts in the medical and surgical treatment of obesity using the edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity edmonton obesity staging system: association 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control of hemoglobin a1c, ldl cholesterol, and systolic blood pressure at 5 years in the diabetes surgery study bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial clinical and patient-centered outcomes in obese patients with type 2 diabetes 3 years after randomization to rouxen-y gastric bypass surgery versus intensive lifestyle management: the slimm-t2d study survival among high-risk patients after bariatric surgery a simple prediction rule for all-cause mortality in a cohort eligible for bariatric surgery long-term mortality after gastric bypass surgery long-term mortality rates (>8-year) improve as compared to the general and obese population following bariatric surgery survival and changes in comorbidities after bariatric surgery predictors of long-term mortality after bariatric surgery performed in veterans affairs medical centers cancer risk 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diabetter scores the advanced-diarem score improves prediction of diabetes remission 1 year post-roux-en-y gastric bypass preoperative prediction of type 2 diabetes remission after roux-en-y gastric bypass surgery: a retrospective cohort study validating risk prediction models of diabetes remission after sleeve gastrectomy incidence and remission of type 2 diabetes in relation to degree of obesity at baseline and 2 year weight change: the swedish obese subjects (sos) study health care use during 20 years following bariatric surgery impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data the business case for bariatric surgery revisited: a non-randomized case-control study long-term expenditures associated with bariatric surgery in va association between bariatric surgery and long-term health care expenditures among veterans with severe obesity clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2020 efficacy and safety of sodium-glucose cotransporter 2 inhibitors (sglt-2is) and glucagon-like peptide-1 receptor agonists (glp-1ras) in patients with type 2 diabetes: a systematic review and network meta-analysis study protocol semaglutide induces weight loss in subjects with type 2 diabetes regardless of baseline bmi or gastrointestinal adverse events in the sustain 1 to 5 trials consensus recommendations for the management of diabetes in patients with covid-19 diets with high or low protein content and glycemic index for weight-loss maintenance two-year sustained weight loss and metabolic benefits with controlled-release phentermine/ topiramate in obese and overweight adults (sequel): a randomized, placebo-controlled, phase 3 extension study weight loss with naltrexone sr/bupropion sr combination therapy as an adjunct to behavior modification: the cor-bmod trial xenical in the prevention of diabetes in obese subjects (xendos) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial adjunctive liraglutide treatment in patients with persistent or recurrent type 2 diabetes after metabolic surgery (gravitas): a randomised, double-blind, placebo-controlled trial joint international consensus statement for ending stigma of obesity bariatric, metabolic, and diabetes surgery: what's in a name? related factors of quality of life of type 2 diabetes patients: a systematic review and meta-analysis effect of laparoscopic roux-en y gastric bypass on type 2 diabetes mellitus key: cord-287376-wxldnlih authors: krüger, colin m.; kramer, axel; türler, andreas; riediger, hartwig title: can surgery follow the dictates of the pandemic “keep your distance”? requirements with covid-19 for hygiene, resources and the team date: 2020-08-03 journal: gms hyg infect control doi: 10.3205/dgkh000354 sha: doc_id: 287376 cord_uid: wxldnlih since the beginning of the pandemic, there have been restrictions in the daily care of surgical patients – both elective and emergency. readying supply capacities and establishing isolation areas and areas for suspected cases in the clinics have led to keeping beds free for treating (suspected) covid-19 cases. it was therefore necessary to temporarily postpone elective surgery. now, elective care can be gradually resumed with the second phase of the pandemic in germany. however, it remains the order of the day to adapt pre-, intraand post-operative procedures to the new covid-19 conditions while maintaining specialized hygiene measures. this concerns the correct procedure for the use of personal protective materials as well as process adjustment for parallel treatment of positive and negative patients in the central or, and handling of aerosols in the operating theater, operating room, and surgical site under consideration of staff and patient protection. although dealing with surgical smoke in the operating theater has long been criticized, covid-19 is forcing a renaissance in this area. finally, the choice of surgical method, whether open surgery or minimally invasive procedures, is critical in determining how many colleagues are exposed to the risk of infection from covid-19 patients, sometimes for hours. here, robot-assisted surgery can comply with the pandemic’s requirement to “keep your distance” in a unique way, since the surgeon can operate at virtually any distance from the surgical site, at least with regard to aerosol formation and exposure. mit beginn der pandemie hat es einschränkungen in der täglichen versorgung chirurgischer patienten -elektiv ebenso wie im notfallgegeben. bereitstellung von versorgungskapazitäten und die einrichtung von isolations-und verdachtsbereichen in den kliniken haben dazu geführt, bettenkapazitäten freizustellen. damit war es erforderlich, temporär eingriffe der elektiven versorgung zurückzustellen. mit eintreten in die zweite phase der pandemie in deutschland kann schrittweise die elektivversorgung wieder aufgenommen werden. es bleibt jedoch gebot der stunde, unter vorhaltung spezialisierter hygienemaßnahmen die chirurgischen abläufe prä-, intra-und postoperativ an die gegebenheiten unter covid-19 anzupassen. das betrifft den ablauf bei der verwendung persönlicher schutzausrüstung wie auch die prozessanpassung bei der parallelen versorgung covid-19-positiver und -negativer patienten in einem zentral-op, den umgang mit aerosolen im op-trakt, with the beginning of the covid-19 pandemic, fundamental changes have taken place in medical care in germany and globally. the preventive, containment, and medical requirements are fundamentally the same, but are being implemented to varying degrees due to different resources of individual countries. since the outbreak of the pandemic in november 2019 in china, the understanding of preventive measures has been steadily growing. the german healthcare system has had time to draw conclusions from the findings in china, but also elsewhere in europe, especially italy and spain. there were two central factors in the german hospital landscape that led to the restrictions described below: first, the call by the german federal ministry of health to substantially increase the number of intensive care beds which would allow invasive ventilation of patients by temporarily postponing elective procedures; and second, the shortage of personal protective equipment (ppe), which is mainly produced in china, that accompanied the beginning of the pandemic. while the problem of ppe procurement was centrally organized by the federal and state governments, each hospital had to secure intensive care resources by reassigning or recruiting personnel to adequately staff isolation areas and icus. part of the new intensive care personnel to be recruited came from the surgical staff, which consequently immediately reduced daily operatingtheater capacity. in addition, inpatient capacities had to be reallocated to create covid-19 isolation and pre-isolation areas to protect the wards. for the surgical department, this meant the immediate suspension of elective surgical procedures. in the recommendations of 24 april 2020, the dgav (german society of general and visceral surgery) compiled a list of diseases that could be considered as indications for urgent surgery [1] . the federal ministry of health has not yet issued a uniform, binding and nationwide guideline for the surgical departments. since then, the following needs have arisen for the surgical clinics: 1. definition of the range of surgical procedures to be continued 2. creation and management of patient waiting lists 3. surgical patient care with reduced intensive care and inpatient bed capacity 4. establishment of care structures for covid-19 patients (including suspected cases) in the operating theater 5. maintaining training and education in the pandemic situation the definition of the range of interventions to be continued has recently been amended. the federal minister of health, with his publication of the fact paper on the new daily routine for hospitals of 27 april 2020 [2], cleared the way for the resumption elective surgery (see no. 1, above). the administration of patient lists generated to date will thus be highly influenced by the regional implementation of this regulation by the states, as well as by the expected renewed increase in the number of newly infected and sick patients after the relaxation of protective measures (see no. 2, above). a bottleneck in the near future will be the intensive care capacity for elective surgery patients. the newly created intensive care capacities will be generated in particular by the nursing staff reassigned from peripheral care areas, which will be able to help out in the intensive care area if necessary after intensive training in recent weeks. since we were already confronted with the much-discussed shortage of nurses in germany before the pandemic, the clinics have been forced to reduce the number of inpatient beds or, if necessary, to carry out short-term personnel rescheduling. this does not increase planning security for patients who require intensive medical monitoring and care in the early post-operative phase (see no. 3, above). if the establishment of a care structure for covid-19 patients (pa-cov19) is successful, it would facilitate the rapid return to a well-organized operative care. comparable to the establishment of isolation and pre-isolation areas in the ward block, this requires parallel structures in the operating theater in order to safely care for pa-cov19 and guarantee human and material resources for the duration of the pandemic. the spatial and building technology situation is usually set. because very few clinics have spatially separate surgical units for pa-cov19 and non-pa-cov19, the analysis below begins with the inward transfer into the operating theatre and ends with the outward transfer. the hygiene requirements of the pandemic regulation in germany mean that central areas of the or tract, such as induction areas and recovery rooms, must not be used simultaneously by pa-cov19 and non-pa-cov19. as a result, in addition to its primary function, the operating theatre should also be used for the induction of surgery and for the phase of early post-operative monitoring. the path of pa-cov19 in the or tract is thus reduced to the operating room with direct insertion. anaesthesia preparation, induction and discharge are performed in the closed or. the operating room functions as a recovery room for the patient. postoperatively, the pa-cov19 is transferred to the isolation area of the intensive care unit or directly to the pre-iso ward in suspected cases or to the isolation ward if sars-cov-2 is detected. sars-cov-2 is transmitted by droplet infection. aerosols from infected carriers pose a particular risk. however, aerogenic spread also takes place. the problem is that testing by deep throat swabbing during the incubation period (2-14 days) [3] may be negative, although the carrier is already infectious. as a result of replication in the throat area, the virus thus also reaches the upper and lower gastrointestinal tract, which means that fluids from these areas can also be considered infectious during surgery. suspected cases of covid-19 and confirmed positive patients must be treated equally in the operating theatre. the hazard for the staff in the or is defined by contact with patient-related aerosols. in accordance with the regulations of din 1946-4:2018-09 (room air technology -part 4 [4], tab. 1 item 5.1: infectious patients), the following ventilation requirements exist for the space in the intensive care unit: staff and third parties must be protected from infectious patients (e.g., patients with multi-resistant tuberculosis). here, the technical requirements for room air requirements apply: patient rooms with supply and exhaust air and negative air balance to the airlock; airlock with negative air balance to adjacent corridors. as a result, these ventilation requirements must be implemented in the pre-, peri-, intra-and post-operative treatment process for infectious patients in whom aerosol formation is to be expected during treatment. ideally, the room air-conditioning system (rats) in the operating theater can be switched to negative pressure. this ensures that no viruses from the or are able to escape into neighboring rooms. since opened doors immediately interrupt the negative pressure, air is exchanged with the environment during door opening. therefore, the doors must be kept closed during surgery. when switching to negative pressure, it is recommended that the surgical field be flushed antiseptically before the surgical suture is applied, in order to kill pathogens originating from the room air and entering the surgical field, due to potential turbulence. with antiseptic irrigation, a reduction of postoperative wound infections can be achieved even without this additional risk factor [5] . in ors that do not allow negative pressure maintenance, the overflow technique contaminates neighbouring rooms. although contamination is lower due to the considerably higher ventilation flow in class 1a (laf, laminar air flow) operating theaters than in air from mixed-ventilation operating theaters (class 1b). however, since sars-cov-2 can survive in room air as an aerosol for 16 hours [6] , there is a risk of infection during this period. operating theaters with laf have a considerably larger ventilation volume flow than operating theaters with mixed ventilation (1b), which means that the aerosol dilution in the operating theatre with laf is considerably faster. in operating theatres with laf, the directional rather than merely mixing ventilation in the or area also ensures additional protection for the surgical team and the patient. due to the characteristics described above, operating theaters of room class ib are associated with a higher risk of contamination for the or team. it is questionable whether the ffp3 mask guarantees such a tight seal that the team is not endangered. in this case, secure protection of the surgical team can be achieved with overpressure bodyexhaust suits [7] . with laf, the surgical team is protected; however, due to the approximately 80-fold air change/h, adjacent rooms are contaminated with overflow technology. if, however, the air should flow directly out of the operating room, the operating theater can be used. the ppe described would be sufficient. we have created a simple control protocol for ventilation evaluation and validated it in the flue gas video test. compared to the or standard ventilation, the rats protocol for the or is adapted as follows: operating theaters or ors of room class ii with rats without sterile filters are not appropriate, for the same reason as operating theaters with turbulent mixed flow. operating theaters without an hvac are also out of the question, since there is no dilution of aerosols released and the highest aerosol concentration occurs after opening the door at the end of the operating theater. in the recommendation of the rki (robert koch institute) on hygiene measures for the treatment and care of patients with a sars-cov-2 infection as of 24 april 2020 [8] , paragraph b, supplementary measures in the clinical field/personal protection measures/personal protective equipment comprise use of ppe consisting of protective gown, disposable gloves, at least tightly fitting mouth-andnose or respiratory mask and safety goggles. in the direct care of patients with confirmed or probable covid-19, at least ffp2 masks and 2 pairs of gloves must be worn in accordance with the occupational safety regulations [9]. with the ebola outbreak, the importance of correctly putting on and taking off the ppe became obvious, in order to prevent infection when the ppe is taken off. it is recommended that staff be trained by the hygiene team to put on and take off the ppe according to a standardized trained procedure (figure 1) , which was successful established in the university medicine as well. particular attention should be paid to all activities that may be associated with aerosol formation (e.g., intubation or bronchoscopy). this means that in case of danger (suspected and confirmed covid-19 infection), everyone in the operating room must be equipped with an ffp3 mask, but at least with an ffp2 mask. the protective materials are to be used on a patient-specific basis and are to be changed from patient to patient. in the event of supply bottlenecks, the measures for reuse of protective masks described in trba 250 and abas decision 609 in the event of a pandemic can be helpful [9], [10] . due to the transmission of sars-cov-2 by aerosols from the respiratory tract, respiratory and other surgery-related aerosols must be avoided or protective measures taken to prevent their transmission to staff and patients. according to the recommendations of the rki [8] , at least one ffp2 mask should be worn in direct patient contact in the case of justified suspicion and confirmed infection with covid-19. depending on material availability, this means one ffp3 mask for daily routine in the anesthesia/high risk/intubation department, and for all others in the operating theater at least one ffp2 mask. the recommendations of the dgav from 24 april 2020 [1] suggest a mouth and nose protective mask for the rest of the or team and an ffp2 mask for the anesthesia team, which in the authors' view does not correspond to the strict interpretation of the current rki recommendations. uncertainty exists with regard to the surgically produced aerosols from mono-and bipolar cutting of tissue [11] as well as the aerosol generation during minimally invasive surgery, which are generated in the course of insufflation. no information is currently available on the infectivity of aerosol from pleural and/or peritoneal fluid. however, it is certain that viruses are detectable in the lungs and upper and lower gastrointestinal tract [12] . fecal or oral transmission is therefore not excluded, but has not yet been proven [13] . for laparoscopy and pleural minimally invasive procedures, there is at least a theoretical risk of infectious aerosols in dissecting and resecting procedures on the lungs as well as the gastrointestinal tract. in addition, sars-cov2 is detectable in the blood at a frequency of 15%, which must be taken into account when bloody aerosols are formed (e.g., in vascular corrosion or orthopedic/accident surgery). as the role of the vapors from electric cautery has not yet been clarified, this should either be avoided or an additional smoke extraction system should be used. the choice of surgical procedure should continue to be based on the principle of "primum nihil nocere". thus, the best possible procedure currently clinically established for the treatment of a disease with the least invasiveness for the patient should be chosen. the personnel in the or is to be reduced to the necessary minimum, optimally to: 1. surgeon + 1 assistant 2. anaesthesiologist + 1 anaesthesia nurse; the work of the circulating nurse in the or is delegated to the anaesthesia nurse; the circulating nurse communicates by telephone with the room team for any additional material requirements 3. ota (physician's assistant) since the risk of exposure to patient-related aerosols is considered to be highest during in-and extubation, but also during surgery directly on the patient, "keep your distance" is to be taken as given, even during the ongoing surgical procedure for everyone who is able to do so, i.e., operate at a distance. in accordance with physiological specifications in the pressure structure of the venous vascular system, insufflation pressures of 12-15 mmhg have been established as the standard in laparoscopy [14] , [15] , [16] . lower pressures of 8-10 mmhg are recommended in children and patients with premature cardiopulmonary disease and, in some studies, have been found to be superior to mechanical retraction systems [17] , [18] , [19] . insufflators of the current generation can produce these low intracavitary target pressures with good intraoperative performance. trocar sites should be kept tight by using assisting sutures or suitable trocar systems [20], [21] , [22] . modern two-lumen insufflation systems with "smoke evacuation" function and dissipative smoke filtration are preferable to others. some of these systems also include the function of directed desufflation towards the end of the operating theater. alternatively, older generations of insufflators with an established disposable smoke evac[23] , [24] with a luer-lock connection can be used to render filtered smoke evacuation. before intubation, as a pre-exposure prophylaxis, it is recommended that the oral cavity be irrigated with 1.25% aqueous pvp-iodine solution, if possible in combination with gargling. the patient is asked to rinse the oral cavity thoroughly, spit out the solution, and then gargle with fresh solution. contraindications are hyperthyroidism, autonomous adenoma of the thyroid gland, and very rarely surgery procedure there are voices -unfortunately without citable references -which proclaim the return to open surgery under covid-19 circumstances with the argumentation of less aerosol production and quicker surgery. open surgery is more personnel-intensive and requires 2 to 3, occasionally even 4 medical colleagues plus instrumental ota over the patient for the duration of surgery. the advantage is the isobaric setting in the operating field, although tissue-specific aerosols can also be generated in the operating field during electrocoagulation. in the opinion of the dgav, there is nothing fundamentally wrong with performing laparoscopy in accordance with the published recommendations of 24 april 2020, provided that the protective measures mentioned above are implemented. one advantage may be the reduced number of surgeons, which is limited to the surgeon and camera assistant in the vast majority of laparoscopic procedures. also, the involvement of the ota is usually less than in open surgery. in the past 5 years, robot-assisted surgery has established itself worldwide as a special form of laparoscopy, also in visceral surgery. currently still far from being considered a "gold standard", the evaluation is undergoing a change based on the first randomized studies of this technique comparing laparoscopy vs. robotics [25] in terms of oncological precision, reduced intraoperative blood loss, shortened inpatient intensive care stay and shortened hospital stay in various indications. while the previous path of robot-assisted surgery was often rocky, not least from an economic point of view, robot-assisted surgery obviously conforms to "keeping your distance" from the pandemic perspective. no other surgical technique in visceral and thoracic surgery is able to reduce the number of high-risk surgeons on patients in a comparable way. this applies to simple operations such as hernias on the groin or diaphragm, up to complex operations on the pancreas, stomach, esophagus and the colorectum. the "first assistant" in the operating field is occasionally needed to change instruments, to apply a suture or a compress at the situs. as a rule, the surgeon can perform the operation alone from the console, which can be placed at any distance. thus, in the discussion about acute and elective surgical interventions in the pandemic situation because of covid-19, robot-assisted surgery can demonstrate its importance in a way not previously shown. in that, even complex and intricate oncological surgical interventions can continue to be offered and performed with the highest possible safety for the patient and the surgical team, with the best possible quality. surgery must be able to be offered continuously without loss of quality for both infected and non-infected patients, even in the pandemic situation. the requirements for protective measures no longer only concern the protection of the patient, but increasingly the protection of the staff against infection by aerosols from the patient. distance to the patient and reduction of the acting persons are current imperatives. in addition, building technology adjustments must be made in the operating theater. the conversion of operating theater ventilation to negative pressure operation in accordance with the specifications for isolation rooms with air-lock operation in intensive care units must be implemented. the choice of the technical operating procedure is not influenced by the covid-19 situation and should continue to be based on the medical requirements of the illness and the respective expertise of the surgeon. laparoscopic techniques produce aerosols from the capnoperitoneum. insufflation systems with smoke evacuation and defined co 2 supply and removal are preferred. robot-assisted surgery increases the safety aspect for the surgical team, as the decentralized position of the surgeon reduces the number of people needed in the direct surgical field to one. in addition, the globally standardized robotic system available can help to quickly share surgical experience with the system in all regions affected by the pandemic and thus make the virus easy to trace, for the protection of patients and staff alike. • surgery under covid-19 conditions is the new daily routine. • the change of surgical procedures is necessary to protect patients and staff in the long term. • minimally invasive procedures, especially robotics, can be performed with fewer staff in high-risk areas. • the risk of aerosol entrainment in minimal invasive surgery can be minimized by insufflation systems with flue gas disposal. • negative pressure ventilation in the or tract while maintaining the directional ceiling to floor ventilation (with or without laminar air flow) can be easily and safely produced technically and supports the prompt, routine treatment of covid-19-affected patients in the or. krüger cm has a consulting mandate with w.o.m. world of medicine gmbh. the wife of türler a is an employee of ethicon medical gmbh. kramer a and riediger h declare that they have no competing interests. ein neuer alltag auch für den klinikbetrieb in deutschland verband pneumologischer kliniken intracavity lavage and wound irrigation for prevention of surgical site infection. cochrane database syst rev persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions surgeon personal protection: an underappreciated benefit of positive-pressure exhaust suits trba 250 biologische arbeitsstoffe im gesundheitswesen und in der wohlfahrtspflege. technische regel für biologische arbeitsstoffe mögliche maßnahmen zum ressourcen-schonenden einsatz von mundnasen-schutz (mns) und ffp-masken in einrichtungen des gesundheitswesens bei lieferengpässen im zusammenhang mit der neuartigen coronavirus-erkrankung covid-19 detection of sars-cov-2 in different types of clinical specimens surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient covid-19: gastrointestinal manifestations and potential fecal-oral transmission high flow insufflation for the maintenance of the pneumoperitoneum during bariatric surgery minim invasive ther allied technol laparoscopic cholecystectomy: instrumentation and technique carbon dioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: a randomised controlled trial physiologic changes in a small animal model for neonatal minimally invasive surgery association of laparoscopic surgeons of great britain and ireland (alsgbi) surgical guidlines during covid-19 richtlijn laparoscopie en covid-19 teil 1: klassifikation, leistungsprüfung, kennzeichnung; deutsche fassung en 1822-1:2019 [high efficiency air filters (epa, hepa and ulpa) -part 1: classification, performance testing, marking chirurgische rauchgase -gefährdungen und schutzmaßnahmen effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the rolarr randomized clinical trial prävention respiratorischer virusinfektionen durch viruzide schleimhautantiseptik bei medizinischem personal und in der bevölkerung colin.m.krueger@immanuelalbertinen.de please cite as krüger cm, kramer a, türler a, riediger h. can surgery follow the dictates of the pandemic "keep your distance"? requirements with covid-19 for hygiene, resources and the team key: cord-295216-eff02z0i authors: ahluwalia, ranbir; rocque, brandon g.; shannon, chevis n.; blount, jeffrey p. title: the impact of imposed delay in elective pediatric neurosurgery: an informed hierarchy of need in the time of mass casualty crisis date: 2020-05-20 journal: childs nerv syst doi: 10.1007/s00381-020-04671-x sha: doc_id: 295216 cord_uid: eff02z0i sars-cov-2 covid-19, coronavirus, has created unique challenges for the medical community after national guidelines called for the cancellation of all elective surgery. while there are clear cases of elective surgery (benign cranial cosmetic defect) and emergency surgery (hemorrhage, fracture, trauma, etc.), there is an unchartered middle ground in pediatric neurosurgery. children, unlike adults, have dynamic anatomy and are still developing neural networks. delaying seemingly elective surgery can affect a child’s already vulnerable health state by further impacting their neurocognitive development, neurologic functioning, and potential long-term health states. the purpose of this paper is to demonstrate that “elective” pediatric neurosurgery should be risk-stratified, and multi-institutional informed guidelines established. the covid-19 pandemic has created unique challenges for pediatric neurosurgeons. elective procedures have been postponed at virtually all major pediatric neurosurgery centers. while there has been some centralized effort in adult surgery to standardize and stratify low vs. high acuity [1] , this has not yet occurred for pediatric neurosurgery. given these new restrictions, many fields of medicine have made some general recommendations including head and neck surgery [2] , anesthesia [3] , cardiac electrophysiology [4] , and colorectal surgery [5] . while some recommendations apply to neurosurgery, particularly endoscopic sinonasal and skull base recommendations [2] , no manuscripts exist to systematically stratify risk associated with delay in common pediatric neurosurgical procedures. the purpose of this paper is to outline the risks associated with delaying elective pediatric neurosurgery. urgent cases that present an immediate threat to the patient's life or neurologic well-being (e.g., shunt malfunction, acute hematoma evacuation, tumor with hydrocephalus, empyema, spinal cord compression) are straightforward and undergo prompt surgical intervention. elective surgery is readily defined as cases that offer a negligible or minimal threat of harm to the patient if surgery is delayed for several months. examples might include skull dermoids/epidermoids, prophylactic spinal lipoma untethering operations, and some craniofacial procedures. these are similarly less challenging in the current environment. however, there are a large number of procedures which are less straightforward in which lack of prompt surgery, while not emergent, may result in neurologic harm to the patient. delaying all "elective" surgeries in this population poses health-related risks, and a review of best available evidence on harm imposed by delaying these operations is warranted. previous presentations: this abstract has not been previously presented. * ranbir ahluwalia ra16@med.fsu.edu the authors have identified a sample of pediatric neurosurgery procedures that are neither clearly emergent nor purely elective. cases considered for review include the following diagnoses/scenarios: 1. tumor recurrence without hydrocephalus 2. chiari i malformation 3. medically resistant epilepsy 4. craniosynostosis-single suture and syndromic multisuture synostosis 5. tethered spinal cord 6. brachial plexus 7. moyamoya disease a pubmed-based literature survey was conducted for manuscripts that addressed morbidity arising from delay in intervention for these diagnoses. manuscripts were prioritized on the basis of relevance of study design and evidence quality and were excluded for the following reasons: opinion paper, review paper, single case report, lack of outcomes results, or pertaining to the adult population. papers that presented outcomes from delayed surgery were included in this review. 1. tumor recurrence without hydrocephalus or symptoms of mass effect (i.e., purely radiographic recurrence): i. issues/threats with surgical delay: (a) sudden decline from hemorrhage into tumor or acute development of hydrocephalus (b) risks of dissemination or de-differentiation into higher grade lesion. supporting evidence low-grade neoplasms characteristically show slow, linear growth with a minimal risk of rapid decline from mass effect [6] . for pilocytic astrocytomas, the greatest risk is likely the development of a cystic component that may show focal accelerated growth [7] . other lesions such as craniopharyngiomas show highly variable growth patterns and often have a cystic component that may expand more rapidly to cause mass effect or obstruction [8] . another important consideration in predicting potential risk for focal mass effect is the degree of surrounding edema elicited by the tumor. this risk also correlates with tumor histology [9] . low-grade tumors such as pilocytic astrocytomas, glioneuronal tumors (dnt, ganglioglioma, etc.) and grade i gliomas typically offer a low risk for acutely developing edema [10] . high-grade pediatric lesions such as pnts, embryonal tumors, choroid plexus carcinomas, or high-grade gliomas (e.g., glioblastoma multiforme) harbor substantially greater risk for edema and secondary rapid increase in mass effect [10] . similarly, the incidence of hemorrhage into a tumor recurrence is predominantly determined by histologic diagnosis [11] . the pediatric brain tumors with the highest risk for hemorrhage include high-grade embryonal neoplasms of infancy [12] , glioblastoma [13] , and mixed malignant germ cell tumors [14] . as such, the prior histology of a recurrent lesion is the principle determinant of the acute risk for a sudden decline from hemorrhage or sudden edema. for example, donofrio et al. [15] noted thin-walled, small, and closely packed vascularization in pediatric patients with cerebellar hemorrhage from pilocytic astrocytomas 10]. white et al. [16] characterized three distinct histological subtypes which correlated with hemorrhagic events in pilocytic astrocytomas [16] . specifically, thick-walled hyalinized vessels with glomeruloid structures of vascular endothelial hyperplasia with ectatic vessels serve as a nidus for bleeds [16] . multiple studies in the literature outline the relationship between histologic features and intratumor hemorrhage [15, [17] [18] [19] [20] . pagano et al. [21] describe recurrent hemorrhage of pilocytic astrocytomas and stressed the importance of vegf for aberrant neov a s c u l a r i z a t i o n a n d h y p e r p e r m e a b i l i t y [ 2 1 ] . immunohistochemistry is now being better understood through genetic markers. as described by phoenix et al. [41] , medulloblastoma genotype highly dictates the vascular environment and hemorrhagic tendencies of tumors [22] . most recently, ishi et al. demonstrated the association of fgfr1 mutation with hemorrhagic events in low-grade pediatric gliomas [23] . i. issues/threats with surgical delay: (a) neurologic decline in upper extremities from syrinx (b) dysesthetic pain from syrinx. supporting evidence chiari i malformation has a range of clinical presentations from headaches to brainstem-related symptoms [24] . when patients are asymptomatic, the clinical course is benign overall [25, 26] . however, neurologic deficits arising secondary to syringomyelia may not be reversible with surgery. a recent practice preference survey by rocque et al. [27] of the membership of the american society of pediatric neurosurgery (aspn) demonstrated a strong preference for using presence of a syrinx regardless of symptoms in the setting of chiari i malformation as a threshold for surgery [27] . most surgical series have reported a 60-85% incidence of syrinx with cim but larger radiographic series show that only 10-15% of patients with a c1m have a syrinx [28, 29] . this suggests that patients with syrinxes are selected in surgical series. several principles emerge that are helpful in approaching the dilemma of acceptable delay challenge for an asymptomatic patient with a c1m-related syrinx: (1) the onset of neurologic symptoms from a c1m syrinx is usually insidious and gradual but can rarely be acute [30] . only a limited number of papers address acute decline from c1m related syringomyelia [28, [31] [32] [33] [34] . massimmi [35] and colleagues identified 3 patients in their center experience and then identified 38 more patients from the literature that showed acute clinical decline [35] . they concluded in 2012 that only 41 of such patients had ever been identified and concluded that sudden presentation is extremely rare [35] . however, morbidity (irreversible motor 37%, 29% respiratory failure) and mortality (20%; 14.5% cardiac arrest) were severe when it did occur [35] . almotairi and colleagues [36] observed 3 patients to acutely decline in a cohort of 65 (3/65 = 4.6%) adult patients from sweden who were followed and treated for c1m-related syrinx [36] . in this series, the patients that declined acutely demonstrated longer and wider syrinxes that extended more rostrally (above c1) than the larger group who demonstrated no acute decline [36] . the extent of tonsillar herniation did not correlate [36] . (2) the response time of a syrinx to operative decompression is unknown and appears gradual. wetjen and oldfield [37] studied 29 patients who underwent posterior fossa decompression for c1m and found a median time of 3.6 months (95%ci = 3.0-6.5 months) [37] . experienced chiari surgeons typically advocate mri imaging follow-up in 6-12 months. (3) surgical decompression has a consistently good but variable impact on syrinx. tubbs et al. [29] found that only 4 out of 285 patients with syrinx demonstrated progression after posterior fossa decompression and cranioplasty [29] . zhang and colleagues [38] demonstrated that 60% of patients who underwent posterior fossa decompression with duraplasty showed a reduction in size. less is written or available on the time course of syrinx change and the common time point for observations is 6 months. a large meta-analysis by durham and fjeld-olenec [39] that compared techniques of c1m decompression (decompression alone vs. decompression with duraplasty) demonstrated 56-87% syrinx resolution with operative decompression [39] . however, small numbers of syrinxes associated with chiari i decrease in size over time without operative intervention and some syrinxes do not change after posterior fossa. (4) recovery of neurologic symptoms from a chiari related syrinx is typically incomplete and permanent. the presence of a syrinx then represents a non-predictable risk factor for irreversible neurologic dysfunction from intrinsic chronic stress and injury to the spinal cord. sudden decline is very rare but can occur especially from minor injury [28, [31] [32] [33] [34] . thus, it appears that there is a strong preference by experienced pediatric neurosurgeons to intervene for a syrinx associated with a c1m but the supporting evidence is incomplete and imperfect. the presence of the syrinx represents a threat to stress and low-grade chronic injury to the cord. it is very uncommon for acute symptoms to develop and the response to treatment usually occurs over months. therefore, a modest delay appears of low risk but the presence of a syrinx appears to be a justifiable intervention in an environment of imposed surgical slow down due to rare but possible neurologic insult that is permanent. by convention, only children with medically resistant epilepsy (mre) are candidates for epilepsy surgery and most epilepsy surgery can be elective. there are however important criteria within the designation of mre that help stratify patients with regard to the risk associated with operative delay. these include the risk for sudden death in epilepsy (sudep), the frequency and severity of status epilepticus (including status epilepticus in sleep or eses), the overall seizure burden for the child, and the degree of medical resistance that the seizures demonstrate. issues/threats with surgical delay: (a) acute threat of catastrophic epilepsy: sudden death in epilepsy (sudep), non-reversible injury to the brain from status epilepticus, and eses (b) sub-acute/chronic impact of uncontrolled seizures: the adverse effects to normal neurologic development from prolonged seizures (c) presence of a lesion (e.g., tumor, cavernomas) (d) palliative interventions: e.g., vagus nerve stimulator implantation. medical resistance/acute threats of mre defining and characterizing medical resistance (mre): candidacy for epilepsy surgery hinges upon defining medical resistance as a failure of 2 anti-epileptic medications at proper dose to confer control of seizures. approximately one-third of patients with epilepsy will demonstrate mre. these patients are candidates for surgical intervention and the overwhelming majority can be evaluated and operated upon electively. however, an increased percentage of children have catastrophic epilepsy which is characterized by highly resistant and threatening generalized seizures. these often culminate in repeated episodes of status epilepticus and raise the risk for sudden death in epilepsy (sudep). children with congenital or acquired s t r u c t u r a l a n o m a l i e s o f t h e b r a i n s u c h a s hemimegalencephaly, holohemispheric dysplasias, hemispheric atrophy, and cystic encephalomalacia (often due to perinatal infarcts/ischemia) are more frequently found to have catastrophic epilepsy than those patients with more normal mri findings. syndromic epilepsies such as lennox-gastaut and rasmussen's encephalitis are highly resistant and associated with progressively severe and difficult to control disease. similarly recurring episodes of status epilepticus, epilepsia partialis continua, or electrical status epilepticus in sleep (eses) threaten the child's safety and neurologic development. children with malignant, threatening patterns such as these warrant an assertive, proactive approach to control and localization of their seizures. when accompanied by a structural change, these epilepsies are typically focal in onset and are amenable to surgical resection. due to the acute risk and lack of other effective strategies, surgery for these cases is often considered urgent and is justifiable and appropriate to proceed to surgery in an environment in which elective cases are suspended. there remains little doubt that uncontrolled epilepsy in children is injurious to the developing brain and adversely impacts normal neurocognitive development. the timing of epilepsy surgery is critical to achieve optimal long-term neurocognitive benefit. a retrospective study conducted by jenny et al. [40] demonstrated higher seizure-free rate in infants (89.5%) vs. children (72.9%) [40] . additionally, binary logistic regression demonstrated that younger children (less than 3 years of age) were 2.76 times more likely to achieve a seizure-free outcome compared with older children (4 to 17 years of age) [40] . furthermore, developmental outcome as assessed by loddenkemper et al. [41] using bayley scales of infant development demonstrated that younger age at time of epilepsy surgery was correlated with a higher improvement in the development quotient (correlation coefficient 0.72, p < 0.001) [41] . finally, pelliccia et al. [42] performed multivariate analysis using stepwise logistic regression to determine factors associated with seizure freedom and found a shorter duration of epilepsy to be significant (or 0.92, 95% ci 0.89-0.94; p < 0.001) [42] . lesional epilepsy represents a unique situation with regard to surgical decision-making. there are often 2 indications for intervention: (1) removal and histologic diagnosis of the lesion and (2) improved seizure control. the presence of a visible lesion in the region implicated by eeg and functional imaging to be epileptogenic markedly increases the likelihood of successful surgery. the most common etiologies for lesional epilepsies in children are ganglioneuronal tumors, cavernomas, and visible cortical dysplasias. gang liog liomas (ggs) and dy sembryoplastic neuroepithelial tumors (dnets) are low-grade brain tumors that commonly present with seizures. seizure-freedom in this group of children is critical. as demonstrated by englot et al. [43] , seizure freedom is achieved with higher success in children less than or equal to 1 year of life compared with those greater than 1 year of age (or 9.48; 95% ci, 2.26-39.66). nolan et al. [44] performed a univariate chi-squared analysis to determine factors influencing favorable prognosis in children with dnts and found shorter duration of epilepsy (p = 0.01) and younger age at surgery (p = 0.04) to be significant [44] . finally, when evaluating cognitive outcomes, earlier surgery for tumor-related epilepsy is ideal. ramantani et al. [45] conducted a retrospective review in children with glioneuronal tumors to determine factors that influenced cognitive outcomes. lower full-scale iq (fsiq) and verbal iq (vq) were related to longer duration between diagnosis and surgery, when controlled for age at epilepsy onset (fsiq r = 20.537, df = 22, p = 0.007; viq r = 20.504, df = 17, p = 0.028) [45] . the nearly uniform good outcomes from lesional resections for epilepsy along with a need for histopathologic diagnosis in many cases make a convincing case for proceeding to surgery even in the presence of initiatives to limit elective cases. (1) issues/threats with surgical delay: ii. candidacy for endoscopic techniques-typically endoscopic preferred less than 12 months iii. capacity for bony defects to fill in declines with age iv. thicker bone is more rigid and offers greater technical challenges with more bleeding, higher morbidity, and associated longer stay and higher cost. (2) supporting evidence: endoscopic techniques in craniofacial surgery are being increasingly utilized due to good outcomes, lower morbidity, costs, blood loss, and equivalent or superior aesthetic outcomes. as demonstrated by thompson et al. [46] , endoscopic treatment utilizes less blood (26% vs. 81%, p < 0.001), coagulation products (3% vs. 16%, p < 0.001), anesthesia (168 vs. 248 min %, p < 0.001), surgical duration (70 vs. 130 min %, p < 0.001), days in icu (0 vs. 2%, p < 0.001), and hospital los (2 vs. 4%, p < 0.001) [46] . however, if a child is not seen within an appropriate timeframe, endoscopic craniosynostosis repair is no longer possible. while there remains debate about the superiority of endoscopic versus open repair, it is clear that in older children, only open repair can be performed. as the skull matures, the capacity for spontaneous filling in of bony defects or gaps between bone grafts becomes reduced. under the age of 18 months, the gaps between bone grafts are largely filled with fibrous tissue and islands of cartilage. the capacity to spontaneously fill and remodel bony defects dissipates with increasing age resulting in less satisfactory results in older children. a retrospective study spanning 6 years, 44 states, and 8417 children under the age of 3 was conducted by bruce et al. [47] to determine the optimal time to surgically repair craniosynostosis. using the healthcare cost and utilization project kids' inpatient database (kid), the overall complication rate was 8.6%: 6.6% for children aged 0 to 6 months, 10.3% for patients aged 7 to 12 months, and 13.9% in children aged 12 to 36 months [47] . additionally, a multivariable logistic regression model to identify factors that increase perioperative surgical complication demonstrated age as a significant factor (or = 2.53 at 3 years vs. < 1, 95% ci 1.67-3.82) [47] . another study using the kid database showed delayed repair of craniosynostosis to be associated with longer length of stay (los) and increased cost [48] . in a sample of 3246 patients with an average age of 181 days, los directly impact mean charge and total cost [48] . when creating a regression model for factors that significantly impacted the length of stay, age was the most significant [48] . older aged children had up to a three times greater odds of a longer los [48] . syndromic multi-suture synostosis (e.g., apert, crouzon, saethre-chotzen, or cloverleaf deformity): multiple suture synostoses can give rise to brain constriction and elevated intra-cranial pressure that can be threatening to brain growth and optic nerve function. in the syndromic cases, the characteristic brachycephaly requires bi-frontal orbital advancement or distraction. the skull characteristically can be molded and reossification occurs readily until about the age of 2 years. after this, the bone is thicker, more brittle, and does not contour as readily. consequently, there is likely limited harm in delaying syndromic cases inside of 2 years of age. treatment of midface hypoplasia occurs in mid-childhood via distraction or lefort midface advancement procedures. the tethered cord syndrome (tcs) may arise from a variety of pathologic entities that share the capacity to fix the spinal cord to surrounding mesenchymal structures (e.g., bony spine or surrounding muscle and connective tissues) [49] . symptoms usually consist of pain in the back, buttocks, and legs and variable but progressive loss of neurologic function in the legs and bladder [49] . prevailing wisdom in pediatric neurosurgery is that once function is lost, it is typically not regained. thus, the critical immediate distinction in tethered cord is between symptomatic and asymptomatic tethered cord. intervention for asymptomatic tethered cord is largely prophylactic and is variably controversial depending on the underlying tethering lesion. for example, split cord malformations have a high incidence of inducing progressive neurologic decline unless repaired whereas the natural history of a low-lying spinal conus medullaris is less well established and there is significant controversy surrounding prophylactic untethering. the fundamental question is the likelihood that delay in surgery may impart a decline in neurological function. koyangi et al. [50] retrospectively described the efficacy of surgery given the natural history of tethered cord syndrome. post-operatively, 7/8 (88%) asymptomatic patients remained this way, 6/26 (23%) improved, and 15/26 (58%) patients were unchanged [50] . hoffman et al. [51] describe a similar relationship in a cohort of 97 pediatric patients. fifty-six patients presented before the age of 6 months, and 35 of these patients were neurologically intact [51] . however, of the 41 patients presenting after the age of 6 months, only 12 patients were neurologically intact [51] . surgery should be performed prior to the onset of neurologic deficits. as demonstrated by kanev et al. [52] in a cohort of 42 patients presenting with neurologic deficit, 0/42 (0%) of patients regained bladder or bowel function post-operatively [52] . a logarithmic model developed by kanev et al. using data from two series [51, 52] demonstrates that all patients would develop neurological deficits over time by 12 years of age [53] . while these studies do not provide definitive evidence of a danger with delay, they do suggest that prevention of deficit or worsening of deficits might be more successful with earlier surgery. prompt neurosurgical evaluation is necessary to determine the level of the lesion and distribution of neurological injury [54] . while the most common presentation is that of an upper plexus injury (erb's palsy) with damage occurring to the c5 and c6 roots [54] , the most serious lesion is a total plexus lesion, which involves c5, c6, c7, and c8, with or without t1 [54] . the patient will present with a flail limb and possibly horner's syndrome [54] . prevailing opinion among surgeons from multiple disciplines is that these children require urgent exploration of the brachial plexus with appropriate nerve grafts and transfers [54] . for patients with an erb's palsy, upper plexus, and pattern of lesion, there are multiple competing studies of various quality regarding the ideal time of surgery [55] [56] [57] . a recent multicenter study [58] evaluated microsurgical outcomes in children who underwent plexus reconstruction before versus after 6 months of age. in the multivariable model, accounting for horner syndrome and baseline toronto score, there was no statistical difference in outcome between the early and late surgery (ams score difference = 0.6, 95% ci = − 8.0 to 9.3, p = 0.88) [58] . in sharp contrast, total obstetric brachial plexus palsy injury requires more prompt surgical treatment and should ideally be performed around 3 months of age [59] . in a cohort of 35 patients with total obstetric brachial palsy injury, younger age at the time of surgery correlated with better functional recovery (r = − 0.356, p = 0.049), particularly with finger and thumb flexion [59] . the onset of covid-19 and the national guidance to delay elective surgery has changed the paradigms of operative pediatric neurosurgical practice. the need for social distancing and preservation, or limited availability, of personal protective equipment has resulted in widespread curtailment of elective operative procedures. during this time, it is essential to establish an informed hierarchy of need for pediatric neurosurgical cases. many pediatric neurosurgery cases are urgent and must proceed. examples include shunt obstructions, infections, post-traumatic hematomas, and myelomeningocele closures. other cases are clearly elective and results are not likely impacted by limited delays. however, there exist a significant number of pediatric neurosurgical cases for which the impact of time delay in intervention is unknown. some cases appear elective but review of published experience demonstrates that poorer outcomes or higher risk accompanies delay. an informed hierarchy of need incorporates the potential increase into adverse outcomes associated with delay as well as the imminent threat to the patient in the short term. the cases selected for this report are not comprehensive but are representative of a substantial component of elective pediatric neurosurgical practice. within these cases, there are multiple examples of how a delay in performing surgery during an optimal eligibility window is associated with more adverse effects over the life span. additional factors that should be considered include the potential for exposure of risk to the operative team. exposure risks not only center on airway control and intubation but also extend to risks associated with aerosolized particles including blood, csf, and bone. cases involving invasion into the airways and bony sinuses also carry elevated risks. examples would include anterior skull base procedures, craniofacial procedures, and evacuation of empyemas that arise from erosion through bony sinuses. presurgical covid19 screening should be implemented in areas where there is no current shortage of testing for symptomatic patients. if limited testing is available, cases in which exposure is gained endonasally should require preoperative covid19 screening. ultimately, ideal timing should be explored for all pediatric neurosurgery. however, an effort that exhaustive is outside the scope of this manuscript's purpose of creating awareness on delay of common pediatric neurosurgical procedures. for the sake of completeness, some basic recommendations can be made regarding the procedures listed. for example, craniosynostosis repair should not exceed 4 months to prevent open surgery. total obstetrical brachial plexus repair should be performed by 3 months of age to prevent neurologic deficit. additionally, asymptomatic tethered cord and chiari i malformation with syrinx should not be postponed longer than 6 months as the purpose of surgery is symptom prophylaxis. lesional epilepsy represents a more complex disease process and a case-by-case evaluation is necessary depending on seizure burden, medication use, and concurrent tumor. as the referenced literature demonstrates, there are clear transition points in childhood (1 year of age and 3 years of age) that represent important checkpoints for intervention. in sum, there are multiple levels of consideration when properly assessing the timing of surgery. imminent danger to the patient is foremost but the potential for adverse outcomes from missing an optimal time window of eligibility should also be considered. this review has demonstrated multiple examples of common pediatric neurosurgical procedures where such phenomena are observed. finally, considerations of operative team exposure and resource utilization need to be considered. proper evaluation of the timing of a pediatric neurosurgery case must extend beyond the period of an imminent threat to the patient. evaluation of a representative sample of pediatric neurosurgical cases demonstrates how adverse outcomes arise consistently when important optimum time windows of candidacy are missed. in addition, exposure risk and resource consumption in an era of scarcity must be considered to attain the best overall decision regarding the timing of pediatric neurosurgical intervention. conflict of interest the other authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. the authors have no personal or institutional financial interest in drugs, materials, or devices described in their submissions. covid-19: guidance for triage of non-emergent surgical procedures safety recommendations for evaluation and surgery of the head and neck during the covid-19 pandemic anesthesia procedure of emergency operation for patients with suspected or confirmed covid-19 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plexus injury before versus after 6 months of age: results of the multicenter treatment and outcomes of brachial plexus injury (tobi) study total obstetric brachial plexus palsy: results and strategy of microsurgical reconstruction publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-285774-hvuzxlna authors: danion, j.; donatini, g.; breque, c.; oriot, d.; richer, j. p.; faure, j. p. title: bariatric surgical simulation: evaluation in a pilot study of simlife, a new dynamic simulated body model date: 2020-07-03 journal: obes surg doi: 10.1007/s11695-020-04829-1 sha: doc_id: 285774 cord_uid: hvuzxlna background: the demand for bariatric surgery is high and so is the need for training future bariatric surgeons. bariatric surgery, as a technically demanding surgery, imposes a learning curve that may initially induce higher morbidity. in order to limit the clinical impact of this learning curve, a simulation preclinical training can be offered. the aim of the work was to assess the realism of a new cadaveric model for simulated bariatric surgery (sleeve and roux in y gastric bypass). aim: a face validation study of simlife, a new dynamic cadaveric model of simulated body for acquiring operative skills by simulation. the objectives of this study are first of all to measure the realism of this model, the satisfaction of learners, and finally the ability of this model to facilitate a learning process. methods: simlife technology is based on a fresh body (frozen/thawed) given to science associated to a patented technical module, which can provide pulsatile vascularization with simulated blood heated to 37 °c and ventilation. results: twenty-four residents and chief residents from 3 french university digestive surgery departments were enrolled in this study. based on their evaluation, the overall satisfaction of the cadaveric model was rated as 8.52, realism as 8.91, anatomic correspondence as 8.64, and the model’s ability to be learning tool as 8.78. conclusion: the use of the simlife model allows proposing a very realistic surgical simulation model to realistically train and objectively evaluate the performance of young surgeons. as obesity has become a worldwide public health concern, bariatric surgery has been also recognized as an appropriate and effective method to treat obesity and its related diseases [1] [2] [3] [4] [5] . the training needs for bariatric surgeons are therefore increasing in order to maintain a high quality of care for obese patients. as reported in the literature [5] , 3 major factors influence bariatric surgery care: hospital infrastructure and volume, surgical team volume, and surgical skills. while it may be difficult to change the first 2 factors that are not dependent on the surgeon, the third can be improved. surgical simulation provides the opportunity for supervised directed learning of trainees, allowing full mastering of technical skill and increasing performances before actual practice on patients [6] [7] [8] [9] . for this purpose, we developed the simlife model, based on fresh human body given to science, dynamized by pulsatile vascularization with simulated blood, warmed to 37°c and ventilation [10, 11] . the objectives of this study were to assess the realism of this model, the satisfaction of learners, and finally the ability of this model to facilitate the learning process. the simlife model consists of a donated human body, which is retrieved by the body donation center of our university, prepared for surgical simulation [10] . bodies arrived within 24 h after death, and a traceability number (anonymity) is established [10] [11] [12] . exclusion criteria included all possible contaminations such as hiv, hbv, hcv, creutzfeldt-jacob, and tuberculosis, through analysis of a blood sample to perform serological tests; at the time of those simulations (2019) we were unaware of the risk of coronavirus infection, but now we systematicaly tested all cadavers about the covid status at their arrival at the body donation center. each body was then prepared for surgical simulation ( fig. 1 ): cannulas were placed in both femoral arteries and left common carotid artery (input) and both femoral veins and left internal jugular veins (output). the vascular axes of superior and inferior limbs may be excluded to target the trunk's vascularization [10] [11] [12] . a tracheotomy or orotracheal tube provided ventilation, and stomach emptying was obtained via a nasogastric tube. body's arterial tree was washed with water at low pressure (0.8 bar) and at a maximum temperature of 30°c to eliminate whole blood and clots. subsequent body cleaning and disinfection was performed and the body was frozen at −22°c in a negative pressure cold room [7, 8] . when a simlife simulation session was scheduled, before use and according to bodies' bmi, progressive body defrosting (at 16°c) over several days (3 days minimum) was achieved. finally, a testing procedure before starting on simlife model was performed to check the physiological behavior of the model. the specific technical module p4p (pulse for practice, patent number 1000318748 with international extension pct/ep2016/075819 published on 2017/05/11, wo 2017/ 076717 a1) animated the body, which was perfused by blood-mimicking fluid (patent l18217) circulating in the arterial system in a pulsating manner, recoloring and warming internal organs to 37°c, and restoring venous turgor. output was guaranteed by venous output. physiological hemodynamic data were computer monitored continuously and adapted as needed, with heart rate, blood pressure, and respiratory rate, which could increase or decreased to mimic a hemorrhagic shock for example. simlife inner organs were re-vascularized, re-colored, and warmed by specific mimicking-blood liquid. hemodynamic conditions were maintained and could be continuously modified by a computer-controlled device, ensuring identical physiological conditions of a real patient. for example, the pulsatile pump controlled by the computer automatically adjusted blood pressure according to possible iatrogenic accidents causing bleeding. thus, a moderate bleeding induced an increase in flow up to a threshold where hemodynamic instability resulted in a complete loss of blood pressure and systemic circulation interruption [10] [11] [12] . the learning platform on cadaveric model was covered by previous approval of french ministry of health ethics committee (protocol number dc-2019-3704). a total of 24 residents and chief residents (table 1) consented to this study on a total of 4 occasions. the training days were hosted at the medical school. before performing each procedure, all participants were given a theoretical approach, which included lectures, videos, description of the technique, and an overview to the reperfused cadaver model. this was followed by hand-on training on simlife models. we associated 2 trainees per station, with at least 1 supervising expert. the theme of the first 2 sessions was the sleeve gastrectomy, and the 2 following sessions were the roux-in-y gastric bypass; this sequence allowed trainees to familiarize themselves with the simlife model for a relatively simple procedure and then to move to a more technically demanding gastric by-pass. at the end of each practical session, all surgical trainees completed an anonymous evaluation survey indicating their degree of satisfaction (feedback) on a likert scale from 0 to 10 (0 = not at all to 10 = perfectly) on 4 items: 1. ease of learning a specific surgical procedure using simlife model, 2. accuracy of anatomic landmarks of simlife model compared with clinical reality, 3. degree of realism of simlife model, 4. overall satisfaction with the training model used. statistical analysis was performed by means of sas 9.3 software. values are reported as means and standard deviation (sd). results are summarized in table 1 . all participants completed and returned the evaluation survey corresponding to a response rate of 100% from the trainees. participants included 20 residents and 4 chief residents from the french nouvelle aquitaine area including three university hospitals: bordeaux, limoges, and poitiers. their status and experience in bariatric surgery are summarized on table 2 . the evaluation survey was carried out at the end of each session. data were collected from the 4 training sessions. the 24 participants answered to the four survey questions. based on these evaluations, the overall satisfaction of the cadaveric model had a mean score of 8.52 with sd of 0.83, realism had a mean score of 8.91 with sd of 0.94, anatomic correspondence had a mean score of 8.64 with sd of 0.96, and the model's ability to be learning tool had a mean score of 8.78 with sd of 0.85 (table 2) . on the evaluation form given to each trainee the final question was as follows: would you advise a colleague to bariatric surgery requires, as well as other surgical subspecialties, acquisition of specific skills, which may be learnt throughout consistent practice. corresponding at the halstedian model of apprenticeship "learning on the job" creates the notion of a learning curve. the relationship between hospital volume and outcomes is well recognized; at least 100 cases annually per hospital are recommended as the minimal requirement to achieve a low risk for serious complications [13] . moreover, a total experience of 500 cases was deemed necessary to diminish the risk for adverse outcomes and meet safety standards [13] . but an individual case report of 100 cases annually is not always feasible, and we focused on revisional bariatric surgery, as cited by bonrath; in germany an individual case volume of 300 procedures is referenced as a quality criterion [5] . the paradigm shift of training in surgery in experimental learning, kolb showed that strategy of the initial used in learning process influences adequate skill acquisition [14] . concerning bariatric surgery, the value of the classical surgical cursus, residency and fellowship training, is well documented [5, 9, [15] [16] [17] [18] . but availability of fellowship in a high debit department of bariatric surgery is not the rule for all young surgeons. in germany, as reported by bonrath, over 80% of surgeons had none or little exposure to fellowship training [5] . while in north america a "fellowship trained" is the rule to independently perform bariatric surgery. so designing fellowship training induced debate within the bariatric surgery societies without finding a worldwide agreement because the means available and the modalities of evaluation vary greatly from one country to another and sometimes from one university to another [8, [19] [20] [21] . other solutions have been proposed, for example, the sages telementoring, which allows surgeons to reach the plateau of maximum performance more quickly by "correcting" intraoperative gestures, thanks to experts who can follow the procedure remotely. an evaluation is proposed via this device; unfortunately, it is only subjective since it is left to the expert's free appreciation [22] and always on a patient. so in the last two decade, the surgical community stated that mentorship should not be the method of instruction that best prepares trainees to enter the modern world of surgery [6, 8, [17] [18] [19] [20] [21] . the milestone of the "new concept of training" should consist in exposing apprentices to features of real-life situations, without risks for living patients. surgical trainees may also benefit by activities performed far from operating theaters such as surgical simulation [23] [24] [25] , coaching [26, 27] , structured training programs [28] , and many others [13] . in fact, the learning curve must shift from the operating theater to a "preclinical" model in simulation. this "natural" evolution of training also follows the incredible technological progress of surgery where the practitioner must master not only his surgical technique but also the tool he uses. which model for surgical simulation and evaluation? donald kirkpatrick [29] in the late 1950s defined a training evaluation model based on four levels of evaluation. each level is built from the information of the previous levels. in other words, a higher level is a finer and more rigorous assessment of the previous level: level 1: assessment of reactions, level 2: learning assessment, level 3: evaluation of transfer, and level 4: outcome evaluation. level 1 with assessment of learners' reactions in front of the simulation model is fundamental. if we try to compare the simulation training of pilots and surgeons: a crucial element emerges. while computer models can perfectly simulate a long-distance flight with all possible anomalies, the same cannot be said for computerized surgical simulation. the root of surgical simulation should be the realism of the model to obtain the most immersive environment to the learners [30, 31] . a wide number of surgical simulators are available for the benefit of trainees [6, 7, 9, 10, 30, [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] . they can be divided into synthetic and organic simulators [7, 9] . within the first group we have plastic, rubber, or latex-based simulator as well as virtual reality (vr) and computer-based simulation. those simulators have the advantage to allow repetition of practice without any risk (no living being used), but these tools may sometimes present a lack of reality compared with human patients [7] . it is necessary to adapt simulation models to anatomical and/or physiological variations that cannot be perfectly programmed in a computerized scenario [42] [43] [44] . organic type simulators provide high-fidelity environment and may be divided into animal-based and human-based. the first type is mainly represented by canine, baboons, or porcine model [7] . nevertheless, some ethical restriction applied as living animal models are forbid in the uk and open discussion exist in some other european countries [7, 44] . the second organic model is represented by human cadaver, the historical model for practical training in surgery or interventional medicine [45, 46] . indeed, fresh or embalmed human cadavers have been used for centuries as a learning tool in clinical anatomy [33, 34] . the major pitfall of human corpse is represented by the fact that this is a static model, which could not simulate actual condition of surgery like bleeding and hemodynamic instability, one of the most critical conditions that a surgeon may face, especially during laparoscopy [35] [36] [37] [38] . to overcome this problem few teams introduced model of perfused cadaveric material, mainly in neurosurgery, reporting higher satisfaction of trainees and increased fidelity, similar to a living patient [6, [40] [41] [42] . these late reports particularly highlight the increased degree of reality represented by a perfused cadaveric model, which allowed training in hyper-realistic environment [39] [40] [41] . furthermore, the use of cadavers is also a source of ethical reflection and emotional and psychological analysis for learners in their surgical behavioral training [47, 48] . training on a cadaveric model (figs. 2 and 3) seems to be the best compromise between learning in the operating room, the animal model, and/or virtual simulators [35] . surgical apprenticeship on simlife is performed safely and achieved a high satisfaction score among trainees, as shown previously. this last point is truly important as apprentice appreciation of simulators is the key to provide successful training as it allows gaining of confidence, increasing of experience, and mastering of surgical techniques, which may be lately translated into proficient medical practice [29, 41] . first, the simlife model revascularization by a bloodmimicking fluid-limited coagulation, platelet activation, and thrombin-derived products could not be achieved as in a real standard patient. so the environment is closer to an extracorporeal circulation model. second, body availability and moreover overall mean cost per procedure limited the access to this model. this simulations' device cannot be reserved as initial training for junior residents, but it has to be implemented at the end of basic skills learning, which may be achieved on simpler models. thus, simlife should ideally be used for training in the last period of residency or during fellowship program to ensure skills mastering just before practicing on clinical theater. to also limit the cost, it is possible to set up simlife training sessions with several specialties: on day one, orthopedic surgery; on day 2, bariatric and/or endocrine surgery (thyroidectomy with lymph node dissection for example, in this case it is necessary to adapt the body preparation without neck dissection: cannulas placement can be modified as required); and on day 3, cardiac surgery (heart valve surgery). to look further, this model can be implemented in other universities and countries. simlife introduced a realistic bariatric surgery simulation model. it represents a relevant tool that can have a positive impact on the acquisition and mastery of advanced technical skills for young surgeons. the next step in this work will be the evaluation of performance acquisition over several sessions using specific evaluation scales. conflict of interest c breque, d oriot, jp richer, and jp faure are patent co-owner of the p4p device permitting revascularization and reventilation. all other authors declare that they have no conflict of interest. the learning platform on cadaveric model is covered by previous approval of french ministry of health ethics committee (protocol number dc-2019-3704). informed assent and consent informed consent was obtained from all individual participants included in the study. prevalence of obesity among adults and youth: united states clinical indications, utilization, and funding of bariatric surgery in europe estimates of bariatric surgery numbers training in bariatric surgery: a national survey of german bariatric surgeons simulation in surgery: a review systematic review of the current status of cadaveric simulation for surgical training the changing face of surgical education: simulation as the new paradigm patient safety and simulation-based medical education simlife a new model of simulation using a pulsated revascularized and reventilated cadaver for surgical education life: a new surgical simulation device using a human perfused cadaver simlife: face validation of a new dynamic simulated body model for surgical simulation the learning curve of one anastomosis gastric bypass and its impact as a preceding procedure to roux-en y gastric bypass: initial experience of one hundred and five consecutive cases experiential learning: experience as the source of learning and development high case volumes and surgical fellowships are associated with improved outcomes for bariatric surgery patients: a justification of current credentialing initiatives for practice and training presence of a fellowship improves perioperative outcomes following hepatopancreatobiliary procedures bariatric outcomes are significantly improved in hospitals with fellowship council-accredited bariatric fellowships systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes see one, do one, teach one": inadequacies of current methods to train surgeons in hernia repair see one, do one, teach one": education and training in surgery and the correlation between surgical exposures with patients outcomes michigan bariatric surgery collaborative. effects of resident involvement on complication rates after laparoscopic gastric bypass sleeve gastrectomy telementoring: a sages multi-institutional quality improvement initiative randomized clinical trial of virtual reality simulation for laparoscopic skills training psychomotor performance measured in a virtual environment correlates with technical skills in the operating room comprehensive surgical coaching enhances surgical skill in the operating room: a randomized controlled trial a randomized controlled study to evaluate the role of video-based coaching in training laparoscopic skills complementing operating room teaching with video-based coaching comprehensive simulationenhanced training curriculum for an advanced minimally invasive procedure: a randomized controlled trial evaluating training programs: the four levels -third edition. berrett-koehler publishers, 1 janv effectiveness of cadaveric simulation in neurosurgical training: a review of the literature testing of a complete training model for chest tube insertion in traumatic pneumothorax cadaver-based simulation increases resident confidence, initial exposure to fundamental techniques, and may augment operative autonomy the role of human cadaveric procedural simulation in urology training preoperative surgical rehearsal using cadaveric fresh tissue surgical simulation increases resident operative confidence back to basics: use of fresh cadavers in vascular surgery training an enhanced fresh cadaveric model for reconstructive microsurgery training basic laparoscopic skills training using fresh frozen cadaver: a randomized controlled trial a perfusion-based human cadaveric model for management of carotid artery injury during endoscopic endonasal skull base surgery live cadaver' model for internal carotid artery injury simulation in endoscopic endonasal skull base surgery endoscopic management of cavernous carotid surgical complications: evaluation of a simulated perfusion model the use of a novel perfusion based human cadaveric model for simulation of dural venous sinus injury and repair surgical skills training and simulation the minimal relationship between simulation fidelity and transfer of learning simulation and surgical training cadaveric surgery: a novel approach to teaching clinical anatomy a fresh cadaver laboratory to conceptualize troublesome anatomic relationships in vascular surgery detached concern" of medical students in a cadaver dissection course: a phenomenological study human dissection: an approach to interweaving the traditional and humanistic goals of medical education publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-306999-bedygxjs authors: kurihara, hayato; bisagni, pietro; faccincani, roberto; zago, mauro title: authors' response: surgery in the coronavirus disease 2019 phase 2 italian scenario: lessons learned in northern italy spoke hospitals date: 2020-07-01 journal: j trauma acute care surg doi: 10.1097/ta.0000000000002837 sha: doc_id: 306999 cord_uid: bedygxjs nan for their appreciation and interesting insights about our work. 1 we perfectly agree with them that coronavirus disease 2019 pandemic dramatically changed the health system organization and surgeons' duties. we would like anyway to make some points clear: • we strongly believe that surgeons used to deal with critical patients and committed in the care of acute patients played a key role in facing this pandemic event, which seems to be a mass casualty event. the attitude of surgeons in managing scenarios involving people with different injuries and their ability to prioritize treatment and resources are crucial and effective in the field and in planning the correct hospital strategy. previous experiences and training in these fields were of paramount importance and deserve attention for the future plans. • surgical critical care knowledge, one of the pillars of acute care surgery, revealed once more a mandatory background for surgeons. 2 • the surgeons' role is important in the "hub" hospitals and much more important in the "spoke" hospitals. in our opinion, their help is fundamental in the crisis unit too, of course together with hospital manager and directors, medical and emergency department, logistic, supply, and strategic staff. • we continue, during this pandemic event, to face different surgical scenarios, emergent, urgent, and elective (particularly cancer related), and we continue to use laparoscopy (in coronavirus disease patients too) when the laparoscopic technique is recommended and widely recognized. [3] [4] [5] • we fully agree in using adequate personal protective equipment and the precautions advised. • regarding patient positioning in severe acute respiratory syndrome coronavirus 2 patients, we never experienced any problem due to trendelenburg position when required. however, we find ourselves in disagreement with some of their statements. the mentioned article takes for granted the risk of viral spread through the surgical smoke and pneumoperitoneum and suggests avoiding the laparoscopic approach as much as possible. while agreeing on the concept of the potential risks of surgical smoke for the theater staff, which have been widely demonstrated, we feel that our clinical decisions during this pandemic must be evidence based to the greatest extent. on this particular topic, there is no published proof of the presence of covid-19 in the surgical smoke, and the suspect is only indirect. 2 the available evidence of the presence of active hepatitis b virus (hbv), human immunodeficiency virus (hiv), and human papillomavirus (hpv) viral particles in the surgical smoke is low level and may not apply directly to the covid-19. at our knowledge, up until now, only one article demonstrated the presence of hbv in the surgical smoke in 10 of 11 hbv-positive patients undergoing laparoscopic or robotic surgery. 3 several articles demonstrated the presence of hpv in the laser plume, 4 whereas the results of studies on hiv yielded contrasting results. 5 although there is evidence of patient-surgeon transmission of hpv through the laser smoke, the particular kind of surgery for hpv-related warts, where the surgeon usually stays very close to the surgical field and easily inhales the smoke, makes hpv a biased experimental model for viral transmission during laparoscopic surgery. despite hivand hbv being blood-borne viruses, laparoscopic surgery is being performed in hiv and hbv patients for many years, and no clear demonstration is available of viral transmission through the pneumoperitoneum or surgical smoke. on the contrary, covid-19 has a special tropism for the upper and lower respiratory tract. viral rna has been found in stools and blood, but no infective virus has ever been demonstrated in the gastrointestinal tract and in the blood. furthermore, it must be emphasized that smoke production and evacuation may be even more difficult during laparotomy than laparoscopy, for the absence of a unique smoke escape channel. for these reasons, we do not believe that results from the available literature can be extrapolated to the covid-19 pandemic as to justify the current too restrictive guidelines on laparoscopic surgery against the evident and well-known and evidence-based advantages of laparoscopy with respect to the open approach in many fields of surgery. we feel that replacing a grade of recommendation a (known benefits of laparoscopic surgery) with a grade d (avoid laparoscopy on the basis of perceived dangerous laparoscopic smoke) is not consistent with a modern healthcare system. last but not the least, we feel that the restrictions placed on the practice of laparoscopic surgery during the pandemic may not be consistent with ethics and professionalism because they reduce the level of care and abdicate to the already world widely accepted criterion standards in surgical care. while this can be acceptable in war scenarios with limited resources, they may not be totally acceptable in the current juncture where, despite undoubtedly facing a challenging pandemic, resources and expertise are widely available and access to the highest standard of care must be granted to everyone. covid-19 outbreak in northern italy: viewpoint references covid-19 outbreak in northern italy: viewpoint of the milan area surgical community redefining acute care surgery: surgical rescue sages and eaes recommendations regarding surgical response to covid-19 crisis surgery in covid-19 patients: operational directives european society of trauma and emergency surgery (estes) recommendations for trauma and emergency surgery preparation during times of covid-19 infection laparoscopy at all costs? not now during covid-19 outbreak and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a hub tertiary teaching hospital in northern lombardy safe management of surgical smoke in the age of covid-19 detecting hepatitis b virus in surgical smoke emitted during laparoscopic surgery is surgical plume developing during routine leeps contaminated with high-risk hpv? a pilot series of experiments presence of human immunodeficiency virus dna in laser smoke the authors declare no conflicts of interest. authors' response: laparoscopy and covid-19: an off-key song?dear editor, w e thank tebala et al. for their interest and comments on our article. 1 at the end of their letter, the authors point out that "resources and expertise are widely available" during coronavirus disease 2019 (covid-19) outbreak and a restrictive use of laparoscopy would have been acceptable only in a war scenario. unfortunately, the current data resemble many features of this kind of scenario, with shortage of personnel, reduction of surgical services, operating rooms converted in intensive treatment unit (itu) beds, and surgeons shifted to medical tasks as a global response to the pandemic. 2 as of may 12, 2020, 163 doctors died after contracting covid-19 in italy, 3 and health workers are heavily affected globally. in this setting, any additional source of contagion may produce catastrophic effects and threat the entire health system. a tailored strategy to protect health workers and patients, avoiding unnecessary risks, is a priority. 4, 5 a second worst pandemic wave, as in the spanish flu, cannot be excluded, and a self-preserving strategy must be already in place to guarantee an adequate surgical response in the future outbreak peaks, despite the shortage of personnel, beds, and operating rooms.regarding the lack of evidence of sars-cov-2 presence in the peritoneal fluid, some anecdotal evidences are emerging. viral rna was detected in the peritoneal fluid of a covid-19 patient who had undergone a laparotomy for a nonischemic small bowel volvulus 6 and in the peritoneal waste of a patient treated with peritoneal dialysis. 7 thus, a prudential approach may be reasonable until key: cord-307945-wkz43axo authors: baud, grégory; brunaud, laurent; lifante, jean christophe; tresallet, christophe; sebag, frédéric; bizard, jean pierre; mathonnet, muriel; menegaux, fabrice; caiazzo, robert; mirallié, éric; pattou, françois title: endocrine surgery during and after the covid-19 epidemic: expert guidelines in france date: 2020-04-30 journal: j visc surg doi: 10.1016/j.jviscsurg.2020.04.018 sha: doc_id: 307945 cord_uid: wkz43axo abstract the covid-19 pandemic commands a major reorganization of the entire french healthcare system. in france, general rules have been issued nationally and implemented by each healthcare center, both public and private, throughout france. guidelines drafted by an expert group led by the french-speaking association of endocrine surgery (afce) propose specific surgical management principles for thyroid, parathyroid, endocrine pancreas and adrenal surgery during and after the covid-19 epidemic. the ongoing covid-19 pandemic commands a major reorganization of the entire french healthcare system (1) . to respond to the present and expected influx of patients needing a period of intensive care (2) , the short-term priority has been directing available material and human resources toward sectors dispensing care for covid-19 patients (3, 4) . this policy has entailed the almost complete de-scheduling of non-urgent surgery (5) . more than a month now after the start of the epidemic, there is a pressing need to manage other health disorders not linked to covid-19 but for which deferral of surgery until after the epidemic is over could worsen prognosis or be life-threatening. it is also important to be thinking now about the conditions under which surgery can be resumed at a normal pace after the epidemic. general rules have been put out nationally and implemented by each healthcare center, both public and private, throughout france. specific guidelines have been proposed for visceral surgery (6) . likewise, to meet their need for specific guidelines, the frenchspeaking association of endocrine surgery (afce) brought together a group of experts to propose principles for the surgical management of thyroid, parathyroid, endocrine pancreas and adrenal pathologies during the covid-19 epidemic and afterwards, when surgical activity will be able to return gradually to its normal pattern. these guidelines were drafted in the light of the existing literature. they will be updated as knowledge advances. four scheduling levels were defined to help prioritize patients (these levels may change according to how the epidemic setting evolves): urgent surgery that must be carried out as soon as possible because even a short deferral would be life-threatening. (ii) semi-urgent surgery that can be deferred for a few weeks but not beyond 3 months without threat to life or adverse effects on cancer or functional prognosis. (iii) high-priority elective surgery that can wait for several months but must be given scheduling priority as soon as the epidemic is over. (iv) distant elective surgery that can be deferred until well after the epidemic is over, even more than 6 months, without compromising the indication. for urgent surgery, the ratio of the benefit expected from surgery to the risks incurred by scheduling it during the epidemic must always be evaluated according to how both the national and local contexts are evolving, in particular the resources available: operating room, consumables and hospital capacities, particular if intensive care may be needed. when surgery is prescribed in the epidemic setting, short hospital stays or outpatient care are recommended (7) , provided this does not increase the risk of rehospitalization. to limit operating time and the risk of post-operative complications, the surgery should also be performed by one or more experienced surgeons. even if no symptoms of covid-19 are apparent, the risk of infection should be assessed beforehand as it may be associated with unfavorable prognosis (8, 9) . any surgery on a patient infected or suspected of being infected must be performed according to the rules laid down by the hospital's hygiene teams and infectiologists (10). a. thyroid cancers (fig. 2) control those of thyroxine (t4) at the time of surgery. non-suspect goiters responsible for severe compressive symptoms (inspiratory dyspnea due to tracheal compression, dysphagia due to esophageal compression, superior vena cava syndrome due to deep vein compression) must also be scheduled for semi-urgent surgery before the epidemic ends. c. hyperparathyroidism (fig. 4) surgical treatment of primary hyperparathyroidism (hpt) is generally not urgent (16) . in the covid-19 epidemic setting, its scheduling depends on the presence or absence of severe hypercalcemia, defined by a very high level of blood calcium > 3.5 mmol/l (140 mg/l) (17) , and/or the presence of clinical complications -acute pancreatitis secondary to hpt, brown tumor, calciphylaxis, fracture osteopenia, heart rhythm disorders (qt shortening on ecg, bradycardia with risk of asystole) with cardiac insufficiency (17) (18) (19) (20) . in all cases, hypocalcemia treatment must first be given. in the epidemic setting, the use of cinacalcet is recommended (21) . in cases of severe hypercalcemia, surgery must be scheduled as semiurgent, without waiting for the epidemic to end, or as urgent when it escapes control by the medical treatment. if there is no severe hypercalcemia, surgery can be deferred without risk until the epidemic is over. these guidelines are valid for cases of genetically determined primary hpt. for tertiary hpt, the blood calcium threshold defining severe hypercalcemia must be lowered to 2.8 mmol/l to protect renal grafts (nephrocalcinosis, acute tubular necrosis, lithiasis) and bone and vascular impact (22, 23) . for secondary hpt, surgical treatment is not recommended during the epidemic because of the higher risk of covid-19 infection in dialyzed patients (24) . when indicated, surgery must be scheduled as a priority in the three months following the epidemic in cases of disabling bone pain, brown tumor or temporary contraindication for renal transplant (25). 6 uni-or bilateral cervicotomy is the approach recommended for the surgical treatment of thyroid or parathyroid pathologies in the epidemic setting, so as to limit operating time and complication risk (26) . surgery requiring a thoracic or mediastinal approach and/or postoperative intensive care (27) in the epidemic setting, the indication for the surgical treatment of a neuroendocrine tumor of the pancreas must be discussed in an mdt meeting to assess the balance between the risks of surgery and its oncological and/or secretory benefits (34) . the management of (36) . a pancreatectomy may be indicated when a curative resection can be considered after clinical and morphological reassessment (37) , in which case surgery is scheduled as semi-urgent before the epidemic has ended. patients with a well-differentiated neuroendocrine tumor of the pancreas (grades g1, g2 or g3) that is nonsecretory can be deferred until well after the epidemic is over. if there is an associated secretory syndrome, a medical treatment should first be given (38) . if this treatment fails to control the secretory syndrome satisfactorily, pancreatectomy must be scheduled as semi-urgent before the end of the epidemic. if the medical treatment is effective, surgery can be deferred until well after the epidemic has ended. when technically possible, laparoscopy is recommended for left pancreatectomies and enucleations to minimize postoperative impact on respiratory function and hospital length of stay (6). in the epidemic setting, the indication for the surgical treatment of an adrenal lesion must be discussed at an mdt meeting to assess the balance of risk and its oncological and/or secretory benefits. lesions suspected to be malignant (cortico-adrenaloma, metastases) must undergo surgery when they are considered resectable (39, 40) . in cases of secretory syndrome, prior management by a medical treatment is recommended (metyrapone, ketoconazole). surgery must be scheduled as semi-urgent, before the end of the epidemic, in an expert center (41). chromaffin lesions (pheochromocytoma and/or paraganglioma) must first receive an appropriate antihypertension treatment (alpha-blocking agents, beta-blocking agents, calcium inhibitors), and be monitored by an experienced care team (42) . if this treatment controls the secretory syndrome, close monitoring can be continued until the for other secretory adrenal lesions (in particular, hypercorticism and hyperaldosteronism), an appropriate medical treatment (steroidogenesis inhibitors, antialdosterone) must first be implemented. if the secretory syndrome is not controlled or if impact is marked, adrenalectomy can be scheduled as semi-urgent during the epidemic. in other cases, adrenalectomy can be scheduled well after the epidemic has ended. during the epidemic, laparoscopy remains the preferred approach for adrenalectomy. conversely, for suspect lesions and/or those larger than 10 cm, laparotomy is recommended (43). post-operative follow-up consultations must be maintained during the epidemic. teleconsultation is recommended to ensure continuity of care while limiting the risks of coronavirus propagation in healthcare centers. for a consultation in which a diagnosis of cancer or a therapeutic strategy is to be announced, some form of video exchange is recommended. whenever possible, blood tests and imaging must be performed outside hospitals. in a situation where medical drugs of major therapeutic importance may be in short supply, patients who are dependent on a hormone substitution treatment should be reminded never to interrupt their treatment longer than 24 h for corticoids (44) , longer than 48 h for calcium (45) , and longer than one week for thyroid hormones (46) . * steroidogenesis inhibitors (metyrapone, ketoconazole), 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long-term normocalcemia in patients with primary hyperparathyroidism tertiary hyperparathyroidism: is less than a subtotal resection ever appropriate? a study of long-term outcomes characteristics of persistent hyperparathyroidism after renal transplantation minimizing the risk of covid-19 among patients on dialysis executive summary of the 2017 kdigo chronic kidney disease-mineral and bone disorder (ckd-mbd) guideline update: what's changed and why it matters is it possible to limit the risks of thyroid surgery morbidity of total thyroidectomy for substernal goiter: a series of 70 patients extracervical approaches to thyroid surgery: evolution and review covid-19 pandemic: effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. head neck sars-cov-2 viral load in upper respiratory specimens of infected patients does intraoperative neuromonitoring of recurrent nerves have an impact on the postoperative palsy rate? results of a prospective multicenter study international neural monitoring study group guideline 2018 part i: staging bilateral thyroid surgery with monitoring loss of signal randomized controlled trial of alfacalcidol supplementation for the reduction of hypocalcemia after total thyroidectomy enets consensus guidelines update for gastroduodenal neuroendocrine neoplasms covid-19 epidemic: proposed alternatives in the management of digestive cancers : a french intergroup clinical point of view enets consensus guidelines for high-grade gastroenteropancreatic neuroendocrine tumors and neuroendocrine carcinomas pancreatic neuroendocrine tumors: the impact of surgical resection on survival enets consensus guidelines for the management of patients with digestive neuroendocrine neoplasms: functional pancreatic endocrine tumor syndromes european society of endocrine surgeons (eses) and european network for the study of adrenal tumours (ensat) recommendations for the surgical management of adrenocortical carcinoma adrenocortical carcinoma: impact of surgical treatment adrenalectomy risk score: an original preoperative surgical scoring system to reduce mortality and morbidity after adrenalectomy long-term survival after adrenalectomy for stage i/ii adrenocortical carcinoma (acc): a retrospective comparative cohort study of laparoscopic versus open approach adrenal insufficiency hypocalcemic emergencies combined levothyroxine plus liothyronine compared with levothyroxine alone in primary hypothyroidism: a randomized controlled trial key: cord-306016-2gudro8v authors: pelt, christopher e.; campbell, kevin l.; gililland, jeremy m.; anderson, lucas a.; peters, christopher l.; barnes, c. lowry; edwards, paul k.; mears, simon c.; stambough, jeffrey b. title: the rapid response to the covid-19 pandemic by the arthroplasty divisions at two academic referral centers date: 2020-04-21 journal: j arthroplasty doi: 10.1016/j.arth.2020.04.030 sha: doc_id: 306016 cord_uid: 2gudro8v the covid-19 pandemic has created widespread changes across all of healthcare. the impacts on the delivery of orthopaedic services has been challenged as a result. in order to ensure and provide for adequate health care resources in terms of hospital capacity, personnel and personal protective equipment (ppe), service lines such as adult reconstruction and lower limb arthroplasty have stopped or substantially limited elective surgeries and have been forced to re-engineer care processes for a high-volume of patients. herein, we summarize the similar approaches by two arthroplasty divisions in high volume academic referral centers in 1) the cessation of elective surgeries, 2) workforce restructuring, 3) phased delivery of outpatient and inpatient care, and 4) educational restructuring. academic referral centers 2 3 abstract: 4 the covid-19 pandemic has created widespread changes across all of healthcare. the 5 impacts on the delivery of orthopaedic services has been challenged as a result. in order to 6 ensure and provide for adequate health care resources in terms of hospital capacity, personnel 7 and personal protective equipment (ppe), service lines such as adult reconstruction and lower 8 limb arthroplasty have stopped or substantially limited elective surgeries and have been forced 9 to re-engineer care processes for a high-volume of patients. herein, we summarize the similar 10 approaches by two arthroplasty divisions in high volume academic referral centers in 1) the 11 cessation of elective surgeries, 2) workforce restructuring, 3) phased delivery of outpatient and 12 inpatient care, and 4) educational restructuring. 13 14 15 introduction: 16 in december 2019, a novel coronavirus (covid-19) broke out in wuhan, hubei 17 province, the people's republic of china. the first reported case in the us was in washington 18 state on january 19, 2020. since that time the covid-19 pandemic has affected most of the 19 world and there are currently over 450,000 cases and over 17,000 deaths reported in the us 20 alone. the unprecedented viral pandemic has motivated rapid societal change, primarily with 21 efforts directed at social distancing in an effort to flatten the peak of the pandemic curve and has 22 also substantially strained health care resources to manage the exponential burden of the 23 disease. although front-line health care providers involved in the diagnosis and treatment of the 24 respiratory transmitted virus deserve most (all) credit, the pandemic has also created challenges 25 for other medical service lines, including orthopaedic surgery. in order to ensure and provide for 26 adequate health care resources, hospital capacity, personnel and personal protective 27 equipment (ppe), service lines such as adult reconstruction and lower limb arthroplasty have 28 stopped or substantially limited elective surgeries and have been forced to re-engineer care 29 processes for a high-volume of patients. 30 our adult reconstruction and arthroplasty practices are located within two large 31 quaternary academic referral centers. one serves the entire intermountain west region, a large 32 geographic area of 7 states and a population area of over 18 million people, and the other 33 serves the entire state of arkansas, with some referrals from neighboring areas of oklahoma, 34 texas, louisiana, tennessee and missouri and a catchment area of over 3.5 million people. 35 our arthroplasty services are both comprised of four high-volume fellowship-trained lower limb 36 arthroplasty surgeons, as well as a combined ten advanced practice clinicians (apcs), seven 37 registered nurses (rns), and multiple other providers including medical assistants (mas), 38 physical therapists (pts), administrative assistants and support staff. our first response as a part of the planning for the impending covid-19 pandemic was 85 to form a platoon of health care provider teams [1] . the previously formalized resident surgeon 86 subspecialty rotations based on broad educational platforms and goals were halted, and 87 resident teams were formed to cover sites of care rather than orthopaedic subspecialty services. 88 the sites of care were set up to be covered by the minimum essential staff on a rotating weekly 89 coverage schedule. residents not currently in the active direct patient care platoons have been 90 assigned work from home and provided enhanced educational assignments (described below). 91 at utah, fellows entered a platoon to alternate with the residents to further mitigate the burden 92 across additional individuals needing to be present at any one time on the inpatient service. 93 to reduce exposure and prevent the mixing of our workforce, the attending surgeons 94 and the apcs were separated. the apcs were assigned to cover insurgeries were deemed non-essential and were cancelled and placed into a rescheduling que. 118 during phase 1, it was not exactly clear how prioritization of cancelled cases would be 119 structured. 120 to clear the or schedule, in utah, we initially set out to delay or reschedule surgeries 121 week-by-week, with our schedulers, mas and apcs calling patients on the upcoming weeks' 122 schedule and informing them that surgery would be postponed. however, as the projected data 123 became clear that the likely duration of the pandemic was going to be prolonged, it became 124 obvious that this strategy was unfair to patients who were being cancelled as it created a "leap 125 frog" scheduling scenario: patients being cancelled had likely signed up for surgery prior to the 126 patients the week after, creating confusion and staff chaos. additionally, the short notice we 127 provided to our patients was likely inadequate due to travel, work and family scheduling. 128 further, we were giving false hope of surgery to patients not yet cancelled. finally, this 129 approach failed to account for the urgent/complex cases that may have warranted surgery more 130 expediently than other patients due to the potential for ongoing and/or irreversible damage with 131 prolonged delay. in arkansas, the decision was initially made to reschedule all elective, non-132 urgent cases until the end of april with the understanding that we would call to reschedule. on 133 april 7, 2020, the decision was made to extend this approach until may 31, 2020. 134 in anticipation for phase 4 (ramp up/return), described below, the utah team has created 135 a ranking list of all patients who are awaiting surgery. two scoring scales were put into place. 136 the first scale is for complexity (joint destructive/erosive arthritis, loose/failed implants 137 compromising bone stock, stage 2 reimplants awaiting surgery to be able to advance 138 activity/motion/weightbearing/return to work, etc). the second scale is for predicted length of 139 stay in order to determine who will likely be successful with outpatient surgery based upon 140 patient health, independence, and support structure. each scoring system is created to account 141 for two potential limitations that may exist on the "ramp up/return" phase 4 (see below). 142 143 phase 2: 144 the messaging to our patients during phase 2 was focused on rescheduling and 145 postponing in-person visits. to continue to provide clinical services to our patients in the setting 146 of the widespread cancellations of non-urgent in-person visits, we quickly ramped up our 147 telehealth and virtual visits by apcs/clinic staff. these virtual visits provided our patients with 148 timely guidance for navigating their home recovery in the setting of the pandemic and helping 149 them with peri-operative home care instructions. 150 given the focus on in-person visit cancellations and clinic visit resecheduling, our offices 151 experienced a significant increase in patient-generated phone calls. patients were calling about 152 a variety of concerns including: surgery cancellation updates, logistical topics such as booking 153 (or cancelling), travel to our medical center, and non-operative treatment recommendations. in 154 addition to the influx of incoming calls, our staff was also making more outbound calls to 155 coordinate care. combined, this strained our clinical resources and created unwanted 156 redundancy as staff members were answering similar questions throughout each day and 157 contacting patients frequently to share updates with them. 158 given this new challenge, the utah group looked for a more efficient solution to help 159 keep our patients updated and engaged using systems that we already had available. prior to 160 the pandemic, we were using a text-messaging program to coach our patients before and after 161 surgery (streamd, chicago, il, usa). we adopted a new use of this system that enabled us to 162 send text alerts to all of our patients awaiting surgery. the content included general updates 163 from our office in regards to surgery scheduling, general information about covid-19 for 164 patients with end-stage arthritis awaiting joint replacement, aahks-sponsored patient education 165 content regarding covid-19, messages of empathy and encouragement from our staff, and 166 personalized video messages from the attending surgeons. 167 the final portion of phase 2 revolved around the provision of postop rehabilitation to our 168 patients. prior to this pandemic, our pt teams had been using some tools to remotely provide 169 our patients with virtual or video-based therapy services in the efforts of avoiding unnecessary 170 outpatient pt visits. in response to the pandemic, and in an effort to continue to provide 171 therapy and rehabilitation instructions for our post-operative patients and keep them out of 172 outpatient and in-home therapy visits to the extent possible, our physical therapists increased 173 the use of remote patient rehabilitation via phone, email, and online videos using our pre-174 existing tele-rehab systems. 175 176 phase 3: 177 as we await the peak-surge of covid-19, our clinical teams have reached a new state 178 of clinical normalcy and equilibrium and our patient messaging has gone through a shift from 179 "cancellation" to "invitation" as we communicate that we are still open for business -just in a 180 different way. we are no longer cancelling or delaying clinic visits, but rather we are shifting to 181 virtual visits and embracing technology to care for our patients remotely to the extent possible. 182 while avoiding unnecessary in-person visits, we still will perform them selectively when needed 183 due to conditions not able to be assessed via telemedicine. 184 185 phase 4: 186 the critical phase of ramp up or return to elective surgery is still on the horizon, but 187 preparations are underway to be ready for a return to normal state. as we have seen the 188 covid-19 "curve" flattening, the projected surge date is postponed as is our likely return to 189 "normal" timeframe. as patients and surgeons wait, the anxiousness and frustration of both no 190 doubt grows in both prevalence and intensity. the decisions on when to return to more normal 191 elective practice and what criteria to use to implement these plans are still dynamic and may 192 vary from state to state based on the level of covid-19 impact on our various healthcare 193 systems. 194 as we look at returning to normal operating room practices at our academic hospitals 195 and outpatient surgery centers, we will likely be faced with difficult decisions regarding 196 prioritization of patients secondary to limited resources within our system. the most likely limited 197 resource will be that of operating room availability and anesthesia providers along with 198 nursing/support personnel as all surgeons within the system will be trying to work through the 199 large backlog of scheduled cases. the second potential resource restriction will be that of 200 limited ppe. if inadequate ppe exists, cases with short operative times and higher volumes are 201 likely to burn through more ppe than longer/complex cases, where fewer gowns/gloves/masks 202 would be used by default due to less changes throughout the day. in this scenario, the short 203 operative time surgeries may be less appropriate to push into the system during early ramp up 204 of elective surgery, even in healthy and likely outpatient surgical candidates. the third potential 205 resource limitation may come in the way of limited hospital space/capacity in terms of bed 206 availability or nursing capacity. if hospital beds remain the limited resource, longer/complex 207 cases in patients with higher comorbidity burden are less desirable, and the healthy patients 208 that can be done efficiently and safely sent home are more likely to be more suitable in this 209 scenario. finally, the availability of testing screening for providers and patients may be a 210 resource limitation if it remains a limited resource, or perhaps just as likely, a potential variable 211 that allows for an accelerated return to increased clinical care if the resource is readily available. 212 it remains unclear as to the timeline of availability of widespread testing. it is likely that a 213 negative covid-19 test will be needed in the preoperative preparation phase before surgery. 214 our academic institutions have 34 and 28 orthopaedic surgeons respectively, and an 215 additional several hundred other surgeons in each academic health system, all postponing a 216 high volume of surgeries. to date within our orthopaedic surgery departments alone, we have 217 postponed a combined of over 1450 elective cases that will need to be rescheduled across 218 multiple subspecialities. due to the aforementioned resource restrictions, either we will all be 219 trying to push through as many relatively young healthy cases all at once, or trying to get 220 through the more urgent, and often more difficult cases. it is unclear which of these scenarios 221 we will begin with, or if it will be a hybrid of the two. however, we are preparing ourselves to be 222 nimble in this time of transition and quickly adjust our surgical scheduling with the use of the 223 scaling systems described above in the phase 1 description. the two scoring systems of 224 surgical complexity, predicted length of stay as well as patient age and comorbidities will help us 225 to properly stratify our patients and adapt to whatever ramp up strategy we are faced with in 226 phase 4 of this pandemic. weighing this with institutional ppe and health care provider 227 availability, it is our hope is that we will be positioned to efficiently, within our arthroplasty 228 division, as well as within the orthopaedic department and across try to continue to get as much volume done early while the prevalence of disease is low in our 263 hospitals and community on the front end of the curve? or should we stay strong in our resolve 264 to aid our own hospitals and surrounding health care community planning and preparation by 265 avoiding adding perioperative patient burden to the healthcare system at a critical time while 266 also using potentially critical resources. and when should we return to operating on elective 267 arthroplasty cases again? 268 cms attempted to provide guidance in a public release: "non-emergent, elective 269 medical services, and treatment recommendations." [4] in that attempted guidance, a 270 "tiered framework is recommended to prioritize services and care to those who require 271 emergent or urgent attention to save a life, manage severe disease, or avoid further 272 harms from an underlying condition." the initial early guidance from cms included 273 example procedures in each tier, and included hip and knee replacement in tier 2a, which 274 recommended considering postponing surgery for intermediate acuity surgery, a healthy 275 patient with non-life threatening but potential for future morbidity and mortality. later 276 revisions of that cms public statement (last update april 7, 2020) removed reference to 277 particular procedure types and expanded considerations that should help guide decisions 278 of the cessation of surgeries to include the surrounding region, and not just the practice or 279 hospital, given that we are all members of a larger healthcare delivery system to a 280 population, as opposed to an isolated silo of care within the walls of a single institution. 281 given the lack of firm guidance, most centers have created written and internally 282 monitored criteria to follow. at our centers, this has included emergent surgeries due to 283 life and limb threat, the potential for significant harm if ongoing delay due to severe joint 284 destruction, bone loss or uncontrollable pain, in addition to fractures, infections and 285 dislocations. 286 the ethical struggles we have all experienced internally, as we have significantly 287 restricted care for total hip and knee arthroplasty patients, have been further complicated 288 by the decision of some surrounding hospitals to continue elective surgeries. due to the 289 continued expenditure of resources, including ppe that could be mobilized to centers in 290 need, among the other burdens that the care of these patients places on the surrounding 291 healthcare community and infrastructure, as a referral center, our groups worry about the 292 difficulty in being able to fully offer assistance in the event of complications of the surgical 293 or medical conditions of those patients. 294 whether considering offering surgical care in our own facilities, or observing it 295 occur in the surrounding area, it is clear that patients receiving surgery at this time are at 296 risk. they are leaving their houses when officials are recommending the public to "stay 297 safe and stay home." patients accessing healthcare facilities for their surgeries and 298 clinical visits are potentially risking exposure during the surgical visits as well as 299 perioperative visits and postoperative and rehabilitative care. the currently poorly 300 understood prevalence of asymptomatic carriers along with the potential inability of 301 current testing to detect cases in the early state of covid-19 infection can lead to us 302 further falsely believing that we could bring in a "healthy" patient, who in fact may even be 303 a carrier, and risk exposing our healthcare teams or even risk worse creating outcomes 304 for the patient. recent studies have suggested that the act of surgery may worsen the 305 outcomes in some patients in the unrecognized incubation period [5] . even for the 306 healthiest of patients, beyond the potential exposure risk, there is a burden for the 307 perioperative care that is placed in the supporting healthcare system which is already 308 taxed with the preparation for and care of covid-19 related cases. this infrastructure 309 must be protected until we can safely move forward as unified healthcare community. 310 beyond restricting offering elective care to even the healthiest of patients, we have also 311 struggled with even offering expedited care to the most severe orthopaedic cases, many of 312 which would be justifiable to offer surgery on at this time due to the disease severity and 313 potential for worsening condition with delay. we have taken a cautious approach in many of 314 these cases as well, as it is these patients with the worst orthopaedic conditions who often also 315 have advanced age, severe medical or social comorbidities and additional risk factors. these 316 are also the patients most likely to require postsurgical stays in inpatient facilities, which could 317 add further risk of exposure [6] . surgery in many of these patients goes beyond exposure 318 operating room, but extends into the inpatient facilities, outpatient or home health nurse or 319 therapists, skilled nursing facilities, laboratories, imaging centers and the community through 320 which they must navigate in order to receive their perioperative care. the decision to operate in 321 these patients exposes them to many risks beyond our standard joint replacement risks, 322 significantly challenging the risk-reward balance. 323 the decision to operate and when remains a challenging one, but the onus remains on 324 us to be stewards of health for both our own patients and their orthopaedic conditions, but also 325 their overall health risk and the risk to the surrounding health care community and population as 326 whole requiring imaging or in person visits are accommodated today, as they will be in the future, 357 additional efficiencies, including offering patients the opportunity to receive labs and imaging 358 remote locations, even at sites outside our own healthcare networks, are also likely to prove 359 beneficial to both patients and providers moving forward. 360 educationally, surveys of the trainees have revealed positive reviews of the improved 361 curriculum, content, and delivery of materials. while no question, some of this has been 362 afforded due to the lower surgical volume during this time, the benefit of remote conferences to 363 allow for clinical care at remote sites, the increased number of potential attendees, and the 364 improved content will likely be able to be long lasting changes and improvements with the 365 ongoing use of virtual meeting platforms to supplement the in-person teaching. 366 our past underutilization and even undervalue of technology which allows us as 367 providers to communicate and care for our patients and provide education to our trainees 368 remotely is now clearer than ever. in our specialty, and throughout healthcare, the changes 369 made in response to the covid-19 pandemic are likely to shape the practice of academic 370 medicine as we go forward 371 372 conclusion: 373 the covid-19 pandemic has created widespread changes within our academic health 374 systems and our adult reconstruction and lower limb arthroplasty practices. to manage our 375 clinical and educational responsibilities during this pandemic, we created a model that consisted 376 of four phases of care delivery. we are prioritizing the health and safety of our patients and 377 workforce along with efforts to preserve resources including ppe and hospital capacity by 378 cancelling non-essential surgeries, creating a ranking list based on system utilization 379 requirements, and relying on telehealth/virtual visits/patient engagement and educational 380 platforms to keep our patients and trainees informed, educated, and engaged. 381 382 managing resident workforce and education during the covid-19 pandemic. the 385 the 387 orthopaedic forum survey of covid-19 disease among orthopaedic surgeons in 388 people's republic of china novel coronavirus and orthopaedic 391 surgery: early experiences from singapore public recommendation on nonemergent medical elective procedures clinical characteristics and outcomes of patients undergoing surgeries during the 398 incubation period of covid-19 infection epidemiology of covid-19 in a long-term care facility in king 404 county key: cord-303600-96vtj89w authors: kapoor, deeksha; perwaiz, azhar; singh, amanjeet; chaudhary, adarsh title: elective gastrointestinal surgery in covid times date: 2020-10-22 journal: indian j surg doi: 10.1007/s12262-020-02642-9 sha: doc_id: 303600 cord_uid: 96vtj89w with the covid pandemic claiming deaths the world over, the healthcare systems were overburdened. this led to the cancellation and delay in elective surgical cases which can have far-reaching consequences this study reports our experience of elective gastro-intestinal surgical procedures during the covid pandemic, after instating preventive strategies and screening protocols to prevent the transmission of covid infection. this is a case series analysis of elective gastro-intestinal surgical procedures performed from march 24, 2020, to july 31, 2020. during this period, 314 gastro-intestinal surgical procedures were performed; of which, 45% were for malignancies. the median age of patients was 54 years (range 8 to 94 years). laparoscopy was used in 43% cases. major postoperative complications (clavien-dindo grade 3 and above) were witnessed in 3.5% (11/314) patients, with no statistically significant difference when compared with the rate of major complications last year (45/914, 4.9% vs 11/314, 3.5%, p = 0.3). the 30-day mortality rate was 1% (n = 3). no patient developed covid in the postoperative period. with preventive and screening strategies and proper patient selection, it is possible to deliver safe gi surgical services during the covid pandemic, without increasing the risk for major postoperative complications. the covid pandemic adversely affected life all over the world. the healthcare systems were challenged and crippled due to the sudden surge of a large number of sick patients. since there was no previous experience with the disease, there was confusion and uncertainty about the appropriate prophylaxis and treatment. surgical procedures in hospitals nearly stopped as the available resources were diverted to covid patients. the patients who needed elective surgery were scared to visit the hospitals because of their legitimate fear of getting infected. the widespread "lockdowns" with the cessation of all forms of public transport further added to the problem, as patients could not reach the hospitals even if they wanted. surgeons were also reluctant to operate because of the potential risk of the transmission of infection to the patients and healthcare workers. like never before, the concept of conserving work force was realized, in case a crisis precipitated. in times of this pandemic, some patients definitely suffered because of delays in surgery, and the real extent of the damage caused by this delay is not easy to assess. india reported the first case of covid 19 on january 30, 2020, followed by a nationwide lockdown from march 24, 2020, onwards. healthcare resources were regulated to optimize services for patients with covid infection, and elective surgeries nearly stopped in most hospitals. despite these problems, we were approached by many patients for surgical treatment, and we did agree to operate on some of these patients. these decisions were not easy, because of the unfortunately unique circumstances where both the patient and the surgical and anesthesia teams were at risk of getting infected. this paper shares the experiences of a functioning surgical unit in covid times in the pattern of the selection of patients for surgery and the overall results of surgery and the efficacy of the preventive strategies. the hospital, being actively involved in treating covid patients, undertook various measures like setting up a dedicated flu clinic, the segregation of buildings into covid and non-covid blocks, the separation of entry/exit, and the complete isolation of the movement circuit for covid-positive or suspected patients. inpatient areas were divided into four zones: "red": covid-positive patients; "orange": untested with covid symptoms; "yellow": untested with no covid symptoms; and "green": covid-negative after testing. patients were planned for elective surgery only after being shifted to the green zone. the team of healthcare providers was separated into covid and non-covid teams, maintained on a rotating schedule, minimizing crossover as far as possible. in case of the exposure of a member of the non-covid team to a positive patient, strict contact tracing was performed, followed by quarantine or testing as indicated. during the initial phase of the pandemic, elective surgical procedures were largely suspended. once inpatient protocols were established and surgical services could be safely delivered, patients were assessed for elective surgery. all patients with proven or suspected malignancies of the gi tract were admitted and evaluated for their fitness for surgery as per the existing policies of the department. patients with the american society of anesthesiologists (asa) grade i/ii, who understood concerns with surgery under such circumstances, were preferentially selected for operations. elderly patients with cancers and comorbidities and those who could be offered preoperative therapy were referred to medical oncology and internal medicine teams respectively for optimal management. patients who had completed neoadjuvant therapy and were due for surgery were followed on teleconsultations and called to the hospital only when the surgery could be planned. fit and young patients, who had completed adjuvant therapy, due for secondary procedures like stoma closures, and wished to be operated upon, were also considered. patients with benign diseases were discouraged for surgery during this period. patients with cholecystitis or appendicitis whose symptoms persisted despite medical treatment were taken up for surgery. patients improving on medical management were asked to wait for elective surgery after the stabilization of the covid condition. the movement of personnel in and out of an operating room was kept to a minimum [1] . the anesthetists used complete personal protective equipment (ppe) (n95 masks, face shield, cap, gloves, and non-porous disposable gowns) for all patients irrespective of covid testing report and previous exposure [2]. the surgical team was allowed to enter the operating room only 10-15 min after the intubation of the patient to allow possible aerosols to settle. the ppe used by the surgical team included n95 masks, gloves, cap, face shields, and regular cloth gowns, for all covid negative patients. complete ppe, along with disposable non-porous gowns, were used for patients for whom preoperative covid testing could not be performed. two operating theaters were segregated and dedicated for surgeries in covid positive patients or for emergency surgeries for which the covid report was not available. post-operatively, patients were nursed in covidnegative wards, as they have tested negative before the operation. minimal movement was allowed across the floors. visitors were restricted, and only one attendant was allowed with the patient. patients were counseled about early discharge and follow-up on tele-consultation where clinically deemed fit. precautions during laparoscopic surgery [3] [4] [5] for laparoscopic surgery, new trocars were used to avoid peritrocar leak. for the proper disposal of carbon dioxide, an underwater seal connected to suction was used, which was connected to an hmef (heat and moisture exchange filter) at both ends. the underwater seal contained 1% sodium hypochlorite solution. once placed, the ports were not used to evacuate smoke or for desufflation unless connected to an underwater seal disposal system. the specimen was removed only after the complete evacuation of carbon dioxide followed by port site closure. clinical, demographic, and surgical parameters of the patients undergoing surgery during this period were retrospectively collected from the electronic hospital information system and medical records department. the data on cancer surgeries was derived from our prospectively maintained database. this data was compared with the surgical results and trends of the same period last year (2019), obtained from our annual audit. complications were classified according to clavien-dindo classification [6] . thirty-day mortality was defined as death occurring within 30 days of surgery because of any medical or surgical cause. re-admissions were defined as any readmission occurring as a result of complication/sequelae of the surgical process, within 30 days of discharge. descriptive analysis of quantitative parameters was expressed as median with interquartile range (iqr). categorical data were expressed as absolute numbers and percentages. the mann-whitney u-test was used for testing of the median age between two independent groups. cross tables were generated, and chi-squared test was used for testing of associations. twoproportion z test was used for testing of the proportion difference. p value < 0.05 is considered statistically significant. all analysis was done using spss software, version 24.0. between march 24, 2020, and july 31, 2020, 314 gi surgical procedures were performed. the department operated at 10% of its capacity in april 2020, which improved to more than 40% in june 2020 and to about 50% operative capacity in july (graph 1). two-thirds of these patients were men. the age of the patients ranged from 8 to 94 years, with a median age of 54 years. about 10% (31/314) were in their 8th decade of life or more. the median age of these patients was not significantly different from the median age of patients in prior months (54 years vs 52 years , p value = 0.45). of these, 141 surgeries (44.9%) were performed for malignancy, and 23 (17.3%) had received preoperative therapy. the proportion of cancer surgeries performed during this period was significantly higher than those from the same quarter last year (23.5% in 2019 vs 44.9% in 2020, p < 0.0001). the spectrum of surgeries performed for gi cancers is described in table 1 . laparoscopy was performed where indicated and executed uneventfully with the help of an underwater seal suction system to dispose carbon dioxide used for the creation of pneumoperitoneum. of 314 procedures, 140 procedures (43.3%) were performed laparoscopically or required the use of laparoscopy for staging or diagnostic purposes. major postoperative complications (clavien-dindo grade 3 and above) [6] were seen in 11 patients (3.5%), and grade 1 and 2 complications were seen in 119 patients (37.9%) ( table 2 ). the incidence of major postoperative complications was not statistically higher than that of last year (45/914, 4.9% vs 11/314, 3.5%, p = 0.3). the rate of surgical site infections declined during this period, though not statistically significant (43/914, 4.7% vs 12/314, 3.8% p = 0.3). the 30-day mortality rate was 1% (n = 3). one of these was a patient with acute severe necrotizing pancreatitis who underwent necrosectomy; the second patient had locally advanced caecal carcinoma who underwent right hemicolectomy, end ileostomy, and distal mucous fistula; and the third patient was a case of metastatic pancreatic cancer with bowel obstruction. the cause of death in them was sepsis leading to multiorgan dysfunction. the 30-day mortality rate was comparable to that of 2019 (11/914, 1.2% vs 3/314, 1%, p = 0.77). until the submission of this paper, 6 patients (1.9%) have been readmitted, 4 with poor oral intake following cancer surgery, one with acute kidney injury, and one with postoperative ileus. on comparing with surgical results of the same period of the previous year, the total number of operative cases was significantly less, but the absolute number of cancer surgeries was similar. six out of 314 patients (1.9%) were detected to be covid positive during preoperative workup (4 malignancy cases and 2 benign), who were all asymptomatic carriers. their surgery was deferred by 3 weeks and planned once the rt pcr turned negative on repeat testing. all of these patients had an uneventful postoperative recovery, with no complications. none of the surgical patients developed covid-related symptoms in the postoperative period or required testing while in the hospital. one of the surgeons developed minor flu-like symptoms but tested negative for covid on the rt pcr of nasopharyngeal swab and improved on symptomatic treatment. two residents and one consultant were quarantined for 2 weeks each, after exposure to positive patients. our experience taught us that there are three main challenges in surgery during the covid pandemic, namely, how to select patients for elective surgical procedures; modifications, if any, of the existing treatment and surgical protocols; and ensuring the safety of patients and the healthcare personnel involved. this study shows that with judicious selection and the requisite precautions, it is not unsafe to perform elective gi surgery during the pandemic. the mortality and morbidity of the patients operated by us during this period were no different from those of earlier months. this can encourage other surgical units and influence the hospital administrators to restart the suspended elective surgical operations. with the pandemic showing no signs of improvement and no reliable preventive treatment, there was an expected decrease in the number of patients seeking surgical care. about 38% of oncology work was cancelled globally [7] with only 10% of major pancreato-biliary centers in the world operating at 75-100% of their usual operating capacity [8] . with the aim of avoiding delays in the surgical management of patients who needed it the most, we restructured the outpatient department to ensure patient and physician safety. tele-consultations were performed extensively to maintain the line of care and guide the management of surgical patients, especially those with gi cancers. although elective procedures were largely cancelled or postponed in the month of april, once inpatient protocols were established, delivering safe surgical services appeared feasible. the majority of patients operated during this period were cancer patients, with many of them with rectal or upper gi malignancies who had completed neoadjuvant therapy and were waiting on surgical resections. we prioritized their care, through proactive reach-out programs and counseling, facilitating a safe access to surgical services. young and fit patients, who were diagnosed with malignancy during this period and did not warrant preoperative therapy, were also taken up for surgery (36.2%). patients with borderline tumors and patients with multiple comorbidities were offered preoperative therapy and medical management to optimize their comorbidities. this led to a significant decrease in asa 3 patients during this period compared with that of the previous year (10.7% vs 7%, p = 0.029). surgery for benign disease was planned only for those who continued to remain symptomatic despite optimal medical management. the most common indications were appendicitis and cholecystitis, which failed during non-operative treatment. given the morbidity associated with pancreatitis, patients with biliary pancreatitis were planned for cholecystectomy as per routine protocols. other patients were followed up with tele-consultations and were advised to undergo surgery only if medical management failed. the increased risks of surgery during covid times have been highlighted in a study from china suggesting that covid-positive patients were more likely to require mechanical ventilation and icu stay and had a higher chance of death [9] . another study reported the increased risk of sars-cov-2 (severe acute respiratory syndrome coronavirus-2) infection in cancer patients (or 2.31, 95% ci: 1.89-3.02) [10] . we did not experience a high rate of sars-cov-2 positivity in malignant patients, and neither did we experience an increase in postoperative complications during this period. we did observe a statistically non-significant decline in the number of surgical site infections which might have been because of decreased operative room traffic, extensive hand hygiene, and limited patient mobility with decreased interpersonal association among admitted patients. we experienced an "all case mortality rate" of 1%, which was definitely not higher than the "all-case surgical mortality rate" for the year 2019 at 1.2%. in addition, none of our patients developed covid-like symptoms in the postoperative period or required retesting. while recommendations exist from various surgical societies, suggesting a delay in surgical procedures with more aggressive use of preoperative therapy, there remains a concern about chemotherapy-induced immunosuppression in malignant patients, which may hypothetically increase the incidence and the severity of covid infections in them. none of our patients who had received chemotherapy developed covid infection postoperatively or on follow-up till the submission of this paper. the quality of evidence for avoiding the use of laparoscopy and the complete use of level 3 ppe (including hazmat suits) is also rather poor [11] . we do not propagate the routine use of hazmat suits for patients who have cleared covid screening protocols, in favor of conserving resources and minimizing excessive costs. many authorities have raised concerns about the dissemination of virus during minimal access surgery based on experience with other viruses [4, 12] ; however, the evidence is not replete on the risk of transmission of the sars-cov-2 virus in surgical smoke [5] . we used level 2 ppe [2] for surgical staff and continued the use of laparoscopy as usually indicated and did not experience any adverse events with the same. preoperative screening protocols not only protect the patients, but also decrease the chances of exposing doctors and staff to the virus. the three-tier screening system helped us in ensuring safe clinical practice both for the patients and healthcare workers. nasopharyngeal samples were used for rt pcr testing as the sensitivity in nasopharyngeal samples has been shown to be higher [13] . real-time reverse transcriptase pcr is considered as a simple qualitative assay with high specificity [14, 15] . although solo reliance on covid testing may be inadequate, combining with clinical parameters and imaging where relevant increases the accuracy of the test [14] [15] [16] . the prompt quarantine of exposed healthcare personnel and a robust contact tracing system helped in securing a safe working environment for the department. most previous publications express opinions and concerns regarding surgery in covid times, while some focus on issues regarding resident training. ours is one of the few studies which shares the result of the actual conduct of surgical procedures during the peak of the pandemic. apart from preoperative screening and the precautions we undertook to prevent the spread of infection, there was no alteration in the protocols and the conduct of surgical procedures. we do realize that the number of procedures performed is small, but we were able to re-establish our services to 40% of the baseline over a period of 6 weeks and have been improving ever since. since the pandemic has not been fully resolved and there is no end in sight, patients who need surgery cannot be made to wait any longer. the fact that the complication rate and mortality in our series were no higher shows that gastrointestinal surgical procedures can be safely performed during the pandemic. encouraging reports are also available from other centers of continuing cancer surgeries with relevant precautions [17] [18] [19] . such mini-victories can help in laying ground rules for delivering successful and safe surgical work during the subsequent waves of the pandemic. by using structured preoperative triaging systems, adequate patient selection, and segregation of covid and non-covid circuits, it is possible to deliver safe surgical care to patients who deserve it, without increasing the virus spread among patients or healthcare providers. author contribution deeksha kapoor: study design conception, data acquisition, interpretation and analysis, drafting of the article, critical review for intellectual content, final drafting, and approval of the manuscript. azhar perwaiz: study design, critical review for intellectual content, final drafting, and approval of the manuscript. amanjeet singh: study design conception, critical review for intellectual content, and final approval of the manuscript. adarsh chaudhary: study design, critical review for intellectual content, final drafting, and approval of the manuscript. the work has been performed in the department of gi surgery, gi oncology, minimally invasive and bariatric surgery, medanta-the medicity, gurugram, haryana, india. compliance with ethical standards the approval from the institutional review board was obtained (micr-1141/2020) and a waiver from the ethics committee obtained given the retrospective nature of this study. we the authors, deeksha kapoor, azhar perwaiz, amanjeet singh, and adarsh chaudhary, have obeyed and complied with ethical standards. protecting health-care workers from subclinical coronavirus infection covid-19 pandemic: perspectives on an unfolding crisis emergency surgery during the covid-19 pandemic: what you need to know for practice safe management of surgical smoke in the age of covid-19: covid-19 surgical smoke the clavien-dindo classification of surgical complications: five-year experience elective surgery cancellations due to the covid-19 pandemic: global predictive modelling to inform surgical recovery plans: elective surgery during the sars-cov-2 pandemic delivery of hepato-pancreatobiliary surgery during the covid-19 pandemic: an european african hepato-pancreato-biliary association (e-ahpba) crosssectional survey cancer patients in sars-cov-2 infection: a nationwide analysis in china sars-cov-2 transmission in patients with cancer at a tertiary care hospital in wuhan, china 0 20 a u g ) recommendations on key practical measures in laparoscopic surgery during the covid-19 pandemic: n/a minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy nasopharyngeal swabs are more sensitive than oropharyngeal swabs for covid-19 diagnosis and monitoring the sars-cov-2 load recent advances and perspectives of nucleic acid detection for coronavirus combination of rt-qpcr testing and clinical features for diagnosis of covid-19 facilitates management of sars-cov-2 outbreak real-time rt-pcr in covid-19 detection: issues affecting the results safety of cancer surgery during the covid-19 pandemic: safety of cancer surgery during the covid-19 pandemic caught in the crossfire: hepato-bilio-pancreatic cancer surgery in the midst of covid-19: n/a outcomes of elective major cancer surgery during covid 19 at tata memorial centre: implications for cancer care policy the authors declare that they have no conflict of interest.this is a retrospective analysis of elective surgical work performed during the covid pandemic, the preventive strategies adopted and postoperative outcomes. this paper represents the original work performed by the authors and is the product of professional research.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-317468-pnxni1x5 authors: louie, philip k.; barber, lauren a.; morse, kyle w.; syku, marie; qureshi, sheeraz a.; lafage, virginie; huang, russel c.; carli, alberto v. title: early peri-operative outcomes were unchanged in patients undergoing spine surgery during the covid-19 pandemic in new york city date: 2020-09-15 journal: hss j doi: 10.1007/s11420-020-09797-x sha: doc_id: 317468 cord_uid: pnxni1x5 background: healthcare resources have been greatly limited by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic halting non-essential surgical cases without clear service expansion protocols. questions/purposes: we sought to compare the peri-operative outcomes of patients undergoing spine surgery during the sars-cov-2 pandemic to a matched cohort prior to the pandemic. methods: we identified a consecutive sample of 127 adult patients undergoing spine surgery between march 9, 2020, and april 10, 2020, corresponding with the state of emergency declared in new york and the latest possible time for 1-month surgical follow-up. the study group was matched one-to-one based on age, gender, and body mass index with eligible control patients who underwent similar spine procedures prior to the sars-cov-2 outbreak. surgeries performed for infectious or oncologic indications were excluded. intraand post-operative complication rates, re-operations, hospital length of stay, re-admissions, post-operative visit format, development of post-operative fever and/or respiratory symptoms, and sar-cov2 testing. results: a total of 254 patients (127 sars-cov-2 pandemic, 127 matched controls) were included. one hundred fifty-eight were male (62%), and 96 were female (38%). the mean age in the pandemic group was 59.8 ± 13.4 years; that of the matched controls was 60.3 ± 12.3. all patients underwent general anesthesia and did not require re-intubation. there were no significant differences in 1-month post-operative complication rates (16.5% pandemic vs. 12.6% control). there was one death in the pandemic group. no patients tested positive for the virus. conclusion: this study represents the first report of post-operative outcomes in a large group of spine surgical patients in an area heavily affected by the sars-cov-2 pandemic. electronic supplementary material: the online version of this article (10.1007/s11420-020-09797-x) contains supplementary material, which is available to authorized users. despite a plethora of editorials and expert opinions, scientific literature exploring the peri-operative outcomes of patients undergoing surgical procedures during the covid-19 pandemic is sparse [2, 3, 7, 13, 17] . a single case series of 34 chinese patients who developed pneumonia due to infection with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) shortly after elective surgery reported catastrophic results, with 44% needing intensive care and 20% not surviving [9] . however, this experience was in the incubation phase of the pandemic, when pre-operative patient screening, scrupulous use of personal protective equipment, and knowledge of critical risks factors for poor outcomes were not available. tracking the peri-operative and post-operative course of patients undergoing essential, non-infectious, non-oncologic surgery in an epicenter of sars-cov-2 cases that was subject to detailed government-led restrictions on social distancing and travel restrictions could help medical institutions, local governments, and public health agencies better determine when to transition surgical care to non-emergent conditions [4, 5, 15] . our tertiary referral center is located in new york city and has provided emergency orthopedic services to patients in the northeastern usa. due to the time-sensitive nature of certain spinal pathologies, the spine service has been the most active surgical service during this time, caring for patients presenting with progressive neurological deficits, myelopathy with cord at risk, spine trauma with instability, and cauda equina syndrome. the purpose of this study was to describe the peri-operative outcomes of patients undergoing spine surgery for spine pathology during the heights of the covid-19 pandemic in new york city, including particular attention to the development of sars-cov-2 symptoms, post-operative complications, and patient monitoring following hospital discharge during the early post-operative period. following institutional review board approval, a retrospective, single-center study was performed to identify all patients undergoing spine surgery at a tertiary referral orthopedic hospital located in new york city from march 9 to april 10, 2020. the surgical dates were chosen specifically to correspond to the weeks in which a state of emergency was declared in new york state and the latest possible time by which a 1-month surgical follow-up of all patients was possible. this minimum follow-up requirement was chosen to cover the 14-day known typical incubation period of sars-cov-2 infection, whereby viral exposure can subsequently lead to manifestation of symptoms [18] . the surgical dates also encompass a period of time in which the institution (1) followed state directives to suspend elective surgery and instead utilize strict criteria to define essential surgical cases (table 1) , (2) dispensed personal protective equipment to medical personnel, (3) selectively performed post-admission sars-cov-2 testing (cepheid xpert xpress sars-cov-2 rt-pcr, sunnyvale, ca, usa) following patient assessment by a multidisciplinary team, (4) initiated a telehealth service for post-operative follow-up, and (5) began a progressively intensive patient screening process (fig. 1) . the study group was matched one-to-one with eligible control patients who underwent similar spine procedures for similar indications within our institution prior to the sars-cov-2 infection based on age, gender, and body mass index (bmi). study exclusion criteria included patients with less than 2 weeks of follow-up and patients undergoing surgery for infectious or oncology-related reasons. the latter criterion was chosen to permit the study group to be more generalizable to elective surgical patients and to minimize confounding reasons for post-operative fever and thromboembolic complications [14] . rationale for "essential surgery" in the earliest phases of the covid-19 pandemic in the usa (early march 2020), prevailing epidemiological models predicted that the number of critically ill patients would vastly exceed the number of intensive care unit (icu) beds and ventilators available. in conjunction with the state government, new york state hospitals developed plans to create additional icu beds and to limit elective surgery in order to prevent exposure to patients and healthcare workers and also to conserve resources (personal protective equipment, ventilators, icu beds) for the anticipated wave of critically ill patients. recognizing not only that the pandemic would likely preclude elective surgery for several months, but also that delay of surgical treatment for several months could result in permanent disability or neurological impairment in a subset of spine surgery patients, the following "essential surgery" criteria were determined: progressive weakness on exam or weakness with active denervation on electromyography, myelopathy with cord at risk, fracture or trauma with spinal instability, or cauda equina syndrome ( table 1 ). of note, new york state banned elective surgery on march 25, 2020; thus, our hospital suspended elective surgery 9 days prior to the state's mandate. scheduled patients underwent a brief pre-operative phone screen, which consisted of 2 major points: (1) asking patients if they were known to have sars-cov-2 and (2) a review of symptoms within the last 2 weeks including fever, cough, shortness of breath, sore throat, loss of taste/smell, myalgias, or abdominal pain/diarrhea. in person, patients underwent oxygen saturation measurement on room air and a temperature check. if there was concern that a patient had sars-cov-2, the patient was promptly placed on the appropriate isolation precautions and tested according to clinical impression. pre-operative patient demographics including age, gender, and body mass index were collected, as well as indicators of relevant comorbidities, including their american society for anesthesiology (asa) score and charlson comorbidity index (cci) score. the zip code, city, county, and state of the patients' primary residence were collected to determine their geographic distribution and if they resided within counties with over twelve thousand reported sars-cov-2 cases within their respective state. these counties included the seven highest in new york (bronx, kings, manhattan, nassau, suffolk, queens, westchester) and five highest in new jersey (bergen, essex, hudson, middlesex, passaic, union). pre-operatively, surgical indications and the status of the patient upon presentation for surgery, including specific indicators of possible viral pneumonia (presence of fever, abnormal acute findings on chest radiographs), were recorded. surgical data included the operative procedure/levels, operative time, and the occurrence of any intra-operative complications. post-operatively, the presence of a fever (temperature > 38.1°c), the number of fever readings, the subsequent medical workup, and sars-cov-2 viral testing were recorded. inpatient complications, necessity for blood transfusions, and length of stay were recorded. following discharge from the hospital, all post-operative encounters between patients and medical personnel were analyzed, with the type of encounter (in-person, telephone call, scheduled telehealth visit) and if common symptoms concerning for sars-cov-2 infection (fever, cough, shortness of breath, new myalgias or arthralgias unrelated to the surgical site, and loss of taste or smell) were discussed. admission to any hospital and any re-operations within the follow-up period were also recorded. univariate comparisons were performed between patients operated during the pandemic versus historical controls. furthermore, a subgroup comparison was performed among pandemic study patients who underwent surgery before versus after the suspension of elective procedures. continuous variables were assessed for normality using the kolmogorov-smirnov test, with unpaired 2-tailed t tests and mann-whitney tests used where appropriate (sigmaplot, san jose, ca, usa). categorical variables were table 2) . additionally, the asa scores, cci scores, indications for surgery, and surgical procedure were similar between the two groups (p = 0.764, 0.823, 0.530, 0.645, respectively). the distribution of surgical procedures that comprised each group was similar as lumbar decompression/ discectomies (32.3% sars-cov-2 period vs. 34.6% control) were the most common procedures, while anterior cervical surgeries (28.3% vs. 29.9%) and lumbar fusions (25.2% vs. 32.3%) were the second and third most common, respectively (p = 0.645; table 3 ). operative durations were similar between both groups of patients (2 h 42 min ± 1 h 29 min sars-cov-2 vs. 2 h 38 min ± 1 h 46 min; p = 0.273). there were 5 reported intra-operative complications (all durotomies) in the pandemic group and 8 intra-operative complications (all durotomies) in the control group. all patients underwent general anesthesia and did not require re-intubation. there were no differences in post-operative complication rates within the 1-month following surgery (16.5% sars-cov-2 period vs. 12.6% control; p = 0.464). of note, there was one death in the pandemic period. approximately 10 days following a l4-5 posterior decompression and fusion for cauda equina syndrome, the 94-year-old patient developed fevers at home. given the high risk of sars-cov-2 exposure in the local emergency departments (ed), the patient was recommended against presenting to the ed. four days later, the patient passed away at home, without formal sars-cov-2 viral testing. there were no reported deaths in the historical control group. following surgery, the length of hospitalization was similar between both groups (3.1 ± 4.2 days sars-cov-2 period vs. 2.6 ± 3.0 days control; p = 0.540) ( table 4 ). there were significant differences in the format of post-operative visits (p < 0.01). in total, 80 patients (63.0%) in the pandemic group underwent formal telehealth visits, while only 3 patients (2.4%) underwent in-person visits. in contrast, no patients in the historical control group participated in formal telehealth visits and 117 (96.7%) returned for in-person post-operative visits. no patients during the sars-cov-2 period who were tested for sars-cov-2 (8 inpatient and 3 post-discharge) tested positive, and no patients in the historical control underwent viral testing. similar findings were observed with the development of a fever (9 inpatient and 8 post-discharge [sars-cov-2 period] vs. 5 inpatient and 2 post-discharge; p = 0.680) and respiratory symptoms (2 inpatient and 3 postdischarge [sars-cov-2 period] vs. 1 inpatient and 0 postdischarge [historical control]; p = 0.111). however, given the small number of patients presenting with respiratory symptoms, our findings do show a trend towards an increased incidence of post-operative respiratory symptoms in the pandemic group (fig. 2) . the historical control patients presented with a greater number of re-admissions within 30 days (7 vs. 1; p = 0.057), but there was no significant difference in re-operation rates between groups (p = 0.348). three patients in the pandemic group required a re-operation within 30 days of surgery. one patient underwent surgery to revise a medial pedicle screw breach resulting in l5 motor weakness. the second patient underwent an irrigation and debridement (i&d) of a lumbar spine hematoma, and the last patient underwent revision decompression for an acute recurrent disc herniation following a single-level lumbar decompression surgery. in the historical control, 5 patients required re-operation. two patients experienced radicular symptoms from an epidural hematoma, which required an irrigation and debridement of the lumbar spine, and 2 patients presented with acute recurrent lumbar disc herniations, which necessitated revision decompression surgeries. the final re-operation in the historical group was a patient who developed an abscess in the neck following an acdf (without evidence of esophageal perforation), which required a cervical irrigation and debridement. when comparing surgical cases performed before (76 cases) and after (51 cases) the suspension of elective cases, there was a significant decline in the number of cases performed per day, indicating surgeon adherence to institutional guidelines (12.6 ± 5.9 vs. 3.0 ± 2.9 cases per day, p < 0.01). furthermore, we identified no difference in patient demographics (age, p = 0.248; gender, p = 0.876; bmi, p = 0.465; asa, p = 0.304; cci, p = 0.50), peri-operative characteristics (surgical time, p = 0.404; post-operative complications, p = 0.989), or post-operative course (length of stay, p = 0.909; post-operative fever, p = 0.989; re-operations, p = 1.0). despite rigorous efforts of containment and quarantine, the incidence of sars-cov-2 continues to steadily rise globally [18] . although viral titers and antibody testing are becoming available across several countries, it remains unclear if patients who (1) actively have sars-cov-2 infection, (2) have recovered and do or do not have high circulating antibody titers, or (3) have not yet been exposed are at an increased risk for developing perioperative or post-operative complications. in fact, to date extremely limited outcome data of any kind on patients undergoing surgery during the pandemic is available, making it difficult for physicians and institutions to determine how to stratify patient risk factors when providing surgical services. this study is the first to describe the inhospital course and short-term outcomes of over one hundred patients living in the global epicenter of sars-cov-2 who underwent spine surgery for essential spine pathologies. with pre-operative viral testing not being available for the majority of the study period, our study cohort was mostly screened using clinically based parameters-a simple questionnaire regarding recent respiratory symptoms, temperature measurements on hospital presentation, and a pre-operative chest x-ray. with this combination of (1) a simplified screening process, (2) clear indications for essential surgery, (3) inpatient isolation protocols, (4) viral testing based on clinical impression, and (5) discharge instructions that emphasized social distancing with close telephone/telehealth follow-up, we found that patients operated on during the pandemic did not have a significantly higher risk of peri-operative complications including postoperative fever and/or respiratory distress compared with a carefully matched pre-pandemic group. we acknowledge limitations in this study. despite a strong likelihood of patients being infected with sars-cov-2, the lack of formal viral testing prior to surgery makes it impossible for us to verify this claim. there were likely asymptomatic sars-cov-2-positive patients in the cohort, but the number of these is difficult to quantify, similar to the general public. post-discharge symptoms were self-reported by patients at the time of telemedicine or telephone interactions, meaning it was not possible to verify if sars-cov-2-related symptoms such as fever or hypoxia were truly occurring. this finding reinforces several consensus documents which recommend that surgery be deferred in such high-risk groups [6, 10] . despite this, most patients returned home to counties with a "high" number of sars-cov-2-positive individuals and have done well overall with proper instruction and communication in the first month after surgery. lastly, our cohort sizes may be small to detect significant differences in post-operative complications; however, given this public health crisis and government mandates, we were limited to treating patients who met essential requirements for surgery. the mortality we describe occurred in a healthy 94-yearold man who had developed cauda equina syndrome. the posterior decompression and fusion for cauda equina syndrome was performed without complication. prior to the onset of fever 10 days after surgery, he had been progressing well. although we did not observe any statistical difference in post-operative complications, the presence of a sars-cov-2-related mortality in our study cohort is a pertinent finding that does highlight the known risk association of age as well as comorbidity profile with serious illness secondary to viral infection [8, 19] . two-thirds of our study cohort presented from counties that have the highest number of sars-cov-2 cases, making it highly likely that more than one patient underwent surgery while being actively infected with the virus. although very recently published consensus statements have emphasized that all patients undergoing surgery should be screening for sars-cov-2, the non-significant differences in the post-operative course of our study cohort question the relevance of viral screening in asymptomatic patients who are clinically well, but require urgent surgery. furthermore, given the likelihood of study patients having undetected viral disease, our inability to find a higher incidence of post-operative pulmonary complications despite vigorous inflammatory provocation (general anesthesia and surgery) encourages future research on the "cytokine storm" associated with sars-cov-2 infection and the likelihood to occur post-operatively [12] . although future investigations involving pre-operative viral testing will clarify this question, our study findings suggest that presurgical clinical status and patient comorbidity status are important predictors of post-operative performance rather than pre-operative viral status alone. our study has also demonstrated that close outpatient surveillance through telephone and telemedicine follow-up is safe and effectively avoids putting patients at risk of sars-cov-2 exposure by returning to the hospital. although telemedicine has been previously shown to be cost-effective, its utility in the context of a pandemic is now clear [1, 11] . although virtual visits for new patients require modified physical examination techniques and pre-visit patient instructions, the capability to evaluate surgical wounds, respiratory symptoms, and a patient's general status make this interaction modality an essential tool that should be utilized across the surgical subspecialties for post-operative care [16] . in conclusion, this study represents the first report of post-operative outcomes in a large group of patients in an area heavily affected by the covid-19 pandemic. our findings illustrate the challenges that institutions face in providing surgical care during a pandemic, and directly demonstrate how innovative interventions (such as telemedicine and patient education regarding social distancing and symptom reporting) can maximize patient safety following surgery. human/animal rights: all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2013. informed consent: informed consent was waived from all patients for being included in this study. required author forms 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international consensus group (icm) evidence of benefit of telerehabitation after orthopedic surgery: a systematic review cytokine storm syndrome in severe covid-19 a review of state guidelines for elective hssj orthopaedic procedures during the covid-19 outbreak postoperative nonpathologic fever after spinal surgery: incidence and risk factor analysis how to risk-stratify elective surgery during the covid-19 pandemic? telemedicine in the era of covid-19: the virtual orthopaedic examination a framework for prioritizing head and neck surgery during the covid-19 pandemic. head neck clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study key: cord-283215-dgysimh5 authors: al-jabir, ahmed; kerwan, ahmed; nicola, maria; alsafi, zaid; khan, mehdi; sohrabi, catrin; o'neill, niamh; iosifidis, christos; griffin, michelle; mathew, ginimol; agha, riaz title: impact of the coronavirus (covid-19) pandemic on surgical practice part 2 (surgical prioritisation) date: 2020-05-12 journal: int j surg doi: 10.1016/j.ijsu.2020.05.002 sha: doc_id: 283215 cord_uid: dgysimh5 the coronavirus (covid-19) pandemic represents a once in a century challenge to human healthcare with 2.4 million cases and 165,000 deaths thus far. surgical practice has been significantly impacted with all specialties writing guidelines for how to manage during this crisis. all specialties have had to triage the urgency of their daily surgical procedures and consider non-surgical management options where possible. the pandemic has had ramifications for ways of working, surgical techniques, open vs minimally invasive, theatre workflow, patient and staff safety, training and education. with guidelines specific to each specialty being implemented and followed, surgeons should be able to continue to provide safe and effective care to their patients during the covid-19 pandemic. in this comprehensive and up to date review we assess changes to working practices through the lens of each surgical specialty. the rapid spread of covid-19 around the world (2.4 million cases and over 165,000 deaths brings new challenges for the international medical and surgical community [1] ; the unprecedented strain it has put on units around the world has unfortunately been accompanied by an increasing number of covid-19 infections and subsequent deaths amongst medical colleagues [2] . it is therefore important to follow the latest guidelines for surgical management of patients in order to reduce the risk of infection for patients and medical personnel. in part 1, the authors have reviewed the current evidence and offered general recommendations for changes to surgical practice to minimise the effect of the covid-19 pandemic on surgical units. prioritisation of surgical services during this pandemic must be a careful balance of patient needs and resource availability and the european association of urology guidelines office offer the following suggestions for factors that must be taken into account [3] oncological surgery with the disruption of normal surgical practices due to workforce shortages as well as resource limitations due to covid-19, it is important to rationalise all surgeries undertaken. this is especially important in cancer surgery where the surgeon must balance risk of potential viral transmission to the surgical team as well as of possible progression of cancer in the patient [4] . in the first instance, patients should be transferred to hospitals with greater capacity to cover procedures, with the suggestion of setting up local 'covid-19 free' surgical hubs for the continuation of oncological surgery. in cancer patients, general considerations must also be taken into account. it is routine that most complex elective surgical procedures receive ward-based care post-operatively. occasionally, patients may develop postoperative complications requiring itu admission and/or re-operation, which may prove to be a challenge with the increasing numbers of covid-19 patients requiring level 3 care. it is recommended that length of stay (los) be decreased to a minimum, especially in critical care [5, 6] furthermore, the nhs has identified the cancer patients which are most at risk during the outbreak and who are likely to become seriously or critically unwell if they were to contract the virus. these include: patients on active chemo-or radiotherapy; immunotherapy or any antibody treatments; or immune system modulation therapy (eg. protein kinase inhibitors or post-transplantation immunosuppressants). this group also includes patients with blood or bone marrow cancers ie. leukemia, lymphoma or myeloma. further to the above, factors such as age above 60, pre-existing cardiovascular and/or respiratory disease have been associated with a worse prognosis. following a multidisciplinary team (mdt) discussion, clinicians are encouraged to clearly outline the risks and benefits with patients before commencing or continuing any cancer treatment [5] . surgical teams are encouraged to offer telephone or video consultations when possible, cancel follow ups which are deemed non-essential in an attempt to minimise patient contact. in cases where patients must attend hospital appointments, time patients spend in services should be minimised. they should have a scheduled appointment time and should be advised not to arrive early [5] . surgeons are encouraged to maximise breast conserving surgery when possible, as definitive mastectomy and/or reconstruction should be deferred when possible if radiotherapy options are available. surgeons should also consider alternative, non-surgical therapy where possible. suggestions for prioritisation are in table 1 additionally, lu et al [8] recommended prioritising breast disease care according to benign or malignant disease. for benign disease, they use the bi-rads grading score and advise that patients with score <3 are suitable for a 3-month deferral. patients grading ≥4 should have a biopsy, reviewed in 4-8 weeks then re-assessed. for malignant disease, with a bi-rads grade ≥4 and highly suspicious for malignancy, a core needle biopsy or fine needle aspirate should be arranged urgently. in hospitals in phase 2 or 3, neoadjuvant therapy is given priority over surgical intervention and is to be administered in a day chemotherapy unit to avoid unnecessary admissions. they also recommend postponing follow-up adjuvant chemotherapy in patients who have recently had surgery for early stage breast cancer. for more at risk patients (such as the elderly or immunosuppressed) with a low tumour burden, a reduced dose (≥85% of the standard dose) is recommended. finally, where possible, adjuvant radiotherapy should be delayed by 1-2 months to avoid nosocomial transmission [8] . for patients with stable remission, they recommend that reviews should be conducted every 6 months instead of 3-monthly. in locally advanced resectable colon cancer, surgeons are urged to consider neoadjuvant chemotherapy and revisit the idea of surgery in 2-3 months. there should also be consideration of further chemotherapy in patients with rectal cancer which have shown a clear response to neoadjuvant chemotherapy. this may also be considered in locally advanced or recurrent rectal cancer requiring pelvic exenteration, in an attempt to delay the operation for a few months. diverting stomas should be utilised or give preference for stoma formation over anastomosis to reduce the risk of postoperative complications (e.g. anastomotic leak) [9] . suggestions for prioritisation are given in table 2 . guanyu et al [11] note that sars-cov-2 has been identified in many faecal specimens and advise extra precautions during colorectal surgery where laparoscopically generated aerosols may mix with blood or intestinal contents during anastomoses. additionally, they note that whilst fever is a main sign of covid-19, it is also a primary manifestation of anastomotic leak and advise surgeons to carefully consider this possibility depending on patient risk factors. in thoracic cancer, care must be taken to differentiate between the symptoms of covid-19 (which are predominately respiratory in nature) or severe acute respiratory distress syndrome and progression in lung cancer. furthermore, patient groups must be very carefully selected for surgery as any reduction in lung reserves may severely affect the risk of complications and morbidity and mortality should they later be infected with covid-19. suggestions for prioritisation are given in table 3 . trauma and orthopaedics is a key speciality where operations will be required to continue despite a patient's covid-19 status. for this reason, extensive planning is required to ensure that optimal injury care is provided regardless of a patient's infection status. trauma coordinators are required to plan for a potential surge in intensive care capabilities, where patients with suspected or confirmed covid-19 should be grouped in a separate area from patients without the virus, while ensuring optimal care is not compromised. policies should be decided in each centre regarding the restriction of elective appointments and procedures [13] . some suggestions for case prioritisation are seen in table 4 . examples of these patients include hip fractures and infected prostheses. these patients will require hospital admission and urgent surgical management that cannot be postponed. efficient treatment is essential to avoid prolonged hospital stay both before and after surgery. a lead attending physician must be allocated to coordinate the flow of patients from the emergency department through to operating room (or) scheduling. it is advised that daily trauma conferences should be held to update on problems faced and logistics of dealing with said issues. elective theatre capacity and rehabilitation services should be utilised to minimise preoperative delay and postoperative stay in hospital. elderly patients will be seen frequently in trauma and orthopaedics; therefore measures must be taken to shield these patients from covid-19 during their stay in hospital. anaesthetic guidelines must be developed for patients requiring surgery who may be covid-19 positive. examples of these patients include ligamentous injuries of the knee. non-operative management must be explored first to avoid hospital admission. a clinical decision must then be made when faced with a serious injury taking into account the availability of available clinicians and resources, as well as the potential impact on society. as resources become more strained, nonoperative care will be emphasised, where possible, to reduce the number of inpatients in hospital and resulting burden on the hospital system. this will also mean more beds are available for obligatory inpatients. many trauma patients may be clinically suitable for day-case surgery such as simple periarticular fractures. by utilising day-case trauma surgery, unnecessary admissions can be avoided thus reducing the likelihood of patients being exposed to a hospital environment while freeing up beds for obligatory inpatient cases. due to covid-19, the only day-case procedures likely to take place are urgent cases therefore careful consideration and prioritisation of these patients is essential to ensure the necessary staff and theatre space is available. first contact and fracture clinics these patients will be outpatients therefore any hospital or clinic attendance must be kept to an absolute safe minimum. emergency departments are likely to be under immense pressure therefore trauma and orthopaedic surgeons may take pressure off the emergency services by utilising a fracture clinic. whilst the emergency departments may continue to care for patients who require resuscitation or a full trauma team, fracture clinics may be asked to take patients directly from ed triage with fractures, wounds and minor injuries prior to examination or diagnosis. surgery must not be scheduled by a junior clinician without approval from an experienced attending. managers can play to become fully integrated in regional and hospital planning. as mentioned previously, intensive care triage and resource allocation are essential when a surge in patients requiring urgent treatment is seen. regarding management of critically injured patients, it is advised that the standards of care for these patients is adapted in that the criteria for early triage to palliative care services is implemented for patients with low chances of survival [13] . furthermore, senior staff such as trauma attendings should triage patients using a uniform triage policy rather than clinical judgement alone for trauma and icu patients. if resources in a care centre become sufficiently limited, exclusion from treatment may be decided based on the probability of the patient surviving to ensure resource allocation is efficient [17] . an essential element of surgical service planning is the delivery of emergency general surgery. it is important to ensure that this continues as normal wherever possible for both patients infected with covid-19 or not [18] . one suggestion is to set up dedicated 'clean' and 'dirty' emergency operating rooms to avoid nosocomial infections in covid-negative patients. operations or procedures should be performed if conservative management has failed, may cause harm to the patient, is likely to prolong hospital stay, or increase the likelihood of readmission at a later stage [19] . surgeons should also be wary of a possible reduction in the availability of blood products. the uk has already seen resources beginning to deplete due to both increased usage as well as a reduction in blood donors due to social distancing and quarantine measures [20] . it is therefore advisable for individual centres to monitor regional blood availability and if required, support a restrictive transfusion strategy both in ors and icu where necessary [13] or intraoperative cell salvage [21] . suggestions for prioritisation are given in table 5 . incision and drainages should continue to be performed in cases of superficial soft tissue abscess, including perianal abscesses, under local anaesthesia where possible. in cases where infection is deep seated (ie. muscle involvement), incision and drainage should be performed in the or, in an attempt to avoid extension of the disease and shorten hospital stay. this classification includes, but is not limited to, perirectal abscesses (ischiorectal, intersphincteric, supralevator). if an operating room is not available, percutaneous drainage should be considered [19] . spinelli et al. [40] warn that cases of covid-19 may present with abdominal symptoms resembling acute pancreatitis. in fact, furong et al. [23] suggest that high angiotensinconverting enzyme 2 (ace2) receptor expression in the pancreas may be a cause of mild pancreatitis in patients infected with sars-cov-2 and advise clinicians to remain vigilant of this phenomenon. in cases of progression to necrotising pancreatitis during the covid-19 pandemic, percutaneous and interventional radiology (ir) drainage strategies should be favoured over endoscopy and laparoscopic or open operative methods [19] . emergency operations should be performed in closed loop bowel obstruction and obstructions due to incarcerated hernias, bowel perforations and intestinal ischemia cases. conservative management should be attempted in bowel obstruction secondary to adhesions [19] . appendicitis, if uncomplicated, may be treated with a trial of intravenous (iv) antibiotics with an aim to switch to oral alternatives. attention must be given to cases with an appendicolith present, or in cases where there is disease extension outside of the right iliac fossa. such cases have a 30-50% failure rate and may constitute a longer than necessary hospital stay. this risk must be assessed against or availability. patients with complicated appendicitis should be treated with iv antibiotics followed by an oral switch. depending on the patient's clinical status, defined abscesses should be drained percutaneously or operated on. in cases where non-surgical management fails, surgery must be performed urgently [19] . management of diseases of the biliary tree remain mostly unchanged. pain control is crucial in cholelithiasis and chronic cholecystitis. an elective cholecystectomy should be performed at a later stage. in cases of refractory pain, an emergency laparoscopic cholecystectomy should be performed. this is also true for acute cholecystitis cases; if the patient is fit and there is an emergency theatre available, they should be operated on in an attempt to minimise hospital stay. if there is limited operating room availability or the patient is not fit for a laparoscopic operation, then treatment should be with iv antibiotics. in cases where iv antibiotics have failed, a cholecystostomy may be performed. patients with choledocholithiasis who fail to pass their stone should undergo an endoscopic retrograde cholangio-pancreatography (ercp) with sphincterotomy. an elective cholecystectomy should be performed at a later stage [19] . uncomplicated diverticulitis management remains unchanged ie. iv antibiotics followed by an oral switch. hinchey grade 1 and 2 cases should undergo percutaneous drainage as well as receive antibiotic treatment. hinchey 3 and 4 classifications should undergo a laparotomy with bowel resection and primary anastomosis or colostomy formation, as appropriate [19] . transplant surgery covid-19 is having a significant impact on organ donation services world-wide. as the pandemic evolves, the transplant community faces various challenges, from allocation of resources and consenting patients, to optimizing immunosuppressive medication in patients with suspected covid-19 infections [24] . currently, there is a limited amount of data to draw firm conclusions on the effect of covid-19 on organ transplantation. however, the immunosuppressive agents used may pose an increased risk of developing severe infections, placing these patients in an extremely vulnerable category. in the uk, transplant patients have been advised to stay at home and avoid face to face contact for 12 weeks. additionally, transplant units should take measures to reduce the need for hospital attendance in these vulnerable patients by postponing nonurgent appointments or conducting them virtually as well as delivering immunosuppressive medication to a patient's home. it is important to note that levels of immunosuppression should be reviewed regularly. however, adjusting the level of immunosuppression should be undertaken with care as this could jeopardise the viability of the transplanted organ [25] . guidance on acute transplantation during this pandemic is currently being developed and is adapting on a regular basis. transplant units are encouraged to take into account the availability of intensive care beds as this will affect feasibility and safety of undertaking organ transplantation. during the covid-19 outbreak, transplant decisions should be made on a case by case basis by balancing the risk of infection due to immunosuppression and hospital stay against the risk of organ failure. acutely however, recipients with an active infection or are recovering from an infection should not undergo transplantation. ultimately, if a unit has a significant number of covid-19 cases and has limited resources available, with a potential for negative impact on patient care, transplant services should be temporarily halted and reevaluated at regular intervals [25] . alterations must be made to the consenting process during this pandemic with several additional factors needing to be taken into consideration when consenting patients for both living organ donation and solid organ transplantation. these include: • risk of transmission of sars-cov-2 from donor to recipient this should consider language barriers and disabilities to reduce the risk of miscommunication [26] . local transplant services are taking drastic measures, making adaptations based on the resources available and the desires of donors and recipients. it is recommended that each centre should use their clinical judgement based on the circumstances of their individual centre. some kidney transplant centres have closed live donor programs due to the risk of patients contracting covid-19 and limited access to critical care beds, while others are conducting risk-benefit analyses on a case by case basis [27] [28] [29] . there are a limited number of case reports relating to the effects of covid-19 on renal transplant patients [30] [31] [32] [33] [34] . guillen et al [30] report a case of a 50-year-old male who had undergone renal transplantation in 2016. they expressed concern that sars-cov-2 may present in an atypical fashion in immunocompromised patients (diarrhoea, nausea and vomiting). there is also some discrepancy in the literature regarding the management of immunosuppression. zhu et al [31] reported a case of a patient being successfully treated by initially stopping immunosuppressive medication followed by the introduction of a reduced regimen. similar findings were reported in two larger case series [33, 34] . in contrast, wang et al [32] successfully treated a patient without altering immunosuppressive therapy. a similar trend is seen in liver transplantation where clinicians should use their clinical judgement, taking into account resource availability in their respective centres. some centres in the uk are aiming to run a reduced service, accommodating those with severe disease (expected to die within the next 3 months without transplantation or a united kingdom model for end-stage liver disease score >60) [29] . decisions to perform heart and lung transplants should also be undertaken at a local level. routine surveillance such as biopsies and bronchoscopies should be postponed in patients who are more than 3 months from transplantation, have not suffered previous episodes of rejection and are clinically stable. in heart transplant patients, it is recommended that non-invasive methods to assess rejection should be employed. such as gene expression profiling. for lung transplant patients, more emphasis should be placed on home spirometry data to be evaluated in virtual consultations. criteria should also be developed so that patients can notify the healthcare team if there is a significant decline in lung function [35] . most patients who have undergone transplant surgery require immunosuppression to prevent graft rejection. however, this requires a careful balance as it can also result in an increased risk of developing covid-19 or severe complications. in suspected covid-19 cases, all other causes of symptoms such as fevers and cough should be excluded. this includes but is not limited to cytomegalovirus, pneumocystis, pneumonia and urinary sepsis. clinicians should also take into account atypical presentations of covid-19 and have a low threshold for testing. management is then categorised based on patients who do not require hospital admission, those who are unwell and admitted to hospital and patients who are progressively deteriorating and require ventilatory support (figure 1) [36] . cardiothoracic practice will be inevitably affected by covid-19. in the uk and us all elective and non-urgent procedures have been postponed with resources being redirected to the emergency and urgent cardiothoracic service. furthermore, cardiothoracic surgeons possess generic skills which are mostly transferable to itu, making them prime candidates for redeployment. nhs england has issued guidance on management of cardiothoracic procedures based on the phase of the covid-19 pandemic [6] . these phases include preparation, escalation, crisis (compensated and uncompensated), resolution, recovery and normal working ( table 6 ). in summary, the elective cardiothoracic surgery service will be greatly reduced throughout the pandemic. surgeons are encouraged to use telephone and video conferencing to limit face-to-face appointments and to delay non-urgent referrals and follow ups. cardiothoracic surgeons can greatly support the itu service and attempts should be made to make senior staff available for redeployment [6] . the vascular society of great britain and ireland have issued guidance for clinicians on the impact of covid-19 on vascular surgery services [38] . these include general principles, outpatient appointments, elective and emergency vascular surgery, alongside trainee advice. regarding outpatients, only urgent cases should be seen, and virtual clinics considered. regarding surgical procedures, most arterial surgery is either classified as urgent or emergency and should therefore continue where possible. elective procedures, venous surgery, and asymptomatic conditions requiring intervention should be deferred. nhs england have classed acute & critical limb ischaemia, symptomatic aortic aneurysm & dissection and unstable carotid plaques as all still being emergency procedures and essential but the threshold for abdominal aortic aneurysm (aaa) should be weighed against the risk of rupture [39] . where possible, ruptured aaas should be treated via endovascular aneurysm repair (evar) to reduce dependency on high dependency units (hdu). in patients with critical leg ischaemia or diabetic foot, urgent intervention is required in those with an immediately threatened leg(s), including an interventional radiological approach or amputation (as opposed to debridement). the american college of surgeons have similarly provided guidelines for the triage of vascular surgery patients (table 7 ) [40] . ahmed et al [41] categorise urological surgeries into: oncological, emergency and benign and offer suggestions for prioritisation. these include the recommendation for liberal usage of local anaesthesia and day-case surgery wherever possible to minimise the impact on both resource usage and workforce shortages with anaesthesists being redeployed. furthermore, they suggested the setting up of parallel urological services with 'cold' hospitals dealing with oncological and emergency work and 'hot' hospitals operating on suspected covid-19 patients. additionally, whilst the extent of urinary viral shedding is not yet fully understood, there is some early evidence that sars-cov-2 viral rna is detectable in urine suggesting precautions must still be undertaken in urological services [42] . moreover, there is some evidence that sars-cov-2 especially targets the cells of the urinary tract as they strongly express angiotensin-converting enzyme 2 receptors -a known method of entry into the human host [43] . this is one possible explanation for the recorded rates of acute kidney injuries in patients with covid-19. additionally, sighinolfi et al [44] warn urologists to consider covid-19 as a differential diagnosis in urosepsis as many of the symptoms (namely fever, leukopenia, tachycardia and tachypnoea) overlap. when prioritising patients, oncological surgeries must be a key priority. this is a major part of urological services with prostate cancer accounting for 7.1% of all cancers [45] , and recommendations are presented in table 8 to be used in conjunction with guidelines issued by the eau guidelines office [3] . due to the complex considerations that must be taken into account for these patients, a robust multidisciplinary team, consisting of urologists, oncologists, urological-specialist radiologists, anaesthetists and infectious disease clinicians, must be utilised for surgical prioritisation [46] . the majority of benign surgeries may be delayed and where they should be prioritised, this is highlighted in table 8 . principles for urological surgery during the covid-19 outbreak include as previously described in part 1, including the use of telephone triage and self-isolation prior to admission. simonato et al [47] advise avoiding laparoscopy/robotic surgery where possible and where surgery is unavoidable, it should be performed only by experienced urological surgeons to decrease the risk of postoperative complications as well as reduce or time. additionally, they advise that enhanced recovery after surgery (eras) programmes be used to reduce length of stay in hospital as well as to reduce complications and admissions to already overstretched critical care units. furthermore, they advise regular correspondence with patients' relatives and to discharge patients who require catheters with video or photographic tutorials for catheter management in addition to virtual follow-up clinics. whilst there have been no publication of guidelines by any professional association for the management of stone surgery during the covid-19 pandemic, there have been some guidance published by proietti et al [48] suggesting telephone triage of patients followed by prioritisation based on stone size and location, the presence of any obstructive uropathy, patient symptoms, presence of any stents or nephrostomy tubes and any other complicating factors such as renal failure or a solitary kidney. additionally, desouky [49] suggests that despite reports in the media, nonsteroidal anti-inflammatory drugs (nsaids) should continue to be used as analgesia and as treatment for renal colic due to high effectiveness. similar considerations for prioritisation of surgery must also be undertaken for patients due to undergo robotic surgery. the eau robotic urology section have issued guidelines for both rationalisation and alterations to operative technique, with the aim of maximising protection for healthcare workers and minimising collateral damage to patients requiring treatment for non-covid-19 conditions [50] . they also recommend that operations only be undertaken by the most experienced operators and that the minimum amount of staff necessary should be present in the or with all unnecessary personnel excluded (including fellows and students). there are specific recommendations for the prioritised ophthalmic operations (table 9 ). when possible and safe, these operations should be performed as day cases. the surgical procedure with the less postoperative follow-up visits and the faster recovery period should be chosen. local anaesthetic is also preferred to general anaesthesia wherever possible [55] . despite the cancellation of ophthalmic operations and outpatient clinics, all patients should be contacted to address any concerns they may have and to be given appropriate advice regarding management and awareness of red flag symptoms. patients should be stratified as low, medium or high risk and contacted by letter, by telephone, by through virtual clinics or remain face to face, depending on the severity and resources available in the eye department [56] . moorfields eye hospital have also published guidance on ophthalmological risk stratification and implementation [58, 59] . in order to further reduce the risk of acquiring covid-19 infection, patients should spend as little time in the department, and come into contact with as few patients and staff, as possible. necessary actions include reducing the number of anti-vegf injections per outpatients list and preference given to longer acting anti-vegf injections; no clinical review for ongoing anti-vegf injections; and stagger arrival times so that they do not occur at the same time. moreover, it is recommended that not all ophthalmology staff should be present. instead, staff could be reorganised into two teams, taking turns every two weeks. the team working from home should be on stand-by and be prepared to cover for any sick colleague from the active team. only senior-level clinicians capable of making decisions should see patients, and any administrative work should be undertaken from home where possible [60] . the use of ppe in ophthalmology should follow local governmental recommendations. other specific recommendations are that surgical masks can be worn for multiple patients examined under the slit lamp, and that slit lamps can be modified with plastic breath shields to prevent droplet transmission of the virus. following these recommendations, reused masks should not be taken off between patients and there should be no contact between the mask and hands or clothes, to avoid contamination. it is also important to disinfect the plastic breath shields with alcohol before and after every consultation [61] . plans for urgent elective cases should be made prior to surgery; neurosurgical teams should see if these plans can be delivered without access to icu. day case surgery and short length stay as routine are encouraged i.e. single night stay. critical care beds should only be reserved for patients who may require invasive monitoring or ventilatory support. for emergencies, the threshold for usual acceptance may change. due to the current situation, decision making will be challenging, hence ultimate decision should be shared by at least 2 attendings, and multi-disciplinary teams should comprise of senior members only [63] . the british neuro-oncology society offers suggestions for prioritisation of neuro-oncology (table 10) . for outpatient referrals, only mri confirmed malignant brain tumour patients should be seen. for any mri confirmed non-malignant brain tumours, referral bodies should be followed up for confirmation. elective surgery for non-malignant brain tumour patients who are asymptomatic should be postponed. contact must be minimised during consultations. furthermore, chemotherapy and radiotherapy must be minimised and triaged for those who are most likely to benefit. if standard treatment is not offered, reasons must be outlined in the records [64] . neuro-oncological treatment for glioma patients young adult patients with high grade malignant glioma should undergo maximal safe glioma resection; carmustine (bcnu) wafer may be used safely with no risks of contamination. radiological investigations alone should be used to generate treatment plans for the elderly and for patients with comorbidities [62] . for low grade glioma patients, the bnos suggests a delay of 3-6 months [65] . mohile et al [62] suggested that only chemotherapy regimens which increase the interval between doses should be considered for patients with idh-wildtype gliomas, and the use of cytotoxic chemotherapy, immunotherapy and other tumour treatments should be evaluated against the potential risks of infection and immunosuppression. for patients with grade 2 and grade 3 idh-mutated gliomas, a similar decision-making plan to idh-wildtype patients may be followed and 1p/19q co-deletion glioma patients should delay therapy. mgmt methylated glioma patients may benefit from standard radiotherapy and chemotherapy courses hence temozolomide and radiation should be considered. on the other hand, mgmt unmethylated glioma patients are unlikely to benefit from temozolomide hence shorter radiotherapy courses with the aim of avoiding adjuvant and/or concurrent chemotherapy may be optimal for these cases [62] . strict ppe must be followed by technicians involved in the care of patients undergoing chemotherapy and radiotherapy and toxicity tests should be done at the longest safe interval to reduce patient risks of covid-19 infections. cancer treatment must be stopped until recovery for any patients who test positive for covid-19 and treatment risk-benefit ratio should be evaluated for these patients. all malignant brain tumour patients should be followed up, preferably via remote tele-consultation at the surgeon's discretion. the following are adapted from guidelines published by the bnvg/sbns for the neurosurgical management of neurovascular conditions during the covid-19 epidemic [65] . cta should be performed prior to transfer to neurosurgery, if possible. if no aneurysm is found and the patient has perimesencephalic sah, then an attending neuroradiologist should confirm perimesencephalic pattern and negative cta. it is encouraged to not transfer these patients or perform dsa. if no aneurysm is found and the patient has non-perimesencephalic sah, then good cta quality needs to be confirmed, which should be repeated if inadequate. an attending neuroradiologist should confirm the absence of an aneurysm and the adequacy of cta. a dsa should be done to address any concerns. otherwise, it is reasonable to repeat a cta at 1 week locally. if an aneurysm is found: • world federation of neurological surgeons (wfns) grading score 1-3: current provided guidelines should still be followed for transfer and treatment. • wfns 4-5: neurosurgical treatment will still be beneficial for low grade patients. patients with poor prognostic factors are likely to undergo conservative treatment at their local hospital. • aneurysmal clot: this should be treated at the discretion of a senior neurosurgeon, although a higher treatment threshold may be followed. transfer patients to emergency surgery if they present with ich causing mass effect. those with ich but absent mass effect should undergo cta/mra: urgent treatment should be provided for ruptured or symptomatic cases from cortical venous reflux, and with regards to spinal fistulas, only cases with rapid neurological deterioration should be treated. treatments for unruptured aneurysms (also including giant aneurysm) should be postponed, unless there is cranial nerve iii palsy. all avms and davfs treatments should also be postponed. guidelines have been published by nhs england and nhs improvement for the management of neurotrauma patients during the covid-19 epidemic [66] . categories to consider for neurotrauma patients include: national and local head injury guidelines should still be followed for these patients (fig 2) [ 66, 67] . treatment for emergency patients should be expedited. an anaesthetic guideline for covid-19 positive patients is required. contingency plans should be made for supply chain issues. this includes patients with easily reversible conditions e.g. extra-axial haematoma (extradural/subdural) with mass/clinical effect. during times of very limited care, withdrawal of treatment may occur earlier after decisions of futility are made for patients with brain injuries which are considered to be unsurvivable. overall, most neurosurgical spine and head procedures are safe to perform with strict ppe. if possible, pcr testing for covid-19 should be done for suspected patients prior to treatment. cranial and spinal drilling should be performed with slower speeds and more thorough irrigations of stationary drills should be done to reduce bone skull aerosol [63, 68] . furthermore, to prevent blood splashing in a negative pressure operating room, surgeries should be performed as gently as possible [69] . in addition, endonasal procedures should be avoided as they produce significant droplet aerosol; in wuhan, despite the use of n95 masks, ent surgeons were the worst affected by bone aerosol [70] . oral and maxillofacial surgery nhs england and nhs improvement have published guidelines for the treatment of acute omfs and trauma patients (table 11 ) [71] . they suggest that senior members of the team should make decisions regarding patient care at the first point of contact with the patient, thus ensuring that unnecessary admissions are avoided, and nosocomial infections are minimised. additionally, a suggested model is that admission from the emergency room be directed to omfs clinics before any examination or treatment which is a divergence from normal practice where initial treatment is started by emergency physicians. in addition to this, they suggested the organisation of a temporary 'clean' minor operating theatre and dressings clinic within a triage clinic room to provide immediate services such as suturing of wounds and lacerations, abscess drainage and any urgent procedures that can be performed under local anaesthesia. non-operative care should be considered for patients with injuries which can be managed conservatively (this includes condylar fractures). for patients requiring surgical treatment, including mandibular and midfacial fracture patients and for cases involving cervicofacial infections, teams should work towards expediting the pre-operative and operative care. to reduce post-operative stay, elective rehabilitation services are suggested. the british association of head & neck oncologists (bahno) have also published guidelines for head and neck cancer management during the covid-19 epidemic [75] . all non-malignant cancer treatments should be postponed, and tele-consultations should be done to assess the severity of any referrals of unclear urgency. priority should be given to malignant cancer patients and to those are older than 70 years of age with/without comorbidities. ppe must be strictly followed during consultations and diagnostics work up should be kept to the minimum required to make informed and safe treatment plans. for any nasal endoscopy procedures, as per the advice of ent uk, aerosol generating procedure (agp) level of protection must be followed; theatre clothes and full ppe should be worn and endoscopy should be carried by remote video monitoring instead of eyepiece [73] . with regards to surgical cancer treatment, it is encouraged to postpone surgical procedures which require itu admission at the discretion of senior surgeons. furthermore, day case surgeries should be prioritised, and their length reduced, if possible. with regards to nonsurgical cancer treatment, palliative chemotherapy should be delayed in asymptomatic patients. all patients should be followed up by telephone. however, it is suggested to minimise patient contact by delaying clinic appointments by the longest interval possible at the discretion of the senior surgeons. furthermore, caprioglio et al [76] offer recommendations for the management of orthodontic emergencies which involve assessment of the patient over telemedicine devices then advising the patient step by step for self-management. although fever, cough and shortness of breath are commonly advertised as the symptoms suggestive of covid-19, numerous reports emerged to reveal anosmia, an ent presentation, as a symptom of covid-19 and in some cases was present as an isolated symptom. hence, it was recommended that patients presenting with anosmia should be treated as a suspected case of covid-19 and healthcare workers should don ppe before making contact [77] . ent surgeons were identified to be among those at an increased risk of contracting covid-19 from their patients due to working for prolonged periods of time in close proximity to their patients' faces as well as due to the presence of several aerosol-generating procedures (agps) in ent. the first hospital doctor fatality during this epidemic was an otolaryngologist and this highlights the risks faced by ent doctors [78] . ent uk has generated a list of procedures that they consider to be agps. examination of the upper aerodigestive tract can be considered as an agp, especially if it triggers coughing, sneezing or pharyngeal reflexes, as well as operative procedures on the aerodigestive tract. it is recommended that all agps (e.g. nasal endoscopy, nasal cautery, foreign body removal, biopsies, tracheostomy tube changes and emergency care provided for acute tonsillitis, quinsy and epistaxis etc.) are carried out wearing full ppe, including ffp3 respirator, which could be substituted with ffp2 or n95 respirator in cases of unavailability of ffp3 respirator. it has also been recommended that all otolaryngeal examinations and operative procedures that are unnecessary are avoided [79] . guidelines for the acute surgical care of quinsy, acute tonsillitis and epistaxis have been revised to minimise the risk posed to ent surgeons whilst providing uncompromising patient care. for example, revised guidelines recommend treating quinsy on history alone where possible, reserving oral examination for severe cases; it also recommends betadine gargles in the management of quinsy, reserving drainage for severe cases [80] . tracheostomy guidelines have also been revised due to an anticipated increase in requests to perform tracheostomies on suspected or confirmed covid patients as well as due to tracheostomy being an agp which poses a considerable risk to the operator [81] . additionally, rokade et al [82] has described the innovative use of microscope drape in endoscopic sinus surgery while hellier et al [83] has described the novel use of microscope drape in mastoidectomy, in both cases to reduce aerosolization in these operative procedures which are considered to be agps. suggestions for prioritisation are given in table 12 . the british association of plastic surgery (bapras) and nhs england has provided advice to its members to help aid the management of plastic surgery patients during covid-19 (table 13 ). the association has provided a plastic and reconstructive surgery escalation policy [84] . this provides hospitals with recommendations on how to cope with an increase in covid-19 prevalence. with high prevalence, emergency surgery should be limited, and all elective surgery should be stopped. all emergency injuries should be triaged to outpatient clinics and minor operations should be performed in outpatient clinics. for the management of burns, breast reconstruction and melanoma specific guidelines have been formulated and to cope with the expected drastic reduction of clinical and surgical facilities advice has been created to guide local services. for patients with a suspected melanoma diagnosis, a referral letter is still required, which will be reviewed at a multidisciplinary team (mdt). the advice will be given on the basis of the photograph. the patient may then be sent directly for surgery to remove the lesion and phoned with the results once the pathology has been analysed [4, 85] . nhs england have also set out specific guidelines for the management of burn injuries during the covid-19 epidemic [86] . the recommendation guidelines for the management of patients with burns includes considering the burn patient into four categories. firstly, obligatory inpatients are those with large burns that will need continued admission and surgical management. however, treatment must be expedited to avoid pre-operation delay and minimize the length of stay. secondly, non-operative patients are those that can be reasonably managed without an operation. during the epidemic it is vital to consider non-operative care for burns to avoid unnecessary admissions. thirdly, day-case patients are those that can be undertaken for a large number of conditions. lastly, first contact and clinics patients are the outpatient attendances that should be kept to the safe minimum. the guidelines highly support non operative care to reduce the inpatient and operative burden on the nhs. many burn related procedures can be considered as day cases and should be considered. to avoid unnecessary admissions, senior presence is vital for the management of burn patients and will help reduce the ed workload as a whole, so the ed can focus on other medical patients. for facial plastic surgery, bapras have adopted the baoms guidance with their four main recommendations of ppe (full ppe including ffp3 mask for face to face exams and treatment), avoid (clinics, contact, transfer and surgery), restrict (visits, generation of aerosols and staff numbers) and abbreviate (time waiting in rooms and treatment) [73] for breast reconstruction, the american society of plastic surgery has provided guidelines to manage breast reconstruction during covid-19. all delayed breast reconstruction, planned secondary or revision breast reconstruction procedures should be postponed. for those patients who were considering immediate reconstruction, the society has advised plastic surgeons to err on the side of caution and delay reconstruction due to the potential risks and complications that may occur postoperatively. the decision to delay should take into account the age and comorbidities of the specific patient and the local-regional and individual institutional factors [7, 87] . the american college of surgeons states that the principle of paediatric surgery during the covid-19 pandemic is to provide appropriate surgical care to children with urgent surgical issues (table 14) while utilising patient care resources effectively in addition to protecting healthcare workers. non-urgent surgery should only be performed if necessary to avoid prolonged hospitalisation or further hospital readmissions [90] . nhs england has also made a further recommendation to continue with elective paediatric surgeries only if patients are asa grade 1, with the exception of cancer cases [91, 92] . paediatric surgical services should focus on the effective management of emergency cases with any elective procedures being postponed wherever possible. this will allow for better access to theatres and increase in the staff capacity, with the aims of decreasing the preoperative period and ensuring an early discharge. the paediatric surgical team should ensure continuous management of urgent surgical cases while minimising the risk of transmission of infection. such strategies could include the reorganisation into two groups, one that is active within hospitals, and one that works remotely in isolation, and the use of telemedicine. whenever possible and safe, the presence of parents during surgery should be considered [90] . there is emerging evidence that paediatric patients suffer complications from preventable conditions due to late access to medical care. in response to this evidence, the royal college of paediatrics and child health has emphasised the importance of acute paediatric services and primary care forming agreed pathways for acute paediatric diseases. they also emphasised the importance of primary care workers having accessible and immediate advice from attendings in hospital and community-based paediatrics, to ensure prompt diagnosis and management [94] . due to covid-19, all surgical specialties have had to limit their surgical practices and rationalize the surgeries which are performed. selection of patients for urgent surgery during the pandemic is vitally important to ensure patients have postoperative reserves to combat any possibility of later being infected with covid-19. surgeons from all specialties have been asked to consider non-surgical treatment where safe and possible to avoid unnecessary hospital admissions and to avoid patient harm. all surgery specialists have been asked to limit their follow up to telephone and video where possible. the delivery of emergency surgery during covid has become difficult due to a reduced workforce and hospital supplies. for example, all surgical specialties must carefully consider the need for postoperative supplements including blood transfusions. surgical consent has been tailored to minimize person to person contact, with written and online documentation being utilized where possible. due to evolving circumstances, guidelines for preoperative evaluation, intraoperative and postoperative management are subject to constant change. it is therefore advised to follow national guidelines to ensure the latest recommendations are implemented across centres. all surgical specialties have been affected by the covid-19 pandemic. all specialties have had to triage the urgency of their daily surgical procedures and consider non-surgical management options where possible. surgeons are having to adapt to new guidelines among covid-19 to continue to provide vital emergency surgery within their specialty. with guidelines specific to each specialty being implemented and followed, surgeons should be able to continue to provide safe and effective care to their patients during the covid-19 pandemic. • supratentorial symptomatic brain metastases. • hydrocephalus patients with rare brain tumours -suggestions of using endoscopic third ventriculostomy or ventriculoperitoneal shunt to delay surgery (except for germ cell tumours and pineoblastoma). • patients with low grade glioma who can reasonably be monitored with mri -a 3-month interval scan should be added to ensure no tumour progression in cases delayed by 3-6 months. • tumours of skull base in patients with minimal symptoms. • for high grade glioma patients, it has been suggested to consider reducing the course and fraction of radiotherapy and chemotherapy if there is no significant worse prognosis. oral therapy regimens are preferred, if possible, instead of iv administration. • for mgmt unmethylated glioblastoma patients, chemotherapy may be excluded; monitor patients for any deterioration. • whole brain radiotherapy patients. • stereotactic radiosurgery patients with brain metastasis. • patients with radiotherapy for other rare malignant tumours including anaplastic astrocytoma, pineoblastoma and primitive neuroectodermal tumour. • radiotherapy and chemotherapy patients with low grade glioma who can safely be monitored for an initial period. • patients with atypical meningioma or recurrent meningioma receiving radiotherapy. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) covid-19 and italy: what next? eau guidelines office rapid reaction group, an organisation-wide collaborative effort to adapt the eau guidelines recommendations to the covid-19 era management of cancer surgery cases during the covid-19 pandemic: considerations clinical guide for the management of noncoronavirus patients requiring acute treatment: cancer clinical guide for the management of cardiothoracic surgery patients during the coronavirus pandemic american college of surgeons, covid-19 guidelines for triage of breast cancer patients the treatment proposal for the patients with breast diseases in the central epidemic area of 2019 coronavirus disease urgent intercollegiate general surgery guidance on covid-19 american college of surgeons, covid-19 guidelines for triage of colorectal cancer patients several suggestion of operation for colorectal cancer under the outbreak of corona virus disease 19 in china american college of surgeons, covid-19 guidelines for triage of thoracic cancer patients american college of surgeons committee on trauma, maintaining trauma center access & care during the covid-19 pandemic: guidance document for trauma medical directors clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic royal college of surgeons in ireland, royal college of surgeons of edinburgh, royal college of physicians and surgeons of glasgow, clinical guide to surgical prioritisation during the coronavirus pandemic covid-19 pandemic: perspectives on an unfolding crisis: covid-19 pandemic: perspectives on an unfolding crisis american college of surgeons, covid-19 guidelines for triage of emergency general surgery patients covid-19 outbreak in northern italy: viewpoint of the milan area surgical community emergency preparedness, resilience and response guidance for uk hospital transfusion teams clinical guide for the management of general surgical patients during the coronavirus pandemic highly ace2 expression in pancreas may cause pancreas damage after sars-cov-2 infection organ donation during the coronavirus pandemic: an evolving saga in uncharted waters covid-19: information for transplant professionals transplant society guidance for clinicians on consent for solid organ transplantation in adults and living organ donation in the context of the covid-19 pandemic covid-19) guidance for patients with kidney disease the renal association, covid-19: challenges for renal services bulletin number 5: organ and tissue donation and transplantation directorate case report of covid-19 in a kidney transplant recipient: does immunosuppression alter the clinical presentation? successful recovery of covid-19 pneumonia in a renal transplant recipient with long-term immunosuppression covid-19 in a kidney transplant patient identification of kidney transplant recipients with coronavirus disease coronavirus disease 2019 pneumonia in immunosuppressed renal transplant recipients: a summary of 10 confirmed cases in guidance for cardiothoracic transplant and ventricular assist device centers regarding the sars cov-2 pandemic guidance on the management of transplant recipients diagnosed with or suspected of having covid19 triage considerations for patients referred for structural heart disease intervention during the coronavirus disease 2019 (covid-19) pandemic: an acc /scai consensus statement covid-19 virus and vascular surgery clinical guide for the management of vascular surgery patients during the coronavirus pandemic american college of surgeons, covid-19 guidelines for triage of vascular surgery patients global challenges to urology practice during covid-19 pandemic persistence and clearance of viral rna in 2019 novel coronavirus disease rehabilitation patients single-cell rna-seq data analysis on the receptor ace2 expression reveals the potential risk of different human organs vulnerable to 2019-ncov infection covid-19: importance of the awareness of clinical syndrome by urologists global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries covid-19 and urology: a comprehensive review of the literature network (run), pathways for urology patients during the covid-19 pandemic endourological stone management in the era of the covid-19 urology in the era of covid-19: mass casualty triage eau robotic urology section (erus) guidelines during covid-19 emergency recommendations for tiered stratification of urologic surgery urgency in the covid-19 era triaging office-based urologic procedures during the covid-19 pandemic considerations in the triage of urologic surgeries during the covid-19 how to prioritize urological surgeries during epidemics: lessons learned from the toronto sars outbreak in 2003 the royal college of ophthalmologists, glaucoma management plans during covid-19 the royal college of ophthalmologists, management of ophthalmology services during the covid pandemic the royal college of ophthalmologists, management plans for children and young people with eye and vision conditions during covid-19 ophthalmological risk stratification & implementation guidance moorfields risk stratification for paediatric ophthalmology the royal college of ophthalmologists, protecting patients, protecting staff the royal college of ophthalmologists, ppe and staff protection requirements for ophthalmology sbns covid-19 bulletin #1 covid-19 treatment pathways and guidance sbns guide for the neurosurgical management of neurovascular conditions during the covid-19 pandemic clinical guide for the management of neurotrauma patients during the coronavirus pandemic clinical guideline [cg176], national institute for health and care excellence (nice) preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of 2019 coronavirus infection experiences of practicing surgical neuro-oncology during the covid-19 pandemic precautions for endoscopic transnasal skull base surgery during the covid-19 clinical guide for the management of patients requiring oral and maxillofacial surgery during the coronavirus pandemic maxillofacial trauma management during covid-19: multidisciplinary recommendations approaches to the management of patients in oral and maxillofacial surgery during covid-19 pandemic british association of head and neck oncologists, bahno statement on covid-19 management of orthodontic emergencies during 2019-ncov anosmia as a potential marker of covid-19 infection -an update practical aspects of otolaryngologic clinical services during the 2019 novel coronavirus epidemic: an experience in hong kong guidelines for changes in ent during covid-19 pandemic adult tonsillitis & quinsy guidelines bla covid-19 tracheostomy guidelines ioannidis, fess in the covid era: the microscope drape method to reduce aerosolization mastoidectomy in the covid era -the 2 microscope drape method to reduce aerosolization clinical guide for the management of patients requiring plastic treatment during the coronavirus pandemic advice for managing melanoma patients during coronavirus pandemic clinical guide for the management of acute burns patients during the coronavirus pandemic asps statement on breast reconstruction in the face of covid-19 pandemic developing a virtual fracture clinic for hand and wrist injuries british society for surgery of the hand, covid-19 resources for members american college of surgeons, covid-19 guidelines for triage of pediatric surgery patients clinical guide for the management of paediatric patients during the coronavirus pandemic clinical guide for the management of paediatric critical care patients during the coronavirus pandemic british association of paediatric surgeons, covid-19 information for paediatric surgeons delayed access to care for children during covid-19: our role as paediatricians -position statement the following additional information is required for submission. please note that failure to respond to these questions/statements will mean your submission will be returned. if you have nothing to declare in any of these categories, then this should be stated. please enter the name of the registry, the hyperlink to the registration and the unique identifying number of the study. you can register your research at http://www.researchregistry.com to obtain your uin if you have not already registered your study. this is mandatory for human studies only.1. name of the registry: n/a 2. unique identifying number or registration id:3. hyperlink to your specific registration (must be publicly accessible and will be checked): please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. others, who have contributed in other ways should be listed as contributors. the guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. please note that providing a guarantor is compulsory.corresponding author: ahmed al-jabir senior author: riaz agha key: cord-321631-ip6tt81e authors: brown, jubilee title: surgical decision making in the era of covid-19: a new set of rules date: 2020-04-03 journal: j minim invasive gynecol doi: 10.1016/j.jmig.2020.04.001 sha: doc_id: 321631 cord_uid: ip6tt81e nan in the time span of two months, everything has changed. the pandemic of covid-19 has torn through the fabric of our society and laid waste to the daily routines we practiced automatically. the most basic assumptions of how we plan our day, how we organize our family life, and how we practice medicine are gone, and in their place we socially isolate, we home school, and we split shifts to decrease exposure. those of us in china, korea, spain, and italy did not see the tidal wave coming; those of us in france and the united states saw our friends suffer and braced for the impact; those of us in africa and south america know it is inevitable. the global impact of this invisible virion is horrific, and we as doctors and health care workers are on the front lines of this war, confronting our own mortality as we continually re-strategize to protect our patients. the covid-19 pandemic has fostered skills we did not know we had. we have innovated so rapidly and learned from our colleagues internationally, utilizing technology to facilitate discussion of issues and dissemination of knowledge. the aagl has been at the forefront of getting this information synthesized and out to the public. i like to think that these webinars and publications are saving lives by sharing information. we have partnered with our colleagues in infectious disease, general surgery, oncology, public health, and even administrators to learn quickly, adapt our personal and institutional practice, and adopt policies to allow a new best practice, conserve ppe, and save our patients and ourselves. it is this last tenet that informs the decision making that we must do -we must be nimble, and we must make rapid decisions based on scant data to protect everyone. as we determine how to pivot our practices in this rapidly changing environment, the issues of who should have surgery and how it should be performed have become key. based on the suggestion that viruses can remain infectious and become dispersed in a plume of aerosolized smoke or steam, we have had to examine the available data and determine if that risk is greater with minimally invasive surgery or laparotomy [1] . in this issue, morris et al take the stand that minimally invasive surgery provides superior patient outcomes, more rapid patient healing, and the risks to staff can be mitigated by patient triage and by modifications to operative technique [2] . cohen et al argue that the risks to operative staff should be minimized at all costs, and that triage, testing, and protection should minimize surgery on covid-19 positive patients, but that when emergent surgery is required for untested or covid-19 positive patients, laparotomy is indicated to minimize the risks to operating room personnel [3] . analysis of the data and synthesis of these pro/con arguments requires us to think in a novel way. as scientists, we are used to making decisions after review of extensive scientific data, dissecting the validity of the studies, and determining what provides the best outcomes for the patient. this scenario with covid-19 is different. determining whether to proceed with minimally invasive surgery versus open surgery is a discussion of ethics. it is influenced by local resources available now and projected to be available in the future. this decision making must account for the safety of our patients, ourselves, our colleagues, and future patient contacts that could be harmed by inaccurate decision making. this discussion is based on very minimal data largely extrapolated from theoretical reports on other viruses [4] . furthermore, the decisions that may be appropriate for one hospital setting may not be appropriate for another based on availability of testing, abundance of ppe, or prevalence of covid-19. all of the decisions made at one time point on the covid curve may completely change at a later time point. more sobering, the discussion becomes moot when all of the operating rooms are used as icu beds during the surge. as with most polarizing discussions, the truth likely lies somewhere in the middle. when deciding how to implement policies and counsel patients on the timing and route of surgery, all of these factors need to be considered [5] . a simple statement of "all laparoscopy" or "all laparotomy" is not appropriate, and algorithms centered on risk reduction to patients and staff need to be based on local resources. the physicians authoring the pro and con perspectives in this issue were kind enough to write their pieces from an assigned vantage point, recognizing that best practice incorporates components from both viewpoints. as i consider the information, three things become evident: 1) minimize the plume. no matter the route of surgery, practice universal covid precautions without venting pneumoperitoneum into the room and suctioning the plume with a closed filtration system whether open or minimally invasive surgery is performed. 2) protection of staff is key. test when you can and use the best ppe that you have. 3) we are innovative beings and we can pivot faster than the virus. we are joined by a bond of humanity, and we as physicians are leaders in our communities and in our world. in this noble profession, we are guided by the principle primum non nocere, and this most fundamental concept must guide how we practice even now. detecting hepatitis b virus in surgical smoke emitted during laparoscopic surgery reduction of hiv transmission during laparoscopic procedures joint statement in minimally invasive gynecologic surgery during the covid-19 key: cord-315297-o8mwmjql authors: stephens, elizabeth h.; dearani, joseph a.; guleserian, kristine j.; overman, david m.; tweddell, james s.; backer, carl l.; romano, jennifer c.; bacha, emile title: covid-19: crisis management in congenital heart surgery date: 2020-04-14 journal: ann thorac surg doi: 10.1016/j.athoracsur.2020.04.001 sha: doc_id: 315297 cord_uid: o8mwmjql nan our nation's health care infrastructure faces unprecedented challenges in the face of the covid-19 pandemic, and the congenital heart disease (chd) community is no exception. these challenges include looming resource scarcities of equipment, personnel, and blood. in addition, there are the substantial infection risks to patients, family members and staff. these factors necessitate thoughtful but often difficult decisions on how to best triage patients with chd. our relatively small workforce adds another dimension to the challenge, since the rapid spread of covid-19 could result in program closure at a moment's notice secondary to insufficient personnel from infection or quarantine. while many sectors of our society can be placed on hiatus during this period of crisis, our patients' diseases continue requiring care, particularly amongst newborns and infants who often require surgery during a narrow temporal window for satisfactory outcomes. practitioners are tasked with optimizing care in the presence of the current and rapidly changing circumstances. while statements have been published relative to adults undergoing surgery, 1 guidance with respect to congenital heart disease patients is currently lacking and is the goal of this manuscript. as we have seen in other countries facing this pandemic, the thoughtful allocation of resources is paramount to the overall welfare of the community 2,3 and has led to such strategies in our country. 4, 5 the safety of our patients, healthcare providers, and our communities is our chief concern. this document is not meant to be a guideline but is designed to provide guidance for decision-making as we face unparalleled challenges related to congenital cardiac surgery care during this pandemic. the circumstances are rapidly changing, even hourly, therefore, the principles outlined herein are meant to be fluid and adaptable. they should be continually reappraised in the context of the dynamic circumstances within a given institution, population base and geographic location. these principles can also provide a framework for prioritization of surgery in other situations when there is lack of resources or personnel, or both. this document is not meant to be prescriptive, but rather serves as an outline of guiding principles to be interpreted in a particular context. lastly, while individual anomalies may be specified, each patient should be considered individually in the context of their clinical status, disease state, institution, and community. perhaps more than ever, these times require us as a specialty, albeit small but with a valuable scope of skillsets, to collaborate and cooperate. this includes the sharing of knowledge and resources, patient transfer in selected situations, and communicating frequently amongst ourselves to provide emotional support and mental fortitude during these periods of stress and isolation. congenital heart surgeons have a track record of effectively working together to advance the specialty, promote quality training and education of our surgical community, and through bold innovation solve some of the most difficult clinical challenges. we are now confronted with a different kind of challenge -a public healthcare crisis. we can rise to meet this challenge by utilizing our collaborative and intellectual abilities to problem solve, plan and prevail for the benefit of children and adults suffering from chd. we must work together with strong leadership from our institutions and central, shared decision-making teams to handle the influx of issues and concerns related to the pandemic. in the setting of substantially limited resources, proper prioritization of patients requiring surgery is of paramount importance. to date, the biggest difficulties have not been covid infections in chd patients, which have been rare. the biggest threat to our patients is the sudden lack of resources, including the requisition of ors (transformed into intensive care units), ventilators and healthcare providers for the fight against covid. as a result, the surgical schedule must be culled to only the most urgent cases, which in our specialty is very difficult with many gray zones. many factors pertaining to an individual case must be weighed, including: 1) resource-utilization, such as anticipated ventilator duration, intensive care unit stay, blood product usage, and other supplies that are or may become limited, 2) clinical status of the patient and risk of delaying surgery, 3) risk of exposure for the patient, family, and healthcare staff, and 4) co-morbidities and complexity of the procedure with implications on the usage of hospital resources, 5) in teaching hospitals, training may have to be curtailed and the most experienced surgeons used liberally, and 6) the safety of the patient's social and clinical situation if surgery is delayed. these decisions will often be made in the context of a hospital that is weighing the needs of other patients from different specialties with similar needs. the timing of surgery is determined by a variety of factors -the clinical status of the patient, recommendations of the cdc, government officials, and professional societies (e.g., american college of surgeons), and local hospital protocols. importantly, this is a shared decision-making with the patient, family, and other specialists with transparency regarding the risks and benefits of proceeding with surgery versus waiting. the difficulty of this decisionmaking regarding timing is compounded by the realization that the duration of this pandemic and thus the delay for a given patient remains unknown. table 1 is provided as general guidance regarding the timing of intervention for various diagnoses, depending on clinical status and other factors. it is not exhaustive and not meant to be a guideline, but highlights common conditions and scenarios. as stated earlier, this should be interpreted with flexibility depending on the current state of resources within a given institution and community. it is important to note that ongoing, close cooperation and communication between the surgical and medical teams is essential to ensure an accurate diagnosis and effective treatment strategy with the fewest resources and involved personnel. while in the setting of unrestricted resources certain conditions can be managed in a standard fashion, consideration during this time should be given to alternative approaches that may drain less resources and/or result in shorter hospitalization; e.g., a ductal stent may optimize resource utilization for a given institution as opposed to a surgical systemic-to-pulmonary artery shunt. depending on the impact of this pandemic, there may be circumstances in the near future when it may not be appropriate or feasible to offer interventions to high-risk patients requiring high resource utilization with anticipated poor outcomes. given the small size of each institutional workforce practicing congenital cardiac surgery (median of 3 surgeons per practice in the united states), 6 which possess unique skillsets not replaceable by other providers, strategies to maintain the integrity of the workforce are crucial. institutions may re-deploy members of the congenital cardiac surgery team to other patient-care settings, further depleting resources and also increasing exposure. in response, employing workplace strategies to reduce overall exposure, such as one-week on/one-week off rotation schedule for selected health-care providers, appropriate use of personal protection equipment (ppe), and downsizing of clinical teams and worksites, seems prudent. vigilant surveillance for symptoms among team members is critical given the close proximity of congenital cardiac team members working together; one exposed or positive provider can put the entire team and program at risk because of quarantine requirements, resulting in a program being shut down because of insufficient staff to provide care. precautions should also be taken for non-clinical support staff to minimize their exposure. strategies of remote tele-working and rotational schedules should be applied to all staff when feasible. regional collaboration should be considered, with the realization that small programs are at risk for closing in the setting of infected staff members and/or those requiring quarantine. babies will continue to be born each day and the 1% incidence of congenital heart disease will remain unchanged during this time of crisis. evaluation and early surgery for many children must continue while much of the world is on hold. an adaptive clinical model should be applied to minimize exposure and prioritize patients for surgery during this crisis period. differentiating who requires surgical evaluation for potential intervention during this time and who does not can be accomplished with a careful history, virtual visits, and review of diagnostic laboratory tests and imaging. after a multi-disciplinary discussion, further imaging or lab-work can be obtained as needed to allow for accurate risk stratification and surgical planning. an ongoing concern is the relative risk of hospital exposure to covid-19. while each hospital strives to carefully monitor and appropriately care for covid-19 patients, in-house patients and healthcare providers may be positive prior to symptom onset or knowledge of their status, putting incoming surgical patients and their families at risk. furthermore, many of our patients' family members may be residing in group facilities, e.g., ronald mcdonald house, also placing them at risk for exposure. while the magnitude of such potential risk is unknown, it must be weighed against the urgency of the operation. covid-19 has had the biggest clinical impact on older patients, especially those with predisposing conditions; however, younger patients without medical conditions are being affected and have also died. this finding is an important consideration since the congenital cardiac population often has underlying pathophysiological abnormalities and co-morbidities that place them at higher risk in the setting of a respiratory illness. social distancing can be particularly challenging for our patients, given their age and family structure. many of our patients have multiple siblings, each with other potential exposures, and depending on their age, require supervision or care by adults. adequate psychosocial support for the child and their family must also be considered, while being mindful of the risk of covid-19 exposure and spread. individual decision-making must be considered in this setting, taking into account specific hospital policies and community recommendations so exposure is minimized; e.g., one parent bedside during hospital stay as opposed to additional family members. the adverse psychosocial impact of such a strategy cannot be underestimated and alternative support mechanisms be provided. discussions continue regarding the appropriate use of personal protection equipment (ppe) for healthcare workers and screening of incoming patients to prevent spread of covid-19 within the hospital setting. such policies will inevitably continue to change with ppe supply, evolution of testing, and knowledge regarding the spread of the virus. ideally, during this pandemic preoperative covid-19 testing should be performed on every patient, even asymptomatic patients, as well as their parents. while the testing yield is poor in asymptomatic patients early in the disease before viral shedding, 7 a positive test would substantially change both decision-making regarding their surgery as well as precautions taken during their hospitalization, use of limited ppe, and interaction with providers and family members. how to manage a covid-19 positive patient with chd who requires urgent surgery remains unclear since the effects of cardiopulmonary bypass and mechanical ventilation on an asymptomatic or symptomatic covid-19 positive patient are currently unknown. while our priority and focus has centered on patients with congenital heart disease, congenital cardiac surgeons also play an integral role in the care of covid-19 positive patients without cardiac disease. this primarily includes patients with respiratory failure from covid-19 who may require extracorporeal membrane oxygenation (ecmo) support. although infrequently needed for covid-19 positive children thus far, the age range of covid-affected patients continues to evolve with an increasing number of younger patients being affected. institution of pediatric ecmo is a unique skill that is most often implemented by congenital cardiac surgeons. while participation of the surgeon is often mostly technical, i.e., cannulation, it also includes patient selection guidelines, strategies for ecmo application with the fewest personnel, transportation protocols, post-ecmo limb monitoring, chest washouts, etc. early consultation with the surgical service and coordinated efforts with clear communication between the involved personnel -surgery, critical care, perfusion, nursing, etc., cannot be overemphasized since the potential for controversy and disagreement is more likely in the covid-19 setting. strategies to limit healthcare personnel exposure during the institution of ecmo and the care of covid-19 patients on ecmo need also be employed. the decision on whether to employ ecmo for covid-19 positive patients can be controversial and will depend on resource availability, co-morbidities, and pre-illness clinical status. ecmo should be considered in a pediatric patient who is positive and otherwise healthy prior to covid infection in an institution with adequate resources and infrastructure. surgical trainees in the field of congenital heart disease are also severely impacted by the current pandemic. residents and fellows are frequently the frontline for many urgent in-patient emergencies, e.g., cardiac arrest in post-cardiac surgery patients, ecmo cannulation, placement of central venous or arterial monitoring lines, intubation, etc. they are also on a specific and very short timeline for acquiring surgical experience with case number and procedural requirements. however, this must be balanced with the risk of their exposure and well-being. hospital policies may limit their participation in in-patient activities, and some may require periods of quarantine. the cumulative effect of these issues could result in a markedly reduced training experience, thus compromising their ability to fulfill certification metrics. most congenital cardiac surgery residents have already completed 5-9 years of elite thoracic surgical training in order to spend 1-2 precious years of training at one of the few congenital residency programs in the country. while post-graduate medical and surgical education has been complemented by various remote or on-line learning modules over the last decade, the bulk of surgical learning continues to be centered in the operating room and icu setting -this experience is essential and not replaceable with on-line education. while some flexibility during this crisis will be considered by the acgme and abts, there may be circumstances where extension of the duration of training is needed; governing boards and program director input will be necessary to ensure competence of the graduating trainee. in the meantime, efforts need to be made to minimize unnecessary exposure to infection, take appropriate precautions, and maximize all supplemental educational measures, e.g., video conferencing, virtual classrooms, etc., so trainees don't fall too far behind. the history of our specialty is defined by courage, resiliency, and tenacity. congenital heart surgeons complete one of the longest and most rigorous training regimens in medicine. it is a specialty marked by long and technically difficult operations. it is a specialty of high risk and high reward, and the cardiac surgical personality thrives on it. difficult decision-making and critical conversations with colleagues and family members are part of our daily experience. as leaders of our teams, we manage pressure and work to address and minimize our team's fatigue, anxiety, or moral distress. these attributes have never been at a higher premium than at the present moment. during this pandemic, the difficult decision-making has shifted to an unprecedented realm -who gets surgery and when, how limited resources will be used, and how our team will be allocated toward the overall good. with our depth of experience and reservoir of emotional and mental toughness, we as a community are a critical public health resource. our patients, families, institutions, and regions are depending upon us to help them navigate these difficult circumstances. this historic challenge calls on us to, as we have throughout our history, meet the toughest of problems head-on. we are a small community with a rich network of relationships. we are now trying to find ways to work together and uplift one another while under duress. while isolated physically, we are virtually connected; and this support is vital to our success. frequent and intentional phone calls, sharing personal experiences, and reaching out to colleagues if institutional capabilities are threatened, as well as finding other ways to balance personal and professional life, are necessary to overcome the present challenge. unprecedented times call for unprecedented measures. prioritization and appropriate timing of surgery are necessary at this time. practical guidance strategies range from ensuring safety and tactics for specific lesions of the patients, to maintaining emotional stability of the staff. our specialty has been marked by solidarity and camaraderie, and carries a history notable for collaboration, flexibility, adaptation and instant readiness. the time to execute these qualities is here and now. covid-19: guidance for triage of non-emergent surgical procedures clinical ethics recommendations for the allocation fo intensive care treatments in exceptional, resource-limited circumstances the extraordinary decisions facing italian doctors. the atlantic fair allocation of scarce medical resources in the time of covid-19 center for disease control and prevention. strategies for optimizing the supply of n95 coronavirus disease 2019 web site report of the 2015 society of thoracic surgeons congenital heart surgery practice survey potential preanalytical and analytical vulnerabilities in the laboratory diagnosis of coronavirus disease 2019 (covid-19) key: cord-320877-1i0hzfjk authors: kiykaç altinbaş, şadıman; tapisiz, ömer lütfi; engi̇n üstün, yaprak title: gynecological laparoscopic surgery in the shade of covid-19 pandemic date: 2020-06-23 journal: turk j med sci doi: 10.3906/sag-2004-272 sha: doc_id: 320877 cord_uid: 1i0hzfjk a global public health problem with a high rate spread and transmission, coronavirus outbreak has become the most talked-about matter throughout the world. we are severely affected by the nations with vast numbers of deaths; it was hard to predict such a colossal pandemic with terrifying consequences. elective surgeries are limited, but situations requiring an urgent gynaecological or obstetric surgical approach must still be performed during the covid-19 pandemic. concerns regarding surgical safety and the risk of viral transmission during surgery are of great importance. in this review, we aimed to summarize the concepts related to laparoscopic gynecological surgery during covid-19 pandemic in the light of current literature. the world health organization (who) announced a novel coronavirus disease (covid-19) as a pandemic on 11 march 2020 due to its speed and global transmission [1] . since then, we are severely affected by the nations with vast numbers of deaths; it was hard to predict such a colossal pandemic with terrifying consequences with a significant influence regardless of any countries, developed, developing or least developed. by 22 april 2020, who has reported 2,471,136 confirmed cases with 169,006 deaths worldwide [1] . a global public health problem with a high rate spread and transmission, coronavirus outbreak has become the most talked-about matter throughout the world. health care providers are at the forefront of all others, and the current crisis is such a difficult time for them. non-urgent elective surgeries have been cancelled or postponed to free up beds for coronavirus critically ill patients, to allow the best use of medical resources for both the patients and the health care providers, and to reduce the contamination risk of healthy people. although elective surgeries are limited during the covid-19 pandemic, situations requiring an urgent gynaecological or obstetric surgical approach must still be performed. it is always essential to apply the most appropriate, personalized treatment modality to patients and to carry out the appropriate and safe treatment by considering safety for both patients and health care providers, adhering to the principle of not harming the highest perception. the routes chosen to perform the surgery either by open or by minimally invasive (laparoscopy, robotics or vaginally) techniques, it is vital to follow patient management algorithms prepared within the evidence during covid-19 pandemic. at this point, concerns regarding surgical safety and the risk of viral transmission during surgery are of great importance. for this purpose, we prepared a review that summarizes the concepts that should be considered about laparoscopic gynaecological surgery during the covid-19 pandemic in the light of current literature. since january, in the three months, changing in the actual policies and getting out of the routine, the decision of the route of surgery either by traditional open surgery or laparoscopic surgery is being discussed and stated regarding surgical safety concerns [2] . the first decision arises from the thought if the patient's situation needs an urgent intervention or not. the second is that if the patient needs urgent surgery, what will be the route, laparoscopy or laparotomy? according to our traditional knowledge, the use of laparoscopy offers many benefits to patients such as shorter recovery time and hospital stay, lower risk of post-surgical complications, reduced risk of pain and pain medication, less bleeding and risk of haemorrhage during the operation [3] . if looked at the point of the surgeon and surgical staff, laparoscopy offers less or no spillage of fluids and tissues, and also provides more distance between each surgeon and the patient. sure, the risks and benefits should be weighed, and the most appropriate decision should be taken after the patient, and the current situation are evaluated in detail. recently, international societies have made recommendations based on published reasonable data and expert opinion about laparoscopic surgery during coronavirus outbreak. the american association of gynecologic laparoscopists (aagl), along with other societies as the american college of obstetricians and gynecologists (acog), the american society of reproductive medicine (asrm), and others released the joint statement regarding the suspension of elective surgical care during the first phase of the pandemic [4] . the royal college of obstetricians and gynaecologists (rcog) with the british society for gynaecological endoscopists (bsge) stated that laparoscopic approaches should be performed when feasible in preference to laparotomy in guidance with the safety of surgeons and patients. the main reason for the preference of laparoscopy is that of its benefits not only for the patients but also for the better use of hospital resources at these unusual times [5] . the european society for gynaecological endoscopy (esge) also declared that elective surgeries for benign conditions should be delayed, and if possible, alternate medical treatments should be considered. if a gynaecological emergency takes place, laparoscopic surgery should be advantageous, weighing all the consequences [6] . in light of all limited data, it may be hard to find the right way to act. at the same time, some scientists advocate the superiority and the high preferability of minimally invasive surgery in all patients [7] , some scientists defend the triage, testing and protection, and minimize and delay the surgical decision on covid-19 (+) patients [8] . the same authors argue that if the patient needs urgent surgery, and not have enough time to test the patient, laparotomy should be performed to minimize the risks. in this instance, the best way to act is as brown explains: "all laparoscopy" or "all laparotomy" is not appropriate, algorithms based on risk reduction need to be attributed to the situation you are in [2] . for all that, deciding the route of the operation may differ upon hospital settings, the condition of the patients and the availability of screening. recommendations based on current evidence and expert opinion are given as follows. at admission, all patients requiring urgent surgery should be assessed for potential sars-cov-2 infection including general screening questions as having contacts with a covid-19 (+) patient within the last 14 days or having any symptoms or not [9] . informed consent concerning the probability of covid-19 exposure and potential consequences should be discussed with the patient [10]. our management protocols in patients with different covid-19 status are stated below (figures 1-3) . covid-19 (+) patients: gynecologic procedures, for which a delay will not negatively affect patient health and safety, should be delayed [4] . if there is no life-threatening condition in the covid-19 (+) patient requiring surgery, the surgical treatment should be postponed until full recovery, nonoperative treatment modalities may be implemented when possible [11] . although different attitudes between laparoscopy and laparotomy are being discussed in covid-19 (+) patients [7, 8] , we recommend laparotomy at our institution if surgery cannot be postponed. if the decision is in the direction of laparotomy, minilaparotomy should be performed if possible (figure 1) . unknown or suspicious covid-19 status: if the patient who needs urgent surgery and whose covid-19 status is not known because of the inability of giving accurate information about covid status or lack of consciousness (dementia, cerebrovascular disease, mental retardation etc.), it is appropriate to perform preoperative covid-19 virology screening, and plan the surgery after the result is obtained. if there is not enough time for preoperative covid-19 screening, urgent surgery should be performed by laparotomy (figure 2) . no suspicion, adequate symptom-free time: if there is not enough time for preoperative covid-19 screening, the surgery can be performed by laparoscopy within taking strict protection measures. it should not be forgotten to take every precaution before every surgical procedure irrespective of the testing results of the patients (figure 3 ). an or with a negative pressure environment is defined ideal for the reduction of the dissemination of the virus [12] . if available, an alternative or separated from main ors only for covid-19 patients would be ideal to avoid contamination of other ors and patients. it is stated that a high frequency of filtered air exchange helps for the reduction of the viral load within the or [13] . detailed hospital guidelines, including workflow definitions and new or rules, appropriate donning, and doffing procedures, should be defined to standardize the procedures and coordination of all surgical staff. in patients with confirmed or suspected covid-19 infection, all surgical team members are required to wear ppe. the who recommends that ffp2/3 and n95 masks can be for up to 4 h [14] . when aerosol-generating procedures are performed, and until air exchanges have reduced the virus after the procedure, airborne precaution ppe is recommended and should be worn by all surgical staff within the or during all operations, whether by laparoscopy or laparotomy [5, 15] . level iii protection of ppe includes face shields, ffp2/3 or n95 filtered masks, fluid-resistant gowns, disposable gloves, disposable eye protection [13] . standard infection controls should be already applied, but the types of transmission and the protection required to handle that of transmission should be also known exactly (table 1 ) [15] . laparoscopic surgery is a surgical method performed by forming the pneumoperitoneum by inflating the abdominal compartment with co 2 . theoretically, it is possible to aerosolize viral particles and contaminate the operating room environment by using the gas supplied into the abdomen and using electrosurgery and ultrasonic devices during the operation; that means laparoscopic operations are aerosol-generating procedures (agp). covid-19 virus (sars-cov-2) is a respiratory agent transmitted via respiratory droplets [7] . the mechanisms are thought to be in three ways: (a) directly by droplets from human to human via someone's nose, mouth, or eyes or (b) smaller but much more numerous particles called "aerosol particles" or (c) from contaminated surfaces with larger droplets that spread onto the surfaces from an infected person's secretions [16] . sites of deposition in the recipient differ between inhaled droplets and aerosol particles; while the bigger ones localize in upper regions of the respiratory tract, the inhaled aerosol particles penetrate deeper into the lungs [17] . in laparoscopy, aerosolized particles are produced mainly by electrosurgical smoke via energy devices. in contrast, particles with the smallest mean size (<0.1 µm) were formed by electrocautery; the largest ones sized 0.35-6.5 µm were shown to be generated by use of the ultrasonic scalpels [18] . the role of co 2 in aerosol formation remains unclear [16] . based on our previous information about the presence of hepatitis b [19] , human immunodeficiency viruses (hiv) [20] , and similar respiratory viruses as influenza or coronaviruses [severe acute respiratory syndrome (sars) or middle east respiratory syndrome (mers)] in surgical plume during laparoscopy, to date, no study presents the ability of viral transmission by laparoscopy [16, 21] . besides, sars-cov-2 has not been detected in agps yet, but the virus has been detected in blood in 1% of cases and stool specimens in 29% of cases [21, 22] . although the virus has not been reported in the genital tract yet, covid-19 seems to be very contagious, and what we do not know is much more than we know about the virus at present. at this point, the most critical aspect of the event is to protect ourselves from potentially dangerous biological materials and minimize the risks we face as much as possible with the use of protective maneuvers and techniques. in laparoscopy, to minimize the use of electrosurgical procedures, especially laser tissue ablation, monopolar electrosurgery, ultrasonic scalpels and advanced bipolar devices, may reduce the probable risk of viral emission [10]. the sudden opening of the trocars causing a chimney effect (a jet stream through the trocars) [18] towards the surgical team or specimen extraction with free gas leakage through the abdominal and vaginal incisions or uncontrolled replacement of laparoscopic instruments at the end of the operation may expose the medical team to these aerosolized viral particles. high-efficiency particulate air (hepa) filters and ultra-low particulate air (ulpa) filters can remove >99% of airborne particles [10], and use of a closed smoke evacuation/filtration system with ulpa capability is recommended if available [11] . using closed smoke evacuation filtering devices may protect the team against the unknown risk of covid-19 transmission [23]. regional anaesthesia options should be discussed with anaesthesiologists in vaginal and open surgeries to avoid aerosol-generating procedures, including intubation and extubation [11] . if general anaesthesia and intubation are required, covid-19 guidance for anaesthesia and all team members should be considered [24] . it is vital to operate in the shortest time by an experienced laparoscopic surgeon. to minimize the number of staff in the operating room is highly recommended to provide safety. as the knowledge of the transmission ability of aerosolized virus during laparoscopy is lacking, all staff in the or should use ppe. to use the trocar sites effectively for safer and faster surgery, the size and number of the incisions for trocars should be appropriate enough, not too small or big with the lowest numbers. intraabdominal pressure should be as low as possible (10-11mmhg) with available trendelenburg position to establish the pneumoperitoneum [5] . the taps of the trocars should be closed before insertion and removal processes to avoid leakage of not only the gas but also the body fluids; it should always be remembered that to minimize the instrument exchange leads to minimizing leakage [13] . it is recommended to lower the electrocautery power settings as possible; caution with ultrasonic devices, monopolar electrocautery and avoidance of prolonged desiccation is considerable. while removing specimens such as in ectopic pregnancy, it is rational to deflate the abdomen with a suction device before removing the bag from the abdomen [6] . surgeries that carry a high risk of bowel involvement as tuboovarian abscess, known pelvic adhesions should be performed by laparotomy [5, 7, 13] ( table 2) . on the review of the present data about the viral transmission of covid-19, performing surgery in any way does not differ in terms of open surgery or laparoscopy. however, it should be remembered that minimally invasive approaches shorten the recovery and hospitalization period of the patients. all precautions should be taken into consideration, including both protective equipment and recommendations about any type of surgery that may have a risk of aerosolization. evidence-based data and expert opinions renewing every day about the issue will address the pros and cons of the way of surgery during covid-19 in the coming period. the authors declare no conflict of interest. set the intraabdominal pressure as low as possible (10-11 mmhg). close the taps of the trocars before insertion and during the operation. pay maximum attention to port sites; (a) a minimum number of incisions, (b) minimum size of incisions, (c) minimum exchange of the instruments. minimize the use of energy devices, lower the electrocautery power settings as possible; (a) avoid using ultrasonic devices, (b) avoid prolonged desiccation. 5. consider using vacuum suction devices, a closed-circuit smoke evacuation device with a hepa filter or a ulpa filter if possible. 6. make sure that the taps of the trocars are closed all the time unless evacuation is achieved. 7. make sure that the pneumoperitoneum and smoke is safely evacuated before specimen extraction, trocar removal, closure of the incisions or conversion to laparotomy. hepa: high-efficiency particulate air; ulpa: ultra-low particulate air. coronavirus disease (covid-19) situation dashboard surgical decision making in the era of covid-19: a new set of rules surgical approach to hysterectomy for benign gynaecological disease american association of gynecologic laparoscopists (aagl) (2020). aagl joint society statement on elective surgery during covid-19 pandemic rcog -bsge statement on gynaecological laparoscopic procedures and covid-19 esge recommendations on gynaecological endoscopic surgery during covid-19 outbreak understanding the "scope" of the problem: why laparoscopy is considered safe during the covid-19 pandemic perspectives on surgery in the time of covid-19: safety first minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy society of american gastrointestinal and endoscopic surgeons (sages) (2020). sages and eaes recommendations regarding surgical response to covid-19 crisis aagl joint statement on minimally invasive gynecologic surgery during the covid-19 pandemic preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore covid 19 pandemic and gynaecological laparoscopic surgery: knowns and unknowns. facts, views & vision in obgyn rational use of personal protective equipment (ppe) for coronavirus disease (covid-19) personal protective equipment during the covid-19 pandemic -a narrative review what is the appropriate use of laparoscopy over open procedures in the current covid-19 climate droplets and aerosols in the transmission of sars-cov-2 surgical smoke and infection control detecting hepatitis b virus in surgical smoke emitted during laparoscopic surgery reduction of hiv transmission during laparoscopic procedures coronavirus disease 2019: coronaviruses and blood safety fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia resources for smoke gas evacuation during open, laparoscopic, endoscopic procedures world federation of societies of anaesthesiologists (wfsa) (2020). covid-19 guidance for anaesthesia and perioperative care providers key: cord-327314-8vz9x8f1 authors: ni, yan; xu, zhi-jie; zhang, zhen-feng; yang, chun; liu, cun-ming; gui, bo title: acute normovolemic hemodilution for major cancer surgeries during the covid-19 pandemic: a beacon of hope date: 2020-05-15 journal: j clin anesth doi: 10.1016/j.jclinane.2020.109871 sha: doc_id: 327314 cord_uid: 8vz9x8f1 nan cancer surgeries to be performed safely and at the earliest in such a situation of insufficient allogenic blood supplies. this retrospective study's protocol was approved by the institutional review board of our hospital (#2020-sr-110). in our hospital, the surgical treatments of 22 cancer patients scheduled for major cancer surgeries were cancelled multiple times because of the shortage of allogenic blood supplies during february 2020. anh was applied to these patients at the suggestion of anesthesiologists. all patients examined successfully underwent the scheduled surgeries. the baseline demographics, comorbidities, and types of surgery were shown in table 1 . the volumes of anh blood drawn and intraoperative blood loss were 400-800 ml and 100-1300 ml, respectively. only one patient received 2 units of erythrocytes intraoperatively. as shown in because safety is a major focus of surgical and perioperative care, preoperatively acquired blood and blood products remain a routine safeguard for patients undergoing major cancer surgeries. although the absolute risk/benefit ratio for anh is controversial, it is crucial to protect cancer patients from experiencing acute blood loss-induced life-threatening situation. in clinical settings, we should address how anatomical features relevant to the surgery, complexity of resections, and technical skills of surgeons might induce massive intraoperative bleeding. a failure to consider these factors, without the availability of substantial allogenic blood supplies, would endanger patients. in conclusion, anesthesiologists and surgeons must work together to surpass and overcome this intractable period. one of the beneficial procedures is to use anh for patients with cancer to permit major surgeries to be performed at the earliest without further delays. intraoperative hb, hct, lac, and ica 2+ levels. e-g). perioperative hb, hct, and plt levels. values was presented as median and interquartile range, and analyzed with the mann-whitney test or kruskal-wallis h test as appropriate. anh: acute normovolemic hemodilution, hb: hemoglobin, hct: hematocrit, ica 2+ : ionized calcium, lac: lactate, plt: platelet, pod: table 1 baseline demographics, comorbidities, and types of surgery. laparoscopic radical nephrectomy 2 (9.1%) laparoscopic radical prostatectomy 2 (9.1%) laparoscopic radical cystectomy 2 (9.1%) intracranial tumor resection 1 (4.5%) thoracoscopic pulmonary resection 1 (4.5%) figure 1 covid-19) pandemic. geneva: world health organization coronavirus disease 2019: coronaviruses and blood safety perioperative care and collaboration between surgeons and anaesthetists -it's about time impact of acute normovolemic hemodilution on allogeneic blood transfusion during open abdominal cancer surgery: a propensity matched retrospective study the efficacy of acute normovolemic hemodilution for preventing perioperative allogeneic blood transfusion in gynecological cancer patients key: cord-332960-h0be6pr0 authors: angioni, stefano title: laparoscopy in the coronavirus disease 2019 (covid-19) era date: 2020-05-14 journal: gynecol surg doi: 10.1186/s10397-020-01070-7 sha: doc_id: 332960 cord_uid: h0be6pr0 the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) that emerged in china at the end of 2019 has become a pandemic infection that has now involved 200 countries with 465,915 confirmed cases and 21,031 confirmed deaths. unfortunately, many data have shown that the high number of undocumented infections could have a major role in the rapid diffusion of the disease. in most of the nations involved, non-urgent, non-cancer procedures have been stopped to reallocate medical and paramedical staff to face the emergency. moreover, concerns have been raised that minimally invasive surgery could be a procedure that carries the risk of virus diffusion in the operating theater during surgery. this paper reports clinical recommendations and scientific studies to assist clinicians in this field. minimally invasive surgery and laparoscopy in particular represent the conventional approach to most abdominal and pelvic surgery [1, 2] . the popularity of these techniques is due to many documented advantages, such as short hospitalization, rapid recovery after surgery, higher precision of the surgical maneuvers, and less bleeding [3] . most surgeries for benign gynecological diseases are performed with laparoscopy [4] , and its advantages have increased its application in malignancies [5, 6] . even less invasive approaches have been developed in recent years, such as the use of very thin instruments in mini-and micro-laparoscopy and the development of single-port access laparoscopy (spal) [7, 8] . these evolutions that minimize the port size in the case of mini-laparoscopy or reduce their number by using only one entrance, as in spal or transvaginal natural orifice transluminal endoscopic surgery (vnotes), could be even less invasive than conventional multiport laparoscopy [9, 10] . nevertheless, everything could change. indeed, we are facing a new respiratory virus that is modifying our operating room activity. the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) that emerged in china at the end of 2019 has spread to a pandemic infection in just a few months. it has now involved 200 countries with 465,915 confirmed cases and 21,031 confirmed deaths (data as at march 26, 2020) [11] . unfortunately, some reports have shown that the high number of undocumented infections could have a major role in the rapid diffusion of this disease [12] . in most of the nations involved, non-urgent, non-cancer procedures have been stopped to reallocate medical and paramedical staff to face the emergency [13] . moreover, concerns have arisen about the possibility that minimally invasive surgery could be a risky procedure in increasing the virus diffusion in the operating theater during surgery. this paper reports clinical recommendations and published scientific data to help clinicians in this field. only a few reports in the literature relate to the possible risk to the surgical team of inhalation of viruses from patients during a laparoscopy. in 1996, des coteaux et al. demonstrated the presence of breathable aerosols and cell-size fragments in the cautery smoke produced during laparoscopic procedures. the particle sizes ranged from 0.1 to 25 μm [14] . the particle size may depend on the device used [15] . an aerosol is defined as a suspension system of solid or liquid particles in a gas. an aerosol includes both the particles and the suspending gas, which is usually air, and in the case of laparoscopy, co 2 . other studies have shown that whole cells can be carried as aerosols in the pneumoperitoneum during laparoscopy in the smoke produced by cauterization [16, 17] . it seems that increasing pneumoperitoneum pressure is correlated to the number of cells found [18] . on the contrary, analysis of the theoretical risk that pneumoperitoneum gas could carry bacteria in aerosol form and spread infection throughout the peritoneal cavity during laparoscopy for infective conditions such as appendicitis was not confirmed in another study, as the pneumoperitoneum gas collected at the end of the procedure did not show any bacterial contamination [19] . nevertheless, the hepatitis b virus and human papillomavirus dna have been detected in surgical smoke, although no data exist on surgical team contamination [20, 21] . during open surgery, electrical or ultrasonic cauterization is able to produce aerosols, but some evidence suggests that particle concentrations in smoke seem higher in laparoscopic surgery [22] . the problem of contamination of operating rooms by aerosol is particularly important in relation to the evacuation of the pneumoperitoneum during laparoscopic surgery [23] . even if it is still unknown whether sars-cov-2 shares the properties of other viruses that can be found in laparoscopic surgical smoke, many scientific societies have published online their recommendations on laparoscopy during this pandemic. the society of american gastrointestinal and endoscopic surgeons (sage) recommends stopping elective surgeries. in urgent or necessary surgeries, since laparoscopy could potentially release viruses, sage states that the use of devices to filter released co 2 for aerosolized particles, the reduction of medical staff to the minimum inside the operating room, and the use of personal protective equipment (ppe) should be strongly considered [24] . the european society for gynecological endoscopy (esge) has also suggested postponing elective surgery for benign conditions until the pandemic ends. the screening of patients for coronavirus infection before planned surgical treatment or the postponement of surgery on suspected or documented sars-cov-2-positive patients until their full recovery, if there is no immediate life-threatening situation, is strongly recommended. if this is not possible, surgery must be performed with full ppe for the entire theater staff. surgery for gynecological cancer should continue unless alternative interim options are possible after the end of the outbreak. the esge also provides suggestions to reduce co 2 release: (a) closing the port taps before insertion, (b) attaching a co 2 filter to one of the ports for smoke evacuation if needed, (c) not opening the tap of any ports unless they are attached to a co 2 filter or being used to deliver the gas, (d) reducing the introduction and removal of instruments through the ports, (e) deflating the abdomen with a suction device before removing the specimen bag from the abdomen, (f) deflating the abdomen with a suction device and via the port with a co 2 filter at the end of the procedure, and (g) minimizing the use of cauterization [25] . the royal college of obstetrics and gynecology (rcog) together with the british society for gynecological endoscopy (bsge) provides similar advice on co 2 evacuation and prevention of aerosol transmission and in addition suggests performing laparotomies or deferring operations that have a risk of bowel involvement due to an increased theoretical risk in such cases [26] . the american association of gynecologic laparoscopists (aagl), along with many other surgical and women's health professional societies, supports suspension of non-essential surgical care during the immediate phases of the coronavirus disease 2019 (covid-19) pandemic [27] . in addition to suggestions to reduce aerosol diffusion during and immediately after laparoscopy, the aagl provides similar advice on screening patients before surgery and suggests additional imaging evaluation (chest computed tomography) prior to any surgical procedure, based on published data on its high predictive ability for early disease [28] . our knowledge of this new virus is still very limited. consequently, the possible risks for health professionals and the risks from operating on an asymptomatic patient positive for sars-cov-2 are still unclear. certainly, in this period, the surgical indications and accurate patient selections should be thoroughly discussed in each case, since it is mandatory to reallocate medical and paramedical staff to face the emergency. another important issue is to decrease operating room use in order to increase the number of lung ventilators available for the great number of coronavirus patients that need respiratory assistance. the need to limit virus diffusion and the published data on other viruses in surgical smoke, in particular in laparoscopy, should be taken into strong consideration. the ideal situation would be to screen all patients before surgery. if this is not possible, ppe should be used and all the strategies to decrease aerosol diffusion in the operating theater should be followed. i strongly suggest using a device that has a close circuit to maintain the pneumoperitoneum to facilitate smoke evacuation and filtration with a 0.01 μm ultra-low particulate air filter. another possible suggestion is to use very low co 2 pressures. this goal can even be obtained using a deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery at very low insufflation pressure [29] . these strategies increase the cost of the surgery but could improve safety. the influence of operative laparoscopy on the general operative concept in gynecology minimally invasive colon cancer surgery treatment of nonendometriotic benign adnexal cysts: a randomized comparison of laparoscopy and laparotomy techniques in minimally invasive surgery for advanced endometriosis advantages of laparoscopy versus laparotomy in extremely obese women (bmi>35) with early-stage endometrial cancer: a multicenter study current recommendations for minimally invasive surgical staging in ovarian cancer minilaparoscopic repair of apical pelvic organ prolapse (pop) by lateral suspension with mesh single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes postoperative outcomes and quality of life following hysterectomy by natural orifice transluminal endoscopic surgery (notes) compared to laparoscopy in women with a non-prolapsed uterus and benign gynaecological disease: a systematic review and meta-analysis single-port access subtotal laparoscopic hysterectomy: a prospective case-control study world health organization. cornavirus disease (covid-2019) situation reports 26 substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov2). science. mar 16. pii: eabb3221 how covid-19 outbreak is impacting colorectal cancer patients in italy: a long shadow beyond infection preliminary study of electrocautery smoke particles produced in vitro and during laparoscopic procedures analysis of surgical smoke produced by various energy-based instruments and effect on laparoscopic visibility cells are present in the smoke created during laparoscopic surgery an experimental model of cellular aerosolization during laparoscopic surgery detection of aerosolized cells during carbon dioxide laparoscopy bacterial contamination of pneumoperitoneum gas in peritonitis and controls: a prospective laparoscopic study detecting hepatitis b virus in surgical smoke emitted during laparoscopic surgery human papillomavirus dna in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon characterization of smoke generated during the use of surgical knife in laparotomy surgeries contamination resulting from aerosolized fluid during laparoscopic surgery sages -society of american gastrointestinal and endoscopic surgeons recommendations surgical response to covid 19 esge recommendations on gynaecological laparoscopic surgery during covid-19 outbreak aagl joint statement on minimally invasive gynecologic surgery during the covid-19 pandemic correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the author declares that he has not conflict of interest.received: 31 march 2020 accepted: 27 april 2020 key: cord-336676-r8x4zhc2 authors: thakkar, m; bednarz, b title: should walant surgery be included in the training curriculum? date: 2020-05-26 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.05.072 sha: doc_id: 336676 cord_uid: r8x4zhc2 nan currently the covid-19 pandemic is putting significant strain on the healthcare systems across the globe. our anaesthetic colleagues are under immense pressure and in some instances have been redeployed to other settings, limiting our ability to operate under general or regional anaesthesia. we propose that training in both wide awake local anaesthesia no tourniquet (walant) as well as ultrasound guided blocks should be incorporated into plastic surgery training or at the very least in to the hand surgery subspecialty curriculum to help overcome such a problem in the future. as a limb salvage team, we have a duty to continue our service during these dire times. to facilitate continued surgical treatment with limited anaesthetic cover, other options should be explored. this approach. this is for the most part due to the unfamiliarity of the technique as well as the dogma of not using adrenaline in the fingers which has been refuted 4 . in the coming weeks, this skill set might make a huge difference in the amount of resources required to maintain a safe and efficient upper limb trauma service, allowing for more injuries to be treated in minor ops theatres provided the right equipment is available. we therefore propose that walant should be incorporated into plastic surgery training curriculum. we recognise that it might not be an approach favoured by all once the pandemic is over however, increasing the variety of skills taught to future plastic surgeons should be encouraged. furthermore, the hand diploma or subspecialty interest in hand surgery curriculum could include training on regional ultrasound guided blocks. this should mainly be as an adjunct for smaller cases with regional anaesthesia remaining under the domain of our anaesthetic colleagues. no funding to declare of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic wide-awake hand and wrist surgery: a new horizon in outpatient surgery a multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the dalhousie project clinical phase a critical look at the evidence for and against elective epinephrine use in the finger key: cord-309629-7jtnhn65 authors: thomas, viju; maillard, charlotte; barnard, annelize; snyman, leon; chrysostomou, andreas; shimange-matsose, lusandolwethu; van herendael, bruno title: international society for gynecologic endoscopy (isge) guidelines and recommendations on gynecological endoscopy during the evolutionary phases of the sars-cov-2 pandemic date: 2020-08-26 journal: eur j obstet gynecol reprod biol doi: 10.1016/j.ejogrb.2020.08.039 sha: doc_id: 309629 cord_uid: 7jtnhn65 the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic has raised some important interrogations on minimally invasive gynaecological surgery. the international society of gynaecological endoscopists (isge) has taken upon itself the task of providing guidance and best practice policies for all practicing gynaecological endoscopists. factors affecting decision making processes in minimal invasive surgery (mis) vary depending on factors such as the phase of the pandemic, policies on control and prevention, expertise and existing infrastructure. our responsibility remains ensuring the safety of all health care providers, ancillary staff and patients during this unusual period. we reviewed the current literature related to gynecological and endoscopic surgery during the coronavirus disease 19 (covid-19) crisis. regarding elective surgery, universal testing for sars-cov-2 infection should be carried out wherever possible 40 h prior to surgery. in case of confirmed positive case of sars-cov-2, surgery should be delayed. priority should be given to relatively urgent cases such as malignancies. isge supports medical optimization and delaying surgery for benign non-life-threatening surgeries. when possible, we recommend to perform cases by laparoscopy and to allow early discharges. any procedure with risk of bowel involvement should be performed by open surgery as studies have found a high amount of viral rna (ribonucleic acid) in stool. regarding urgent surgery, each unit should create a risk assessment flow chart based on capacity. patients should be screened for symptoms and symptomatic patients must be tested. in the event that a confirmed case of sars-cov-2 is found, every attempt should be made to optimize medical management and defer surgery until the patient has recovered and only emergency or life-threatening surgery should be performed in these cases. we recommend to avoid intubation and ventilation in sars-cov-2 positive patients and if at all possible local or regional anesthesia should be utilized. patients who screen or test negative may have general anesthesia and laparoscopic surgery while strict protocols of infection control are upheld. surgery in screen-positive as well as sars-cov-2 positive patients that cannot be safely postponed should be undertaken with full ppe with ensuring that only essential personnel are exposed. if available, negative pressure theatres should be used for patients who are positive or screen high risk. during open and vaginal procedures, suction can be used to minimize droplet and bioaerosol spread. in a patient who screens low risk or tests negative, although carrier and false negatives cannot be excluded, laparoscopy should be strongly considered. we recommend, during minimal access surgeries, to use strategies to reduce production of bioaerosols (such as minimal use of energy, experienced surgeon), to reduce leakage of smoke aerosols (for example, minimizing the number of ports used and size of incisions, as well as reducing the operating pressures) and to promote safe elimination of smoke during surgery and during the ports’ closure (such as using gas filters and smoke evacuation systems). during the post-peak period of pandemic, debriefing and mental health screening for staff is recommended. psychological support should be provided as needed. in conclusion, based on the existent evidence, isge largely supports the current international trends favoring laparoscopy over laparotomy on a case by case risk evaluation basis, recognizing the different levels of skill and access to minimally invasive procedures across various countries. the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic has raised some important interrogations on minimally invasive gynaecological surgery. the international society of gynaecological endoscopists (isge) has taken upon itself the task of providing guidance and best practice policies for all practicing gynaecological endoscopists. priority should be given to relatively urgent cases such as malignancies. isge supports medical optimization and delaying surgery for benign non-life-threatening surgeries. when possible, we recommend to perform cases by laparoscopy and to allow early discharges. any procedure with risk of bowel involvement should be performed by open surgery as studies have found a high amount of viral rna (ribonucleic acid) in stool. regarding urgent surgery, each unit should create a risk assessment flow chart based on capacity. patients should be screened for symptoms and symptomatic patients must be tested. in the event that a confirmed case of sars-cov-2 is found, every attempt should be made to optimize medical management and defer surgery until the patient has recovered and only emergency or life-threatening surgery should be performed in these cases. we recommend to avoid intubation and ventilation in sars-cov-2 positive patients and if at all possible local or regional anesthesia should be utilized. patients who screen or test negative may j o u r n a l p r e -p r o o f have general anesthesia and laparoscopic surgery while strict protocols of infection control are upheld. surgery in screen-positive as well as sars-cov-2 positive patients that cannot be safely postponed should be undertaken with full ppe with ensuring that only essential personnel are exposed. if available, negative pressure theatres should be used for patients who are positive or screen high risk. during open and vaginal procedures, suction can be used to minimize droplet and bioaerosol spread. in a patient who screens low risk or tests negative, although carrier and false negatives cannot be excluded, laparoscopy should be strongly considered. we recommend, during minimal access surgeries, to use strategies to reduce production of bioaerosols (such as minimal use of energy, experienced surgeon), to reduce leakage of smoke aerosols (for example, minimizing the number of ports used and size of incisions, as well as reducing the operating pressures) and to promote safe elimination of smoke during surgery and during the ports' closure (such as using gas filters and smoke evacuation systems). during the post-peak period of pandemic, debriefing and mental health screening for staff is recommended. psychological support should be provided as needed. in conclusion, based on the existent evidence, isge largely supports the current international trends favoring laparoscopy over laparotomy on a case by case risk evaluation basis, recognizing the different levels of skill and access to minimally invasive procedures across various countries. the international society of gynaecological endoscopists (isge) is privileged to enjoy patronage of members from around the globe. countries affiliated with the isge are experiencing different stages of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic, for example, south africa is slowly reaching its peak while other countries such as china and italy have passed their first peak and plateau phases and others usa, brazil are still in the midst of the pandemic. factors affecting decision making processes in minimal invasive surgery (mis) vary depending on factors such as the phase of the pandemic, policies on control and prevention, expertise and existing infrastructure. given the uncertainty of immunity and new emerging strains, caution must be practiced to ensure the safety of all health care providers, ancillary staff and patients during this unusual period. the isge is proud to be a global leader in this regard. we the outbreak of sars-cov-2 (coronavirus disease 19 -covid 19) which originated in hubei was declared a pandemic in march 2020 by the world health organization (who) [1, 2] and now poses a massive health and economic burden internationally [3, 4] . this pandemic is further complicated by the substantial risk of viral spread posed by asymptomatic carriers [5] . endoscopic procedures potentially and theoretically put all involved at risk of inhalation and j o u r n a l p r e -p r o o f conjunctival exposure from bioaerosol (endoscopically generated and otherwise), direct contact and contact with fecal matter [6, 7, 8, 9, 10] . as gynecological endoscopists, it is imperative to review current practices by evaluating and mitigating risks, to ourselves, colleagues, staff and above all, to patients. the theoretical risk of infection from endoscopically generated bioaerosols may potentially be increased due to three main factors peculiar to laparoscopy [11, 12] : 1. the use of gas insufflation, both during entry and intra-operatively. creation of bioaerosols from electrosurgery, a cornerstone of endoscopy. with four documented cases of hpv and none of hbv or hiv. despite the reassuring nature of these findings, caution should be maintained, especially when extrapolating to potentially more virulent pathogens such as sars-cov-2 [6, 7, 8, 9, 10] . the main route of transmission is via droplet spread and via contact transmission from contaminated surfaces to mucosal surfaces [14, 15, 16] . the virus may also become aerosolized during certain airway interventions and cardiopulmonary resuscitation [17] . additionally, wang this is supported by a study in children where they tested negative for nasopharyngeal swabs but positive for rectal swabs and further highlights the false negative rates of nasopharyngeal swabs [19] . the above information is mostly anecdotal evidence and highlights a severe paucity of academic ammunition available for decision making and we must attempt to apply it with care and caution to clinical practice]. it must also be noted that the risk of open surgery with regards to the spread of covid-19 disease is also not known, and open surgery also produces electrocautery fumes that can potentially spread the virus. it is important to take advantage of governmental strategies in the early phase of an outbreak which would be to create capacity by anticipating the exponential nature of infection. for example, the australian and new zealand hepatic, pancreatic and biliary association categorized three phases [20] : it would be prudent in the early phase to fast track "time sensitive diseases" during this time, such as certain oncological cases, as failure to do this might worsen patients' outcomes. once the exponential phase overruns capacity, surgeons will find themselves with inadequate operating j o u r n a l p r e -p r o o f time and safe recovery facilities for their urgent cases and left with uncertainty as to when these cases can be performed.  priority should be given to urgent cases such as early stage endometrial and cervical cancer.  perform urgent cases by laparoscopy and discharge early while the pandemic and the cancer are in their early phases.  it would be prudent to prospectively stratify and prioritize the urgency of each cancelled case.  universal testing for sars-cov-2 infection should be carried out wherever possible 40 hours prior to surgery for all patients booked for semi-urgent surgery such as endometrial cancer cases to be performed laparoscopically. this will allow identification of most asymptomatic carriers and will allow appropriate management of those who test positive, including postponement of surgery where possible. in the acute phase of the covid-19 pandemic, all elective surgical procedures should be postponed where it is possible to safely to so without harm to patients [21, 22, 23] . it is prudent to ensure that postponement is balanced against the patient's outcome and quality of life.  decisions regarding the management of malignancies should be undertaken in conjunction with an oncologist.  isge supports medical optimization and delaying surgery for prolapse and incontinence.  where a delay in surgery will influence the reproductive prognosis of a patient, the case should be managed with a reproductive medicine specialist with the aim of optimizing medical management and consideration given to fertility preservation options.  surgery for endometriosis should be deferred as it is not life threatening and when j o u r n a l p r e -p r o o f bowel involvement is present, the risk of viral exposure is increased during excision [22] .  any procedure where there is a risk of bowel involvement including conditions (such as pelvi-abdominal sepsis, or tubo-ovarian abscesses) should be performed by open surgery as studies have found a high amount of viral rna in stool [18] . in countries where the peaks have been reached, there is ongoing uncertainty as to when elective surgeries can begin. this period should start with addressing the needs of the health care workers and an inventory of available capacity / resources. these need to be balanced against the backlog of the elective cases.  debriefing and mental health screening for staff is recommended.  psychological support should be provided as needed.  human inventory must be balanced with hospital capacity. although universal testing is probably ideal for all patients, this may not be practical in all settings. screening and testing should be employed as per local protocol. testing includes screening for symptoms, nasopharyngeal swabs with nucleic acid amplification such as polymerase chain reaction (pcr) which has a high specificity but a low sensitivity, rapid antigen/antibody but considering the 5-10-days delay for the production of antibodies [24] . the role of chest imaging is controversial. zhu et al demonstrated radiological evidence of pneumonic changes in 67% of sars-cov-2 patients who tested negative [25] . in contrast pcr confirmed patients had normal computed tomography (ct) scan findings in 56% of positively tested patients [26] . the role of imaging probably lies in the "grey zone" where there is discrepancy between clinical suspicion and test results. with a high index of clinical suspicion, imaging is probably beneficial.  each unit/center should create a risk assessment flow chart based on capacity.  ideally all preoperative patients should be tested if resources allow.  where universal testing is not available, patients should be screened for symptoms based on the local guidelines for example the national institute of communicable diseases [27] .  symptomatic patients must be tested.  with a high clinical suspicion pulmonary assessment with chest x-ray or ct scan preoperatively may be of benefit. in addition to laparoscopically generated bioaerosols, sars-cov-2 is primarily a respiratory virus and the team involved in general anesthesia performing endotracheal intubation and extubation, are at the highest risk of viral transmission [17, 29, 30] .  in the event that a confirmed case of sars-cov-2 is found, every attempt should be made to optimize medical management and defer surgery until the patient has recovered, and only emergency or life-threatening surgery should be performed in these cases.  every attempt should be made to avoid intubation and if at all possible local or regional anesthesia should be utilized.  trendelenburg optimization may facilitate ventilatory needs and this should be balanced between surgical and anesthetic requirements. a study by li et al. concluded that the risk of aerosol spread may be lower during laparotomies [11] , however this theoretical risk must be balanced with the advantages associated with laparoscopies, including: earlier discharge, reduced nosocomial infections, reduced rates of complications (and therefore re-admissions into hospital, thus increasing the potential risk of sars-cov-2 infection) [31] . these advantages are robustly supported in the literature [31, 32, 33, 34, 35, 36, 37, 38] and provide much needed capacity in terms of bed space and critical staff for health care institutions during this time. brücher et al. did assess the risk of open and laparoscopic surgery to be the same provided the gas/smoke was evacuated safely and water lock filters were used or if gasless laparoscopy was performed [24] . and it stands to reason that the sars-cov-2 virus which has a wider diameter of 70-90 nm would not pass through the filter [39] . this highlights the role of filters which may be used during laparoscopy after which these filters should be discarded according to local protocols. it must be clearly stated that there is no robust evidence of increased risk of viral transmission during laparoscopy. the current evidence is purely extrapolated from work with other, above mentioned, pathogens. while recognizing these facts, all precautions must still be taken during this time until more evidence becomes available. aerosols are also produced during open and vaginal surgery [6, 11, 13] . unlike during laparoscopy there is no way to contain the aerosols by using filters and closed system smoke evacuators. this risk is increased with the use of any electrosurgery including monopolar, bipolar and advanced energy devices such as advanced bipolar, laser and ultrasonic devices [13, 40] .  in a patient who screens low or tests negative, although carrier and false negatives cannot be excluded, laparoscopy should be strongly considered. currently we need to balance a hypothetical risk of aerosol spread in low risk patients to the vast array of evidence proving the benefits of laparoscopic surgery. the importance of infection, prevention and control (ipc) and adequate ppe cannot be over emphasized. whilst prioritizing patients' needs first, it is imperative that the safety of healthcare workers is not compromised.  ensure that only essential personnel are exposed. for example, there is no need for the entire theatre staff to be present during intubation.  although disposable instruments, tubing and filters are ideal, this should be tailored to resources within the unit. j o u r n a l p r e -p r o o f there is no substitute for practicing sound surgical principles to ensure seamless surgery and good patient outcome. care should be employed when choosing advanced energy sources. the theoretical risk of increased smoke and particle dispersion is associated with the high frequency oscillating mechanism of ultrasonic devices [13, 40] .  consider potential particle dispersion when choosing energy devices.  employ sound principles of energy to optimize tissue effect.  employ basic surgical principles: minimize bleeding, careful handling of tissue, minimal use of energy at the lowest but effective settings and use of atraumatic instruments.  the most experienced, proficient and knowledgeable surgeon available should perform the procedure. this will ensure the implementation of sars-cov-2 protocols, shortest operating time and minimal exposure of the theatre staff to potential aerosols. communication and meticulous planning will result in fewer human errors. staff should be well briefed on the surgical plan. if needed sop and protocols can be simulated for intraoperative strategies such as avoiding leakage by not opening ports to release smoke, use of filters, smoke evacuators, disposable tubing, use of wall suction and removal of specimens to name a few.  provide in service training for theatre staff and detail the surgical plan preoperatively.  consideration should be given to the number of ports used and size of incisions.  minimize the operating pressures where possible to minimize gas leaks.  prudent preoperative planning helps reduce gas leaks which occur during instrument changes. where gas leaks are anticipated, such as with specimen retrieval and removal of the uterus at total laparoscopic hysterectomy, certain strategies may be employed:  use of retrieval devices may minimize gas leaks.  ensure all colpocleiators (vaginal cuff delineators with air seal) are checked preoperatively for gas leaks.  once the vault has been circumcised, all the gas should be removed by suction and/or closed system evacuators, before removing the specimen vaginally.  if one is not able to maintain colpocleisis during colpotomy, then consider an alternative strategy such as vaginal colpotomy after removing all the gas, as performed at laparoscopic assisted vaginal hysterectomy (lavh).  it is advisable to use closed smoke evacuation systems intra-operatively when available.  filters should be used and tailored to what is available to the center.  wall suction connected to a central system is preferable to mobile suctioning devices.  suction should be generously utilized to remove the plumes of smoke generated during surgery.  suction should be used at the end of the procedure to remove all the gas from the abdominal cavity prior to removing the ports.  use closed system smoke evacuators to safely remove surgical gas at the end of the procedure. the trough of the pandemic should not herald old practices. this must be done for two reasons: uncertainty of repeated waves of infection [41, 42, 43] and even in a post sars-cov-2 world, this j o u r n a l p r e -p r o o f practice will continue to keep staff from unknown toxins and bioaerosols.  even after the peak of the disease the practice of safe elimination of smoke should continue.  where possible central suction should be used in all cases the recent article by mallick et al. discusses the conflict between the traditional practice of port removal under vision before desufflation and the newly adopted practice of desufflating prior to removing the ports to prevent bioaerosol infection [13] . this deviation in practice marginally increases the risk of port site herniation and unrecognized port site bleeding but supports the reasoning and applied practice. port site herniation is more likely to occur if all the gas has not been removed and the ports are not removed under direct vision. this occurs because the positive pressure in the abdomen can push structures such as omentum and small bowel through the port while the gas is trying to escape.  isge supports the interim practice of desufflation prior to the removal of ports for purposes of reducing bioaerosol spread.  remove all ports only after all the gas has been removed to reduce port site herniation.  at the end of the procedure, the sheath at port-sites ≥ 10 mm must be closed using a j needle.  avoid using commercial endoscopic port closure devices as they may allow for gas leaks.  consider the routine use of gas filters.  remove ports only after all the gas is removed.  if ports are removed before gas is removed, this must be done under vision.  the use of a protective fitting face mask is recommended. as with laparoscopy the evidence on hysteroscopic bioaerosol production is sparse. electrosurgery during hysteroscopy seems to produce less smoke than laparoscopy, although there are no comparative studies to support this. in this regard mechanical hysteroscopic morcellators pose an advantage [21, 35] . in the absence of evidence, it is not possible to adequately quantify the risk of bioaerosol production at hysteroscopy but the risk appears low.  all elective cases should be postponed.  it is plausible that hysteroscopic tissue removal systems reduce bioaerosol exposure.  suction device should be connected to an outflow sheath.  isge recommends no anesthesia or if indicated conscious sedation, local or regional anesthesia for hysteroscopy.  hysteroscopic morcellators may pose an advantage over hysteroscopic electrosurgical devices.  hysteroscopy is preferentially performed on a day case/outpatient basis to relieve the pressure on main theatre resources. the literature supports laparoscopy in allowing for same-day or early discharge [30, 44] . this reduces patient exposure and enhances capacity at hospitals during this resource constrained era. although screened, patients may not have been symptomatic at the time of surgery but may have been infected. it would be prudent to identify false negatives, their contacts (at home and at the hospital) need to be identified and appropriately managed.  attempt same-day or early discharge where possible to avoid nosocomial infections.  employing early recovery after surgery (eras) principles will help facilitate quicker discharge.  it may be prudent to telephonically contact the post-operative patient to screen for symptoms after the surgery.  a log should be kept of all staff involved in the care of any specific patient in order to aid contact tracing should a patient test positive at a later stage. gynaecological endoscopy (sasge) and the british society for gynaecological endoscopy (bsge) [21, 22, 2345, 46] recommend the use of laparoscopic procedures over open procedures when appropriately evaluated. isge acknowledges the dynamic times we are in and based on current evidence, isge largely supports the current international stance favoring laparoscopy over laparotomy on a case by case risk evaluation basis. isge also recognizes the different levels of skill and access to minimally invasive procedures across various countries, and supports individual clinical decision making during this time with regards to surgical access. this document will be revised as more data becomes available. the authors wish to thank the south african society of gynaecological endoscopy for their collaboration. none. ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. no funding was obtained. j o u r n a l p r e -p r o o f who director-general's opening remarks at the media briefing on covid-19 world health organization declares global emergency: a review of the 2019 novel coronavirus 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minimally invasive gynecologic surgery esge and esgena position statement on gastrointestinal endoscopy and the covid-19 pandemic key: cord-323314-y3k9dntf authors: aggarwal, sandeep; mahawar, kamal; khaitan, manish; raj, praveen; wadhawan, randeep; dukkipati, nandakishore; kular, kuldeepak s; prasad, arun; bhasker, aparna govil; soni, vandana; madhok, brijesh; baig, sarfaraz; palaniappan, raj; shivaram, h. v.; goel, deep; bindal, vivek; saggu, sukhvinder; shrivastava, rajesh; shah, sumeet; dhorepatil, shrihari; khullar, rajesh title: obesity and metabolic surgery society of india (ossi) recommendations for bariatric and metabolic surgery practice during the covid-19 pandemic date: 2020-08-22 journal: obes surg doi: 10.1007/s11695-020-04940-3 sha: doc_id: 323314 cord_uid: y3k9dntf bariatric and metabolic surgery (bms), the only effective option for patients with obesity with or without comorbidities, has been stopped temporarily due to the ongoing novel corona virus disease (covid-19) pandemic. however, there has been a recent change in the governmental strategy of dealing with this virus from ‘stay at home’ to ‘stay alert’ in many countries including india. a host of health services including elective surgeries are being resumed. in view of the possibility of resumption of bms in near future, obesity and metabolic surgery society of india (ossi) constituted a committee of experienced surgeons to give recommendations about the requirements as well as precautions to be taken to restart bms with emphasis on safe delivery and high-quality care. the covid-19 pandemic has resulted in postponement of all planned elective operations. unfortunately, bariatric and metabolic surgery (bms) has taken the worst brunt of the pandemic. most centers have put a complete halt to new referrals and operations. obesity is associated with several comorbidities including type 2 diabetes mellitus (t2dm), hypertension, and obstructive sleep apnea (osa) [1] . patients with obesity have an impaired immune response resulting in enhanced risk of various infections including covid-19 [2] . worryingly, the severity of covid-19 is worse in patients suffering from obesity [3, 4] . as the bms has been deferred due to the covid-19 pandemic, the patients with obesity continue to suffer from its adverse consequences [5] [6] [7] . in view of the above and considering obesity and bariatric surgery to be of equal importance as other chronic lifethreatening diseases and cancer, the obesity and metabolic surgery society of india (ossi) decided to frame recommendations which will help bariatric surgeons to prepare for the possible recommencement of bariatric surgery in the near future. these recommendations are predominantly based on the opinion of experts given the paucity of data on this subject. the published recommendations by several national and international societies were also taken in account while compiling these [8] [9] [10] [11] . patients with obesity have a higher risk of morbidity/ mortality should they develop covid-19 infection [3, 4] . this will hold true for the perioperative period too as the patient is still obese in the immediate perioperative period [12] . thus, the aim of these recommendations is to accord the highest priority to the safety of patients and healthcare workers (hcw) while resuming bms. this will mandate the induction of safety measures in all standard operating procedures (sops) involving the journey of the patient from the pre-admission phase to discharge from the hospital as well as post-discharge care. it is generally accepted that resumption of bms, like any elective surgery, will require a sustained decrease in new covid-19 cases in the community as a prerequisite [5, 8] . therefore, resumption of bariatric surgery must be done cautiously based on national, state, and local health authority policies. there should be sufficient availability of resources including testing for covid-19, personal protective equipment (ppe), and health personnel. emergency surgeries including those for bleeding, perforation, and acute small bowel obstruction need to be performed urgently with all precautions including a full personal protective equipment (ppe). similarly, some conditions including vomiting due to anastomotic strictures, internal hernias causing symptoms, and gastric band erosion may require an early-urgent/semi-urgent surgery [13] . for non-urgent elective surgery, to restart the practice, patient deemed to be less complex should be selected. younger patients with few comorbidities may be ideal. initially, it may be best to avoid patients more than 60 years, those with a body mass index of 50 kg/m 2 or more, complex revisional bariatric operations, and highrisk patients including those with severe obstructive sleep apnea (osa), history of venous thromboembolism (vte), moderate to severely impaired pulmonary function, history of significant heart disease, cirrhosis, and end-stage renal disease [7, 14] . preoperative patient counselling and evaluation should be done using telemedicine protocols. the counselling should include the discussion about covid-19-related risk. all investigations including tests for covid-19 must be complete before admission. the patient should be admitted a day prior to surgery and the pre-arrival swab should be done 48-72 h prior to date of admission. all patients should preferably self-isolate for 2 weeks before the operation. good control of comorbidities is desirable especially in patients with diabetes mellitus, hypertension and osa. pre-arrival screening should be done to include a detailed covid-19-related history and history of fever, cough, travel/contact, and other suspicious symptoms as per the government and hospital protocols. testing for covid-19 should be guided by the national and state health policies. the reverse transcriptase-polymerase chain reaction (rt-pcr) should be done. all patients should have negative results for the covid-19 antigen test 48-72 h before the operation. the tests should be done preferably prior to admission for surgery. the patient should be admitted a day prior to the surgery to decrease the hospital stay. at reception area, the patient and attendant body temperature should be screened using the non-contact method, and surgical masks should be provided. the patient should be admitted in an isolation room with only one attendant and reevaluated thoroughly by the operating team. all hcw should always wear a mask. imaging if required, imaging should be focused on portable radiographs and bedside portable ultrasound/ pocus-point-of-care ultrasonography-to avoid unnecessary patient transport. chest computed tomography (ct) scan is a useful screening method [15] and can be done routinely or selectively in high-risk patients, e.g., those with pre-existing cardio-respiratory comorbidity including but not limited to severe osa, coronary artery disease, pulmonary hypertension, bronchial asthma, and interstitial lung disease. ct should be done preferably in the morning of the surgery or a day prior to further reduce the risk of operating on patients with active infection. the consent form should be modified to include the following salient points: • patient is willing to get operated while the pandemic situation has not subsided. • hospital will not be held responsible if patient develops covid-19 after surgery. • patient has been explained that they may have a more severe disease and increased risk of mortality should they develop covid-19 after surgery. a consent form specially modified for surgery during the covid-19 pandemic has been included in appendix 1. general guidelines about hand hygiene, physical distancing, cough etiquettes, and cleaning and disinfection protocols are well known and should always be adhered to. all healthcare personnel must be assessed and monitored daily. the hcw should be regularly updated about the latest protocols. elective bariatric operations should ideally be carried out on a cold, covid negative site. if such a separate hospital is not available, then all elective operations should be carried in a different area/wing of the main hospital. new operating room (or) sops regarding covid-19 should be created and nursing, anaesthesia, surgery checklists revised. the operating team should allow for longer-than-usual time per case (add 50% to 75% of total theatre time required) for adequate checks to be performed, ppe donning and doffing safely, and cleaning the or space in between cases. although it is desirable to consider changing the pressure inside the or from positive to negative [16] , a suitable alternative is to switch off the positive pressure 30 min before induction and start 30 min after sanitization at the end of the surgery since positive pressure is a feature in most ors [17] . all the staff in the or should be asymptomatic and ideally tested regularly for covid-19 based on national/ state/local guidelines. they should work exclusively in a non-covid or. they should undergo fit testing for fil endotracheal intubation is a high-risk procedure for cross transmission both to the anaesthetist and patient. the number of personnel in the or during the intubation procedure should be limited. detailed guidelines about such protocols are available in literature [18, 19] . the surgical and nursing teams should enter 15 min after intubation although yeo et al. has recommended this time interval to be 3 min based on an air recycling rate of 25 to 30 cycles per hour [20] . there should be a minimum number of staff in the or, and everyone should wear ppe. there is some concern that the surgeons may be out of practice. so, it may be important to develop procedure-specific "time out" checklists that reduce errors and ensure that surgeons finish all steps of the operation. in the beginning, it may be worth two trained surgeons pairing up to facilitate surgery and reduce chances of errors and complications. although other viruses have been demonstrated in surgical smoke [21] , there is no evidence at present that smoke can transmit covid-19. however, the absence of evidence at present does not mean that transmission cannot occur. thus, even at the cost of erring on the side of being overcautious, all practical measures for prevention of exposure to surgical plume must be followed. these include avoidance of open technique for pneumoperitoneum, the use of by muscle splitting optical trocar for entry into obese abdomen, use of balloon ports, reduction of the intra-abdominal pressure to as low as possible without compromising surgical exposure or patient safety, careful handling of ports, and keeping the electrosurgery settings to minimum possible [10, 11] . some of the precautions required specially in bms are listed in table 1 . smoke evacuation systems with filtration mechanism can be used to reduce the risk of infection from surgical plume. several commercial devices are available, and it is recommended to procure one such system during the preparation period. one extra 5-mm port can be used for suction cannula to suck simultaneously during energy usage in the absence of commercial smoke evacuation systems. at the end of the procedure, the pneumoperitoneum should be completely evacuated safely, and only then the trocars should be removed. the same precaution is required during the extraction of the specimen (if any) or conversion to open procedure. surgical drains and nasogastric tubes should be avoided. if used, the drain should be clamped until complete evacuation of gas. port closures must be done carefully in deflated obese table 1 suggested additional precautions during bariatric and metabolic surgery • leaks around nathanson liver retractor during surgery need to be minimized by additional purse string skin sutures when needed • surgeon should ensure careful and swift introduction of staplers and suture material to reduce gas leaks • the gastric calibration tube should be handled with all precautions that were taken during intubation. abdomen and if need be, incision extended slightly to ensure a proper closure. in case of robotic surgery, the robotic surgeon at console should also wear basic ppe and take precautions. the team should include experienced surgeons who can handle leakage and smoke evacuation beside the patient. the surgical team should adhere to standardized enhanced recovery after bariatric surgery (erabs) protocols for early discharge [22] . strict vte prophylaxis is indicated as there is a greater risk of complications such as deep vein thrombosis (dvt) in patients with covid-19 [23] . in case of the patient developing cough, fever, or breathlessness after surgery, testing for covid-19 and/or ct may be needed to confirm or exclude this dreaded possibility. diet and exercise do not require any special modifications beside general advice on immunity boosting diet, vitamin d, vitamin c, and zinc-rich food/supplements. there may be difficulty in procuring supplements; hence, importance of nutritious home food should be stressed. low-intensity home exercises and yoga can be suggested due to closure of gymnasiums and fitness centers during the lockdown. patients should be discharged as early as possible to "only discharge at home" as the default pathway. general covid-19 prevention advice including social distancing and the use of mask should be reiterated. the patient should be taught about covid-19-related symptoms and signs and those suggestive of surgical complications. any respiratory symptoms in the postoperative period should be treated urgently, and covid-19 pneumonia must be considered in the differential diagnosis. patients should be provided an emergency 24×7 contact number. patients should call the operating surgeon directly for any problem rather than going through their own general practitioner. regular video interactions with patients should be scheduled to ensure safe recovery. ossi encourages all bariatric surgeons in india to submit data regarding any serious adverse events (sae) as soon as possible following resumption of bariatric surgery. a sae form with separate questions for covid-19 will be created and put on the ossi website soon. the covid-19 pandemic in india is still spreading, and the crisis is evolving. as such, it is not possible for ossi to predict any time frame for resumption of bariatric surgery. it may be prudent to initiate bms when the pandemic curve shows a deceleration in a region. the local, state and national advisories/guidelines should be adhered to for resumption of surgery and rational use of resources. the safety of patients and hcw is extremely important, and therefore, all suggested measures regarding patient and hcw screening, ppe, and or protocols should be adopted to minimize transmission of covid-19 during bms. as the covid-19 situation is dynamic, these recommendations may be revised according to the evolving situation as well as the collected data over next 3-6 months. bariatric surgery and covid-19 outbreak we produced this information sheet to provide patients undergoing bariatric surgical procedures with additional information on the risks of undergoing anaesthesia and surgery around the coronavirus (covid-19) outbreak. it is very important that you notify your medical team of any risks you may have had of being exposed to coronavirus. these include (but are not limited to contact with people who have been ill in the last two weeks and underlying medical conditions. as with any surgical procedure, there are benefits and risks to undergoing general anaesthesia and surgery. however, there are additional risks related to the covid-19 outbreak that we need you to be aware of. this will ensure that you are giving your informed consent to undergoing your procedure. please read the below carefully and add your initials in the boxes to confirm you understand the information you have read and been given. epidemiology of obesity and associated comorbidities the effect of lipopolysaccharideinduced obesity and its chronic inflammation on influenza virusrelated pathology high prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (sars-cov-2) requiring invasive mechanical ventilation presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area are patients suffering from severe obesity getting a raw deal during covid-19 pandemic? obes surg the impact of covid-19 pandemic on obesity and bariatric surgery safer through surgery: american society for metabolic and bariatric surgery statement regarding metabolic and bariatric surgery during the covid-19 pandemic recommendations for metabolic and bariatric surgery during the covid-19 pandemic from ifso joint statement: roadmap for resuming elective surgery after covid-19 pandemic sages and eaes recommendations for minimally invasive surgery during covid-19 pandemic surgical practice recommendations for minimal access surgeons during covid 19 pandemic-indian inter society directives bariatric surgical practice during the initial phase of covid-19 outbreak bariatric and metabolic surgery during and after the covid-19 pandemic: dss recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery a structured approach for safely reintroducing bariatric surgery in a covid-19 environment published online ahead of print correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases conversion of operating theatre from positive to negative pressure environment surgery in covid-19 patients: operational directives consensus guidelines for managing the airway in patients with covid −19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists covid operation theatre-advisory and position statement of indian society of anaesthesiologists covid-19 & the general surgical department-measures to reduce spread of sars-cov-2 among surgeons detecting hepatitis b virus in surgical smoke emitted during laparoscopic surgery is there a role for eras program implementation to restart bariatric surgery after the peak of covid-19 pandemic? recommendations for surgery during the novel coronavirus (covid-19) epidemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-344508-a67vsux2 authors: campanile, fabio cesare; podda, mauro; arezzo, alberto; botteri, emanuele; sartori, alberto; guerrieri, mario; cassinotti, elisa; muttillo, irnerio; pisano, marcello; brachet contul, riccardo; d’ambrosio, giancarlo; cuccurullo, diego; bergamini, carlo; allaix, marco ettore; caracino, valerio; petz, wanda luisa; milone, marco; silecchia, gianfranco; anania, gabriele; agrusa, antonino; di saverio, salomone; casarano, salvatore; cicala, caterina; narilli, piero; federici, sara; carlini, massimo; paganini, alessandro; bianchi, paolo pietro; salaj, adelona; mazzari, andrea; meniconi, roberto luca; puzziello, alessandro; terrosu, giovanni; de simone, belinda; coccolini, federico; catena, fausto; agresta, ferdinando title: acute cholecystitis during covid-19 pandemic: a multisocietary position statement date: 2020-06-08 journal: world j emerg surg doi: 10.1186/s13017-020-00317-0 sha: doc_id: 344508 cord_uid: a67vsux2 following the spread of the infection from the new sars-cov2 coronavirus in march 2020, several surgical societies have released their recommendations to manage the implications of the covid-19 pandemic for the daily clinical practice. the recommendations on emergency surgery have fueled a debate among surgeons on an international level. we maintain that laparoscopic cholecystectomy remains the treatment of choice for acute cholecystitis, even in the covid-19 era. moreover, since laparoscopic cholecystectomy is not more likely to spread the covid-19 infection than open cholecystectomy, it must be organized in such a way as to be carried out safely even in the present situation, to guarantee the patient with the best outcomes that minimally invasive surgery has shown to have. following the spread of the infection from the new sars-cov2 coronavirus in march 2020, several surgical societies have released their recommendations to manage the implications of the covid-19 pandemic for the daily clinical practice. the recommendations on emergency surgery have fueled a debate among surgeons on an international level. the sice (società italiana di chirurgia endoscopica e nuove tecnologie), acs-italy chapter (american college of surgeons), aico (associazione italiana infermieri di camera operatoria), crsa (clinical robotic surgery association), sicg (società italiana di chirurgia geriatrica), sicop (società italiana di chirurgia dell'ospedalità privata), spigc (società polispecialistica italiana dei giovani chirurghi), and the wses (world society of emergency surgery) have come out in favor of a rational analysis of the issue, especially about the choice of the surgical techniques to be implemented, preferring a "selective" approach that does not exclude the use of laparoscopy a priori but, instead, strongly considers it. this approach is based on an analysis of the organization of human and logistical resources within which each of us operates, and takes into account the surgical skills that each surgeon has developed in the non-covid era. the british intercollegiate general surgery guidance on covid-19 stated that during the covid-19 pandemic, "whenever non-operative management is possible (such as for early appendicitis and acute cholecystitis), this should be implemented" [1]. other surgical societies, however, including the sice, the society of american gastrointestinal and endoscopic surgeons (sages), and the european association for endoscopic surgery (eaes), have recommended a more patient-centered and hospital-centered approach [2-4]. there is still an essential ongoing debate on the specific question: "should we change our surgical indications for urgent conditions in this global situation?" reports from china told us that asymptomatic covid-19-positive patients undergoing surgery go against unfavorable clinical outcomes, characterized by increased mortality and pulmonary complication rates [5] . this issue, along with the increased non-surgical care load that has impacted, and in some cases continues to impact profoundly on the activity of many hospitals in the world and also in italy, has favored a change in the therapeutic approach for some surgical diseases, including acute cholecystitis (ac). the debate that arose from these recommendations has revealed some further concerns about the possible evolution towards the aggravation of ac during nonoperative treatment, such as to require a higher level of care following the failure of antibiotic therapy. a level of care that would not be possible to achieve in specific contexts with intensive care units still occupied by patients with covid pneumonia. as a scientific society, we must remember that therapeutic indications are established based on the best scientific evidence available at the moment and organizational choices must be founded on the evidence that science and research make available to health systems. this underlying assumption should never be forgotten, and even the possible revision of the surgical indications for the covid-19 emergency (or other future emergencies) should take into account this fundamental principle. therefore, it is necessary to refer to the best available evidence to choose the therapeutic strategy for our patients, and do not allow the pressure imposed by the emergency conditioning to change our choices. laparoscopic cholecystectomy (lc) remains the treatment of choice for ac, even in the covid-19 era. all current guidelines recommend lc as the gold standard of therapy for ac, because of the better results in terms of mortality, morbidity, and postoperative hospital stay compared to open cholecystectomy (oc) [6] [7] [8] . the italian guidelines, promoted by sice in 2012 in collaboration with all the leading italian scientific societies [8] and our evidence-based guidelines on laparoscopic cholecystectomy published in 2015 [6] , reiterated that "patients with acute cholecystitis should be treated with laparoscopic cholecystectomy" with a grade of recommendation a in the former and "strong" in the latter. this indication also applies in the case of elderly patients and those with severe ac. the guidelines from the world society of emergency surgery (wses) agree with this setting [7, 9] . several studies have emphasized that many toxic components of the surgical smoke may endanger the operating team's health. blood-borne viruses (hpv, hbv, hiv) are known to be present in the plume produced by electrocautery and other energy devices [10, 11] . however, although the sars-cov-2 rna has recently been detected in the peritoneal cavity [12] , there is no evidence to indicate the presence of sars-cov-2 in surgical smoke. no evidence emerged suggesting that the risk of covid-19 infection related to lc may be higher than that of oc, neither for the patient nor for the health professionals. therefore, this working group does not consider that patients should be denied the benefits that high-quality studies have shown to be associated with lc. we recommend surgeons to take the necessary safety measures to reduce the risk of viral diffusion in the operating theater and ensure that patients continue to benefit from advantages of laparoscopic surgery [13] . if, on the one hand, laparoscopy contains the surgical smoke within the peritoneal cavity, on the other, the pneumoperitoneum evacuation could put the staff at risk of infection. we suggest filtering the pneumoperitoneum through filters able to remove most viral particles. the ulpa (ultralow particulate air) filters are extremely efficient to filter the sars-cov-2 virus whose diameter is about 0.06-0.14 μm. according to the iso standard 29463 (issued to harmonize the european standard en 1822 and the us mil-std-282), an ulpa filter must have a ≥ 99.9995% efficiency at filtering particles with a mmps (most penetrating particle size) of 0.12 μm. the mmps is the particle that the filter is less efficient to remove. smaller particles are filtered with an even higher efficiency. the use of these filters is recommended [3, 4, 13]. it is crucial nowadays to examine the evidence concerning the timing of lc for ac, which compares the results of "early" cholecystectomy with those of "delayed" cholecystectomy, that is carried out after a period of conservative therapy to overcome the acute phase. early cholecystectomy is recommended in all the guidelines mentioned above, based on the results of several meta-analyses of randomized controlled trials that compared the two different approaches. it has been demonstrated that early cholecystectomy (i.e., performed "as soon as possible" after the onset of symptoms and, in any case, not later than the tenth day from it) has not shown inferior results compared with the delayed one in terms of morbidity, mortality, and conversion rate (i.e., six weeks after the acute episode). therefore, early cholecystectomy is preferable to the delayed, for its shorter overall length of hospitalization (considering the sum of the stay of the first hospitalization-that is, of acute cholecystitis-and the second-that of the delayed intervention). the equivalency of the two strategies in terms of morbidity, mortality, and conversion rate cannot justify the systematic use of delayed cholecystectomy. during the covid epidemic, it may instead be desirable to postpone the surgical act away from the epidemic period, even at the cost of greater use of resources of the health system (length of stay). the equivalency in terms of morbidity and mortality between the two approaches can be a solid basis for more extensive use of delayed cholecystectomy, based on the analysis of the human and logistical resources of the hospital in which each of us works, the organizational pathways adopted, and the local epidemiological situation. it is mandatory that during the conservative treatment period, attention must be paid to monitoring sepsis parameters and pain progression despite appropriate analgesic therapy. the danger of progress of the septic state and the risk of progression towards the gangrene, emphysematous cholecystitis, or the rupture of the gallbladder may, anyway, require emergency cholecystectomy. if it is true that in the pre-covid period, cholecystectomy in patients classified as high risk according to the various guidelines has a mortality rate that can reach 19% [14] , clearly this aspect assumes greater relevance in positive or suspected covid-19 patients, which are considered at high surgical risk in themselves. both the incidence of ac and the mortality from covid-19 are higher in elderly patients. although elderly patients are more likely to present with different comorbidities that complicate any postoperative course, early la for ac is safe and effective in this group of patients, albeit burdened by increasing conversion rates [15] . the italian guidelines (by sice, acoi, sic, sicut, sicop) on lc [6] and the recent wses guidelines [7, 9] refer as in the case of patients with prohibitive surgical risk ("unfit for surgery") percutaneous drainage of the gallbladder may be considered after the failure of conservative therapy with antibiotics. however, it must be stressed that advanced age, or other factors of higher covid-19 risk, cannot be regarded as sufficient to indicate this alternative treatment except in real conditions of the impracticability of cholecystectomy. the analysis of the international literature, despite being mainly based on observational studies with a low level of evidence, demonstrates a high mortality rate for patients undergoing percutaneous gallbladder drainage. high mortality was also shown in recent extensive retrospective analyzes [16, 17] . moreover, the chocolate trial, a randomized controlled trial that had been started to compare the results of percutaneous drainage vs cholecystectomy, was prematurely terminated because the ethical problems arising from the observation of the high mortality in patients who underwent percutaneous drainage did not allow the further continuation of the study [18] . as indicated, the execution of a percutaneous cholecystostomy (only in patients with prohibitive surgical risk) takes place, as specified above, after the failure of conservative therapy, which constitutes the first therapeutic strategy in these particularly fragile patients. of all the options currently listed in the literature (percutaneous transhepatic cholecystostomy, transpapillary drainage, transmural drainage), percutaneous transhepatic cholecystostomy is generally the preferred one, due to its simplicity of execution, safety, and reduced costs. the optimal timing for performing percutaneous cholecystostomy is widely debated. however, when the cholecystostomy is carried out within 24 h from the onset of the clinical presentation is associated with fewer complications in terms of bleeding and lower hospital stay [19] . however, the timing of percutaneous cholecystostomy depends primarily on the clinical indication. urgent drainage should be considered in case of severe sepsis in a patient not eligible for surgery. for the remaining patients not eligible for surgery, it is common practice to proceed with cholecystostomy if the patient does not improve within 1-3 days of starting antibiotic therapy. we maintain that, since laparoscopy is not more likely to spread the covid-19 infection than open surgery, it must be organized in such a way as to be carried out safely even in the present situation, to guarantee the patient with the best outcomes that minimally invasive surgery has shown to have. in the case of patients unfit for surgery, percutaneous transhepatic cholecystostomy may be considered after the failure of conservative therapy with antibiotics. division of general surgery department of surgical sciences ospedale san filippo neri, roma, italy. 9 department of general surgery, ospedale san marcellino di muravera, cagliari, italy. 10 department of general and emergency surgery 23 division of general surgery, casa di cura nuova itor 26 department of general and minimally invasive surgery, misericordia hospital clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection laparoscopic cholecystectomy: consensus conference-based guidelines. langenbeck's arch surg laparoscopic approach to acute abdomen from the consensus development conference of the società italiana di chirurgia endoscopica e nuove tecnologie (sice) wses and sicg guidelines on acute calcolous cholecystitis in elderly population surgical smoke and infection control detecting hepatitis b virus in surgical smoke emitted during laparoscopic surgery sars-c ov-2 is present in peritoneal fluid in covid-19 patients. ann surg. 2020. e-published ahead-of-print a low cost, safe and effective method for smoke evacuation in laparoscopic surgery for suspected coronavirus patients systematic review of cholecystostomy as a treatment option in acute cholecystitis cholecystectomy in elderly: challenge and critical analysis of available evidence outcome comparison between percutaneous cholecystostomy and cholecystectomy: a 10-year population-based analysis emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (chocolate): multicentre randomised clinical trial early percutaneous cholecystostomy in severe acute cholecystitis reduces the complication rate and duration of hospital stay publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations all the authors contributed equally to this article. the author(s) read and approved the final manuscript. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. there are no individual author data that reach the criteria for availability. no ethical approval was required for this article. the authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. not applicable. key: cord-349206-f77ofx1w authors: hutter, matthew m.; kothari, shanu n.; lamasters, teresa l.; demaria, eric j. title: open letter to insurance companies regarding mandatory in office visit weight documentation in an era of covid-19 date: 2020-05-26 journal: surg obes relat dis doi: 10.1016/j.soard.2020.05.020 sha: doc_id: 349206 cord_uid: f77ofx1w nan to: insurance company, medical director during these unprecedented times with the covid-19 pandemic, it has become clear that some 10 populations are at increased risk of severe illness, complications, and death once contracting the novel coronavirus. this is particularly the case for patients with obesity and type 2 diabetes. 1-5 treatment of people with the disease of obesity and related disease is critical in the strategy to decrease risk of poor outcomes and death following covid-19. metabolic/bariatric surgery is the only proven, long-term, successful intervention for patients suffering from clinically 15 severe obesity. in addition, there are over 12 prospective, randomized trials showing the superiority of metabolic/bariatric surgery over optimal medical management for patients with type 2 diabetes. 6, 7 increased morbidity and mortality due to coronavirus infection is only the newest of several hundred medical comorbid conditions caused or aggravated by obesity including some of the most serious diseases impacting our society today including type 2 20 diabetes, hypertension, heart disease, obesity-related cancers, etc. currently there are multiple insurance-mandated barriers to care that are placed on people seeking treatment of severe obesity. one of these barriers relates to specific diet and weightrelated requirements. this typically includes regular in-office weight measurements and in some 25 2 cases the requirement for documentation of weight loss prior to receiving surgical treatment for the disease of obesity. based on data from multiple studies that show no benefit to insurancemandated documentation of diet effort and/or weight loss prior to metabolic/bariatric surgery, as summarized by the asmbs clinical issues committee in our peer-reviewed publication from 2016 8 , we recommend immediate termination of all insurance-mandated diet and weight 30 related prerequisites for bariatric surgery including the excessive, burdensome, and potentially dangerous requirement for in-office weight documentation. these requirements not only have no scientific basis to support their existence, but they also create barriers to care. [9] [10] [11] [12] [13] [14] [15] [16] furthermore, by requiring in-person visits to accomplish repeated weight checks, these requirements lead to unnecessary health care facility visits for some of our most 35 vulnerable patients, putting them at increased risk for exposure to, and transmission of, covidthe best preoperative care and preparation for surgery is determined at the local level by the multidisciplinary team caring for their patients on the front lines. 8 many healthcare providers and 40 patients are finding telehealth solutions in the current environment that allow for effective care without the risks incurred by in-office visits. in recent weeks, the u.s. health care system has been stressed to unprecedented levels as many healthcare providers have been reassigned, furloughed, or have lost their jobs. adding 45 unnecessary in-person appointments and presurgical weight loss requirements will only stress the system further in a time of scarce resources. consequently, we feel there is no better time than the present for health plans to use evidence-based recommendations and terminate these unsubstantiated discriminatory policies. risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical characteristics of coronavirus disease 2019 in china obesity and covid-19 severity in a designated hospital in shenzhen covid-19): 75 people who are at higher risk for severe illness hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 -covid-net, 14 80 states outcomes of bariatric surgery versus medical management for type 2 diabetes mellitus: a meta-analysis of randomized controlled trials surgical versus medical treatment of type 85 2 diabetes mellitus in nonseverely obese patients: a systematic review and metaanalysis american society for metabolic and bariatric surgery clinical issues committee. asmbs updated position statement on insurance 6 mandated preoperative weight loss requirements number of weight loss attempts and maximum weight loss before roux-en-y laparoscopic gastric bypass surgery are not predictive of postoperative weight loss insurance-mandated preoperative counseling does not improve outcome and increases dropout rate in patients considering gastric bypass for morbid obesity the natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric 100 surgery insurance-mandated preoperative diet and outcomes after bariatric surgery postoperative 105 outcomes in bariatric surgical patients participating in an insurance-mandated preoperative weight management program evidence base for optimal preoperative preparation for bariatric surgery: does mandatory weight loss make a difference? insurance-mandated medical 110 weight management before bariatric surgery insurance-mandated medical programs before bariatric surgery: do good things come to those who wait? the authors have no conflicts of interest pertaining to this letter to disclose. key: cord-321142-807sfjiv authors: sommer, jordana l.; jacobsohn, eric; el-gabalawy, renée title: impacts of elective surgical cancellations and postponements in canada date: 2020-10-21 journal: can j anaesth doi: 10.1007/s12630-020-01824-z sha: doc_id: 321142 cord_uid: 807sfjiv purpose: worldwide, patients experience difficulties accessing elective surgical care. this study examined the perceived health, social, and functional impacts of elective surgical cancellations and postponements in canada. methods: we analyzed a subset of aggregate data from the canadian community health survey (cchs) annual components from 2005 to 2014. multivariable logistic regressions examined associations between past-year non-emergency surgical cancellations/postponements and perceived impacts of waiting for surgery (e.g., worry/stress/anxiety, pain, loss of work, loss of income, deterioration of health, relationships suffered). results: among those who experienced a cancellation or postponement of a past-year non-emergency surgery (weighted n = 256,836; 11.8%), 23.5% (weighted n = 60,345) indicated their life was affected by waiting for surgery. after adjusting for type of surgery, year, and sociodemographics, those who experienced a surgical cancellation or postponement had increased odds of reporting their life was affected by waiting for surgery (adjusted odds ratio [aor], 2.67; 99% confidence interval [ci], 1.41 to 5.1); in particular, they reported greater deterioration of their health (aor, 3.47; 99% ci, 1.05 to 11.4) and increased dependence on relatives/friends (aor, 2.53; 99% ci, 1.01 to 6.3) than those who did not have a cancellation or postponement. conclusion: results highlight the multifaceted perceived impacts of surgical cancellations/postponements. these findings suggest there is a need for improvements in reducing elective surgical cancellations and postponements. results may also inform the development of targeted interventions to improve patients’ health and quality of life while waiting for surgery. components from 2005 to 2014. multivariable logistic regressions examined associations between past-year nonemergency surgical cancellations/postponements and perceived impacts of waiting for surgery (e.g., worry/ stress/anxiety, pain, loss of work, loss of income, deterioration of health, relationships suffered). results among those who experienced a cancellation or postponement of a past-year non-emergency surgery (weighted n = 256,836; 11.8%), 23 .5% (weighted n = 60,345) indicated their life was affected by waiting for surgery. after adjusting for type of surgery, year, and sociodemographics, those who experienced a surgical cancellation or postponement had increased odds of reporting their life was affected by waiting for surgery (adjusted odds ratio [aor], 2.67; 99% confidence interval [ci], 1.41 to 5.1); in particular, they reported greater deterioration of their health (aor, 3.47; 99% ci, 1.05 to 11.4) and increased dependence on relatives/ friends (aor, 2.53; 99% ci, 1.01 to 6.3) than those who did not have a cancellation or postponement. conclusion results highlight the multifaceted perceived impacts of surgical cancellations/postponements. these findings suggest there is a need for improvements in reducing elective surgical cancellations and postponements. results may also inform the development of targeted interventions to improve patients' health and quality of life while waiting for surgery. l'enqueˆte sur la sante´dans les collectivite´s canadiennes (escc) collige´es de 2005 a`2014. des re´gressions logistiques multivarie´es ont examine´les associations entre les annulations / reports de chirurgies non urgentes de l'anne´e pre´ce´dente et les impacts perçus d'une attente pour une chirurgie (par ex., inquie´tude/stress/anxie´te´, perte de travail, perte de revenus, de´te´rioration de la sante´, impact sur les relations interpersonnelles). résultats parmi les personnes ayant subi une annulation ou un report d'une chirurgie non urgente au cours de l'anne´e pre´ce´dente (n ponde´re´= 256 836; 11,8 %), 23,5 % (n ponde´re´= 60 345) ont indique´que leur vie avait e´te´affecte´e par l'attente d'une chirurgie. apre`s avoir ajuste´les donne´es pour tenir compte du type de chirurgie, de l'anne´e et des donne´es sociode´mographiques, la probabilite´que les personnes ayant ve´cu une annulation ou un report de chirurgie rapportent que leur vie avait e´teá ffecte´e par l'attente d'une chirurgie e´tait plus e´leve´e (rapport de cotes ajuste´ [ keywords surgery á cancellations and postponements á perceived impacts worldwide, elective surgery patients are faced with lengthy waiting times and cancellations. studies have established rates of elective surgical cancellations ranging from 9 to 44%, with variations according to type of surgery and country. [1] [2] [3] [4] [5] [6] [7] the 2018 fraser institute report highlights that surgical patients across canada experience longer waiting times than deemed ''clinically reasonable'', ranging from approximately one week longer than reasonable for general surgeries to approximately ten weeks longer than reasonable for orthopedic surgeries. 8 lengthy surgical waiting times have adverse impacts on patients. for example, among orthopedic surgery patients in canada and spain, a wait time longer than six months was associated with greater patient dissatisfaction, increased preoperative anxiety and depressed mood, poorer preoperative quality of life, and reduced physical functioning compared with a wait time of less than six months. 9, 10 research has also shown negative emotional impacts of waiting for general surgery, including stress, anxiety, frustration, and anger. 11, 12 other canadian studies have found that increased surgical wait times were associated with less improvement in postoperative outcomes (e.g., physical functioning, pain). 13, 14 in addition, among a canadian sample of cardiac surgery patients, waiting longer than 97 days was associated with worse pre-and postoperative quality of life, a higher incidence of adverse postoperative events, and a greater likelihood of not returning to work postoperatively. 15 despite extant research on health-related correlates of waiting for surgery, and high rates of surgical cancellations, little is known about the perceived impact of elective surgical cancellations. to our knowledge, no canadian population-based research to date has established an estimate of elective surgical cancellations or examined patient-reported impacts of those cancellations. using population-based data, we aimed to understand the health, social, and functional impacts of elective surgical cancellations in canada. this is a timely study in light of growing recognition of the importance of integrating patient-reported outcomes into healthcare research, 16, 17 and research showing associations between patientreported outcomes with objective health outcomes. 18 further, the aims of this study align with the canadian anesthesia research guidelines, which highlight patientoriented research as a priority. 19 finally, given the high rates of non-emergent surgical delays and cancellations related to the coronavirus disease pandemic, this research provides insight into some of the broader implications for patients. considering the limited research in this area, the current study is an exploratory epidemiological examination of relationships between surgical cancellations and postponements with perceived impacts of waiting for elective surgery (e.g., worry/stress/anxiety, pain, deterioration of health, increased dependence on relatives/friends, and loss of work). we analyzed protected aggregate data from the annual components of the canadian community health survey (cchs) from 2005 to 2014, maintained at the research data centre in winnipeg, manitoba. access to these data requires security clearance and project approval. the cchs is an annual, cross-sectional, population-based survey, conducted by statistics canada. 20 multistage sampling using three sampling frames selected participants for recruitment, including the labour force survey area frame, telephone number lists, and random digit dialling. approximately 65,000 canadians, aged 12 years and older, are surveyed on an annual basis; however, prior to 2007, data were collected from approximately 130,000 individuals every second year. trained personnel administered the cchs to consenting participants using computer-assisted interviews. participants were excluded if they were active members of the canadian armed forces, lived on a canadian reserve, or were institutionalized. the manitoba research data centre provided clearance for the use of these data for the current research. additional details regarding the survey methodology and ethical approval for these surveys have been published elsewhere. [20] [21] [22] measures as part of the cchs module on access to healthcare services (acc), participants were asked whether they required any non-emergency surgery in the past 12 months: ''in the past 12 months, did you require any non-emergency surgery?''. those who responded ''yes'' were asked what type of surgery they required, as part of the waiting times (wtm) module: ''what type of surgery did you require?'' (cardiac, cancer, hip/knee, cataract/eye, hysterectomy, gall bladder, other). for those who had multiple past-year surgeries, participants were prompted to respond regarding their most recent surgery. of note, some participants were still waiting for surgery at the time of the survey across all years included. within the wtm module, participants who required a pastyear non-emergency surgery were asked whether their surgery had been cancelled or postponed: ''was your surgery cancelled or postponed at any time?''. also as part of the wtm module, those who required a past-year non-emergency surgery were asked whether they felt affected as a result of waiting for surgery: ''do you think that your health, or other aspects of your life, have been affected in any way due to waiting for this surgery?'' (referred to as ''life affected total''). those who responded ''yes'' were then asked, ''how was your life affected as a result of waiting for surgery?''. participants were permitted to endorse multiple responses, including: worry/anxiety/ stress, worry/stress for family/friends, pain, problems with activities of daily living, loss of work, loss of income, increased dependence on relatives/friends, increased use of over-the-counter drugs, overall health deteriorated/condition got worse, health problem improved, personal relationships suffered, other (we excluded ''health problem improved'' due to insufficient cell sizes). participants were asked these questions regardless of whether or not they endorsed a surgical cancellation/postponement, with the understanding that all participants undergoing non-emergency surgery waited for surgery. cchs acc and wtm modules were both optional; subsequently, only certain provinces responded to these modules each year (see appendix). participants self-reported their age (12-34, 35-49, 50-64, 651 yr), sex (male, female), marital status (married/common law, widowed/separated/divorced, single), race/ethnicity (white, other), income (\ $60,000, $60,000?), and urbanicity (urban, rural). these variables were included in regression models as covariates to account for the variability in impacts of waiting for surgery according to sociodemographic disparities. 13 analytic strategy analyses were restricted to those who had a past-year nonemergency surgery. weighted cross-tabulations assessed the frequency of each impact of waiting for surgery among those who experienced a surgical cancellation/postponement and those who did not. multivariable logistic regressions examined associations between surgical cancellations/postponements (independent variable; reference = no cancellation/postponement) and impacts of waiting for surgery (dependent variable; each assessed individually). we included an unadjusted model, a model adjusting for type of surgery (i.e., cardiac, cancer, hip/knee, cataract/eye, hysterectomy, gall bladder, other) and year (i.e., 2005-2014; assessed categorically), and a final model additionally adjusting for sociodemographics (i.e., age, sex, marital status, race/ethnicity, income, urbanicity). we computed 99% confidence intervals (ci) and used an alpha cut-off of \ 0.01 for regressions to correct for multiple comparisons. analyses were conducted using spss and stata statistical software. 23, 24 data were weighted and analyses employed 500 bootstrap weights (from each annual cchs component) for variance estimation to account for the complex survey and sampling design; weights were developed by statistics canada and applied as recommended. please refer to the cchs user guide (for years 2005-2014) for additional information regarding sampling, weighting, and bootstraps. among those who completed the optional cchs module on acc (weighted n = 42,245,996), 7.2% (weighted n = 3,052,072) endorsed a past-year non-emergency surgery. of those who endorsed a past-year non-emergency surgery and were asked about surgical cancellations/postponements within the module on wtm (weighted n = 2,169,690), 11.8% (weighted n = 256,836) indicated their surgery had been cancelled/postponed. several participants were still waiting for surgery across all years included (weighted n = 132,717) at the time of survey administration. as shown in table 1 , participants who experienced a surgical cancellation/postponement were primarily between the ages of 35 and 64 (59.2%), white (87.4%), and married (71.1%), with a household income of less than $60,000 (51.5%), and living in an urban area (83.3%). there was a values represent the n (%) of each sociodemographic characteristic and type of surgery among those who did and did not experience a surgical cancellation/postponement a values represent m (se) = mean with standard error; b values represent t statistic *p \ 0.05, **p \ 0.01, ***p \ 0.001 similar proportion of males (49.4%) and females (50.6%) who experienced a cancellation/postponement. these individuals waited, on average, over 65 days longer for surgery than those who did not experience a cancellation/postponement (121.6 days vs 55.8 days; t = 6.7, p \ 0.001), and on average, individuals who experienced a cancellation/postponement and noted being affected by waiting for surgery endorsed 2.5 types of impacts of waiting. differences also emerged in rates of cancellations/postponements according to type of surgery (v 2 = 44.5, p \ 0.001); cancellations/postponements were highest for those who had gall bladder surgery (23.3%) and lowest for those who had cancer surgery (6.5%; see figure) . among those who endorsed a past-year surgical cancellation/postponement, 23.5% (95% ci, 17.5 to 30.9; weighted n = 60,345) reported their life was affected by waiting for surgery; in comparison, 10.9% (95% ci, 9.7 to 12.2; weighted n = 207,391) of individuals who did not experience a cancellation/postponement indicated their life was affected by waiting for surgery. common types of impacts for individuals who experienced cancellations/postponements included pain (10.8%; 95% ci, 7.1 to 16.2; weighted n = 27,784), worry/stress/anxiety (10.6%; 95% ci, 7.4 to 15.0; weighted n = 27,246), and problems with activities of daily living (8.8%; 95% ci, 5.4 to 13.9; weighted n = 22,467); these impacts were prevalent among 6.2% (95% ci, 5.2 to 7.4; weighted n = 118,746), 5.6% (95% ci, 4.6 to 6.7; weighted n = 106,085), and 4.2% (95% ci, 3.4 to 5.3; weighted n = 81,007) of those who did not experience cancellations/postponements, respectively. less common impacts for individuals who experienced cancellations/postponements included loss of income (1.4%; 95% ci, 0.7 to 2.8; weighted n = 3,488), personal relationships suffered (1.7%; 95% ci, 0.8 to 3.4; weighted n = 4,341), and increased use of over-the-counter drugs (3.2%; 95% ci, 1.4 to 7.0; weighted n = 8,233); these impacts were prevalent among 1.4% (95% ci, 0.9 to 2.2; weighted n = 26,604), 1.1% (95% ci, 0.6 to 1.9; weighted n = 20,930), and 1.5% (95% ci, 1.0 to 2.4; weighted n = 28,877) of those who did not experience cancellations/postponements, respectively (note: weighted n values for impacts among the no cancellation/postponement group are larger than those in the cancellation/postponement group because of the large majority [[ 88%] not experiencing a cancellation/postponement; however, as evident by the weighted percentage, most impacts were more prevalent among the cancellation/postponement group). in the most stringent model of multivariable logistic regressions, those who experienced a surgical cancellation/postponement had significantly increased odds of indicating their life was affected by waiting for surgery (adjusted odds ratio [aor], 2.67; 99% ci, 1.41 to 5.1; p \ 0.001) than those who did not experience a cancellation/postponement. in particular, these individuals had significantly increased odds of endorsing overall health deterioration (aor, 3.47; 99% ci, 1.05 to 11.4; p = 0.007) and increased dependence on relatives/friends (aor, 2.53; 99% ci, 1.01 to 6.3; p = 0.009) as a result of waiting for surgery (see table 2 ). to our knowledge, this is the first study to examine patientreported health, social, and functional impacts of waiting for surgery associated with non-emergent surgical cancellations and postponements, using population-based data. results revealed nearly one quarter of individuals who experienced a surgical cancellation/postponement indicated their life was affected by waiting for surgery; this represents over double the number of individuals endorsing an impact among those whose surgery was not cancelled or postponed. these results highlight the broad implications of surgical cancellations/postponements. results also underscore the importance of targeted interventions both to reduce cancellation/postponement rates and to provide additional supports to patients while they are waiting for surgery. although, to our knowledge, no previous populationbased estimates exist of the proportion of patients with surgical cancellations whose lives were impacted, prior research with smaller samples has yielded estimates of 20-45% endorsing emotional and financial impacts of cancellations. 25, 26 more recently, a study examining nearly 400 patients who experienced a surgical cancellation revealed that over 30% reported extreme emotional impacts (e.g., extreme sadness, stress, anger) and nearly 60% reported moderate concern about their deteriorating health condition as a result of the 27 the lower value from the current study may reflect the fact that the majority of patients eventually underwent surgery, meaning the adverse impacts of their surgical cancellations/postponements may have been less salient at the time of the survey. participants with surgical cancellations/postponements in the current study endorsed poorer physical health, increased functional impairments, and worse psychological functioning than those who did not experience surgical cancellations/postponements. for example, over 10% of those who experienced a cancellation/postponement endorsed increased pain (10.8%) and mental health symptoms (e.g., worry/stress/anxiety; 10.6%) related to waiting for surgery, compared with only 5-6% of those who did not experience a cancellation/postponement. of concern, several prior studies have shown that preoperative mental health symptoms and pain are associated with greater surgical complications and poorer postoperative quality of life. [28] [29] [30] taken together, these results highlight the potential adverse impact of surgical cancellations/postponements on perioperative outcomes and the need for improvements in patient care during the waiting period for elective surgery. with a few exceptions, all impacts of waiting for surgery were elevated for those who experienced a cancellation/postponement compared with those who did not. the largest discrepancies between groups emerged for increased dependence on relatives/friends (4.0% vs 1.4%; or, 2.96) and deterioration in overall health (7.5% vs 2.8%; or, 2.77), evidenced by the largest effect sizes from -note. reference group = no cancellation/postponement; weighted n (%) = prevalence of each dependent variable among those who did and did not experience a surgical cancellation/postponement; or = unadjusted odds ratio; aor1 = adjusted odds ratio, controlling for type of surgery and year; aor2 = adjusted odds ratio, controlling for type of surgery, year, and sociodemographics (i.e., age, sex, marital status, race/ethnicity, income, urbanicity); ci = confidence interval; adls = activities of daily living. -= could not compute estimates because of small cell sizes. **p \ 0.01, ***p \ 0.001 the unadjusted regression model; these impacts were also associated with the strongest effects in the fully adjusted model (aor, 2.53 and 3.47, respectively). the relatively consistent trend of increased adverse impacts for those with surgical cancellations/postponements suggest the impacts assessed are likely interrelated (i.e., do not occur in isolation); in fact, those who experienced a cancellation/postponement and noted being affected by waiting for surgery endorsed 2.5 types of impacts on average. for example, individuals who experience deterioration in their health while waiting for surgery may become less able to function, and subsequently may become more dependent on social support systems (e.g., relatives, friends). despite the generally consistent elevation across impacts, each impact has unique and notable implications. for example, becoming increasingly dependent on social support systems may be associated with higher rates of caregiver burnout, 31 experiencing increased pain may impact activity levels and general mobility, 32,33 and increased use of over-the-counter drugs can lead to maladaptive self-medicating practices. 34 although this study produced novel findings, they must be considered alongside some limitations. first, although the cchs is a population-based survey, results may not generalize to the full canadian population because of the optional nature of the modules of interest and the exclusion of active members of the canadian armed forces, those living on a canadian reserve, and institutionalized individuals. relatedly, because institutionalized individuals (e.g., those who are hospitalized at the time of the survey) were excluded, results may not have captured the full severity of adverse health impacts associated with surgical cancellations/postponements. second, we were unable to determine whether results differ according to the province of residence because of limited participation in the modules of interest, or whether there are differences in impacts according to type of surgery because of limited statistical power. although we were able to examine rates of cancellations according to type of surgery, this analysis was limited to the categories defined by the cchs, and we were unable to further subcategorize the ''other'' surgery category. third, although analyses were focused on non-emergency surgery specifically, we were unable to identify whether or not participants were outpatients or inpatients preoperatively, which would have provided important context to the cancellation/postponement rate. 35 fourth, all variables in this study were assessed by self-report, which may be susceptible to response biases. nevertheless, patient-reported outcomes (i.e., self-reported) are designed to capture patients' lived experiences, and research has shown that these subjective measures have utility in understanding outcomes in health research, and how to improve patient healthcare experiences. 17 in addition, the current study focused on past-year surgeries, as opposed to lifetime surgeries, which likely limits issues related to recall bias, specifically. fifth, as indicated, the majority of participants had already undergone surgery at the time of the survey; this may have resulted in a reporting bias, where the adverse impacts of waiting for surgery were underestimated as a result of these experiences being less salient at the time of the survey. sixth, due to the crosssectional nature of the cchs, caution is warranted upon inferring temporality and causality regarding the emergent associations. finally, it is possible that factors leading to surgical cancellations/postponements directly contributed to the adverse impacts of waiting for surgery, as opposed to the cancellation/postponement having a direct and independent influence on the impacts of waiting. despite these limitations, results of this study are in line with the canadian anesthesia research priority setting partnership's ''top 10'' priorities, geared toward improving patients' anesthesia care experiences. 19 the current study produced novel findings that have important implications for the healthcare system. over 85% of elective surgical cancellations are preventable, and cost the united states healthcare system approximately 5,000 usd per cancellation, totalling millions of dollars per year 36, 37 (to our knowledge, these rates have not been estimated using canadian data). in addition to systemic costs, results from this study highlight the multifaceted perceived impacts of surgical cancellations/postponements. these results outline the need for reductions in elective surgery cancellations and postponements, as well as improved support for patients who are affected by these cancellations and postponements. results also underscore the importance of developed interventions to reduce preventable cancellations. for example, research has shown that improved preoperative anesthesia interviews, 38 modifications to surgical scheduling procedures, 39 and increased communication between healthcare professionals and surgical patients 40 can help reduce elective surgical cancellation rates. further investigation is warranted to address additional strategic intervention opportunities for reducing surgical cancellation rates. finally, results may inform the development of targeted interventions to improve patients' health status and quality of life while waiting for surgery, which may have positive implications for the healthcare system. further research is warranted to understand other health-related impacts of patient difficulties accessing surgical care and how these impacts translate to health status and potential complications at the time of surgery. author contributions jordana sommer and rene´e el-gabalawy contributed to all aspects of this manuscript including study conception and design, analysis and interpretation of data, and drafting the article. eric jacobsohn contributed to study conception, interpretation of data, and drafting the article. elective surgical case cancellation in the veterans health administration system: identifying areas for improvement incidence and root causes of cancellations for elective orthopaedic procedures: a single center experience of 17,625 consecutive cases causes of cancellations on the day of surgery at two major university hospitals high elective surgery cancellation rate in malawi primarily due to infrastructural limitations reasons for operation cancellations at a teaching hospital: prioritizing areas of improvement the burden of surgical cancellations and no-shows: quality management study from a large regional hospital in oman elective surgery cancelation on day of surgery: an endless dilemma 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on pain and quality of life: an australian survey chronic musculoskeletal pain and its impact on older people risks of self-medication practices relative influence on total cancelled operating room time from patients who are inpatients or outpatients preoperatively contributing factors for cancellations of outpatient pediatric urology procedures: single centre experience cancellation of surgeries: integrative review reducing preventable surgical cancellations: improving the preoperative anesthesia interview process reducing cancellations and optimizing surgical scheduling of ophthalmology cases at a veterans affairs medical center reducing surgery cancellations at a pediatric ambulatory surgery center publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. impacts of elective surgical cancellations key: cord-354593-35qkn381 authors: sii, samantha siaw zhen; chean, chung shen; sandland-taylor, laura emma; anuforom, udochukwu; patel, deepisha; le, giang troung; khan, abdul jabbar title: impact of covid-19 on cataract surgerypatients’ perceptions while waiting for cataract surgery and their willingness to attend hospital for cataract surgery during the easing of lockdown period date: 2020-10-22 journal: eye (lond) doi: 10.1038/s41433-020-01229-8 sha: doc_id: 354593 cord_uid: 35qkn381 nan there has been significant re-organisation of ophthalmology services worldwide to adapt to the covid-19 pandemic, for instance in glaucoma care [1] , acute ophthalmology services [2] , as well as uveitis [3] , medical retina [4] and oculoplastic care [5] . elective cataract surgery postponed during the pandemic invariably led to longer wait and possible anxiety among patients [6] . patients' apprehension about having cataract surgery during the easing of covid-19 lockdown should not be ignored. during these unprecedented times, it is therefore important to keep patients informed, particularly about the potential risk of contracting covid-19 infection during restoration of cataract surgery services [7] . despite significant changes made within the plethora of ophthalmology services during this time, there is scarcity of research centred on patients' perspectives during the restructuring of these services. the aim of this survey is to determine patients' perceptions while waiting for cataract surgery during the pandemic and their willingness to have their operation following the easing of lockdown. the survey was carried out using structured questionnaire over the telephone (appendix 1a) from 14th to 30th june 2020. patients were recruited from the waiting lists in two hospitals within the uk. patients who had been given a date for cataract surgery, who could not be contacted after three separate attempts, and who had problems hearing or understanding interview questions were excluded. vision related quality of life (vrqol) was assessed by asking patients to grade their level of difficulty in carrying out activities due to their vision. the survey's composite outcome measures were patients' concern regarding cataract surgery delay, their willingness to attend hospital for cataract surgery during easing of the covid-19 lockdown, and their maximum acceptable waiting time (mawt) for cataract surgery [8, 9] . additional demographic data including visual acuity and ocular comorbidities were collected from clinic letters and the electronic medical records. statistical analysis was carried out using pearson's chi-square test. as this survey lied outside the scope of the uk policy framework for health and social research, the need for independent ethical review was waived by the local research ethics committee. there were 180 patients on the waiting list. 120 eligible patients completed the interview (fig. 1) . demographic information and results of patients' responses to the questionnaire are shown in table 1 . our survey showed that the current pandemic did not affect patients' decision to attend hospital for cataract surgery as 83.3% indicated their willingness to come for cataract surgery. our survey showed that patients who reported worse vrqol and higher level of concern regarding delay were more likely to have a mawt <3 months, which is statistically significant (p < 0.05) (appendix 1b). however, those with ocular comorbidities other than cataract were more likely to have a mawt >3 months (p < 0.05). predictors for those prioritising vision needs over official public health advice include male gender (p = 0.022), younger age (p = 0.002) and those who normally drive (p = 0.014). our survey results could not be generalised to other hospital trusts within the uk due to the small sample size. furthermore, confounding factors were not accounted for during data analysis. however, we found that vrqol, independent of visual acuity is an important factor to be taken into consideration when listing patients for cataract surgery [9, 10] . communication about waiting time to manage expectations is essential to dampen patient anxiety whilst waiting for cataract surgery. patient prioritisation for cataract surgery during the restoration of cataract surgery services may need to take account patients' visual needs and their willingness to come rather than waiting time criteria or referral to treatment targets. conflict of interest the authors declare that they have no conflict of interest. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. the covid-19 pandemic will redefine the future delivery of glaucoma care the impact of covid policies on acute ophthalmology services-experiences from moorfields eye hospital nhs foundation trust implications of covid-19 for uveitis patients: perspectives from hong kong current safety preferences for intravitreal injection during covid-19 pandemic oculoplastic video-based telemedicine consultations: covid-19 and beyond the effect of the covid-19 pandemic on electively scheduled hip and knee arthroplasty patients in the united states bloom p cataract surgery guidelines for post covid-19 pandemic: recommendations v 1 rcophth covid-19 review team and ukiscrs waiting time for cataract surgery and its influence on patient attitudes steering committee of the western canada waiting list project. patient and physician perspectives of maximum acceptable waiting times for cataract surgery which factors influence patients' maximum acceptable waiting time for cataract surgery? -a questionnaire survey key: cord-321633-qr2w7azj authors: yadav, sanjay kumar; agrawal, vikesh; agarwal, pawan; sharma, dhananjaya title: rapid scoping review of laparoscopic surgery guidelines during the covid-19 pandemic and appraisal using a simple quality appraisal tool “emerge” date: 2020-09-17 journal: indian j surg doi: 10.1007/s12262-020-02596-y sha: doc_id: 321633 cord_uid: qr2w7azj the theoretical danger of virus transmission during laparoscopic surgery (ls) via surgical smoke and laparoscopy gas has led to the formulation of many guidelines during the covid-19 pandemic. this rapid scoping review of these guidelines was done to assess the quality of their evidence and appraise them for their impact on surgical services from the global south. a simple quality appraisal tool was constructed which can be used to evaluate rapidly emerging guidelines for evidence as well as for the needs of the global south. this rapid scoping review was conducted according to the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews protocol. electronic databases were searched with predefined strategy and retrieved papers were screened according to relevant criteria. a simple objective tool to assess the quality of rapidly emerging guidelines including evidence, methodology, ease, resource optimization, geography, and the economy was constructed. twenty studies met the inclusion criteria. none of the guidelines qualified to be evidence-based clinical practice guidelines as the level of evidence was uniformly rated “low”. a newly constructed tool showed good validation, reliability, and internal consistency. this rapid scoping review found two major research gaps: lack of systematic review of evidence during their development and insufficient weightage of their impact on surgical services from the global south. these significant issues were addressed by constructing a simple and more representative tool for evaluating rapidly emerging guidelines which also gives the rightful importance of their impact on surgical services from the global south. the ongoing covid-19 pandemic has already claimed hundreds of thousands of lives. uncertainty, risk of exposure, and a large number of healthcare professionals (hcp) getting infected have changed surgical practice to a great extent. the theoretical danger of virus transmission during laparoscopic surgery (ls) via surgical smoke and laparoscopy gas prompted several academic/national associations to issue laparoscopic surgery guidelines during the covid-19 pandemic. even a cursory glance at these "guidelines" reveals that these do not qualify as "guidelines" because they have not passed the stringent tests of the quality of evidence and methodology by systemic review for each recommendation and hence cannot be graded by conventional tools like grade and agree ii [1, 2] . additionally, recommendations from these "guidelines" have not been evaluated in terms of their consequences on already resource-constrained surgical services in low and middle-income countries (lmics) [3] . given the importance of this subject, we recognized an overt need to evaluate these guidelines in the form of a rapid scoping review and to construct a simple quality appraisal tool which gives due weightage to their impact on surgical services from the global south and can be used to evaluate rapidly emerging guidelines. this rapid scoping review of guidelines on laparoscopic surgery during covid-19 was conducted according to the prisma-scr (preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews) protocol and did not need prior registration. the following databases were searched from january 2020 to 15th june 2020 for relevant studies: medline, embase, global health, scopus, web of science core collection, who, global index medicus, and google scholar. the search strategy included terms related to clinical practice guidelines and its synonyms ("clinical pathway", "clinical protocol", "consensus", "consensus development conference", "critical pathways", "guidelines", "practice guidelines", "health planning guidelines", "guideline", "practice guideline", "position statement", "policy statement", "practice parameter", "best practice", "standards", "recommendations") and coronavirus diseases and its synonyms ("sars-cov 2", "covid 19", "coronavirus", "novel coronavirus", "coronavirus covid-19"). apart from scholarly/published material, hand-searching of key international surgical associations, minimal access surgery associations and laparoscopic and endoscopic surgery associations, and grey literature search was also performed. the inclusion criterion was that the guidelines on laparoscopic surgery must have been produced by a national/ international academic association/organization, in english literature. exclusion criteria were guidelines exclusively concerned with anaesthesia procedure or open surgery; regional/ hospital/government guidelines; non-peer-reviewed guidelines; commentaries, reviews, viewpoints, opinions, or recommendations from individual author or group of authors or institutes. two reviewers (sky and va) reviewed the potential abstracts and, if required, full texts of the search material to select the studies that appeared to be a "best fit" with stated objectives. full articles of selected studies were reviewed in detail, and resolution of any disagreements was done in consultation with third and fourth authors (pa and ds). an all-inclusive list of relevant geographical, methodological, and surgical evaluation of evidence parameters was made after a preliminary review of included guidelines. then, these parameters were looked for in every included guideline and were finally tabulated in a standardized microsoft excel version 16 form. the result was assessed for each of the criteria and evaluated as recommended/not recommended/not available. quality of evidence was graded according to grade guidelines: which grades them as very low/low/moderate/high [1] . a simple objective framework to assess the quality of rapidly emerging guidelines-emerge (evidence, methodology, ease, resource, geography & economy)-was constructed and utilized for appraisal [4] . in addition to evidence and methodology, it included 4 other domains: ease of understanding, optimization with available resources, the inclusion of input for different geographical areas, and economic implications with each domain having two rating items (table 1) . items included in the domains had item-correlation value ≥ 0.3 (0.73, 0.75, 0.66, 0.74, 0.30, and 0.48 for e, m, e, r, g, and e, respectively). countries were graded as lmic according to who definition. quality appraisal two independent reviewers (va and pa) appraised each eligible guideline by using the emerge tool, and inter-rater variability was measured by intra-class correlation coefficient (icc). the score was completed by assessors on a seven-point likert scale (1 = strongly disagree, 7 = strongly agree). total domain scores are scaled to a percentage of the maximum score in each domain; 100% is achieved if each reviewer scores 7 for both the items in a domain. the domain would score 0% if each reviewer scored 1 (the minimum value) for both the items in the domain. construct validity of tool emerge validation was done by circulating the highest-rated guideline on emerge in a pdf format to 50 responders, across the country, having more than 10 years of experience in laparoscopic surgery. another document explaining the items and basics of emerge score was circulated for their understanding and were asked to fill a google form (likert scale on 12 items). using statistical software, the responses were collated and the reliability and internal consistency of the tool were assessed using cronbach's coefficient (cɑ > 0.7, reliable) and inter-rater reliability was assessed using the intra-class correlation coefficient. statistical analysis was done using ibm spss statistics for windows, version 21 (ibm corp, armonk, ny, usa). the initial search yielded a total of 4098 studies, out of which 5 were found to be duplicate. a total of 3903 studies were excluded as they did not fulfil the inclusion criteria. the remaining 190 studies were screened; 170 were found to be recommendations from a group of authors, not national associations, and were excluded. the remaining 20 guidelines on laparoscopic surgery during the covid-19 matching with predefined criteria were evaluated in this rapid scoping review ( fig. 1) . a summary of all guidelines with the origin of their country, academic association, type of study, type of evidence, and recommendations based on various surgical/technical parameters are shown in table 2 [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] . in general, guidelines were embedded within a document that primarily focused on prevention of covid-19 spread to hcps, and recommendations provided by them were mostly non-specific covering a narrow range of items (table 3) . a maximum number of guidelines originated from individual national associations (13/20) , followed by regional societies (5/20) and international societies (2/ 20). globally, only 4/20 guidelines were published by national associations from lmics. none of the guidelines qualified to be evidence-based clinical practice guidelines in terms of the level of evidence and the methodology adopted for the development of guidelines. the level of evidence was uniformly rated "low", as assessed by grade guidelines. [1] half (11/20) of them were expert opinions, and a half (9/20) were consensus statements and therefore lacked a clear evidence base (table 2) . all guidelines unequivocally recommended avoiding routine laparoscopic surgery, and some recommended avoiding emergency laparoscopic surgery and suggested a preference for open surgery (tables 2 and 3) . emphasis differed amongst guidelines, but most common recommendations (≥ 70%) were on negative-pressure operating rooms, preoperative testing, use of personal protection equipment (ppe), reduction in hospital staff, low pneumoperitoneum pressure, and low flow rate during laparoscopy, minimizing energy device usage, use of smoke evacuator, and use of filtration system before trocar's removal. few suggested avoiding high aerosol-generating procedures, avoiding surgical drains, avoiding frequent suction during surgery, and not using water seal for suction; however, most others were silent on these issues ( table 3 ). the safety of using the veress method over open trocar access and safety of using a mesh was mentioned by only one guideline. there was no mention of advice on the selection of cases, induction of anaesthesia in a separate room, hand-assisted laparoscopic surgery, and provisions for simultaneous training and teaching (tables 2 and 3) . maximum possible score for a domain = 7 (strongly agree) × 2 (items) × 2 (appraisers) = 28 minimum possible score = 1 (strongly disagree) × 2 (items) 2 (appraisers) = 4 domain score ¼ obtained scoreàminimum possible score ð4þ maximum possible score ð28þàminimum possible score ð4þ â 100 recommendations involving economic implications included the use of ppe (90%), preoperative testing (80%), use of negative pressure or (70%), use of commercial smoke evacuator (65%), disposable trocar (55%), dedicated covid operating room (40%), and preoperative ct chest in all patients (10%). many guidelines did not recommend any type of smoke filter while only one recommended using the indigenous low-cost filters to reduce cost (table 3) . on appraisal of emerge by two independent reviewers (va and pa), the iccs were 0.78, 0.83, 0.76, 0.84, 0.47, and 0.64 for e, m, e, r, g, and e, respectively (< 0.5-poor reliability, 0.5 to 0.75-moderate reliability, 0.75 to 0.9good reliability). the emerge appraisal of included guidelines revealed poor overall rating with a mean of 38 [5, 7, 9, 12, 17] (table 4 ). endoscopic surgery guideline's highest overall mean score, it stood 2nd in resource optimization and 8th in economic implication domains [12] . guidelines originating from lmics stood poor on the evidence domain, but indian inter-society guidelines and association of surgeons of india guidelines from lmics scored maximum in the resource optimization and economic implication domains [5, 17] . on validation of the emerge tool, the cronbach's α coefficient was 0.95 (reliable) and cα for each domain was more than 0.7. the inter-rater reliability showed moderate agreement (icc = 0.571, p < 0.001, 95% ci, 0.428 < icc < 0.717). there are only three things that matter in science: evidence, evidence, and evidence (to paraphrase harold samuel's famous quote about the value of property in relation to its location). since widespread acceptance of evidence-based medicine as the gold standard of clinical practice, the weight of each and every scientific publication must be measured on the balance of evidence. clinical experience and evidence for purse-string suture/skin blocking system the ongoing covid-19 pandemic are still evolving, making its analysis similar to the live coverage of an unfolding history. this makes a rapid scoping review an ideal approach to assess research conduct and identify knowledge gaps to provide knowledge synthesis in a timely manner, provided it is conducted with simplified but rigorous and transparent methods [25] . evidence-based guidelines are important as they are looked up to and followed by all clinicians; these become even more relevant when faced with the challenge of a rampaging pandemic. a clinical decision can be well-informed and evidencebased only if the available guideline is the logical end-product of scientific evaluation, collation, and summarization of currently available evidence. to mitigate transmission of infection to healthcare professionals during laparoscopic surgery, many guidelines and recommendations emerged rapidly as the covid-19 pandemic unfolded. the present rapid scoping review revealed that all laparoscopy guidelines for covid-19 were either expert opinions or consensus statements and did not qualify as evidence-based clinical practice guidelines in the absence of necessary evidence and methodology in their development ( table 2 ). this is symbolized by all laparoscopy procedures being labelled as high risk because an allpervading grave fear of infection to hcps via surgical smoke and laparoscopy gas prompted the guidelines to err on the "side of safety" [26] . studies have isolated bacterial/viral fragments in surgical smoke, but presently pathogen transmission via smoke and laparoscopic gas to hcps has not been shown [27, 28] . in addition to a low level of evidence involved in the development of these rapidly emerging guidelines on laparoscopic surgery, the process of obtaining evidence and knowledge synthesis was lacking from these published guidelines. the guidelines for laparoscopy in high-risk groups like older people and those with comorbidities are conspicuously missing, as is any guideline on laparoscopic surgery from the world health organization. inclusivity is vital in a pandemic; however, only 20% of guidelines originated from resourcepoor countries suggesting a low representation ( table 2) . the speed and severity of this unprecedented covid-19 pandemic are posing critical challenges to the resources of even high-income countries (hics). the strain put on already resource-constrained surgical services in lmics has been unparalleled and crippling [3, 29] . this coupled with exclusion of their needs in laparoscopic surgery guidelines amounts to epistemic injustice [30] . this is illustrated by exorbitant costs of negative pressure ors and commercial smoke evacuators, which are beyond the reach of most standalone hospitals that form the backbone of surgical care in lmics. it proves that bearing the economic costs of these guidelines, like so many other covid-19 issues, is significantly more difficult for lmics. this rapid scoping review revealed that much-needed resource optimization and economic implications of recommendations were not considered by most guidelines. other studies have also noted that clinical guidelines and or operation room, ct computed tomography, hme heat and moisture exchangers, ulpa ultra-low particulate air their appraisal tools rarely include domains like cost implication, barriers, and facilitators in their implementation, alternative solutions, and practice settings [31, 32] . conventional appraisal tools like agree ii, which mainly assess the quality of evidence and methodological rigor in the development of guidelines, have rigorous but very exhaustive checklists. this makes them impractical for the evaluation of rapidly emerging guidelines in a pandemic scenario [33, 34] . emerge was developed to address these research gaps and followed the key steps to the development of appraisal tools: content analysis, identifying domains and items, construction of rating/scoring, and validation [31, 35] . emerge includes, apart from the level of evidence and methodological rigor, crucial and wider domains like the ease of applicability, resource optimization, geographical representation, and economic consideration which are equally relevant to face such challenges. its additional advantage is that its simple structure allows quick appraisal of rapidly emerging guidelines (table 1) . when appraised by emerge, a low evidence base and a poor methodological rigor of all guidelines were reconfirmed. similarly, issues of resource optimization, geographical inclusion, and economic implications drew poor scores, even the guideline with the maximum score for quality of evidence scored poorly on this issue [12] . however, a couple of guidelines from lmics scored maximum in these domains, demonstrating the weight of their input on such a crucial issue [5, 17] . the end of covid-19 is nowhere in sight, and its impact on global health will be long-lasting. therefore, the quality of such rapidly emerging recommendations needs to be assessed in terms of infrastructure, resource, workforce, and financial challenges apart from the level of evidence and methodology [3] . it could be argued that there is no need for a duplication scoping review or a new appraisal tool. however, it has been shown that adopting a different type of evidence synthesis, i.e. a purposeful rapid scoping review with different aims, cannot be called duplication and can lead to important information and useful quality control process [36] . when research, writing, and peer review are rushed, as it was in the early part of the covid-19 pandemic, opinions and anecdotes were confused with evidence, resulting in "research waste" with many methodological weaknesses and damaging consequences [37, 38] . in such a rapidly evolving scenario, replication by a rapid scoping review can provide the necessary insight for the specific needs of decision-makers and vitally contribute to the progress of research [39] . moreover, failure to conduct upto-date reviews of guidelines may result in substantial adverse consequences for patients, practitioners, and health services [40] . similarly, rapid research needs a rapid appraisal of relevant parameters; hence, emerge, a simple and quick "guideline to assess guidelines", was constructed. "primum non nocere: first, do no harm to the patient" have been the guiding words for physicians since time immemorial. the current pandemic prompted this principle to be expanded for the first time to include hcps due to the risk of cross-infection [41] . this pressure and the urgent need for the prompt production of laparoscopic surgery guidelines may have led to a temporary suspension of fundamental scientific principles in conducting evidence synthesis [42] . however, better scrutiny of evidence has led to many recent publications that suggest laparoscopy is safe in the covid-19 era, provided precautions are taken [43] [44] [45] . this change is likely to be reflected in newer versions of guidelines, as they have to be continuously developing, more so in a rapidly evolving epidemic. the need for rapid scaling in every context has led to many frugal innovative responses from lmics [46] . in the context of surgical services, these include the use of strong exhaust fans in ors to create a temporary negative pressure room and use of indigenous low-cost heat and moisture exchanger (hme) smoke filters [47, 48] . these low-cost ideas may not be ideal but have the potential to provide good enough healthcare in the best way possible under given constraints [49] . these frugal innovations are in sync with the resource, geographic, and economic domains of the emerge tool. the term "global south" is increasingly being used for the "lmics" and "developing countries" which were earlier rather insensitively called the "third world countries". economic constraints of these countries are well known, but many were progressing towards sustainable development goals before being hit hard by the covid-19 pandemic. their fragile efforts are now at increased risk of falling behind [50] . however, their pride and ambitions remain intact and this newly developed simple tool and its acronym "emerge" coincide with the aspirations of these "emerging economies". moreover, "social distancing" has become a current buzz word; greater inclusion of needs of lmics in rapidly emerging guidelines and their appraising tools will avoid the impression of "social distancing" between the global north and global south [49] . this rapid scoping review pointing out the exclusion of needs of the global south and development of a simple appraisal tool which includes those is a small step in that direction. this rapid scoping review of rapidly emerging laparoscopic surgery guidelines during covid-19 found two major research gaps: lack of systematic review of the evidence (due to the urgency of situation and fear for the safety of hcps) during their development and insufficient weightage of their impact on surgical services from the global south. both these significant issues were addressed by constructing a simple, easy, and more representative appraisal tool for evaluating rapidly emerging guidelines which give the rightful importance of their impact on surgical services from the global south. data availability available. conflict of interest the authors declare that they have no conflict of interest. ethics approval ethical approval was obtained. consent to participate not applicable. code availability not applicable. grade guidelines: a new series of articles in the journal of clinical epidemiology for the agree next steps consortium (2010) agree ii: advancing guideline development, reporting and evaluation in health care exploring the impact of covid-19 on progress towards achieving global surgery goals emerge': construction of a simple quality appraisal tool for rapid review of laparoscopic surgery guidelines during covid-19 pandemic. special research letter surgical practice recommendations for minimal access surgeons during covid 19 pandemic -indian inter-society directives covid-19: joint statement on minimally invasive gynecologic surgery correction to: european hernia society (ehs) guidance for the management of adult patients with a hernia during the covid 19 pandemic the argentine society of laparoscopic surgery letter on covid-19 elsa recommendations for minimally invasive surgery during a community spread pandemic: a centered approach in asia from widespread to recovery phases association of gynecological endoscopy surgeons of nigeria (ages) advisory on laparoscopic and hysteroscopic procedures during the covid-19 pandemic society of robotic surgery review: recommendations regarding the risk of covid-19 transmission during minimally invasive surgery sages and eaes recommendations for minimally invasive surgery during covid-19 pandemic robot assisted surgery during the covid-19 pandemic, especially for gynecological cancer: a statement of the society of european robotic gynaecological surgery (sergs) laparoscopy in the covid-19 environment -alsgbi position statement. alsgbi. 2020 available from covid-19 guidance statement recommendations of the brazilian college of surgeons for laparoscopic surgery during the covid-19 pandemic asi's consensus guidelines: abcs of what to do and what not during the covid-19 pandemic gynaecological laparoscopy in the time of coronavirus eau robotic urology section (erus) guidelines during covid-19 emergency | uroweb. uroweb. 2020 joint rcog / bsge statement on gynaecological laparoscopic procedures and covid-19 guidance for endoscopic surgery during covid-19: 6 f251dec1-9b82-ea11-90fb-0050568796d8/pol-023-guidelines%2d%2d-laparoscopy-case-deferral-during-covid%2d%2dfinal systematic review or scoping review? guidance for authors when choosing between a systematic or scoping review approach initial advice to avoid laparoscopic surgery due to fear of covid-19 virus transmission: where was the evidence? operating during covid-19: is there a risk of viral transmission from surgical smoke during surgery? risks of viral contamination in healthcare professionals during laparoscopy in the covid-19 pandemic global surgery 2030: evidence and solutions for achieving health, welfare, and economic development epistemic injustice: power and the ethics of knowing appraisal tools for clinical practice guidelines: a systematic review tools developed and disseminated by guideline producers to promote the uptake of their guidelines efficient clinical evaluation of guideline quality: development and testing of a new tool validation and reliability of a guideline appraisal minichecklist for daily practice use agree next steps consortium (2016) the agree reporting checklist: a tool to improve reporting of clinical practice guidelines one more time': why replicating some syntheses of evidence relevant to covid-19 makes sense waste in covid-19 research scope, quality, and inclusivity of clinical guidelines produced early in the covid-19 pandemic: rapid review what is replication? getting to grips with archie cochrane's agenda perspectives on surgery in the time of covid-19: safety first covid -19 pandemic and the quality of evidence synthesis understanding the "scope" of the problem: why laparoscopy is considered safe during the covid-19 pandemic safe management of surgical smoke in the age of covid-19 covid-19 and laparoscopic surgery, a scoping review of current literature and local expertise fast and frugal innovations in response to the covid19 pandemic conversion of operating theatre from positive to negative pressure environment fingerhut a; and the technology committee of the european association for endoscopic surgery (2020) a low cost, safe and effective method for smoke evacuation in laparoscopic surgery for suspected coronavirus patients frugal solutions for operating room during covid-19 pandemic covid-19: rethinking risk publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-323592-ymvvexfi authors: botteri, emanuele; podda, mauro; arezzo, alberto; vettoretto, nereo; sartori, alberto; agrusa, antonino; allaix, marco ettore; anania, gabriele; contul, riccardo brachet; caracino, valerio; cassinotti, elisa; cuccurullo, diego; d’ambrosio, giancarlo; milone, marco; muttillo, irnerio; petz, wanda luisa; pisano, marcello; guerrieri, mario; silecchia, gianfranco; agresta, ferdinando title: current status on the adoption of high energy devices in italy: an italian society for endoscopic surgery and new technologies (sice) national survey date: 2020-11-05 journal: surg endosc doi: 10.1007/s00464-020-08117-y sha: doc_id: 323592 cord_uid: ymvvexfi background: in the past three decades, different high energy devices (hed) have been introduced in surgical practice to improve the efficiency of surgical procedures. hed allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. this survey was designed to verify the current status on the adoption of hed in italy. methods: a survey was conducted across italian general surgery units. the questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. only one member per each surgery unit was allowed to complete the questionnaire. for elective procedures, the survey included questions on thyroid surgery, lower and upper gi surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. the list of alternatives for every single question included a percentage category as follows: “ < 25%, 25–50%, 51–75% or > 75%”, both for open and minimally-invasive surgery. results: a total of 113 surgical units completed the questionnaire. the reported use of hed was high both in open and minimally-invasive upper and lower gi surgery. similarly, hed were widely used in minimally-invasive pancreatic and adrenal surgery. the use of hed was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of hed in less than 25% of elective cholecystectomies. hed were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. similarly, very few respondents declared to use hed in abdominal wall surgery and proctology. the distribution of the most used type of hed varied among the different surgical interventions. us hed were mostly used in thyroid, upper gi, and adrenal surgery. a relevant use of h-us/rf devices was reported in lower gi, pancreatic, hepatobiliary and breast surgery. rf hed were the preferred choice in proctology. conclusion: hed are extensively used in minimally-invasive elective surgery involving the upper and lower gi tract, liver, pancreas and adrenal gland. nowadays, reasons for choosing a specific hed in clinical practice rely on several aspects, including surgeon’s preference, economic features, and specific drawbacks of the energy employed. three distinct technologies are mainly involved in building hed: ultrasonic (us), radiofrequency (rf), and hybrid us/rf energy (h-us/rf). us devices work based on the transformation of electrical energy into high-frequency (55000 khz) frictional energy. the vibrating blades allow the denaturation of hydrogen bonds in tissue and blood vessel proteins with the result that the coagulum seals the lumen of vessels up to 5 mm in diameter [4] . rf instruments apply bipolar high electric current (4 a) at a low voltage (< 200 v). this way, energy denatures the collagen and elastin within the blood vessel wall and can seal vessels with a diameter of up to 7 mm [5, 6] . nowadays, a device that integrates both us and advanced bipolar energy in a unique instrument (h-us/ rf) is also available: it allows to cut tissue with us energy on the one hand and seal vessels with bipolar energy. there are several disadvantages of hed instruments for hemostasis, including the relatively high costs due to the non-reusability of disposable instruments, and the generation of smoke, which may compromise visibility [7] . today the choice among the hed is mainly based on the surgeon's preference. in fact, only a few studies that compare the different technologies have been published to date [8] [9] [10] without finding a clear advantage for the use of us or rf. there is also a lack of multidimensional evaluation of available instruments. the origins of the present work rely on the assumption that nowadays none knows how many surgeons choose hed in their clinically practice. moreover, the use of hed in specific field, such as urgency, is not reported in high-quality literature. the present study aims to report and critically appraise the results of a web-survey promoted among italian surgeons, endorsed by the italian society for endoscopic surgery and new technologies (società italiana di chirurgia endoscopica e nuove tecnologie, sice), about the current habits of italian surgeons in the use of hed. this work represents the scaffold for an hta or another multidimensional evaluation for hed. the executive board of sice promoted a web-based survey to investigate how surgeons working in general surgery units across italy currently use hed in daily clinical practice. their participation remained voluntary, as no incentives were offered to participants. all parts of the study, and the present manuscript have been checked and presented according to the e-surveys checklist for reporting results of internet (cherries) [11] . the study steering committee (eb, nv, fa, mp, ar, as) developed the questionnaire using remote brainstorming, after identifying the questions to include. the technical functionality of the electronic questionnaire was tested before the invitations were sent. once an agreement was reached, the questionnaire was completed using google form (google llc, mountain view, california us). the questionnaire included 44 questions divided into three sections (general information, elective surgery, emergency surgery) ( table 1 ). only closed-ended questions were used. the list of alternatives for every single quantitative question included a percentage category as follows: " < 25%, 25-50%, 51-75% or > 75%", both for open and minimally-invasive surgery. the steering committee decided to use ranges of predetermined percentages to allow a more accessible aggregation of the information collected. each field required to specify the most used hed type choosing between us, rf, or h-us/rf. if one kind of surgery was not performed at the surgical unit, this would be classified as na (not applicable). among elective procedures, the survey included questions on thyroid surgery, lower and upper gi surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, abdominal wall surgery, and breast surgery. elective cholecystectomy was listed separately from the hepatobiliary section. according to the distribution of emergency surgical operations, appendectomy, cholecystectomy for acute cholecystitis, and bowel obstruction due to adhesions were considered representative for emergency surgery. the estimated time to complete the survey was 7-9 min. on february 24th, 2020, the questionnaire was available online and open for completion until april 14th, 2020. the link (https ://docs.googl e.com/forms /d/13tbi ow0ac al-ah47c agsgx at7kp qyyna riiss keg_ni/edit) was circulated through personal email invitations to the members of the sice across the country by the sice secretary, including four reminders sent during the opening of the questionnaire. the link to complete the questionnaire was also always available in the area of the sice website (https ://sicei talia .com), a website dedicated to the dissemination of updates on scientific research regarding minimallyinvasive surgery and surgical innovations, mainly visited by surgeons with a particular interest in laparoscopic and minimally-invasive techniques. the sice regional coordinators were involved for a better spread of the survey. they were stimulated to give notice of the initiative by means of several social networks (facebook, linkedin, twitter) available. only one member per each surgery unit was allowed to complete the questionnaire, as the aim of the study was to define the trend in the use of hed within the italian departments of surgery, rather than the attitude of the single surgeon. respondents remained anonymous. the invitation to participate came with a letter in which the types of surgical procedure for each question were listed. moreover, we explained that the answers should not represent the preferences of the respondent, but rather should reflect the habits of the unit. in case of two answers coming from the same division the former would be erased. a member of the steering committee (mp) downloaded the results of the survey and shared them with the other members of the steering committee for analysis of data and discussion. results were reported using percentages and presented as histograms. in total, surgeons from 113 different surgical units completed the questionnaire. in italy, there are 445 general surgery units. assuming the survey news had reached all surgical units, we reported a 25% of reply to the survey. we received at least one answer from each italian region. one hundred thirteen answers were registered (fig. 1) . both in open and minimally-invasive upper gi surgery, the reported use of hed was extensive. in open surgery, 76.6% of surgeons declared to use hed in more than 50% of procedures (60.4% ' > 75%', 16.2% '51-75%'). in minimallyinvasive surgery, 82.3% of participants declared to use hed in more than 75% of procedures. there was no real preference for the type of hed used, with a slight prevalence of us devices (38.9% us and 35.4% h-us/rf). one hundred thirteen answers were registered (fig. 1) . in open lower gi surgery, 77.9% of respondent surgeons stated to use hed in more than 50% of the procedures (58.4% ' > 75%', 19.5% '51-75%'). results regarding minimallyinvasive surgery showed 89.4% of participants who declared to use hed in more than 75% of the procedures. there was no real preference for the type of hed used, (23.4% rf, 35.1% us, and 41.4% h-us/rf). one hundred twelve answers were registered (fig. 1) . 32.1% of the centers declared to use hed in less than 25% of the procedures. the other frequencies were less represented in one hundred twelve answers were registered (fig. 2) . as pancreatic surgery is a hyper-specialistic branch of general surgery, 25.9% of na responses for open surgery, and 33.6% of na for minimally-invasive surgery were registered. hed were mostly used in minimally-invasive pancreatic surgery, reaching 57.3% of ' > 75%' answers. 37.6% of respondents who declared to perform pancreatic surgery used h-us/ rf hed, 36.6% stated to use us hed, and 25.8% of the respondents declared to use rf hed. one hundred thirteen answers were registered (fig. 2) . the one hundred thirteen answers were registered (fig. 2) . the reported use of hed was scarce in elective cholecystectomy. more than 70% of the respondents reported using any type of hed in less than 25% of the procedures, both for open and laparoscopic cholecystectomy. both groin and incisional hernias were included in abdominal wall surgery in the present survey (fig. 3) . one hundred thirteen answers were registered. decidedly few respondents declared to use hed in abdominal wall surgery (< 10%). a not negligible surgical unit rate does not perform abdominal wall surgery in our survey (30.1%). one hundred ten answers were registered (fig. 4) . 43.1% of respondents declared to use hed for > 75% of open thyroidectomies. only a few centers declared to perform minimally-invasive thyroid surgery. 77.3% of na answers were reported. units that perform minimally-invasive thyroidectomy stated that us (50%) was the most frequently used hed. one hundred eleven answers were registered (fig. 4) . several surgical units do not perform adrenal surgery. na was chosen in 37.8% and 28.6%, respectively, for open and minimally-invasive surgery. a broader tendency to use hed in minimally-invasive surgery (61.6% of > 75%) than in open adrenal surgery (36.9% of > 75%) was reported. significant use of us devices (41.8% us and 29.7% h-us/rf) was noted in this field. one hundred eleven answers were registered (fig. 4) . the majority of our survey centers declared not to perform breast surgery (58.6% of na answers). the overall use of hed was low, as shown by the reported values of ' < 25%' (23.4%) and '25-50%' (9.8%). one hundred thirteen answers were registered (fig. 5) . hed are employed in < 25% of the open procedures according to 62.8% of the respondents, and in < 25% of the minimally-invasive procedures according to 56.3%. a higher tendency in the use of hed in minimally-invasive than in open appendectomy was reported, as evidenced in the more significant percentage of the choices '51-75%' and ' > 75%' when compared to open surgery. us hed were the most frequently used (42%), followed by rf (29%) and h-us/rf. one hundred thirteen answers were registered (fig. 5) . hed are only rarely employed (< 25%) in the majority of cholecystectomies, both in open and in minimally-invasive surgery (65.5% vs. 63.4% respectively). us hed are the most used (43.9%), followed by h-us/rf (29.6%) and rf (26.5%). one hundred thirteen answers were reported (fig. 5) . 62.8% of the respondents declared to use hed in < 25% of the open adhesiolysis. the result is not far from that we reported for the minimally-invasive approach (58.9%). hed were used in ' > 75%' of minimally-invasive procedures according to 5.4% of respondents, whereas the rate drops to 2.7% for open surgery. we surveyed the italian general surgery units to investigate the use of hed in daily clinical practice. the questions were divided into different type of surgery, and each of them required an independent answer based on a minimally-invasive approach or open surgery. one hundred thirteen surgery units joined the survey, representing about 25% of the italian units. the result falls in the usual rate of responses reported for email and web-surveys. shih et al. showed that webbased surveys generally have an average response rate of 33% (± 22%) [12] . we found that not all surgery units performed the same surgical procedure with either an open and minimally-invasive approach. so, for several pathologies, a high rate of na answers was reported. there are different explanations for this phenomenon: for adrenal, pancreatic, breast, thyroid, and abdominal wall surgery, it could be due to the type of treatment performed only in hyper-specialistic centers or dedicated centers like breast unit. conversely, for elective open cholecystectomy and open appendectomy, the reason lies in the minimally-invasive approach's better outcomes. nowadays, laparoscopy is considered the gold standard in literature for both appendectomy and cholecystectomy [13, 14] . for upper and lower gi surgery hed are widely used, especially in laparoscopic surgery, reaching a rate of answer ' > 75%' more than 80%. we observed a slight prevalence in h-rf/us use in lower gi surgery (41.4%) and us devices in upper gi procedures (38.9%). such a trend was not confirmed in proctology, where only 33% (11.6% ' > 75%' and 21.4% '50-75%') of the centers survey results for emergency surgery declared to use hed for more than 50% of surgical procedures. when hed were used in proctology, surgeons mainly choose rf devices (57.1%). as hemorrhoids mainly consist of vascular tissue, safe and quick surgery, avoiding the closure of hemorrhoidal vascular pedicles with stitches may be performed using the better sealing attitude of rf hed. moreover, there are several surgical options available and nowadays, no single technique has been universally accepted as the best treatment. the therapeutic choice of treatment is largely dependent on the severity of the symptoms, the size of haemorrhoidal tissue, the extent of displacement and last but not least the surgeon's preference. reports from thyroid surgery showed that a not negligible rate of the involved centers declared to not perform thyroidectomy, primarily through a minimally-invasive approach (77.3% na). however, when minimally-invasive thyroidectomy is carried out, the use of hed is broad, and half of the surgeons choose us hed. us hed have a small and accurate tip that allows a careful dissection with a low lateral thermal spread to protect the laryngeal nerve. hed were scarcely used in elective cholecystectomy and abdominal wall surgery, without differences between open and minimally-invasive approach. for cholecystectomy, the visceral dissection is carried out through a relatively low vascularized plane with only two anatomical structures to seal (cystic artery and cystic duct). reason for which, cholecystectomy is safely performed with monopolar scalpel and clips without the need for hed in most cases. the same considerations may be done for abdominal wall surgery: dissection is limited and performed safely following avascular planes with monopolar scissors or scalpel. when bleeding occurs, it can be controlled with bipolar claw. the most frequent interventions for emergency surgery, such as appendectomy, adhesiolysis for acute small bowel obstruction, and cholecystectomy for cholecystitis, were considered. even for these procedures, the use of hed was low both in open and laparoscopic approaches. finally, adhesions are often managed with cold scissors to avoid thermal injuries to the adjacent organs. thermal injuries could bring to late bowel perforation, which may require a reintervention. according to guidelines, no evidence-based recommendation to use hed routinely in these types of surgical operations can be formulated [13, 14] . it is still matter of debate whether heds represent an advantage or a risk for thermal injuries [15, 16] . also, the production of smoke is highly debated [17, 18] especially in time of covid-19 pandemic [19] [20] [21] . ultimately, the issue of high costs is still slackening the implementation of hed in surgical activity. accurate evaluation for public health sustainability, defining cost-effectiveness for surgical devices in the hospital setting, is difficult and can be highly variable, while the possible reduction in operative time could be a minor advantage only. web-based surveys may be subject to relevant bias, especially from the non-representative nature of the web population and participants' self-selection (also called "the volunteer effect"). the study sample's representativeness is supported by the fact that at least one respondent from each italian region was registered, making us confident that the respondents reflect the attitudes of the entire italian surgical population. generally, web-based surveys are limited because of the possibility that the respondents (general surgeons performing mostly minimally-invasive surgery in this case) do not reflect, close enough, the target population (all general surgeons). in our case, the study sample was identified by the official list of sice members, obtained from the society secretariat. in our survey, the questionnaire related to aspects concerning minimally-invasive surgery and open surgery, surgical emergencies, and proctology. although a high response rate minimizes the potential for bias and enhances the results of a web-based study, it has been remarked that there is no scientifically established minimum acceptable response rate, and it may not be associated with survey reliability or quality [21] . a further potential limitation of our study relies on the difficulty to accurately quantify the number of recipients, as we cannot argue the precise number of surgeons who read the invitation to complete the questionnaire. although the questionnaire was open to all italian surgical units, most of the responding surgeons were sice members. since the society's mission is to promote minimally-invasive surgery, this could represent a possible bias reflecting mainly the habit of laparoscopic surgeons in the use of hed. there is a lack of evidence-based data in the literature to support the use of rf, us o h-rf/us in different types of surgical operations, so nowadays, the choice of technology is based on the surgeon's preference. a complete cost-effective analysis is also lacking, and this could represent a motivation for future research. the present study highlights the high use of hed in major elective minimally-invasive surgery. choosing a specific hed in clinical practice relies on several aspects, including the surgeon's preference, economic features, and specific drawbacks of the energy employed. recent innovations in bipolar electrosurgery alternative surgical dissection techniques surgical efficacy among laparoscopic ultrasonic dissectors: are we advancing safely? a review of literature comparison of four energy-based vascular sealing and cutting instruments: a porcine model comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries real time thermography during energized vessel sealing and dissection analysis of surgical smoke produced by various energy-based instruments and effect on laparoscopic visibility energy sources for laparoscopic colorectal surgery: is one better than the others? radiofrequency versus ultrasonic energy in laparoscopic colorectal surgery: a meta-analysis of operative time and blood loss electrothermal bipolar vessel sealing system vs. harmonic scalpel in colorectal laparoscopic surgery: a prospective, randomized study improving the quality of web surveys: the checklist for reporting results of internet e-surveys (cherries) comparing response rates in email and paper surveys: a meta-analysis italian surgical society working group laparoscopic cholecystectomy: consensus conference-based guidelines diagnosis and treatment of acute appendicitis: 2020 updates of the wses jerusalem guidelines evaluation of emissivity and temperature profile of laparoscopic ultrasonic devices (blades and passive jaws) evaluation of an innovative, cordless ultrasonic dissector aerosol exposure from an ultrasonically activated (harmonic) device comparison of surgical plume among laparoscopic ultrasonic dissectors using a real-time digital quantitative technology the technology committee of the european association for endoscopic surgery (2020) a low-cost, safe, and effective method for smoke evacuation in laparoscopic surgery for suspected coronavirus patients acute cholecystitis during covid-19 pandemic: a multisocietary position statement the covid-19 pandemic should not take us back to prelaparoscopic era key: cord-303054-s1clwunc authors: velly, lionel; gayat, etienne; jong, audrey de; quintard, hervé; weiss, emmanuel; cuvillon, philippe; audibert, gerard; amour, julien; beaussier, marc; biais, matthieu; bloc, sébastien; bonnet, marie pierre; bouzat, pierre; brezac, gilles; dahyot-fizelier, claire; dahmani, souhayl; de queiroz, mathilde; maria, sophie di; ecoffey, claude; futier, emmanuel; geeraerts, thomas; jaber, haithem; heyer, laurent; hoteit, rim; joannes-boyau, olivier; kern, delphine; langeron, olivier; lasocki, sigismond; launey, yoan; saché, frederic le; lukaszewicz, anne claire; maurice-szamburski, axel; mayeur, nicolas; michel, fabrice; minville, vincent; mirek, sébastien; montravers, philippe; morau, estelle; muller, laurent; muret, jane; nouette-gaulain, karine; orban, jean christophe; orliaguet, gilles; perrigault, pierre françois; plantet, florence; pottecher, julien; quesnel, christophe; reubrecht, vanessa; rozec, bertrand; tavernier, benoit; veber, benoit; veyckmans, francis; charbonneau, hélène; constant, isabelle; frasca, denis; fischer, marc-olivier; huraux, catherine; blet, alice; garnier, marc title: guidelines: anaesthesia in the context of covid-19 pandemic date: 2020-06-05 journal: anaesth crit care pain med doi: 10.1016/j.accpm.2020.05.012 sha: doc_id: 303054 cord_uid: s1clwunc abstract objectives: the world is currently facing an unprecedented healthcare crisis caused by covid-19 pandemic. the objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the covid-19 pandemic. methods: the group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) pre-operative assessment and decision on intervention; (4) modalities of the pre-anaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. results: the sfar guideline panel provides 51 statements on anaesthesia management in the context of covid-19 pandemic. after one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. conclusion: we present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to covid-19 pandemic context the outbreak of covid-19 (sars-cov-2) has been spreading globally outside the first chinese outbreak since january 2020 and the world health organization (who) declared a pandemic situation on march 11, 2020 . the epidemic situation has led to a drastic reduction in hospital activities. the evolution of the pandemic allows us to resume some of these activities. beyond this resumption, the persistence of the virus defines a new situation that will have to be taken into account for the care of patients in the coming months. the size and type of activities that will resume depend on many factors outside the organisation of care within our establishments. these factors include the availability of personal protective equipment, anaesthesia/critical care drugs, and critical care beds. finally, it seems important to point out that the epidemic situation is fluctuating not only in time but also in space, so it will be necessary to modulate the recommendations according to the region of exercise and the incidence of covid-19 cases. we need to organise access to this care by meeting a dual imperative: 1) providing access to quality care for patients whose procedures cannot (or can no longer) be postponed, and 2) limiting the risk of contamination of these patients and healthcare professionals. the choice of specific measures to be implemented for the management of a patient in this context will be guided by the risk associated with the patient and the risk associated with the procedure. the persons at risk of serious forms of covid-19 are:  people aged 70 years and over (although people aged 50 to 70 years should be monitored more closely);  people with a history of cardiovascular disease: complicated high blood pressure, history of stroke or coronary artery disease, heart surgery, nyha stage iii or iv heart failure;  insulin-dependent diabetics who are unbalanced or have secondary complications;  people with chronic respiratory disease that may decompensate for a viral infection;  people with morbid obesity (body mass index > 30 kg/m 2 ).  concerning the risk related to surgery, two situations have been identified:  surgery with a high risk of contamination of caregivers by aerosolisation of sar-cov-2 (intervention with opening or exposure of the airways: lung resection surgery, ent surgery, neurosurgery of the base of the skull, rigid bronchoscopy);  major surgery, with a high risk of postoperative critical care stay, where the perioperative respiratory risk inherent to surgery and anaesthesia is likely to be increased by sar-cov-2 infection or even porting. the objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the covid-19 pandemic. the group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas. the basic rules of universal good medical practice in perioperative medicine were considered to be known and were therefore excluded from the recommendations. the recommendations made concern 7 fields: to the drafting of the recommendations to adopt a format of expert opinion. the recommendations were then drafted using the terminology "experts suggest doing" or "experts suggest not doing". proposed recommendations were presented and discussed one by one. the aim was not to necessarily arrive at a single, convergent expert opinion on all the proposals, but to identify points of agreement and points of divergence or indecision. each recommendation was then evaluated by each of the experts and subjected to an individual rating using a scale ranging from 1 (complete disagreement) to 9 (complete agreement). the collective rating was based on a grade grid methodology. in order to validate a recommendation, at least 70 per cent of the experts had to express a favourable opinion, while less than 20 per cent expressed an unfavourable opinion. in the absence of validation of one or more recommendations, the recommendation(s) was/were reformulated and submitted again for scoring with the aim of reaching consensus. the experts' synthesis work resulted in 51 recommendations. after one round of scoring, a strong agreement was reached for 100% of the recommendations and algorithms. in order to protect them during this pandemic, strict safety measures should be implemented. these measures should be carried out all throughout the patient's healthcare pathway: preanaesthetic assessment, operating theatres, recovery rooms, intermediate care units and critical care units. these safety measures will be implemented directly by providing healthcare professionals with adequate ppe, but also indirectly by supplying patients with the right equipment. administrative measures (patient information, preoperative laboratory testing, check-up modalities, anaesthesia modalities, dedicated healthcare pathways, patient and surgery selection), which also help protecting staff members, will be detailed in the following/other chapters. staff members should apply strict social and physical distancing measures when not caring for patients (team rounds, discussions about patients, hand-offs, breaks, meals...): they must keep at least 1 to 2 meters apart from one another, especially during times when wearing a mask is not possible. using alcohol-based hand sanitiser and put on a surgical mask type ii/iir when entering a hospital. this also applies to kids for whom fitted masks should be provided. page 11 of 57 j o u r n a l p r e -p r o o f 11 alcohol-based hand sanitiser before and after every contact with the patient or his surroundings, in addition to wearing a surgical mask type ii or iir and eye protection (goggles) during any clinical examination which requires the patient to take off his mask.  setting up a safety distance in addition to specific physical distancing devices (like temporary plexiglass barriers, interphones…) for those whose work position requires them to be in physical proximity to other people. these devices should be cleaned frequently, following the same cleaning procedures that are used on other surfaces;  removing magazines, documents and other commonly used objects from waiting rooms and common areas, including children's toys;  regularly cleaning surfaces (counters, computers, phones...) and equipment (blood pressure cuffs, pulse oximeter, stethoscopes…) after each patient. during this covid-19 pandemic, every patient could potentially be contaminated and should therefore protect other patients and hospital staff by applying alcohol-based hand gel and wearing a surgical mask type ii or iir. [1] [2] [3] by blocking large droplets, surgical masks protect staff members from droplet and contact transmission. 4 surgical masks can provide protection for healthcare professionals against droplet transmission within a one-meter radius of the patient. four rcts compared the efficiency of n95 or ffp2 masks and surgical masks in healthcare workers performing non aerosol-generating procedures. 5-8 a meta-analysis including these studies reported no significant difference in the occurrence of viral respiratory infections (rc 1,06; 95% ic 0, 25) between the 2 types of mask. 9 only one study specifically evaluated coronaviruses and reported no significant difference between the 2 types of masks in non-aerosol generating procedures. 6 1.3. operating theatre 12 r1.3.1 -experts suggest that healthcare professionals involved in airway management (intubation, extubation, supraglottic airway insertion and/or removal…), or those who could be brought to do so in some given situations, wear a fit tested respirator mask (respirator n95 or ffp2 standard, or equivalent) in addition to a disposable face shield or at least, in the absence of the latter, safety goggles, regardless of the patient's covid-19 status (table 1) there is a great risk of becoming infected during airway management. therefore, strict safety measures should be applied during aerosol-generating procedures such as bag mask ventilation, endotracheal intubation, open/endotracheal suctioning and extubation. the use of a respirator ffp (filtering face piece mask) type 2 is recommended by the french society of hospital hygiene (sf2h) and the french-speaking society of infectious disease for all healthcare professionals manipulating the airway. 10 respirators are tight fitting masks, designed to create a facial seal that protect the person wearing them from droplets and airborne particles inhalation. however, wearing this type of mask can bring more discomfort than wearing a surgical mask (overheating, page 13 of 57 j o u r n a l p r e -p r o o f 13 respiratory resistance...). they have the advantage of blocking at least 94% of aerosol particles (total inward leaking < 8%) and are more effective than surgical masks type ii/iir in blocking < 5 µm particles. 11 nonetheless, a poorly fitted n95 or ffp2 respirator does not protect more than a surgical mask. a leak test must be performed systematically. furthermore, a beard (even a stubble one) reduces the mask's adherence to the face and thus decreases its global efficiency. in case of n95 or ffp2 respirators shortage, some experts suggested using n99 or ffp3 respirators which block at least 99% of aerosol particles (total inward leaking < 2%). however, the problem with these respirators in that the air is most often exhaled through an expiratory valve without being filtered. they do not filter the wearer's exhalation, only the inhale. this one-way protection puts others around the wearer at risk, in a situation like covid-19. covid-19 can also be transmitted by aerosol contact with conjunctiva 12 and lead to a respiratory infection. 13 the fact that unprotected eyes increase the risk of transmission has been demonstrated with coronaviruses. 14 face shields provide a barrier against high velocity aerosol particles and are commonly used as alternatives to safety goggles as they provide greater face protection. 15 using a droplets simulator loaded with influenza viruses (mean droplet diameter: 3.4 µm) and a breathing simulator, it was demonstrated/shown that the use of a face shield reduces the risk of aerosol inhalation by 70%. 16 when spraying fluorescent dye (particle diameter = 5 µm) from a distance of 50 cm towards a mannequin head equipped with an n95 respirator and a face shield, no contamination was noted in either nostrils nor eyes nor mouth folds. the same researchers found that using safety goggles in combination with an n95 respirator did not prevent some eye contamination. 17 face shields also contribute to sparing n95 or ffp2 respirators by limiting their contamination with aerosol projections. n95 or ffp2 respirators can be used for up to 8 hours. during the pandemic period, and a minimal distance of 7-8 meters if an extubation is performed in the recovery room. whenever possible, in order to spare n95 or ffp2 respirators and to protect staff members and other patients, extubation should be performed in the operating theatre by the person who performed the intubation. if this is not possible, the same precautions should be taken in the recovery room for staff protection. in the latest world health organization (who) recommendations for covid-19, health care personnel and other staff are advised to maintain a one-meter distance away from a person showing symptoms of disease. 19 the centre for disease control and prevention recommends a two-meters separation. 20 however, these distances are based on estimates of range that have not considered the possible presence of a high-momentum cloud carrying the droplets long distances recent work has shown that exhalations, sneezes and coughs emit turbulent multiphase flows that can contain pathogen-bearing droplets of mucosalivary fluid. 21 when sneezing or coughing, these droplets/gas clouds can travel in the air for up to 7 to 8 meters. 22 this new understanding of respiratory emissions dynamics has implications on social distancing strategies during the covid-19 pandemic. similarly, swabs taken from air exhaust outlets in covid+ patients' rooms were found to contain rna fragments, suggesting that small virus-laden droplets may be displaced by airflows. 23 however, in this study, no viral culture was done to demonstrate virus viability. for these reasons, extubation should remain exceptional in the recovery room, and giving out surgical masks type ii/iir to patients after their extubation is essential.  administration of nebulised treatment by a device other than vibrating membrane nebulisers. r1.5.3 -when the patient's covid-19 status is unknown, experts suggest using a closed suction system for tracheal suctioning. if this system is unavailable, it is necessary to interrupt the patient's ventilation during suctioning, ideally with the help of a second operator. respiratory droplets are the main source of contamination in healthcare professionals. 2 during aerosol-generating procedures, there is a consensus on the efficiency of n95 or ffp2 respirators (see questions 1.3) and the wear of protective gear such as a fluid resistant long-sleeved gown or a combination of a conventional gown and a plastic apron. 10, 24 the number of asymptomatic patients carrying the virus is high 25 , which is why caregivers should systematically use protection during high-risk procedures. 10,24,25 1.6. paediatric particularities r1.6.1 -experts suggest allowing only one parent to be present during kids' preanaesthetic assessment. and gloves, when performing any procedure with a high transmission risk, particularly when examining the oral cavity. r1.6.3 -experts suggest wearing an n95 or ffp2 respirators, a head cap, a gown with an apron, gloves and a face shield or, failing that, protective goggles, when performing airway procedure in children who are awake in the recovery room, regardless of their covid status. during this covid-19 pandemic, applying enhanced safety measures for the paediatric population is justified due to the existence of a significant proportion of possibly asymptomatic covid+ children (up to 16% depending on the series) and the likely difficulty in complying with social distancing and safety measures (difficulty of continuous wearing of the surgical mask) by children. [26] [27] [28] these findings imply that anaesthesia staff should wear a surgical mask type ii/iir, protective goggles (or a face shield) and gloves when performing any procedure with a high risk of transmission, and particularly when examining the oral cavity during anaesthesia consultation. r2.1 -in asymptomatic patients, during a covid-19 pandemic, experts suggest evaluating the benefit/risk ratio of the intervention according to criteria related to the patient, the pathology and the procedure ( table 2) . the circulation of sars-cov-2 in the population and the existence of asymptomatic carriers affect the risk-benefit ratio of performing a planned surgical procedure during the covid-19 pandemic and require rigorous evaluation. this consideration must integrate three types of criteria related to the patient, the pathology and the procedure. the data in the literature, although heterogeneous and with a low level of evidence, identify several patientrelated risk factors for serious forms of covid-19 potentially associated with an increase in postoperative complications: asa class, obesity, age (> 65 years, < 1 year), underlying respiratory (asthma, copd, cystic fibrosis) or cardiovascular (hypertension, coronary artery disease and chronic heart failure) pathology, obstructive sleep apnoea syndrome, diabetes, and immunosuppression. 29, 30 this increase in perioperative risk is, however, offset by the potential deleterious effect of cancelling or postponing the procedure on the patient. 31 the loss of chance in the absence of intervention must be estimated and the effectiveness and availability of therapeutic alternatives (curative or waiting) explored. finally, two types of factors related to the surgical procedure must be considered: resource utilisation and the risk of transmission of cov-2-sars to the healthcare team. surgical time and expected length of stay provide an indication of the staff and hospital resources required. for each intervention, the foreseeable use of postoperative management in a critical care area must be anticipated in order to adapt surgical activity to the supply available at the time. transfusion needs must also be assessed due to the difficulties of public access to blood donation collection points. the number of personnel required must be taken into account as it increases the risk of contamination of the health care team due to the impossibility of complying with the recommendations for intraoperative distancing. finally, the risk related to the type of anaesthesia and the type of surgery must be evaluated. upper airway management has been identified as a high-risk event for potential transmission of the aerosolised airway secretion virus that persists several minutes after the procedure. 32, 33 the same risk is observed for upper aerodigestive tract and thoracic procedures. finally, the risk related to the surgical site must take into account the probability of postoperative mechanical ventilation, the consequences of which could be aggravated in the context of an infection, or even portage, with sars-cov-2. during the preanaesthetic consultation, detailed information must be provided to the patient and/or his/her legal representative about the perioperative strategy decided regarding his specific situation in the context of covid-19 pandemic. the message must be clear, objective and based on the currently available data, while trying to be reassuring for the patient and/or his legal representative. this message must be given orally during the consultation but also disseminated through a document (established and validated by each structure), which can be given to the patient and/or his legal representative during the preoperative consultation (surgical or preanaesthetic). this information must appear in the medical record. in the appendix, based on current data, we propose examples of model documents (appendix 1, 2 and 3). in the event of cancellation or postponement of the intervention, it is essential to keep in touch with the patient, mostly through the surgical teams, and to reassess the possible alternatives and the feasibility of the procedure according to the evolution of the circumstances. if the decision of postponement or cancellation of the surgery is taken by the patient, it must be recorded in the medical record. the use of a standardised questionnaire increases the completeness of the symptom collection and the reproducibility of the medical examination. it is an appropriate tool for collecting accurate information from a large number of subjects. the data collected are easily quantifiable and traceable. the essential qualities of such a questionnaire are acceptability, reliability and validity. the questions must be formulated to be understood by the largest number of patients, without ambiguity, and be based on validated items. because of the wide variety of symptoms attributable to the sars-cov-2, the questionnaire should be designed to look for the most frequent symptoms (fever, dry cough, etc.) and/or the most evocative ones (anosmia, ageusia, etc.), without however declining all the unusual symptoms that have been reported in the literature. an example of a standardised questionnaire distinguishing between major and minor symptoms is proposed for adults in the appendix #4 and for children in the appendix #5. cov-2 infection at the minimum during the preanaesthetic consultation/teleconsultation and during the preanaesthetic visit. whenever possible, searching symptoms during a phone call with the patient or his legal representative 48-72 hours before the intervention is also recommended to avoid a last-minute postponement of surgery. assessment of specific perioperative risk during the covid-19 pandemic requires, as in the usual situation, the joint consideration of the surgical, patient and anaesthetic risks. in addition, searching usual and/or evocative symptoms of sars-cov-2 infection is an important time of the preanaesthetic consultation in the current pandemic context and during the first months following the easing of the lockdown. the presence of major (i.e., very frequent or relatively characteristic) and/or minor (i.e. more inconsistent and/or less specific) symptoms allows to orient the preoperative covid-19 status assessment, and then to estimate the benefit/risk balance of maintaining or postponing the surgery, taking into account the risk of contamination of health personnel and others patients within the care structure. 34 the integration of these different risks must be collectively weighed against the potential consequences of postponing or cancelling a scheduled intervention. 31 this search for symptoms compatible with a sars-cov-2 infection must take place at the time of the preanaesthetic consultation in order to discuss the postponement of the intervention, if possible, and to anticipate the protective measures that should be applied for the health personnel, and the care circuit that should be used. the questionnaire can be completed by the patient himself, by a nurse just before the consultation or by the anaesthesiologist during the consultation. then, it must be explained that the patient must immediately contact the anaesthesia team, without waiting for admission to the hospital, in case one or more symptoms compatible with a sars-cov-2 infection appear between the preanaesthetic consultation and the day of the intervention. it will also be necessary to explain the importance of the strictest compliance with protective measures, particularly hand-washing and wearing systematically a face mask outside home, between the preanaesthetic consultation and the day of the intervention. if the local organisation allows it, a contact with the patient 48 to 72 hours prior to its admission to the hospital, to ensure that no symptoms have appeared, can also be planned. this timeframe can be adapted locally, the objective of this contact being to have a pcr performed and its results available before coming to the hospital for surgery if the patient has become symptomatic since the preanaesthetic consultation. however, taking into account that the delay between the preanaesthetic consultation and the intervention may correspond to the incubation period of the disease, and that spontaneous reporting by the patient of the onset of symptoms since the consultation will not be systematic nor exhaustive, the search for these same symptoms must be systematically renewed during the "physical" preanaesthetic visit the day before or on the day of surgery. fever, although non-specific, is a very common symptom of symptomatic sars-cov-2 infections, present in 75% to 95% of cases. [35] [36] [37] [38] the presence of fever is a major symptom and an important warning sign that should raise the suspicion of a possible sars-cov-2 infection during the current pandemic. however, since the sensation of fever is highly imperfectly correlated with the temperature objectively measured, 39 it is suggested that patient's temperature should be measured during the preanaesthetic consultation. in addition, antipyretic drug intake should also be systematically collected at the same time as the temperature measurement because acetaminophen (or even nsaids when taken as self-medication by the patient) can normalise the patient's temperature. as the delay between the pre-anaesthetic consultation and the intervention may correspond to the incubation period of the disease, an objective measurement of the patient's temperature must be renewed during the preanaesthetic visit the day before or on the day of the intervention. (figures 1 and 2) for the preoperative covid-19 status assessment and perioperative strategy before scheduled or emergency surgery. these 2 algorithms are the result of a work that tried to take into account a maximum number of clinical situations in a maximum number of structures, while trying to keep it simple. if local provisions, linked to access to diagnostic tests, to the typology of patients, to the prevalence of the virus in the geographical area concerned, or to an agreement between the different specialties at the local level, have led to propose a local algorithm different from those proposed, we suggest that the local algorithm may take precedence over those proposed here. if the patient presents with signs compatible with a sars-cov-2 infection but that the pcr is negative, the evocative paraclinical signs are absent, the ct-scan shows no signs of sars-cov-2 viral pneumonia, and the serology performed after at least 7-10 days of symptoms is negative, a differential diagnosis is then the most likely, and the intervention will be postponed until this other pathology has recovered. in a completely asymptomatic patient, a distinction should be made between: 1) surgeries with opening or exposure of the airways (ent surgery, thoracic surgery, oral surgery, surgery of the base of the skull, rigid bronchoscopy, etc.) for which there is a significant risk of aerosolisation for the operating theatre staff, motivating the realisation of a pcr even in an asymptomatic patient as long as the virus is circulating in the population; and 2) surgeries for which a sars-cov-2 infection could have serious postoperative consequences, thus motivating pcr testing. these surgeries can probably be summed up as "major" surgeries (open-heart surgery, major abdominal or pelvic surgery, organ transplantation, etc.), particularly due to their frequent respiratory impact, since the risk of synergy between sars-cov-2 and perioperative lung injury is not known. to date, this preoperative screening for covid-19 indicated by the type of surgery is based on pcr and there is no indication to perform a thoracic ct scan in this context. in these two situations, the pcr will ideally be performed in the 24 hours preceding the intervention, at most 48 hours, in order to have an idea of the viral carriage as close as possible to the high-risk procedure while taking into account the time required to obtain the results in each structure in order to have them available before the intervention. finally, non-major surgeries in an asymptomatic patient can be performed in a conventional non-covid-19 circuit. 46 if possible, it is suggested that the close contacts of these patients (such as the immediate neighbours in the postoperative recovery room) should be traced to facilitate contact tracing if the patient develops symptoms consistent with sars-cov-2 infection in the days following surgery. it should be noted that if the presence of antibodies in the plasma of a convalescent patient 7 to 10 days after the onset of symptoms has been reported, the positivity of the serology is sometimes later (up to several weeks). in addition, the antibody titre and their neutralising character against sars-cov-2 may vary depending on the patient. [47] [48] [49] [50] [51] [52] furthermore, diagnostic performances vary greatly depending on the type of kit used in the laboratory. finally, the neutralising character of the detected antibodies depends on the viral antigens against which the detected antibodies are directed. [47] [48] [49] [50] [51] [52] consequently, the only place of serology in the diagnostic strategy to date is in addition to a chest ct-scan and a new pcr sample if the first pcr in a symptomatic patient is negative and the symptoms have been evolving for at least 7 to 10 days. new data may change its place in the diagnostic algorithm in the future, especially if it allows the formal detection of patients who are genuinely cured and protected against re-infection, so that surgery can be performed without risk for the patient and staff. by definition non-deferrable, the surgery has to take place. however, pcr sampling should be performed in symptomatic or mildly symptomatic patients who have had close contact with a covid-19 patient within the last 15 days, or who themselves have risk factors for severe forms of covid-19 or are operated from surgery with postoperative respiratory risk. surgery is performed without waiting for the results. in the case of major surgery, a postoperative surveillance in the intensive care unit (potentially already justified by the complexity of the surgery and/or the patient's comorbidities) may be considered, especially in a symptomatic patient, as a risk of synergy between perioperative lung injury and infection/carry of sars-cov-2 cannot be excluded at this time. an outpatient procedure, the experts suggest that the covid-19 status should be sought, at a minimum by using the standardised questionnaire (paediatric version, appendix 5) at the call on d-1. if the interview proves positive, the procedure is rescheduled at least 15 days later. if the questioning does not appear to be interpretable, the child will, depending on the degree of urgency of the procedure, either be rescheduled or hospitalised with a pcr screening test. severe forms of covid-19 are uncommon in children compared to adults, with an estimated incidence of resuscitation of 0.6% of symptomatic forms. 53 clinical manifestations are generally limited to a mild form with fever, myalgia, dry (or productive) cough, runny nose and digestive disorders (nausea, vomiting, diarrhoea, abdominal pain) in 54% of cases. [53] [54] [55] finally, more specific to covid-19 is the presence of anosmia and/or ageusia without nasal obstruction, which are strongly suggestive of this pathology. 1, 2 the presence of skin signs such as pseudo frostbite or urticarial elements are also signs suggestive of covid-19 in children and adolescents. in all cases, the majority of reported paediatric cases are familial in origin and a history of covid-19 in the family environment should be considered a risk factor for this disease in children, even if the child is asymptomatic. 56, 57 radiological signs are identical to those in adults but are inconsistently found (43% of cases on average) and therefore do not contribute much to the diagnosis in this population. 56, 57 the same limitation applies to pulmonary ultrasonography given the lack of studies in the paediatric population. 58 biologically, the published series show lymphopenia or hyperlymphocytosis associated with increased crp. 56 it is important to note that recent studies conducted on cohorts of individuals on an epidemiological basis tend to show that for one person expressing the disease, 7 people are asymptomatic, which reflects the limitations of the clinic to screen all potentially contaminating patients (prepublication study 1) [9-10]. taking into account these elements and the asymptomatic or paucisymptomatic nature of the disease, the problem of the preoperative assessment in paediatrics is above all that of diagnosing this pathology in children, given the risks incurred by caregivers (representing between 3 and 15% of covid-19 infections) [6] , but also that of nosocomial contamination of other patients given the particularly high number of reproductions of this condition (between 2 and 3.5). 56, 57 in the same vein, ambulatory surgery should in theory be favoured in order to avoid cases of nosocomial contamination. it is therefore proposed to perform a pcr test for the virus for each paediatric patient before surgery. in the context of the emergency department, pcr is carried out on admission of the child, but surgery can be performed before the results are obtained. r4.1.1 -during covid-19 crisis, the experts suggest that telemedicine is an alternative to face-to-face consultation and must be used to reduce patient in-visit. the current outbreak of covid-19 has placed a heavy burden on global medical systems, particularly with regard to the preoperative assessment of patients for surgery. for all elective surgeries in france and in many countries for major surgery, preoperative physical assessment by physicians had become a standard of care. the current crisis has reduced this possibility because patients should not be exposed to potentially contagious structures. in for patients, prior agreement to carry out a telemedicine evaluation is a mandatory step. it is advisable to send beforehand a guide to prepare the teleconsultation (including: connection modalities, health questionnaire on current treatments, information documents...) to facilitate the smooth running of the consultation. if necessary, a person close to the patient or an interpreter may, if present during the tlc, assist the doctor in carrying data of the clinical examination within the limits of his or her competence. not all patients desire remote evaluation, and the exact reasons for this have not been elucidated. patient selection is an important step for virtual preoperative evaluation. for example, patients in whom arranging travel is complicated underwent successful telemedicine preoperative evaluation before oral and maxillofacial surgery with no complications, highlighting this patient population as one in whom remote evaluation may be beneficial. the use of telemedicine preoperative evaluation has been studied in a variety of patient populations. all types of surgery can be performed with telemedicine evaluation but major surgery (cardiac, vascular, thoracic, etc.) and patients with many comorbities or treatment are obstacles to the development of this technique. similarly, patients must be able to connect to a platform and know how to use the software. failure to undergo a preoperative anaesthesia evaluation may contribute to day of surgery cancellation, which has a negative financial impact on both patients and hospitals. up to 25% of day of surgery cancellations are due to inadequate preoperative workup, and it is well established that preoperative clinics reduce risk of such cancellations and delays. with telemedicine, we found a 1.3% last minute cancellation rate, consistent with the international average, in patients who underwent telehealth evaluation as opposed to an in-person visit, thus suggesting an equivalent performance between the 2 evaluation options. teleconsultation is carried out using tools that guarantee the security of patient data. it is carried out in conditions that must guarantee : authentication of the healthcare professionals involved in the procedure; identification of the patient; access by healthcare professionals to the patient's medical data required to perform the procedure; access by the patient to the patient's medical data required to perform the procedure. informed consent is an important factor in surgery and telemedicine itself is no different. the evaluation of the practices is advised to optimise these new modalities. as stated in the introduction, in the context of the covid-19 pandemic, the resumption of surgical activity is subject to several major limitations: the strain on the supply of certain anaesthesia drugs, the change in hospitalisation capacities, the risk of contamination of healthcare providers and patients and the application, throughout the patient's journey, of the "distancing" principle. in addition, some peculiarities of covid-19 patients (risk of drug interactions, worsening of the condition, etc.) are to be taken into account. these limitations lead us to propose an adaptation of anaesthesia procedures. favour strategies that reduce the exposure of health professionals to a risk of contamination while maintaining optimal safety conditions for the patient is one of the most important objectives. when safety conditions are met (especially for postoperative follow-up), outpatient management should probably be prioritised. r5.1.2 -experts suggest giving priority whenever possible to regional anaesthesia. regional analgesia and infiltration techniques should also be considered. tensions on drug stocks and even shortages of drugs such as propofol, midazolam, atracurium, cisatracurium or rocuronium require the choice of anaesthesia protocol that spares these drugs, which are otherwise subject to quotas. to do so, the experts propose several principles: -prefer regional anaesthesia (ra) for anaesthesia and analgesia, rather than general anaesthesia. in the context of -peripheral and topical local anaesthesia allow postoperative follow-up directly in the room or in a dedicated space, without going through the recovery room in accordance with regulations. this facilitates compliance with distancing measures specific to the current epidemic context. 65 in children, since ra techniques are regularly associated with general anaesthesia or sedation, they do not make it possible to bypass the recovery room. -when ga is required, inhaled anaesthesia should probably be preferred in this context to intravenous targetcontrolled anaesthesia. -monitoring of the depth of anaesthesia when possible, and of curarisation may be required in order to best adapt drug dosages. 66 these recommendations apply to both elective and emergency care. in conjunction with the institution's pharmacy, it is important to monitor local stock trends. epidemics" published by the srlf-sfar and to the "airway management principle" sheet, which are also applicable in the operating theatre. during the covid-19 pandemic period, the intubation of a covid+ patient in the operating theatre is based on the same rules as those issued in critical care units, due to the risk of spraying of the virus during this risky procedure. in order to minimise the risk of aerosolisation and contamination of personnel, it is necessary to: -limit the number of staff present in the operating theatre -avoid ventilating the patient with a face mask during the preoxygenation phase. -stop oxygen before removing the bag valve mask. -intubate the patient by the most experienced senior using a video laryngoscope -connect the ventilator after inflating the intubation tube balloon. highly suspected patients. patient. if general anaesthesia is required, the patient's clinical condition and covid-19 status should be considered in the airway management strategy. -if the patient is covid+ or highly suspected: the procedure described by sfar 46 should be followed with rapid sequence induction and intubation. special attention should be paid to tracheal extubation with the same barrier precautions as for intubation. this applies to patients under emergency management when the covid-19 status is unknown. special attention should also be paid to hand hygiene. -if the patient is non-covid or asymptomatic, there is no need to modify usual procedures because of the covid-19 pandemic. routine airway management is recommended. if intubation is chosen, conventional induction is recommended according to standard recommendations, with adaptation of the induction sequence according to haemodynamic conditions, drug contraindications, and compliance with fasting conditions and the patient's age. the frequency of anaphylaxis related to atracurium has been estimated to be 1/22451 administrations. the frequency of anaphylaxis due to fast-acting myorelaxant is about 10 times higher (succinylcholine: 1/2080 and j o u r n a l p r e -p r o o f 27 rocuronium: 1/2499). 67 the severe over-risk of allergy to the patient linked to a rapid sequence induction does not seem to be justified by the sole risk of sars-cov-2 contamination of the caregivers, this risk being low when protective measures are well respected (cf. item 1). readers are invited to refer to "guidelines on muscle relaxants and reversal in anaesthesia". 66 in a non-covid patient, spontaneous ventilation anaesthesia or the use of supraglottic devices such as laryngeal masks is possible. we insist on the importance during the preoperative checklist to share with the operating theatre staff, in addition to the usual information, the covid status of the patient which will determine his perioperative circuit and the strategy adopted by the anaesthesia team for airway management. cov-2 is available online from the university of liverpool. 68 a summary is provided below for drugs frequently used in the perioperative period ( table 3) . the hydroxychloroquine has multiple cardiac adverse events, including significant qt prolongation. combinations with other drugs that prolong the qt interval, frequently used in the perioperative period such as halogenated drugs, droperidol, ondansetron, or hypothermia related to surgery and anaesthesia may increase the risk of developing a serious arrhythmia, such as ventricular fibrillation. the combination of hydroxychloroquine and azithromycin, proposed by some, carries a risk of additive/synergistic qt interval prolongation. ecg monitoring is essential. in addition, the combination of lopinavir/ritonavir carries a risk of overdosage with amide type local anaesthetics (lidocaine, levobupivacaine, bupivacaine, prilocaine, mepivacaine, ropivacaine), ketamine, midazolam, sufentanil, oxycodone or tramadol due to ritonavir-related cytochrome p3a inhibition, but also to underdosage of propofol and morphine due to increased biotransformation of products metabolised by cytochrome p2c9 and p2c19 or by glucuronidation. remdesivir, tocilizumab, and interferon beta do not show significant interactions with drugs normally used perioperatively, nor do they have cardiac effects. nsaids may be associated with worsening of symptoms during respiratory viruses, with an increased risk of empyema. 70 despite recent alerts, there is no scientific evidence to date linking nsaid use to the aggravation of sars-cov-2 infection. a precautionary principle applies. 71 thus, in a patient with an established or strongly suspected sars-cov-2 infection, the prescription of nsaids will be avoided. however, in asymptomatic patients, there appears to be no contraindication to their use if their benefit is established. 72, 73 discontinuation of corticosteroids is not recommended in patients on long-term therapy. 70 steroid treatment of patients with covid-19 is controversial and is not currently recommended. 74 the single intraoperative injection of dexamethasone, at the usual recommended doses, does not appear to present an over-risk in the asymptomatic patient. anaesthesia is indicated, experts suggest that rapid sequence anaesthesia be performed regardless of the patient's covid-19 status. in the context of covid-19 pandemic, obstetric patients present two particularities. first, unlike scheduled surgical activities, obstetrical activity in essence cannot be postponed and therefore remained at its usual level at the peak of the pandemic. the organisation of care had to be adapted, with the establishment of specific care channels for women infected with sars-cov-2 or suspected of being infected, not only to optimise the care of these women, but also to avoid the contamination of other pregnant women and of caregivers working in maternity wards. these covid-positive or suspected covid-positive/non-covid channels are logically maintained as long as the pandemic persists. the resumption of surgical activity during the covid-19 outbreak exposes no-covid-19 patients and healthcare workers to contamination. the following expert proposals should be discussed within each institution in a collegial manner (extended executive board, operating theatre committee, healthcare infection control practices advisory committee) and lead to protocols that take into account the specific characteristics of each institution (architectural constraints, recruitment) and the local incidence of covid-19 infection. appropriate signage has to be applied throughout the specific covid-19 pathway. in the context of non-covid patients management in the operating theatre, the aim of this guideline was to avoid both the occurrence of nosocomial sars-cov-2 infection 87 and the contamination of caregivers by asymptomatic patients 88 . for any planned surgical procedure, the risk/benefit balance must be discussed in a multidisciplinary manner, given the probably high postoperative morbidity and mortality in this epidemic context. 88 management of "non-covid" patients must be considered in a specific pathway. 89 this pathway covers the entire patient's hospitalisation day: from the anaesthesia consultation to discharge from the hospital after surgery, following the guidelines for protection (chapter 1). suggest that for both adults and children, priority should be given to outpatient treatment and enhanced recovery after surgery as much as possible. in the context of covid-19 outbreak, outpatient management should be considered and preferred to conventional hospitalisation when feasible. outpatient management reduces the length of stay, thereby reduces the risk of patient exposure and the risk of contamination in case of asymptomatic infection. 90 outpatient management of surgical emergencies should be considered whenever possible. 91 outpatient pathways for resumption of activity during the pandemic period need to consider several points: 1/ the planning and convocation schedules should be staggered to avoid waiting times and gathering of patient; 2/ the use of single or isolated rooms should be preferred to wait or exit lounges; 3/ limit admissions in the postoperative recovery room must be applied as much as possible, in particular after performing locoregional anaesthesia. depending on the local outpatient surgery units, this recommendation may limit the number of patients treated. finally, waiting areas for companions should be arranged in order to respect the safe distances. 91, 92 the number of companions should be limited to one person per patient (adult or child). in case of conventional hospitalisation, enhanced recovery after surgery should be preferred as far as possible in order to reduce, once again, the length of stay. in the same way, hospitalisation on the day of surgery should be considered if the healthcare institution ensures that there is no risk of infected patient by the covid-19 (for example by a phone call the day before hospitalisation). the rapidly changing covid-19 pandemic situation requires a periodic review of the measures taken and an analysis of the clinical, social and economic context derived from each decision. the resumption of surgical activity will be gradual and spread over time. the objective is to summarise, as a priority and progressively, those activities that prove decisive in limiting the loss of chance for patients awaiting cancer or non-cancer surgery. 93 the gradual deployment of surgical activity in a controlled number of operating theatres will make it possible to achieve efficiency in open operating theatres and facilitate compliance with reinforced hygiene rules to ensure the safety and protection of patients and caregivers. experts suggest that public and private facilities agree to propose a common approach to the provision of care adapted to the population and regional conditions of the covid-19 pandemic. the pace of rescheduling elective surgery in children and adults will vary according to geographical location, epidemiological pressure, and the possibility of redeploying staff from critical care to operating theatres. elements to be evaluated for the resumption of surgical activity are the following:  timing of resumption: there should be a sustained reduction in the rate of new covid-19 cases in the geographical area concerned for at least 14 days before the resumption of elective surgery. 94  any resumption must be authorised by the relevant regional and national health authorities.  facilities are able to safely treat all patients requiring hospitalisation without the need for a crisis care organisation.  the facility has an appropriate number of critical and non-critical non-covid and covid+ beds, ppe, ventilators, drugs, blood products and all necessary medical and surgical equipment. the facility has a number of trained and educated staff appropriate to the planned surgical procedures, the patient population and the facility resources. health care staff fatigue and the impact of stress must be considered in order to perform planned procedures without compromising patient safety or staff safety and well-being. 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outbreak: is there still a place for scheduled surgery? "reflection from pathophysiological data the authors want to thank all the reviewers from others medical specialties who brought their expertise on several hand disinfection with a hydro-alcoholic based hand gel, a surgical mask type ii/iir.patients must wear a surgical mask type ii/iir when leaving their unit and heading for the or.coded covid-19 dedicated routes should be followed.surgical mask type ii/iir. discuss 1) a chest ct-scan, and/or 2) a control of the pcr on a new sample, and/or 3) a serology* key: cord-345496-gdnpz6a1 authors: lópez cano, manuel; saludes serra, judit; rosselló-jiménez, daniel; antonio pereira, josé; rodrigues gonçalves, victor; garcía alamino, josep m. title: abdominal wall surgery after sars-cov-2: time to reestablish postponed non-essential procedures? date: 2020-10-19 journal: nan doi: 10.1016/j.cireng.2020.10.013 sha: doc_id: 345496 cord_uid: gdnpz6a1 pandemic by the covid-19 has found us unprotected to provide an adequate and rapid sanitary response. the hospital network of our public health system has provided most of the resources for the treatment of patients affected by the infection. non-essential (non-priority) surgeries have been postponed. the optimal and proportionate reestablishment of these non-priority surgeries can be a problem. this article offers a technical and non-technical view of reestablishment non-priority surgeries from the perspective of abdominal wall surgery. la pandemia por el covid-19 nos ha encontrado desprotegidos ante la dificultad para dar una respuesta sanitaria adecuada y rápida. la red de hospitales del sistema sanitario público ha dispuesto la mayoría de los recursos para el tratamiento de los pacientes afectos por la infección. las cirugías no esenciales (no prioritarias) han sido aplazadas. el reinicio óptimo y proporcionado de estas cirugías no prioritarias puede representar un problema. en el presente artículo se ofrece una perspectiva técnica y no técnica del reinicio de las cirugías no prioritarias desde la óptica de la cirugía de la pared abdominal. pandemic by the covid-19 has found us unprotected to provide an adequate and rapid sanitary response. the hospital network of our public health system has provided most of the resources for the treatment of patients affected by the infection. non-essential (non-priority) surgeries have been postponed. the optimal and proportionate reestablishment of these non-priority surgeries can be a problem. this article offers a technical and non-technical view of reestablishment non-priority surgeries from the perspective of abdominal wall surgery. palabras clave: covid-19; cirugías no esenciales; hernia; pared abdominal; cirugía keywords: covid-19; non-essential surgeries; hernia; abdominal wall; surgery the novel coronavirus responsible for severe acute respiratory syndrome (sars-cov-2) has caused, is causing and unfortunately will continue to cause physical health sequelae (morbidity and mortality) as well as mental health consequences (exhaustion, stress and anguish) in patients, healthcare workers and society in general. likewise, sars-cov-2 will leave its mark on the structure and organization of healthcare facilities secondary to the 'express' change in the order and provision of care, resulting in the reorganization of hospitals and the provision of most resources for the treatment of patients affected by covid-19. in surgery, this quick restructuring has led to the recommendation (at varying degrees) to cancel or postpone all non-essential/non-priority surgical activities, and only emergency surgical activities have continued to function in many hospitals. 1,2 one such 'deferred' non-essential surgical activity is abdominal wall surgery (primarily hernias). as we write these lines, the previously described context is our current reality. however, there is undoubtedly a future that awaits us. in the short term and after the pandemic, we will logically have to face the effects of the pandemic on the public healthcare structure and organization. it is unquestionable that, when elective surgical activity is resumed, delayed or canceled oncological surgery and other preferential surgeries will be prioritized for operating room sessions. it is also obvious that, sooner or later, postponed non-essential surgical activities will have to be restarted. we do not intend to discuss all of them here, although abdominal wall surgery could be used as an example. to what extent and at what rate will it restart? we believe that it is pertinent to remember here that, in a 'normal care' situation (such as the situation prior to the current international public health emergency), hernia pathology is one of the most common surgeries and has the longest waiting lists. 3 furthermore, patients with hernia do not present a uniform pattern of medical 'importance' in terms of the repercussions of the pathology and the effect on quality of life. consequently, we feel that its postponement until after the pandemic would generate an important organizational problem, with greater delays until surgery or a growing number of urgent complications and the consequent increase in morbidity and mortality rates. 4 we live in a public health system with universal coverage, which for years has survived under the burden of spending cuts and restrictions. 5 this healthcare crisis has cruelly revealed that our public health system suffers from a lack of means (both material and human) and resources (funding). 6 in addition, there are two circumstances that provide a 'perfect storm' environment. first, those who are most affected by the return to 'normal care' are exactly those who have suffered the most from this health crisis (patients and healthcare workers). second, the probable post-crisis economic recession and increased public debt will most likely make us have to adapt to an even more hostile environment. given this situation, in our opinion, the reorganization task of returning to 'normal' abdominal wall surgery activity can only be achieved through the cooperation of all healthcare professionals, optimizing the available resources and once again reinventing, with much effort and burnout, an insufficient and weakened healthcare model. perhaps, on the way back to normalcy, we could lay the foundation of a more extensive reorganization that would restore the esteemed role that medical professionals should have in our society. thus, if we exclude the use of major ambulatory surgery, which will be an essential resource in the treatment of wall pathology that does not require hospitalization and whose implementation may be less complex, it is likely that patients with wall disease who do require hospitalization should be approached from a technical perspective as well as a non-technical one. complex abdominal wall hernias usually occur in patients with high associated morbidity and a very deficient quality of life secondary to their hernia. 7 they usually require prehabilitation, which in some cases can be ambulatory (respiratory rehabilitation, botulinum toxin, weight loss), but in other cases it may require hospitalization (progressive pneumoperitoneum). surgical treatment is associated with long surgeries and the need for close monitoring in the immediate postoperative period (beds in postoperative resuscitation units or intensive care) as well as potentially serious postoperative complications. these patients, whose surgery cannot be postponed indefinitely, should have a place among the priority procedures and not after them, both in the operating room and in resuscitation/postoperative icu beds. less complicated wall surgeries for elderly patients with significant associated morbidity (heart disease, lung disease, kidney failure, treatment with anticoagulants), whose pathology also alters their quality of life, will also need treatment in surgical programs. these patients can benefit from short-stay units for patients with scheduled surgical procedures whose estimated hospital stay is less than 72h, 8 which also promotes more efficient bed management. in this context, it is likely that afternoon/evening surgical programs will have to be intensified to treat the patients described above. however, surgeons (like other doctors and healthcare professionals) are not 'heroes' who are able to save a limitless number of patients from a waiting list after also having contributed to saving lives during a pandemic. we are providers of a specialized product who, for the proper function of the system, must be adequately regulated and incentivized in accordance with the value we bring to society. most public hospitals have residents in surgical training. we believe that, even though a specific type of surgery is prioritized in the reorganization period after the pandemic, resident training needs to continue in all possible areas of general surgery, including abdominal wall surgery and others that may be in a similar situation. we cannot and should not add more precariousness to training programs that have already been affected by funding restrictions for years. 9 in our opinion, the task of surgical reorganization should not be the sole responsibility of surgeons. in exceptional situations such as the one generated by the current health crisis, non-surgical specialists should also collaborate in cases of exacerbated chronic diseases or infectious diseases, optimizing the overall hospital stay of these patients, reducing the saturation of beds available and facilitating surgical programming. in the same manner, patients awaiting an abdominal wall procedure (and society in general) should be aware of the problem of delayed treatment for their pathology. in this sense, we believe that the administration of the public health system should raise public awareness and offer a realistic perspective of the situation, at the very least. in short, we believe that abdominal wall surgery (at least a portion of patients requiring hospitalization) should return to surgical reorganization programs after the pandemic. we do not believe that it should go ahead of other priority procedures, but we do believe that it should not wait for their completion. instead, it should be done simultaneously, perhaps not with the same intensity of resources, but parallel. we have used abdominal wall surgery as the guiding example of this text since it is our daily environment. however, many of the previously described factors, except for the particularities specific to each area, are probably applicable to most non-essential (nonpriority) surgical procedures. it is likely that this is the only way 'proportionate' access to healthcare services can be achieved following criteria of effective equality, while respecting basic aspects such as the severity of the pathology as well as the efficacy and timeliness of the surgery. this article has not been funded by public or private entities. general recommendations for action and basic organization of surgery units in areas highly affected by the covid-19 pandemic (sars cov-2). from the spanish association of surgery general recommendations for action and basic organization of surgery units in areas with low affection by the covid-19 pandemic (sars cov-2). from the spanish association of surgery hernias: inguinal and incisional specific improvement measures to reduce complications and mortality after urgent surgery in complicated abdominal wall hernia la reducción del gasto sanitario en españa durante la crisis cuadernos de información económica-funcas. nº 248. octubre reflexiones derivadas de la pandemia covid-19. enfermería intensiva 2020 criteria for definition of a complex abdominal wall hernia hospitalisation in short-stay units for adults with internal medicine diseases and conditions grado de burnout en especialistas en formación de medicina y psicología clínica the authors have no conflict of interests to declare related with this article. key: cord-350377-vq9eblr0 authors: sukumar, vivek; pandey, diwakar; kumar, barath raj; patel, swapnil; pawar, tushar; rohila, jitender; desouza, ashwin; saklani, avanish title: colorectal services in covid-19 times: minimally invasive surgery and enhanced recovery, the need of the hour date: 2020-10-14 journal: indian j surg oncol doi: 10.1007/s13193-020-01241-0 sha: doc_id: 350377 cord_uid: vq9eblr0 the health services across the world have been deeply impacted by the ongoing covid-19 pandemic which has resulted in diversion of resources to testing, isolating and treating covid-19 patients. this meant cutting down resources and manpower away of various healthcare facilities and severely hampering the functioning of various cancer services across the world. it is however, important to understand, cancer itself is a life-threatening condition, and there is a need to continue running cancer care services, at least for those who needed the most. various clinical societies have put forward guidelines and protocols to help continue surgical services during the pandemic. the role of minimally invasive surgery (mis) was initially questioned at the start of the pandemic, however gradually increasing evidence favored mis as it reduced hospital stay and complication. enhanced recovery programs which have been introduced to various fields of surgery to improve outcomes and reduce hospital stay. it plays an essential role in times like this, where the optimal usage of minimal resources is essential. we embraced these methods to ensure safety of our patients and staff and at the same time provide the highest standards of care. here we are presenting our experience of running a colorectal surgical unit during these difficult times with emphasis on promotion of minimally invasive surgery, at the epicenter of the pandemic in india. the covid-19 pandemic has impacted healthcare services around the world presenting with challenges to provide essential healthcare services. a recent survey of the who, which was conducted in 155 countries over a 3-week period in may, confirmed 42% of countries reporting partial or complete disruption of services for cancer treatment [1] . at the onset of the pandemic, various clinical societies across the world released guidelines to facilitate optimum delivery of healthcare in resource constrained settings taking cognizance of the risks faced by the healthcare providers. there is a need to incorporate and strictly enforce various strategies such as enhanced recovery programs which have demonstrated to lower recovery time and post-operative complication rates, helping us to optimally utilize the minimum available resources without burdening the already strained health care infrastructure [3] . we present the outcomes of our patients who were treated in the division of colorectal and peritoneal surgery oncology services during this pandemic (tables 1 and 2 ). tata memorial hospital is the apex oncology referral center of the country located in mumbai, a city which has continued to share the maximum disease burden of covid-19 of the nation till date. prospectively maintained database of surgeries done in the department over a 60-day period between march and may 2020 was analyzed. all patients admitted and undergoing major elective as well as emergency surgeries under the division of colorectal and peritoneal surface oncology were included in the study. exclusion criteria included patients with incomplete medical records, primarily admitted with another department for whom surgical cover was provided by the division of colorectal surgery and day care procedures. the primary objective of this study was to assess the outcome of the patients undergoing surgery during the study period. it included surgical duration, blood loss, post-operative hospital stay, and post-operative morbidity. apart from the routine treatment and infection control protocols, emphasis was laid on the following in concert with the guidelines issued by the hospital infection control committee. & after pre-anesthetic checkup, only patients with controlled comorbidities were scheduled for elective surgery after adequate optimization. & preoperative hospital visits and stay were minimized, once the surgical plan was made. & in the initial 2 weeks of the study period, only symptomdriven testing for covid-19 was in place at the hospital. thirty-six of the 90 patients had a comorbidity such as diabetes mellitus, hypertension, asthma, and ischemic heart disease and were actively taking treatment for the same. the median duration of surgery was 240 min (60-480 min). the median blood loss was 225 ml (50-2000 ml). the median post-operative stay was 5 days (1-30 days) . the post-operative stay of the laparoscopic group and open surgery group were 4.3 day (1-15 days) and 8.3 days (1-30 days) respectively. the median post-operative stay in the elective case and emergency cases were 5 days (1-30 days) and 6 days (1-21 days) respectively. ten patients had a significant post op morbidity (clavien dindo grade iii and above) in the postoperative period (tables 2). four out of 43 rectal resections had a positive circumferential resection margin which corresponds to 9.3%, which is slightly higher that our institutional rate of below 5%, which probably is attributed to a selection bias of advanced cases during this period. one of the patients who underwent exploratory laparotomy for perforation peritonitis died in the post-operative period. one patient was taken up for an emergency surgery without waiting for the result of covid-19 (due to deterioration of symptoms) turned positive. adequate precautions were taken in the preoperative and intraoperative period. no staff needed to be quarantined and his post-operative course was uneventful. no other patient developed the infection during their postoperative hospital stay. the covid-19 pandemic has presented a unique set of challenges. india being a developing nation with limited healthcare infrastructure and over a billion-population responded by nationwide lockdown extending over 2 months putting severe socio-economic constraints. the cancer care services had taken a hit after data emerged from china showing inferior outcomes in cancer patients undergoing treatment [4] . it is important to understand that cancer is also a life-threatening condition, which needs treatment with adequate precautionary measures and involvement of all oncological disciplines based on treatment protocols to obtain best possible outcomes [5] . various guidelines have recommended that emergencies like intestinal occlusion, bowel perforation, peritonitis, massive gi bleeding, post-surgical complication, and postprocedural complications have to be attended with no delay. however, there have been contrasting views regarding the management of colorectal cancers. the european society of medical oncology (esmo) guidelines and american college of surgeons (acs) have advised to give priority to patient with cancers with the acs suggesting surgeons to look at the elective surgery acuity scale (esas) from st. louis university which include most cancers in tier 3a and calls for non-post-ponement of surgery in these cases [6, 7] . the nhs guidelines, on the other hand, on a more cautionary note has suggested surgery only for patients presenting in an emergency, colonic lesions, rectal cancers who are poor responders to nactrt or 12-14 weeks post nactrt [8] . the tata memorial centre in india is the largest cancer center in the country and being the apex oncology referral center of the country; we had to continue to provide cancer care. however, our center did scale back our operations to function at 65% of routine capacity [9] . we also had to allocate beds for initial screening, testing, isolation, and treatment of covid-19 patients. the division of colorectal and peritoneal surface oncology has a footfall of around 1500-1800 patients annually. during these difficult times, the resources allocated to the colorectal unit was cut down to a third. the department strives to provide the highest standards of cancer care while ensuring the safety of patients and healthcare providers. this resulted to adoption of best surgical practices suggested and put forward by various clinical societies and enforcing eras protocols. the adoption of mis and enhanced recovery programs became mandatory for optimal usage of resources. tackling the reduction in hospital resources towards surgical care, the department managed to operate 90 patients over a 2-month period. emergency services were not hampered with 26.6% of the surgeries being done for emergent conditions like obstruction and bleeding. guidelines from all the surgical societies have advocated the highest priority to emergency procedures [2] . the decision to perform a surgical procedure must be made in the context of numerous medical and logistic considerations taking into account the real risk of proceeding and the risk of delay. while covid-19 testing was done for the semi-emergency surgeries, the urgent surgeries were never delayed for the lack of it proceeding with all the necessary precautions [10] . there has been hue and cry about the feasibility of minimally invasive surgery without clear guidelines for the same. we continued with mis taking appropriate precautions, with 57.8% of the surgeries having been performed with laparoscopic approach. the proven benefits of mis leading to reduced length of stay and complication should be strongly considered in these patients, in addition to the potential for ultrafiltration of the majority or all aerosolized particles. filtration of aerosolized particles may be more difficult during open surgery [11] . the overall median post-operative stay was 5 days with laparoscopic group and open surgery group having a stay of 4.3 days (1-15 days) and 8.3 days (1-30 days) respectively. this was comparable with the average post-operative stay for colorectal surgeries. various studies have demonstrated different lengths of stay in the hospital from 9 to 12 days [12] to 5 to 8 days [13] . the length of hospital stay also depends on whether the patient underwent emergency or elective surgery. our series demonstrated the median hospital stay of 5.7 days (1-20 days) for elective surgeries and 8.5 days (2-30 days) for emergency surgeries which is comparable to published literature [14] . strict enforcement of eras protocols especially during the postoperative period helped us achieve equivalent results. javier et al. demonstrated that the implementation of eras protocol for colorectal surgery was associated with a significantly reduction of post-operative complications and length of stay [15] . the short-term outcomes of our cohort such as median blood loss, surgery duration, and post-operative morbidity were comparable with standard published literature [7] . we introduced a simplified enhanced recovery with early initiation of diet, mobilization, and discharge of patient's home with jackson pratt close suction drains. an interesting finding was even though the patients were keen on getting operated, they wanted to spend minimum time in the hospital and were not keen on a prolonged stay in the hospital after surgery. this made them receptive for an early discharge and care at home. a specialist nurse from our survivorship program called them on a regular basis to confirm their well-being. at the same time, none of our patients barring one developed any covid-19 infection in the perioperative period. we did not witness any increased morbidity or mortality due to covid-19 infection. even the safety of healthcare providers was optimum with no one testing positive for the same. after the initial 2 weeks, routine preoperative testing for covid-19 was performed in concert with the sages guidelines which state that surgical patients should be tested pre-operatively for covid-19 [11] . the patients who tested positive were kept quarantined at an associated medical facility to be operated after 2 weeks pending a negative result. the challenges we face today as healthcare professionals are unparalleled, but we have successfully demonstrated the feasibility of cancer surgery during these difficult times by following strict protocols in testing, safety of personnel, and aggressive perioperative and post-operative care. the shortterm outcomes in our cohort are similar to those during non-covid times and probably show us a way forward as treatment of cancer patients cannot be deferred for prolonged period of time. authors' contributions all author equally contributed in preparation of this manuscript. manuscript review was done by dr. avanish saklani. data availability data available on request. conflicts of interest/competing interests none. covid-19: pandemic is having "severe" impact on non-communicable disease care, who survey finds covid-19 guidance for surgeons current status of enhanced recovery after surgery (eras) protocol in gastrointestinal surgery zhou m clinical characteristics of covid-19-infected cancer patients: a retrospective case study in three hospitals within wuhan iaso covid-19 guidelines esmo management and treatment adapted recommendations in the covid-19 era: colorectal cancer (crc) covid-19: guidance for triage of non -emergent surgical procedures. american college of surgeons clinical guide to surgical prioritization during the coronavirus epidemic cancer management in india during covid-19 di carlo v. laparoscopic versus open colorectal surgery: cost-benefit analysis in a single-center randomized trial sages and eaes recommendations regarding surgical response to covid-19 crisis. society of american gastrointestinal and endoscopic surgeons short hospital stay after laparoscopic colorectal surgery without fast track factors predicting hospital length-of-stay and readmission after colorectal resection : a population-based study of elective and emergency admissions enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery a single center cohort study laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-348537-rsdyiygo authors: pignatti, marco; pinto, valentina; miralles, maria elisa lozano; giorgini, federico a.; cipriani, riccardo title: how the covid-19 pandemic changed the plastic surgery activity in a regional referral center in northen italy date: 2020-05-15 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.05.002 sha: doc_id: 348537 cord_uid: rsdyiygo the covid 19 epidemic has modified the way that plastic surgeons can treat their patients. at our hospital all elective surgery was canceled and only the more severe cases were admitted. the outpatient department activity has been reduced also. we present the number and diagnoses of patients, treated as inand out-patients, during seven weeks from the onset of the epidemic, comparing our activity from the lockdown of elective surgery with the numbers and diagnoses observed during the same weeks of last year. finally we underline the importance of using telemedicine and web-based tools to transmit images of lesions that need the surgeon's evaluation, and can be used by the patient to keep in touch with a doctor during the distressing time of delay of the expected procedure. on february, 21st 2020, the first case of coronavirus disease 2019 (covid19) was reported in italy. since then the disease rapidly expanded and on march 11, 2020 , the world health organization (who) declared it to be a pandemic 1 . as of april 6, 2020, italy, with a number of deaths exceeding 16.500 2 we established that patients with melanoma, merkel carcinoma, infiltrative large squamous cell, and basal cell carcinoma, mainly of the face, had to be considered as surgical emergencies and their treatment was guaranteed. in addition, our team of plastic surgeons continued to be involved in multidisciplinary groups to provide reconstruction in other urgent cases, such as head & neck cancers, breast cancer, pelvic-perineal cancers, sarcomas or soft tissue infections such as necrotizing fasciitis. all the patients already booked on an outpatient clinic at the time the switch from elective to urgent activity was implemented were contacted, on a daily basis, to evaluate the urgency of their case and to decide whether to cancel, postpone or maintain their appointment. in most cases this was done by a doctor, specific expertise being needed to judge the urgency and to assume the responsibility for the postponement. the appointments for large, bleeding, rapidly growing, or dangerously located squamous and basal cell carcinomas were kept as booked. in all other cases, prescriptions or suggestions for conservative treatment were given and the appointment postponed to 3 to 6 months. for the patients of this "uncertain group" the use of telemedicine and webbased tools was particularly useful to decide whether a visit was necessary, and also to follow the evolution of the problem. figure 2 all the patients booked at the outpatient clinic for the following day, for whom the need to be seen at the hospital was uncertain, were contacted by telephone. to gain more visual information of the clinical condition, after clarifying the privacy matters and obtaining consent, the patients were invited to send pictures of the lesion that should be evaluated. the patients chose the web -based tool, email or messaging apps (e.g. whatsapp, telegram, messenger), they were more familiar with. on the basis of the image, further decisions were taken. few days before the first covid-19 case diagnosed in italy) to friday, april 3 2020, for a total of 7 weeks. the "pre-covid-19" period used as a control went from monday, february 18 to friday, april 5 2019, for the same number of weeks. consulting the hospital database, we collected the number of all surgical procedures performed by plastic surgeons on patients admitted to the university hospital or in the satellite hospitals during the two periods. also, we collected the number of patients accessing the plastic surgery outpatient clinic and the reason for access. data analysis and data manipulation have been developed using python's library pandas while all the images have been produced using matplotlib library. in the entire "covid-19" period (7 weeks 2020) 98 surgical procedures were performed (78 at the university hospital, 20 at the satellite hospitals). the activity had a gradual reduction in the first 5 weeks and reached a nadir at week 5, after closure of the elective activity (friday, march 13, week 4). in the "pre-covid-19" 7 weeks period (2019) 152 surgical procedures were performed (109 at the university hospital, 43 at the satellite hospitals). as expected, the reduction of surgical activities was evident when comparing the two 4 weeks periods. in the "covid-19" period (7 weeks 2020), patients accessed 908 times the plastic surgery outpatient clinic compared to 1678 times on the "pre-covid-19" period. in the "covid-19" period (7 weeks 2020), 108 surgical procedures were performed at the plastic surgery outpatient minor surgeries under local anaesthetic compared to 200 procedures on the "pre-covid-19" period. the decisional flow chart that we applied for the screening of outpatients and follow-up of operated patients is shown in detail in figure 1. as expected, a significant reduction of the total number of surgical procedures was seen in the "covid-19" period compared to the usual activity. the reasons for surgery also changed significantly. as required by the reorganisation of the hospital activity, only patients with a diagnosis of malignancy were operated on during the covid-19 period. no urgent surgery for infection, haematomas, necrosis, delayed wound healing or other complications was performed in the study period. if, on one hand, this might be justified by the reduced number of technically demanding procedures, such as elective free flaps, or extensive surgeries like abdominoplasty or breast reduction, this may also be due to a general reduction in access to the emergency room. overall, the non-covid-19 use of the emergency room was greatly reduced, both because of the limitations in movement imposed to the population (with consequent less accidents and crime) and by the fear of getting infected inside the hospital's premises. in fact, the cardiology association has issued a warning on the increased numbers of heart-related deaths because of the reluctance of the patients to go to the hospital 7, 8, 9, 10 . the consequences of canceling elective surgery are difficult to foresee. as stated in a recent editorial 11 , many elective non-urgent surgeries will become urgent at some point in time, and therefore we will probably face a consistent back-log of procedures that we'll need to perform when the covid-19 epidemic will end (nobody still knows when) 12 . the delayed surgeries that we'll certainly need to perform in the future are the squamous and basal cell carcinomas that, at the moment, are only treated when severe and progressive. it is possible that these skin cancers will grow in the next months, requiring a more complex surgical approach 4 . how will the hospital organization change after covid-19? as many opinion makers say, this epidemic will force all of us to reconsider, and possibly change, many aspects of our living style. this is true also for the health system. as an example, the consistent reduction in number of patients accessing the outpatient clinic demonstrates that a considerable amount of work could benefit from reorganization. the follow-up visits after minor surgeries performed under local anaesthesia could be avoided by using only subcutaneous reabsorbable sutures and providing adequate training for stitch removal and dressing to the personnel already working in the territorial ambulatory services. another example concerns the pathology reports that, before covid-19, were given to the patient in the outpatient clinic, in order to explain the diagnosis and the plan for subsequent surgical or medical interventions. during the epidemic, all the patients who had undergone a biopsy were contacted by telephone, the report was explained, sent by email and only a subset of the patients were invited to return to the hospital. in what may be the first pandemic of the social-media age, plastic surgeons are trying to manage patients remotely, in real time, by using online services. telemedicine has been in use for a long time in some countries including, among others, the united kingdom, scandinavia, north america, bolivia, brazil, and australia, especially where big distances and a low population density made it necessary 13, 14, 15 . with the evolution of modern technology and of the internet web applications, the interest for telemedicine has expanded to more countries and medical specialities, including plastic surgery 16 . due to the "visual nature" of their field, plastic surgeons have pioneered the professional use of social networks. often, the commercial nature of cosmetic surgery has played a role in the use of the internet 17, 18, 19, 20, 21 . however the use of internet tools for monitoring reconstructive surgery patients has been largely described 22, 23, 24 .instant sharing of images or video calls allow plastic surgeons to make an easy consultation, filtering only clinical cases that really need to be evaluated in person for an adequate treatment. copyrighted material is shared through personal messages according to each own social media copyright policy 30, 31, 32, 33 . to avoid legal action for malpractice in telemedicine, it is mandatory for the surgeons to establish appropriate boundaries in online communication with patients, keeping highest ethical and deontological standards in physicianpatient relationship 28, 29, 34 . the importance of these legal and privacy limitations was recognized the destructive effect of covid 19 in our lives has changed also the working way of hospitals. in our department of plastic surgery, in the second most affected region in italy, the number of patients admitted to hospital for elective procedures greatly decreased, surgery being limited to malignancies. in the outpatient department, where also the number of patients have been reduced to 26% of the previous load, a great help to surgeons was given by the internet. in fact it was possible for the surgeons to make an approximate diagnosis on the basis of the images provided by the patients and for the patients to feel connected with the surgeons, despite the lockdown. these web based tools, allow patients to communicate with their treating surgeons, not only to discuss medical problems but also to express psychological frailties due to the delaying of treatment. the internet resources, however, cannot completely replace the direct diagnostic opinion nor the human relationship. the authors declare no potential conflicts of interest with respect to the research, authorship, and publication of this article. the authors received no financial support for the research, authorship, and publication of this article. neurosurgery during the covid-19 pandemic: update from lombardy, northern italy italian ministry of health. www.salute.gov.it cms, part of the department of health and human services (hhs) recommendations-adult-elective-surgeries-non-essential-medicalsurgical-and-dental italian society of plastic reconstructive and aesthetic surgery italian health magazine italian society of interventional cardiology (gise) position paper for cath lab-specific preparedness recommendations for healthcare providers in case of suspected, probable or confirmed cases of covid-19 covid-19 protocol how to risk-stratify elective surgery during the covid-19 pandemic? what it really means to cancel elective surgeries. the atlantic telemedicine: opportunities and developments in member states: report on the second global survey on ehealth 2009. who global observatory for ehealth adoption of routine telemedicine in norwegian hospitals: progress over 5 years telemedicine versus face to face patient care: effects on professional practice and health care outcomes telemedicine for acute plastic surgical trauma and burns social media in plastic surgery practices: emerging trends in north america italian society of plastic reconstructive and aesthetic surgery italian society of plastic reconstructive and aesthetic surgery a picture speaks a thousand words: the use of digital photography and the internet as a cost-effective tool in monitoring free flaps remote real-time monitoring of free flaps via smartphonephotography and 3g wireless internet: a prospective study evidencing diagnostic accuracy an evolution of communication in postoperative free flap monitoring: using a smartphone and mobile messenger application take two and text me in the morning: optimizing clinical time with a short messaging system plastic surgery faces the web: analysis of the popular social media for plasticsurgeons a cross-sectional study of the presence of united kingdom (uk) plastic surgeons on social media a primer on social media use by young plastic surgeons electronic communication in plastic surgery: guiding principles from the american society of plastic surgeons health policy committee telemedicine and plastic surgery: a review of its applications, limitations and legal pitfalls the marriage of plastic surgery and social media: a relationship to last a lifetime the plastic and reconstructive surgery facebook page: newfound treasure social networks uncovered: 10 tips every plastic surgeon should know facebook: statement of rights and responsibilities department of health and human services department of health and human services, usa. bulletin: hipaa privacy and novel coronavirus telemedicine in the time of coronavirus figure 1. the flowchart explains wich patients can be managed by telemedicine: patients already booked in outpatients clinic; patients needing follow up for previous surgeries (either complicated or complex to manage at home); patients looking for a surgeon the plastic surgery outpatient clinic activity during the overall "covid-19" period (7 weeks 2020) and during the corresponding period of 2019 are shown stop of elective surgery figure 6. comparison of the reasons for access to the outpatient clinic during the 4 last weeks 2020 the chart shows the outpatient minor surgery (local anaesthetic) activity during the overall "covid-19" period (7 weeks 2020) and during the corresponding period of stop of elective surgery figure 8. comparison of the diagnosis for minor surgery in the 4 last weeks 2020, after stop of elective activity table 1. the numbers of outpatient clinic access , outpatient minor surgery key: cord-034185-e0am7pa6 authors: piccioni, federico; droghetti, andrea; bertani, alessandro; coccia, cecilia; corcione, antonio; corsico, angelo guido; crisci, roberto; curcio, carlo; del naja, carlo; feltracco, paolo; fontana, diego; gonfiotti, alessandro; lopez, camillo; massullo, domenico; nosotti, mario; ragazzi, riccardo; rispoli, marco; romagnoli, stefano; scala, raffaele; scudeller, luigia; taurchini, marco; tognella, silvia; umari, marzia; valenza, franco; petrini, flavia title: recommendations from the italian intersociety consensus on perioperative anesthesa care in thoracic surgery (pacts) part 2: intraoperative and postoperative care date: 2020-10-23 journal: perioper med (lond) doi: 10.1186/s13741-020-00159-z sha: doc_id: 34185 cord_uid: e0am7pa6 introduction: anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. there remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. methods: a multidisciplinary expert group, the perioperative anesthesia in thoracic surgery (pacts) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. the project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. a series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. the quality of evidence and strength of recommendations were graded using the united states preventive services task force criteria. results: recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (icu) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. conclusions: these recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. further refinement of the recommendations can be anticipated as the literature continues to evolve. thoracic surgery requires an evidence-based multidisciplinary approach that extends across the perioperative period, from preadmission evaluation to postoperative care and discharge. although such perioperative care protocols, known as the enhanced recovery after surgery (eras ® ) "philosophy," have been developed in many surgical settings, including lung surgery (batchelor et al. 2019) , and have been shown to be effective in reducing postoperative complications and length of hospital stay (los) (nicholson et al. 2014) , systematic reviews of studies in thoracic surgery (cerfolio et al. 2001a; das-neves-pereira et al. 2009; muehling et al. 2008; salati et al. 2012 ) have highlighted significant heterogeneity and methodological flaws in many trials (fiore jr et al. 2016; li et al. 2017 ). to address this, an italian expert group, the perioperative anesthesia care in thoracic surgery (pacts) group, was convened to develop evidence-based recommendations for the management of thoracic surgery patients. the pacts group is a joint task force of the italian society of anesthesia, analgesia, resuscitation, and intensive care the methods used to develop the pacts recommendations have been described in full in an accompanying paper. in brief, the project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic), and postoperative procedures and discharge in adult patients undergoing elective lung resection for lung cancer. a series of clinical questions were framed using the pico (patients, intervention, comparison, outcome) approach, and a delphi consensus method was used to reach agreement based on comprehensive literature searches. the quality of evidence and strength of recommendations were graded according to the united states preventive services task force (uspstf) criteria (united states preventive services task force 2019); in addition, the panel classified as "best practice" the recommendations considered to have a high level of certainty despite a lack of direct evidence. for uspstf grade a, b, or c recommendations, consensus required > 70% a/b/c ratings with < 15% d/i ratings. for grade d or i recommendations, consensus required > 70% d/i ratings and < 15% a/b/c ratings. the uspstf system was used in preference to the grade system, which has been used in the eras lung surgery guidelines (batchelor et al. 2019) , because the intention was to produce a position statement rather than full practice guidelines. the grade system involves full appraisal of a limited number of pico questions, and is therefore timeand resource-consuming. it is not always feasible where a number of recommendations are required in fields where no large evidence base exists, or which cannot easily be addressed using a pico framework. each author approved the final version prior to submission. this paper summarizes the final recommendations for intraoperative and postoperative care (table 1) , and the supporting evidence for each recommendation. the recommendations for preadmission and preoperative care are presented in the accompanying paper. airway management recommendation 1: the use of videolaryngoscopy for tracheal intubation with a double-lumen tube might improve visualization of the glottis and the success rate at the first attempt, reducing difficulty and positioning time. videolaryngoscopy can be used in cases of unexpected difficult intubation. level of evidence: poor the use of videolaryngoscopy for tracheal intubation with a double-lumen tube might improve visualization of the glottis and the success rate at the first attempt, reducing difficulty and positioning time. videolaryngoscopy can be used in cases of unexpected difficult intubation. poor c we recommend the use of a double-lumen tube to manage one-lung ventilation. a single lumen tube with a bronchial blocker, rather than a double-lumen tube, is recommended for patients with difficult airways. good a we recommend the use of a flexible bronchoscope to control the position of the lung isolation device. flexible bronchoscopy must always be available, even if not used routinely. thoracic anesthesiologists must have adequate bronchoscopy skills to manage dlt and bronchial blockers for one-lung ventilation. good a we recommend monitoring arterial blood pressure with invasive (intra-arterial) techniques, rather than the non-invasive oscillometric cuff technique, in patients undergoing major thoracic surgery, or when sudden changes in hemodynamics, hemoglobin and blood gas concentrations (oxygen and carbon dioxide) are expected. we suggest considering the use of a central venous catheter on a case-by-case basis in patients undergoing thoracic surgery. peripheral catheters are safe for short-term and low-dose treatment with inotropic vasoactive drugs. in patients undergoing thoracic surgery who are considered at higher risk of postoperative complications, we suggest the use of hemodynamic monitoring with cardiac output estimation systems. we do not recommend the use of dynamic preload indices during open-chest thoracic surgery, because these parameters might not be reliable. we suggest that patients undergoing thoracic surgery under general anesthesia are monitored with processed electroencephalography (peeg) in order to titrate anesthetic administration. we recommend that intraoperative temperature be monitored using an appropriate system in all patients undergoing thoracic surgery lasting more than 30 minutes. a core temperature of at least 36°c should be maintained. we recommend monitoring neuromuscular blockade in all patients receiving neuromuscular blocking agents during general anesthesia for thoracic surgery. in low risk patients (simple procedures, younger patients and without cardiac or renal comorbidities), the use of a bladder catheter is not recommended. we recommend using balanced crystalloid solutions, rather than normal saline (nacl 0.9%), as standard fluid of choice. we do not recommend the use of hydroxyethyl starch as routine fluid therapy in patients undergoing thoracic surgery. we recommend a near-zero, rather than restricted or permissive, fluid balance to patients undergoing thoracic surgery. in high-risk patients a goal-directed approach to fluid therapy should be applied. we suggest using serum hemoglobin concentration in the evaluation of volume status in nonbleeding patients undergoing thoracic surgery. we recommend a protective ventilation approach during one-lung ventilation, based on the combination of low tidal volumes (≤ 6 ml/kg ideal body weight) with alveolar recruitment maneuvers, adequately titrated positive end-expiratory pressure (peep) and the lowest fraction of inspired oxygen (fio2) to maintain satisfactory arterial oxygen saturation. fair a volatile anesthesia cannot be recommended over intravenous propofol administration in order to reduce postoperative complications, although there is evidence of a lower degree of both systemic and local inflammation when volatile anesthetics are used. we recommend the early removal of urinary catheters to promote mobilization in patients undergoing lung surgery, including those receiving thoracic epidural catheters. fair a we recommend the use of pre-emptive locoregional analgesia as part of a multimodal analgesic approach for thoracic surgery. systemic opioids, nonsteroidal anti-inflammatory drugs, and paracetamol have shown no evidence of benefit when used as pre-emptive analgesics. currently, there are no elements to suggest the routine perioperative use of gabapentinoids in patients undergoing thoracic surgery, but their use can be effective in a comprehensive multimodal analgesia protocol. we suggest intraoperative intravenous administration of ketamine to reduce postoperative pain after thoracic surgery. there is no evidence about the best dose and timing of administration of ketamine. we suggest intraoperative intravenous administration of magnesium sulfate to reduce postoperative pain after thoracic surgery. there is no evidence to suggest the routine use of α 2 -agonists as part of a multimodal analgesia regimen to reduce postoperative pain after thoracic surgery. there is no consensus on the best timing and schedule for administration of these drugs. we suggest considering the use of intravenous steroids as part of a multimodal approach to reduce peripheral sensibilization of inflammatory-induced pain in patients undergoing thoracic surgery. adverse effects of single doses of steroids are of trivial clinical impact. we recommend the use of intravenous nonsteroidal anti-inflammatory drugs (nsaids) to reduce peripheral sensitization to inflammation-induced pain in patients undergoing thoracic surgery. combined use of nsaids and paracetamol may give a further analgesic advantage. we recommend the use of locoregional anesthesia for intraoperative and postoperative pain management. poor a we recommend the use of thoracic epidural analgesia in high-risk patients or in major surgical procedures where the parietal pleura (eg chest wall resection) is violated (i.e. thoracotomy, thoracosternotomy, chest wall resection). we recommend thoracic paravertebral block for vats, as part of a multimodal approach. good a we recommend paravertebral block in preference to thoracic epidural analgesia in patients with known or suspected coagulopathy. we suggest that intercostal nerve blockade should be considered only as a second choice for analgesia after thoracic surgical procedures. we suggest erector spinae plane block as part of a multimodal analgesia for thoracic surgery, especially for vats. we suggest the use of fascial pain blocks as part of multimodal analgesia for thoracic surgery, particularly for vats. we suggest considering the use of adjuvants (i.e. opioids, clonidine, dexmedetomidine b , dexamethasone, magnesium) when loco-regional anesthesia is performed, because the use of adjuvants can potentiate and prolong the effect of local anesthetics. we suggest considering the use of a single large-bore chest tube instead of a double tube after thoracic surgery. insertion of more than one chest tube may be considered in selected cases (e.g., bi-lobectomy or bleeding patients). we suggest considering the use of digital chest drainage systems to promote early mobilization of the patient. the routine use of drainage with suction is not recommended in the absence of complications, provided there is full re-expansion of the residual parenchyma after lung resection. we suggest removing chest tubes in lung resection patients when liquid output is ≤ 5 cm 3 /kg/ 24 h of serous fluid. we do not recommend systematic icu admission after thoracic surgery. poor d we recommend that, in adult patients undergoing thoracic surgery, oral intake, including clear liquids, can be initiated 4-6 hours after surgery, in the absence of nausea and vomiting. oral intake should, however, be adapted to individual tolerance. we recommend early mobilization of patients within the first 24 h after both minor and major fair a strength of recommendation: c several studies have compared videolaryngoscopy with the macintosh blade laryngoscope for tracheal intubation, in order to determine whether videolaryngoscopy improves the speed and success of double-lumen tube (dlt) positioning and reduces malpositioning rates (el-tahan et al. 2018; hamp et al. 2015; lin et al. 2012; purugganan et al. 2012; russell et al. 2013; wasem et al. 2013 ). these studies have yielded conflicting results: while some authors have reported that videolaryngoscopy is superior to the macintosh laryngoscope blade in terms of ease of use and higher rates of correct positioning of the dlt (lin et al. 2012; purugganan et al. 2012) , others have found no significant differences between the two techniques in terms of time to intubation and hemodynamic stress response (hamp et al. 2015; russell et al. 2013; wasem et al. 2013 ). there are limited data to suggest that videolaryngoscopy may improve visualization of the glottis, resulting in higher success rates at the first attempt, and reduced difficulty and positioning time (lin et al. 2012; purugganan et al. 2012 ). however, the success rate is highly dependent on the operator's experience (el-tahan et al. 2018) . recommendation 2: we recommend the use of a double-lumen tube to manage one-lung ventilation. a single lumen tube with a bronchial blocker, rather than a double-lumen tube, is recommended for patients with difficult airways. level of evidence: good strength of recommendation: a lung isolation techniques are designed to facilitate surgical exposure of the lung and achieve one-lung ventilation in patients undergoing thoracic surgery (campos and kernstine 2003; narayanaswamy et al. 2009 ). these techniques use either a dlt with both an endotracheal and an endobronchial lumen, or a bronchial blocker inside a single-lumen endotracheal tube, which allows collapse of the lung distal to the site of occlusion. dlts offer a number of advantages over bronchial blockers, including faster and easier positioning (campos and kernstine 2003; narayanaswamy et al. 2009; clayton-smith et al. 2015; dumans-nizard et al. 2009; ruetzler et al. 2011) , and a lower likelihood of displacement requiring repositioning under bronchoscopy (campos and kernstine 2003; narayanaswamy et al. 2009 ). in addition, pulmonary collapse can be achieved more quickly with dlts, because bronchial blockers do not allow adequate suction to cause lung collapse (campos 2002; yoo et al. 2014) . dlts also ensure pulmonary isolation, protecting the contralateral lung from blood or infections (santana-cabrera et al. 2010) , although the incidence of trauma during intubation is comparable with the two types of device (clayton-smith et al. 2015; knoll et al. 2006) . for these reasons, siaarti guidelines recommend dlts for routine clinical use (merli et al. 2009 ). the decision to use a bronchial blocker, rather than a dlt, in an individual patient should be based on the specific clinical circumstances (merli et al. 2009; campos 2007) . recommendation 3: we recommend the use of a flexible bronchoscope to control the position of the lung isolation device. flexible bronchoscopy must always be available, even if not used routinely. thoracic anesthesiologists must have adequate bronchoscopy skills to manage dlt and bronchial blockers for one-lung ventilation. level of evidence: good strength of recommendation: a the use of a flexible bronchoscope to confirm the correct placement of dlts for lung resection is we recommend a physiotherapy program after thoracic surgery. fair a we suggest considering daily chest radiographs only in selected cases under specific clinical indications. we do not recommend the routine use of either continuous positive airway pressure (cpap) or non invasive ventilation (niv) to prevent postoperative pulmonary complications, prolonged length of stay, and mortality (both in icu and in hospital) in patients undergoing major thoracic surgery. cpap or niv could be considered case by case in selected high risk patients. we suggest the use of niv or cpap to treat acute respiratory failure complicating thoracic surgery. poor b we suggest considering the use of high-flow nasal cannula oxygen therapy (hfnc) as an alternative or integrative support to cpap or niv to prevent or treat acute respiratory failure complicating thoracic surgery. dexmedetomidine is currently approved in italy only for sedation, and thus cannot be recommended for analgesic use in italian settings recommended. studies have shown that flexible bronchoscopy after auscultatory or tactile confirmation of the location of the dlt can identify malpositioning in more than one-third of patients (klein et al. 1998; de bellis et al. 2011) , and hence some authors have recommended that the position of the dlt should routinely be confirmed by fiberoptic bronchoscopy (klein et al. 1998; cohen 2004) . however, this requires technical expertise in flexible bronchoscopy, and a detailed knowledge of tracheobronchial anatomy (cohen 2004; campos 2009; solidoro et al. 2019) . it remains unclear whether routine bronchoscopic confirmation of the position of the dlt is necessary. malpositioning of the dlt is a major cause of intraoperative hypoxemia: in one case series, 21 of 56 patients in whom the dlt was positioned too deeply in the left bronchus developed hypoxemia during one-lung ventilation of the left lung (brodsky and lemmens 2003) . for this reason, the position of the dlt must be rechecked by flexible bronchoscopy after the onset of intraoperative hypoxemia, with the patient in the lateral decubitus position (brodsky and lemmens 2003; inoue et al. 2004) . obstruction of the left or right upper lobe bronchus is the most common significant malposition with dlts (slinger 1989 ), but there is no consensus as to the optimal position of the dlt. many malpositions may be attributable to an inappropriate choice of dlt or suboptimal positioning technique (slinger 1989; fortier et al. 2001; seymour and lynch 2002) . to date, no data have demonstrated the clinical relevance of malpositioning to patient outcomes, except in cases of dangerous or critical malposition, and there is no evidence that routine confirmation of dlt positioning by flexible bronchoscopy reduces morbidity after thoracic surgery. when a left dlt is inserted, the use of tubes with integrated high-resolution cameras can facilitate correct positioning and easier one-lung ventilation (massot 2015; schuepbach et al. 2015) . in one study, the mean time to successful intubation was significantly shorter with the vivasight-dl (etview medical ltd, misgav, israel) than with conventional dlts (63 s versus 97 s, respectively, p = 0.03), and all vivasight-dl tubes were correctly positioned (schuepbach et al. 2015) . furthermore, compared with blind placement, the use of tubes with integrated high-resolution cameras can shorten the intubation time and permits continued monitoring of the carina, thereby allowing prompt management of intraoperative tube displacement (massot 2015; schuepbach et al. 2015; belze et al. 2017; chen et al. 2017; heir et al. 2014) . recommendation 4: we recommend monitoring arterial blood pressure with invasive (intra-arterial) techniques, rather than the non-invasive oscillometric cuff technique, in patients undergoing major thoracic surgery, or when sudden changes in hemodynamics, hemoglobin and blood gas concentrations (oxygen and carbon dioxide) are expected. level of evidence: good strength of recommendation: a limited data suggest good concordance between invasive and non-invasive arterial pressure measurements in patients undergoing major thoracic surgery (bardoczky et al. 1992; d'antini et al. 2016; martina et al. 2012) , but further studies are needed in this area. due to the possibility of rapid changes in stroke volume and arterial blood pressure, and the potential usefulness of arterial blood sampling for gas, hemoglobin, and electrolyte analysis, invasive (intra-arterial) monitoring of arterial blood pressure is recommended in patients undergoing major thoracic surgery. in general, the risk of significant blood loss is very low in patients with no history of radiotherapy or chemotherapy who are undergoing primary lung surgery. for patients undergoing minor resections, the use of invasive blood pressure monitoring should be considered on a case-by-case basis according to the patient's comorbidity and surgical complexity. although specific studies on thoracic surgery patients are lacking, studies in mixed surgical populations have demonstrated that even short periods of hypotension significantly increase postoperative complications such as acute kidney injury (aki), myocardial injury after non-cardiac surgery (mins), and death (van waes et al. 2016; walsh et al. 2013; sessler et al. 2019) . in a review of data from 33,330 patients undergoing non-cardiac surgery, the relative risks of both aki and mins increased progressively with increasing duration of hypotension (mean arterial pressure < 55 mmhg), compared with patients with mean arterial pressure above this threshold, even when the duration of hypotension was only 1-5 min (walsh et al. 2013) . a mean arterial pressure threshold of 65 mmhg, or 60-70 mmhg with a systolic arterial pressure of 100 mmhg, has been identified as critical to reduce the occurrence of aki, mins and mortality (sessler et al. 2019; salmasi et al. 2017) . recommendation 5: we suggest considering the use of a central venous catheter on a case-by-case basis in patients undergoing thoracic surgery. peripheral catheters are safe for short-term and low-dose treatment with inotropic vasoactive drugs. level of evidence: fair strength of recommendation: c there is no evidence that central venous catheters are essential for the intraoperative and postoperative management of thoracic surgery patients. measurement of central venous pressure to predict the response to volume expansion may be inconclusive in a significant proportion of patients (cannesson et al. 2011 ). furthermore, several studies have shown that low doses of vasoactive medications can be safely administered via peripheral intravenous catheters, with extravasation rates of approximately 2-4% (cardenas-garcia et al. 2015; lewis et al. 2019; medlej et al. 2018) . for these reasons, the routine use of central venous catheters is not recommended in patients undergoing thoracic surgery: the need for central venous catheterization should be evaluated on a case-by-case basis. recommendation 6: in patients undergoing thoracic surgery who are considered at higher risk of postoperative complications, we suggest the use of hemodynamic monitoring with cardiac output estimation systems. level of evidence: poor strength of recommendation: c there is evidence that hemodynamic monitoring using cardiac output estimation systems to inform goal-directed fluid management is beneficial in thoracic surgery patients at higher risk of postoperative complications (cecconi et al. 2013; kaufmann et al. 2017; michard et al. 2017; searl and perrino 2012; zhang et al. 2013) . furthermore, such monitoring can be useful to avoid hypoxemia during one-lung ventilation, because extreme increases or decreases in cardiac output can impair the hypoxic pulmonary vasoconstriction (lumb and slinger 2015) . the use of this approach should be based on the estimated risk of complications in the individual patient. recommendation 7: we do not recommend the use of dynamic preload indices during open-chest thoracic surgery, because these parameters might not be reliable. level of evidence: good strength of recommendation: d a recent meta-analysis of seven trials has found that pulse pressure and stroke volume are inaccurate predictors of fluid responsiveness in patients undergoing open thoracotomy (piccioni et al. 2017) , and a subsequent study has shown that this is also true in patients undergoing vats procedures (jeong et al. 2017) . recommendation 8: we suggest that patients undergoing thoracic surgery under general anesthesia are monitored with processed electroencephalography (peeg) in order to titrate anesthetic administration. level of evidence: fair strength of recommendation: b processed electroencephalography (peeg) based on bispectral index (bis) reduces recovery times (punjasawadwong et al. 2014; chiang et al. 2018 ). however, the impact of peeg on the risk of intraoperative awareness is unclear (punjasawadwong et al. 2014) . postoperative delirium occurs in approximately 14% of patients (berian et al. 2018) , and it is believed that monitoring the depth of anesthesia by peeg is associated with reductions in the incidence of postoperative delirium and cognitive dysfunction (pocd) (aldecoa et al. 2017; fritz et al. 2016) . a recent meta-analysis of six randomized controlled trials showed moderate-quality evidence that peeg-guided anesthesia could reduce the risk of postoperative delirium and pocd (punjasawadwong et al. 2018) . conversely, the engages study, a rct of 1232 patients undergoing major surgery under volatile general anesthesia, did not find any decrease in the incidence of postoperative delirium among patients managed with peeg, compared with usual care (wildes et al. 2019 ). peeg has been included in guidelines for the prevention of postoperative delirium from a number of organizations (aldecoa et al. 2017; j am coll surg 2015; gelb et al. 2018) . advanced peeg technology is considered useful to improve anesthesia monitoring, individual titration of anesthetics and optimized patient care (eagleman and drover 2018; fahy and chau 2018; montupil et al. 2019) . recommendation 9: we recommend that intraoperative temperature be monitored using an appropriate system in all patients undergoing thoracic surgery lasting more than 30 min. a core temperature of at least 36°c should be maintained. level of evidence: good strength of recommendation: a hypothermia occurs in approximately 35-50% of thoracic surgery patients because the pleural surface on one side of the thorax is exposed to dry air during surgery, leading to evaporative heat loss (batchelor et al. 2019) . avoidance of hyperthermia is essential to prevent deleterious effects on homeostasis and reduce the risk of a systemic inflammatory response. hence, the eras guidelines for thoracic surgery recommend that body temperature should be continuously monitored to guide therapy, and that active warming should be continued postoperatively until the patient's temperature is greater than 36°c (batchelor et al. 2019) . siaarti guidelines recommend that intraoperative temperature should be monitored in all patients undergoing thoracic surgery lasting more than 30 min, and that the aim should be to maintain a core temperature of at least 36°c (di marco and cannetti 2019). suitable monitoring systems include heated servo-controlled sensors, intra-vascular catheters with thermistor tips, or rectal or bladder probes, but esophageal probes may be less accurate (di marco and cannetti 2019). a number of studies in various surgical settings have found that zero-heat-flux systems can be used for non-invasive temperature measurement, and show good agreement with conventional core temperature measurements (eshraghi et al. 2014; iden et al. 2015; makinen et al. 2016) . recommendation 10: we recommend monitoring neuromuscular blockade in all patients receiving neuromuscular blocking agents during general anesthesia for thoracic surgery. level of evidence: good strength of recommendation: a neuromuscular blockade should be monitored in all patients receiving neuromuscular blocking agents (nmbas) during general anesthesia for thoracic surgery (ortega et al. 2018) . quantitative (objective) neuromuscular monitoring is more reliable than subjective and clinical tests to assess the neuromuscular block level and, more importantly, recovery before extubation (naguib et al. 2018 ). neuromuscular monitoring is essential for correct administration of both nmbas and reversal agents. recommendation 11: in low-risk patients (simple procedures, younger patients and without cardiac or renal comorbidities), the use of a bladder catheter is not recommended. level of evidence: fair strength of recommendation: d there is no evidence that urine output should be monitored in all patients undergoing thoracic surgery. recommendation 12: we recommend using balanced crystalloid solutions, rather than normal saline (nacl 0.9%), as standard fluid of choice. level of evidence: good strength of recommendation: a balanced crystalloid solutions differ from normal saline (nacl 0.9%) in that they contain anions other than chloride, such as lactate, acetate, malate, and gluconate, which act as physiological buffers (reddy et al. 2016; vincent and de backer 2016) . although specific studies in thoracic surgery patients are lacking, the available evidence suggests that normal saline is associated with risks of hyperchloremia, hyperchloremic acidosis and aki (reddy et al. 2016; zampieri et al. 2016) . for example, in a study in noncritically ill patients, the 30-day incidence of major renal adverse events in patients receiving balanced crystalloids or saline was 4.7% and 5.6%, respectively (odds ratio [or] 0.82, 95% confidence interval [ci] 0.70-0.95, p = 0.01), although there was no difference in the number of hospital-free days between the two treatments (self et al. 2018) . in general, most authors recommend that balanced crystalloids should be used in preference to normal saline (reddy et al. 2016; vincent and de backer 2016) . administration of normal saline is indicated only in specific circumstances, such as metabolic alkalosis, hyponatremia, or severe brain injury requiring normotonic fluid administration (vincent and de backer 2016) . recommendation 13: we do not recommend the use of hydroxyethyl starch as routine fluid therapy in patients undergoing thoracic surgery. level of evidence: good strength of recommendation: d patients undergoing lung resection surgery are at risk of postoperative respiratory failure, which could be related to the volume of fluid administered during surgery. hydroxyethyl starches could be administered in order to reduce the total amount of fluid given during surgery, but are associated with an increased risk of renal impairment (ahn et al. 2016 ). hence, the use of hydroxyethyl starch as routine fluid therapy should be avoided in patients undergoing thoracic surgery, although it could be considered in patients with severe hemorrhage who are not responding to crystalloid infusion (de hert and de baerdemaeker 2014). recommendation 14: we recommend a near-zero, rather than restricted or permissive, fluid balance to patients undergoing thoracic surgery. in high-risk patients, a goal-directed approach to fluid therapy should be applied. level of evidence: fair strength of recommendation: a there is evidence that a near-zero, rather than restricted or permissive, fluid balance is beneficial for patients undergoing thoracic surgery (searl and perrino 2012) , and hence this approach is recommended in normovolemic patients (chappell et al. 2008; licker et al. 2016 ). in highrisk patients, a goal-directed approach to fluid therapy is recommended because this has been shown to significantly reduce mortality and morbidity, compared with standard hemodynamic fluid management (cecconi et al. 2013; kaufmann et al. 2017; michard et al. 2017; zhang et al. 2013) . for example, a recent meta-analysis of 19 trials involving over 2000 patients found that goal-directed therapy was associated with a significant decrease in postoperative morbidity, compared with controls (or 0.46, 95% ci 0.30-0.70, p < 0.001) (michard et al. 2017 ). similarly, a meta-analysis of 32 trials involving approximately 2800 patients found a significant reduction in postoperative mortality with goal-directed therapy, compared with controls, in patients at highest risk of postoperative complications (or 0.20, 95% ci 0.09-0.41, p < 0.0001); there was also a significant reduction in complication rates (or 0.45, 95% ci 0.34-0.60, p < 0.00001), which was particularly marked in the highest risk subgroup (or 0.27, 95% ci 0.15-0.51, p < 0.0001) (cecconi et al. 2013) . recommendation 15: we suggest using serum hemoglobin concentration in the evaluation of volume status in nonbleeding patients undergoing thoracic surgery. level of evidence: poor strength of recommendation: c because hemoglobin concentrations reflect plasma volume changes in patients without significant bleeding, monitoring of hemoglobin levels may play a role in the evaluation of volume status in patients undergoing thoracic surgery (perel 2017; otto et al. 2017) . recommendation 16: we recommend a protective ventilation approach during one-lung ventilation, based on the combination of low tidal volumes (≤ 6 ml/kg ideal body weight) with alveolar recruitment maneuvers, adequately titrated positive end-expiratory pressure (peep) and the lowest fraction of inspired oxygen (fio 2 ) to maintain satisfactory arterial oxygen saturation. level of evidence: fair strength of recommendation: a although there is an emerging consensus in favor of protective ventilation during one-lung ventilation (lohser and slinger 2015) , relatively few well-designed randomized trials have compared protective and conventional onelung ventilation (lohser and slinger 2015; ahn et al. 2012; kim et al. 2019; yang et al. 2011; zhu et al. 2017) : most published studies have involved small patient populations, or had other methodological limitations. in one of the largest randomized trials, 100 patients undergoing elective lobectomy were randomized to receive either protective ventilation with an inspired oxygen fraction (fio 2 ) of 0.5, a tidal volume of 6 ml/kg, a positive end-expiratory pressure (peep) of 5 cm h 2 o, and pressure-controlled ventilation, or conventional ventilation with higher fio 2 and tidal volume, zero end-expiratory pressure, and volume-controlled ventilation (yang et al. 2011) . the incidence of pulmonary dysfunction (defined as pao 2 /fio 2 < 300 mmhg, lung infiltration or atelectasis) was significantly lower in patients receiving protective ventilation than in those receiving conventional ventilation (4% versus 22% respectively, p < 0.05). a further randomized trial, involving 65 patients undergoing vats lobectomy, found no significant difference in postoperative complication rates between patients receiving either volume-controlled or pressure-controlled protective ventilation (zhu et al. 2017) . by contrast, a randomized study in 50 patients found that protective ventilation did not offer any significant advantage, compared with conventional ventilation, in terms of postoperative pulmonary dysfunction (pao 2 / fio 2 < 300 mmhg or radiographic abnormalities) in patients undergoing vats (ahn et al. 2012) . further evidence supporting the use of protective ventilation in thoracic surgery patients comes from observational studies (blank et al. 2016; okahara et al. 2018) . in a review of data from 1019 thoracic surgery patients (blank et al. 2016) , there was an inverse relationship between tidal volume and the incidence of respiratory complications (or 0.84, 95% ci 0.73-0.96); however, a low (physiologically appropriate) tidal volume had no protective effect in the absence of an adequate peep. a further study found that fio 2 during one-lung ventilation was an independent predictor of the risk of postoperative pulmonary complications: the risk of such complications increased by 30% for each 0.1 increase in fio 2 (okahara et al. 2018) . two small studies have examined the effect of protective ventilation on inflammatory responses following one-lung ventilation. a small randomized study in vats patients found that the combination of protective ventilation with a recruitment maneuver was associated with attenuated inflammatory responses, compared with either conventional ventilation or protective ventilation alone (kim et al. 2019) . by contrast, a non-randomized study in 28 patients found no significant difference in local inflammatory cytokine responses between lung resection patients receiving protective or conventional ventilation (fiorelli et al. 2018) . recommendation 17: volatile anesthesia cannot be recommended over intravenous propofol administration in order to reduce postoperative complications, although there is evidence of a lower degree of both systemic and local inflammation when volatile anesthetics are used. level of evidence: good strength of recommendation: i the clinical impact of the choice of anesthetic in thoracic surgery patients is unclear because published studies differ markedly in their design, and have yielded conflicting findings. it has been suggested that only patients with severe surgical injuries (i.e., those undergoing pneumonectomy) may benefit clinically from the anti-inflammatory effects of volatile anesthetics (beck-schimmer et al. 2016) , but further studies are needed to clarify this. several studies have compared the use of volatile halogenated anesthesia and intravenous propofol administration, most of which have found that volatile anesthetics are associated with a lower degree of alveolar-and possibly systemic-inflammatory responses (de conno et al. 2009; de la gala et al. 2017; potocnik et al. 2014; schilling et al. 2011; sun et al. 2015) . in a meta-analysis of eight randomized controlled trials in patients undergoing one-lung ventilation, volatile anesthetics were associated with significant decreases, compared with intravenous anesthetics, in alveolar concentrations of inflammatory mediators (sun et al. 2015) . other studies have shown that, compared with propofol, the volatile halogenated anesthetics desflurane and sevoflurane reduce the expression of inflammatory mediators in bronchoalveolar lavage fluid, and the inflammatory response of alveolar epithelial cells to one-lung ventilation; these effects may be attributable to protective effects on the endothelial glycocalyx (de conno et al. 2009; de la gala et al. 2017; schilling et al. 2011; duthie 2013; schilling et al. 2007) . in contrast to the consistent evidence for antiinflammatory effects of volatile anesthetics, studies of the effects of volatile or intravenous anesthetics on postoperative complications have yielded conflicting results, possibly due to differences in study designs and the definition of postoperative complications. several studies have shown lower rates of postoperative pulmonary complications with volatile anesthetics, compared with propofol, in patients receiving one-lung ventilation (de conno et al. 2009; de la gala et al. 2017; potocnik et al. 2014 ). in the meta-analysis cited above (sun et al. 2015) , the relative risk of pulmonary complications in patients receiving inhalation anesthetics, compared with those receiving intravenous anesthetics, was 0.42 (95% ci 0.23-0.77, p = 0.005), and the mean duration of hospitalization was approximately 4 days shorter. however, a recent large, multicenter, randomized trial involving 460 thoracic surgery patients found no significant difference in complication rates between patients receiving desflurane or propofol (beck-schimmer et al. 2016) . the proportion of patients with major complications was 13.0% and 16.5%, respectively, during hospitalization (hazard ratio [hr] 0.75, 95% ci 0.46-1.22; p = 0.24) and 39.6% and 40.4%, respectively, at 6 months (hr 0.95, 95% ci 0.71-1.28, p = 0.71). subgroup analyses suggested that only patients with severe surgical injuries benefit from the anti-inflammatory effects of volatile anesthetics (beck-schimmer et al. 2016) . recommendation 18: we recommend the use of a steroid neuromuscular blocking agent because of the availability of sugammadex, a reversal agent that, unlike acetylcholinesterase inhibitors, can be used even in cases of deep residual block, and reduces both extubation time and adverse events (bradycardia, postoperative nausea and vomiting, and postoperative residual paralysis). level of evidence: fair strength of recommendation: a deep neuromuscular blockade, with appropriate reversal prior to extubation, is recommended for patients undergoing thoracic surgery (umari et al. 2018; granell et al. 2018; végh et al. 2014) . complete reversal of neuromuscular blockade after surgery is important because it facilitates ventilator movements and expectoration, thereby decreasing the risk of postoperative respiratory complications (végh et al. 2014) . the use of a steroid nmba, such as rocuronium, with complete reversal, reduces the extubation time, compared with non-steroidal nmbas (carron et al. 2017; hristovska et al. 2017) . the use of a selective relaxant-binding agent such as sugammadex is more efficient and safer than neostigmine for reversing moderate or deep induced paralysis (flockton et al. 2008) . in a prospective observational study involving 3000 patients, the use of neostigmine for reversal of neuromuscular blockade did not improve oxygenation at the time of admission to the postanesthesia care unit, and was associated with a higher rate of atelectasis, compared with patients who did not receive neostigmine (8.8% versus 4.5%, or 1.67, 95% ci 1.07-2.59) (sasaki et al. 2014 ). in addition, high-dose neostigmine (> 60 μg/kg) was associated with longer stays in the post-anesthesia unit (mean 176 versus 157 min) and longer postoperative hospitalization (mean 2.9 versus 2.8 days). by contrast, a 2017 cochrane review found that patients receiving sugammadex for reversal of neuromuscular blockade had 40% fewer adverse events (risk ratio [rr] 0.60, 95% ci 0.49-0.74), including less postoperative nausea and vomiting (ponv), bradycardia, or postoperative residual paralysis, than those receiving neostigmine (hristovska et al. 2017) . furthermore, sugammadex produced faster reversal of neuromuscular blockade than neostigmine, irrespective of the depth of blockade (hristovska et al. 2017) . recommendation 19: we recommend evaluation of the risk of postoperative nausea and vomiting, and the use of appropriate prophylaxis according to the level of risk, in all patients undergoing lung surgery. level of evidence: good strength of recommendation: a there is a lack of specific data on ponv after thoracic surgery. recently, a randomized controlled trial in patients undergoing vats procedures showed a lower incidence of nausea on the day of surgery in patients receiving preoperative treatment with methylprednisolone, compared with placebo-treated patients, although there was no difference between the groups on postoperative days 1 and 2 (bjerregaard et al. 2018) . the 2014 society for ambulatory anesthesia guidelines for the management of postoperative nausea and vomiting recommend preoperative evaluation of ponv risk using validated scores, such as the simplified apfel score, and the use of appropriate prophylaxis (gan et al. 2014 ). strategies to reduce the risk of ponv suggested in these guidelines include the use of propofol rather than volatile anesthetics, and minimization of intra-and postoperative opioids. prophylaxis against ponv is also recommended in eras guidelines (batchelor et al. 2019; ljungqvist and hubner 2018) . recommendation 20: we recommend avoiding the routine placement of a nasogastric tube, and early removal in patients in whom a nasogastric tube is used. level of evidence: fair strength of recommendation: a nasogastric tubes can be used to identify the esophagus, and to reduce gastric distension and risk of aspiration. there are no specific data in the literature on the use of nasogastric tubes in patients undergoing lung surgery, but several studies have identified perioperative nasogastric tube use as a risk factor for postoperative pulmonary complications after abdominal surgery (miskovic and lumb 2017) . guidelines published by the eras society recommend avoiding routine nasogastric tube placement in patients undergoing liver and gastric surgery (melloul et al. 2016; mortensen et al. 2014) , and the removal of nasogastric tubes before anesthesia reversal following elective colonic surgery (gustafsson et al. 2013) . recommendation 21: we recommend the early removal of urinary catheters to promote mobilization in patients undergoing lung surgery, including those receiving thoracic epidural catheters. level of evidence: fair strength of recommendation: a monitoring of urine output to evaluate perioperative aki is included in all classification systems for renal dysfunction (goren and matot 2015) , but a large prospective observational study found no association between intraoperative oliguria (urine output < 0.5 ml/kg/h) and postoperative aki in patients undergoing major noncardiac surgery (kheterpal et al. 2007) . higher rates of urinary retention after early urinary catheter removal (within 24-48 h after surgery), compared with later removal, have been reported in patients who received epidural analgesia for pain management after thoracotomy (allen et al. 2016; hu et al. 2014) , but other studies have found no association between early removal and increased complication rates (chia et al. 2009; ladak et al. 2009; young et al. 2018) . a systematic review recommended early removal of the urinary catheter, on the first postoperative day, in order to promote mobilization and reduce pain and discomfort (zaouter and ouattara 2015) . early removal of urinary catheters is one of the overall eras items intended to promote mobilization and ambulation (ljungqvist and hubner 2018) . in addition, the eras guidelines for lung surgery strongly recommend not to routinely use urinary catheterization solely to monitor urine output in patients with normal kidney function, but to use a urinary catheter in patients receiving epidural analgesia (batchelor et al. 2019 ). pre-emptive analgesia recommendation 22: we recommend the use of preemptive locoregional analgesia as part of a multimodal analgesic approach for thoracic surgery. systemic opioids, nonsteroidal anti-inflammatory drugs, and paracetamol have shown no evidence of benefit when used as preemptive analgesics. level of evidence: fair strength of recommendation: a multiple studies in various surgical settings have shown that the use of pre-emptive locoregional analgesia attenuates postoperative pain scores, decreases supplemental analgesic requirements, and prolongs the average time to first use of rescue analgesia (nosotti et al. 2015; ong et al. 2005; yang et al. 2015) . as a result, preemptive locoregional analgesia is recommended as part of a multimodal analgesic strategy for thoracic surgery patients. there is currently no evidence to support the use of one form of analgesia (opioids, nonsteroidal antiinflammatory drugs [nsaids] , paracetamol, etc) over another. recommendation 23: currently, there are no elements to suggest the routine perioperative use of gabapentinoids in patients undergoing thoracic surgery, but their use can be effective in a comprehensive multimodal analgesia protocol. level of evidence: poor strength of recommendation: i studies evaluating gabapentin in thoracic surgery patients are limited, and have yielded conflicting results. a randomized, active placebo (lorazepam)-controlled, trial in a mixed surgical cohort found that perioperative gabapentin administration until the third postoperative day had no effect on the time to cessation of acute postoperative pain (hr 1.04, 95% ci 0.82-1.33, p = 0.73), but had a moderate effect on the time to opioid cessation (hr 1.24, 95% ci 1.00-1.54, p = 0.05) (hah et al. 2018) . two further studies found no benefit of gabapentin treatment, in terms of postoperative pain relief, opioid consumption, and the incidence of chronic pain 3 months after thoracotomy (grosen et al. 2014; kinney et al. 2012 ); similarly, a small randomized trial found that gabapentin had no significant effect, compared with placebo, on the incidence or severity of post-thoracotomy shoulder pain (huot et al. 2008 ). on the basis of such findings, a 2013 review concluded that there is no evidence to support the role of a single preoperative oral dose of gabapentin in reducing pain scores or opioid consumption following thoracic surgery (zakkar et al. 2013) . more recently, a randomized, placebo-controlled, trial involving 60 patients concluded that pregabalin administration before thoracotomy is effective in reducing postoperative pain, but in this study pregabalin did not form part of a multimodal analgesic strategy (sattari et al. 2018) . in contrast to the studies described above, there are data to support the use of pregabalin or gabapentin as part of a multimodal analgesic strategy to improve postoperative pain and reduce opioid consumption (mishriky et al. 2015; tiippana et al. 2007 ). in a systematic review of 55 studies in surgical patients, pregabalin was associated with significant reductions, compared with placebo, in pain scores and opioid consumption 24 h after surgery; however, it was also associated with significantly higher rates of sedation, dizziness, and visual disturbances (mishriky et al. 2015) . current guidelines for the management of postoperative pain issued by the american society of anesthesiology recommend the use of pregabalin and gabapentin as part of a postoperative multimodal analgesia regimen: this is considered a strong recommendation with a moderate level of evidence (chou et al. 2016) . recommendation 24: we suggest intraoperative intravenous administration of ketamine to reduce postoperative pain after thoracic surgery. there is no evidence about the best dose and timing of administration of ketamine. level of evidence: fair strength of recommendation: b a systematic review of 70 randomized controlled trials including 4701 patients found that the use of intravenous ketamine for postoperative pain management resulted in consistent reductions, compared with controls, in opioid consumption, and increases in the time to first use of analgesic (laskowski et al. 2011 ). the greatest benefits were seen in patients undergoing thoracic, upper abdominal or major orthopedic surgery. based on such evidence, us guidelines for the management of postoperative pain recommend evaluating the use of intravenous ketamine in multimodal analgesia regimens (chou et al. 2016 ). however, there is currently no evidence to determine the optimal dosage of perioperative ketamine. there is evidence that a single dose of ketamine may be inadequate, and therefore some authors recommend the administration of a pre-operative bolus and intraoperative maintenance dosing (mishriky et al. 2015; himmelseher and durieux 2005) . one randomized controlled trial in patients undergoing major abdominal surgery has found that a reduced infusion regimen (0.015 mg/kg/h infusion following a saline bolus) and a conventional low-dose regimen (0.25 mg/kg bolus and 0.125 mg/kg/ h infusion for 48 h) were comparable in analgesic efficacy, in terms of postoperative opioid consumption and rates of hyperalgesia (bornemann-cimenti et al. 2016). other authors have suggested that ketamine can be administered in a series of boluses depending on the duration of the procedure (bell et al., 2006) . ketamine should be used with caution in elderly patients. recommendation 25: we suggest intraoperative intravenous administration of magnesium sulfate to reduce postoperative pain after thoracic surgery. level of evidence: fair strength of recommendation: b magnesium blocks n-methyl-d-aspartate (nmda) receptors, which mediate central sensitization to pain and thus contribute to postoperative pain and hyperalgesia (ko et al. 2001; wilder-smith et al. 1997) . hence, many trials have investigated the use of intravenous magnesium to reduce postoperative pain (albrecht et al. 2013 ). in a meta-analysis of 20 randomized trials including over 1200 surgical patients, magnesium treatment was associated with significant improvements, compared with controls, in pain at rest and on movement, and with reductions in postoperative opioid consumption (de oliveira jr et al. 2013) . a further meta-analysis of 25 trials found that perioperative magnesium administration reduced opioid consumption, and to a lesser extent pain scores, during the first 24 h after surgery (albrecht et al. 2013) . however, other studies have reported that intravenous magnesium does not reduce postoperative pain and opioid consumption (ko et al. 2001; wilder-smith et al. 1997) . a study in gynecological surgery patients suggests that variability in the efficacy of magnesium may be related to baseline magnesium levels: low preoperative magnesium levels were significantly (p < 0.001) associated with increased postoperative pain (ulm et al. 2016 ). clinical trials have consistently shown that intravenous magnesium has a favorable safety profile, even at high doses (albrecht et al. 2013; de oliveira jr et al. 2013; fawcett et al. 1999) . recommendation 26: there is no evidence to suggest the routine use of α 2 -agonists as part of a multimodal analgesia regimen to reduce postoperative pain after thoracic surgery. there is no consensus on the best timing and schedule for administration of these drugs. level of evidence: fair strength of recommendation: i a meta-analysis of 30 studies involving almost 1800 surgical patients showed that both dexmedetomidine, and to a lesser extent clonidine, reduce postoperative opioid consumption and postoperative nausea, compared with controls (blaudszun et al. 2012 ). however, dexmedetomidine was associated with an increased risk of postoperative bradycardia, while clonidine increased the risks of both intraoperative and postoperative hypotension, although none of these adverse events required specific interventions, and recovery times were not prolonged (blaudszun et al. 2012) . furthermore, in a rct involving 10,010 patients undergoing noncardiac surgery, clonidine was associated with an increased rate of important hypotension and nonfatal cardiac arrest, compared with placebo (devereaux et al. 2014) . dexmedetomidine is currently approved in italy only for sedation, and thus cannot be recommended for analgesic use in italian settings. recommendation 27: we suggest considering the use of intravenous steroids as part of a multimodal approach to reduce peripheral sensibilization of inflammatoryinduced pain in patients undergoing thoracic surgery. adverse effects of single doses of steroids are of trivial clinical impact. level of evidence: fair strength of recommendation: c a meta-analysis of 45 studies including almost 5800 patients showed that a single perioperative dose of intravenous dexamethasone resulted in significant reductions in pain scores and opioid use, and was associated with shorter stays in the post-anesthesia recovery room, compared with placebo or antiemetic treatment (waldron et al. 2013) . a further meta-analysis of 24 randomized controlled trials found that preoperative dexamethasone, at doses > 0.1 mg/kg, had a greater analgesic effect than perioperative treatment, although there was no difference in los between the two dosing schedules (de oliveira jr et al. 2011) . in a randomized, placebo-controlled trial in 64 patients undergoing uterine artery embolization, administration of dexamethasone 1 h before surgery resulted in significant reductions in postoperative concentrations of cortisol and inflammatory mediators, and less pain and severe ponv, compared with placebo . although long-term glucocorticosteroid treatment is associated with significant adverse events such as hyperglycemia, increased infection risk, bleeding, and recurrence of disease in cancer patients, such events do not appear to be a concern when dexamethasone is used as part of a multimodal analgesic strategy. studies have generally shown few serious adverse events, and no delay in wound healing, following single perioperative doses of dexamethasone in surgical patients (de oliveira jr et al. 2011; holte and kehlet 2002; snall et al. 2013; thoren et al. 2009 ). recommendation 28: we recommend the use of intravenous nonsteroidal anti-inflammatory drugs (nsaids) to reduce peripheral sensitization to inflammationinduced pain in patients undergoing thoracic surgery. combined use of nsaids and paracetamol may give a further analgesic advantage. level of evidence: good strength of recommendation: a a meta-analysis of 17 trials evaluating the efficacy of nsaids in surgical patients found that these drugs were effective in reducing a composite endpoint of pain intensity scores, supplemental analgesic consumption, and time to first analgesic consumption, compared with controls (effect size 0.39, 95% ci 0.27-0.48) (ong et al. 2005) . however, although preoperative administration reduced opioid consumption and lengthened the time to first use of rescue analgesic, it reduced postoperative pain scores in only six of 12 randomized controlled trials. nsaid treatment has also been reported to reduce opioid-related adverse events such as ponv (gan et al. 2004; maund et al. 2011) . there is evidence that the analgesic effects of nsaids on postoperative pain are potentiated by concomitant administration of paracetamol (ong et al. 2005) . a number of studies have examined the efficacy and safety of ketorolac in surgical patients. a meta-analysis of 27 randomized, double-blind, trials in 2314 patients undergoing major abdominal surgery, neurosurgery, or orthopedic surgery showed that ketorolac does not increase clinically significant bleeding, compared with controls (or 1.1, 95% ci 0.61-2.06, p = 0.72); however, there appeared to be a slight trend toward more bleeding with higher doses (> 30 mg) (gobble et al. 2014) . these results suggest that increases in bleeding time observed with ketorolac are not clinically relevant, and that there does not appear to be a significant risk of postoperative bleeding with ketorolac, compared with controls. low doses of ketorolac (10 and 15 mg) appear to be equivalent in analgesic efficacy to ketorolac 30 mg. although no studies were identified that directly compared the analgesic efficacy of different doses of ketorolac in thoracic surgery patients, a double-blind, randomized, controlled trial in patients with moderate or severe acute pain treated in the emergency department found no significant differences in pain score reductions or adverse event profiles between patients receiving ketorolac 10 mg, 15 mg, or 30 mg (motov et al. 2017) . these findings are consistent with those of a prospective, randomized, non-inferiority trial in patients undergoing spine surgery, which found that ketorolac 30 mg was not superior to 15 mg for postoperative pain management (duttchen et al. 2017) . based on such findings, we suggest the use of low doses of intravenous ketorolac (15 mg 2-3 times a day) for a maximum of 2 days; however, we suggest caution in using ketorolac in elderly patients (> 65 years). ketorolac can be also administered orally (10 mg 3-4 times a day) for a maximum of 5 days. recommendation 29: we recommend the use of locoregional anesthesia for intraoperative and postoperative pain management. level of evidence: poor strength of recommendation: a recommendation 30: we recommend the use of thoracic epidural analgesia in high-risk patients or in major surgical procedures where the parietal pleura (e.g., chest wall resection) is violated (i.e., thoracotomy, thoracosternotomy, chest wall resection). level of evidence: fair strength of recommendation: a recommendation 31: we recommend thoracic paravertebral block for vats, as part of a multimodal approach. level of evidence: good strength of recommendation: a recommendation 32: we recommend thoracic paravertebral block in preference to thoracic epidural analgesia in patients with known or suspected coagulopathy. level of evidence: fair strength of recommendation: a multiple clinical trials have shown that, in patients undergoing open thoracotomy or other major surgical procedures, thoracic epidural analgesia (tea) is superior to intravenous opioid administration in terms of postoperative pain relief, length of hospital stay, and incidence of postoperative complications (hazelrigg et al. 2002; block et al. 2003; della rocca et al. 2002; meierhenrich et al. 2011; wheatley et al. 2001) . however, in patients undergoing vats procedures, less invasive procedures such as paravertebral block (tpvb) appear to be at least as effective as tea (kosinski et al. 2016; steinthorsdottir et al. 2014 ). there is moderate-quality evidence that tea may reduce the risk of developing persistent postoperative pain 3-18 months after thoracotomy (weinstein et al. 2018) . clinical trials and meta-analyses have consistently shown that tea and tpvb are comparable in efficacy for the management of postoperative pain in thoracotomy patients (baidya et al. 2014; ding et al. 2014; júnior ade et al. 2013; kobayashi et al. 2013; raveglia et al. 2014; scarfe et al. 2016; yamauchi et al. 2017) . there is also clear evidence that tpvb is associated with fewer intraoperative complications than tea, with improved hemodynamic stability and less need for intravenous colloid therapy (pintaric et al. 2011) , probably due to unilateral segmental block. compared with tea, tpvb is associated with lower rates of minor postoperative complications such as urinary retention, nausea and vomiting, and hypotension (baidya et al. 2014; ding et al. 2014; raveglia et al. 2014; scarfe et al. 2016; biswas et al. 2016; gulbahar et al. 2010; yeung et al. 2016) , and the majority of studies have shown no significant differences in pulmonary function and pulmonary complications between the two procedures (ding et al. 2014; biswas et al. 2016; blackshaw et al. 2018) . furthermore, some studies have found that epidural anesthesia may be associated with serious complications such as epidural hematoma, epidural abscess, and nerve injury: the risk of these potentially devastating complications may be reduced with tpvb, particularly in patients with known or suspected coagulopathy (davies et al. 2006; horlocker et al. 2018) . although data from randomized controlled trials are lacking, several studies have shown that tpvb is associated with a low risk of bleeding complications (naja and lönnqvist 2001; katayama et al. 2012; okitsu et al. 2017) . in some studies, tea has also been associated with higher rates of procedural failure, compared with tpvb (kosinski et al. 2016; ding et al. 2014; gulbahar et al. 2010; hermanides et al. 2012) . there are no studies comparing the efficacy and safety of tpvb when performed by the anesthetist before the beginning of surgery, or by the surgeon under direct vision at the end of surgery. together, the available evidence indicates that tpvb and tea provide comparable analgesia in thoracotomy patients, but tpvb offers advantages in terms of its technical simplicity and better safety profile. tpvb is therefore a valid alternative to tea, particularly in patients who are not suitable for tea. recommendation 33: we suggest that intercostal nerve blockade should be considered only as a second choice for analgesia after thoracic surgical procedures. level of evidence: good strength of recommendation: c several studies have shown that intercostal nerve blockade is not comparable in terms of analgesia to tea or tpvb in thoracic surgery patients (meierhenrich et al. 2011; joshi et al. 2008; wurnig et al. 2002) . this is at least partially due to the shorter duration of analgesia achievable with intercostal nerve blockade (wurnig et al. 2002; linden et al. 2014) , although a recent study has shown that this can be prolonged by a combination of intravenous and perineural dexamethasone (maher et al. 2017) . as a result, we suggest that intercostal nerve blockade should be considered only as a second choice for analgesia after thoracic surgical procedures, because more effective techniques are available. suitable alternatives include tea and (especially for vats) tpvb, and possibly erector spinae plane blockade and serratus anterior plane blockade (see below). recommendation 34: we suggest erector spinae plane block as part of a multimodal analgesia for thoracic surgery, especially for vats. level of evidence: poor strength of recommendation: b erector spinae plane blockade (espb) is a recently developed fascial block that allows sensory blockade over both the posterior and anterolateral thorax. it is relatively safe and simple to administer, because it is performed in a musculofascial plane away from the neuraxis, with minimal risk of serious complications (other than local anesthetic systemic toxicity) (forero et al. 2016; forero et al. 2017) . in an initial series of seven patients with post-thoracotomy pain syndrome, who underwent espb as part of a multimodal analgesia strategy, all patients experienced immediate pain relief and four experienced prolonged pain relief for 2 weeks or longer (forero et al. 2017) . randomized controlled trials are needed to confirm the effectiveness of this technique in thoracic surgery. recommendation 35: we suggest the use of fascial pain blocks as part of multimodal analgesia for thoracic surgery, particularly for vats. level of evidence: fair strength of recommendation: b serratus anterior plane blockade (spb) provides good analgesia, comparable to that provided by tea, for acute post-thoracotomy pain, while maintaining a more stable blood pressure (khalil et al. 2017; okmen and okmen 2017) . like espb, spb offers a less invasive approach in patients with contraindications to more invasive techniques (park et al. 2018) . a recent placebo-controlled trial has suggested that spb reduces postoperative pain and opioid consumption during the first 24 h after vats , but further studies are needed to confirm the potential of the technique in thoracic surgery (park et al. 2018; okmen and okmen 2018) . nevertheless, we suggest the use of fascial plane blocks as part of multimodal analgesia for thoracic surgery, particularly for vats patients. a recent study, involving 60 patients undergoing minimally invasive thoracic surgery, has found that espb provides superior quality of recovery, with lower morbidity and better pain control, compared with spb (finnerty et al. 2020) . recommendation 36: we suggest considering the use of adjuvants (i.e., opioids, dexamethasone) when locoregional anesthesia is performed, because the use of adjuvants can potentiate and prolong the effect of local anesthetics. level of evidence: poor strength of recommendation: c low-to moderate-quality evidence suggests that, when used as an adjuvant to peripheral nerve blockade in upper limb surgery, both perineural and intravenous dexamethasone may prolong the duration of sensory blockade and reduce postoperative pain intensity and opioid consumption (pehora et al. 2017) . specific evidence regarding the use of dexamethasone as an adjuvant in thoracic anesthesia is not available. recommendation 37: we suggest considering the use of a single large-bore chest tube instead of a double tube after thoracic surgery. insertion of more than one chest tube may be considered in selected cases (e.g., bilobectomy or bleeding patients). level of evidence: poor strength of recommendation: c a meta-analysis of nine studies, including 918 patients undergoing pulmonary resection by vats, found that approximately 50% of patients did not have a chest tube inserted. in these patients, postoperative pain scores and los were significantly reduced, compared with patients who had a chest tube inserted, with no difference in 30day morbidity or re-intervention rates between the two groups (li et al. 2018) . these findings suggest that omitting the chest tube is safe and feasible in selected patients. in patients in whom a chest tube is considered necessary, there is consistent evidence that the use of a single large-bore tube to remove both air and fluid is as effective as the use of double chest tubes (filosso et al. 2017; zhou et al. 2016) . furthermore, comparative studies and meta-analyses have shown that, compared with double chest tubes, the use of a single chest tube is associated with less pain, decreases in the amount and duration of drainage, and reduced healthcare costs (zhou et al. 2016; okur et al. 2009; zhang et al. 2016) . recommendation 38: we suggest considering the use of digital chest drainage systems to promote early mobilization of the patient. level of evidence: fair strength of recommendation: b external pleural suction is commonly used after lung resection to promote lung expansion and minimize the duration of air leakage (lang et al. 2016; leo et al. 2013 ). the airintrial, which involved 500 lung resection patients, found that the incidence of prolonged air leakage (defined as still having a chest drain in place 7 days after surgery) was not significantly different in patients in whom external suction was used, compared to those without suction (10% versus 14%, respectively, p = 0.2), although a trend toward significance favoring the use of external suction was seen in patients undergoing anatomical resection (9.6% versus 16.8%, p = 0.05) (leo et al. 2013 ). however, a subsequent meta-analysis of eight randomized, controlled, trials found that, although the use of suction reduced the incidence of postoperative pneumothorax, it was associated with significant increases in los, duration of chest tube drainage, and air leak duration (lang et al. 2016) . the effect of digital chest drainage systems on outcomes after pulmonary resection was studied in a trial including 103 patients who were randomized to either analog or digital drainage systems (de waele et al. 2017) . the use of digital systems had no significant effect on pleural fluid formation, but was associated with a significantly lower incidence of prolonged air leakage, compared with analog systems (3.8% versus 18%, respectively, p = 0.025). there was also a trend toward a shorter duration of chest tube drainage with digital systems, but this did not reach statistical significance. by contrast, an international randomized trial involving 381 lung resection patients found that, compared with traditional drainage systems, digital drainage systems were associated with a significantly shorter duration of chest tube placement, shorter hospital stays, and higher satisfaction scores (pompili et al. 2014) . we suggest using digital chest drainage systems, rather than traditional water seal devices, in order to promote early mobilization. recommendation 39: the routine use of drainage with suction is not recommended in the absence of complications, provided there is full re-expansion of the residual parenchyma after lung resection. level of evidence: good strength of recommendation: d in a prospective randomized trial involving 254 lung resection patients with full parenchymal re-expansion, suction drainage was found to be less effective than nonsuction drainage in terms of time to chest tube removal (5.6 days versus 4.5 days, respectively, p = 0.0014) and incidence of prolonged air leakage (5.6% versus 0.7%, p = 0.032) (gocyk et al. 2016 ). however, no-suction drainage was associated with a significantly higher incidence of asymptomatic residual air spaces, compared with suction drainage (9.4% versus 0.8%, respectively, p = 0.0018). other studies have found that suction drainage does not reduce prolonged air leakage or duration of drainage in patients without complications such as large expiratory leaks (alphonso et al. 2005; brunelli et al. 2004; cerfolio et al. 2001b; coughlin et al. 2012; marshall et al. 2002) . recommendation 40: we suggest removing chest tubes in lung resection patients when liquid output is ≤ 5 cm 3 /kg/24 h of serous fluid. level of evidence: poor strength of recommendation: b in a prospective observational study in 88 patients who underwent posterolateral thoracotomy for lung resection, early removal of the chest tube resulted in an statistically significant improvement in static and dynamic pain scores, and in better functional respiratory outcome (dokhan and abd elaziz 2016) . the criteria for chest tube removal in this study were resolution of air leaks and fluid drainage ≤ 350 ml/day, provided that the drained fluid was macroscopically non-chylous and nonhemorrhagic. several authors have suggested that a cut-off of 3-5 cm 3 /kg of serous liquid is a good option because this is within the normal physiological range of daily pleural fluid filtration, and is suitable for early chest drain removal without increasing complications and re-admission rates (brunelli et al. 2011; mesa-guzman et al. 2015; miserocchi 1997) . based on this clinical evidence, we suggest chest tube removal when fluid output is ≤ 5 cm 3 /kg/24 h of serous liquid. recommendation 41: we do not recommend systematic icu admission after thoracic surgery. level of evidence: poor strength of recommendation: d postoperative pulmonary complications occur in as many as 15-40% of patients after major thoracic surgery, and are associated with prolonged los, and poor longterm outcomes (brunelli et al. 2009; agostini et al. 2018) . although vats procedures are associated with a reduced incidence of postoperative pulmonary complications, compared with thoracotomy, such complications still lead to significant short-term morbidity and mortality in these patients (agostini et al. 2018) . implementation of appropriate postoperative medical strategies, and monitoring and treatment of high-risk patients in dedicated care units, are aimed at improving postoperative outcomes (brunelli et al. 2009 ). currently, many centers routinely admit patients to the icu after surgery, whereas in others icu admission is reserved for patients requiring ventilator support, emergency treatment of perioperative complications, or both (brunelli et al. 2009 ). multiple preoperative factors can influence the likelihood of postoperative admission to the icu in patients undergoing lung resection (brunelli et al. 2009; agostini et al. 2018; ferguson et al. 2009; brunelli et al. 2008; brunelli et al. 2005; cywinski et al. 2009; dulu et al. 2006; keegan et al. 2007; mccall et al. 2015; pinheiro et al. 2015) . these include open thoracotomy, rather than vats (brunelli et al. 2008; dulu et al. 2006; mccall et al. 2015; pinheiro et al. 2015) , more extensive resection (cywinski et al. 2009 ), and impaired preoperative lung function or pulmonary comorbidities such as chronic obstructive pulmonary disease (copd) (brunelli et al. 2008; cywinski et al. 2009; pinheiro et al. 2015) . however, there is evidence that routine admission of thoracic surgery patients to the icu does not reduce mortality rates (brunelli et al. 2005) , and may result in inappropriate icu admission, increased healthcare costs, delayed mobilization, and increased risks of nosocomial infections (brunelli et al. 2009 ). to date, no studies have compared outcomes in thoracic surgery patients admitted to icus, high dependency units (hdus), or surgical wards (brunelli et al. 2009) , and there are no data to identify patients who might benefit from postoperative intensive care, or to determine the necessary degree of postoperative care for an individual patient. for these reasons, we do not recommend systematic icu admission after thoracic surgery. we suggest postoperative admission of high-risk patients to dedicated care units (hdus or dedicated thoracic surgical wards). these facilities may allow icu admission to be limited to patients requiring support for organ failure. identification of high-risk patients, and management of their postoperative course, should be planned according to the number and type of complications, and the available resources. ers/ests working group recommendations (brunelli et al. 2009 ) state that lung resection patients should be managed in a dedicated thoracic surgical ward or respiratory hdu (scala et al. 2011) if available, and that icu admission should be limited to patients requiring organ support. the appropriateness of this policy, and its influence on early outcomes, is still controversial. recommendation 42: we recommend that, in adult patients undergoing thoracic surgery, oral intake, including clear liquids, can be initiated 4-6 h after surgery, in the absence of nausea and vomiting. oral intake should, however, be adapted to individual tolerance. level of evidence: fair strength of recommendation: a although it has traditionally been believed that enteral nutrition should not be resumed in postoperative surgical patients until normal bowel function has been restored, studies have consistently shown that early resumption of oral feeding is safe and well tolerated, and is associated with decreased wound morbidity, fewer septic complications, and less weight loss, compared with delayed enteral nutrition (warren et al. 2011 ). hence, early oral feeding has been endorsed in a number of guidelines in different surgical settings, including the eras/ests lung surgery guidelines (batchelor et al. 2019; muehling et al. 2008; smith et al. 2011; weimann et al. 2017; nelson et al. 2016; nygren et al. 2013) . in patients undergoing lung resection, early resumption of oral feeding does not depend on the surgical technique (open versus minimally invasive) (batchelor et al. 2019; smith et al. 2011; jones et al. 2013) . hence, we recommend that, in the absence of nausea and vomiting, oral intake, including clear liquids, can be initiated 4-6 h after surgery in adult patients undergoing elective pulmonary lobectomy. oral intake should, however, be adapted according to the individual patient's tolerance and the type of surgery carried out. recommendation 43: we recommend early mobilization of patients within the first 24 h after both minor and major thoracic surgery. level of evidence: fair strength of recommendation: a recommendation 44: we recommend a physiotherapy program after thoracic surgery. level of evidence: fair strength of recommendation: a delayed mobilization in patients undergoing lung resection is predictive of increased postoperative morbidity and delayed hospital discharge (das-neves-pereira et al. 2009; rogers et al. 2018) , and hence early ambulation and physiotherapy have been recommended irrespective of the surgical approach (nygren et al. 2013) . several studies have shown that eras programs that include early ambulation are feasible in lung resection patients, and can improve outcomes (das-neves-pereira et al. 2009; cywinski et al. 2009; dulu et al. 2006; keegan et al. 2007; mccall et al. 2015; pinheiro et al. 2015; scala et al. 2011; warren et al. 2011; nygren et al. 2013; jones et al. 2013; rogers et al. 2018; dumans-nizard et al. 2016; kendall et al. 2017; martin et al. 2018 ). there is evidence from a propensity score matching study in 524 patients that patients undergoing vats lung resection require less physiotherapy than those undergoing open thoracotomy (agostini et al. 2017) . recommendation 45: we suggest considering daily chest radiographs only in selected cases under specific clinical indications. level of evidence: good strength of recommendation: c two meta-analyses have concluded that routine chest radiographs offer no advantage over clinically indicated radiographs in cardiothoracic surgery patients (sepehripour et al. 2012; reeb et al. 2013) . in one of these analyses, pulmonary pathology was detected in 2-40% of routine chest radiographs, compared with 79% (p = 0.005) of radiographs that were taken only when clinically indicated (sepehripour et al. 2012 ). furthermore, a prospective comparative study in cardiothoracic surgery patients in an icu/post-icu ward showed that the elimination of daily routine chest radiographs reduced the total number of radiographs per patient per day in the icu, but had no effect on chest radiography practice in the post-icu ward (mets et al. 2007 ). there is also evidence that chest radiographs are poor predictors of postoperative complications in patients undergoing lung resection. in a retrospective chart review of 86 patients undergoing vats lung resection, the sensitivity and specificity of chest radiographs for pulmonary complications ranged from 0-100% and 58-97%, respectively, depending on the reviewer, and there was only slight overall agreement between reviewers (troquay et al. 2013) . for these reasons, we suggest considering daily chest radiographs only in selected patients. bedside, lung ultrasound may also be useful in some patients (chiappetta et al. 2018; touw et al. 2018) . recommendation 46: we do not recommend the routine use of either continuous positive airway pressure (cpap) or non invasive ventilation (niv) to prevent postoperative pulmonary complications, prolonged length of stay, and mortality (both in icu and in hospital) in patients undergoing major thoracic surgery. cpap or niv could be considered on a case by case basis in selected high-risk patients. level of evidence: poor strength of recommendation: d postoperative pulmonary complications are the principal cause of mortality and morbidity after lung resection (torres et al. 2019) . acute respiratory failure has been reported to occur in 2-30% of patients after lung resection (lorut et al. 2014) , and overall pulmonary complication rates have been reported to be as high as 49% (nery et al. 2012) . because prolonged invasive mechanical ventilation has been shown to be an important risk factor for such complications, prophylactic non-invasive ventilation (niv) has been proposed as a means of reducing this intubation-related risk (riviere et al. 2011) . although niv offers the potential to improve lung function, unload respiratory muscles and reduce postoperative hypoxemia and atelectasis, randomized controlled trials have not shown consistent evidence that the addition of either niv or continuous positive airway pressure (cpap) to standard medical therapy offers no significant benefit (lorut et al. 2014; nery et al. 2012; aguilo et al. 1997; barbagallo et al. 2012; danner et al. 2012; garutti et al. 2014; liao et al. 2010; perrin et al. 2007 ). in a recent cochrane review of eight trials involving a total of 486 patients, there were no significant differences between patients receiving niv and control groups in terms of pulmonary complications (rr 1.03, 95% ci 0.72-1.47), intubation rates (rr 0.55, 95% ci 0.25-1.00), mortality (rr 0.60, 95% ci 0.24-1.53), length of icu stay (mean difference − 0.75 days, 95% ci − 3.93-2.43) or length of hospital stay (mean difference − 0.12 days, 95% ci − 6.15-5.90) (torres et al. 2019) . however, the quality of the evidence was poor, due to the limited number of studies, heterogeneity of the patient populations and of the scheduled ventilator treatment, small sample sizes, and low frequencies of outcomes (torres et al. 2019) . however, it could be speculated that selected patients at higher risk of developing pulmonary complications (e.g., obese patients or patients with copd, obese, chronic heart failure, or chronic hypersecretion) are likely to benefit from the administration of cpap or niv in addition to standard medical and physiotherapy, consistent with the established use of these techniques for the prevention of post-extubation failure (rochwerg et al. 2017; scala and pisani 2018) . recommendation 47: we suggest the use of niv or cpap to treat acute respiratory failure complicating thoracic surgery. level of evidence: poor strength of recommendation: b one small study (n = 24) in patients with acute hypoxemic respiratory insufficiency after lung resection found that the addition of niv to standard therapy was associated with significant reductions, compared with controls, in the need for endotracheal mechanical ventilation (20.8% versus 50%, respectively, p = 0.035) and 120-day mortality (12.5% versus 37.5%, p = 0.045); however, there were no differences in length of icu and hospital stays between the two groups (auriant et al. 2001 ). on the basis of these findings, it is suggested that niv or cpap could be used in the management of acute respiratory insufficiency following thoracic surgery, but it should be noted that the availability of only a single study limits the strength of this recommendation. however, it should be remembered that niv is associated with a number of adverse events (e.g., poor compliance, leaks, sensory dysfunction, hypersecretion, unprotected airways, patient-ventilator asynchronies) that are likely to be associated with the need for intubation (scala and pisani 2018) . furthermore, niv failure occurs in approximately 20% of patients, and is associated with increased rates of nosocomial pneumonia and postoperative mortality (riviere et al. 2011 ). in a prospective study of 664 patients admitted to the icu after lung resection or pulmonary thrombendarterectomy, four independent risk factors for niv failure within the first 48 h were identified: increased respiratory rate (or 4.17, 95% ci 1.63-10.67), increased sequential organ failure assessment (sofa) score (or 3.05, 95% ci 1.12-8.34), number of fiberoptic bronchoscopies performed (or 1.60, 95% ci 1.01-2.54), and number of hours on niv (or 1.06, 95% ci 1.01-1.11) (riviere et al. 2011) . risk stratification of candidates for thoracic surgery is likely to be useful for selecting sub-sets of patients who may benefit from either prophylactic or therapeutic niv. these might include patients with copd or severely impaired respiratory function (danner et al. 2012; garutti et al. 2014; perrin et al. 2007 ) and obese patients (stephan and berard 2017) . further research is needed to clarify the potential usefulness of prophylactic or therapeutic niv in such groups, and to determine the most efficacious scheduled regimens. recommendation 48: we suggest considering the use of high-flow nasal cannula oxygen therapy as an alternative or integrative support to cpap or niv to prevent or treat acute respiratory failure complicating thoracic surgery. level of evidence: poor strength of recommendation: c high-flow nasal cannula (hfnc) oxygen therapy is considered to be a non-invasive form of respiratory assistance for spontaneously breathing hypoxemic patients with early stages of acute respiratory failure. this technique delivers high inspiratory flow rates (up to 60 l/ min) that match the oxygen demands of ventilated patients; in addition, hfnc oxygen therapy offers good comfort, efficient wash-out of the upper airway and clearance of co 2 , provision of adequate humidification, and reduction of respiratory effort (although this latter effect is less than can be achieved with niv) (stephan and berard 2017) . a post hoc analysis of a large randomized trial in obese patients undergoing major thoracic surgery investigated the impact of hfnc on rates of treatment failure, defined as the need for re-intubation or switching to alternative treatments, or premature discontinuation (stephan and berard 2017) . this analysis found that hfnc is not inferior to niv in terms of treatment failure rates (13.3% versus 15.4%, respectively, p = 0.62), icu mortality (2.2% versus 5.9%, p = 0.22), length of icu stay (median 5.0 versus 4.0 days, p = 0.63), or length of hospital stay (median 10.0 versus 11.1 days, p = 0.71). however, skin breakdown at 24 h was significantly more common with niv than with hfnc (9.2% versus 1.6%, respectively, p = 0.01). on the basis of these findings, it is suggested that hfnc may be considered as an alternative to cpap or niv for the prevention or treatment of acute respiratory failure complicating thoracic surgery. it should be noted that the lack of corroborating randomized trials limits the strength of this recommendation. however, the demonstration of the effectiveness and acceptability of hfnc in milder degrees of acute (particularly hypoxemic) respiratory failure is consistent with the potential use of hfnc in patients with postoperative pulmonary complications following major thoracic surgery (rochwerg et al. 2019) . it should also be noted that the integrated use of hfnc during times off niv could be an effective strategy, especially in patients showing poor tolerance to the niv interface (scala and pisani 2018; longhini et al. 2019) . recommendation 49: for prophylaxis and management of atrial fibrillation after thoracic surgery, we recommend reference to the society of thoracic surgery (sts) 2011 guidelines. level of evidence: good strength of recommendation: a postoperative cardiac arrhythmias, particularly atrial fibrillation, occur in approximately 10-20% of patients undergoing major noncardiac thoracic surgery, including both thoracotomy and vats lobectomy (garner et al. 2017; onaitis et al. 2010; park et al. 2007 ). potential risk factors for atrial fibrillation include increasing age, male gender, hypertension, comorbidities such as copd or heart failure, extent of lung resection, and postoperative infection (batchelor et al. 2019; garner et al. 2017; onaitis et al. 2010) . postoperative atrial fibrillation can lead to hemodynamic instability, potentially prolonging icu and hospital stay (frendl et al. 2014) . furthermore, atrial fibrillation may persist beyond hospital discharge in a proportion of patients, and some patients may require long-term anticoagulation (garner et al. 2017) . it is recommended that the society of thoracic surgery (sts) 2011 guidelines for the prophylaxis and management of atrial fibrillation (fernando et al. 2011) should be followed in patients undergoing pulmonary lobectomy. these guidelines recommend pharmacological prophylaxis with β-blockers or diltiazem: amiodarone is not recommended for patients undergoing pneumonectomy. electrical cardioversion is recommended for patients who develop hemodynamically unstable atrial fibrillation, and for patients with symptomatically intolerable atrial fibrillation in whom treatment with metoprolol (or diltiazem for patients with severe copd), alone or followed by flecainide, is ineffective. anticoagulation with aspirin (for patients at low thromboembolic risk), or warfarin or heparin (for high-risk patients), is recommended for patients with persistent or recurrent atrial fibrillation after 24 h of metoprolol treatment (fernando et al. 2011) . it should be noted, however, that to date no scoring system has been developed to identify lung resection patients at high risk of atrial fibrillation, although promising results have been obtained with the chads 2 score (kotova et al. 2017) . furthermore, there is little evidence that prophylaxis for atrial fibrillation improves outcomes after thoracic surgery [1]. anesthesia in patients undergoing thoracic surgery is a complex undertaking that requires a multidisciplinary approach to risk assessment, perioperative monitoring, and postoperative care. recognizing this, the pacts group has sought to identify critical issues in the preoperative, intraoperative and postoperative care of patients undergoing lung resection, and to provide appropriate guidance. wherever possible, our recommendations are based on good-quality supporting evidence: where such evidence is limited, the recommendations are framed as suggestions or possibilities for consideration. in a few cases, there was insufficient evidence to make formal recommendations: in such cases, our guidance is based on expert opinion, supported by published literature where possible. our literature reviews and discussions highlighted the importance of the choice of anesthetic and lung isolation procedure, attention to airway management, and comprehensive monitoring of vital signs, hemodynamics, neuromuscular blockade, and depth of anesthesia, for achieving optimal outcomes. postoperatively, a multi-modal analgesic strategy that includes pre-emptive analgesia and locoregional blockade is required for optimal pain control. finally, decisions on icu care, chest drainage, and other interventions should be individualized for each patient. the eras lung surgery guidelines (batchelor et al. 2019) were published while our recommendations were in development. we believe that these recommendations extend and complement those of the eras guidelines for a number of reasons. first, aspects of anesthesiologic care such as depth of anesthesia monitoring, neuromuscular blockade, and hemodynamic monitoring are covered in greater detail than in the eras guidelines. in addition, our recommendations focus specifically on elective surgery for lung cancer. it is hoped that these recommendations will help to achieve optimal postoperative outcomes in the greatest number of thoracic surgery patients. further refinement of our recommendations can be anticipated as the literature continues to evolve. postoperative pulmonary complications and rehabilitation requirements following lobectomy: a propensity score matched study of patients undergoing video-assisted thoracoscopic surgery versus thoracotomy risk factors and short-term outcomes of postoperative pulmonary 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note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations medical writing and editorial assistance was provided by michael shaw phd, on behalf of editamed srl, torino, italy. the authors wish to thank the following colleagues who served as external independent reviewers for the final manuscript editing: prof. paolo navalesi (anesthesiology and intensive care unit -university of padua, italy), dr. alessandro pardolesi (thoracic surgery unit -fondazione irccs istituto nazionale dei tumori, milan, italy), dr. giulio rosboch (department of anesthesia and intensive care -azienda ospedaliera città della salute e della scienza, turin, italy), dr. domenico santonastaso (anesthesia and intensive care unit -ausl romagna bufalini hospital, cesena, italy). all the authors contributed equally to the consensus. all the authors revised and approved the final manuscript. this work, including travel and meeting expenses, was supported by an unrestricted grant from msd italia srl. the sponsor had no role in selecting the participants, reviewing the literature, defining consensus recommendations, drafting or reviewing the paper, or in the decision to submit the manuscript. data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.ethics approval and consent to participate not applicable. not applicable. key: cord-349740-xed4aybr authors: wang, yulong; zeng, lian; yao, sheng; zhu, fengzhao; liu, chaozong; di laura, anna; henckel, johann; shao, zengwu; hirschmann, michael t.; hart, alister; guo, xiaodong title: recommendations of protective measures for orthopedic surgeons during covid-19 pandemic date: 2020-06-10 journal: knee surg sports traumatol arthrosc doi: 10.1007/s00167-020-06092-4 sha: doc_id: 349740 cord_uid: xed4aybr purpose: it was the primary purpose of the present systematic review to identify the optimal protection measures during covid-19 pandemic and provide guidance of protective measures for orthopedic surgeons. the secondary purpose was to report the protection experience of an orthopedic trauma center in wuhan, china during the pandemic. methods: a systematic search of the pubmed, cochrane, web of science, google scholar was performed for studies about covid-19, fracture, trauma, orthopedic, healthcare workers, protection, telemedicine. the appropriate protective measures for orthopedic surgeons and patients were reviewed (on-site first aid, emergency room, operating room, isolation wards, general ward, etc.) during the entire diagnosis and treatment process of traumatic patients. results: eighteen studies were included, and most studies (13/18) emphasized that orthopedic surgeons should pay attention to prevent cross-infection. only four studies have reported in detail how orthopedic surgeons should be protected during surgery in the operating room. no detailed studies on multidisciplinary cooperation, strict protection, protection training, indications of emergency surgery, first aid on-site and protection in orthopedic wards were found. conclusion: strict protection at every step in the patient pathway is important to reduce the risk of cross-infection. lessons learnt from our experience provide some recommendations of protective measures during the entire diagnosis and treatment process of traumatic patients and help others to manage orthopedic patients with covid-19, to reduce the risk of cross-infection between patients and to protect healthcare workers during work. level of evidence: iv. in december 2019, the coronavirus disease 2019 (covid-19) caused by coronavirus (2019-ncov) was found in wuhan (hubei, china) [44] and then became a worldwide pandemic on 11th march 2020. compared with severe acute respiratory syndrome (sars) coronavirus, covid-19 has a lower mortality, but it is more infectious and pathogenic [4, 31, 36] . according to statistics from johns hopkins university [24] , a total of 4,136,056 cases of covid-19 have been confirmed globally until 11 may, 2020. due to the high infectivity of 2019-ncov, the source of infection can be covid-19 patients and asymptomatic infected people. the main routes of transmission of 2019-ncov are respiratory droplets, close contact and aerosol transmission [4, 17, 31-33, 36, 45] . furthermore, covid-19 has a latent period yulong wang and lian zeng have contributed equally to this paper, and considered as first co-authors. of 1-14 days, up to 24 days [17] . therefore, in the process of patient treatment and diagnosis, there is a high risk of cross-infection to healthcare workers [19] . the pandemic of covid-19 has brought great challenges at every step in the patient pathway, from pre-hospital, emergency diagnosis and treatment, emergency surgery, anesthesia, and perioperative management. in every step of treatment, the strategies for the treatment of trauma patients should be formulated and protective measures should be taken. what ppe should be worn, and what preventive steps should be undertaken by healthcare workers in different areas of the patient pathway? hence, we performed the present systematic review that aimed to identify the optimal protection measures during covid-19 pandemic and provide guidance of protective measures for orthopedic surgeons. the secondary purpose was to report the protection experience of an orthopedic trauma center in wuhan, china. as of march 26, 2020, a total of 23,187 cases with covid-19 including rescuing 1,134 cases of acute and critical illness and more than 400 patients with ventilators have been treated in our institution (hubei, china) located in the center of the epidemic; meanwhile, various surgeries are performed in more than 300 cases with covid-19. the orthopedic department has handled more than 260 emergency cases. recommendations of protective measures was developed in a learning by doing and consensus process [14, 17, 20, 26, 31-33, 37, 42, 45, 48] . this paper also describes what was done and how it was implemented. a systematic review of the available literature was performed for articles published up to april 27, 2020 using the keyword terms "covid-19", "fracture", "trauma", "orthopedic", "surgeon", "healthcare workers", "protection", "telemedicine" in several combinations. the following databases were assessed: pubmed, cochrane, web of science, google scholar, and all the publications were searched. the search was limited to english studies only. studies in other languages were not included in this review. all peer-reviewed articles were considered. randomized controlled trials (rcts), prospective trials and retrospective studies as well as reviews and case reports were included in this systematic review. two authors independently screened the titles and abstracts of all the articles were identified. if the abstract and the full-text was unavailable, the paper was excluded. in the event of disagreement, a consensus was reached by discussion, if needed with the intervention of the senior author. this systematic review was conducted in accordance with the established guidelines from preferred reporting items for systematic reviews and meta-analysis (prisma). however, due to the heterogeneity of available data, it was decided to present the review in a narrative manner. one author extracted data from all the selected original articles, which was repeated by two other authors. if there was no agreement between the three, the senior author was consulted. where required, the corresponding authors were contacted for additional information. this review focused on protective measures in the entire diagnosis and treatment process. at each stage of the literature search, a kappa value was calculated to determine inter-reviewer agreement on study selection. pertinent information extracted included author, date and journal of publication, study design (and level of evidence). descriptive statistics, such as the means, ranges, and measures of variance [e.g., standard deviations (sd)], are presented where applicable. the initial literature search found 176 articles. after removing 23 duplicates, 153 studies were screened. of the 153 studies, 126 were excluded after screening of the title and abstract. additional 9 studies were excluded after full-text review. thus, 18 articles were finally eligible for data extraction. agreement between the reviewers on study selection was substantial at the title review stage (k = 0.705; 95% ci 0.563-0.828), almost perfect at the abstract review stage (k = 0.871, 95% ci 0.475-0.999), and perfect at the full-text review stage (k = 1.0). based on the analysis of levels of evidence, one study was classified as level iii, fourteen studies were classified as level iv and the remaining three studies were classified as level v. due to study design heterogeneity it was not possible to pool results across studies and perform a meta-analysis. only one case series study reported 10 fracture patients (8 women and 2 men) with covid-19, for which the mean age was 68.4 ± 17.5 years old (range 34-87). eight (80%) with complications such as hypertension, diabetes, brain injury, etc., and 4 (40%) patients eventually died [29] . it indicated that enormous challenges to treat patients with traumatic fracture are given to orthopedic surgeons during covid-19 pandemic. many studies [1, 27, 28, 30, 39, 50] reported that using video or teleconference for morning rounds, electronic consultations, videoconferencing, digital outpatient and other telemedicine methods to provide medical guidance and follow-up instruction for patients can reduce unnecessary contact, limiting the spread of the virus and save protective materials. two surveys of surgeons found that the kind of protective measures should be taken and how to or not to screen patients with covid-19 are different in different countries or different departments [16, 30] . another survey of covid-19 disease among orthopedic surgeons from 8 hospitals in wuhan found a total of 26 surgeons were diagnosed with covid-19 [19], and the incidence varied from 1.5 to 20.7%. training on prevention measures and wearing of respirator masks was found to be protective. not wearing an n95 respirator was a risk factor for infection with covid-19 as well as severe fatigue due to work overload [19] . delaying and canceling elective surgery, and the exact definition of emergency surgery are still under debate [1, 11, 13, 14, 16, 27, 29, 37, 39, 42, 50] . emergency surgery in the context of the current crisis can be defined as urgent pathologies that could result in long-term disability and/or chronic pain if surgery is postponed [14, 35, 37] . trauma related fractures are the most common cause of emergency surgery [5, 6, 9, 12, 21, 23, 38, 47] . the who and evidencebased literature have not given any detailed recommendations for emergency orthopedic treatment during covid-19 pandemic. there was no study concerning the management of an outpatient clinic and surgical activities and the challenges in handling with a high-volume practice during epidemic. only one article offered important points and strategies to provide the highest level of safety to healthcare workers during the start-up phase [13] . most studies (13/18) emphasized that orthopedic surgeons should pay attention to personal protection when facing the covid-19 pandemic to prevent cross-infection [1, 11, 13, 14, 16, 19, 20, 27, 34, 35, 39, 42, 50] . four studies have reported in more detail on personal protection [1, 11, 20, 35] (table 1) . there are no studies about the level of protection should be recommended for orthopedic surgeon from on-site emergency to patient discharge. only hirschmann et al. [20] gave an evidence-based recommendation on which ppe should be used to avoid occupational transmission of covid-19 during surgery. during the covid-19 pandemic, orthopedic patients as well as medical staff may be infected with covid-19 when they are exposed to people infected with covid-19 during their work. transmission from medical staff to medical staff, patient to medical staff, as well as medical staff to patient, has been demonstrated. the most commonly suspected areas of exposure during the entire diagnosis and treatment process were general wards, followed by public places at the hospital, operating rooms, the intensive care unit, and the outpatient clinic [19] . to avoid occupational transmission of covid-19 to medical staff, appropriate protective measures taken by orthopedic surgeons during pandemic in different sites from pre-hospital, emergency diagnosis and treatment, emergency surgery, anesthesia, and perioperative management are of great importance. in principle, all patients with fractures which occurred in pandemic areas should be treated as suspected covid-19 cases [11, 35, 46] . the ambulance requires sufficient protective equipment and rescue equipment [32] . all medical personnel should be familiar with the symptoms of covid-19 and should have received professional training in levelthree personal protective equipment (ppe) [11, 19, 20, 29, 31, 34, 35, 45] (table 2 ). in addition, all should be educated well in wearing and taking off a disposable hat, disposable protective clothing, long shoe cover, n95/ffp2 mask, goggles, double-layer gloves and protective face screen. ppe is important to minimize the chance of contact with body fluids of the wounded. before arriving at the scene, all the healthcare workers and drivers involved in the pre-hospital emergency should take level-two ppe. for patients with contact with covid-19 patients or exhibiting the symptoms of fever and/or respiratory symptoms, the pre-hospital emergency healthcare workers and drivers in the non-pandemic area should take level-two ppe in advance. in principle, all the injured patients should be transported to the nearest hospital with proper isolation facilities, adequate levels of ppe and the ability to diagnose and treat covid-19 patients. the ambulance is exposed to high concentration of aerosol for a long time in a relatively closed environment, and must be cleaned and disinfected thoroughly [4, 17, [31] [32] [33] 45] . negative pressure ambulances are preferred. only patients with excluded infection of covid-19 can be sent to the general emergency department, the rest should be sent to the covid-19-designated hospital for treatment. all staff who receive patients with suspected or confirmed covid-19 need at least level-two ppe in the emergency room (er) [1, 11, 31, 35, 45] (table 2 ). if the patient is unconscious, or his/her family members cannot describe the epidemiological history, the suspected cases shall be treated as covid-19. during pandemic, all patients should be treated as suspected cases of covid-19 (table 3) . adequate ppe and disinfection of medical equipment is paramount [17, 32, 33, 45] . if possible, the hospital personnel should take sputum, nasopharynx swab or blood samples using real-time fluorescent rt-pcr to rapidly detect viral nucleic acid or gene sequencing to make the final diagnosis. according to the guidelines [33] , the physicians should make a suspected or confirmed diagnosis of covid-19. if the patients who are sent to the emergency room are preliminarily assessed as suspected covid-19, they might be transferred immediately to complete a chest ct scan [13, 31, 33] . all patients admitted should be screened for 2019-ncov (table 3 ) [13, 30, 31, 39] , and covid-19 needs to be differentiated from traumatic wet lung. in the pandemic area, the patients who do not need emergency surgery are admitted to the emergency buffer ward in single room isolation, and treated as suspected cases of covid-19. after screening for covid-19 (table 3) , covid-19 negative patients can be transferred to the general ward in a single room, minimizing the number of family caregivers (at most 1 member) and forbidding other family members to visit [30, 39] . caregivers should be screened for covid-19 [14, 39] (table 3) , and must be negative. confirmed cases can be admitted in the same negative-pressure isolation ward with multiple persons. severe or critical patients can be admitted to the intensive care unit as soon as possible [31, 46] . the criteria for emergency surgery is "threat to the patient's life if surgery or procedure is not performed, threat of permanent dysfunction of an extremity or organ system, risk of metastasis or progression of staging, risk of rapidly worsening to severe symptoms" [27, 35, 37, 42] . the main indications for emergency surgery at our center are: trauma seriously endangering life or limb [5, 14, 22] , such [15, 23, 40, 47] . patients with mild to moderate covid-19 are treated as above, whereas those with severe covid-19 are more likely to be treated non-operatively (table 4 ). in other words, severe covid-19 is a relative contraindication for emergency orthopedic surgery. patients with critical covid-19 or those who are intolerant to operation or anesthesia are an absolute contraindication [33, 35, 37, 46] . according to patient's condition, trauma, injury type, stability, neurological function, medical equipment and technical conditions, the purpose of operation should be completed in a single approach or minimally invasive surgery as far as possible [2, 6, 7, 9, 10, 18, 22] . the team should take measures to reduce the influence of time, trauma, hemorrhage and anesthesia on patients with covid-19. disposable surgical instruments should be used where possible and non-operative treatment should be strongly considered [26, 33] . the covid-19 testing is difficult to get quickly enough in an emergency setting. all emergency patients are protected according to suspected or confirmed patients [1, 31, 35] . all medical personnel should take level-two protective measures, using the special transfer vehicle with disposable sheets to lead patients to transfer to the negative pressure operation room through a special channel and a special lift [1, 25, 31, 32, 35, 41, 48] . the door of the operating room should be marked with a covid-19 sign. staff numbers should be minimized in the operating room [1, 11, 35] . visitors to the or should be restricted and medical personnel should not enter or leave the operating room to avoid interrupting the negative pressure. level-three ppe is required in the operating room for all staff [31, 48, 49] , except patrol nurses/runners who can use level-two ppe. the operating room must be in a state of negative pressure (− 5 pa) before the operation [11, 13, 41, 43, 48] . the buffer room should be closed, and equipment should be minimized in the operating room. staff wearing ppe in the operating room are forbidden to leave the operating room until the ppe has been removed and the operation has finished. patients with non-generalized anesthesia should wear surgical masks throughout the operation [11, 34, 43, 48] . for patients under general anesthesia, a breathing filter should be installed between the anesthetic mask and the respiration loop, and a breathing filter should be installed at the inhalation and exhalation end of the anesthesia machine, respectively [41, 43, 48] . the high-efficiency particulate air (hepa) filters must be in use and the room should have a negative pressure [35, 41, 43, 48] . after surgery, the room should be disinfected by spraying peracetic acid or hydrogen peroxide for more than two hours, and the laminar flow should be off and air supply closed. sampling of the surfaces and air in the operation room should be tested by the hospital infection control team after the disinfection process. the next operation can the clinical symptoms are mild and no pneumonia manifestations can be found in imaging no contra-indication due to covid-19 moderate patients have symptoms such as fever and respiratory tract symptoms, etc. and pneumonia manifestations can be seen in imaging no contra-indication due to covid-19 severe adults who meet any of the following criteria: respiratory rate ≥ 30 breaths/min; oxygen saturation ≤ 93% at a rest state; arterial partial pressure of oxygen (pao 2 )/oxygen concentration (fio 2 ) ≤ 300 mmhg. patients with > 50% lesions progression within 24-48 h in lung imaging should be treated as severe cases critical meeting any of the following criteria: occurrence of respiratory failure requiring mechanical ventilation; presence of shock; other organ failure that requires monitoring and treatment in the icu absolute contraindication be continued only after the monitoring results are qualified [33, 43, 48] . surgery using the electrocautery, ultrasonic bone knife, drill, pulsatile lavage and other powered equipment result in aerosolization of blood, bone, and tissue fluid [20] . covid-19 is present in all body fluids and so will be present in this aerosol. limitation of the use of these procedures will minimize the aerosol [20, 49] . hirschmann et al. reported that orthopedic surgery in particular to the lower limb produces vast amounts of aerosols when high-speed power tools are used, and orthopedic surgeons should use ffp2-3 or n95-99 respirator masks [20] . the ability for the aerosol to cause infection of the surgical team is unknown and dependent on the ppe worn by the surgical team. smoke generated should be removed by an aspirator (note that suction also generates an aerosol) [49] . during the operation, normal saline for flushing should be minimized, splashing of the patient's body fluids should be avoided, and the residue of the fluid should be reduced as much as possible to prevent the pollution of the surrounding environment [20, 49] . the surgical team need to cooperate closely to prevent smoke from electrocautery, splashing of the patient's body fluid, and sharp instrument injury [1, 11, 35, 48] . surgical instruments that have been directly exposed to the patient's body fluid should be immediately scrubbed with 1000-2000 mg/l chlorine-containing preparation, and then placed into double-layer yellow medical waste bags, labeled with 2019-ncov, and immediately inform the disinfection and supply center to take them away [32, 33] . medical staff are advised to take appropriate protective measures according to the patient with/without covid-19 and the environment which they are exposed in their work (table 5) . preoperative chest ct scan [13, 31, 46] is an important investigation for clinical diagnosis of covid-19, as well as diagnosing lung injury caused by high-energy trauma. nevertheless, nucleic acid testing for covid-19 or virus sequencing should be done as soon as possible after surgery. the body temperature of patients should be monitored at least three times a day after operation. for patients with covid-19, wound infection should not be judged only by the results of blood tests and body temperature [3] . consider whether fever is caused by a wound infection or covid-19 [46] . for patients undergoing a routine operation, if covid-19 has been excluded, the surgery should be arranged with the normal treatment procedure according to the patient's priority; healthcare workers should take level 1 protective measures at least during surgery. for patients with surgery contraindicated in the early stage or other reasons such as conservative treatment failure, fear of hospitalization during the pandemic, etc., surgery can be performed according to treatment experience for delayed union [10, 25] , referring to the aforementioned protective measures. during the transition period, it is necessary to strengthen the monitoring and protection of patients and family caregivers [13, 30, 39] . for patients without covid-19, discharge should be scheduled time after 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teams caring for novel coronavirus (2019-ncov) patients novel coronavirus (2019-ncov) situation report infection prevention and control during health care when covid-19 is suspected. interim guidance characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention epidemiology of worldwide spinal cord injury: a 307 literature review anesthetic management of patients with suspected or confirmed 2019 novel coronavirus infection during emergency procedures minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy advice on standardized diagnosis and treatment for spinal diseases during the coronavirus disease 2019 pandemic the authors wish to thank healthcare workers who key: cord-018363-qr1pk78u authors: casey, ashley; conrad, kevin title: consultative and comanagement date: 2015-10-10 journal: absolute hospital medicine review doi: 10.1007/978-3-319-23748-0_2 sha: doc_id: 18363 cord_uid: qr1pk78u this chapter covers the role of the hospitalist as a consultant and their interaction with surgical specialties. included are discussions of perioperative care in the hospital and clinic. oral and parenteral nutrition for the hospitalized patient are examined. a special emphasis is placed on palliative care for the hospitalized patient. comanagement of surgical patients with an emphasis on orthopedics is reviewed. a 66-year-old male presents to the emergency room with a chief complaint of a severe headache that developed approximately 10 h ago. he describes the headache as the worst headache of his life. he has a history of myelodysplasia for which he has been followed as an outpatient. he reports no history of spontaneous bleeds and denies any spontaneous bruising. on physical examination, he is alert and oriented, and his speech is slightly slurred. the prothrombin time and activated partial thromboplastin time are within normal range. a ct scan is performed in the emergency room that shows an intracerebral bleed with a mild amount of extravasation of blood into the ventricular system. which of the following is the most appropriate minimum platelet threshold for this patient? a) 40,000 b) 60,000 c) 100,000 d) 150,000 answer: c thresholds for platelet transfusions are undergoing close examination. some areas continue to provoke debate especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding. guidelines recommend maintaining platelet count at 100,000 after a central nervous system bleeding event. this would also be the case immediately prior to and after surgery performed on the central nervous system. this patient has a potentially life-threatening intracranial bleeding. the bleeding source is probably secondary to hypertensive disease and not thrombocytopenia. however, the patient is at continued risk for extension of the intracerebral bleeding because of her thrombocytopenia. guidelines do not suggest additional benefi ts to maintaining platelet counts >100,000. a 44-year-old woman undergoes preoperative evaluation prior to surgery to repair a congenital defect of her pelvis. her expected blood loss is 2.0 l. she has a prior history of severe anaphylactic reaction to a prior erythrocyte transfusion that she received for postpartum hemorrhage at age of 27 years. in addition she has a history of rheumatoid arthritis. on physical examination, the temperature is 36.8 °c (98.5 °f), blood pressure is 140/70 mmhg, and heart rate is 76 bpm. laboratory studies indicate a hemoglobin level of 12.0 g/dl, a leukocyte count of 6500 μl, and a platelet count of 150,000 μl. previous laboratory studies indicate an igg level of 800 mg/dl and an igm level of 65 mg/dl. which of the following is the most appropriate erythrocyte transfusion product for this patient? a) leuko-reduced blood b) cytomegalovirus-negative blood c) irradiated blood d) phenotypically matched blood e) washed blood answer: e this patient has iga defi ciency. the most appropriate product to minimize the risk of an anaphylactic transfusion reaction in this case is washed erythrocytes. most patients with an iga defi ciency are asymptomatic. they are prone to gastrointestinal infections such as giardia. they also have an increased risk of autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. some patients with iga defi ciency have anaphylactic reactions to blood products containing iga. fresh frozen plasma (ffp) is the main blood component containing iga antibodies. anaphylaxis may occur with a variety of transfusions including ffp, platelets, and erythrocytes. washing erythrocytes and platelets removes plasma proteins and greatly decreases the incidence of anaphylaxis. a 34-year-old man with a history of superfi cial thrombophlebitis presents with bilateral foot pain of 3-days duration. over the 6 months, he has had several distinct episodes of severe burning pain of the foot and several toes. the pain persists at rest and is debilitating. the patient smokes one to two packs of cigarettes a day. on physical examination, he is thin; his feet are erythematous and cold. there are ulcerations noted distally on both feet. the femoral pulses are strong and intact, and the dorsalis pedis and posterior tibialis pulses are absent bilaterally. no discoloration is noted on his leg and a normal hair pattern is noted on his legs. the pain is not worsened by deep palpation. what is the most likely diagnosis for this patient? a) plantar fasciitis b) spinal stenosis c) thromboangiitis obliterans d) raynaud phenomenon e) atherosclerotic claudication answer: c this patient has thromboangiitis obliterans, also called buerger's disease. this results from infl ammatory blockage of arterioles in the distal extremities and is usually seen in male smokers who are typically less than 40 years of age. other typical features include a history of recurrent thrombophlebitis and rest pain. distal pulses are often absent. plantar fasciitis is usually relieved with rest. weight bearing and exercise exacerbate it. spinal stenosis usually occurs in older patients. it is exacerbated by standing or walking and is relieved by rest. atherosclerotic claudication is also seen in older patients. it has a steady progression. it starts with exercise-related pain and progresses slowly to pain at rest. raynaud phenomenon is seen mostly in women. it is caused by vasospasm of small arterioles. it more commonly occurs in the hands but can be seen in the feet. the vasospasm is precipitated by cold, temperature change, or stress. color changes, which can be profound, occur in the digits from white to blue to red. pain is usually not severe and peripheral pulses remain intact even during episodes of vasospasm. in buerger's disease, among patients who stop smoking, 94 % avoid amputation. in contrast, among patients who continue using tobacco, there is an 8-year amputation rate of 43 %. espinoza lr. buerger's disease: thromboangiitis obliterans 100 years after the initial description. am j med sci. 2009;337(4):285-6. olin jw, young jr, graor ra, ruschhaupt wf, bartholomew jr. the changing clinical spectrum of thromboangiitis obliterans (buerger's disease). circulation. 1990; 82 (5 suppl) : . preoperative malnutrition is associated with which outcome in patients undergoing gastrointestinal surgery? a) increased 30-day mortality b) increased 60-day mortality c) increased length of stay d) all of the above answer: d good nutritional status is an important factor in the outcome of gastrointestinal surgery. several studies have confi rmed this. preoperative malnutrition is an independent predictor of length of hospital stay, 30-day, and 60-day mortality, as well as minor medical complications, in patients undergoing gastrointestinal surgery. preoperative nutrition including total parenteral has been proven to be benefi cial in malnourished patients undergoing gastrointestinal surgery. reference burden s, todd c, hill j, lal s. pre-operative nutrition support in patients undergoing gastrointestinal surgery. cochrane database syst rev. 2012;(11):cd008879. a 52 year-old male presents with the chief complaint of daily seizures. he reports that he has had seizures weekly for the past several years since an automobile accident, but these have increased to nearly daily in the past few weeks. he states he takes levetiracetam, but is not certain of the dose. while in the emergency room, he has a generalized grand mal seizure and is given lorazepam. he has recently moved to the area and has no old records. he is admitted to the hospital medicine service and a 24 h eeg is instituted. on the fi rst night of his admission, he has an apparent seizure but no seizure activity is noted on the eeg. the next morning he develops an inability to move the left side of his body and dysar-thria. urgent mri of his head reveals no evidence of acute cerebrovascular accident. the most likely cause of his paralysis is? a) early cerebral infarction b) todd's paralysis c) malingering d) migraine variant e) conversion disorder answer: c this patient has several factors that suggest malingering. he presents with two relatively easy to mimic symptoms. first, he has a seizure with no eleptiform activity and then paralysis with a normal mri. his recent travel from another area is also suggestive of the diagnosis. malingering is not considered a mental illness and its diagnosis and treatment can be diffi cult. direct confrontation may not work best. hostility, lawsuits, and occasionally violence may result. it may be best to confront the person indirectly by remarking that the objective fi ndings do not meet the objective criteria for diagnosis. it is important to demonstrate to the patient that his abnormal behavior has been observed and will be documented. at the same time an attempt should be made to allow the patient who is malingering the opportunity to save face. obviously this can be a challenge. invasive diagnostic maneuvers, consultations, and prolonged hospitalizations often do more harm than good and add fuel to the fi re. people who malinger rarely accept psychiatric referral, and the success of such consultations is minimal. it may be considered to address a specifi c psychiatric complaint. the most common goals of people who malinger in the emergency department are obtaining drugs and shelter. it may be benefi cial to offer the patient some limited assistance in these areas. in the clinic or offi ce, the most common goal is fi nancial compensation. 259. a 60-year-old male with chronic obstructive pulmonary disease is admitted for a hip fracture sustained after a fall. he undergoes surgery without complication. on the second day of hospitalization, he develops some mild dyspnea and nonproductive cough. he is currently on 2 l of oxygen at home and states that he will often get somewhat short of breath with any change in his living situation. on physical exam, the patient appears comfortable. his temperature is 37.8 °c (100.1 °f), heart rate is 70 bpm, and respirations are 16 per minute. oxygen saturation is 96 % on pulse oximetry with 2 l. a chest x-ray shows no acute changes and white blood cell count is within normal limits. which of the following is the appropriate management of this patient? a) prednisone b) doxycycline plus prednisone c) levofl oxacin d) azithromycin answer: a american college of chest physician guidelines for chronic obstructive pulmonary disease exacerbation support inhaled beta agonists and steroids alone for mild fl ares. in this particular case, the patient is having a mild exacerbation of his typical chronic obstructive pulmonary disease. antibiotics should be reserved for moderate to severe cases. the criteria for moderate disease exacerbation include cough, change in color of sputum, and increased shortness of breath. 260. a 74-year-old man is admitted for cough, dyspnea, and altered mental status. the patient is noted to be minimally responsive on arrival. results of physical examination are as follows: temperature, 38.9 °c (102.1 °f); heart rate, 116 bpm; blood pressure, 96/60 mmhg; respiratory rate, 35 breaths/min; and o 2 saturation, 74 % on 100 % o 2 with a nonrebreather mask. the patient is intubated urgently and placed on mechanical ventilation. on physical exam, coarse rhonchi are noted bilaterally. a portable chest x-ray reveals good placement of the endotracheal tube and lobar consolidation of the right lower lobe. empirical broad-spectrum antimicrobial therapy is started. which is true concerning his nutritional management? a) enteral nutrition is less likely to cause infection than parenteral nutrition. b) parenteral nutrition has not consistently been shown to result in a decrease in mortality, compared with standard care. c) the use of oral supplements in all hospitalized elderly patients has been shown to be benefi cial. d) immune-modulating supplements are no better than standard high-protein formulas in critically ill patients. e) all of the above answer: e comparisons of enteral nutrition with parenteral nutrition have consistently shown fewer infectious complications with enteral nutrition. several studies have looked at specialized feeding formulas in the treatment of the critically ill. there is little evidence to support their use over standard high-protein formulas. in one study among adult patients breathing with the aid of mechanical ventilation in the icu, immune-modulating formulas compared with a standard high-protein formula did not improve infectious complications or other clinical end points. elderly patients require special consideration. a trial in 501 hospitalized elderly patients randomized to oral supplements or a regular diet showed that, irrespective of their initial nutritional status, the patients receiving oral supplements had lower mortality, better mobility, and a shorter hospital stay. 261. you are called to see a patient urgently in the postpartum ward. she is a 32-year-old female who, 20 min prior, had an uneventful vaginal delivery. in the past 20 min, the patient has become abruptly short of breath, hypoxic, and severely hypotensive with a blood pressure of 72/palpation mm hg. on physical exam, she is obtunded and in serve respiratory distress. she has no signifi cant past medical history documented and has had an uneventful pregnancy. mild wheezes with decreased breath sounds are heard. chest radiograph and arterial blood gasses are pending. the most likely diagnosis is? a) pulmonary embolism b) sepsis c) peripartum cardiomyopathy d) amniotic fl uid embolism e) eclampsia answer: d amniotic fl uid embolism is a rare complication of pregnancy. it presents acutely during and immediately after delivery, usually within 30 min. the exact mechanisms are unclear, but it is thought that amniotic fl uid gains entry into the maternal circulation. this triggers an intensive infl amma-tory reaction, resulting in pulmonary vasoconstriction, pulmonary capillary leak, and myocardial depression. patients present with acute hypoxemia, hypotension, and decreased mental status. treatment is supportive but may be improved by early recognition and cardiopulmonary resuscitation. the other answers do occur in pregnancy, but the severity, rapid onset, and timing to delivery strongly suggest amniotic fl uid embolism. the mortality rate may exceed 60 %. immediate transfer to an intensive care unit with cardiovascular resuscitation is recommended. over the past 4 days since surgery, she has been on parenteral nutrition. oral intake has been started gradually 2 days ago. diarrhea has occurred both at night and day. stool cultures and clostridium diffi cile polymerase chain reaction are negative. her current medications include low-molecular-weight heparin as well as loperamide two times daily. which of the following is the most appropriate management? a) increase loperamide. b) initiate cholestyramine. c) initiate omeprazole. d) stop oral intake. e) decrease lipids in parenteral nutrition. answer: c patients who have undergone signifi cant bowel resection should receive acid suppression in the postoperative period with a proton pump inhibitor. this patient has short-bowel syndrome. any process that leaves less than 200 cm of viable small bowel or a loss of 50 % or more of the small intestine as compared to baseline places the patient at risk for developing shortbowel syndrome. in short-bowel syndrome, there is an increase in gastric acids in the postoperative period. this can lead to inactivation of pancreatic lipase, resulting in signifi cant diarrhea. stopping the patient's oral intake may lead to temporary improvement. it is important that the patient continues her oral feedings, as this will eventually allow the gut to adapt and hopefully resume normal function. a 58-year-old female who underwent an elective cholecystectomy is noted to be in atrial fi brillation by telemetry. her heart rate is 108 bpm. she has a history of hypertension. her medications are verapamil and fullstrength aspirin. she states that several years ago, she had palpitations after exercise, but that has since resolved, and she has noticed no problems. you are consulted by the surgical team for management of her heart rate in preparing her for discharge. on physical exam she appears in no distress and is not short of breath. which of the following is the appropriate management of the patient's atrial fi brillation? a) maintain her current dose of verapamil. b) increase her dose of verapamil with a target rate of 80 beats per minute. c) add digoxin to control her heart rate to a target of 80 beats per minute. d) consult cardiology for possible cardioversion. answer: a a 2010 study compared lenient control of heart rate less than 110 beats per minute to more strict control of less than 80 beats per minute. the study found that achieving strict heart rate control resulted in multiple admissions with no perceivable benefi t outcomes. in this particular case, a heart rate of 108 bpm is acceptable, and patient the can be discharged on her current medications. follow-up with her primary care physician should be obtained to monitor heart rate. digoxin can be used in the acute setting but does little to control the ventricular rate in active patients. it is rarely used as monotherapy. caution should be exercised in elderly patients with renal failure due to toxicity. digoxin is indicated in patients with heart failure and reduced lv function. 266. you are called to the fl oor to see a patient who has developed acute onset of shortness of breath. she is a 56-year-old female who was admitted for upper gi bleed. she is currently receiving her fi rst unit of packed erythrocytes, which was started 1.5 h ago. on physical examination, temperature is 38.9 °c(102 °f), blood pressure is 110/65, pulse rate is 115 beats per minute, and respirations are 22 per minute. her current oxygenation is 83 %. she has been placed on 3 l by nasal cannula. no peripheral edema is noted. mild wheezes and diffuse crackles are heard throughout her lung fi elds. a stat x-ray is ordered which reveals diffuse bilateral infi ltrates. on review of her records, type and screen reveal an a+ blood type with a negative antibody screen. which of the following is the most likely diagnosis? a) transfusion-related acute lung injury b) acute hemolytic transfusion reaction c) febrile nonhemolytic transfusion reaction d) transfusion-associated circulatory overload e) transfusion-related sepsis answer: a this patient has likely developed transfusion-related acute lung injury (trali). the patient developed dyspnea, diffuse pulmonary infi ltrates, and hypoxia acutely during the blood transfusion. it usually occurs shortly after the transfusion or can be delayed for several hours. both the classic and delayed trali syndromes are among the most frequent complications following the transfusion of blood products. they are associated with signifi cant morbidity and increased mortality. antileukocyte antibodies in the donor blood product directed against the recipient leukocytes cause this reaction. trali can occur with any blood product. which of the following is most likely regarding cognitive function in patients such as this? a) return to baseline in an average of 5 days b) return to baseline in 2 weeks c) return to baseline in an average of 30 days d) return to baseline in an average of 6 months e) permanent loss of cognitive function answer: a postoperative cognitive dysfunction (pocd) is common in adult patients of all ages, recovery in the younger age group is usually within 5 days, and complete recovery is the norm for patients less than 60 years old. patients older than 60 years of age are at signifi cant risk for long-term cognitive problems, and in this group recovery from pocd may last as long as 6 months and may be permanent. patients with pocd in all age groups are at an increased risk of all-cause death in the fi rst year after surgery. most dizziness is benign and is self-limited. vertigo is often described as an external sensation such as the room is spinning. vertigo is most commonly from peripheral causes which affect labyrinths of the inner ear. focal lesions of the brainstem and cerebellum can also lead to vertigo. vertical nystagmus with a downward fast phase and horizontal nystagmus that changes direction with gaze suggest central vertigo. signifi cant non-accommodating nystagmus is most often a sign of central vertigo but can occur with peripheral causes as well. in peripheral vertigo, nystagmus typically is provoked by positional maneuvers. it can be inhibited by visual fi xation. central causes of nystagmus are more likely to be associated with hiccups, diplopia, cranial neuropathies, and dysarthria. 274. you are called to see a 43-year-old female who is 3 days postpartum. she has had a non-complicated pregnancy. she has not been discharged due to feeding issues with her child. she had a normal spontaneous vaginal delivery. this is her fourth vaginal delivery. on physical exam, she has nontender bilateral leg swelling, orthopnea, and a cough with frothy white sputum. her blood pressure is 150/87 mmhg. her temperature is 37.2 °c (99.0 °f). she has mild chest pain with inspiration. she has bilateral pulmonary crackles and pitting edema of her lower extremities. wbc is 16,000/μl. cxr is pending. which of the following is the most likely diagnosis? a) pulmonary embolism b) peripartum cardiomyopathy c) hospital-acquired pneumonia d) amniotic fl uid embolism e) acute myocardial infarction 275. a 65-year-old male presents with progressive shortness of breath over the past month. he has a 40-pack-year history of smoking. ct scan of the chest reveals a right middle lobe mass for which he subsequently undergoes biopsy, which reveals adenocarcinoma. magnetic resonance imaging of the brain reveals a 1-cm tumor in the left cerebral cortex, which is consistent with metastatic disease. the patient has no history of seizures or syncope. the patient is referred to outpatient therapy in the hematology/oncology service as well as follow-up with radiation oncology. the patient is ready for discharge. which of the following would be the most appropriate therapy for primary seizure prevention? a) seizure prophylaxis is not indicated. b) valproate. c) phenytoin. d) phenobarbital. e) oral prednisone 40 mg daily. answer: a there is no indication for antiepileptic therapy for primary prevention in patients who have brain metastasis who have not undergone resection. past studies have revealed no difference in seizure rates between placebo and antiepileptic therapy in patients who have brain tumors. antiepileptic therapy has high rates of adverse reactions and caution should be used in their use. 276. a 78-year-old male is admitted due to swelling over his chest wall. during discussion with the patient, he notes that he had an aicd implanted in the area of the swelling over 3 years ago. his postoperative course had been uneventful and he had never developed any wound dehiscence before. on physical examination, there are palpable swelling and fl uctuance over the right upper chest wall at the site of a well-healed incision. the patient notes some fevers and chills on and off the last few weeks. you are very concerned for a cardiovascular implantable electronic device (cied) infection. which of the following is appropriate in the care of your patient? a) draw two sets of blood cultures before beginning initiation of antimicrobial therapy. b) percutaneous aspiration of the generator pocket. c) attempt to preserve the placement of this aicd via empiric antibiotics. d) request removal of device and obtain gram stain and cultures of the tissue and lead tip. e) a and d. answer: e a patient with a suspicion of a cied infection should have two sets of peripheral blood cultures drawn before prompt initiation of antimicrobial therapy. the implantable device should be removed by an expert and the generator-pocket tissue and lead tip should be cultured on explanation. it is appropriate to obtain a transesophageal echocardiogram (tee) to assess for cied infection and valvular endocarditis. percutaneous aspiration is not needed, as the device will be removed. 277. which of the following occurs in the cognitive function following major cardiac surgery? a) all patients experience some transient cognitive decline. b) return to baseline can take as long as 6 months. c) greater declines will be seen in patients with postop delirium. d) most return to baseline at 5 days. e) all of the above. what is his expected postoperative risk of a major cardiac event? a) 0.5 % b) 1 % c) 5 % d) 10 % e) 20 % answer: d one of the most widely used preoperative risk assessment tools is the revised cardiac risk index (rcri). the rcri scores patients on a scale from 0 to 6. the patient here has a rcri score of 3. his score includes high-risk surgery, creatinine greater than 2 mg/dl, and diabetes mellitus requiring insulin. the six factors that comprise the rcri are high-risk surgical procedures, known ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus requiring insulin, and chronic kidney disease with a creatinine greater than 2 mg/dl. 0 predictor = 0.4 %, 1 predictor = 0.9 %, 2 predictors = 6.6 %, ≥3 predictors = >11 % 279. a 24-year-old woman is admitted with signifi cant fatigue, fever, and a sore throat. she reports due to throat pain she has been unable to swallow any liquids for the past 24 h. on physical examination, she is found to have anterior cervical lymphadenopathy, erythematous throat, and mild hepatosplenomegaly. she remembers having mononucleosis in high school. she has mild elevations of her transaminases. her heterophile antibody test is positive. which of the following is true concerning the heterophile antibody test? a) heterophile antibody testing would not be helpful for this patient because the results may be positive owing to her previous episode of mononucleosis. b) she has acute infectious mononucleosis from primary epstein-barr virus (ebv on physical exam, she has marked abdominal pain. her temperature is 39.5 °c (103.0 °f), heart rate is 100 beats per minute, and respirations are 15 per minute. her blood pressure is 100/62. she has marked hyperactive bowel sounds as well as signifi cant abdominal distention. laboratory studies include a leukocyte count of 28,000 and hematocrit of 25 %; and blood cultures are negative. stools are sent for clostridium toxin which is positive. which of the following is the most appropriate treatment for the patient's diarrhea? a) metronidazole orally b) metronidazole intravenously c) vancomycin oral d) vancomycin intravenously answer: c this patient has severe clostridium diffi cile -associated diarrhea (cdi). for patients with severe cdi, suitable antibiotic regimens include vancomycin (125 mg four times daily for 10 days; may be increased to 500 mg four times daily) or fi daxomicin (200 mg twice daily for 10 days). vancomycin has been shown to be superior to metronidazole in severe cases. fidaxomicin has been shown to be as good as vancomycin, for treating cdi. one study also reported signifi cantly fewer recurrences of infection, a frequent problem with c. diffi cile . other considerations in this case may be to obtain a ct scan and possible colorectal surgery consultation. 282. a 67-year-old man was admitted with a cerebrovascular accident. he has done well during his hospitalization and is preparing for discharge to a skilled nursing facility. a catheter, which was placed in the emergency room, has been in for 3 days. he reports no prior incident of urinary retention. it is removed, and patient has diffi culty voiding. which of the following would be considered an abnormal post-void residual (pvr) amount? a) 15 ml b) 50 ml c) 100 ml d) 200 ml e) 300 ml answer: c abnormal residual bladder volumes have been defi ned in several ways. no particular defi nition is clinically superior. some authorities consider volumes greater than 100 ml to be abnormal. others use a value greater than 20 % of the voided volume to indicate a high residual. in normal adults, the post-void residual volume should be less than 50 ml. over the age of 60, a range of 50 ml to 100 ml can be seen but is not known to cause signifi cant issues. post-void residual (pvr) volume increases with age but generally do not rise to above 100 ml unless there is some degree of obstruction or bladder dysfunction. urinary retention is common after several days of catheter placement, particularly in males. caution should be used when placing urinary catheters, as they are a signifi cant cause of urinary retention. whenever possible urinary catheters should be removed. bladder training and time may improve the retention. some consideration may be given to starting the male patient on medications to reduce benign prostatic hypertrophy as well. ultrasound can be used as a noninvasive means of obtaining pvr volume determinations, especially if a precise measurement is not required. the error using this formula, compared with the standard of post-void catheterization, is approximately 21 %. in patients with ascites bedside measurement by ultrasound of pvr can be inaccurate due to an inability to differentiate bladder fl uid from ascitic fl uid. lisenmeyer ta, stone jm. neurogenic bladder and bowel dysfunction. in: de lisa j, editor. rehabilitation medicine. philadelphia: lippincott-raven; 1998. p. 1073-106. a 37-year-old male has been admitted for alcohol-related pancreatitis. after six days, he continues with severe midepigastric pain that radiates to the back with nausea and vomiting. he has not been able eat or drink and has not had a bowel movement since being admitted. on physical examination, the temperature is 37.6 °c (99.5 °f), the blood pressure is 120/76 mmhg, the pulse rate is 90 bpm, and the respiratory rate is 20 breaths/ min. there is no scleral icterus or jaundice. the abdomen is distended and with hypoactive bowel sounds. laboratory studies show leukocyte count 12,400/ μl, amylase 388 μ/l, and lipase 924 μ/l. repeat ct scan of the abdomen shows a diffusely edematous pancreas with multiple small peripancreatic fl uid collections. some improvement from the ct scan 3 days ago is noted. he is now afebrile. which of the following is the most appropriate next step in the management of this patient? a) enteral nutrition by nasojejunal feeding tube b) intravenous imipenem c) pancreatic debridement d) parenteral nutrition e) continue with npo status answer: a this patient has ongoing moderate pancreatitis. with his possible underlying poor nutritional status due to alcoholism and expected inability to eat, the patient will need nutritional support. this patient will likely be unable to take in oral nutrition for several days.. enteral nutrition is preferred over parenteral nutrition because of its lower complication rate and proven effi cacy in pancreatitis. enteral nutrition is provided through a feeding tube ideally placed past the ligament of treitz so as not to stimulate the pancreas. broad-spectrum antibiotics such as imipenem therapy are primarily of benefi t in acute pancreatitis when there is evidence of pancreatic necrosis. randomized, prospective trials have shown no benefi t from antibiotic use in acute pancreatitis of mild to moderate severity without evidence of infection. pancreatic debridement is undertaken with caution and is not indicated here. eatock fc, chong p et al. a randomized study of early nasogastric vs. nasojejunal feeding in severe acute pancreatitis. am j gastroenterol. 2005;100:432-9. eckerwall ge, axelsson jb, andersson rg. early nasogastric feeding in predicted severe acute pancreatitis: a clinical, randomized study. ann surg. 2006; 244:959-65. 284 . a 64-year-old female with a past medical history signifi cant for type 2 diabetes mellitus is admitted with increasing shortness of breath. she is admitted for mild congestive heart failure and responds well to therapy. of note she reports increasing left knee pain. the pain is heightened when she tries to walk with physical therapy. three months ago she had left knee arthroplasty, and postoperative course was uneventful. her vital signs are stable. the patient's knee exam reveals a surgical scar but no joint effusion or redness. what should be done next? a) orthopedics consult b) arthrocentesis c) discharged with mild opioid d) order a knee mri e) discharged home with a trial of nsaids a 82-year-old female is admitted to the hospital service with urinary tract infection and sepsis. on admission she is noted to be lethargic and unable to swallow medicines. she develops progressive respiratory failure and is intubated. a cxr is consistent with ards. an ng tube is placed for administration of medicines. you are considering starting tube feeds in this patient. which of the following is the most accurate statement regarding enteral tube feeds in this patient? a) early enteral tube feeds can be expected to reduce her mortality risk. b) the use of omega-3 fatty acids will reduce her mortality risk. c) enteral tube feeds will increase the risk of infection. d) the benefi ts of early nutrition can be achieved with trophic rates. answer: d the benefi ts of early enteral tube feedings in the critically ill patient are uncertain. studies have revealed inconsistent results. there is some suggestion that the incidences of infection can be reduced, but there is no data to suggest long-term mortality improvement. in patients with ards, trophic tube feedings at 10 ml/h seem to concur the same benefi t as early full-enteral tube feedings. 286. which of the following is an acceptable indication for urinary catheter placement? a) a patient who has urinary incontinence and a stage ii pressure ulcer b) a patient who is under hospice care and requests a catheter for comfort c) a patient who is delirious and has experienced several falls d) a patient who is admitted for congestive heart failure whose urine output is being closely monitored answer: b urinary tract infections (utis) are the most common hospitalacquired infections. most attributed to the use of an indwelling catheter. there should always be a justifi able indication for placement of a urinary catheter, and whenever possible prompt removal should occur. this may be assisted by hospital protocols that trigger automatic reviews of catheter use. 287. an 88-year-old man in hospice care is admitted for dyspnea. he has advanced dementia, severe copd, and coronary artery disease. he has been in hospice for 2 months. he and his family would like to be discharged to home hospice as soon as possible. he is only on albuterol and ipratropium. on physical examination, he is afebrile, and his blood pressure is 110/76 mmhg, pulse rate is 110 beats/min, and respiratory rate is 28 breaths/min. oxygen saturation is 90 %. he is cachectic, tachypneic, and disoriented. he is in moderate respiratory distress. chest examination reveals decreased breath sounds and fi ne inspiratory crackles. in addition to continuing his bronchodilator therapy, which of the following is the most appropriate next step in the treatment of this patient? a) ceftriaxone and azithromycin b) morphine c) methylprednisolone d) haloperidol e) lorazepam answer: b this patient is enrolled in hospice. every effort should be made to ensure comfort and limit unnecessary treatments. dyspnea is one of the most common symptoms encountered in palliative care. opioids are effective in reducing dyspnea in patients with chronic pulmonary disease. a 5-mg dose of oral morphine given four times daily has been shown to help relieve dyspnea in patients with endstage heart failure. extended-release morphine, starting at a 20 mg given daily has been used to relieve dyspnea in patients with advanced copd. bronchodilator therapy should be continued to maintain comfort. antibiotics and corticosteroids are not indicated. 288. a 59-year-old man presents with fever and a diffuse blistering skin rash. he is recently started on allopurinol for gout. the patient also complains of sore throat and painful watery eyes. on physical examination, the patient is found to have blisters developing over a quarter of his body. oral mucosal lesions are noted involvement. the estimated body surface area that is currently affected is 15 %. which of the following statements regarding this patient's diagnosis and treatment are true? a) immediate treatment with intravenous immunoglobulin has been proven to decrease the extent of the disease and improve mortality. b) immediate treatment with glucocorticoids will improve mortality. c) the expected mortality rate from this syndrome is about 10 %. d) the most common drug to cause this syndrome is diltiazem. e) younger individuals have a higher mortality than older individuals with this syndrome. answer: c this patient has stevens-johnson syndrome (sjs). there is no defi nitive evidence that any initial therapy changes outcomes in sjs. early data suggested that intravenous immunoglobulin (ivig) was benefi cial, and this traditionally has been the recommended treatment. however, more recent studies have not shown consistent benefi t with ivig. immediate cessation of the offending agent or possible agents is necessary. systemic corticosteroids may be useful for the short-term treatment of sjs, but these drugs increase longterm complications and may have a higher associated mortality. therapy to prevent secondary infections is important. in principle, the symptomatic treatment of patients with stevens-johnson syndrome does not differ from the treatment of patients with extensive burns, and in many instances, these patients are often treated in burn wards. future studies are required to determine the role of ivig in the treatment of sjs. the lesions typically begin with blisters developing over target lesions with mucosal involvement. in sjs, the amount of skin detachment is between 10 and 30 % . mortality is directly related to the amount of skin detachment with a mortality of about 10 % in sjs. other risk factors for mortality in sjs include older age and intestinal or pulmonary involvement. the most common drugs to cause sjs are sulfonamides, allopurinol, nevirapine, lamotrigine, and aromatic anticonvulsants. 289. a 57-year-old woman with a history of diabetes and familial history of breast cancer is admitted with malaise, an appetite decline, and new-onset ascites. she denies having fevers, chills, diarrhea, nausea, and vomiting. on physical exam, there is no evidence of spider nevi or palmar erythema. her serum albumin is 3.4 g/ dl. on chest x-ray, a right-sided pleural effusion is noted. a diagnostic paracentesis reveals a glucose of 85 mg/dl, an albumin of 2.8 g/dl, and a wbc of 250/ ul, of which 45 % are neutrophils. based on the data provided, what is the most likely cause of her ascites? a) cirrhosis b) metastatic disease c) pelvic mass d) spontaneous bacterial peritonitis e) tuberculous peritonitis answer: c meigs' syndrome is the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. typical diagnostic paracentesis reveals a serum-ascites albumin gradient < 1.1 suggesting a nonportal hypertension-mediated process. of the possibilities for that, ovarian mass is the most likely here. transdiaphragmatic lymphatic channels are larger in diameter on the right. this results in the pleural effusion being typically classically located on the right side. the etiologies of the ascites and pleural effusion are poorly understood. further imaging is indicated. riker d, goba d. ovarian mass, pleural effusion, and ascites: revisiting meigs syndrome. j bronchology interv pulmonol. 2013;20(1):48-51. 290. a 77-year-old female patient presents with dizziness, headache, nausea, and vomiting for the past 48 h. she states that the fl oor feels like it is moving when she walks. the patient is alert, and she tells you she suffered from no recent trauma. on physical exam you note the patient's speech is slightly abnormal. during the neurological examination, the patient is able to understand your questions, respond appropriately, and repeat words, but her words are poorly articulated. she has a great deal of diffi culty walking across the room without assistance. what is your next step in the management of this patient? a) administer unfractionated heparin b) epley maneuver c) ct scan without contrast d) emergent mri or mra e) observation alone answer: d this patient has central vertigo possibly due to a cerebellar infarction. multiple cerebellar signs are noted which help distinguish this from benign peripheral vertigo. due to obstruction by a posterior fossa bone artifact, ct scan may not be of benefi t. emergent mri and mra if available are the tests of choice. this should be done to confi rm the diagnosis and followed for the development of an obstructing hydrocephalus, which can occur with cerebellar infarction. since the posterior fossa is a relatively small and nonexpandable space, hemorrhage or edema can lead to rapid compression. early neurosurgical consultation should be considered. on physical examination, temperature is normal. blood pressure is 147/83, pulse rate is 70 beats/min, and respiratory rate is 12 breaths/min. other physical examination fi ndings are within normal limits. which of the following is the most appropriate insulin therapy after surgery? a) continuous intravenous insulin infusion b) previous schedule of 70/30 insulin c) subcutaneous insulin infusion d) insulin glargine once daily and insulin aspart before each meal e) sliding-scale insulin alone f) insulin aspart before each meal alone answer: d this patient should receive basal insulin as well as scheduled insulin before each meal. this should be adjusted for conditions that occur in the hospital. a patient with longstanding type 1 diabetes makes no endogenous insulin and requires a maintenance dose of insulin postoperatively. it is expected that her po intake would be markedly decreased, and subsequently her insulin dose should be decreased. 293. you are urgently called to see in consultation of a 36-year-old woman who is in postop recovery. she has a sudden elevation of her temperature and is thought to be septic. her laparoscopic cholecystectomy was completed 45 min ago without complication. on physical exam her temperature is 40.5 °c (105 °f). she has respiratory rate of 28 breaths per minute. she is tachycardic, shaking, and confused. there is diffuse muscular rigidity noted. which of the following drugs should be administered immediately? a) acetaminophen b) haloperidol c) hydrocortisone d) ibuprofen e) dantrolene answer: e the patient has malignant hyperthermia. dantrolene should be given. physical cooling in addition to dantrolene with cooling blanket or iv fl uids should be used as well. dantrolene may be used in other central causes of extreme hyperthermic such as neuroleptic malignant syndrome. in this case, the episode was probably caused by succinylcholine and/or inhalational anesthetic. this syndrome occurs in individuals with inherited abnormality of skeletal muscle sarcoplasmic reticulum. more than 30 mutations account for human malignant hyperthermia. genetic testing is available to establish a diagnosis. the caffeine halothane contracture test remains the criterion standard. this is a muscle biopsy and performed at a designated center. the syndrome presents with hyperthermia or a rapid increase in body temperature that exceeds the ability of the body to lose heat. muscular rigidity, acidosis, cardiovascular instability, and rhabdomyolysis also occur. antipyretics such as acetaminophen, ibuprofen, and corticosteroids are of little use. the dantrolene dose is 2.5 mg/kg rapid iv bolus and may be repeated prn. occasionally a dose up to 30 mg/kg is necessary. which of the following is the most appropriate perioperative recommendation regarding anticoagulation in this patient? a) discontinue warfarin 5 days before surgery and bridge with full-dose iv heparin before and after surgery. b) discontinue warfarin 5 days before surgery and restart on the evening of the surgery. c) continue with warfarin. d) reverse anticoagulation with fresh frozen plasma transfusion 1 h before surgery and restart warfarin on the evening of the surgery. in patients with mechanical valves and at low risk for thromboembolism, low-dose low-molecular-weight heparin or no bridging is recommended. the short-term risk of anticoagulant discontinuation in this patient is small. the current recommendation is to stop warfarin 5 days before the procedure. the inr goal is 1.5. warfarin should be restarted within 24 h after the procedure. in patients with a mechanical valve and an increased risk of a thromboembolic event, it is recommended that unfractionated heparin be begun intravenously when the inr falls below 2.0. this should be stopped 4-5 h before the procedure and restarted after surgery. in patients with a mechanical heart valve who require emergent surgery, reversal with fresh frozen plasma may be performed. 297. an 88-year-old female who was admitted to the hip fracture service for a right hip fracture has currently become agitated and confused. she underwent hip fracture repair two days prior. she has a history of osteoporosis, dementia, and type 2 diabetes. her postoperative medicines include oxycodone 5 mg every 4 h as needed for pain as well as iv morphine 1-2 mg/h as needed for the pain. during the patient's fi rst night, she was calm and relatively free of pain. however, on her second night, she has become acutely agitated and is reported by the nurse to be screaming and pulling out lines and drains. her temperature is 99.1 °f. her pulse rate is 100 beats/min. her respirations are 20 per minute. her oxygenation is 92 % on room air. her hematocrit and hemoglobin are within normal limits as well as the rest of her electrolytes. which of the following is the appropriate response/ treatment for this patient's delirium? a) four-point restraints b) one 2 mg dose of intravenous lorazepam c) one 5 mg dose of oral haloperidol d) one 0.5 mg dose of oral haloperidol e) one 5 mg dose of intravenous haloperidol answer: d treatment of postoperative-induced delirium is a common issue confronted in the hospital setting. delirium that causes injury to the patient or others should be treated with medications. this can be a diffi cult management issue. no medication is currently approved by the food and drug administration for the treatment of delirium. current guidelines recommend using low-dose antipsychotics such as haloperidol. the use of benzodiazepines should be limited, unless concurrent alcohol withdrawal is present. a specifi c fda warning has been issued for intravenous haloperidol due to the risk of torsades de pointes in 2007. low-dose haloperidol, less than 2 mg, has a low incidence of extrapyramidal side effects. qtc prolongation monitoring is recommended for patients. if feasible, this patient should have had a baseline ekg as well as a follow-up ekg. haloperidol at doses greater than 4.5 mg increases the incidence of extrapyramidal side effects and should be avoided. the surgery was uneventful. on hospital day 2, she has a sudden onset of tachypnea and hypoxemia. a computed tomography pulmonary angiogram reveals a thrombus in the pulmonary artery to the right lower lobe. her inr is 1.0. what is the most likely cause of her thrombosis? a) surgery-induced thrombosis b) depletion of thrombin due to the surgical acutephase response c) thrombogenesis due to postoperative hypovolemia d) undetected prior thrombus e) rebound hypercoagulability and subsequent thromboembolism answer: e rebound hypercoagulability is the most likely cause. this may occur after abrupt cessation of warfarin. in addition, surgery increases the risk of thromboembolic events. following an abrupt withdrawal of warfarin, thrombin and fi brin formation increase and very high levels of thrombin activation are seen. if possible, warfarin withdrawal should be gradual which would not have been feasible in the current case. safely resuming anticoagulation after surgery should be a goal as well. a 60-year-old man who has metastatic lung cancer and painful bone metastases reports severe pruritus that started when he began to take morphine for his pain. pain in his chest wall and legs has been successfully treated with sustained-release morphine (80 mg every 12 h) and short-acting morphine (15 mg orally every 2 h as needed for breakthrough pain) which he uses two or three times daily, depending on his level of activity. on physical examination, the temperature is 37 °c (98.6 °f), pulse rate is 80 beats per minute, respirations are 16 per minute, and blood pressure is 115/70 mmhg. oxygen saturation by pulse oximetry is 95 % on room air. the patient is alert and oriented. his pupils are 4 mm initially and constrict to 2 mm with a light stimulus. the lungs are clear. cardiac examination shows a normal rate and regular rhythm. no rash is seen. examination of the abdomen is signifi cant for suprapubic dullness and sensitivity. neurological examination is nonfocal. which of the following should be done next? a) change to oxycodone, 40 mg every 12 h, and oxycodone, 5-10 mg every 2 h as needed b) lower the dosage of sustained-release morphine to 30 mg every 12 h c) continue with same morphine dose d) change to oxycodone, 60 mg every 12 h, and oxycodone, 15 mg every 2 h as needed answer: a oxycodone may cause somewhat less nausea, hallucinations, and pruritus than morphine. mild to moderate morphineinduced puritis may be managed by small-dose reductions or antihistamines. this patient has severe puritis which may be relieved by changing to oxycodone. the patient's baseline long-acting morphine daily dose was 160 mg, with a minimum short-acting morphine dose of 30 mg daily, which yields a total daily dose of 190 mg. the morphine-to-oxycodone ratio is 1.5:1. this patient's morphine-equivalent daily dose of oxycodone would be 120 mg. the daily dose of oxycodone would be 60 mg. thus, the every-12-h dose of long-acting oxycodone would be 40 mg. a 68-year-old female who has metastatic small cell lung cancer presents to the emergency room with shortness of breath. she is noted to be in marked respiratory distress and is intubated by emergency room personnel. she is admitted to the intensive care unit. on review of the medical records, you fi nd that the patient has an advanced directive, which indicates that the patient did not want to be intubated. this is noted both in a signed advanced directive as well as in the hospital records. you arrange a family meeting to discuss goals of care. the patient's daughter has recently quit her job and has moved in with her mother to provide care. you discuss the case with her, and she states that her mother has changed her mind recently and would like to be on the ventilator at all costs. which of the following is the correct course of action? a) follow the patient's written documentations and extubate the patient and provide comfort care. b) follow the daughter's instructions and have patient remain intubated. c) request an ethics consultation. d) consult the hospital's legal affairs department. answer: c it is of primary importance to follow the patient's wishes. in this particular case, there is some diffi culty in determining if the patient has recently changed her mind, as is suggested by the daughter. she has clearly documented her advance directives, and it would be appropriate to withdraw life support if the daughter did not provide the confl icting statement. financial confl icts of interest often interfere with the surrogates ability to act in the best interest of the patient. in this particular case, there are circumstances that suggest that fi nancial considerations may be infl uencing the statement. it would be diffi cult for an individual practitioner to make this determination, without the potential of liability. subsequently, an ethics consultation would be the correct course of action. as there are several factors, ethics and clinical, involved, an attorney alone would not be in a position to resolve the issue. 303. an 83-year-old female is admitted from a nursing home to the hospital for shortness of breath. on chest x-ray, she has a new-onset pleural effusion for which thoracentesis is indicated. on her medical record, it is reported that she has a history of dementia. on physical exam she is awake and alert. she knows that she is in the hospital, knows her name and address, but is confused about the current date. on review of her medical records, you discover that she has neither family members nor a durable power of attorney. in attempting to obtain consent for the procedure, which of the following is the next best step? a) proceed without consent. b) assign guardianship. c) determine capacity yourself. d) psychiatric consultation for competency. e) ethics consultation. answer: c there are four components of determining capacity in decision-making concerning a particular treatment or test: (1) an understanding of relevant information about proposed diagnostic tests or treatment, (2) appreciation of their medical situation, (3) using reason to make decisions, (and 4) ability to communicate their choice. in most instances, the primary physician should possess the ability to determine capacity. capacity is not the same measurement as competence. competence is determined by a court of law and uses issues of capacity in evaluating the legal ability to contract. a psychiatric consultation can determine competency but is usually not needed to determine capacity. assigning guardianship or an ethics consultation can be a lengthy process and should be reserved for cases with signifi cant issues to be resolve. a 65-year-old male is admitted to the hospital for elective total knee arthroplasty. he has a history of type 2 diabetes mellitus and is treated with metformin. he reports fair glucose control with diet and oral agents. he has never been on insulin. on physical examination he has mild edema of his lower extremities but otherwise is within normal range. preoperative laboratory studies have been done 1 week prior. his hemoglobin a1c revealed a concentration of 6.8 %. plasma glucose level measured on the day of surgery is 210 mg/l. which of the following is the most appropriate treatment for patients with elevated blood sugars preoperatively and postoperatively? a) metformin b) sliding-scale insulin c) iv hydration d) basal and sliding-scale insulin e) diet control alone answer: d the goal of glycemic control in the hospitalized patient is balancing the risks of hypoglycemia against the known benefi ts in morbidity and mortality. although tight control has been advocated in the past, current consensus guidelines recommend less stringent glycemic goals, typically between 80 and 150 mg/dl. the ultimate goal in the management of diabetic patients (dm) is to achieve outcomes equivalent to those in patients without dm. a meta-analysis of 15 studies reports that hyperglycemia increased both in-hospital mortality and incidence of heart failure in patients admitted for acute myocardial infarction. several other studies have also demonstrated the benefi ts of glycemic control in the perioperative area. type 2 diabetes mellitus often requires insulin while in the hospital. the requirements may be unpredictable. this may be due to the stress of hospitalization, dietary changes, glucose added to iv fl uids, and medicine interactions. sliding scale alone has often been traditionally used in the past. however, this method of control often results in wide fl uctuations in glycemic control. the optimal plasma glucose level postoperatively is not known, and certainly tight control has its risks. a 55-year-old female has been admitted for cellulitis. she has responded well to antibiotics and is ready for discharge. on admission she was noted to be in atrial fi brillation. she has been treated with low-molecularweight heparin in the hospital. she fi rst noted the irregular heartbeat 4 weeks ago. she denies chest pain, shortness of breath, nausea, or gastrointestinal symptoms. past medical history is unremarkable. there is no history of hypertension, diabetes, or tobacco use. her medications include metoprolol. on physical examination, she has a blood pressure of 124/76 mmhg and a pulse of 70 beats/min. an echocardiogram shows a left atrial size of 3.5 cm. left ventricular ejection fraction is 63 %. there are no valvular or structural abnormalities. which of the following would be the appropriate treatment of her atrial fi brillation? a) she requires no antiplatelet therapy or anticoagulation because the risk of embolism is low. b) lifetime warfarin therapy is indicated for atrial fi brillation in this situation to reduce the risk of stroke. c) she should be started on iv heparin and undergo electrical cardioversion. d) she should continue on sc low-molecular-weight heparin and transitioned to warfarin. e) her risk of an embolic stroke is less than 1 %, and she should take a daily aspirin. answer: e patients younger than 60 years of age without structural heart disease or without risk factors have a very low annual risk of cardioembolism of less than 0.5 %. therefore, it is recommended that these patients only take aspirin daily for stroke prevention. the risk of stroke can be estimated by calculating the chads2 score. older patients with numerous risk factors may have annual stroke risks of 10-15 % and must take a vitamin k antagonist or alternate indefi nitely. cardioversion may be indicated for symptomatic patients who want an initial opportunity to remain in sinus rhythm. a) peg tubes reduce aspiration as opposed to nasogastric tubes. b) in end-stage advanced malignancy with cachexia, peg tubes have been proven to improve survival and reduce morbidity. c) peg tubes have been proven to improve survival in end-stage dementia. d) mean survival after peg tube placement for failure to thrive is 6 months. answer: d the physician is often faced with this decision in a variety of end-of-life situations to consider placement of a peg tube. survival benefi ts of peg tube placement are often minimal at best. there is a wide range of cultural expectations in reference to this issue. it is important to understand the facts concerning the possible benefi ts or lack of benefi ts of peg tube placement when counseling the patient and family. as noted in this question, survival benefi ts for peg tube placement in a patient with failure to thrive to variety of conditions are modest at best. a 59-year-old man has been admitted for congestive heart failure. his symptoms have resolved. prior to discharge the cardiology service would like him to undergo placement of an automatic implantable cardiac converter defi brillator (aicd). he is on warfarin with an inr of 2.9. his other problems include rate-controlled atrial fi brillation and coronary artery disease. an echocardiogram performed 2 weeks ago showed a left ventricular ejection fraction of 25 % and a well-functioning mechanical mitral valve. trace edema is noted in the extremities. how should his warfarin be managed prior to placement of his aicd? a) continue warfarin, with a target inr of 3.5 or less on the day of the procedure. b) discontinue warfarin 5 days before the procedure and resume the day after the procedure. c) discontinue warfarin 5 days before the procedure and bridge with an unfractionated heparin infusion. d) discontinue warfarin 5 days before the procedure and bridge with low-molecular-weight heparin. answer: a not all procedures require warfarin to be stopped. in some cases, there is data to support continuing warfarin as opposed to bridging therapy. a randomized, controlled trial found that patients at high risk for thromboembolic events on warfarin who need a pacemaker or implantable cardioverter defi brillator (icd) can safely continue warfarin without bridging anticoagulation. continuing warfarin treatment at the time of pacemaker in patients with high thrombotic risk was associated with a lower incidence of clinically signifi cant device-pocket hematoma, as opposed to bridging with heparin. a 56-year-old male is admitted to the hospital with fever and cough. he was well until 1 week before admission when he noted progressive shortness of breath, cough, and productive sputum. on the day of admission, the patient's wife noted him to be lethargic. the past medical history is notable for alcohol abuse and hypertension. on examination, the patient is lethargic. temperature is 38.9 °c (102 °f), blood pressure is 110/85 mmhg, and oxygen saturation is 86 % on room air. there are decreased breath sounds at the right lung base. heart sounds are normal. the abdomen is soft. there is no peripheral edema. chest radiography shows a right lower lobe infi ltrate with a moderate pleural effusion. the white blood cell count is 15,000/μl and 6 % bands. he is admitted and started on broad-spectrum antibiotics. on hospital day 3 he is not eating due to lethargy. a nasogastric tube is inserted, and tube feedings are started. the next day, plasma phosphate is found to be 1.2 mg/dl and calcium is 9.2 mg/dl. what is the most appropriate approach to correcting the hypophosphatemia? a) administer iv calcium gluconate 1 g followed by infusion of iv phosphate at a rate of 8 mmol/h for 6 h. b) administer iv phosphate alone at a rate of 4 mmol/h for 6 h. c) administer iv phosphate alone at a rate of 8 mmol/h for 6 h. d) stop tube feedings, phosphate is expected to normalize over the course of the next 24-48 h. e) initiate oral phosphate replacement at a dose of 1750 mg/day. answer: c severe hypophosphatemia occurs when the serum concentration falls below 2 mg/dl . in this circumstance, iv replacement is recommended. in this patient with a level of 1.2 mg/dl, the recommended infusion rate is 8 mmol/h over 6 h for a total dose of 48 mmol. levels should be checked every 6 h as well. malnutrition from fasting or starvation may result in depletion of phosphate. when nutrition is initiated, redistribution of phosphate into cells occurs. this is common in alcoholics. it is generally recommended to use oral phosphate repletion when the serum phosphate levels are greater than 1.5-2.5 mg/dl. a 58-year-old male is admitted to the hospital for elective hip replacement therapy. he has a history of chronic pulmonary disease and takes inhaled steroids as well as albuterol inhalers. he was admitted to the hospital 2 weeks ago for a moderate exacerbation of copd for which he recently completed a 10-day course of prednisone. he is currently asymptomatic, and his breathing is back to baseline. he states that he has not taken steroids within the past year other than his recent admission. you are asked to provide clearance for the orthopedic service of this patient. which of the following is the most appropriate treatment? a) obtain a cortrosyn stimulation test and begin steroids if there is evidence of cortisol defi ciency. b) administer intravenous hydrocortisone 50 mg on the morning of surgery. c) administer intravenous hydrocortisone 100 mg preoperatively and then 50 mg every 8 h for 2 days after surgery. d) proceed with surgery. e) postpone surgery for 2 weeks. 316. an 86-year-old male is admitted for cough, dyspnea, and dysphagia. he has a known large non-small cell cancer in the upper lobe of the right lung and is on week 4 of palliative irradiation. he reports anorexia, diffi culty swallowing solid food, and right shoulder pain. his wife and family are concerned about dehydration. they request iv fl uids and nutrition. on physical examination, the patient is thin and appears weak but alert. pulse rate is 120 beats per minute, respirations are 24 per minute, and blood pressure is 150/70 mmhg. there are temporal wasting and a dry oropharynx. the patient's breathing is shallow, with mild tachypnea. breath sounds are diminished in the upper lobe of the right lung. you convene a family meeting to discuss options. which of the following would be the most likely outcome of intravenous hydration or nutrition in this patient? a) reduced bun/serum creatinine ratio b) prolonged survival c) increased albumin level d) improved quality of life answer: a families feel an important obligation to provide nutrition and hydration to the dying patient. a randomized controlled trial found that parenteral hydration did not improve quality of life in advanced cancer. the intravenous fl uids would likely reduce this patient's prerenal azotemic state in the short term but would not have a benefi cial impact on his quality of life. these facts can guide counseling of patients and families in seeking noninvasive measures for this stage of advanced cancer. 318. a 26-year-old woman is evaluated in the emergency department for abdominal pain. she reports a vague loss of appetite for the past day and has had progressively severe abdominal pain at her umbilicus. the pain is collicky. she reports that she is otherwise healthy and has had no sick contacts. surgery has been consulted and recommends observation. you are consulted for admission. on physical exam her temperature is 38.2 °c (100.8 °f), heart rate 110 bpm, and otherwise normal vital signs. her abdomen is tender in the right lower quadrant and pelvic examination performed in the emergency room is normal. urine pregnancy test is negative. which of the following imaging modalities would you do next? a) colonoscopy b) pelvic ultrasound c) ct of the abdomen without contrast d) ultrasound of the abdomen e) transvaginal ultrasound f) plain fi lm of the abdomen answer: c ct scan is indicated for the diagnoses of acute appendicitis. it has been shown to be superior to ultrasound or plain radiograph in the diagnosis of acute appendicitis, the appendix is not always visualized on ct, but nonvisualization of the appendix on ct scan is associated with surgical fi ndings of a normal appendix 98 % of the time. this patient presented with classic fi ndings for acute appendicitis. initial anorexia progressed to vague periumbilical pain. this was followed by localization to the right lower quadrant. low-grade fever and leukocytosis may be present. acute appendicitis is primarily a clinical diagnosis. however, imaging modalities are frequently employed as the symptoms are not always classic and take time to evolve. plain radiographs are rarely helpful. ultrasound may demonstrate an enlarged appendix with a thick wall, but is most useful to rule out gynecological disease such as ovarian pathology, tuboovarian abscess, or ectopic pregnancy, which can mimic appendicitis. an abdominal and pelvic computed tomography scan shows a large amount of stool but no bowel obstruction. which of the following is the correct treatment for this patient's ongoing constipation? a) add lactulose. b) add n-methylnaltrexone. c) add docusate. d) place a nasogastric tube for bowel decompression. e) request a colorectal surgery consult for manual disimpaction. answer: a constipation is the most frequent side effect associated with long-term opioid therapy. osmotic laxatives, such as mannitol, lactulose, and sorbitol, are effective in the palliation of opioid-induced constipation. although expert consensus supports the use of prophylactic bowel regimens in all patients taking opioids, little evidence demonstrates the effi cacy of one regimen over another. bulk-forming laxatives increase stool volume but should be used with caution in patients with advanced cancer because they require adequate fl uid intake and physical activity to prevent exacerbation of constipation. docusate has very little effect when given alone for opioidinduced constipation. gastric motility is decreased in these patients and softening of the stool alone may not alleviate the symptom. in many situations, its effi cacy has been questioned. n-methylnaltrexone is used for the treatment of opioidinduced constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has been insuffi cient. in this patient adding, starting and continuing with lactulose is the next step. in addition a bowel diary may be beneficial to review on her follow-up appointment. pappagallo m. incidence, prevalence, and management of opioid bowel dysfunction. am j surg. 2001;182 (suppl 5a):11s-8s. a 53-year-old woman who has hepatitis c cirrhosis is admitted for worsening ascites. in addition to complaints of abdominal pain, she complains of severe puritis. she has been on cholestyramine for several months for the itching. on physical exam multiple excoriations of her skin are noted and she is unable to stop scratching. she is very anxious and fatigued. her serum laboratory results are stable from last admission, including a stable total bilirubin. ultrasonography shows no evidence of biliary ductal dilatation or changes in her liver. which of the following should you now recommend? a) ursodeoxycholic acid at 30 mg/kg daily b) diphenhydramine 50 mg every 6 h c) naltrexone 25 mg daily d) morphine 5 mg bid e) hydroxyzine 10 mg bid answer: c refractory itching is a common in end-stage liver disease patients. it may be severe leading to signifi cant excoriations. cholestyramine has been the mainstay of treatment. patients who do not respond to continued doses of cholestyramine probably will not respond to an antihistamine. naltrexone is tolerated well and is a reasonable option in these cases. patients started on naltrexone should be followed for signs of withdrawal. wolfhaqen fh, sternieri e, hop wc et al. oral naltrexone therapy for cholestatic pruritus: a double-blind, placebocontrolled study. gastroenterology. 1997; 113:1264-9. 322 . a 69-year-old female with osteoarthritis of the knees for many years and has been advised by her orthopedist that the timing is now right to undergo knee arthroplasty. she has a history of diabetes, high cholesterol, hypertension, and coronary artery disease. nine months ago, she underwent a drug-eluting stent placement for worsening angina, which she tolerated well. she has been angina-free since that time and is able to walk up several fl ights of stairs without angina. current medications are aspirin, clopidogrel, losartan, and metoprolol. your recommendations concerning surgery are the following: a) surgery can proceed as planned. b) surgery should wait for 2 months. c) surgery can occur in 3 months. d) surgery can occur in 9 months. answer: c elective surgery should be delayed at least 1 year after the placement of a drug-eluting stent. rapid thrombosis of a drug-eluting stent (des) is a catastrophic complication. the risk of stent thrombosis is increased in the perioperative setting and is strongly associated with the cessation of antiplatelet therapy. to avoid thrombosis with des, aspirin and antiplatelet agents should be continued throughout surgery. in spite of the increased risk of bleeding, this strategy is acceptable in many types of invasive surgical procedures with no change in outcome. in situations where surgery may be needed on a semi-urgent basis in patients who have received a drug-eluding stent within 1 year and the risk of bleeding is high. in these situations, consultation with cardiology is recommended. elective surgery with bare metal stents should be delayed for 30-90 days. a patient with severe dementia is admitted for worsening anorexia and nausea over the past 6 weeks. she lives at home with her family. the family would like to continue palliative care but are looking to improve her appetite and diminish her nausea. you and the family meet and agree on a conservative course of action. which of the following statements accurately characterizes the treatment of these complications of severe dementia? a) haloperidol has minimal effects against nausea. b) even though this patient has severe dementia, it would be unethical to withhold nutrition and hydration. c) a feeding tube will reduce the risk of aspiration pneumonia. d) a trial of antidepressants is indicated. e) impaction may explain all the symptoms. f) a trial of megestrol acetate. answer: e anorexia and gastrointestinal symptoms are common near the end of life. despite a nonaggressive approach, some simple measures may improve symptoms. haloperidol may be highly effective against nausea and may be less sedating than many commonly used agents, such as prochlorperazine. impactions are common and can present with a variety of symptoms. treatment can be relatively easy and can improve comfort. because of the terminal and irreversible nature of end-stage dementia and the substantial burden that continued lifeprolonging care may pose, initiating aggressive hydration and nutrition would not be indicated. appetite stimulants such as megestrol acetate have not been shown to be of any benefi t in the anorexia of end-stage dementia. hanson lc, ersek m, gilliam r, carey ts. oral feeding options for patients with dementia: a systematic review. j am geriatr soc. 2011;59(3):463-72. a 23-year-old female is admitted with a new deep venous thrombosis (dvt). she is pregnant and in her late second trimester. you are consulted for management of her dvt. in review of her labs, it is noticed that her liver functions are elevated. her ast is 120 units/l; her alt is 140 units/l. t. bili is 1.6 mg/dl. which of the following is the likely diagnosis? a) hyperemesis gravidarum b) hellp c) cholestasis of pregnancy d) acute fatty liver of pregnancy e) none of the above answer: c gestational age of the pregnancy is a great guide to the differential of liver disease in the pregnant woman. cholestasis of pregnancy is common and most typically presents in the late second trimester. approximately 1 % of pregnancies in the united states are affected by this condition. some hepatic diseases of pregnancy are mild, and some require urgent and defi nitive treatment. a common condition of the fi rst trimester is hyperemesis gravidarum and may result in elevated ast and alt; however this usually resolves by week 20 of gestation. acute fatty liver of pregnancy is a cause of acute liver failure that can develop in the late second or third trimester. elevated lfts and bilirubin are most commonly seen. although symptoms and signs are similar to those of preeclampsia and hellp syndrome, aminotransferase levels tend to be much higher. riely ca. liver disease in the pregnant patient. am j gastroenterol. 1999; 94:1728-32. 326 . a 66-year-old male is admitted with acute onset of left hemiplegia. he has a history of hypertension, nonvalvular atrial fi brillation, and thyroid disease. he has been lost to medical follow-up in recent years and has been on no anticoagulation. on physical exam, motor strength is 1/5 in the left arm and 2/5 in the left leg. electrocardiogram reveals atrial fi brillation with a heart rate of 70 beats per minute. mri performed on presentation reveals a right middle cerebral artery infarction. which of the following is appropriate treatment for stroke prevention? a) aspirin 350 mg daily alone b) clopidogrel 25 mg daily c) warfarin, adjusted to achieve an inr of 2-3 d) unfractionated heparin bolus, followed by infusion e) enoxaparin answer: c guidelines do not support the routine use of anticoagulation for acute ischemic stroke. in this particular case with a large territory middle cerebral artery infarct, any urgent anticoagulation may increase the risk of conversion to hemorrhage. several randomized, controlled trials that used heparin early after ischemic stroke failed to show a signifi cant overall benefi t of treatment over controls. an exception may be in patients with acute ischemic stroke ipsilateral to a severe stenosis or occlusion of the internal carotid artery. stroke prevention treatment for atrial fi brillation is most often determined according to the chads2/chads2vas system. warfarin continues to be the most commonly used agent, although a number of newer agents including dabigatran are increasingly being prescribed. current recommendation is that warfarin be started during the hospitalization. bridging with low-molecular-weight heparin is not usually needed but may be considered in certain circumstances. a 37-year-old male with a history of intravenous drug abuse is admitted with fever and hypertension. a diagnosis of mitral valve endocarditis is made by echocardiogram. he is noted to have a large lesion on his mitral valve with moderate regurgitation. he is started on broadspectrum antibiotics and has a clinically good response. when is surgery indicated in the presence of endocarditis? a) heart failure b) after several embolic events c) myocardial abscess d) confi rmed fungal endocarditis e) all of the above answer: e fifteen to twenty percent of the patients who have endocarditis will ultimately require surgical intervention. congestive heart failure in a patient with native valve endocarditis is the primary indication for surgery. the decision to proceed with surgery is often diffi cult due to patient comorbidities. traditional criteria include those listed above. it is suggested that surgery may be considered in patients with large lesions and signifi cant valvular disease. early surgery reduces the risk of embolic events, although this has not been proven to change overall mortality. failure of medical treatment is another indication for surgery, although guidelines are not specifi c. in addition surgery should be considered in patients with multiresistant organisms. endocarditis in many circumstances warrants early cardiothoracic surgery consultation. 328. which of the following patients with metastatic disease is potentially curable by surgical resection? a) a 22-year-old man with a history of osteosarcoma of the left femur with a 1-cm metastasis to his right lower lobe b) a 63-year-old woman with a history of colon cancer with one metastases to the left lobe of the liver c) operable non-small cell lung cancer with a single brain metastasis d) all of the above e) none of the above answer: d in colon, non-small cell lung and osteosarcoma cancer cures have been reported with resection of solitary metastatic lesions. metastases typically represent widespread systemic dissemination of disease and are associated with poor prognosis. palliative chemotherapy is generally the accepted method of treatment. over the last several years, numerous reports and studies have demonstrated long-term survival after resection of isolated metastasis. after extensive investigation for further metastatic sites, isolated metastasis should be considered for reaction in select cases. manfredi s, bouvier am, lepage c et al. incidence and patterns of recurrence after resection for cure of colonic cancer in a well defi ned population. br j surg. 2006; 93:1115-22. 329 . a 56-year-old white male with known clinical atherosclerotic disease is admitted with severe leg cramps. his past medical history is signifi cant for a myocardial infarction (mi) 4 years ago requiring stent placement. at the time of his mi, he was initiated on a high-intensity statin; since then he has developed severe leg cramps. what would be the next best alternative in lipid therapy for this patient? a) start atorvastatin 20 mg po daily. b) no longer a need for statin therapy since his mi was 4 years ago. c) start rosuvastatin 20 mg po qhs. d) start pravastatin 10 mg po qhs. answer: a he should be on a high-intensity statin, but he was unable to tolerate the side effects. according to american college of cardiology guidelines, patients with known clinical atherosclerotic disease should be on a moderate-intensity statin if not a candidate or cannot tolerate the highintensity regimen. atorvastatin 20 mg is a moderateintensity statin. the moderate-intensity daily dose will lower ldl-c by approximately 30 to <50 %, whereas the high-intensity therapy lowers ldl-c by approximately ≥50 %. lastly, pravastatin 10 mg is a low-intensity statin. 330. a 62-year-old man is admitted for dehydration. he also reports severe nausea and vomiting that began 24 h ago. he recently started chemotherapy for non-small cell lung cancer. his last dose was 48 h ago. on physical examination his abdomen is soft and nontender. bowel sounds are present. he is admitted and started in intravenous fl uids. despite several doses of ondansetron, he continues to have near constant nausea. what would be the next appropriate treatment for his nausea and vomiting? a) dexamethasone b) haloperidol c) lorazepam d) octreotide answer: a dexamethasone is recommended for the management of delayed chemotherapy-induced nausea and vomiting. delayed nausea and vomiting are any nausea and vomiting that occurred after the day that chemotherapy is infused. nausea and vomiting are two of the most feared cancer treatment-related side effects for cancer patients. dexamethasone has synergistic action with many antiemetic medications. its specifi c antiemetic mechanism of action is not fully understood. it is generally started at 8 mg once or twice daily. corticosteroids may be effective as monotherapy as well. a 63-year-old man is admitted to the hospital because of hematemesis. he has gastroesophageal refl ux disease and atrial fi brillation; he takes warfarin. he had felt well until this morning when nausea developed after eating. he vomited blood once and was brought to the hospital. on physical exam, the temperature is normal. pulse rate is 84 beats per minute and irregular, and blood pressure is 112/74 mmhg. abdominal examination is normal. hemoglobin is 11.8 g/dl, serum creatinine is 0.9 mg/dl, and egfr is greater than 60 ml/ min/1.73 m 2 . intravenous isotonic saline is given, and nasogastric lavage is subsequently performed. upper endoscopy reveals a duodenal ulcer, which is successfully cauterized. warfarin is discontinued, and intravenous pantoprazole is begun. no additional bleeding is noted after 48 h, and the patient is prepared for discharge. how long after the bleeding episode can this patient's warfarin be safely restarted? a) one week. b) one month. c) six weeks. d) three months. e) warfarin should not be restarted. answer: a gastrointestinal (gi) bleeding affects an estimated 4.5 % of warfarin-treated patients annually and is associated with a signifi cant risk of death. these patients present a dilemma for clinicians regarding when to restart warfarin. a recent study examined patients who had gi bleeds when on warfarin. they found that warfarin therapy resumption within 1 week after a gi bleed was, after 90 days, associated with a lower adjusted risk for thrombosis and death without signifi cantly increasing the risk for recurrent gi bleeding compared to those who did not resume warfarin. the median time to restart warfarin was 4 days. from this study, a reasonable period of 7 days is suggested. 332. an 82-year-old male is admitted for communityacquired pneumonia. during the fi rst 24 h of admission, he undergoes cardiopulmonary arrest. he was subsequently successfully coded on the fl oor. the family cannot be contacted, and full resuscitation measures are taken. he is transferred to the icu. which of the following will characterize the patient's post-arrest clinical course? a) increased intracranial pressure b) intact cerebrovascular autoregulation c) myocardial dysfunction d) minimal infl ammatory response answer: c the post-cardiac arrest syndrome (pcas) is an infl ammatory syndrome that best resembles sepsis. infl ammatory mediators are released, resulting in activation of the coagulation cascade. cerebral edema, ischemic degeneration, and impaired autoregulation characterize the brain injury pattern in the pcas. brain injury alone contributes greatly to overall morbidity and mortality in the resuscitated cardiac arrest patient. there is impaired autoregulation as well as impaired oxidative metabolism. there is predictable myocardial dysfunction. myocardial dysfunction in the pcas seems to be reversible and is characterized largely by global hypokinesis. elevations of intracranial pressure are not prominent. treatment during this period involves hemodynamic support and the use of inotropic and vasopressor agents if warranted. hyperthermia should be avoided at all costs in patients with the pcas. if aggressive therapy is pursued, consider sedation with hypothermia to improve neurological outcome in the icu setting. a 72-year-old female is admitted with abdominal distension. she has history of colon cancer. her last bowel movement was 4 days ago despite her taking scheduled polyethylene glycol. her cancer was diagnosed 2 years ago and has been treated with chemotherapy after her disease was determined to be surgically unresectable. on physical exam the bowel is distended with absent bowel sounds. lungs are normal. a nasogastric tube is placed with some mild improvement of distension. ct scan shows dilated loops of small bowel and colon with a transition point in the mid-descending colon. which of the following will most likely improve this patient's ability to eat and ensure adequate caloric intake and fl uids? a) referral for radiation b) placement of a colonic stent across the single site of obstruction c) fleet enema d) exploratory surgery e) placement of a venting percutaneous endoscopic gastrostomy (peg) tube answer: b a single-site bowel obstruction can be successfully palliated with colonic stent placement. most self-expandable metal stent (sems) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. this would be a reasonable approach in this patient as opposed to surgery. when performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. hand decontamination with either antisepticcontaining soaps, alcohol-based gels, or a combination has consistently been shown to reduce clabsi rates. skin antisepsis with chlorhexidine was found to be associated with a 50 % reduction in the subsequent risk of clabsi compared with povidone iodine. hypocalcemia has also been reported following massive transfusions due to the binding citrate agent. however, this is transient, and there is no evidence that calcium supplementation will be of benefi t. septic shock and severe sepsis are also associated with hypocalcemia. this is due to abnormalities of vitamin d and parathyroid hormone. there is no evidence that septic patients benefi t from calcium repletion. the optimum dietary protein intake in patients with pressure ulcers is unknown, but may be much higher than the current adult recommendation of 0.8 g/kg/day. increasing protein intake beyond 1.5 g/kg/day may not increase protein synthesis and may cause dehydration. it has been suggested that a reasonable protein requirement is therefore between 1.0 and 1.5 g/kg/day. zinc and vitamin c are often included in supplements but have not been shown to improve healing in decubitus ulcers. med. 1980; 133:485-92. 338 . a 35-year-old female is admitted with severe pain to her left foot. she states that she had a fracture of her ankle due to a fall 2 months ago. since that time, she has had limited mobility and has infrequently gotten out of bed. she has had a follow-up appointment with her orthopedist who reports the ankle is healing well. she states that for the past 2 weeks, she has been completely unable to ambulate and has been bed bound. she reports a past medical history of anxiety and fi bromyalgia. on physical exam, the ankle is noted to be painful to mild touch. she states that the pain has a burning quality. the affected area is also noted to have an increased temperature, but no erythema is noted. x-rays are negative for fracture or any other noted pathology. what test would be most likely to make the diagnosis? a) magnetic resonance imaging. b) computed tomography c) triple-phase bone scan d) electromyography e) depression screen answer: c this patient's symptoms are consistent with a complex regional pain syndrome. this was formerly known as refl ex sympathetic dystrophy. this condition often occurs following trauma or surgery that results in a extended immobilization of the affected limb. attempts have been made to quantify this syndrome. criteria have been established to make the diagnosis. this includes pain due to mild stimuli and burning quality as well as changes in temperature, hair, and color of the affected extremity. bone scan has been shown to reveal a typical pattern and can be a useful adjunct in confi rming the diagnosis. diffuse increased perfusion to the entire extremity is usually noted. therapy is directed toward nonnarcotic alternative medications that address neuropathic pain and increasing mobility to the affected area. prevention focuses on early physical therapy. on exam, her temperature is 37.1 °c (98.8 °f), pulse rate is 90 beats per minute, respirations are 18 per minute, and blood pressure is 158/74 mmhg. oxygen saturation by pulse oximetry is 96 %. the cardiopulmonary examination is normal. no edema is noted, but the left leg is shortened and externally rotated. complete blood count and basic metabolic panel are normal. chest radiograph is normal. electrocardiogram shows sinus rhythm. which of the following interventions is most likely to increase mortality in the postoperative period? a) proceeding to surgery urgently in the next 48 h b) prescribing a beta-adrenergic blocking agent within 24 h before surgery c) postoperative venous thromboembolism prophylaxis d) early postoperative mobilization e) nicotine patch answer: b a recent meta-analysis demonstrated that, despite a reduction in nonfatal myocardial infarction, perioperative betablockers started less than one day prior to noncardiac surgery were associated with an increased risk of death 30 days after surgery. proceeding to surgery within 48 h has been shown to be benefi cial in hip fracture patients. bouri s, shun-shin mj, cole gd, mayet j, francis dp. metaanalysis of secure randomised controlled trials of betablockade to prevent perioperative death in non-cardiac surgery. heart. 2014;100(6):456-64. 340. you are consulted to see a 36-year-old woman that has been admitted for shortness of breath to the obstetrics service. she is 4 months pregnant and has a prior history of asthma. she uses her albuterol inhaler several times per week to achieve symptomatic relief, but this has proven to be inadequate. history includes mild persistent asthma that was well controlled before her pregnancy with an as-needed short-acting β2-agonist and mediumdose inhaled glucocorticoids. on physical examination, vital signs are normal. the lungs have diffuse wheezes. she appears in minimal distress. cardiac examination shows normal s1 and s2 with no gallops or murmurs. no leg edema is noted. what is the correct treatment? a) prednisone. b) add a long-acting β2-agonist. c) add theophylline. d) double the dose of inhaled glucocorticoid. e) a and b. answer: e approximately one-third of patients with asthma experience worsening of symptoms during pregnancy. patients who present with mild exacerbations of asthma may be treated with bronchodilator therapy and steroids. severe asthma exacerbations warrant intensive observation. close monitoring of oxygen levels should be undertaken. inhaled beta2-agonists are the mainstay of treatment. in particular, beta-adrenergic blocking agents should be avoided due to a possible increased bronchospastic effect. the early use of systemic steroids has not been shown to be detrimental and should be given when indicated. intense follow-up care should occur. this may include referral to an asthma specialist. reference rey e, boulet lp. asthma in pregnancy. bmj. 2007; 334(7593):582-5. 341 . a 32-year-old male is evaluated in the emergency department for diffuse muscle aches. he reports starting an extremely intense "boot camp" exercise routine 3 days ago. on physical examination, the patient is diffusely tender to touch. he appears uncomfortable. arms and legs display moderate diffuse swelling. temperature is normal, blood pressure is 92/50 mmhg, pulse rate is 120 beats/min, and respiratory rate is 20 breaths/min. oxygen saturation is 97 %. skin is mottled on the posterior back. neurological examination fi ndings are nonfocal. creatinine is 2.2 units/l, bicarbonate is 17 meq/l, and creatinine kinase (cpk) is 36,000 units/l. which of the following is the most appropriate treatment for this patient? a) hemodialysis b) intravenous mannitol c) rapid infusion of intravenous 0.9 % saline d) rapid infusion of 5 % dextrose in water e) surgical consultation answer: c rhabdomyolysis is a syndrome caused by extensive injury to skeletal muscle. it involves leakage of potentially toxic intracellular contents into plasma. this can occur in both the trained and non-trained athlete. this often occurs with the initiation of a new intense exercise regimen. the most severe complication is acute kidney injury (aki). etiologies of aki may be related to hypovolemia, vasoconstriction, and myoglobin toxicity. compartment syndrome of infl amed muscles may be either a complication of or the inciting cause of rhabdomyolysis. mild diffuse swelling of muscle groups is common. recommendations for the treatment of rhabdomyolysis include fl uid resuscitation fi rst and subsequent prevention of end-organ complications. this is best achieved with 0.9 % saline. other measures to preserve kidney function may be considered after adequate volume has been given. other supportive measures include correction of electrolyte imbalances. fluids may be started at a rate of approximately 400 ml/h and then titrated to maintain a urine output of at least 200 ml/h. treatment should continue until cpk displays a marked reduction or until the urine is negative for myoglobin. a 34-year-old woman is admitted overnight for the acute onset of pain after 10 days of bloody diarrhea. the diarrhea has escalated to 15 times per day. she has ulcerative colitis that was diagnosed 5 years ago. she currently takes azathioprine. on physical examination, she appears ill. following aggressive fl uid resuscitation overnight, temperature is 38.6 °c (101.5 °f), blood pressure is 68/45 mmhg, pulse rate is 120 beats/min, and respiratory rate is 35 breaths/min. abdominal examination discloses absent bowel sounds, distention, and diffuse marked tenderness with mild palpation. radiographs on admissions reveal colonic distension of 5 cm. this am repeat radiographs reveal colonic distension of 8 cm. which of the following is the most appropriate management? a) ct scan b) immediate surgery c) start infl iximab d) start intravenous hydrocortisone e) immediate gastroenterology consult answer: b early surgical consultation is essential for cases of toxic megacolon (tm). indications for urgent operative intervention include free perforation, massive hemorrhage increasing toxicity, and progression of colonic dilatation which is the case here. most guidelines recommend colectomy if persistent dilatation is present or if no improvement is observed on maximal medical therapy after 24-72 h. the rationale for early intervention is based on a marked increase in mortality after free perforation. the mortality rate for perforated, acute toxic colitis is approximately 20 %. some recommend providing up to 7 days of medical therapy if the patient demonstrates clinical improvement despite persistent colonic dilatation. tm was fi rst thought to be the only complication of ulcerative colitis. it has been described in a number of conditions, including infl ammatory, ischemic, infectious, radiation, and pseudomembranous colitis. 345. an 85-year-old man with very poor functional status is admitted from the nursing home with severe shortness of breath. he has a history of a prior cerebrovascular accident that has resulted in right hemiparesis and aphasia. chest x-ray shows that he has severe pneumonia. before the entire family arrives, the patient is intubated immediately and transferred to the icu. after a joint conference, the family decides to remove life support. which of the following statements accurately characterizes ventilator withdrawal in this situation? a) you should suggest 24 more hours of observation. b) limit family interaction while the patient is extubated. c) pulse oximetry should be followed to help guide the family through the dying process. d) you should demonstrate that the patient is comfortable receiving a lower fraction of inspired oxygen (fio2) before withdrawing the endotracheal tube. e) such patients generally die within 30 min to an hour after the endotracheal tube is removed. answer: d the family should be given the opportunity to be with the patient when the endotracheal tube is removed. the decision should be theirs to make and be a part of hospital protocol. all monitors including oxygen saturation should be turned off. the patient's comfort should guide therapy. fio2 should be diminished to 20 %. the patient should be observed for respiratory distress before removing the endotracheal tube. distress and air hunger can be treated with opioids and benzodiazepines prior to endotracheal tube removal. the family often expects an immediate response when the ventilator is turned off. it is important to inform them that the patient may live for hours to days. also it is important to explain that you and staff will continue to follow and provide comfort during this period. end-of-life care is increasingly seen not as medical failure but a special time to assist the patient, family, and staff with the physical and emotional needs that occur with the dying of a patient. resources, protocols, and education should be provided to staff to enhance these efforts. answer: e the fat embolism syndrome typically presents 24-72 h after the initial injury. dyspnea, tachypnea, and hypoxemia are the earliest fi ndings. this may progress to respiratory failure and a syndrome indistinguishable from acute respiratory distress syndrome (ards) may develop. cerebral emboli produce neurological signs in up to 80 % of cases. this is often the second symptom to appear. the characteristic petechial rash may be the third component of the triad to occur. there is no specifi c therapy for fat embolism syndrome. early immobilization of fractures has been shown to reduce the incidence of fat embolism syndrome and should be of primary importance with extensive long bone fractures. the risk is reduced by operative correction rather than conservative management. the use of steroids has been extensively studied for both prevention and treatment. it is recommended by some, for the management of the fat embolism syndrome. on admission amylase is 235 units/l, lipase is 175 unit/l, and alkaline phospatase is 52 g/dl. he is started in intravenous fl uids and has a rapid resolution of his symptoms the following day. amylase on the second day is 38 units/l and lipase is 86 units/l. ultrasound of the abdomen reveals a gallbladder with several stones. no gallbladder wall thickening is appreciated. what is the correct management of this patient? a) discharge home with no further intervention. b) surgical follow-up for cholecystectomy c) cholecystectomy prior to discharge d) hida scan answer: c if possible, patients admitted with gallstone pancreatitis should undergo cholecystectomy before discharge, rather than being scheduled as an outpatient. patients discharged without a cholecystectomy are at high risk for recurrent bouts of pancreatitis. recurrent episodes may be more severe than the original presentation. in one study, patients with mild gallstone pancreatitis who underwent laparoscopic cholecystectomy within 48 h of admission resulted in a shorter hospital stay. there was no apparent impact on the technical diffi culty of the procedure or the perioperative complication rate. 353. which of the following will provide the best bowel preparation for a morning colonoscopy? a) 4 l polyethylene glycol-based preparation plus citric acid taken the evening before the procedure b) 2 l polyethylene glycol-based preparation taken the evening before the procedure c) 2 l of polyethylene glycol-based preparation on the evening before and 2 l of the same preparation on the morning of the procedure d) 1 l of polyethylene glycol-based preparation n the evening before and 1 l of the same preparation on the morning of the procedure answer: c signifi cant evidence exists that better colon preparation is associated with increased detection of colon polyps. split-dose bowel preparation remains an essential concept for enhancing the quality of colonoscopy. this limits the amount of agent remaining in the colon prior to examination. many bowel preparations for colonoscopy are available. no preparation has been shown to be superior to 4 l of a polyethylene glycol-based preparation split into two 2-l doses that are given the evening prior to and the morning of the procedure. a 67-year-old man with metastatic lung cancer is admitted for failure to thrive. during this admission, several end-of-life issues are addressed. he has chosen not to consider additional chemotherapy or radiation therapy. his cancer is unlikely to respond to such treatment. he and his family are focused on upcoming visits with his 4 children and 14 grandchildren over the next several weeks. however, the family reports that his lethargy, poor appetite, and depression will make this diffi cult. you estimate the patient's life expectancy to be weeks to several months. which of the following would be the best management of this patient's symptoms? a) initiation of a trial of a methylphenidate b) referral of the patient to a psychologist c) trial of a selective serotonin reuptake inhibitor d) initiation of enteral feedings through a nasogastric tube e) initiation of oral morphine answer: a the use of psychostimulants, such as methylphenidate, is an effective management for cancer-related fatigue, opioidinduced sedation, and the symptoms of depression in the setting of a limited prognosis. helping this patient achieve some of his end-of-life wishes is important. psychostimulants have the benefi t of providing more immediate response than conventional therapies. it is improbable that this patient will live long enough to benefi t from cognitive behavioral therapy, ssri, or nutritional support. starting methylphenidate 2.5 mg po bid is a reasonable choice when time is limited. li m, fitzgerald p, rodin g. evidence-based treatment of depression in patients with cancer. j clin oncol. 2012;30:1187-96. a 67-year-old man is admitted with severe right buttock pain. in the previous year, the patient underwent resection and laminectomy for metastatic renal cell tumor compressing his lower thoracic and upper lumbar spinal cord. the mass is inoperable, and he is receiving palliative chemotherapy. hospice has not been discussed yet. during his admission, the pain has been severe and refractory to intravenous opioids. his daily requirement of hydromorphone is 150-175 mg for the past 4 days. on physical examination, vital signs are stable. he is somnolent, and when he wakes up he is in severe pain. motor strength assessment is limited by pain. which of the following should you recommend now? a) trial of methylphenidate b) placement of an implanted intrathecal drug pump c) optimization of the opioid regimen d) a trial of intrathecal analgesia e) lidocaine patch answer: d this patient requires aggressive pain control measures. changing opioid regimens will probably be of little benefi t. evidence supports the use of intrathecal drug delivery systems compared with systemic analgesics in opioidrefractory patients. a trial of intrathecal medication is important, to determine the effect, prior to permanent placement of an implanted device. his previous laminectomy and associated scarring may limit the effect of intrathecal delivery as well as make catheter placement diffi cult. the use of palliative sedation therapy is indicated in patients with refractory symptoms at the end of life. although his pain is severe and unresponsive to systemic medications, she is not at the end of life, nor have all interventions been pursued to address her pain. deer tr, smith hs, burton aw et al. comprehensive consensus based guidelines on intrathecal drug delivery systems in the treatment of pain caused by cancer pain. pain physician. 2011;14(3):e283-312. a 56-year-old woman has widely metastatic breast cancer. she is admitted for sepsis. the decision has been made to withdraw care and to allow a natural death preferably as an inpatient. the family is at the bedside. oxygen saturation is 85 % with the patient receiving supplemental oxygen, 2 l/min by nasal cannula. on physical examination, she is nonverbal and restless in bed. her respirations have become more difficult. the family appears fatigued and anxious. which of the following should you do now? a) request a sitter. b) provide 100 % oxygen by face mask. c) administer a dose of parenteral haloperidol. d) administer a dose of parenteral morphine. e) administer a dose of parenteral dexamethasone. answer: d morphine is the drug of choice with air hunger at the end of life. it is preferred over other sedation. there is no evidence that supplemental oxygen is benefi cial at the end of life. in addition, many patients experience increased agitation when a mask is placed over the mouth and nose. family members may not desire a face mask for the patient as well during this special time. ben-aharon i, gafter-gvili a, leibovici l, stemmer sm. interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. acta oncol. 2012;51(8):996-1008. a 78-year-old woman who has recurrent breast cancer with metastasis is admitted for decreased appetite. her last bowel movement was 4 days ago. she is on longacting morphine with oxycodone for breakthrough pain. her bowel regimen is docusate, 100 mg twice daily. on physical examination, her abdomen is distended. a radiograph of the abdomen demonstrates a large amount of stool. she is given three enemas, which produce a small amount of stool. which of the following is the most appropriate next step in the management of this patient's constipation? a) administer lactulose. b) administer methylnaltrexone. c) administration of high-dose senna. d) placement of a nasogastric tube (ngt) for highvolume laxative. e) rotation to another opioid. answer: b methylnaltrexone is used for severe constipation in opioidinduced ileus. it is well tolerated in most instances. this patient has already shown an intolerance of stimulant laxatives; further measures are unlikely to be successful. an ngt would be uncomfortable. 358. a 68-year-old female is evaluated for preoperative clearance before she goes in for left knee elective surgery. she has a history of chronic hypertension. she has on amlodipine but has been noncompliant with her medicines. her knee pain limits her activities but she is able to walk up two fl ights of stairs with minimal diffi culty. on physical exam her blood pressure is 145/99 mmhg, heart rate is 55 bpm, and respiratory rate is 11 breaths/ min. extremities pulses are 2+ and bilateral. an echo done 7 months ago shows an ejection fraction of 30 %. the patient denies any new complaints. what is the next step? a) proceed with surgery without additional preoperative testing. b) control bp to ideal measurement of <130/85. c) delay elective surgery for further evaluation or treatment. d) exercise stress test. e) start metoprolol. answer: a preoperative hypertension is frequently a hypertensive urgency, not an emergency. in general, patients with chronic hypertension may proceed to low-risk surgery as long as the diastolic bp is <110 mmhg. there continues to be some debate over the use of betablockers preoperatively. current guidelines state that in patients with no risk factors, starting beta-blockers in the perioperative setting provides unknown benefi t. thomas dr, ritchie cs. preoperative assessment of older adults. j am geriatr soc. 1995;43 (7):811-21. 359. you are asked to admit a 32-year-old female for a 4-day history of lower abdominal pain that she describes as intermittent cramps. she denies nausea or vomiting. she also denies having urinary frequency, dysuria, and fl ank pain. her only medication is an oral contraceptive agent. on physical examination, her temperature is 38.5 °c (101.4 °f), blood pressure is 120/68 mmhg, pulse rate is 100 beats/min, and respiratory rate is 18 breaths/min. abdominal examination is normal. there is no fl ank tenderness. pelvic examination shows cervical motion tenderness. bilateral adnexal tenderness is appreciated on bimanual examination. she is in minimal distress and is tolerating liquids. the hematologic and serum chemistries are normal. urine and serum pregnancy tests are negative. what is the next best step in the management of this patient? a) consult for laparoscopic diagnosis and treatment. b) admit the patient to the hospital, obtain pelvic ultrasound, and start ceftriaxone. c) administer a single-dose im ceftriaxone and discharge the patient. d) administer a single-dose im ceftriaxone and oral doxycycline for 14 days. e) obtain pelvic and abdominal ultrasound and prescribe oral doxycycline with metronidazole. answer: d this patient's clinical fi ndings are compatible with pelvic infl ammatory disease (pid). women with mild to moderate pid may receive outpatient medical treatment without increased risk of long-term sequelae. laparoscopy is the criterion standard for the diagnosis of pid, but the diagnosis of pid in emergency departments is often based on clinical criteria, without additional laboratory and imaging evidence. she should receive intramuscular ceftriaxone and oral doxycycline for 14 days. all women with suspected pid should be tested for infection with gonorrhea and chlamydia. in severe cases, imaging should be performed to exclude a tuboovarian abscess. patients with pid should be hospitalized if there is (1) no clinical improvement after 48-72 h of antibiotics, (2) an inability to tolerate food or medicine, (3) severe symp-toms, (4) suspected abscess, (4) pregnancy, or (5) answer: b one of the most common predisposing factors for erythema multiforme is infection with herpes simplex virus, which may or may not be active at the time of the em eruption. em is an acute, self-limited, and sometimes recurring skin condition that is considered to be a type iv hypersensitivity reaction. it is associated with infections, medications, and other various triggers. patients with recurrent em are typically treated with acyclovir or valacyclovir. mycoplasma pneumonia, amoxicillin, ibuprofen, and cytomegalovirus may cause em, but are not as common. aurelian l, ono f, burnett j. herpes simplex virus (hsv)associated erythema multiforme (haem): a viral disease with an autoimmune component. dermatol online j. 2003;9:1. a 65-year-old male with a long history of type ii diabetes is admitted with the chief complaint of hematuria. his blood pressure is 130/65 mmhg. otherwise his physical exam is normal. urinalysis shows blood 3+ and protein 3+. no casts are seen. a 24-h urinary protein shows 8 g of protein and serum creatinine is normal. urine microscopy shows isomorphic red blood cells with no casts. renal and bladder ultrasound are normal. his hematuria is less by day 2 of his admission. what is the next most appropriate investigation? a) renal angiogram b) renal biopsy c) doppler ultrasound of the kidneys d) ct scan of the abdomen and thorax alone e) cystoscopy f) observation alone 364. a 33-year-old woman is admitted to the hospital for evaluation of blurry vision and new-onset paraparesis. she has been followed closely by neurology in the past for two recent episodes of optic neuritis in the past 2 years. her only other history is hypothyroidism. her only medication is levothyroxine. on physical examination vital signs are normal. visual acuity is 20/200 in the right eye and 20/30 in the left. per ophthalmology consult, optic disks display pallor. signifi cant spasticity is noted in her legs. the patient requires bilateral assistance to ambulate. laboratory studies including a complete blood count, liver chemistry and renal function tests, and erythrocyte sedimentation rate are normal. the antinuclear antibody is positive. anti-double-stranded dna and anti-ssa/ssb antibodies are negative. analysis of the cerebrospinal fl uid shows a normal igg index and no abnormalities in oligoclonal banding. an mri of the spinal cord reveals an increased signal extending over fi ve vertebral segments with patchy gadolinium enhancement. an mri of the brain shows no abnormalities. which of the following is the most appropriate next diagnostic test? a) electromyography b) serum antineutrophil cytoplasmic antibody test c) serum neuromyelitis optica (nmo)-igg autoantibody test d) testing of visual evoked potentials e) neuromyelitis optica (nmo)-igg autoantibody test f) csf to serum protein ratio answer: e neuromyelitis optica (nmo), the presentation of myelitis and optic neuritis, may be a variant of multiple sclerosis (ms) or a unique disease. this patient very likely has neuromyelitis optica (nmo). she should be tested for the autoantibody marker nmo-igg. differentiating between nmo and ms early in the disease may be important because the prognosis and treatment of the two diseases are different. nmo is a more severe disease treated with immunosuppressive drugs. ms is often initially treated with immunomodulatory therapies, such as β-interferon and glatiramer acetate. the mri is suggested of nmo. in typical ms, lesions are usually less than two segments in length. the nmo-igg test is approximately 75 % sensitive and more than 90 % specifi c for nmo. cognitive trajectories after postoperative delirium multifactorial index of cardiac risk in noncardiac surgical procedures derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery early surgery versus conventional treatment for infective endocarditis management of infective endocarditis: challenges and perspectives evidence that gabapentin reduces neuropathic pain by inhibiting the spinal release of glutamate gabapentin for acute and chronic pain constant observation in medicalsurgical settings: a multihospital study in their own time: the family experience during the process of withdrawal of life-sustaining therapy on day 3 she is started on tube feeds at 40 ml/h. her goal rate is 70 ml h. four hours after her tube feeds are started, gastric residuals are measured to be 375 ml. which of the following should you recommend now? a) withhold the feeding for 2 h c) continuing the feeding at the current rate advancing the feedings toward the patient's goal rate poor validity of residual volumes as a marker for risk of aspiration in critically ill patients what is the best method for assessing pain in the nonverbal patient? e in nonverbal patients, pain assessment relies less on vitalsign changes and more on observing behaviors fat embolism and the fat embolism syndrome 4-liter split-dose polyethylene glycol is superior to other bowel preparations, based on systematic review and meta-analysis a predictive model identifi es patients most likely to have inadequate bowel preparation for colonoscopy high-dose methylprednisolone in the treatment of active ulcerative colitis predicting outcome in severe ulcerative colitis on physical exam, he has moderate diffuse joint tenderness which is no different from his baseline. he has some nontender bumps palpated on the forearm bilaterally near to the olecranon process and displacement of metacarpal bones over the proximal phalanges with fl exion at proximal joints and with extension of distal interphalangeal joints. labs are within normal range ct scan of the neck prior to surgery c) avoidance of a paralytic drug during surgery d) radiograph of the neck in fl exion and extension a serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis the clinical course of neuromyelitis optica (devic's syndrome) answer: d in this patient, the feedings should be increased toward the goal rate. there is no correlation between gastric residual volume and the incidence of aspiration. evidence shows that checking gastric residuals doesn't provide reliable information on tube-feeding tolerance, aspiration risk, or gastric emptying. current guidelines recommend withholding feedings for gastric residual volumes greater than 500 ml.answer: e this man has hematuria without evidence of dysmorphic red cells or casts in urinary sediment. macroscopic hematuria in the absence of signifi cant proteinuria or rbc casts is an indication for imaging to exclude malignancy or cystic renal disease. approximately 80-90 % of patients with bladder cancer present with painless gross hematuria. urine cytology is extremely valuable but would not eliminate the need for cystoscopy, which is the standard for diagnosing bladder cancer. many bleeding urinary tract lesions arise in the bladder and lower urinary tract, and no imaging technique is completely satisfactory for ruling out disease at these sites. further imaging may be of use but cystoscopy will ultimately be needed. answer: e the american college of gastroenterology practice guidelines defi ne severe colitis as the passage of six or more stools per day with evidence of systemic toxicity. intravenous corticosteroids, which are essential in severe cases, are effective in the induction of remission in the majority of cases. a daily intravenous steroid dose of hydrocortisone 300 mg or methylprednisolone 60 mg is suggested. fortunately, most patients with severe uc respond to intravenous steroid therapy. however, 30 % of patients fail to respond after 5-7 days. these patients are considered to be steroid refractory. one of the simplest algorithms predicts that at the third day of intravenous steroid therapy, patients with a stool frequency of greater than eight per day or three per day plus a crp greater than 45 mg/dl have an 85 % likelihood of requiring colectomy. medical treatment of steroid-refractory severe uc has expanded with the availability of both cyclosporine and infl iximab as rescue agents. the need for colectomy may be reduced with the use of these agents. in addition, stool samples should be collected for culture and toxin analysis to rule out enteric infection.answer: d patients with -ra presenting for tkr represent those patients who have failed medical management and are a high-risk group for cervical spine involvement. radiographic screening of ra patients presenting for joint replacement surgery reveals cervical spine instability in 44 %, which is typically asymptomatic. lateral fl exion/extension views are more sensitive and are recommended. cervical spine subluxation is less likely in ra patients presenting for general surgery, and there is currently no consensus on who should be screened in this population. key: cord-353587-5e0kxjlt authors: aggarwal, shruti; jain, punya; jain, amit title: covid-19 and cataract surgery backlog in medicare beneficiaries date: 2020-07-17 journal: j cataract refract surg doi: 10.1097/j.jcrs.0000000000000337 sha: doc_id: 353587 cord_uid: 5e0kxjlt purpose: to forecast the volume of cataract surgery in medicare beneficiaries in the united states in 2020 and to estimate the surgical backlog that may be created due to covid-19. design: epidemiologic modeling. methods: baseline trends in cataract surgery among medicare beneficiaries were assessed by querying the medicare part b provider utilization national summary data. it was assumed that once the surgical deferment is over, there will be a ramp-up period; this was modeled using a stochastic monte carlo simulation. total surgical backlog 2 years postsuspension was estimated. sensitivity analyses were used to test model assumptions. results: assuming cataract surgeries were to resume in may 2020, it would take 4 months under an optimistic scenario to revert to 90% of the expected pre-covid forecasted volume. at 2-year postsuspension, the resulting backlog would be between 1.1 and 1.6 million cases. sensitivity analyses revealed that a substantial surgical backlog would remain despite potentially lower surgical demand in the future. conclusions: suspension of elective cataract surgical care during the covid-19 surge might have a lasting impact on ophthalmology and will likely result in a cataract surgical patient backlog. these data may aid physicians, payers, and policymakers in planning for postpandemic recovery. t he volume of cataract surgeries performed per year has increased steadily over the past few decades in the united states. [1] [2] [3] advancements in technology have resulted in enhanced safety and improved visual outcomes, resulting in more second-eye surgeries being performed, and a lower visual threshold for performing vision correction cataract surgery in younger patients. 4 furthermore, increased utilization of ambulatory surgical centers in the past few years has improved efficiency and contributed to greater cataract surgical volume. 5 the ongoing covid-19 pandemic resulted in a temporary halt in all elective ophthalmic surgeries. although an important step, the impact of this suspension on current and future volume of cataract surgery is unknown. in this investigation, our goals were (1) to model the volume of cataract surgery in medicare beneficiaries in 2020 in light of to estimate the surgical backlog that might have been created due to elective surgery suspension and subsequent ramp-up. backlog in this context refers to surgical cases that have been indicated and the patient has consented to surgery, however, the surgical case has not yet been performed. medicare part b provider utilization national summary from 2008 to 2018, which contains summary statistics of the 100% sample of the medicare part b claims data, was queried. 6 the total volume of cataract surgeries for a given year was calculated by adding the number of surgical claims for current procedure terminology (cpt) code 66984, extracapsular cataract removal with insertion of intraocular lens (iol) prosthesis, and claims for cpt code 66982, extracapsular cataract removal with insertion of iol-prosthesis complex. these data were used for subsequent analyses. the study adhered to the tenets of declaration of helsinki; institutional review board approval was not required as the data was derived from a free, publicly available resource that did not contain any patient-level data. the cataract surgery volume that might have been performed in the year 2020 based on pre-covid trends from 2008 to 2018 was forecasted with linear regression model. it was assumed that 100% of the prepandemic forecasted volume was performed in january and february 2020. for the number of cases performed between march and may 2020, estimates based on the practice patterns of the first author (s.a.) were used, which is a busy multisurgeon ophthalmology community practice. based on the practice patterns, it was assumed that 50% of the volume was performed in march 2020 and 3% in april 2020 (at the peak of the suspension). in most states in the united states, the mandated suspension on elective surgeries ended early in may. for example, in the state of maryland, they ended on may 6, and in the first author's practice, they performed 50% of the previous year's surgical volume for the month of may. however, other practices in the community lagged due to operational considerations. in another practice in the same state, only 30% of the previous year's volume was performed in may. furthermore, nationally, not all states allowed resumption of elective surgery in early may, and some states did not allow this until mid-may. thus, it was assumed that the national volume of cataract performed in may 2020 would be 40% of expected. it was assumed that once the elective surgical suspension period is over, there would be a ramp-up period, and the volume of cataract surgeries performed would not immediately revert back to 100% of the prepandemic forecast. to model the ramp-up, a stochastic monte carlo simulation of a gompertz function in a manner similar to that described for an elective orthopedic surgical population was used. 7 a gompertz function is a sigmoid curve with a rapid acceleration phase followed by a plateau phase. 8 it has been previously used to describe a variety of biological growth and recovery phenomena. 9 the rise in volume of cataract surgeries postpandemic was forecasted under an optimistic and a pessimistic scenario; we arbitrarily assumed growth velocities of 90% and 50% for the 2 scenarios, respectively. the growth velocities do not refer to a linear percentage change in surgical volume but are variables in the gompertz function that affect the nonlinear slope of the ramp-up phase. the 90% and 50% were chosen as the bounds of the likely scenario. these assumptions were further tested with sensitivity analyses as described further. the primary outcome of interest was the number of months it would take until the number of cataract surgeries performed would reach 90% of the prepandemic forecasted volume. the total backlog of cataract surgeries was calculated by adding the fixed backlog (created from march to may 2020, when surgeries were deferred) with the new backlog (created from june 2020 onward during ramp-up, when the number of surgeries performed in a given month is less than 100% of the capacity). the outcome of interest was the total number of surgical cataract cases that would be backlogged 2-year postsuspension (may 2022). to model the uncertainty in our assumptions, one-way sensitivity analyses were conducted. because the growth rates in the optimistic and pessimistic scenarios were chosen arbitrarily, first, the impact of ranging the growth rates from 30% to 95% was simulated. the minimum possible growth rate was assumed to be at least 30% because most centers would be able to be up and running, at least to some capacity, due to the ambulatory nature of our practice. it is possible that hospital-based practices might have a slower ramp-up phase due to lack of hospital operating room availability. the second analysis investigated what would happen if the number of cases deferred during the pandemic was not as large as modeled. this was tested by varying the fixed backlog from à50% to +50%. third analysis investigated what would happen if the future demand for cataract surgery were to decline in response to the pandemic. the impact of decline in elective surgical demand was modeled to be from à10% to à30%. a fourth analysis estimated the amount of time it would take to catch up on backlog under the ideal conditions. in this scenario, the growth rate was assumed to be 95%, fixed backlog to be à50%, and future demand to be à30%, and it would continue to grow at 10% per month after reaching the plateau phase. stata ic/15.0 (statacorp) was used for all analyses. monte carlo simulations were run for 10 000 runs for each scenario. the number of cases were rounded to the nearest 10 000 throughout the manuscript for ease of read. once elective surgical suspension is lifted and surgeries resume, the monte carlo simulation revealed that under the optimistic scenario, it would take 4 months to revert to 90% of the prepandemic forecasted volume (performing at least 280 000 cases per month). under the pessimistic scenario, it would take 7 months (figure 1 ). in both scenarios, the size of the surgical cataract case backlog at 2-year postsuspension (may 2022) would be tremendous: 1 080 000 cases in the optimistic scenario, and 1 550 000 cases in the pessimistic scenario (figure 2 ). varying the growth velocity from 30% to 95% resulted in significant variation in the time to revert to 90% of the prepandemic forecasted volume. with a 30% growth rate, it would take 12 months, whereas with a 95% growth rate, it would take 3.5 months to recover. varying the fixed backlog from à50% to +50% resulted in the total backlog at 2-year post-suspension ranging from: 740 000 to 1 420 000 cases, respectively, assuming the optimistic scenario growth (90%) rate. of interest, the backlog persisted despite varying surgical demand in the sensitivity analysis. under the optimistic recovery model, if surgical demand decreased by 10%, the backlog would be 990 000 cases at 2 years, and if demand decreased by 30%, there would be a backlog of 850 000 cases at 2 years. under the backlog minimization scenario where growth rate was assumed to be 95%, fixed backlog was assumed to be à50%, and future demand was assumed to be à30%, with a compounded 10% per month growth rate, it would still take 9 months to catch-up on the backlog. based on the trends in surgical volume of cataract surgery over the past decade, 3.7 million cataract cases would have been performed in 2020 in the united states among medicare beneficiaries. however, the covid-19 pandemic has resulted in a large-scale disruption of healthcare. although many centers are restarting surgery, because of safety concerns and operational and supply chain considerations, the ramp-up is restrained. there is significant uncertainty about volume of elective surgeries. in this article, we explored these issues. our analysis indicates that suspension of elective cataract surgical care will have a lasting impact on ophthalmology and will likely result in a sizeable backlog. the suspension of elective cases during covid surge was an important step for safety of both patients and surgical teams. viral transmission through aerosols and fomites and prolonged infectivity of virions in aerosols are a threat. a case series from china found that of 34 asymptomatic patients who underwent elective surgery during the incubation period of covid-19, the mortality rate was an alarming 20%. 10 now that the suspension is over, the surgical volume might not revert to pre-covid forecasts immediately for a variety of reasons. because this event is unprecedented in modern medicine, the growth velocity at which the volume of cataract surgery would ramp-up is unknown. using simulation techniques, we modeled a range of scenarios and found that it would take a minimum of 4 months to revert to near prepandemic forecasted volume even under optimistic conditions with high (90%) growth velocity. unlike other surgical disciplines that might be more reliant on expansive resources such as intensive care and inpatient hospitalization, it might be possible to reach high ramp-up velocities in ophthalmology due to outpatient nature of surgeries and relatively limited resource footprint. however, this ramp-up might vary based on different states. for example, in the first author's practice, in the state of maryland, it was possible to go from 4% of the previous year's volume performed in april 2020 to 50% of the previous year's volume performed in may 2020 at the author's practice. by contrast, in california, because of regulations, many ambulatory surgical centers had slower opening, and the surgical volume at most centers for may did not reach that level. it is difficult to predict how the regulator decisions in each state would affect ramp-up. furthermore, patient care logistics, such as surgical consultation, consent, and preoperative medical and financial clearance, will contribute to the ramp-up time. in the future, we will be able to ascertain the real growth velocities based on retrospective review of actual surgical volume. the estimated forecasts in our study provide a benchmark to compare actual future volume against. regardless of the growth velocity during the ramp-up period, a substantial backlog is likely. the source of the backlog is both the cases that are deferred during the suspension period and the additional cases that are not being performed while the production is not at 100% capacity during the ramp-up phase. our analysis reveals that even under optimistic conditions, the backlog would be greater than 1 million surgical cataract cases at 2 years postsuspension. even in the backlog minimization sensitivity analysis with all ideal conditions, it would take 9 months to catch up on the backlog. the impact of covid on elective surgery demand is also unclear. with the aging of the population and innovations in treatment, the demand for cataract surgery has been steadily increasing over the past 2 decades. 4 the sensitivity analysis reveals that even if demand fell by 30%, a substantial surgical backlog would remain. furthermore, there have been several studies that document adverse events arising from delay in cataract treatment, such as depression, falls, and traffic accidents. [11] [12] [13] it is possible that we might see a rise in these events in the medicare population. for instance, a systematic review of 27 studies found that patients who waited more than 6 months for surgery had worse outcomes compared with patients who waited <6 weeks, such as worse vision and poor quality of life. 14 addressing the backlog would require eventually increasing production beyond the prepandemic levels. this necessitates proactive planning. greater efficiency is required in preoperative components such as: measurements for iols, presurgical imaging, and medical and financial clearance. establishing collaborative and cohesive relationships with our optometry colleagues will be critical to expand access to care and triage. increasing available operative time and space per surgeon might help increase throughput. when appropriate, using topical anesthesia for cataract surgery might aid in the efficiency. 15 for surgeons who prefer femtosecond laser-assisted cataract surgery, strategies to improve workflow and reduce time such as moving the laser to the operating room or alternatives to laser-assisted capsulotomy such as zepto and miloop for dense lenses might be of consideration. [16] [17] [18] [19] furthermore, same-day sequential cataract surgery might be considered for patients needing bilateral surgery owing to considerations of anisometropia and intended monovision. 20 it might be possible to covert some postoperative visits to telemedicine or to defer them altogether without compromising patient safety. 21, 22 there are insufficient real-world data to assess how the aforementioned various strategies might increase throughput and potentially help diminish the backlog. production would have to increase beyond previous throughput levels to catch up on the backlog. this might be a potential direction for future health services research in ophthalmology. another important point is that keeping ophthalmology practices solvent through governmental and private aid would be critical to preserving the workforce and taking care of the population. a secondary analysis we performed indicates that once we reach prepandemic surgical volume, we would have to keep growing at a compounded rate of 10% per month to start reducing the backlog and go beyond the 100% throughput compared with what was being performed previously. however, despite best efforts and surgeon's desires to increase throughput, it might not be possible to increase throughput at this extreme rate owing to a variety of health system constraints. one such constraint in the foreseeable future is that surgical centers are limiting the number of cases to maintain social distancing guidelines and reduce infection spread. our study has multiple limitations. first, we do not account for second or other future waves of the pandemic. this adds significant uncertainty that might influence the backlog estimations. second, we focused on medicare beneficiaries, which underestimate the total volume of cataract surgeries in the united states. however, according to the centers of disease control vision and eye health surveillance system, approximately 80% of the patients who underwent cataract surgery in the united states in 2016 were medicare beneficiaries. 23 furthermore, we did not take into account the potential seasonality of cataract surgery because the number of surgeries performed each month might potentially vary depending on the geographical region of the country. despite these assumptions, our sensitivity analyses revealed that although the magnitude might vary, there inevitably will be a surgical cataract backlog, even in the face of potential reduced demand. in conclusions, suspension of elective cataract surgical care during the covid surge will have a significant and lasting impact on ophthalmology and will likely result in a large surgical backlog. addressing the backlog through proactive planning would be vital to success. our data might aid physicians, payers, and policymakers in planning for postpandemic recovery. suspension of elective surgery during covid-19 has impacted surgical cataract volumes. this study provides a numerical estimate of how long it will take to revert to near prepandemic levels and much surgical cataract backlog will be created over time. increasing incidence of cataract surgery: population-based study projecting the growth of cataract surgery during the next 25 years changing incidence of lens extraction over 20 years: the beaver dam eye study rising cataract surgery rates: demand and supply trends in use of ambulatory surgery centers for cataract surgery in the united states data-and-systems/downloadable-public-use-files/part-b-national-summary-data-file/overview sars-cov-2 impact on elective orthopaedic surgery: post-pandemic recovery implications on the nature of the function expressive of the law of human mortality, and on a new mode of determining the value of life contingencies the use of gompertz models in growth analyses, and new gompertz model approach: an addition to the unified richards family clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection consequences of waiting for cataract surgery depressive symptoms in older adults awaiting cataract surgery association of cataract surgery with traffic crashes the consequences of waiting for cataract surgery: a systematic review factors affecting cataract surgery operating time among trainees and consultants current and effective advantages of femto phacoemulsification femtosecond laser-assisted cataract surgery in complex cases thermal capsulotomy: initial clinical experience, intraoperative performance, safety, and early postoperative outcomes of precision pulse capsulotomy technology microinterventional endocapsular nucleus disassembly: novel technique and results of first-in-human randomised controlled study immediately sequential bilateral cataract surgery: advantages and disadvantages safety of deferring review after uneventful cataract surgery until 2 weeks postoperatively deferral of first review after uneventful phacoemulsification cataract surgery until 2 weeks: randomized controlled study vision and eye health surveillance system disclosures: none of the md suspension of elective surgical care during covid-19 will result in a large backlog of cataract surgeries in medicare beneficiaries key: cord-336438-mlgxiyur authors: huda, farhanul; kumar, praveen; singh, sudhir k.; agarwal, saumya; basu, somprakas title: covid-19 and surgery: challenging issues in the face of new normal – a narrative review date: 2020-10-23 journal: ann med surg (lond) doi: 10.1016/j.amsu.2020.10.039 sha: doc_id: 336438 cord_uid: mlgxiyur this review aims to outline the current perspectives of surgery in the covid 19 pandemic associated with the pitfalls in implementing the emerging guidelines to continue patient care without compromising the safety, both from surgeons' and patients' points of view. the fight between the surgeon and the pandemic will be a dragging one since the post-pandemic efflux of the surgical patients coupled with the ‘new normal’ practices to prevent covid 19 spread requires pertinent resources, well-trained personnel, and co-operation among different departments. emergency surgeries and cancer care have continued all this while, undoubtedly, with unwanted delays and distress. while we continue to prepare ourselves and work in a whole new environment, surgeons are facing the increased chances of litigations and compromised safety. we review what we have come to understand about safe surgical practices during and after the pandemic and the unanswered questions. the global impact of the covid 19 pandemic has challenged the healthcare system worldwide to provide quality care while restricting transmission to non-covid 19 patients and health care workers (hcw). since surgery exposes the healthcare team to blood and body fluids of infected patients, surgical specialties have been struggling all this while trying to strike a balance between the evolving guidelines of sick patient management who need surgical care and protecting themselves and their hcw from undue exposure. the path to this struggle has not always been easy. it has opened up newer hospital management paradigms, surgical care, and postoperative management, including intensive care. it has also made us bend ways to develop newer guidelines without evidence or minimal or insignificant evidence. in learning newer ways of adjusting to the situation, surgeons have come across pitfalls in areas that were not expected or planned but have only made us wiser and sometimes at the cost of exposing the hcw to infection transmission threat. this narrative review aims to highlight important areas of surgical practice that are witnessing unprecedented change and, at the same time, how pitfalls can silently creep up in these altered practices. symptoms of covid-19 is seven days, and the maximum estimated incubation period is approximately 14 days. thus it is recommended that measures to decrease covid-19 incidence should be taken for at least 14 days before planning for surgery unless in life or limb-threatening conditions [43] . the implied time constraint in cancer management, one of the biggest killers, made it undeniable for treatment during the pandemic. most guidelines recommend that, if possible, these patients should be offered alternate therapy, such as neoadjuvant chemotherapy [6] . however, the multimodality treatment of cancer needs multiple visits, follow up visits, and hence enhanced exposure and increased chances of contracting the viral infection, both by the hcw and the vulnerable, immunosuppressed cancer patients. as the patients may harbour asymptomatic infection, testing them at every visit will burden the already overwhelmed resources especially in resource-poor settings, and cause intense mental agony to the already suffering patient. however, unfortunately, there are no set standards to accurately weigh the benefits of this practice against its hazards as of today. the main determinants of decision making for cancer treatment included patient-and tumor-related factors, the current status of covid pandemic in that region, and availability of resources. virtual tumour board should be arranged for shared decision making, including all the stakeholders, such as the patient, family members of the patient, surgical oncologist, medical oncologist, and radiation oncologist for shared decision making. the final decision should be documented clearly in the case file. teleconsultation should be used for those who have completed treatment or those who are disease-free. patients who present with onco-surgical emergencies should be operated with all precautions and recommendations j o u r n a l p r e -p r o o f 5 | p a g e laid for any surgical emergency. decisions regarding elective surgeries for cancer should be made depending upon type, stage, biology, availability of non-surgical treatment options, and resources available in the treating center [7] . non-surgical treatment should be considered whenever possible in consultation with medical and radiation oncology; however, surgery should be offered to those patients where non-surgical options are not available or delay in surgery will threaten the patient's life [7] . elective surgery should be postponed in patients with less aggressive and slowly growing cancers [7] . it applies to all common cancers as each cancer treatment remains a challenge. indications of emergency surgery remain the same during this pandemic as before, but a balance between timely treatment and protection of hcw from the virus is essential [8] . a narrow surgical time window may not give us the benefit of having a reverse transcriptasepolymerase chain reaction (rt-pcr) test report before surgery, and these patients should be treated as potentially infected. cect chest can help these patients due to urgent surgical intervention without the rt-pcr report [9] . full compliance with tertiary protection regulations and other precautions mentioned should be complied with [10] . mention may be made here that despite full precautions, all operating room (or) staff, anesthetists, and the surgeons have been infected from patients who later turned out to be positive on testing [11] . it should make us rethink whether we are truly aware of all possible viral transmission modes and are implementing adequate strategies to combat this difficult situation. moreover, what it does tell us is that since surgical care involves a team approach, all members such as doctors, nurses, technicians, attendants, physician assistants, as well as j o u r n a l p r e -p r o o f janitors and housekeeping staff should be trained to prevent the spread of the virus from or and postoperative rooms. it is for the team's safety and the hospital services at large that such understanding is significant. it includes, in addition to the proper way of donning and doffing personal protective equipment (ppe), the correct way of disposal of the used items, sterilization of the surgical equipment, and cleaning of the theatre after every case, which needs to be grounded in the daily practice of or staff. all necessary equipment should be made available before the start, and minimum personnel should be present inside the or [12, 13] . the surgeon should enter the or 15 minutes after intubation, duration of the surgery should be kept minimum, and lengthy and complex procedures should be avoided [12] . minimum gap of one hour should be there between two cases. after completion of the surgery, hcws should follow a well-planned exit sequence from the or. the surgical team should leave first, followed by the patient after extubation, then the anesthesia team, and, last of all, the cleaning and sterilization crew [12] . transportation of patients should be via a pre-defined route to avoid unnecessary exposure. operating room air pressure should be changed from positive to negative or can be switched off 30 minutes before and restarting 30 minutes after sanitization at the end of surgery. disposable items should be used as far as possible. high-efficiency particulate air (hepa) filters and smoke evacuation devices should come easy for the working personnel. general anesthesia poses a high risk to hcws as it is an aerosol-generating procedure, therefore whenever possible regional anesthesia is preferred. guidelines laid down by the airway and anesthesia societies should be followed for intubation [14] . limiting the use of most surgeon-friendly but aerosol-producing gadgets such as electrocautery, laser, and ultrasonic scalpels might increase the operative time and prove exhausting for the surgeons. this sudden shift in the working protocol is difficult to cope with and needs behavioral change for a better outcome. a perceived threat that the virus may be found in tissue and body fluids and concentrated virus-aerosol can occur due to pneumoperitoneum [15] has suggested limiting its use. despite available information, appropriate precautions are of utmost importance when laparoscopic techniques are used to reduce the length of hospital stay and faster recovery. practices that may be of help include small port incisions to prevent gas leakage, low co2 insufflation pressure [16] , and careful evacuation of smoke by using filtration systems [17] . when no smoke evacuation system is at hand, it is best not to opt for laparoscopy. direct use of suction applied to trocars may be an option [16] but at the cost of efficiency and safety. proper desufflation can decrease the chances of infection transmission. the patient should lie flat, and the least dependent port should be used for desufflation. controlled smoke evacuation should be done by a designated team member, using the port's side-channel [18] . the use of drains should be kept minimal. fascial closure is a must after desufflation, and the use of any suture closure device allowing gas leakage should be avoided. specimen removal, either hand-assisted or with a wound protection device, should be done only after desufflation [18] . for endoscopic procedures, the society of american phase ii-immediate preoperative period j o u r n a l p r e -p r o o f 9 | p a g e anaesthesia, surgery, and nursing checklist need to be revised for the covid status of the patient, and optimum precautions should be taken. phase iii-intraoperative period ensure revised time outs are being followed concerning covid risk, covid results, and ppe guidelines. a briefing should be done inside the or before starting surgery. guidelines laid down by the society of anaesthesiologists should be followed during intubation [42] . adequate waiting time and movement of team members should be planned [12, 13] . specimen retrieval guidelines should be followed [18] . phase iv -postoperative care since postoperative patients are in an inflammatory state and prone to developing pulmonary complications such as atelectasis, pneumonia, and thrombo-embolism that can mimic symptoms of covid 19 infection, they should be closely monitored and tested by rt-pcr in the event they develop symptoms. it has been observed that rt-pcr has a high variation in the false-negative rate, which implies that the interpretation of rt-pcr should be made with caution, particularly early in the course of infection. rt-pcr alone should not be the basis to rule out infection if there is high clinical suspicion. we should carefully consider the clinical and epidemiological situations [20] . a particular challenge to hcw safety is our current lack of understanding of the virus's transmissibility duration in either asymptomatic or symptomatic patients [21] . sars-cov-2 rna continues to be detected in upper respiratory tracts of patients recovered from covid-19 for 12 weeks [22] . according to recent cdc recommendations, isolation can be discontinued ten days following onset of j o u r n a l p r e -p r o o f symptoms, because the replication-competent virus has not been detected ten days following onset of symptoms [23] . there is evidence that even after respiratory samples are negative for virus in patients who have recovered from a covid-19 illness, viral rna remains in the stool for more than 30 days. the clinical significance of fecal rna is not well understood [24] . postoperative care such as the liberal use of 2 to 3 antiemetics to control nausea and vomiting more aggressively might help decrease contamination and reduce the risk of spread [2] . administration of high-flow supplemental oxygen should be avoided because of concerns of aerosol generation. if necessary, low flow supplemental oxygen should be provided through a nasal cannula [2] . every effort to adhere to enhanced recovery protocols should be made for standardized postoperative care and optimize lengths of hospital stay, efficiency, and complications. after discharge from the hospital, follow-ups may be done through telemedicine or video calls to reduce unnecessary hospital visits. the availability of post-acute care facilities, such as rehabilitation medicine and skilled nursing, should be made. these patients may need early re-intervention (with testing and adequate protection for hcw) in case of any complication as evidence suggests that patients operated upon in the month before the infection clinically manifested demonstrate a severe disease course in 75% of cases [16] . even patients who recover have a higher risk of future infection and a more complicated recovery pattern [14] . the patient's attendants need to be trained in picking up subtle signs of unusual recovery and report immediately. virtual consultation obviates the need for physical interaction between the patient and the doctor and reduces the risk of disease transmission. a survey conducted by american well [25] reports that some barriers exist with teleconsultation. in times of need, many people want a physical interaction with the physician. patients also like to see their physician through teleconsultation, vis-a-vis someone with whom they do not have a previously established relationship. patients may be unaware that they have teleconsultation as an option and do not know how to access it. cost barriers to establishing a broad-based telecommunication platform can be significant, especially in resource-poor settings. several practical issues can crop up during such practice. the interactive communication has some regulations as it involves providing sensitive information and also monetary transactions. secondly, providing telemedicine services in different centers may be difficult as these may vary on the quality of facility, resources, and workforce. moreover, the referral services can be complicated as it may not be easy to book referral services in the same hospital or between hospitals. thirdly, the issues of licensure, facility accreditation, and certification and reimbursement are also uncertain. lastly, and most importantly, is the issue of privacy and data protection [26] . according to portnoy et al. [27] , educating hcws, doctors, and patients about telemedicine's importance during the pandemic, helping people understand how it works, and reducing costs can help remove these barriers. conventionally, informed consent for surgery focuses on risks and expected benefits, the likely outcome of the proposed procedure, and alternative options. according to a report by the canadian medical protective association, [28] over a recent 5-year period, 65% of medico-legal cases involving informed consent disputes were of surgical procedures, and only 21% of these cases have been decided in favor of the surgeon. therefore, it is essential to know whether patients are aware of this impact and proceed or postpone their surgery during this pandemic. in the current crisis, postponement may initiate some queries related to morbidity, the medico-legal impact of which is unknown. in this pandemic where many hospitals have turned out to be hotspots of covid 19 infection, is it justified to suggest that covid 19 has become a healthcare-associated j o u r n a l p r e -p r o o f infection, though temporarily? do we need to tell the patient of such a probability during admission? there is an increasing perception among health authorities that the risk of infection with covid 19-should be a part of informed consent for surgery [29] . ferguson et al. recommend to include five additional points while discussing "enhanced informed consent" with the patients. firstly, there is a lack of information on the risks of routine procedures during the pandemic. secondly, there is an increased risk of acquiring sars-cov-2 from the hospital. a significant third point is the changed day-to-day hospital operations, which may alter the patient's perioperative experience. due to visitor restriction policies, the patients might not be able to communicate with their family members, or there might be a possibility that postoperative care might be delivered in general nursing units with staff that is not well trained to look after postoperative patients. another significant issue that should be discussed is a possible altered outcome resulting from a shortage of resources due to the pandemic. lastly, the surgeons should respect the patient's wishes and dignity amidst considerable uncertainties that the pandemic has introduced in an evolving publichealth crisis [29] . many guidelines recommend postponing elective surgeries but rightly advocate to consider malignancy as semi-urgency where alternative treatment is not possible. long hours of surgery with wearing full ppe will lead to burnout of the surgical team. patients with malignancies are already immunocompromised, which may increase the risk of covid-19 infection. an intensive care unit bed may not be available in an already compromised hospital resource, which can compromise postoperative care following a lengthy surgery. voluntary blood donation and the availability of blood and blood products may be not as per expectation. moreover, operated patients are under metabolic stress and temporarily j o u r n a l p r e -p r o o f immunocompromised due to surgery, which puts them at increased risk of acquiring sars-cov-2 infection [30] . a retrospective study done by wang et al. reported that 41.3% of their patients had the hospital-related transmission of covid-19, out of which the majority were hcws [31] . it calls for regular staff rotation, testing, and designating covid-19 and non-covid-19 areas in the hospital, which are necessary measures to limit spread. doubling or cross-covering of duty rotas anticipating staff absence due to sickness or quarantine, reducing doctor-topatient ratios in some parts of the hospital, and strengthening surgical teams by recruiting retired surgeons, clinical academics, or final-year medical students are some of the possible approaches to meet the crisis. however, this model works only until the community transmission reaches a critical threshold when the hospital designation does not matter [32] . nevertheless, we do not have sufficient data to suggest that hcws are a source of infection and have led to the hospital or even community spread. the lockdown was imposed in many countries worldwide, exempting the health care industry, and no guidelines were developed on how to protect hcws who are at increased risk of infection. the centre for disease control and prevention (cdc) reports that health care workers account for at least 11% of reported sars-cov-2 infection [33] . however, no riskstratification has been done for hcws. according to larochelle et al., there is no robust data on the occupational risk of covid-19 [34] . the authors propose a framework of risk stratification based on the risk of occupational exposure to covid-19 and death risk. persons with a high risk of occupational exposure and death should consider staying at home, while those with high risk in one domain and medium risk in the other should discuss with their physician. stress and fatigue in otherwise healthy hcws are challenging issues. hcws returning to work after recovery from a covid-19 infection may be at risk of physical and emotional exhaustion [35] . a review governance committee should be made to clarify, interpret, and iterate policies, make real-time decisions and initiate and communicate all planning. its members should be from different disciplines, and it should conduct meetings at least daily to solve problems. it should retrieve data on the availability of resources and their utilization, covid-19 awareness data amongst hcws and community, management of covid-19 patients, and errors during management, complications, and the means to rectify those. the committee should set priorities and ensure adequate strategies for newly diagnosed patients and staff. these include isolation of infected staff and ensuring replacement, optimum patient assessment, and clearing the backlog. convenient planning should be done so that patients can access healthcare facilities easily. there has been a trend from an operative to delayed-operative management of surgical conditions such as intestinal perforation, intestinal obstruction, or intra-abdominal inflammation [36] . however, it is still a question of whether to wait and watch management in acute surgical conditions should increase and be the norm [37] . as of now, we rely on extrapolating the evidence from outcomes of elective surgical patients infected with covid 19 [36] . the cancellation of elective operations creates a massive pile-up of patients. there are no robust data available to calculate the number of operations postponed and how this backlog will be dealt with after the pandemic. approximately 330 million operations are done worldwide annually. with an average of about six million procedures per week internationally [38] , the total number of patients affected is increasing at a concerning pace. we have minimal idea about these cancellations or how to reopen these services [39] . j o u r n a l p r e -p r o o f after a crisis" [40] . we have to take care that our workforce does not get exhausted once the elective surgeries start in the later pandemic stages. data on the effects of surgical cancellation on psycho-social and physical health are lacking, but surely it will damage the health and wellbeing and will increase the risk of shortened life span in countries of all income, and more so, in the poor and marginalized communities. the profound effect of the pandemic has left hcws and the healthcare industry worldwide in a critical situation. in the altered situation, the crucial things lacking are a management model and adequate training to deliver in an unsafe environment, while continuously protecting oneself. surgeons are always under stress while operating and managing increased medico-legal issues. most of the current guidelines are based more on observation or experience than on a high level of evidence. telemedicine has gained worldwide acceptance but comes at the cost of denying physical examination. postoperative care has become more challenging. although care of cancer patients has been prioritized, these patients theoretically have a higher chance of getting infected. training the or team and keeping a regular check on their practices is essential. amongst all these challenges, the world is getting used to a "new normal". only time will tell whether we have to get used to it for good. j o u r n a l p r e -p r o o f speech may spread more covid-19 than faeces covid-19: role of ambulatory surgery facilities in this global pandemic exploring the adoption of telemedicine and virtual software for care of outpatients during and after covid-19 pandemic virtually perfect? telemedicine for covid 19 don't delay care for chronic illness over coronavirus. it's bad for you and for hospitals american college of surgeons, covid-19 guidelines for triage of cancer surgery patients guiding principles for cancer surgery during the covid-19 pandemic emergency surgery in suspected covid-19 patients with acute abdomen: case series and perspectives emergency surgery in suspected covid-19 patients with acute abdomen: case series and perspectives national health commission of the people's republic of china, diagnosis and treatment of novel coronavirus pneumonia covid-19 and the risk to health care workers: a case report amasi (association of minimal access surgeons of india) guidelines for conducting minimal access surgery during covid-19 pandemic sages and eaes recommendations for minimally invasive surgery during covid-19 pandemic guiding airway management and personal protective equipment for covid-19 intubation teams appropriate use of laparoscopy over open procedures in the current covid-19-19 climate? surgical practice recommendations for minimal access surgeons during covid-19 pandemic -indian inter-society directives sages and eaes recommendations for minimally invasive surgery during covid-19 pandemic iages (indian association of gastrointestinal endoscopic surgeons) covid surgery recommendations. 11th clinical insights for our community of gastroenterologists and gastroenterology care providers variation in false-negative rate of reverse transcriptase polymerase chain reaction-based sars-cov-2 tests by time since exposure the relative transmissibility of asymptomatic cases among close contacts positive rt-pcr test results in patients recovered from covid-19 presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility prolonged presence of sars-cov-2 viral rna in faecal samples. the lancet gastroenterology & hepatology consumer survey telehealth-opportunities and pitfalls telemedicine in the era of covid-19-19 informed consent for surgery: risk discussion and documentation unknown unknowns: surgical consent during the covid-19-19 pandemic covid-19-19 pandemic: perspectives on an unfolding crisis clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in immediate and long-term impact of the covid-19-19 pandemic on delivery of surgical services characteristics of health care personnel with covid-19 -united states risk stratification for workers during the covid-19 pandemic multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science covid-19 and emergency surgery global guidance for surgical care during the covid-19-19 pandemic covid-19surg size and distribution of the global volume of surgery in 2012. bull world health organ elective surgery cancellations due to the covid-19 pandemic: global predictive modelling to inform surgical recovery plans response of a european surgical department to the covid-19-19 crisis preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery consensus guidelines for managing the airway in patients with covid-19: guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists euro 1. the healthcare industry and health care workers are under immense pressure due to the covid 19 pandemic the struggle to deliver in this "new normal environment" is taking its toll on the health and mental well being of patients as well as health care workers if physicians, especially surgeons, are not aware of the pitfalls during this pandemic, mishaps are bound to occur the following information is required for submission. please note that failure to respond to these questions/statements will mean your submission will be returned. if you have nothing to declare in any of these categories then this should be stated. all authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert 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drafting of the manuscript. somprakas basu was involved in conceptualisation of the study, critically analysing literature and expert input in synthesis of knowledge and finalising the content of the manuscript. all authors have seen and approved the final manuscript. in accordance with the declaration of helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. please enter the name of the registry and the unique identifying number (uin) of your study.you can register any type of research at http://www.researchregistry.com to obtain your uin if you have not already registered. this is mandatory for human studies only. trials and certain observational research can also be registered elsewhere such as: clinicaltrials.gov or isrctn or numerous other registries.not applicable. name of the registry: unique identifying number or registration id:3. hyperlink to your specific registration (must be publicly accessible and will be checked): key: cord-353004-ocnp758o authors: prakash, lakshmanan; dhar, shabir ahmed; mushtaq, muzaffar title: covid-19 in the operating room: a review of evolving safety protocols date: 2020-07-20 journal: patient saf surg doi: 10.1186/s13037-020-00254-6 sha: doc_id: 353004 cord_uid: ocnp758o background: the covid-19 pandemic has already infected more than 3 million people across the world. as the healthworkers man the frontlines, the best practices model is continuously evolving as literature concerning the coronavirus develops. methods: a systematic review of the available literature was performed using the keyword terms “covid-19”, “coronavirus”, “surgeon”, “health-care workers”, “protection” and “orthopaedic surgery”. all peer-reviewed articles we could find were considered. randomized controlled trials (rcts), prospective trials and retrospective studies, as well as reviews and case reports, were included in this systematic review. results: even though surgical specialties including orthopedics are on the relative sidelines of the management of this pandemic but best practices models are inevitably developed for surgical specialties. the algorithm of postpone, delay, and operate only when life-threatening conditions exist is going to be useful up to a point. conclusion: the surgical staff needs to keep abreast of the latest literature concerning safety measures to be taken during surgical procedures. review articles can go some distance in helping in this educational process. this knowledge must evolve as new information comes to light. the covid 19 was labeled as a pandemic on 11 march 2020 [1] . at the time of writing nearly 4 million people have been affected. the clinical spectrum of this disease is known to be very heterogeneous [2] . as the number of cases increases worldwide, the possibility of having to operate cases with the coronavirus infection is increasing. this will happen despite the current recommendations of operating only the emergent cases [3] . cheney c in his write up on march 27 mentions that according to the guidelines of the centers for disease control and prevention elective surgery during the pandemic should be delayed [4] . these recommendations were made with the foresight of infrastructure and staff shortages. however, as the pandemic progresses two things have to be kept in mind by the health care authorities [1] . the increasing likelihood of covid positive emergency cases presenting for surgical intervention. the inevitability of having to restart elective procedures at some point in time. this is likely to happen whilst the pandemic is still around in some form. with the proven contagious properties of the virus and the relatively newer concept of the viral load, surgical safety measures need to be discussed as extensively as possible [2] . gleaning from trauma literature it is seen that there is an increased likelihood of contracting covid-19 in hospitals. thousands of healthcare providers have been infected with covid-19 despite their adherence to infection control measures [5] . this paper attempts to look at the current relatively scarce literature and answer some questions about the readiness and methods required for conducting safe surgery especially orthopedic intervention during the covid-19 pandemic. the evolving literature must be published and read worldwide as covid-19 is an occupational hazard to surgeons, health care workers, and their families. a systematic review of the available literature was performed using the keyword terms "covid-19", "coronavirus", "surgeon", "health-care workers", "protection" and "orthopaedic surgery". all peer-reviewed articles we could find were considered. randomized controlled trials (rcts), prospective trials and retrospective studies, as well as reviews and case reports, were included in this systematic review. the current covid-19 pandemic underlines the importance of careful and sensible utilization of financial and human resources. preserving manpower is vital. a definite attempt should be made to minimize infection amongst surgeons and specialized professionals. while it is true that the surgical specialists are not at the forefront of managing the pandemic but two points have to be kept in mind vis a vis these specialists [6] . 1. the likelihood of getting infected in the confines of the operation theatres is disproportionately high. 2. the training period of a surgeon is quite long. replacing the surgeon is not a straightforward task. the pandemic preparedness and literature evolution have mainly been on the personal protective equipment (ppe) and intensive care unit (icu) areas. not much has been written on the risks involved, methods and precautions required for an orthopedic surgeon and his operating room personnel whilst carrying out surgical procedures within the theatre. mild cases of covid-19 have been found to have an early viral clearance, with 90% of these patients repeatedly testing negative on rt-pcr by day 10 post-onset. by contrast, all severe cases still tested positive at or beyond day 10 post-onset. overall, our data indicate that, similar to sars in 2002-03, patients with severe covid-19 tend to have a high viral load and a long virus-shedding period. this finding suggests that the viral load of sars-cov-2 might be a useful marker for assessing disease severity and prognosis [2] . this concept of viral load is especially important for the operating surgeon. coccolini et al. believe that all known or suspected covid-19 positive patients requiring surgical intervention must be treated as positive until proven otherwise to minimize infection spread [6] . however, it is preferable to order immediate sars-cov-2rt-pcr assay if a patient is being admitted and especially before surgery and possible intubation. the surgeon also has to factor in staff sickness, reduced supply of surgical materials, alternate use of surgical facilities, and relatively lower availability of anaesthesiologists because of their additional intensive care loads [1] . lei et al. studied 34 patients who underwent elective surgeries during the incubation period of covid-19 at 3 hospitals. all their patients developed covid-19 pneumonia shortly after surgery. 44.1% of patients needed intensive care postoperatively and the mortality rate was 20.5% [7] . five of these surgeries were conducted in orthopedic specialist areas. the correlation is explained by the probable lowering of cell-mediated immunity after surgery which is vital for defense against viral infections [8] . similar to the middle east respiratory syndrome coronavirus (mers-cov) infection, the severe acute respiratory syndrome-related coronavirus (sars-cov) infected lung could induce and increase the amount of macrophage and neutrophil infiltration and increase the levels of pro-inflammatory cytokines and chemokines [9] [10] [11] . from the literature mentioned, it is clear that a covid-19 patient undergoing surgery is at a higher risk of complications. even though scientific literature on the surgeons getting affected during surgery is not available, it is important to view the media reports with more seriousness than usual [12] . the sages and eaes recommendations regarding surgical response to covid-19 mention that services should be rationed [13] . they have included the following points, amongst others, in the rationing 1. all elective surgical and endoscopic cases should be postponed at the current time. 2. all non-essential hospital or office staff should be allowed to stay home and telework. the procedural considerations laid down in the same paper include 1. it is strongly recommended however, that consideration be given to the possibility of viral contamination to staff during surgery either open, laparoscopic, or robotic and that protective measures are strictly employed for or staff safety and to maintain a functioning workforce. 2. for mis procedures, the use of devices to filter released co2 for aerosolized particles should be strongly considered. 3. there may be an enhanced risk of viral exposure to proceduralists. the surgical team needs to be updated as to the latest protocols being used to ensure increased safety within the operation theatres to prevent the spread of the coronavirus outside the theatre and disease amongst the theatre personnel. philip f. stahel published an editorial in which he divided elective procedures into "essential", which bear an increased risk of adverse outcomes if surgery is delayed indefinitely, "non-essential" or "discretionary", in which the results are not time-sensitive to surgery and "equivocal" which don't fall clearly into one or the other category. he proposed an decision-making algorithm ( fig. 1 ) for deciding whether and when to proceed with an elective surgery, based on surgical indications and predicted requirement of critical resources, including blood product transfusions, estimated length of hospital stay, and the possible requirement for post-operative ventilation and icu care [14] . ti et al. have written that a relatively isolated theater with separate access and a negative pressure environment should be designated for such patients [15] . the negative pressure method is restricted in the anteroom and the induction room. the scrub area and the main operating room have positive pressures. the main operating room should have more than 25 air exchange cycles per hour. according to them understanding the airflow within the operation theatre is crucial to minimizing the risk of infection. operating rooms are usually designed to have positive pressure to prevent intraoperative contamination. coronavirus is 125 nm in diameter and a high proportion of particles [up to 100%] are captured by high-efficiency particulate air (hepa) filters. this may be combined with the aforementioned high-frequency air exchanges to reduce the chance of virus dissemination [1, 16, 17] . pinto et al. recommend that the operative complex be divided into 5 zones as shown in table 1 . this ensures an orderly process reducing dissemination. a route to minimize exposure and contact between triage to induction room, or and then to recovery rooms should be frequently cleaned and disinfected [18] . the surgeons scrubbing routine has to change when entering the corona designated theatres. in zone 1 a disposable surgical scrub suit, surgical boots, waterproof boot and a waterproof apron should be donned. surgical hand preparation should also be done with water and chlorhexidine gluconate [1] . the surgeon should use either n95 or ffp 2 masks as recommended by the centers of disease control and prevention. they are effective for viruses including the coronavirus [19] . powered airpurifying respirators [papr] is preferred for longer operations. double surgical masks should be avoided especially in aerosolized blood generating procedures ( table 2) . eye protection equipment is also important during aerosol-generating procedures [18] . full face shield or goggles are recommended. in zone 2 either a surgical spacesuit or the second layer of sterile protective garments should be used. a surgical shield is also desirable. an aqueous alcohol solution is used for scrubbing. the first pair of gloves are donned. this should be followed by a sterile surgical scrub suit and second pair of gloves [1] . surgical gowns (aami) [association of the advancement of medical instrumentation] -level iii (typically those found in operating rooms) or coveralls should be prioritized for surgical and aerosolized-blood generating procedures. surgical caps should be used as per protocol, but surgical hood with ties should be used for the head and the neck for aerosol-generating procedures [18] . shoes or booties should be fluid resistant and double high cuffed surgical gloves are preferable. after the surgery the staff exits through zone 4 where doffing is done. in zone 5 the scrub suit is removed and bathing is done. strict and frequent screening of the segregated or staff is mandatory. members of the segregated or exposed staff should immediately report any signs of illness and must be taken off duty immediately. besides, all contact events between patients and staff must be recorded so that contact tracing and infection control measures can be implemented quickly, in case any member of segregated staff tests positive. the most experienced anaesthesiologist should intubate the patients. ti et al. also recommended that the same operation theatre be used along with the same anesthesia machine for covid cases. a heat and moisture exchanger (hme) filter is used on the expiratory limb of the circuit. the soda-lime and filters are exchanged after each case. disposable airway equipment is to be used. the airway should be secured with the method which has the highest chance of first-time success especially video-laryngoscope [20] . airway manipulation, face mask ventilation, and open airway suction should be minimized. bag mask ventilation should also be avoided. if a patient is transferred directly from the intensive care unit, a dedicated transport ventilator should be utilized. to reduce aerosolization risks, the gas flow should be turned off and the endotracheal tube clamped with forceps when switching from the portable device to the or ventilator [15] . regional anesthesia is preferable. nasal oxygen should be administered under the surgical mask. antiemetics should be used to reduce post-operative retching. if the patient is already in an icu, firstenberg et al. recommended intubation in the negative flow icu prior to transport to the or by the attending intensivist, while using appropriate precautions including n95 mask or ppe, gown, eye protection and hair cover, to avoid exposure to the anaesthesia team [21] . the transfer from the ward to the or will be done by the ward nurses in full personal protective equipment (ppe) ( table 2 ) including a well-fitting n95 mask, goggles, or face shield, splash-resistant gown, and boot covers. for patients coming from the icu, a dedicated transport ventilator is used. to avoid aerosolization, the gas flow is turned off and the endotracheal tube clamped with forceps [15] . fisrtenberg et al. used a portable travel ventilator with a high-efficiency particulate air (hepa) filter placed between the endotracheal tube and the circuit and a second hepa filter between the circuit and ventilator. they advised that two members of hospital security escort the transporting team to ensure elevator availability, open doors, and to minimize the risk of accidental contact with others during the transport [21] . while li tk et al. have recommended an operation theater at the corner of the operation theatre complex with separate access, coccolini et al. recommend an ot closest to the entrance of the complex [5, 15] . this probably depends on the architecture of the theatre complex as pinto et al. mention a satellite position of the operation theatre [1] . they also recommend a 5room complex. transfer routes should be as short as possible and precisely planned, with the same transport personnel throughout the shifting process [6] . we feel that this shall again vary depending on theater design and layout. air exchange cycles should be increased whenever possible to ≥ 25 exchanges/h between surgeries [22, 23] . even though no data currently exist on covid-19 viral load in bodily fluids or tissue samples, extreme care is mandatory. surgeons and personnel not needed for intubation should remain outside the operating room until anesthesia induction and intubation are completed for patients with or suspected of having covid-19 infection [24] . orthopedic surgery offers specific challenges and difficulties. hart mentions that with the asymptomatic patients being quite large, the operation theatre might be a viral lab in a wind tunnel. writing about orthopedic surgery he mentions that power tools, hammers, and other instruments spread a lot of material around. even though we do not know about the concentration of covid19 in blood and muscle, research into the airborne transmission of sars and mers makes it plausible that transmission is likely [25] . a recent canadian study described low-fidelity simulation training to evolve the modified ppe used for aerosolgenerating procedures of suspected/confirmed covid-19 patients and assess sites of contamination [26] . the spread of the aerosolized respiratory secretions and contamination sites were visualized with a commercial powder product and ultraviolet light. they demonstrated a significant amount of contamination on the provider's neck, the base of the wrist, and their lower pants and shoes. aerosols have been shown to spread from 5 to 7 m during orthopedic surgery. hip replacement surgery can cause a spread of aerosol from 8 to 9 m [27, 28] . minimum personnel should be placed in the operating room. firstenberg et al. kept two runners were outside of the or. only minimum required supplies were opened in the procedure room, and whenever required the runners fetched the additional supplies needed for the case which were placed on a cart in the containment room and transported into the or only when the outside door was shut. no additional phones or breaks/ changes in staff should be allowed [21] . a smoke evacuator should be used when electrocautery is to be used. particles in surgical smoke have been demonstrated to contain a variety of toxic and virulent materials thought to be capable of infecting those who inhale them, with case reports of doctors contracting rare papillomavirus when surgical smoke exposure was suspected to be the source [29] . hence electrosurgery should be minimized or excluded. bulb syringes should be used for lavage. in trauma and orthopedic surgical procedures, the use of power tools, such as electrocautery, bone saws, reamers, and drills, releases aerosols [15] , increasing the risk of virus spread. as such, their use should be reduced to the minimum and the power settings should be as low as possible [30] . some possible complications include the formation of a viral biofilm. disposable medical equipment should be used. a sharp injury should be avoided to the ppe. all body fluids, blood, secretions, pathological specimens should be disposed of in double bags that are sealed. any specimens taken should be placed into a biohazard bag inside the or and subsequently placed in another biohazard bag in the containment room before being sent to the lab being properly labeled, for example as "covid positive" or "suspected covid" [21] . covid-19 is presumed to spread directly via infectious respiratory droplets and close contact (since sars-cov-2 cannot survive without carrier) [12] however, these transmission modes do not explain all cases. recent data has shown that covid-19 might survive and be transmitted indirectly from virus contamination of common surfaces and objects after virus aerosolization in a confined space with infected individuals [31] . the incubation period for covid-19 is approximately 4 days and studies suggest it may range anywhere from 2 to 14 days. individuals with respiratory sickness should not be allowed to donate blood due to a lack of definitive evidence of blood transmission of covid-19 [32] [33] [34] . theoretically, viremia in patients with asymptomatic or confirmed covid-19 patients could pose a risk of transmissibility to the orthopedic team during aerosolized-blood generating procedures. the theatre is to be disinfected between surgeries. but the disinfecting personnel should enter the theatre only after enough air changes have occurred to remove infectious particles [18] . if possible, no other surgery should be carried out in the same or for the day, and theatre disinfected with uv light. the instruments sent to the sterilization unit must be labeled and the staff in the unit must be made aware of the covid status of the case, and must handle the instruments while wearing a full ppe [21] . the risk in theatres might be more in resourceconstrained settings. jain et al. mention that the emergence of covid-19 has impacted orthopedic surgery worldwide. india, with its large population and limited health resources, will be overwrought over the coming days due to the number of cases of critically ill patients with covid-19 [35] . guo x et al. showed that 26 orthopedic surgeons got infected with covid-19 in 3 hospitals in wuhan. this highlights the fact that despite being a surgical specialty, the risk is quite high [36] . it is important to understand that aerosols can be generated either by surgery or by the respiration of the patient within the theatre [37, 38] . ent, neurosurgery, and opthalmology surgeons are at risk from both types of aerosols while orthopedic surgeons are exposed to high levels of surgical aerosol but a lower risk of respiratory aerosol. surgeries that take longer time are likely to have more postoperative complications in a routine setting. these complications must be differentiated from covid 19. surgeons, nurses, and medical staff share equal responsibility for postoperative management, particularly in monitoring the patients' families and visitors to ensure strict adherence to the pandemic emergency system. when possible, it is important to limit visitors as much as possible. most hospitals have recently discontinued visitation by anyone [18] . lei et al. showed significantly higher covid related complications in these cases [7] . massey e al recommended additional measures including physical distancing and use of emerging technologies such as inpatient telemedicine and online file sharing applications to enable orthopedic programs to still function, while attempting to protect medical staff and patients from covid-19 spread [39] . cohen et al. suggest championing an alternative solution whereby we as a medical community become proactive rather than reactive, adopting a conservative yet balanced plan to protect both the patient and the health-care team. when faced with a biologically plausible concern that could infer serious harm, we are obligated to act with an abundance of caution, examining and questioning our standard practices [40] . it is acknowledged that, during the coronavirus pandemic, surgeons and patients will have difficult choices to make about management options for a wide variety of injuries and urgent conditions. they will need to balance optimum treatment of a patient's injury or condition against clinical safety and resources [41] . the orthopedic community is continuing to develop strategies to deliver a safe musculoskeletal skeletal service at this difficult time, while many members of the orthopedic workforce move to the front line [42] . in the end, we must admit that however thorough our search through the literature maybe, in the current trend of evolving guidelines and protocols about surgical care of covid-19 patients, any meticulously drafted treatise will quickly become obsolete if not updated along. here we list a few resources that we find immensely helpful for surgeons and orthopedic surgeons to keep themselves aware of the best practice guidelines issued from time to time by these reputed public health organizations: the surgical staff needs to keep abreast of the latest literature concerning safety measures to be taken during surgical procedures. review articles can go some distance in helping in this educational process. this knowledge must evolve as new information comes to light. infection or death of sub-specialized staff must be minimized to preserve the ability to face surgical emergencies and associated activities that will continue to occur or perhaps increase during a mass casualty incident. it is important for surgical specialists to stay up to date with the latest information concerning safety measures while conducting surgeries. the evolution of literature should be closely followed so that the best practices are instituted and upgraded. availability of data and material the data collected for this review article are available by the corresponding author upon request. authors' contributions lp contributed to the formulation of the idea and collected data. sad wrote and reviewed the article. mm helped with the revision. the author(s) read and approved the final manuscript. the authors received no funding for this article. ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing or conflicting interests with any of the specific entities mentioned in this manuscript. author details 1 the orthopedic forum. preparing to perform trauma and orthopedic surgery on patients with covid-19 clinical characteristics of coronavirus disease 2019 in china clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic corona virus; follow 7 overarching principles for delaying elective surgery. 2020. health leaders clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan surgery in covid-19 patients: operational directives clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection immune function after major surgical interventions: the effect of postoperative pain treatment active replication of middle east respiratory syndrome coronavirus and aberrant induction of inflammatory cytokines and chemokines in human macrophages: implications for pathogenesis temporal changes in cytokine/chemokine profiles and pulmonary involvement in severe acute respiratory syndrome chemokine up-regulation in sars-coronavirus-infected, monocytederived human dendritic cells neurosurgeon dies of covid-19. fatalities mount to 16 in tamil nadu sages and eaes recommendations regarding surgical response to covid-19 crisis how to risk-stratify elective surgery during the covid-19 pandemic? what do we do when a covid 19 patient needs an operation; operating room preparation and guidance coronaviruses: an overview of their replication and pathogenesis submicron and nanoparticulate matter removal by hepa-rated media filters and packed beds of granular materials perioperative considerations in urgent surgical care of suspected and confirmed covif-19 orthopaedic patients. operating room protocols and recommendations in the current covid-19 pandemic coronavirus (covid-19) outbreak of a new coronavirus: what anaesthetists should know isolation protocol for a covid-2019 patient requiring emergent surgical intervention: case presentation preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore. se préparer pour la pandémie de covid-19: revue des moyens déployés dans un bloc opératoire d'un grand hôpital tertiaire au singapour ventilation performance in operating theatres against airborne infection: review of research activities and practical guidance covid-19; considerations for optimum surgeon protection before, during, and after operation why surgeons don't want to operate right now. bloomberg opinion simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (covid-19) pandemic aerosols produced by high-speed cutters in cervical spine surgery: extent of environmental contamination contamination during removal of cement in revision hip arthroplasty. a cadaver study using ultrasound and highspeed cutters minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy characterization of aerosols produced during surgical procedures in hospitals indirect virus transmission in cluster of covid-19 cases early transmission dynamics in wuhan, china, of novel coronavirusinfected pneumonia a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study covid-19 and orthopaedic surgeons: the indian scenario survey of covid-19 disease among orthopaedic surgeons in wuhan, people's republic of china covid-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon sterile field contamination from powered air-purifying respirators (paprs) versus contamination from surgical masks orthopaedic surgical selection and inpatient paradigms during the coronavirus covid-19 pandemic perspectives on surgery in the time of covid-19. safety first management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic the impact of the novel coronavirus on trauma and orthopaedics in the uk publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-016372-opojt70e authors: dimarco, ross f. title: postoperative care of the cardiac surgical patient date: 2010 journal: surgical intensive care medicine doi: 10.1007/978-0-387-77893-8_47 sha: doc_id: 16372 cord_uid: opojt70e the subspecialty of interventional cardiology began in 1977. since then, the discipline of interventional cardiology has matured rapidly, particularly with regards to ischemic heart disease. as a result, more patients are undergoing percutaneous catheter interventional therapy for ischemic heart disease and fewer patients are undergoing surgical myocardial revascularization. those patients referred for surgical revascularization are generally older and have more complex problems. furthermore, as the population ages more patients are referred to surgery for valvular heart disease. the result of these changes is a population of surgical patients older and sicker than previously treated. the open-heart patient requires specialized care because physiologic systems are disrupted by cardiopulmonary bypass (cpb). cpb results in a generalized inflammatory response caused by blood contact with the synthetic surfaces of the bypass circuit. 1 the interface between blood elements and the surfaces of the circuit causes a generalized inflammatory response. this inflammatory response results in a series of complex reactions that activate the complement, clotting, and fibrinolytic cascades causing bleeding, microemboli, fluid retention, and an altered hormonal response. [2] [3] [4] [5] cpb is a nonspecific activator of the inflammatory system. 6 after the discontinuation of cpb, generalized complement activation occurs with elevations of c3a and c5a anaphylatoxins. 7 the activation of these anaphylatoxins can result in pulmonary sequestration of leukocytes 7, 8 and the production of superoxides. there then occurs further leukocyte activation and the generation of leukotactic factors that further increase the local inflammatory response. 9,10 also, vasoactive amines from platelets are liberated in response to cpb or possibly from protamine administration, which can result in pulmonary hypertension and systemic hypotension. 11 yet another result of the complement activation is an increase in vascular permeability that may predispose the patient to a capillary-leak syndrome with fluid sequestration in the third space, particularly the lung. 12 from a clinical perspective, the generalized inflammatory response results in postoperative pulmonary dysfunction, renal dysfunction, and a resetting of the hypothalamic thermoregulatory center. 9, 12 the inflammatory response caused by cpb also has direct negative cardiac effects. the inflammatory state caused by cpb involves platelet-endothelial cell interactions and vasospastic responses resulting in low-flow states in the coronary circulation. 13 the anaphylatoxin c5a is a potent molecule that is spasmogenic and has leukocyte-activating properties that cause degranulation and release of toxic oxygen free radicals. the complement-exposed leukocytes are attracted to adhere to the vascular endothelium and to aggregate, resulting in margination in blood vessels and leukoembolization. these inflammatory cells mediate injury by increasing their production and releasing oxygen free radicals or proteolytic enzymes. 14 at its worse at 4-5 h after cpb. 15, 16 recovery of ventricular function begins in 8-10 h and full recovery usually occurs by 24-48 h. 16 the systemic vascular resistance rises as ventricular function worsens. this is a compensatory mechanism in an effort to maintain systemic blood pressure and perfusion in the face of depressed ventricular contractility. the oxygen free radicals and the proteolytic enzymes released by the neutrophils also damage endothelial cells increasing capillary permeability resulting in capillary leak during this period. 17 the capillary leak may last from 1 to 2 days and is related to the duration of cpb. hypothermia has multiple adverse effects on the postoperative open-heart patient. regarding the circulatory status, it predisposes cardiac dysrhythmias, increases svr, precipitates shivering and impairs coagulation. 18 it also indirectly decreases cardiac output by increasing vasoconstriction and causing bradycardia. as a consequence of the inflammatory state after cpb, the postoperative open-heart patient is in a unique physiologic state where rules applicable to other physiologic situations may not apply, and a failure to recognize this concept results in management errors. concerns about the short-and long-term effects of cpb has generated the recent concept of off-pump coronary artery bypass surgery. while there seems to be growing evidence that this off-pump approach to the surgical management of ischemic heart disease is advantageous, there does remain some debate. 19 despite the movement toward avoidance of cpb in selected patients with ischemic heart disease, the majority of these patients as well as virtually all patients with valvular heart disease are operated on using cpb. the cpb circuit is not the only factor responsible for this altered physiologic state. the time of ischemia and reperfusion, hypothermia, hypotension with nonpulsatile flow, altered coagulation, and the administration of blood and products are other factors contributing to the altered postoperative physiologic state. 20 management of the postoperative open-heart patient initial management the patient after open-heart surgery presents with multiple, rapidly changing clinical problems. initially, these patients are unstable and their clinical status is extremely fluid and dynamic. caring for the postoperative open-heart patient requires bedside presence and the knowledge of general fundamental concepts of patient care as well as concepts specific to this set of patients. the initial management of these patients as they return from the operating room is critical, for it may well set the tone for the rest of the recovery period. clinical errors at this time can have farreaching implications. the initial management should begin even before the patient arrives in the intensive care unit (icu). it is vital to review the chart noting indications for surgery, preoperative hemodynamic data, comorbid conditions, medications, and allergies. upon the patient's arrival in the icu, perform a careful systematic assessment of the patient. begin the assessment by speaking directly to the surgical and anesthesia team. ascertain what procedure was done in the operating room and inquire as to any intraoperative events that might impact the patient's postoperative course. then, physically examine the patient as part of this initial evaluation. during the initial assessment, avoid focusing on any one issue and attempt to get a global picture of the patient's clinical status. at this time, the patient is completely dependent on support systems, and dysfunction of any one of these can lead to disaster. 21 the following points must be observed: heart rate and rhythm, blood pressure, temperature, right and left heart filling pressures, hemodynamic profile, pharmacologic support, ventilator status, chest drainage, neurologic status, laboratory results, ekg, and chest x-ray. a thorough knowledge of the specific monitoring and drug delivery lines is imperative as is knowledge of where the drains are placed. once the initial assessment is complete, specific issues can be identified, prioritized, and addressed. the primary objective in managing the postoperative openheart patient is achieving adequate hemodynamic performance by optimizing myocardial oxygen supply and demand. 22 optimal tissue oxygenation is essential to avoid organ dysfunction and can be determined by calculating oxygen delivery and oxygen demand. oxygen delivery is a function of oxygencarrying capacity and cardiac output. oxygen demand is a function of oxygen consumption. 23 the most important concept in the optimization of myocardial oxygen supply and demand, and tissue oxygenation is an adequate cardiac output. cardiac output is expressed as liters per minute and cardiac index as liters per minute per square meter. normal cardiac index is between 2.0 and 4.4 l/min/m 2 . 24 an uncomplicated recovery from cardiac surgery can be anticipated when the cardiac index is maintained greater than 2.0 and 2.2 l/min/m 2 . 24, 25 cardiac output is a function of stroke volume and heart rate, where cardiac output (co) is the product of heart rate (hr) and stroke volume (sv). an optimal heart rate is usually between 80 and 110 beats per minute. 26 this rate allows for optimal filling of the heart at an economic level of myocardial oxygen consumption. stroke volume is determined by preload, afterload, and contractility, and can be influenced by cardiac rhythm. stroke volume is the end-diastolic volume minus the end-systolic volume and in normal states is 70 ml preload refers to left ventricular end-diastolic sarcomere fiber length and is a function of end-diastolic ventricular volume (lvedv). it can be directly measured by echocardiography and is indirectly measured by left heart filling pressures; i.e., pulmonary artery diastolic pressure (padp), pulmonary capillary wedge pressure (pcwp), and left atrial pressure (lap). the former are all reflections of the left ventricular end diastolic pressure (lvedp). the compliance of the left ventricle is determined by the relationship between filling volumes and pressures, or lvedv/lvedp. stiff ventricles have low compliances and require higher filling pressures to achieve adequate volumes. this scenario is almost universal after cardiac surgery. afterload is a reference to left ventricular wall tension during systole. it is determined by intraventricular systolic pressure and ventricular wall thickness. 27 since there is minimal change in left ventricular wall thickness during cardiac surgery, intraventricular systolic pressure has the most impact on afterload. systolic blood pressure (sbp) as a function of systemic vascular resistance (svr) is the major determinant of afterload. an elevated sbp resulting from peripheral vasoconstriction and an elevation of the svr negatively influences both stroke volume and myocardial oxygen demand. myocardial oxygen demand is elevated because a major determinant of myocardial oxygen consumption is ventricular wall tension. contractility is the intrinsic strength of myocardial contraction at a constant preload and afterload. it is best assessed by echocardiography, and can be inferred from an analysis of cardiac output and filling pressures. while cardiac output is an important component of oxygen delivery, it is not the only factor. oxygen delivery is a function of cardiac output, hemoglobin, and arterial oxygen saturation (sao 2 ). most of the oxygen delivered to tissues is bound to hemoglobin. low hemoglobin is a major factor adversely affecting oxygen delivery; therefore, maintenance of optimal hemoglobin is essential. conversely, efforts should be made to limit transfusions, if possible, to avoid transfusion-related illnesses, immunologic compromise, and cost. a strategy should be in place to guide transfusions and should be based on criteria providing adequate oxygen delivery. the optimal postoperative hemoglobin is probably 22-24%. 28, 29 red blood cell (rbc) transfusions should be considered in patients with hematocrits lower than 22-24% and those patients with poor lv function, marginal sao 2 , ischemic findings on electrocardiogram (ecg), hypotension, tachycardia, and effort-related symptoms. similarly, the optimal oxygen saturation is 95-100%, and maintaining an sao 2 greater than 95% does not enhance oxygen delivery. mixed venous oxygen saturation (svo 2 ) is a measure of the adequacy of oxygen delivery to the tissues. it can be measured from blood drawn from the distal port of a swan-ganz catheter or continuously using a fiber-optic oximetric pulmonary artery catheter. a diminished svo 2 generally indicates decreased tissue perfusion and/or increased oxygen extraction by tissues. svo 2 is an indirect correlate of the cardiac output. in the absence of factors that increase oxygen utilization, a 10% decrease in svo 2 is an indication of a low cardiac output and can be seen before any change in other hemodynamic parameters. other causes of a diminished svo 2 are shivering, elevated temperature, anemia, alteration in inspired oxygen, and altered alveolar gas exchange. these conditions cause a diminished svo 2 in the presence of a normal cardiac output by causing increased oxygen utilization. svo 2 measurement can be of particular help in assessing adequate oxygen delivery when thermodilution cardiac output is unreliable (e.g., tricuspid regurgitation, improperly placed swan-ganz catheter, malfunctioning swan-ganz catheter), when thermodilution cardiac output is unavailable because swan-ganz cannot be placed (e.g., mechanical prosthesis in the tricuspid position), or when the clinical situation is unstable requiring online, minute-to-minute cardiac evaluation. 22 another important aspect in the appropriate management of the postoperative patient is minimizing the myocardial oxygen demand (mvo 2 ). 30 the mvo 2 is influenced by afterload, preload, heart rate, and contractility. reducing afterload will reduce oxygen demand. increasing preload, heart rate, and contractility will improve cardiac output but will also increase mvo 2 . providing adequate myocardial oxygen supply is equally important to the postoperative patient. myocardial oxygen supply is determined by coronary blood flow, duration of diastole, coronary perfusion pressure (systemic diastolic pressure minus lvedp), hemoglobin level, and arterial oxygen saturation. postoperatively, myocardial oxygen supply is optimized by avoidance of tachycardia, maintenance of adequate perfusion pressure (avoid hypotension and hypertension), avoiding ventricular distention and inappropriately elevated lvedp, and by managing preload judiciously. the goal of postoperative management is the maintenance of a satisfactory cardiac output. hemodynamically, the cardiac index (ci) should be greater than 2.2 l/min/m 2 at a pulmonary capillary wedge pressure (pcwp) of less than 20 mmhg or pulmonary artery diastolic pressure (padp) of less than 22-27 mmhg with a heart rate less than 100 bpm. clinically, the patient should be warm, well perfused, and with an appropriate urine output. 22 by definition, a ci greater than 2.2 l/ min/m 2 is satisfactory, a ci of 2.0-2.2 l/min/m 2 is marginal, and a ci below 2.0 l/min/m 2 is unacceptable and calls for intervention. ninety percent of all postoperative open-heart patients demonstrate a transient low cardiac output (lco) related to the release of oxygen free radicals in response to the induced inflammatory state of cardiopulmonary bypass, or from ischemic/reperfusion injury as a result of cardioplegic arrest. 15, 18, 31, 32 the ventricular function becomes depressed in 2 h and is at its worst at 4-5 h. generally, there is significant recovery in about 8-10 h and full recovery by 24-48 h. 33 lco is more common in patients with preoperative lv systolic dysfunction, diastolic dysfunction, prolonged cardiopulmonary bypass, and in women. 34, 35 clinical manifestations of low cardiac output as cardiac output deteriorates, compensatory mechanisms develop and are the result of sympathetic autonomic stimulation and endogenous catecholamine production. these compensatory mechanisms result in an increased heart rate, increased contractility, and increased arterial and venous tone (resulting in elevation of preload and afterload). these compensatory mechanisms may increase the cardiac output but at the expense of myocardium oxygen utilization, and consequently the myocardium may become more depressed. as the myocardium becomes depressed, the left ventricular function worsens and the systemic vascular resistance (svr) increases in an attempt to maintain systemic blood pressure. this elevation in the svr is compounded by the vasoconstriction seen with hypothermia. the early clinical manifestations of low cardiac output may be subtle. the only findings may be cool extremities accompanied by progressive tachycardia. as the compensatory mechanisms fail, more advanced clinical manifestations occur. overt findings of poor peripheral perfusion such as pale, cool extremities and diaphoresis, pulmonary congestion and poor oxygenation, oliguria secondary to poor renal perfusion, and metabolic acidosis will be manifest. early intervention is indicated at the onset of the early manifestations to avoid the complications of prolonged hypoperfusion and progression to the advanced manifestations. the etiology of lco can be abnormal preload, afterload, contractility, or heart rate and rhythm or a combination of these. the most common causes of lco after surgery are related to decreased left ventricular preload caused by hypovolemia and bleeding, vasodilatation, rewarming, drugs, cardiac tamponade, right ventricular dysfunction, positive pressure ventilation, and a tension pneumothorax. increased afterload is usually the result of acute vasoconstriction most often related to vasoactive drug therapy. it can also be from preexisting hypertension, pain or awareness, fluid overload, or hypothermia. decreased contractility is causative of lco in patients with preexisting lv dysfunction in association with perioperative ischemia. perioperative ischemia is usually a consequence of poor intraoperative myocardial protection, incomplete revascularization, coronary artery or conduit spasm, coronary artery "trash" syndrome, graft closure, acute anemia, hypoxia, or acidosis of any etiology. tachyarrhythmias adversely affect cardiac output by decreasing cardiac filling time and subsequently decreasing stroke volume coronary perfusion time. tachyarrhythmias also increase myocardial oxygen demand. bradyarrhythmias depresses cardiac output, especially when left ventricular dysfunction limits the compensatory mechanism of an increasing stroke volume. bradyarrhythmias are particularly deleterious in association with aortic insufficiency of any degree. when atrial fibrillation occurs, there is a loss of atrial contribution to cardiac output and subsequent fall in the cardiac output. finally, any ventricular arrhythmia adversely affects the cardiac output. diastolic dysfunction causes lco in a specific set of patients. it is often seen in small women with hypertension, patients with long-standing aortic stenosis, or patients with hyperdynamic left ventricles. all of these situations are associated with left ventricular hypertrophy, poor ventricular relaxation, and near-obliteration of the left ventricular cavity during systole. 36, 37 diastolic dysfunction presents with nor-mal lv function and normal or elevated pcwp, but a lco syndrome. these patients deteriorate quickly if sinus rhythm or atrial-ventricular synchrony is lost. miscellaneous noncardiac causes of lco include anaphylaxis or anaphylactoid reaction, marked alterations in temperature, sepsis, adrenal insufficiency, and the various protamine reactions. when no obvious diastolic or systolic dysfunction is present, then consider tamponade from blood or clot within the confines of the mediastinum and pericardium. the diagnosis of low cardiac output begins with a bedside physical examination. the early clinical manifestations of lco are apparent to the clinician with a heightened suspicion for their presence. the importance of a careful bedside assessment cannot be overstated. the examination should include the condition and appearance of skin and mucous membranes, breath sounds, murmurs, temperature of extremities, and a level of consciousness. the ekg monitor is a minimum level of monitoring after open-heart surgery. it is a screening device for ischemia and arrhythmias, both causes of lco. all ischemic changes on monitors must be further assessed with a 12-lead ekg and it is prudent to confirm all but the most obvious arrhythmias with a 12-lead ekg. hemodynamic monitoring, at a minimum, includes a central venous pressure (cvp) line and can be used to assess preload as well as right ventricular function. clinical lco and low cvp suggests inadequate preload as the cause of lco. clinical lco and an elevated cvp are more complicated. this situation may be the result of right heart failure, volume overload, left heart failure, tamponade, or some preexisting problem such as severe chronic obstructive pulmonary disease (copd). in this circumstance, the information from a swan-ganz catheter or transesophageal echocardiogram (tee) can clarify the situation. swan-ganz catheters (pulmonary artery catheters) are used in all patients in some institutions and selectively in others. oximetric swan-ganz catheters are optional and are used in highly selected situations when minute-to-minute cardiac assessments are necessary. swan-ganz catheters provide an assessment of right and left heart filling pressures, determine cardiac output, stroke volume, svr, and svo 2 . the information acquired from these catheters confirm the diagnosis of clinical lco and provide information as to the etiology. for example, low filling pressures suggest preload as the causative factor, whereas high filling pressures indicate a problem with contractility or afterload. a chest x-ray is a valuable and essential tool in the postoperative period for multiple reasons, but it can also assess the lungs as a cause for low cardiac output. in particular, a chest x-ray can identify a pneumothorax, hemothorax, pleural effusion, adult respiratory distress syndrome, and the endotracheal tube position as potential causes of a low cardiac output. it also assesses the mediastinum for an enlarged mediastinal silhouette suggesting tamponade or incorrect position of intrathoracic monitoring lines. echocardiography has become a first-line tool in evaluating the postoperative patient suspected of having lco. it can either be a transthoracic examination or a transesophageal examination. the surface echocardiography has limited value in the immediate postoperative period because of the presence of dressings and chest tubes, but can provide some information about lv function and recognize obvious tamponade. transesophageal echocardiography is an extremely valuable tool in the postoperative period and can be carried out at the bedside. it provides excellent visualization of cardiac dynamics, the pericardial space, and the mediastinum. it is the best diagnostic modality for lv function, presence of tamponade, and the development of new valvular abnormalities. it is also good for right ventricular assessment. each of the previous diagnostic modalities has an important role in the assessment of the postoperative cardiac surgical patient with suspected lco. once the diagnosis of lco is established and the etiology determined, appropriate treatment actions can be instituted. the management of low cardiac output begins by excluding tamponade as the cause. if there is no indication of tamponade, treat the correctable noncardiac abnormalities such as respiratory abnormalities, acid-base and electrolyte imbalances, and anemia. if lco persists, direct therapy at treatable cardiac abnormalities such as ischemia with a nitroglycerine infusion and consider diagnostic catheterization with catheter or operative intervention if ischemia persists. consider coronary spasm, but this is a difficult diagnosis. suspect coronary spasm when the patient presents with hemodynamic instability and ekg changes, especially st segment elevation. coronary spasm usually responds to calcium channel blockers and is a particular threat in patients with arterial conduits as grafts. arrhythmias can also cause lco. ideally, the patient should be in sinus rhythm at 70-90 bpm. in the presence of lco, arrhythmia management should be aggressive and pacing support may be needed to maintain atrial-ventricular synchrony. after the initial steps of correcting obvious noncardiac and cardiac abnormalities, the volume status should be assessed and preload optimized. it is helpful to know what filling pressures resulted in the best cardiac performance in the operating room or catheterization laboratory (cath lab) and adjust the volume accordingly. the cardiac performance should be followed closely as volume is administered, and if filling pressures increase without concomitant improvement of cardiac output, an inotrope will be needed. be mindful that the injudicious use of volume administration will result in distention of the ventricle (right, left, or both) with a shift in the frank-starling curve. as the ventricular wall tension increases, the myocardial oxygen demand increases and contractility becomes impaired. if volume administration fails to improve filling pressures, there may be ongoing volume loss from hemorrhage, diuresis, capillary leak syndrome, or vasodilatation from drugs, warming, or previous comorbid conditions. volume should be given in doses of 10% of estimated blood volume (blood volume is estimated as 0.065 ã� body weight in kg for adults). orders for volume expansion should be written with a prescribed stop order when the optimal filling pressure is exceeded to prevent ventricular distension. the choice of the appropriate volume expander is important. if the hemoglobin is less than 9.5 g, give packed red blood cells (prbcs); if the hemoglobin is 9.5-11.5 g, give prbcs and a colloid of choice; and if the hemoglobin is 11.5 g or greater, give a colloid of choice or equivalent dose of crystalloid. 38 pharmacologic support is considered when the cardiac output fails to improve after optimizing preload, afterload, rate and rhythm, and metabolic abnormalities. the threshold for using vasoactive agents should be low in patients with a preoperative history of compromised ventricular function. the choice of the agent depends on multiple factors: the hemodynamic profile of the patient; associated medical conditions; treating physician's understanding of the agent; and, to a lesser extent, cost. of these factors, the most important is the hemodynamic profile of the patient. inotropic agents must be chosen based on the specific hemodynamic abnormality most responsible for the current lco state. often, the causative factors are multifaceted and dynamic, making flexibility and vigilance key. it is not unusual to need a combination of agents to successfully treat lco. at the initiation of therapy for lco, a bedside presence is mandatory to respond minute-to-minute to hemodynamic changes. an understanding of the basic mechanism of action and of the inotropic agents comprises the basis for agent selection. in general, each category of agents exerts their effects differently. catecholamines affect -adrenergic and -adrenergic receptors. they elevate the levels of intracellular cyclic amp (camp) by -adrenergic stimulation of adenylate cyclase. the phosphodiesterase (pde) inhibitors, inamrinone and milrinone, elevate camp by inhibiting camp degradation. elevation of camp augments calcium influx into myocardial cells and increases contractility. 34 the stimulation of 1 -and 2 -adrenergic receptors results in elevation of svr and pvr. cardiac 1 receptors increase contractility and decrease heart rate. stimulation of 1 receptors results in increased contractility, heart rate, and conduction. in contrast, 2 stimulation results in peripheral vasodilatation and bronchodilatation. the overall hemodynamic effect of these agents is dose-related. the need to use these agents in combination is often beneficial and necessary to achieve the desired hemodynamic effect and lessen undesired sequelae. 22 when infusing vasoactive agents, several caveats are noteworthy. first, these agents have a lessened effect in an acid medium; therefore, it is important to maintain the patient in proper acid-base balance to achieve the full effect of the therapy. an increasing dose of the agent may be indicating a falling ph. secondly, the route of administration should always be through a central line and not peripherally. thirdly, these agents should always be administered with a rate-controllable infusion pump. finally, higher blood levels can be attained by infusing them directly into the left atrium to avoid partial deactivation or removal by the lungs. this method can also be employed to lessen the pulmonary vasoconstrictive effects and subsequent rv dysfunction of catecholamines such as epinephrine or norepinephrine. this method of infusion has its own inherent risks and should be reserved for extreme circumstances. 39 epinephrine is the catecholamine of choice for low cardiac output in many institutions. it has potent 1 inotropic effects and increases cardiac output by increasing contractility and heart rate. some of its effects are dose-related. at doses lower than 2 mcg/min (<0.03 mcg/kg/min), its 2 effects result in mild vasodilatation and a decrease in the svr while maintaining an adequate blood pressure. doses greater than 2 mcg/ min (>0.03 mcg/kg/min) produce effects that cause vasoconstriction with an increased svr potentially decreasing cardiac output further as well as increasing myocardial oxygen demand. epinephrine may cause tachycardia, but often less than that with dopamine or dobutamine at comparable doses. it can be arrhythmogenic, usually causing ventricular ectopy. hyperglycemia and metabolic acidosis are not infrequently associated with its use. while epinephrine can be used as a first-line agent in patients with ventricular arrhythmias or brittle diabetes mellitus, it must be done so with care. in some institutions, it is used as a second-line agent if dopamine and/ or dobutamine are not tolerated or ineffective. secondary uses for epinephrine include stimulation of heart rate in patients with bradycardia, bronchospasm, anaphylaxis, and general resuscitation for cardiac arrest. epinephrine is the least expensive of the commonly used inotropes. epinephrine is begun at 1 mcg/min and titrated to effect or to 4-6 mcg/min. dopamine is also a first-line agent for low cardiac output in some institutions. it is indicated for lco with a low svr and diminished systemic blood pressure. it also may be beneficial in the face of decreased urine output. aside from its inotropic and chronotropic effects, an added effect is the selective "dopaminergic" effect that increases renal perfusion, glomerular filtration rate, and urine production by directly reducing renal afferent arteriolar tone and indirectly increasing efferent arteriolar tone. the hemodynamic effects of dopamine are largely dose-dependent. despite its ability to increase urine production in some instances, it has never been shown to prevent acute renal failure. 40, 41 at doses of 2-3 mcg/kg/min, the main effects are renal as described, although there can be a mild 2 effect with a decrease in svr and systemic blood pressure. at doses of 3-8 mcg/kg/min, 1 effects are predominant increasing contractility. at this dose, there is also a chronotropic effect that increases heart rate and has the potential for arrhythmogenesis. doses of dopamine of greater than 8 mcg/kg/min results in increasing inotropy, but also this dose causes a predominant effect. this effect occurs directly but also indirectly from the release of norepinephrine. the svr increases as do the filling pressures and myocardial oxygen consumption leading to ventricular dysfunction. these adverse effects can be somewhat mitigated by the concomitant use of vasodilator therapy. its use may be limited by profound tachycardia even at low doses and excessive urine production. dopamine is begun as an infusion at 2.5 mcg/kg/min and titrated to 10-20 mcg/kg/ min if needed. if a 1 favorable response is not achieved at 10 mcg/kg/min, it is unlikely that higher doses will result in hemodynamic improvement. dobutamine has similar effectiveness as dopamine, but does not have its renal dopaminergic effect. dobutamine may augment myocardial perfusion better than dopamine. 42 it is a positive inotrope with strong 1 effect that increases contractility and also heart rate. dobutamine has mild 2 effect and decreases svr; this effect is mild and may be offset by its mild 1 vasoconstricting effect present in some specific circumstances. 43 also, unlike dopamine, dobutamine reduces ventricular wall tension by reducing afterload and preload particularly in the presence of volume overload. 44, 45 there appears to be augmentation of myocardial blood flow and an improvement of the myocardial oxygen supply and demand curve, but this positive effect may be lessened by tachycardia. 42 the usefulness of dobutamine may be limited by tachycardia that may be profound and may trigger atrial fibrillation. because of its hypotension from the vasodilating effect, dobutamine should be used with caution in the hypotensive or hypovolemic patient and is contraindicated if tamponade is suspected. it is most commonly used for low cardiac output associated with a mildly elevated svr and may have a synergistic effect when used with pde inhibitors. it does have a moderate pulmonary vasodilatory effect and can improve rv dysfunction. it is more expensive than dopamine, yet only minimally more effective. dobutamine is begun as an infusion at 5 mcg/kg/min and can be increased for effect up to 20 mcg/kg/min. inamrinone and milrinone are phosphodiesterase inhibitors known as "inodilators." 46 these agents produce positive inotropic effects and vasodilation independent of 1 adrenergic stimulation. they improve biventricular output by increasing stroke volume index, left ventricular contractility, and producing pulmonary vasodilation. these agents also produce vasodilation in arteriolar and venous smooth muscle, thus reducing preload and afterload, and their use is associated with decreased myocardial oxygen consumption, despite a modest positive chronotropic effect. inamrinone and milrinone decrease coronary vascular resistance, improve coronary perfusion, and improve the myocardial oxygen supply/ demand ratio. 47 pde inhibitors have an additive effect when used with catecholamines because of their differing sites of action. [48] [49] [50] catecholamines stimulate the production of camp whereas pde inhibitors slow the hydrolysis of camp. 51 inamrinone and milrinone are generally considered second-line agents in the treatment of lco. they are usually employed when first-line agents like dopamine or epinephrine are not providing adequate hemodynamic improvement or if side effects are limiting their effectiveness. however, there is evidence that administering these agents preemptively, prior to separation from cardiopulmonary bypass in patients with preoperative lv dysfunction, may eliminate the need for inotropic therapy subsequently. 52, 53 inamrinone and milrinone are particularly useful in patients with rv dysfunction secondary to pulmonary artery hypertension and elevated pvr. these agents are also useful in treating diastolic dysfunction as they have been shown to have relaxant or lusitropic properties. they also appear to have direct vasorelaxant effects on arterial graft conduits and may be useful in patients with evidence of internal mammary spasm or in the presence of radial artery grafts. 54, 55 these drugs have a relatively long half-life of 2-4 h; consequently, the loading dose will be effective for several hours after administration but the patient should be reassessed at that time for any ongoing need for therapy. since the pde-inhibitors are effective vasodilators, the systemic blood pressure may require support, usually with agonists. vasopressin may be an alternative drug to support the systemic blood pressure while reducing the need for catecholamine pressors. 56 inamrinone is associated with thrombocytopenia, but this is rare with milrinone. there does not appear to be any significant hemodynamic difference between inamrinone and milrinone, but milrinone has largely replaced inamrinone in clinical use because of the latter's thrombocytopenic effects. 57 both are relatively expensive compared to other inotropic agents. inamrinone is given as a loading dose of 0.75 mg/ kg over 10 min (may need 1.5 mg/kg if bolus given while on cardiopulmonary bypass) followed by an infusion of 10-15 mcg/ kg/min. milrinone is given as a loading dose of 50 mcg/kg over 10 min, then an infusion dose of 0.375-0.75 mcg/kg/min. norepinephrine is another naturally occurring catecholamine. it has a pronounced effect on peripheral receptors resulting in peripheral vasoconstriction, elevated svr, and elevated systemic blood pressure. norepinephrine also is a 1 agonist increasing myocardial contractility and heart rate. the increased afterload, contractility, and heart rate result in an increase in myocardial oxygen consumption. the overall increase in myocardial oxygen consumption may have a deleterious effect on ischemic myocardium. the primary effect of norepinephrine is elevation of blood pressure and mildto-moderate elevation of the cardiac output. it also has been shown to cause regional redistribution of blood flow with reduced renal, mesenteric, and peripheral perfusion. the primary indication for norepinephrine is a low cardiac output associated with a low svr. it is a reasonable choice of pharmacologic support if the svr is low and the cardiac output is 2.0-2.5 l/min/m 2 . if the svr is low and the cardiac output greater than 2.5 l/min/m 2 , a pure agonist may be used. if the svr is low and the cardiac output is less than 2.0 l/min/ m 2 , another inotrope should be used in addition to or in place of norepinephrine. 31 norepinephrine can be used in combination with afterload reduction to titrate the systemic blood pressures to acceptable levels and to maintain a satisfactory systemic blood pressure. it can also be used in combination with epinephrine to augment the 1 effect. the starting dose is 1 mcg/min (0.015 mcg/ kg/min) and titrated to the desired systemic blood pressure. at doses greater than 20 mcg/min (0.2 mcg/kg/min), visceral and peripheral perfusion is reduced to such an extent the patient may become acidotic. isoproterenol is a -adrenergic agonist. it has strong 1 effect, some 2 effect, and little action. the 1 effects increase cardiac output by its moderate increase in contractility and marked increase in heart rate. the 2 effect reduces svr. it has been shown to reduce pulmonary vascular resistance and may be effective in treating reactive pulmonary hypertension when right heart failure is contributing to low cardiac output. it can afterload reduce the right ventricle. isoproterenol also has strong 2 bronchodilator effect. the indications include right ventricular failure associated with elevated pvr and bronchospasm, and can be used to stimulate heart rate in patients with bradycardia and no functioning pacemaker wires. its use is limited because it increases heart rate and myocardial oxygen demand. since it is a nonselective -adrenergic agonist, it will predispose to tachyarrhythmias, ventricular irritability, and ventricular dysrhythmias. as a result of the tachyarrhythmias, isoproterenol has been largely replaced by pde inhibitors. 58 phenylephrine has no direct cardiac effects. it is a pure -agonist that increases svr. it does have some usefulness in the treatment of lco resulting from myocardial ischemia secondary to global hypoperfusion. if systemic blood pressure is reduced as a consequence of vasodilatation, coronary perfusion may be compromised leading to myocardial ischemia and ventricular dysfunction. phenylephrine directly stimulates -adrenergic receptors leading to an elevation of the coronary perfusion pressure and resolution of global myocardial ischemia. systemic vasodilatation is most often seen immediately following cpb or in the early hours of recovery as the patient rewarms. in these circumstances, phenylephrine may be helpful. since it provides no direct cardiac benefits, its role is limited. phenylephrine can cause vasoconstriction of an arterial conduit and should be used with caution in patients with arterial conduit grafts. its main indication is to increase svr in patients with low svr and normal or elevated cardiac output. it can also be used as a temporizing measure in a hypotensive, hypovolemic patient until the volume status is corrected. the usual starting dose is 5 mcg/min and the usual dosing range is 0.05-1.5 mcg/kg/min. nesiritide is a recombinant b-type natriuretic peptide. it is identical to the endogenous b-type natriuretic peptide secreted by the ventricles in response to increased cardiac volume and pressure overload. 59 nesiritide decreases sympathetic stimulation and inhibits the neurohumoral responses seen in heart failure. it exerts its effects by inhibiting the renin-angiotensinaldosterone system to decrease aldosterone, norepinephrine, and endothelin levels resulting in natriuresis and diuresis. the net effect is a balanced reduction in preload and afterload, and relaxation of smooth muscle. 60 it indirectly improves cardiac output with no increase in heart rate and no increase in myocardial oxygen demand. nesiritide is lusitropic and dilates native coronary arteries and arterial conduits. it is not proarrhythmic. it has been shown to dilate afferent and efferent renal arterioles increasing glomerular filtration resulting in natriuresis and diuresis. like pde inhibitors, it can be used synergistically with catecholamines to reduce dosages and side effects. while nesiritide has demonstrated favorable clinical results in nonsurgical patients with decompensated heart failure and it has pharmacologic effects possibly beneficial to the postoperative cardiac surgical patient, experience with nesiritide in surgical patients is limited. early results indicated that it may not be any better than milrinone. 61 one clinical trial did demonstrate a trend toward reduced length of stay without adverse effects. 62 its main indication in the surgical patient is in conditions of diastolic dysfunction or lco states associated with elevated pulmonary artery pressures. it is also useful in conditions of fluid overload and postoperative renal failure. 31 nesiritide is given, a dose of a 2 mcg/kg over 1 min followed by an infusion of 0.01-0.03 mcg/kg/min. vasopressin is a peptide hormone synthesized in the hypothalamus and is released from the posterior pituitary upon stimulation by hyperosmolality, hypotension, and hypovolemia. it has two sites of action: kidney and blood vessels. the primary function of arginine vasopressin (avp) is to regulate extracellular fluid volume by affecting renal tubular absorption of water. it acts on the renal collecting tubules by increasing water permeability and results in decreased urine formation. this is its antidiuretic function and is why it is commonly known as antidiuretic hormone (adh). the antidiuretic effect increases blood volume and indirectly increases cardiac output and arterial blood pressure. a secondary function of avp is vasoconstriction. it binds to vascular smooth muscle to cause vasoconstriction. avp is a potent vasopressor even in patients with catecholamine-resistant hypotension. loss of catecholamine pressor effect is a well-established phenomenon. 63 in acute shock states, vasopressin levels increase rapidly and then decrease in prolonged shock states leading to a relative deficiency of vasopressin. 64, 65 the deficiency of vasopressin is thought to contribute to hypotension refractory to catecholamines, especially in sepsis. 65, 66 because vasopressin is a potent vasopressor, infusions of vasopressin leads to improved organ perfusion, increased mean arterial pressure, and improved neurological function. 63, 65, 67 vasopressin is indicated for the management of severe vasodilatory shock. in patients with "vasoplegia," profound peripheral vasodilatation with preserved cardiac output, vasopressin may have a role. this condition is usually associated with patients on preoperative angiotensin-converting enzyme inhibitors or amiodarone. it may also be the consequence of leukocyte activation and release of proinflammatory mediators caused by the systemic inflammatory response to cpb. 68, 69 vasopressin is usually successful in reversing the low svr when phenylephrine and norepinephrine are not. 68, 70 vasodilatory shock is not uncommon in patients with a ventricular assist devices (vad) and may benefit from the vasoconstrictive actions of vasopressin. 71 despite vasopressin's effect in vasodilatory shock, it remains a second-line agent because there is no current evidence to support the use of vasopressin as a first-line agent instead of catecholamines. 72 there is growing evidence that vasopressin may provide comparable or superior efficacy to epinephrine as a resuscitative agent for cardiac arrest and hemodynamic collapse when administered as a single bolus of 40 units intravenously. 73 the recommended infusion rate for vasopressin in the treatment of vasodilatory shock is 0.01-0.04 units/min. doses greater that 0.04 units/min may lead to cardiac arrest. 64 rapid rebound hypotension commonly occurs after vasopressin infusion is discontinued. 74 potential adverse sequelae of vasopressin therapy include ischemic cutaneous necrosis, intestinal ischemia, and decreased hepatosplanchnic flow and cardiac output. 75 ionized calcium is critical for excitation-contraction coupling in cardiac muscle. 76 hypocalcemia depresses ventricular contractility and peripheral vascular resistance; the net effect is lco and low systemic blood pressure. the hemodynamic effects of calcium chloride are more profound if the patient is hypocalcemic. serum ionized calcium levels are low postoperatively, particularly just prior to weaning from cpb, and a bolus of calcium is frequently given just prior to weaning from cpb. the effect of a bolus of calcium is increased contractility and increased svr. it has little effect on the heart rate. it is more effective when the patient is hypocalcemic, but is also efficacious even if the patient is normocalcemic. calcium chloride provides ionized calcium, which acts as a strong but very evanescent inotrope. a continuous infusion of calcium does not sustain its hemodynamic effect. ionized calcium is necessary for the effective action of catecholamines. the main indication for calcium chloride is at the termination of cardiopulmonary bypass to augment systemic blood pressure during separation from bypass. it is also used as an emergency resuscitation agent to support hemodynamics until a more complete evaluation can be performed and more specific measures utilized. the dose is in increments of 0.5-1.0 g slow iv bolus. cardiopulmonary bypass and hypothermic arrest results in low levels of circulating thyroid hormone. 2, 77, 78 triiodothyronine (t 3 ) has hemodynamic effects based on this reduction in the plasma-free level of t 3 following cardiopulmonary bypass. t 3 remains low for 24 h, but not low enough to cause symptoms of hypothyroidism. augmenting the levels of t 3 can increase myocardial function and has been shown to increase cardiac output and lower svr in patients with ventricular dysfunction. 79-81 t 3 exerts its positive inotropic effect by increasing aerobic metabolism and synthesis of highenergy phosphates. it directly stimulates calcium adenosine triphosphatase (atpase) in the sarcolemma and sarcoplastic reticulum. 82 the enhancement of calcium transport decreases intracellular calcium aiding myocardial relaxation, myocardial compliance, and diastolic function. 2,77,82 t 3 also decreases svr. 83 currently, there are conflicting results on the use of t 3 in the treatment of lco. the current role for t 3 is salvage when cardiopulmonary bypass cannot be terminated despite maximum support including inotropic agents and intra-aortic balloon counterpulsation. there are no studies, to date, that show that t 3 favorably improves outcome in patients failing to separate from cardiopulmonary bypass even though hemodynamics have improved in patients with ventricular dysfunction. 84 the dosage is 0.05-0.8 mcg/kg as an iv bolus. pharmacologic support is the first-line therapy for lco. mechanical support should be considered for the management of lco when there is need for more than two inotropic agents used at the upper range of their therapeutic efficacy, when there are complications from these agents, or when lco progresses to cardiogenic shock. other uses of mechanical support postoperatively include myocardial ischemia or the development of mitral regurgitation that cannot be managed medically. finally, mechanical support is indicated for the patient experiencing acute deterioration and in need of a transplant. available mechanical support devices are the intraaortic balloon and circulatory assist devices such as left and/or right ventricular assist devices. the intra-aortic balloon pump has been an effective tool for the management of lco states, ongoing ischemia, valvular disease, and the complications of myocardial infarction since its development in 1968. 85 intra-aortic balloon pump (iabp) counterpulsation provides hemodynamic support and control of ischemia before and after surgery. 86 it has been shown to be effective in improving the diastolic function of the left ventricle. 87 iabp counterpulsation is very effective in the management of low cardiac output states. unlike most inotropic agents, it provides hemodynamic support to the failing heart by decreasing myocardial oxygen demand and improving coronary artery perfusion. iabp counterpulsation acts to improve the myocardial oxygen supply:demand ratio. it reduces the impedance of left ventricular ejection by rapidly deflating just before systole, thus unloading the lv, and in this way decreases myocardial oxygen demand. as it rapidly inflates just after aortic valve closure, it increases the diastolic coronary perfusion and improves myocardial oxygen supply. the survival rate of patients requiring postoperative iabp support is 60-70%. 88, 89 the indications for iabp counterpulsation are perioperative ischemia, mechanical complications of myocardial infarction (such as acute mitral regurgitation, ventricular septal defect, and cardiogenic shock), postoperative low cardiac output states not responsive to moderate doses of inotropic agents, and for the acute deterioration of myocardial function to provide temporary support or a bridge to transplantation. iapb counterpulsation is contraindicated in the presence of aortic insufficiency, aortic dissection, and severe aortic and peripheral vascular disease. the iabp can be inserted percutaneously or surgically. the percutaneous approach is favored despite its somewhat higher prevalence of vascular complications. 90 percutaneous insertion is preferred because of ease of insertion and removal. the iabp is inserted percutaneously using the seldinger technique and is positioned fluoroscopically. the balloon tip marker should be positioned just distal to the origin of the left subclavian artery. the surgical insertion requires the exposure of the femoral artery and creation of a sidearm to the femoral artery with a vascular graft, followed by the insertion of the balloon through the graft. an alternative open surgical approach is exposure of the femoral artery and then direct cannulation with a vascular sheath using a guide wire. a hemostatic suture is placed in the femoral artery around the stem of the iabp. the iabp can be inserted by an open supra-inguinal approach in cases of severe femoral arterial disease, or the transthoracic approach via the ascending aorta in cases of severe aortoiliac peripheral disease. triggering of the device is timed using ekg or arterial waveform. if ekg is used, the inflation is set at the peak of t wave, the end of systole. deflation is set just before or on the p wave. arterial waveform triggering is more reliable and a better timing technique when outside electrical impulses (i.e., pacemaker, electrocautery) may interfere with interpretation of the ekg signal. with arterial triggering, the inflation should occur at the dicrotic notch and deflation just before the onset of the aortic upstroke. proper timing will show an arterial waveform with augmentation of the diastolic portion of the curve. support with the iabp is instituted at a 1:1 ratio with ventricular systole based either on ekg monitoring or the arterial pressure pulse tracing. there is often immediate hemodynamic improvement and the patient requires less inotropic support. when the required inotropic support reaches moderate levels (generally half the doses required prior to iabp support) consideration for weaning is possible. the iabp is weaned by reducing the assist ratio from 1:1 to 1:3 or less depending on the system. the weaning process can usually begin after 12-24 h of support and completed by 24-48 h. if the device was placed percutaneously, it can be removed similarly with firm pressure to the groin for 30 min. since the arterial puncture site is several centimeters proximal to the skin insertion site, a common mistake is to direct the pressure at the skin insertion site instead of the arterial puncture site. when this error occurs, a large hematoma develops in the groin proximally. if a hematoma occurs or if the perfusion to the distal limb is compromised, immediate exploration is required. 91 at times, there is a failure to achieve augmentation from the counterpulsation with the iabp. this can be the result of tachycardia and arrhythmias, inadequate balloon volume, and/or balloon rupture. arrhythmias effect augmentation by disrupting the normal inflation and deflation patterns of the device. rapid heart rates, usually atrial fibrillation with ventricular responses greater than 150 bpm, interfere with the balloon's ability to inflate and deflate. in this circumstance, augmentation can be achieved by changing the triggering ratio to 1:2 (one iabp cycle for every second cardiac cycle). inadequate gas volume in the balloon can also result in an inability to augment. volume loss from the balloon can result from a gas leak or from failure of the balloon to unwrap. either circumstance necessitates the removal of the balloon. of more immediate concern is a balloon rupture. this is heralded by blood in the balloon tubing. the balloon must be removed immediately as helium and blood can create a rock-hard thrombus making surgical removal necessary. vascular complications are the most commonly encountered complications of iabp counterpulsation. the most catastrophic complication is an aortic or iliac artery dissection or rupture. fortunately, this is an uncommon occurrence. equally catastrophic is paraplegia from a periadventitial aortic hematoma or as the consequence of embolization of atherosclerotic debris to the spinal cord. embolization or altered perfusion to visceral vessels can also occur with iabp counterpulsation. the most common vessels involved are the renal arteries. this usually occurs in the presence of significant atherosclerotic disease in the aorta. altered perfusion of the kidneys and renal failure can happen if the balloon is situated below diaphragm. 92 the iabp can also restrict perfusion to the lima if it is advanced too far proximally into the subclavian artery. 93 distal limb ischemia is the most common complication of the iabp. the occurrence rate is 5-10% and occurs more commonly with percutaneous placement, in women, and in patients with small femoral arteries. heparin therapy is advisable if the iabp is in place more than 2-3 days after surgery. the management of compromised distal perfusion begins by knowing the preoperative vascular status of the patient as well as obtaining a baseline status of the distal extremities with physical examination and doppler assessment as soon as possible after implantation of the iabp. thereafter, the distal pulses or doppler signals should be assessed hourly and recorded along with the vital signs of the patient. if the pulses or doppler signals deteriorate, initially rule out peripheral vasoconstriction from hypothermia, low cardiac output, or as a result of vasopressor agents. if limb ischemia persists, remove the sheath from the femoral artery if the iabp was inserted percutaneously. if distal perfusion remains compromised, then remove the balloon and place it on the contralateral side if counterpulsation remains necessary. femoral artery exploration is necessary if iabp removal does not improve the vascular integrity of the threatened limb. if the patient remains dependent on the iabp and the femoral artery approach is not feasible any longer, consider the transthoracic approach. thrombocytopenia can occur from the mechanical destruction of the platelets by the iabp. thrombocytopenia may also be related to drug interactions (heparin, amrinone, etc.) when the iabp is implanted, a platelet count should be checked daily and if a downward trend develops, then every 8-12 h. circulatory assist devices were introduced by cooley and his associates in 1969. 94 these devices, commonly referred to as ventricular assist devices (vads), are used as a bridge to transplantation, a bridge to recovery, and for support after cardiac surgery. they are the ultimate therapy for low cardiac output. they are usually employed intraoperatively for failure to wean from cardiopulmonary, but can also be an option postoperatively if the patient fails to respond to vasoactive agents and the iabp. vads should be considered if the patient does not respond to maximum medical therapy including the iabp. 95, 96 the therapeutic strategy of vads is to provide sufficient flow to support the systemic and/or pulmonary circulation while the myocardium recovers. short-term devices are used if there is a reasonable chance for recovery, whereas long-term devices are considered if the chances of recovery are remote and the patient is a suitable candidate for transplantation. prior to committing to circulatory assist, a thorough investigation for correctable causes of lco must be made. transesophageal echocardiography is helpful in evaluating ventricular wall motion and excluding other structural conditions related to the cardiac procedure. preload and afterload should be optimized, appropriate inotropic therapy instituted, and placement of the iabp accomplished before considering circulatory assist. 91 circulatory assist can be left or right heart bypass or combined biventricular bypass. the general indications for vad implantation include a complete and adequate cardiac surgical procedure, the correction of all metabolic problems, the inability to wean from cardiopulmonary bypass, the inability to reverse deteriorating hemodynamic embarrassment despite maximum drug therapy and iabp, and a cardiac index less than 1.8-2 l/min/m 2 . 22 left ventricular assist devices (lvads) provide systemic perfusion while the left ventricle recovers. the indications for lvad support include those general indications for vads as well as a systolic bp less than 80 mmhg, left atrial pressure greater than 20 mmhg, svr greater than 21 dyne s/cm 5 , and urine output less than 20 ml/h. 97 lvads require a left atrial cannula connected to an aortic cannula via a centrifugal pump. the lvad flow is dependent on the intravascular volume and right ventricular function. the goal of management is a lvad flow of 2.2 l/min/m 2 . these devices reduce left ventricular wall stress by 80% and left ventricular myocardial oxygen demand by 40%. monitoring mixed venous oxygen saturation can assess adequacy of tissue perfusion. after lvad implantation, inotropic support should be discontinued to decrease myocardial oxygen demand. in some circumstances, an inotrope may be needed to support the right ventricle and vasoconstricting agents may be needed to maintain the svr and a mean arterial pressure greater than 75 mmhg. heparin therapy is necessary after postoperative bleeding stops and, particularly, when flow is decreased to less than 1.5 l/min. after implant a long-term device as a bridge to transplantation if the patient is an appropriate candidate. 98 right ventricular assist devices (rvads) provide support to the right ventricle (rv) and allow recovery much the same as do lvads. the main contributing factor to right ventricular failure is an elevated pulmonary vascular resistance; however, it can also be the result of an rv infarction, or inadequate intraoperative protection. indications for an rvad include the general indications for vads as well as a right atrial pressure greater than 20 mmhg, left atrial pressure less than 15 mmhg, and no tricuspid regurgitation. right heart bypass is established by connecting the right atrial cannula to a pulmonary artery cannula via a centrifugal pump. despite the presence of an rvad, adequate systemic flows depend on intact left ventricular function. 99 management goals are an rvad flow of 2.2 l/min/m 2 and an increase in left atrial pressure to 15 mmhg while maintaining a right atrial pressure of 5-10 mmhg. impaired rvad support may be the result of hypovolemia or inadequate cannula drainage. during rvad support, if the patient becomes hypotensive it may be the result of hypovolemia, left ventricular dysfunction, or a decreased systemic vascular resistance. a tee to assess the left ventricular function may be appropriate at this time as well as the use of an inotrope or vasopressor. interval tee examinations may be used to assess the recovery of the right ventricle, and weaning criteria are the same as those for an lvad. 22 from the standpoint of prognosis, generally patients requiring rvad have a poor prognosis. weaning is accomplished in only about 35% and survival to discharge in about 25%. 99 biventricular failure occurs in 10-15% of patients requiring postoperative circulatory assist. biventricular assist devices (bivads) support both pulmonary and systemic circulation and can even be used in periods of ventricular fibrillation. the indications for bivad implantation are a right atrial pressure greater than 20-25 mmhg, left atrial pressure greater than 20 mmhg, no tricuspid regurgitation, and inability to maintain lvad flow greater than 2.0 l/min/m 2 with a right atrial pressure greater than 20 mmhg. it is not an unusual circumstance for lvad implantation to unmask right ventricular dysfunction and the need for an rvad. 100 bivads are managed to create a sequential adjustment of rvad and lvad flow achieving a systemic flow rate of 2.2 l/min/m 2 . the heparin requirements, the assessment of recovery, and device weaning are the same as for the lvad and rvad. 22 weaning is accomplished in 35% of patients and survival to discharge in only 20%. this poor prognosis is a reflection of the adverse impact biventricular failure has on survival. 99 to be optimally effective, circulatory assist devices as support for lco require adequate pulmonary function and gas exchange. in circumstances of compromised cardiac and pulmonary function, cardiopulmonary function support is also required. cardiopulmonary support (cps) is accomplished with a portable centrifugal pump, membrane oxygenator, heat exchanger, and heparin-coated tubing. this system is generally referred to as extracorporeal membrane oxygenation (ecmo). indications for ecmo or cps are those of vads in association with impaired oxygenation. ecmo can also be used for cath lab catastrophes or in support of high-risk angioplasty. 101, 102 only two cannulae are required for ecmo/cps support, a venous drainage cannula and arterial perfusion cannula. if the sternum is open, the cannulation technique is the right atrium and aorta. the percutaneous cannulation can also be used using the common femoral artery and vein or the jugular vein. since this system does not completely divert all the blood from the lv (pulmonary venous return to the lv persists), the lv is not completely decompressed, and a beating heart and competent aortic valve is necessary. an iabp is frequently concomitantly used to provide augmented pulsatile coronary perfusion. 103 the management of the patient on ecmo/cps is complicated and labor intensive. it requires an experienced, committed, and well-trained staff. preload must be optimized and the svr may need support with -agonist agents or vasopressin. pulmonary artery hypertension must be controlled and may require using inhaled nitrous oxide. if renal failure occurs, consider early continuous venovenous hemofiltration. ventilation with low tidal volumes is helpful. 22 heparin-coated tubing may eliminate the need for full anticoagulation, but heparin anticoagulation is required to prevent excess fibrin formation in the oxygenator membrane. the activated clotting time (act) is maintained 160 s by continuous heparin infusion. 91 the results of ecmo/cps depend on the degree of organ dysfunction at the time of initiation and the indication for its use. if it was instituted for cardiac arrest, the survival is 31%. 104 of those patients placed on ecmo/cps for postcardiotomy cardiogenic shock, 40-50% will die on support and only half of those who do not will survive the hospitalization. patients who survived 30 days had a 63% 5-year survival. 105, 106 currently, there are a variety of mechanical assist drive devices available for ventricular assist. selection of the particular device depends on the length of support required. there are short-term devices and long-term devices. 107 the short-term devices are non-implantable and employed if recovery of ventricular function is expected. the long-term devices function as bridges to transplant and may be a long-term alternative to transplant. these devices are pulsatile, implantable, and provide total support of circulation. the selection of a long-term support device is rarely a consideration in the acute care management of the postoperative open-heart patient. however, a working understanding of the short-term devices may be required in the management of the postoperative patient with low cardiac output. the complications of these devices include mediastinal bleeding, mediastinal sepsis, thromboembolic events, renal failure, malignant ventricular arrhythmias, respiratory failure, refractory systemic vasodilatation, and immunocompromise. most patients return to the intensive care unit following openheart surgery with an arterial line, foley catheter, and usually a thermodilutional swan-ganz catheter. the hemodynamic status of the patient can be determined by careful assessment of data provided by these monitoring devices. with information collected by these monitoring devices, an accurate and realtime profile of the patient's hemodynamic status can be calculated and appropriate therapeutic interventions prescribed. the following is a discussion of commonly encountered hemodynamic situations in the postoperative open-heart patient. this is a very common postoperative occurrence. it usually occurs with rewarming and responds well to volume expansion. if hypotension persists despite volume expansion, or if presenting hypotension is severe, consider temporizing with a vasopressor such as phenylephrine or norepinephrine. the systemic vascular resistance (svr) and cardiac output/index must be followed closely when using either drug. the hemodynamic effects of phenylephrine are purely -adrenergic and act to increase the systemic vascular resistance. it has no cardiac effects. the indirect cardiac effects include a decrease in cardiac output caused by an increasing afterload as well as a potential increase in the cardiac output by raising perfusion pressure in coronary arteries. patients may become refractory to the therapeutic effects of phenylephrine after several hours and may require a change to norepinephrine. the starting dose of phenylephrine is 5 mcg/min and increase to effect up to 500 mcg/min, with the usual dosage range of 0.05-1.5 mcg/ kg/min. if there is inadequate therapeutic response to phenylephrine, switching to norepinephrine may prove effective. norepinephrine has powerful -adrenergic properties and some weaker -adrenergic effects. the -adrenergic stimulation will increase the systemic blood pressure by increasing the svr. the -adrenergic effects will increase contractility and heart rate. clinically, the -adrenergic effects predominate and will increase myocardial oxygen demand and may cause a fall in cardiac output despite its -adrenergic effect on contractility. the vasoconstrictive effects of norepinephrine may increase organ perfusion pressure but decrease absolute blood flow and result in visceral ischemia; this is an important potential adverse effect of this agent. the initial dose of norepinephrine is 1 mcg/min (0.015 mcg/kg/min) and titrate to effect. recall that at doses greater than 20 mcg/min (0.2 mcg/ kg/min), visceral and peripheral perfusion is reduced to such an extent the patient may become acidotic. this is another common occurrence and is seen in patients with normal left ventricular function. it is related to an increased arterial resistance secondary to hypothermia and increased levels of circulating catecholamines, plasma reninangiotensin, and vasopressin. 22, 108, 109 postoperatively, systemic hypertension is more commonly seen in patients with normal left ventricular function, preoperative hypertension, preoperative use of -blockers, and patients having aortic valve replacement. 110 the adverse sequelae of systemic hypertension include exacerbation of any latent myocardial ischemia by increasing afterload, stresses on suture lines, a predisposition to bleeding, and an increased potential for stroke and aortic dissection. 22, 111 hypertension may be the result of hyperdynamic cardiac function or peripheral vasoconstriction, or both; and a hemodynamic profile must be ascertained before initiating therapy so as to direct therapy at the appropriate cause. the usual criterion for pharmacologic treatment is a mean arterial pressure 10% above the upper level of the normal patientspecific mean arterial pressure (map), usually greater than 96 mmhg, or arbitrarily, a systolic blood pressure greater than 140 mmhg (map greater than 110 mmhg). in managing the postoperative hypertensive patient, a few caveats are important to keep in mind. first, a patient with a history of longstanding hypertension or critical carotid stenosis may require a higher perfusion pressure to maintain adequate cerebral and renal perfusion. secondly, a patient with a tenuous aorta or thin-walled vein grafts may require a lower pressure to avoid suture line dehiscence and catastrophic hemorrhage. the treatment goal in this scenario is to lower the svr and reduce myocardial oxygen demand without adversely affecting coronary artery perfusion. the treatment of systemic hypertension in the early postoperative period is vasodilator therapy. this can be augmented with -blocker therapy, calcium channel blocker therapy, angiotensin converting enzymes (ace) inhibitor therapy, and sedation, depending on the clinical circumstances. the vasodilator of choice for systemic hypertension postoperatively is sodium nitroprusside (snp). snp has a rapid onset of action and can produce rapid and excessive hypotension, but it has a short half-life. it is imperative that filling pressures are optimized before beginning snp, or a hypotensive collapse will occur. snp relaxes smooth muscle and as such decreases arterial resistance in the systemic and pulmonary circuit. it also relaxes venous capacitance vessels. it should be used with caution in the setting of myocardial ischemia as it can produce a coronary steal phenomenon. it has the potential for either short-term cyanide toxicity or thiocyanate toxicity with prolonged use. 112 snp can also cause hypoxemia by opening intra-pulmonary shunts. the dosage is initiated at 0.1-0.25 mcg/kg/min and titrated to a maximum dose of 8 mcg/kg/min. nitroglycerine (ntg) is primarily a venous dilator that lowers blood pressure by reducing preload, filling pressures, stroke volume, and cardiac output. since its primary action is on venous vessels, it usually maintains arterial diastolic pressure, but at high doses can produce arterial dilatation of varying degree and lower coronary artery perfusion pressure. ntg must be used with care if the patient is hypovolemic or the cardiac output is marginal, as reducing preload further will reduce cardiac output further and produce a reflex tachycardia. ntg works best in the hypertensive patient with active ischemia and high filling pressures. 113 the major adverse effect of ntg is methemoglobinemia and impaired oxygen transport. the dosage begins at 0.1 mcg/kg/min and can be titrated up to 10 mcg/kg/min. hydralazine is a direct arterial vasodilator that can be used to unload the left ventricle and treat systemic hypertension. it produces arterial vasodilatation and usually a compensatory tachycardia. in the immediate postoperative period, it is used as a supplement to other agents and not as the primary drug for the management of hypertension. hydralazine most commonly is used in the hemodynamically stable patient that remains hypertensive several days postoperatively but is unable to take oral medications. the dosage is 5-10 mg iv bolus every 4 h as needed. calcium channel blockers primarily produce antihypertensive effects by relaxing vascular smooth muscle. they are very effective for managing postoperative hypertension, but do have a variety of cardiovascular hemodynamic effects and conduction alterations specific to each particular agent. calcium channel blockers are also used for the treatment of coronary spasm and rapid atrial tachycardias as well as for hypertension. nicardipine is a strong systemic and coronary vasodilator that does not cause coronary steal or tachycardia. it has little or no effect on the venous system and can be used without great concern for altering preload. the onset of action is rapid and has a relatively long half-life of 40 min. nicardipine is not a negative inotrope and has no effect on av conduction. the dosage is an initial iv bolus of 2.5 mg over 5 min and repeat every 10 min to a total dose of 12.5 mg, then begin an infusion of 2-4 mg/h. diltiazem also acts as a peripheral vasodilator that reduces svr; however, it decreases cardiac output as a result of its negative inotropic and chronotropic (slows av conduction) effect. diltiazem is a good choice when hypertension is associated with coronary spasm because it is a potent coronary artery vasodilator. it is also a good option if hypertension is associated with atrial fibrillation and a rapid ventricular response. the dosage is 0.25 mg/kg iv bolus over 2 min and a repeat dose in 15 min of 0.35 mg/kg, then an infusion of 5-15 mg/h. verapamil is a peripheral vasodilator with moderate negative inotropic and chronotropic effects. its indications for usage are similar to diltiazem. the dosage is 0.1 mg/kg iv bolus initially, then 2-5 mcg/kg/min infusion. nifedipine, like all calcium channel blockers, lowers blood pressure by reducing the svr. it has potent vasodilatory actions. it causes a slight increase in heart rate and inotropy. when compared to snp, an infusion of nifedipine has a more positive effect on cardiac output and a greater decrease in svr. it has no effect on venous capacitance and preload. 114 nifedipine is a potent coronary vasodilator and is an effective agent for managing suspected coronary spasm or arterial conduit spasm. 115 while an intravenous form is available, it is primarily given sublingually or orally at a dose of 10-30 mg every 4 h. amlodipine acts on the svr as do all other calcium channel blockers and may result in an increased cardiac output as a result of decreasing afterload. it has no negative inotropic or chronotropic properties by virtue of its lack of effect on the sa and av nodes. amlodipine exerts its antihypertensive effect gradually over a 24-h span and is used mainly for the long-term management of hypertension. the dose of amlodipine is 2.5-10 mg daily. -blockers reduce pressure by negative inotropic and chronotropic actions. they reduce contractility, lower stroke volume and cardiac output, and lower heart rate. these agents are used to control hypertension associated with normal or hyperdynamic cardiac output, especially if the patient is tachycardic. esmolol is an ultrafast, short acting, cardioselective agent. because it is so short acting, it is the -blocker of choice for transient hypertension in a hemodynamically unstable patient. it should be used with caution in a patient with marginal cardiac output. the reduction in blood pressure is generally greater than the reduction in heart rate. it is cardioselective and can be used in a patient with bronchospasm. the dosage is an initial dose of 0.25-0.5 mg/kg over 1 min, followed by 50 mcg/kg/min over 4 min followed by a continuous infusion titrated to effect. if an adequate response is not obtained after the initial dose, another loading can be given followed by 100 mcg/kg/min over 4 min. there is little to be gained by cumulative doses of more than 200 mcg/kg/min. labetalol has -adrenergic and -adrenergic blocking effects as well as a direct vasodilatory effect. the -adrenergic blocking effect prevents reflex vasoconstriction. 116 this agent is used when a longer-acting antihypertensive effect is needed because its duration of action is 6 h. labetalol has a rapid onset of action resulting in a blood pressure response within 5 min. the dosage is 0.25 mg/kg iv bolus over 2 min, with subsequent dosing at 0.5 mg/kg every 15 min until desired effect is reached or a total dose of 300 mg is administered. metoprolol is a cardioselective -blocker used mainly to control ischemia or to slow ventricular response in atrial fibrillation, but rarely can it be used to treat postoperative hypertension. the onset of action is 2 min and duration of action is about 5 h. the dosage is 5 mg iv bolus every 15 min until the desired effect is reached or a total dose of 15 mg. propranolol is a non-cardioselective agent with a long duration of action and has negative inotropic effect and as such is rarely used to treat postoperative hypertension. the dosage is in 0.5 mg increments given every 2-5 min until desired effect is reached or a total dose of 0.1 mg/kg. enalaprilat is an ace inhibitor that reduces blood pressure by inhibiting the activation of the renin-angiotensin system. it causes a balanced arterial and venous dilatation and acts to reduce myocardial oxygen consumption by its action on preload and afterload. it generally does not cause a reflex tachycardia. enalaprilat can be used alone or as a supplement in situations requiring high doses of nitroprusside or nicardipine. the onset of action is 15 min and usually has a 4-h duration of action. the dosage is 0.625-1.25 mg iv over 15 min every 6 h. it can be used as a continuous infusion of 1 mg/h with a doubling of the dose every 30 min until the desired effect is reached or a total dose of 10 mg. 117 fenoldopam mesylate is a dopamine receptor agonist that is a rapid-acting peripheral and renal vasodilator. it is indicated for the short-term management of severe hypertension. fenoldopam mesylate causes a rapid fall in blood pressure and a reflex tachycardia. other hemodynamic effects include increase in stroke volume index and cardiac index attributed to the fall in svr. there is also an associated fall in pulmonary vascular resistance that may make its use beneficial in patients with pulmonary artery hypertension and rv failure. these properties make it an option for the management of postoperative hypertension in the cardiac surgical patient. 118 it also has a beneficial effect on the kidneys. it dilates renal afferent arterioles and increases renal blood flow. the dosage of fenoldopam mesylate is an initial infusion of 0.05-0.1 mcg/ kg/min and increases at increments of 0.05 mcg/kg/min to the desired effect or a maximum of 0.8 mcg/kg/min. the renoprotective dose is 0.1 mcg/kg/min and is usually not associated with hypotension. while it has been shown to be effective in the management of postoperative hypertension in the cardiac surgical patient, it is not cost-effective and should be reserved for instances when other agents are ineffectual. the two most common causes of this scenario are right ventricular failure and diastolic dysfunction. right ventricular failure is rarely an isolated clinical situation. when it is, it is the result of poor intraoperative protection or a right ventricular infarct. more commonly, it is associated with pulmonary artery hypertension, either preexisting or the result of infused vasoconstricting adrenergic agents, administration of blood products, a type iii protamine reaction, hypoxemia, acidosis, or a tension pneumothorax. the hemodynamic hallmark of rv failure is a central venous pressure (cvp) higher than the pulmonary artery diastolic pressure (pad) or pulmonary capillary wedge pressure (pcwp). tee is an excellent mode of rv assessment and diagnosis of rv failure. 119 the treatment of rv dysfunction begins by optimizing preload to a cvp of 18-20 mmhg. pushing the cvp higher may result in rv dilatation and exacerbation of rv dysfunction. also, a distended rv can have an adverse effect on the lv by shifting the intraventricular septum into the lv and impairing lv filling and stoke volume. hypoxemia, hypercarbia, and acidosis must be corrected as these adversely affect rv function. there must be active transport of volume from the right atrium to the rv, so it is imperative that atrioventricular (av) conduction be maintained or established using sequential av pacing if necessary. the addition of inotropic support is often necessary. inotropes that support biventricular function and are pulmonary vasodilators should be selected. the phosphodiesterase inhibitors are reasonable agents, but their action on the svr may necessitate the use of -adrenergic agents and lead to further vasoconstriction of the pulmonary vasculature. isoproterenol may improve rv contractility, but its proarrhythmic effects may not be well tolerated. when rv failure is associated with an elevated pulmonary vascular resistance (pvr), it is mandatory to decrease rv afterload by using a pulmonary vasodilator. the pulmonary vasodilators have no direct effect on rv or lv inotropy. their effect is indirect by afterload reduction of the rv. nesiritide (see prior description) is a synthetic -type natriuretic peptide that reduces pulmonary artery pressure and unloads the rv. it also has vasodilatory effects on the svr and renal arterioles resulting in improved cardiac output and a synergistic effect with loop diuretics. 120, 121 inhaled nitric oxide (ino) is a selective pulmonary vasodilator and decreases rv afterload. this results in enhanced rv performance. it has little, if any, effect on the svr. 122 inhaled nitric oxide is administered through a ventilator circuit designed to mix o 2 and no. this generates a low level of no 2 , which must be monitored as it is toxic to lung parenchymal tissue. inhaled nitric oxide is quite effective, but it is cumbersome and expensive. the usual dose is 10-40 ppm administered through a ventilator circuit. prostaglandin e 1 and its analogs, epoprostenol and iloprost, are potent pulmonary vasodilators effective in the treatment of pulmonary hypertension. these agents are most frequently used in cardiac transplantation, but have been used effectively after mitral valve surgery. 58, 123, 124 diastolic dysfunction is a function of impaired myocardial relaxation. in the postoperative period, it results in lco with normal or elevated filling pressures in patients with normal or hyperdynamic lv function. it is commonly seen in small women with left ventricular hypertrophy from hypertensive cardiovascular disease or aortic stenosis. severe diastolic dysfunction is associated with reduced left ventricular compliance exacerbated by edema often associated with ischemic cross-clamping, reperfusion, and cpb. inotropic agents used to treat the lco in the postoperative period will worsen diastolic dysfunction. diastolic dysfunction is frequently associated with tachycardia. 125 the filling pressures are high and stroke volume reduced because the impaired left ventricular relaxation leads to impaired filling of the lv and a deceased lv end-diastolic volume (lvedv). swan-ganz monitoring confirms high left-sided filling pressures and lco. the svr is elevated as a compensatory mechanism. tee is diagnostic. it confirms a hypertrophic lv with decreased compliance and filling. the lv may be so hyperdynamic as to obliterate the lv cavity at end-systole. diastolic dysfunction is difficult to manage. if not managed successfully, end-organ dysfunction is inevitable. the initial steps in management are to assure av synchrony and adequate preload. volume should be infused until the pcwp is 20-25 mmhg to increase lvedv. intuitively, it may seem inappropriate to give volume in the setting of elevated filling pressures, but the elevated filling pressures are the consequence of impaired lv compliance and not volume overload. inotropic agents should be replaced with lusitropic agents. ace inhibitors may improve diastolic compliance. calcium channel blockers also have some lusitropy and may be of benefit. finally, inamrinone and milrinone have lusitropic properties as does nesiritide. there is no one agent shown to be better than the others and often management requires courses of therapy and observation. if the patient can be guided through the first few days, the cardiac output gradually improves. 22 arrhythmias cardiac arrhythmias carry a source of morbidity and mortality in the postoperative surgical patient. these arrhythmia are usually an indicator of some underlying abnormality and should alert the clinician to closely evaluate the patient. in addition to standard electrocardiograms (ekg), the temporary atrial and ventricular pacing wires are useful in the diagnosing and treatment of postoperative arrhythmias. 126 the ideal postoperative rhythm is sinus rhythm at 70-110 bpm. 127 sinus tachycardia is frequently seen in the early postoperative period and is most commonly caused by vasodilatation secondary to rewarming, reperfusion injury to the left ventricle secondary to cardiopulmonary bypass, sympathomimetic drugs, pain and anxiety as the patient awakens from anesthesia, normovolemic anemia, withdrawal from -blocker therapy, occasionally fever, and idiopathic. isolated ventricular ectopy may be an indication of ongoing myocardial ischemia, particularly within the first 6 h postoperatively. other causes of ventricular ectopy are hypokalemia, hypomagnesemia, hypoxia, preexisting ectopy, sympathomimetic drugs, and mechanical irritation from the swan-ganz catheter. there remains controversy as to the significance of isolated ventricular ectopy. it is not clear what the incidence of isolated premature ventricular contractions (pvcs) degenerating to malignant ventricular arrhythmias actually is. however, most agree that in the presence of active myocardial ischemia, pharmacologic suppression is indicated and this concept includes those patients in the first 24 h after surgery when the myocardium may be irritable. unlike chronic pharmacologic treatment of isolated ventricular ectopy, treatment in the acute postoperative period is not usually associated with the risk of proarrhythmia. treatment is particularly beneficial in patients with lv dysfunction and ejection fractions less than 40%. in the first 24 h after surgery, ventricular ectopy is treated if the ectopic beats occur at a rate greater than 6 beats/min or ventricular tachycardia of less than 1 min. the treatment of pvcs begins with the correction of any underlying correctable cause such as hypokalemia or hypomagnesemia. if atrial wires are present, overdrive atrial pacing at a rate greater than the current sinus rate can be tried. lidocaine is the initial drug treatment for ventricular ectopy. the dosage is an initial loading dose of 1 mg/kg as an initial bolus followed by one or two additional doses of 0.5 mg/kg mg every 10 min. after the initial bolus, an infusion of 1-2 mg/min can be started. an alternative option is an initial bolus of 75 mg followed by a loading infusion of 150 mg over 20 min. the loading dose is followed by a maintenance dose of 1.5-2.5 mg/min. if the ectopy is uncontrolled, an additional bolus of 25-50 mg can be given and the infusion rate increased. lidocaine toxicity is a significant risk at infusion rates greater than 4 mg/min, especially in the elderly. if lidocaine does not suppress ectopy, it can be elected not to treat unless ventricular tachycardia occurs or with intravenous amiodarone. sustained ventricular tachycardia (vt) or ventricular fibrillation (vf) are usually associated with acute myocardial ischemia or infarction or an electrolyte imbalance, but can occur without the obvious presence of either. 128 these arrhythmias are most often seen in patients with previous infarcts and subsequent revascularization to the infarcted area, and occur with a frequency of 1-3% after cardiac surgery. 129 reperfusion of areas of ischemia or infarction can precipitate vt of vf as the areas of ischemic myocardium are reperfused. the reperfusion arrhythmias occur in patients with unstable angina, recent infarction, and ejection fractions of less than 40%. in these circumstances, nonviable myofibrils embedded in the scar are triggered and this leads to an altered dispersion of repolarization and the development of reentry arrhythmias. the resultant ventricular arrhythmia is usually a sustained polymorphic vt with a normal qt interval as compared to the monomorphic vt noted in patients with a previous myocardial infarction and depressed lv function. this reentry arrhythmia rarely responds to lidocaine and usually requires amiodarone and possible -blockade. the treatment of nonsustained vt in patients with preserved lv function is similar to the treatment of pvcs. in patients with ejection fractions less than 30% and nonsustained vt, the prognosis is poor without treatment, and an electrophysiologic evaluation is necessary as an implantable cardioverter-defibrillator may be indicated. 130 sustained vt without hemodynamic instability can be managed with ventricular overdrive pacing. cardioversion may be necessary if overdrive pacing is not successful or if the patient becomes unstable. an amiodarone bolus of 150 mg infused over 15 min followed by an infusion of 1 mg/min for 6 h, then 0.5 mg/ min for 18 h should be prescribed. these patients will ultimately need an electrophysiologic evaluation. all patients with vt or af with hemodynamic instability require immediate defibrillation as per acls protocol. 131 if the patient is unresponsive to defibrillation or persistence of hemodynamic instability, the sternotomy must be reopened emergently at the bedside. torsades de pointes is an uncommon but malignant arrhythmia not often related to the postoperative cardiac surgical patient. on the ekg monitor, the qrs complex appears to "twist" around the isoelectric baseline. its onset is usually pause-dependent, initiated by a pvc occurring at the end of a t wave. it is usually associated with a prolonged qt interval. treatment of torsades de pointes is immediate cardioversion. if the patient is not hyperkalemic, potassium chloride should be administered to shorten the qt interval. magnesium and -blockers may eliminate the trigger and prevent recurrence. finally, ventricular pacing at 90-100 bpm or an isoproterenol infusion of 1-4 mcg/min will shorten the action potential and prevent early afterdepolarization. 132, 133 be aware that a wide complex tachyarrhythmia does not necessarily indicate ventricular tachycardia because atrial fibrillation with a rapid ventricular response can result in rbbb with aberrant conduction (so-called ashman phenomenon) mimicking ventricular tachycardia. 20 atrial fibrillation (af) is the most common arrhythmia after cardiac surgery. despite the recent institution of prophylactic regimens for af, the overall incidence remains 25-30%. it has an occurrence of 10-40% after coronary artery bypass graft (cabg) surgery and up to 65% of patients undergoing combined cabg valve procedures. [134] [135] [136] after on-pump coronary artery bypass surgery, the incidence is 27-33%, 127, 135 after minimally invasive cabg it is 19%, and following valve surgery it is 30-70%. 137, 138 there is controversy as to whether off-pump cabg has a lower incidence of af. 139 patient's age appears to be the most powerful predictor of the occurrence of af. the incidence is 3.7% in patients less than 40 years of age and 28% in those older than 70. 127, 135 other predictors are a history of congestive heart failure, preoperative atrial fibrillation, and chronic obstructive pulmonary disease. [140] [141] [142] atrial fibrillation is most likely to occur 2-4 days after surgery. the episodes of these arrhythmias may recur or persist for up to 6 weeks before resolving spontaneously. ten to 15% of patients are discharged in atrial fibrillation whereas 80% will return to sinus rhythm within 1-3 days with only digoxin or -blockade therapy. 138, [143] [144] [145] it is a leading cause for readmission after early discharge. the management of postoperative af begins with an assessment of the patient. if the patient is unstable, immediate cardioversion is indicated. a synchronized shock of 50-100 j is applied. rarely is this the only treatment necessary, as the patient often reverts back to af, especially if this occurs in the early postoperative period. if the patient is hemodynamically stable, the initial treatment of postoperative af is rate control and is indicated if it lasts longer than 15-30 min or is associated with severe symptoms. 138 the most important aspect of the treatment of postoperative af is the control of the ventricular rate. in many protocols, the first-line agent for rate control is the calcium channel blocker diltiazem. therapy is initiated with a bolus of 0.25 mg/kg over 2 min and followed by an infusion of 10-15 mg/h to titrate the heart rate to less than 120 bpm. slowing of the ventricular rate is usually noted within 3 min and is more effective for atrial fibrillation than atrial flutter. the use of diltiazem is limited by hypotension, which occurs with an incidence of 5-20%. 146, 147 pretreatment with 500 mg of calcium may lessen the hypotensive effect. diltiazem has a mild negative inotropic effect and must be used with caution in patients with compromised left ventricular function. while diltiazem is extremely effective in slowing the ventricular rate, it converts fewer than 10% to sinus rhythm. verapamil can be used in lieu of diltiazem for rate control in rapid atrial fibrillation. begin with a bolus of 20-25 mg, then an infusion of 10-15 mg/h. if the blood pressure is tenuous, pretreat with 500-1,000 mg of calcium chloride. while calcium channel blockers are effective rate control agents, they are not as effective as -blockers in converting patients back to normal sinus rhythm (nsr). beta-blockers are equally or more effective for rate control and also can effect conversion to nsr 50% of the time. 148, 149 they are not used as frequently for postoperative af by some clinicians because of their negative inotropic properties. esmolol is a short acting, selective -blocker. it must be used in an icu setting with appropriate monitoring because of its propensity to cause hypotension, particularly in patients with poor lv function. the loading dose is 0.25-0.5 mg/kg over 1 min followed by an infusion of 50-200 mcg/kg/min. metoprolol has less of a tendency to cause hypotension and is more suited for use in a non-icu area. it is a long-acting, selective -blocker. it is dosed at 5 mg iv every 5 min to a total dose of 15 mg. digoxin has only a modest response in the acute setting. there is only a 10-15% decrease in ventricular rate with digoxin alone. 150 at least half of the patients remain in af after the rate has been slowed. an effort should be made to cardiovert the patient back to sinus rhythm. if the patient is hemodynamically unstable, electrical cardioversion is an option. there is a high incidence of recurrent atrial arrhythmia unless an antiarrhythmic regimen is instituted. currently in many institutions the antiarrhythmic of choice is amiodarone. amiodarone has properties of class iii antiarrhythmics and -blockade. it is becoming the drug of choice for postoperative af because it is safe and effective. it is associated with only modest hypotension and has no proarrhythmic effects. it does slow the ventricular rate as effectively as -blockers or calcium channel blockers, which are often used as adjuncts to amiodarone. 151 it does have a higher rate of cardioversion than either calcium channel blockers or -blockers. amiodarone has the same frequency of cardioversion as type 1c antiarrhythmics, but takes longer. 152 amiodarone has fewer adverse side effects than those antiarrhythmics. it can be given intravenously, but is just as effective orally for non-life-threatening arrhythmias. the half-life of the drug is long, up to 120 days, and its long-term use is associated with visual disturbances, tremors and other neurologic sequelae, hepatitis, pulmonary fibrosis, photosensitivity, skin discoloration, thyroid abnormalities, and cardiac conduction disturbances. these side effects, however, are rarely a factor when used to treat postoperative atrial fibrillation because amiodarone is administered only for 6 weeks. if given intravenously, the initial loading dose is 150 mg over 15 min, followed by an infusion of 1 mg/min for 6 h, then 0.5 mg/min for 18 h. an oral taper dose is then prescribed of 400 mg bid for 1 week, 400 mg daily for 1 week, then 200 mg daily for 2 weeks. if the patient has no further episodes of af, it can be discontinued at that time. procainamide is a type 1a antiarrhythmic that once was a first-line antiarrhythmic for the postoperative cardioversion of af in most centers. it restores nsr in 87% of patients within 40 min. 153 procainamide is proarrhythmic and has a mild negative inotropic effect. it is associated with more short-term side effects than amiodarone. it has vasolytic properties and as such should not be used until the ventricular rate has been slowed to less than 120 bpm. the loading dose is an intravenous bolus of 17 mg/kg (dose not to exceed 1 g total) at a rate not exceeding 30 mg/min. this can be followed by an infusion of 2 mg/min or converted to an oral procainamide derivative in 24 h. up to one-third of patients cannot tolerate procainamide because of gastrointestinal, hematological, or immunologic side effects. this drug is cleared by the kidneys and blood levels of procainamide and its active metabolite, n-acetyl procainamide (napa), should be monitored, particularly, in patients with renal and hepatic dysfunction. 154 ibutilide is a rather new agent for the treatment of postoperative atrial fibrillation. the incidence of torsades de pointes is about 1-2%, which is considerably higher than with either procainamide or amiodarone. 154 ibutilide is useful in patients with poor left ventricular function or chronic lung disease, but its use is limited by its proarrhythmic effect. conversion to sinus rhythm occurs at a rate of 30-50% for atrial fibrillation and 50-70% for atrial flutter. 155 the dose begins with a bolus of 1 mg over 10 min with a second infusion 10 min later. no further dosing is indicated. the drug must be stopped if qt prolongation occurs as it may contribute to torsades, but sustained polymorphic ventricular tachycardia may occur even in the absence of qt interval prolongation. there are several strictly oral agents that can be used for pharmacologic conversion back to sinus rhythm. sotalol is useful as a single-agent therapy for atrial fibrillation cardioversion. it is a class iii antiarrhythmic with beta-blocking activity. it can cause prolongation of the qt interval and initiation of therapy must be done while monitoring the patient. the drug is limited mainly by its beta-blocking effects such as reactive airway disease, depression, and negative inotropy. the dose is 80-160 mg twice daily. quinidine is still used by some clinicians for the conversion of atrial fibrillation to sinus rhythm. it may be slightly more effective than amiodarone, but it is being used with decreasing frequency. 156, 157 though quinidine is cost-effective and has very little negative inotropy, it is associated with a high incidence of side effects, particularly gastrointestinal, neurological, and hematological. also, the proarrhythmic and frequent dosing make other agents a better choice. flecainide can also be used for the management of atrial fibrillation. flecainide was found to be associated with an increased mortality when given after a myocardial infarction, and created much concern when given with ischemic heart disease. it is not recommended for patients with structural heart disease. 158 postoperative atrial fibrillation is associated with increased morbidity and cost; therefore, there is great interest in the prophylaxis of postoperative atrial fibrillation. multiple trials and multiple protocols have been investigated searching for an effective prophylactic regimen. the most effective and practical regimens all include preoperative -blockade therapy started 12-24 h preoperatively. [159] [160] [161] [162] beta-blockade therapy given preoperatively and through the postoperative period is superior to their use only postoperatively. when given preoperatively and postoperatively, the incidence of af is 17%. [163] [164] [165] magnesium sulfate has been used as prevention for postoperative af. hypomagnesemia is common after cardiac surgery and is associated with atrial arrhythmias. there is a debate as to whether routine magnesium administration lowers the incidence of postoperative af. 166 it may be effective when used with -blockers and when the serum magnesium is low. 167, 168 since it is relatively benign and may be potentially effective, some recommend its routine administration through the first postoperative day. sotalol is a -blocker with class iii antiarrhythmic properties. it reduces the incidence of postoperative af by as much as 65% when given preoperatively and postoperatively. 169 because it has -blocker action, it must be used with caution in patients with lv dysfunction and those with marginal systemic blood pressure. it is excreted by the kidneys and is not recommended in patients with renal insufficiency. sotalol can also cause qt interval prolongation and has been associated with torsades de pointes. it is not well tolerated in 20% of patients and must be withdrawn. the dose of sotalol is 80 mg twice daily. amiodarone is a class iii antiarrhythmic with some properties of class i, ii, and iv drugs. it is as effective as sotalol in preventing postoperative af and can be used alone or in conjunction with -blockers. [170] [171] [172] [173] amiodarone is particularly useful in patients with intolerance to -blockers. it is rarely associated with pulmonary toxicity when used as a short-term therapy, but the rare incidence of amiodarone toxicity can cause hypoxemia. 174 as prophylaxis, amiodarone is started in the operating room as a 150 mg bolus over 15 min followed by an infusion of 1 mg/min for 6 h then 0.5 mg/min for 18 h. the oral dose of 400 mg twice daily is continued for 1 week. if the patient should develop af, a 6-week regimen is recommended. in the event the patient should develop af with either the sotalol or amiodarone prophylactic regimen, the ventricular response rate is usually slow and easier to manage. the efficacy of both sotalol and amiodarone as prophylaxis is better if started several days preoperatively. postoperative stroke as a consequence of atrial fibrillation is well documented. the incidence of stroke is between 3 and 7% in patients with postoperative atrial fibrillation as compared to 1-1.5% in patients without atrial fibrillation. 141, 175 the risk of embolic stroke is substantial after 48 h or more of atrial fibrillation. 176 all patients with postoperative atrial fibrillation should be anticoagulated unless there is a contraindication. anticoagulation should be started within 24-36 h of the onset af. bradycardia requiring pacing occurs in approximately 10% of postoperative patients. the most common defect is right bundle branch block (rbbb). about 5% of the patients will have permanent conduction abnormalities. the associated bradycardia is treated with temporary epicardial pacing. the most commonly used mode is ventricular pacing. in all the open-heart patients, temporary epicardial ventricular pacing wires are fixed to the right ventricle and, in many, right atrial wires are also placed. bradycardia from any etiology is an indication for ventricular pacing. if the patient is hemodynamically unstable with simple ventricular pacing, physiologic pacing may be required if atrial electrodes are available. if an atrial electrode was not fixed to the heart, a temporary transvenous atrial pacing electrode can be inserted. simple ventricular pacing is accomplished by connecting the temporary electrodes to an external pacemaker. these pacemaker units are bipolar and require the ventricular lead electrode be connected to the negative pole and an indifferent electrode, often a skin wire, connected to the positive pole of the pacemaker. the output is set initially at 10 ma and the threshold adjusted to assure a safe margin of capture. a decision is then made as to the mode of pacing; i.e., synchronous (demand) or asynchronous (fixed). the synchronous mode is chosen to avoid pacer stimulation on the t wave and the resulting ventricular fibrillation. the asynchronous mode is used only in unusual situations, such as the use of electrocautery, when other electrical activity interfere with the sensing in the synchronous mode. the rate must be set depending on the needs of the patient. physiologic pacing requires choosing the desired mode, atrial thresholds, atrioventricular intervals, as well as the ventricular settings. failure to pace may be the result of faulty electrical connections, dislodgment of the epicardial electrodes from the heart, a faulty pacemaker, the development of electrically silent areas of the myocardium in the region of the electrodes, or the development of a rhythm incompatible with pacing such as atrial or ventricular fibrillation. postoperative bleeding is always present to some extent. it is related to mechanical factors and coagulopathy. mechanical factors are considered surgically correctable. less than 3% of postoperative bleeding is from surgically correctable causes. it is usually indicated by bleeding greater than 200 ml/h with normal or near-normal coagulation studies. mechanical bleeding is characterized by clots in the drainage tubes. 177 coagulopathy is present to some extent in all patients after cardiopulmonary bypass. with the current aggressive use of percutaneous catheter intervention for the treatment of various acute coronary syndromes (acs), drug-induced coagulopathy is frequently seen. following deployment of stents for acs, patients are placed on platelet inhibitors such as glycoprotein iib/iiia inhibitors (eptifibatide, tirofiban, or abciximab) or the adp binding inhibitor clopidogrel. in some instances, acute myocardial infarctions are treated with thrombolytic therapy and this results in a profound coagulopathy. 178, 179 fibrinolysis results from the activation of the fibrinolytic system either intrinsically from cardiopulmonary bypass or therapeutically from preoperative thrombolytic therapy. 180, 181 this appears to be the primary cause in coagulopathy following cardiopulmonary bypass (cpb). a progressive fibrinolytic state occurs and its intensity is directly related to the duration of cardiopulmonary bypass. 182 it is associated with the degradation of clotting factors as well as platelet dysfunction. platelet defects are also an important cause of postoperative bleeding. the platelet-related bleeding diathesis is a result of a decrease in the absolute platelet number, and more importantly, secondary to impaired platelet function. 183, 184 the decrease in the platelet number, or quantitative defect, results from hemodilution, preoperative thrombocytopenia from medications, and the consumption of platelets by the cardiopulmonary bypass circuit. the cpb circuit itself can reduce the platelet count by 30-50% and worsens as the duration of bypass lengthens. the diminished platelet function, or qualitative defect, may be directly related to the duration of cpb. passage of platelets through the cardiopulmonary bypass circuit results in decreased platelet membrane receptors for fibrinogen and glycoprotein ib and glycoprotein iib/iiia complex. 185 thrombocytopenia may also be caused by heparin-induced thrombocytopenia. this usually occurs in patients with a previous exposure to heparin within 3 months. it is the result of heparin antibodies causing platelet aggregation. there is often a history of heparin resistance during cpb. 186 the qualitative defect in platelets may also be related to preoperative medications such as aspirin, heparin, and the glycoprotein iib/iiia inhibitors. 187, 188 residual heparin effect can account for a postoperative bleeding diathesis. heparin effect is usually reversed by the time the patient gets to the intensive care unit. it should always be considered as a possibility in the bleeding patient. heparin rebound is the recurrence of measurable heparin activity after complete protamine neutralization. it is associated with larger heparin doses given intraoperatively, after long cpb runs, and obese patients. 189 it is thought to be the result of elution of heparin from plasma proteins 190 hypothermia is a significant cause for postoperative coagulopathy. the coagulation cascade is mediated by enzymatic reactions. these reactions are temperature-sensitive and occur most efficiently at normothermia. hypothermia retards the normal coagulation cascade as a result of this altered enzymatic activity. hemodilution of cpb is another source of coagulopathy and affects all blood elements including coagulation factors. most factors are reduced by 50% and factor v by 80%. 191 this phenomenon affects patients with small blood volumes more profoundly. also, coagulation factors are lost with cell saving. an attempt should be made to specifically diagnose the coagulopathy. the specific abnormalities can usually be diagnosed if appropriate studies are ordered. platelet defects are both quantitative and qualitative. the diagnosis of quantitative defects, thrombocytopenia, can be made early in the postoperative period with a simple platelet count. if thrombocytopenia occurs later in the course, consider hit and obtain a heparinplatelet aggregation test to confirm the presence of heparin antibodies. qualitative platelet defects, thrombasthenia, can be present with a normal platelet count but platelet function will be abnormal and the clot formation inadequate. the bleeding time is prolonged and indicates abnormal platelet aggregation and adhesiveness. residual heparin effect is diagnosed by a prolonged partial thromboplastin time (ptt) and/or activated clotting time (act). either a ptt or an act should be measured on admission to the intensive care unit because inadequate heparin reversal with protamine is usually seen early in the postoperative period. generally, other laboratory values will be normal. a heparin-protamine titration test can be performed if the hepcon system (medtronic inc., minneapolis, minnesota) is available. this test directly quantifies the amount of heparin circulating. it will detect any residual heparin and also allow for a calculation of the appropriate dose of protamine needed to neutralize the residual heparin. if the ptt or act are elevated 5 h after the last heparin dose, it is unlikely secondary to heparin as the half-life of heparin is 1 h; if heparin effect is suspected at this time, obtain heparin levels to confirm the diagnosis. 191 fibrinolysis is associated with an elevated pt and ptt; decreased levels of factors i, v, and viii; rapid euglobulin clot lysis; and the presence of d-dimers. d-dimers indicate the presence of fibrin monomers, and their presence is diagnostic for fibrinolysis if accompanied by decreased fibrinogen levels. an elevated d-dimer alone is not uncommon, particularly if shed blood is being reinfused and in itself is not diagnostic of fibrinolysis. 192 disseminated intravascular coagulation (dic) is the severest form of coagulopathy. from a laboratory standpoint, it is manifested by an elevated pt and ptt, decreased fibrinogen levels, thrombocytopenia, and an elevated fibrinsplit products (greater than 40 mcg/ml) and d-dimer. 193 dic is rarely seen in the early postoperative period and usually is associated with other complications. 194 thromboelastography 195 and sonoclot 196 analysis are two studies available in some institutions that have been shown to specifically identify the source of the bleeding diathesis. these studies are not commonly available. coagulation factor deficiencies either from hemodilution or true deficiencies can be diagnosed by measuring the specific factors, but in the acute setting this may not be practical as obtaining these results is time-consuming. increased ptt and pt (prothrombin time) usually manifest factor deficiencies. specific studies can be ordered, but it is usually reasonable to proceed with the empiric treatment before results are available. there must be a high degree of suspicion for factor deficiencies in the patient with a previous or family history of abnormal bleeding, liver disease, prior warfarin therapy, hemodilution, or clinical evidence of disseminated intravascular coagulation. the treatment of a postoperative coagulopathy must be prompt and aggressive. the bleeding cycle must be interrupted as "bleeding begets bleeding." 195 the specific treatment consists of blood component therapy based on an accurate diagnosis. initial therapy begins by sending coagulation studies to include a pt, ptt, platelet count, and fibrinogen level. then, notify the blood bank that component therapy will be needed and an adequate supply of cross-matched packed red blood cells, fresh frozen plasma (contains all coagulation factors except platelets), cryoprecipitate (factor viii and fibrinogen), and platelet concentrates should be readily available. next, hypothermia should be corrected. within the first 2 h and even before the coagulation studies are available, consider the empiric use of protamine sulfate in the event residual heparin or heparin rebound is the cause. if the bleeding continues after the hypothermia is corrected and the empiric protamine is given, an algorithmic approach can be used. 194 this algorithm begins by sending coagulation studies. then, transfuse platelets, 1 unit/10 kg body weight, and draw post-transfusion platelet count. if the bleeding continues and the posttransfusion platelet count is less than 100,000, repeat the platelet transfusion of 1 unit/10 kg body weight. if the posttransfusion platelet count is greater than 100,000, but the fibrinogen is less than 100 mg/100 ml, give 1 unit of cryoprecipitate/4 kg body weight. if the posttransfusion platelet count is greater than 100,000, but fibrinogen is greater than 100 mg/100 ml, and the pt or ptt is less than 1.5 times control value, recheck for surgical bleeding and do a bleeding time; and if it is greater than 9 min, give desmopressin 0.3 mcg/kg iv. if the posttransfusion platelet count is greater than 100,000, but the fibrinogen is greater than 100 mg/100 ml, and the pt or ptt is greater than 1.5 times control value, give fresh frozen plasma 15 ml/kg. if bleeding persists at the completion of the algorithm, consult a hematologist. in addition to blood component therapy, there are drugs available for the treatment of postoperative coagulopathy. protamine is the specific drug for the reversal of heparin. the dosage is 25-50 mg increments given iv over 10 min. be aware there are three types of adverse reactions to protamine administration. type i reaction is systemic hypotension from rapid administration that usually occurs if the entire neutralizing dose is given in less than 3 min. it is a histamine release reaction that causes a reduction in the svr and pvr. it can be avoided by giving the dose over 10-15 min. type ii reaction is an anaphylactic or anaphylactoid reaction resulting in hypotension, bronchospasm, flushing, and edema. it is further divided into type iia that is an idiosyncratic reaction mediated by ige or igg and is caused by the release of histamine or leukotrienes producing a capillary leak syndrome with hypotension and edema. it usually occurs within the first 10 min of administration. type iib is an immediate reaction and is not related to immunoglobulins. type iic is a delayed reaction occurring after 20 min or longer, and seems to be related to complement activation and leukotriene release producing bronchospasm and a capillary leak syndrome that leads to hypovolemia and noncardiac pulmonary edema. type iii reaction is catastrophic pulmonary vasoconstriction with acute pulmonary hypertension, right ventricular failure, and severe peripheral vasodilatation with hypotension and myocardial depression. it occurs 10-20 min after the protamine is given and is thought to be secondary to the heparin-protamine complex. this complex incites leukocyte aggregation and the release of liposomal enzymes that damage pulmonary tissue. type iii reactions are highly lethal unless cardiopulmonary bypass can be reinstituted to support the patient. treatment is initially calcium chloride and -agonists to support the svr. it may also be beneficial to add -agonists to reduce the pvr. specific drugs to lower the pvr (such as prostaglandin e) may be helpful, but usually it is necessary to readminister heparin and reinstitute cardiopulmonary bypass. desmopressin (ddapv) has not been shown to be of benefit in the uncomplicated patient, but is of value in patients with platelet dysfunction secondary to uremia, liver dysfunction, and antiplatelet medications. [196] [197] [198] it is specific therapy for patients with an acquired defect in platelet plug formation as a result of a deficiency in von willebrand's factor. the dosage is 0.3-0.4 mcg/kg iv over 20 min. epsilon-aminocaproic acid (eaca) is an antifibrinolytic agent that inhibits conversion of plasminogen to plasmin. it may act to preserve platelet function. eaca is best used when given before cardiopulmonary bypass prophylactically, but it can also be used as a rescue agent for severe bleeding, especially if fibrinolysis is present. 199 it should be used with caution or not at all with aprotinin as the combination appears to cause a prothrombotic state with associated graft closure, renal dysfunction, and stroke. the rescue dose for postoperative bleeding is usually 5-10 g iv bolus. aprotinin is a serine protease inhibitor that preserves adhesive platelet receptors (gpib) during the early phase of cardiopulmonary bypass. it also has antifibrinolytic properties by inhibiting plasmin. aprotinin has been demonstrated to reduce blood loss when given before and during cardiopulmonary bypass in patients at high risk for postoperative bleeding, such as thrombocytopenia, uremia, hepatic dysfunction, and long complex procedures, particularly reoperations. 200 it does have a role as a rescue agent for postoperative bleeding, but must be used with caution as it may be prothrombotic in the nonheparinized patient. 201 the rescue dose is two million kiu. aprotinin therapy has been associated with an increased morbidity and mortality in some studies and its use is controversial. blood component therapy includes packed red blood cells (rbcs), fresh frozen plasma (ffp), cryoprecipitate (factor viii and von willebrand's factor), and platelets. rbc transfusion should be managed by protocol and determined by the clinical status of the patient. rbcs are indicated in the anemic patient with normal lv function when the hematocrit is 22-24%. 29, 202 if the patient is actively bleeding, the hematocrit should be maintained at 26% to afford a margin of safety. 22 if the patient is elderly or has lv dysfunction and cannot increase the cardiac output in response to anemia, the hematocrit should be maintained at a higher level. platelet transfusions are indicated for a platelet count under 70,000 if the patient is bleeding excessively. ffp is recommended in the excessively bleeding patient for an inr (international normalized ratio) of greater than 1.5-1.7. specific treatment with cryoprecipitate and other components is indicated in the presence of a consumptive coagulopathy as reflected by a diminished fibrinogen level, positive d-dimer assay, or the presence of fibrin degradation products. 91 blood conservation is an important part of managing the postoperative patient both with and without significant bleeding. there are preoperative measures, intraoperative measures, and postoperative measures. the preoperative measures include autologous blood donation for elective cardiac procedures. this must be done with care, particularly in the patient with ischemic heart disease or congestive heart failure secondary to valvular heart disease. therefore, it is not a measure widely practiced. another preoperative measure is the modification of the preoperative antiplatelet regimen within limits of therapeutic prudence. and, finally, preoperative erythropoietin can be used in the anemic patient to improve hemoglobin levels sufficiently to avoid perioperative transfusions. 203 intraoperatively, the crystalloid prime of cardiopulmonary bypass circuit with resultant hemodilution to hematocrit of 20-30% minimizes the loss of red cells. also, blood salvage with reinfusion of washed, centrifuged red cells, both from the field and from the circuit after separation from cardiopulmonary bypass, conserves blood. careful operative hemostasis is a must for blood conservation. postoperative autotransfusion and cell saving also conserve blood and reduce the complications of transfusions. the "cell saver" in most institutions has supplanted traditional autotransfusion techniques. the cell saver is a system that combines washing and centrifuging shed blood before reinfusing, as opposed to directly reinfusing shed blood after passing it though a filter. shed blood does not require an anticoagulant because it has undergone fibrinolysis, unless the hemorrhage was extremely rapid. shed, traditional autotransfused blood has low levels of factors viii and fibrinogen as well as platelets, but the platelets present are dysfunctional. autotransfused blood does contain fibrin-split products. conversely, cell saver blood is devoid of clotting factors and platelets as well as fibrin-split products. 204 transfusion of less than one liter of either autotransfusion blood or cell saver blood is without significant risk of exacerbating a coagulopathy. transfusion of greater amounts can potentially worsen the coagulopathy by infusing fibrin monomers, in the case of autotransfusion, and from platelet and factor depletion with both. 205, 206 autotransfusion of greater than 1,500 ml of shed blood should be avoided and blood component therapy should be used to augment reinfusion of cell saver blood to avoid depletion of platelets and clotting factors. multiple factors contribute to postoperative bleeding. 207, 208 despite deficiencies in the coagulation cascade and multiple potential sites of surgical bleeding, mediastinal drainage slows over the first few hours in the majority of patients. aggressive management of the bleeding patient is generally successful, such that only about 1-3% of patients require reoperation for persistent bleeding. normally, when the patient returns from the operating room, mediastinal drainage is in the order of 100-300 ml/h for the first 2-3 h and 50 ml/h thereafter. the initial steps in managing the bleeding patient after openheart surgery are aggressive treatment of hypothermia and hypertension, order coagulation studies, notify the blood bank to have blood products available, and consider an empiric dose of protamine. if coagulation studies indicate a coagulopathy, proceed with the algorithm for management. in any patient with excessive mediastinal drainage, cardiac tamponade must be considered. be alert for the followings signs of tamponade: equalization of filling pressures, low cardiac output, hypotension, wide respiration variation of systolic blood pressure with positive pressure ventilation, and a narrowed pulse pressure. at times, the classic findings of tamponade may be absent, but the following points may signal tamponade: the sudden cessation of chest tube drainage, progressive low cardiac output in a patient with a previously normal cardiac output, an unexplained left or right heart failure, severe peripheral vasoconstriction with cyanosis of the ears and digits, progressive fall in the urine output, an unexplained tachycardia, mediastinal widening on chest x-ray, pleural effusion, and diminished ecg voltage. there are caveats regarding cardiac tamponade in the immediate postoperative setting. first, a pulsus paradoxus is not an applicable sign of tamponade in the patient on positive pressure ventilation. positive pressure ventilation reverses blood pressure response to respiration. on the ventilator, during early inspiration, the positive airway pressure causes a compression of the pulmonary veins augmenting left heart filling and thus blood pressure, whereas, later in the inspiratory cycle, left heart filling is diminished and the blood pressure falls. this early rise in the blood pressure is opposite of the fall in blood pressure seen during spontaneous inspiration and makes pulsus paradoxus an unreliable sign of tamponade during positive pressure ventilation. also, it is not unusual for a clot to accumulate next to the right or left atrium and cause unequal elevations of the ra or la pressures. most important, the diagnosis will be made only if a high degree of suspicion is maintained. the diagnostic modality of choice for cardiac tamponade in the postoperative period is transesophageal echocardiography. the definition of excessive mediastinal bleeding is 500 ml/h for 1 h, 400 ml/h for 2 h, and 300 ml/h for 3 h. if mediastinal bleeding persists despite correction of the coagulopathy or if the patient demonstrates evidence of hemodynamic compromise, mediastinal reexploration in the operating room is indicated. an aggressive approach to mediastinal reexploration is in the best interest of the patient. reexploration is associated with increased mortality and morbidity usually because of a delay in proceeding. 209 early reexploration reduces these complications. 210 an emergency reexploration in the intensive care unit is indicated for exsanguinating hemorrhage or impending arrest from any cause. the technique for emergency reexploration begins with a call for the necessary assistance. intubate the patient if necessary and hand ventilate the patient with inspired oxygen of 100%. remove the dressing and pour antiseptic over the sternotomy incision and block drape the site with sterile towels. reopen the incision with a scalpel and cut or untwist the wires. the sternum is opened with a sternal spreader. then, evacuate the hematoma and attempt to identify the source of bleeding. if a bleeding site is identified, tamponade it with digital pressure. proceed to complete the resuscitation of the patient. ideally, the site of hemorrhage should be repaired in the operating room, but if this is not practical or feasible, repair it in the icu. if internal cardiac massage is needed, do so with two hands by placing the left hand beneath the heart and compressing the anterior aspect of the heart with the right hand using the palm and flattened fingers and take care not to injure the grafts. if the patient has a prosthetic mitral valve in place, take care not to injure the posterior left ventricle with the struts during internal massage. once some semblance of hemodynamic stability has returned, return the patient to the operating room for repair of the bleeding site, irrigation of the mediastinum, and closure. if the reason for emergency re-sternotomy was hemodynamic collapse not related to bleeding or tamponade, placement of an iabp is highly recommended. after the heart, the lungs are the organs most likely to be dysfunctional after cpb. during cpb, neutrophils are sequestered in the pulmonary vasculature and oxygen free radicals cause peroxidation of membrane lipids. these changes produce pulmonary vasoconstriction and are thought to increase the permeability of the alveolar-capillary barrier and consequently produce interstitial edema within the lungs. leukocytes are also activated and cause an inflammatory response of the pulmonary vasculature. 211 during cpb and diminished pulmonary arterial flow, plasma thromboxane b 2 increases, further contributing to the pulmonary vascular inflammation. 212 the cumulative effect of these responses is a more permeable alveolar-capillary membrane and a predisposition to interstitial pulmonary edema. 213 atelectasis also contributes to pulmonary dysfunction. this appears in some way to be linked to a decrease in pulmonary surfactant, and may partially explain the left lower atelectasis seen almost universally after cardiac surgery. 214 thermal injury to the phrenic nerve and/or diaphragmatic dysfunction as well as effusions, pain, and chest tubes are other contributing factors to altered pulmonary function postoperatively. lung and chest wall compliance decrease significantly following cardiac surgery, with the maximum decrease occurring at 3 days and lasting as long as 6 days. the respiratory management of the postoperative cardiac surgical patient is not unlike any other postoperative patient, but there are several factors that are unique to these patients. the unique factors include: incision pain, the interference of chest tubes with the respiratory function, an element of diaphragmatic dysfunction, elevated left heart filling pressures with alveolar edema and diminished compliance, and capillary permeability. 20, 31, 215 atelectasis is the most common pulmonary complication occurring in 70% of these patients. 216 after cardiac surgery, atelectasis occurs most commonly in the left lower lobe. the exact etiology of this phenomenon remains unclear. it is associated with left phrenic nerve paralysis only in 11% of patients. 217 alterations of the chest wall result in a decrease in the fev 1 and frc and persist for 6 weeks. these alterations lead to an increased respiratory rate, decrease tidal volume, decreased respiratory efficiency, and increased oxygen utilization. pulmonary infiltrates are the result of pneumonia, pulmonary embolism, and adult respiratory distress syndrome (ards) -although with ards, there is typically more of a diffuse process and is associated with more severe hypoxemia. the basic treatment of pneumonia and ards includes blood and sputum cultures, hemodynamic maintenance, euvolemic fluid management with a consideration of fluid restriction and the use of colloid for ards, and the maintenance of an arterial saturation greater than 50 mmhg with minimum inspired oxygen content. [218] [219] [220] bronchospasm can occur immediately after cpb and may interfere with hemodynamic stability. the probable cause is activation of c5a anaphylatoxin by cpb. other causes include pulmonary edema, exacerbation of preexisting reactive airway disease, the use of -blockers, and a reaction to protamine. 216 the treatment for bronchospasm includes the exclusion of heart failure, inhaled 2 -agonists, the addition of cholinergic agents, a short course of systemic steroids for refractory bronchospasm, and intravenous aminophylline. aminophylline is reserved for refractory situations because of its arrhythmogenicity in the postoperative period. during cpb, renal blood flow and glomerular filtration rate are reduced 25-75%, with partial but not complete recovery in the first day after cpb. 221, 222 this is thought to be secondary to renal artery vasoconstriction, hypothermia, and loss of pulsatile flow. the nonpulsatile blood flow of cpb promotes renal artery vasoconstriction and diminishes renal blood flow to the cortex. in addition, angiotensin ii levels are elevated by nonpulsatile flow. 223, 224 there appears to be a relationship between length of cpb and renal insufficiency, but not pressure or flow rates while on pump. 225 other factors associated with renal failure include preexisting renal dysfunction (creatinine greater than 1.5 mg/dl), older age, poor left ventricular function and congestive heart failure, emergency surgery, the use of deep hypothermic circulatory arrest, moderate hypothermia, a preoperative history of hypertension, diabetes, and peripheral vascular disease, isolated valve operations, and the use of radiocontrast dye agents immediately preoperatively. postoperative factors contributing to renal insufficiency include: low cardiac output; hypotension; vasoconstriction; atheroembolism from the iabp; sepsis; rv failure with systemic venous hypertension; respiratory insufficiency with hypoxemia; and medications such as cephalosporins, aminoglycosides, and ace-inhibitors. 22, [226] [227] [228] [229] [230] [231] [232] the incidence of renal complications following open-heart surgery has been reported as high as 35%. the frequency of oliguric renal failure requiring dialysis is 2-3% with a mortality of 50%. [230] [231] [232] [233] the most common form of renal failure after cpb, is nonoliguric renal failure. nonoliguric renal failure has a better prognosis with a mortality rate of 10-17%. 231, 234 the management goal of nonoliguric renal failure is the maintenance of an appropriate glomerular filtration rate by maintaining an adequate cardiac output and an adequate systemic blood pressure. the use of loop diuretics is controversial. they are unlikely to prevent the progression of nonoliguric to oliguric renal failure. dopamine at a "renal dose" of 1-2.5 mcg/ kg/min is commonly used to preserve renal function. there are no studies demonstrating a renoprotective effect. dopamine may increase urine output, but it has been shown to be associated with renal tubular necrosis equal to or worse than controls. 41, 235 in patients with a serum creatinine of >1.4 mg/ dl, infusion of fenoldopam of 0.03-0.1 mcg/kg/min has been shown to preserve renal function. 236 the best management of oliguric renal failure is prevention by early identification and treatment of deteriorating renal function. this prevention begins by avoiding hypotension and low cardiac output states, optimizing volume status, considering the early use of inotropic agents and pressors, and the early use of iabp. once oliguric renal failure occurs, a nephrology consultation is in order. strict euvolemia must be maintained, as well as careful monitoring of metabolic status and electrolyte balance and the daily review of medications looking for drugs excreted by kidneys. if renal failure occurs several days following surgery, it is most likely not related to cpb but more likely as a result of sepsis, nephrotoxic drugs, low cardiac output, and obstruction of the urinary tract. the perfusion of intra-abdominal viscera is also adversely effected by cpb. the blood flow to the liver is reduced by 19% during cpb and there is concomitant relative hypoperfusion of splanchnic and gastric flow. the decrease in gastric flow results in gradual decreasing of gastric ph and is associated with the appearance of endotoxin in the circulation, suggesting that the intestinal barrier is compromised and translocation is a possibility. 237, 238 gastrointestinal complications are generally not a common source of significant morbidity after open-heart surgery. they occur at a rate of approximately 1-2%. these complications are the result of a low cardiac output state with its associated sympathetic vasoconstriction and hypoperfusion of the abdominal organs. the most common serious complication after cpb is gastrointestinal hemorrhage from gastritis or gastroduodenal ulcer disease. 239 the pathology is usually hemorrhagic gastritis or duodenitis. 240, 241 occasionally, the hemorrhage is from previous duodenal ulcer disease and rarely from the colon. 242 gastrointestinal hemorrhage occurs in only about 1% of cases and the risks are higher in patients with copd, hypotension, excessive postoperative bleeding, reoperation, and a prior history of peptic ulcer disease. 234 it is recommended that these high-risk patients have prophylactic ulcer therapy. 243 an appropriate prophylactic regimen would include sucralfate 1 g q6h orally or down a nasogastric tube. another option is omeprazalone 20 mg daily. ranitidine appears to be the best option with a lower rate of gastrointestinal hemorrhage and an equivalent incidence of pneumonia. 244 hepatic dysfunction is marked by transient elevation of liver function tests in 20% of patients. less than 1% of the patients will develop significant hepatocellular damage resulting in either chronic hepatitis or liver failure. 245, 246 the risk factors for these complications are prolonged cpb, multiple transfusions, and multiple valve replacements. elevated lfts in association with hyperbilirubinemia occurring within the first 1-10 days is a result of low cardiac output and "shock liver." shock liver may cause hemodynamic instability with low systemic vascular resistance. hyperbilirubinemia without elevated lfts, if it occurs early, may be the result of cholestasis from red blood cell trauma and destruction, as well as from right heart failure with passive congestion of the liver, although the alkaline phosphatase may be elevated in this instance. bilirubin usually normalizes in 1-14 days with observation only. if isolated hyperbilirubinemia occurs late, it is caused by infection from transfused blood products. the risk of infection after transfusion depends on the number of units transfused and types of products transfused. the most common infections are non-a, non-b hepatitis (seen more often after clotting factor transfusions), cytomegalovirus, epstein-barr virus, and acute cholecystitis. 247 acute cholecystitis is seen more often in the elderly after prolonged cpb, suggesting hypoperfusion may be a factor. transient hyperamylasemia can be found in as many as 35% of patients after cpb, yet is associated with pancreatitis in only 1-3% of the patients. 248 the risk factors include long cpb time and multiple transfusions. it is a must to exclude postoperative pancreatitis as this is a serious problem with a high mortality rate. 249 ischemic bowel syndrome as a result of mesenteric ischemia is a catastrophic complication. it is often associated with the hypoperfusion of low cardiac output, particularly the elderly patient requiring inotropic or iabp support. electrolyte imbalances are common after cardiopulmonary bypass. potassium alterations are the result of rapid shifts that occur during cardiac surgery and cpb. the factors related to potassium fluxes are hyperkalemic cardioplegia, renal dysfunction while on cpb, low cardiac output and associated oliguria and acidosis, hemolysis of red cells, diuresis, and diminished potassium uptake in the face of diabetes mellitus. 20 certain medications also impair potassium excretion and cause hyperkalemia. this list of medications include ace inhibitors, potassium-sparing diuretics, non-steroidal anti-inflammatory drugs, angiotensin receptor blockers, and -blockers. 22 the principal adverse effect of potassium alterations is on the electrical activity of the heart and can be lifethreatening. hyperkalemia manifests itself predominantly electrocardiographically. asystolic arrest can occur when potassium rises rapidly to a level exceeding 6.5 meq/l. the ekg findings are more related to the rate of rise of potassium level than to an absolute level. they are peaked t waves, st depression, prolonged pr interval, loss of p wave, qrs widening, bradycardia, and asystole. hyperkalemia may result in failure of the heart to respond to the pacemaker stimulus and this may be a factor during resuscitation. treatment includes optimizing cardiac function and shifting potassium into the cells and increasing its excretion. the cardiac function is optimized with calcium gluconate. if there is evidence of cardiac toxicity, 0.5-1 g of calcium gluconate is given intravenously over 15 min. potassium is shifted into the cells by giving 50 meq of nahco 3 to correct acidosis and giving 10 units of regular insulin and 25 g of 50% dextrose. potassium excretion is enhanced with furosemide 10-200 mg iv, kayexalate enema 50 g in water enema or 50 g po with sorbitol or dialysis. hypokalemia is usually a result of diuresis without adequate replacement of potassium. diuresis is usually profound after cpb owing to hemodilution. diuretics, insulin administration, or alkalosis may exacerbate this diuresis. hypokalemia promotes atrial, junctional, and ventricular ectopy. 22 it can cause life-threatening ventricular tachycardia, but usually does not become clinically evident until serum concentration is less than 2.5 meq/l. hypokalemia can also be the cause of metabolic alkalosis as hydrogen ions replace potassium within the cells. the treatment is potassium chloride (kcl) administration through a central line at 10-20 meq/h. serum potassium raises approximately 0.1 meq/l for each 2 meq of kcl given. a slower rate is recommended in the presence of renal insufficiency. calcium plays a complex role in myocardial reperfusion damage and energetics. ionized calcium should be measured during and after cpb because hemodilution, hypothermia, ph shifts, and use of citrated blood will affect protein binding of calcium. hypocalcium is the most frequently seen calcium abnormality in the perioperative period. the treatment of hypocalcemia is a calcium chloride bolus of 0.5-1 g. calcium gluconate 10 ml of 10% solution will have fewer cardiovascular effects than calcium chloride. hypomagnesemia is not uncommon after cpb. the incidence is 70%. 250 the most common etiology for hypomagnesemia is the diuresis and hemodilution associated with cpb. the effects of hypomagnesemia are mainly cardiac effects and similar to those of potassium on the electrical activity of the heart. manifestations of hypomagnesemia include atrial and ventricular dysrhythmias, potentiation of digoxin-related dysrhythmias, and a predilection to coronary spasm. since magnesium is also related to energy metabolism, prolonged ventilator support has also been related to low serum magnesium levels. treatment is an infusion of 2 g magnesium sulfate in 100 ml of solution to raise the serum level to 2 meq/l. note that magnesium has been shown to inhibit the vasoconstrictive effect of epinephrine but not its cardiotonic effect. 251 hyperglycemia routinely occurs during cpb. modest elevations are present during hypothermia, but more marked elevations of blood glucose happen during rewarming. hyperglycemia is caused by increased glucose mobilization related to increases in cortisol, catecholamines, and growth hormone levels during cpb. there also appears to be a blunted insulin response and impaired insulin production as well as a peripheral insulin resistance during cpb. 20 the impaired insulin secretory response may last 24 h. these changes are exaggerated in the diabetic patient, and insulin requirement may be seven times greater than preoperative requirements in the first 4 h after surgery. 252 hyperglycemia postoperatively is associated with osmotic diuresis, impaired wound healing, increased risk of infection, and impaired blood pressure regulation. 22 hyperosmolar, hyperglycemic, non-ketotic coma is unusual following open-heart surgery. it usually occurs in type ii diabetics 4-7 days after surgery. 253 diabetic ketoacidosis is rarely encountered in the postoperative period. the most efficient method of managing the postoperative patient is with an insulin infusion. the usual dose is 0.1 unit/kg/h of regular insulin in a saline mix. blood glucose levels must be monitored every 4 h to maintain serum glucose of 70-200 mg/dl. type ii diabetics should be restarted on their oral regimen as soon as they are taking po. the most common and most frequent hematologic complication of open-heart surgery is thrombocytopenia and platelet dysfunction. 207, 254 platelet counts decrease rapidly by 50% soon after the institution of cpb but usually remain above 100k. platelet counts less than 150,000/mm 3 occur in approximately 62% of patients on postoperative day one. 20 platelet counts begin to increase by the third postoperative day. bleeding from thrombocytopenia is usually not a problem until the platelet count falls below 60,000/mm 3 . of greater clinical significance is the progressive deterioration of platelet function during cpb. within minutes of cpb, platelet aggregation is impaired and continues to worsen throughout cpb. this platelet dysfunction is precipitated by contact of the platelets with synthetic surfaces of the cpb circuit as well as by hypothermia. also, the mechanical stresses of cpb cause fragmentation of the platelets and a temporary depletion in the membrane antigen for glycoproteins ib, iib, and iiia. 255 hypothermia impairs platelet thromboxane a2 synthesis resulting in reversible platelet dysfunction. bleeding time returns to normal in about 2-4 h and the platelet count is restored in several days. 208, 256, 257 platelet dysfunction occurs less commonly with the use of antifibrinolytic drugs, such as -aminocaproic acid, because these agents act in part by reducing platelet activation during cpb. indications for platelet transfusion are as follows: a platelet count less than 20-30,000/mm 3 , ongoing bleeding with a platelet count less than 100,000/mm 3 , and a platelet count less than 60,000/mm 3 if a surgical procedure is planned. 22 cpb also effects the plasma concentration of coagulation factors ii, v, vii, ix, x, and xiii. the plasma concentration of these factors decline during cpb secondary to hemodilution but remain at levels adequate for hemostasis, and, with the exception of fibrinogen, return to normal by 12 h. 208, 256 fibrinogen and plasminogen decrease during cpb from dilution and not consumption, and usually return to normal by 24 h. heparin-induced thrombocytopenia (hit) is an infrequent but serious complication with a high mortality rate if the fulminant course progresses to heparin-induced thrombotic thrombocytopenia (hitt). 186 hit is caused by the formation of igg platelet membrane antibodies, which, in the presence of heparin, produce platelet aggregates and heparin resistance. the range of intensity of hit and hitt spans from only moderate thrombocytopenia to a syndrome of arterial or venous thrombosis caused by platelet aggregation and bleeding from profound thrombocytopenia. 258, 259 if the diagnosis of hit is suspected, all heparin must be discontinued including therapeutic infusions, line flushes, heparin-coated monitoring lines, and low-molecular-weight heparins. the laboratory confirmation by platelet aggregation testing is important, but may take at least 24 h to confirm; therapy should be instituted as soon as the diagnosis is suspected. platelet counts must be monitored on a daily basis. in-hospital, postoperative infections after open-heart surgery occur at a rate of 12-20%. the most common infections are the respiratory, urinary, and wound or surgical site infections. 260 while all postoperative infections adversely affect outcomes, it is the sternal wound infection and mediastinitis that have the greatest adverse effects. the overall incidence of sternal wound infections is 0.8-1.4%. 261, 262 when sternal wound infections are associated with mediastinitis, the mortality varies from 6 to 70%. 263 when recognized early and effectively treated, the mortality is 5-10% 264 the rate of mediastinitis is higher in valvular procedures and in combined procedures. 265 the use of bilateral internal mammary arteries increases the risk of sternal wound complications to 5%. 262 staphylococcus aureus and staphylococcus epidermidis are the most common pathogens encountered accounting for 42% of infections. 266 preoperative predisposing factors include type and timing of skin preparation, cardiopulmonary failure, need for an iabp, diabetes mellitus, steroid use, a history of mediastinal radiation, osteoporosis, age, and copd. 264, 267 intraoperative factors are a cpb run greater than 3 h, excessive bleeding, the use of bilateral internal mammary arteries, valve procedures, combined procedures, and inadequate sternal fixation. 268 postoperative bleeding will increase the risk for sternal wound complications, as will low-flow states, concurrent infections, tracheotomies, and prolonged ventilatory support. 269 the most obvious sign of a wound infection is purulent drainage from the incision. there should be a heightened level of suspicion in a patient whose pain begins to increase toward the end of the first postoperative week rather than decrease. 268 also the wound is reddened and swollen and there is a localized area of skin necrosis associated with the drainage. the drainage is serous if the complication is minor, involving only the superficial soft tissue. however, if the complication is a major one with mediastinitis there is extensive purulent drainage with infection extending down to the sternum and mediastinum. these findings may not always be an indication of infection, but could be aseptic necrosis from internal mammary artery mobilization. fever, leukocytosis, or gram-positive bacteremia should raise the suspicion of a sternal wound infection. any fever of undetermined etiology should raise the question of wound sepsis, particularly in diabetics where few other local or systemic signs may be present as a result of a poor inflammatory response. the evaluation begins with a culture of the purulent drainage. if there is no drainage, a likely area of the wound should be opened and careful cultures obtained. radiographic workup is of limited value. routine chest x-rays are of little help. a chest computed tomography (ct) scan may identify indolent, retrosternal infections, particularly if gas-forming organisms are present. [270] [271] [272] minor infections usually respond to treatment with antibiotics and local care, including wound packing. major infections require mediastinal exploration and debridement of infected tissue, including the sternum. if the sternum is necrotic or grossly infected, removal of the sternum is necessary and requires closure with a muscle flap, either a pectoralis major or rectus abdominis flap. omentum can also be used to provide a vascular bed for healing, but omental mobilization is associated with a higher morbidity than the creation of a muscle flap. appropriate parenteral antibiotics are required for a 6-week period. the incidence of leg wound infections is 1-10%. these complications may result from poor surgical technique with a creation of flaps, failure to eliminate dead space, or hematoma formation. the risk factors are obese women, use of thigh veins, diabetes, and severe peripheral vascular disease. 273 the prevention of leg infections involves careful surgical technique and the use of suction drains to eliminate dead space in the leg. the treatment is appropriate antibiotic coverage, debridement, and a consideration for early plastic surgery involvement. prophylactic antibiotics should be administered for 48 h starting in the operating room just prior to the incision. firstor second-generation cephalosporins are used because of their effectiveness against gram-positive cocci. vancomycin is used in patients with true anaphylactic allergy to penicillin or cephalosporins. if the patient does not have a documented history of a severe anaphylactic reaction to penicillin or a cephalosporin, a cephalosporin should be used. attempts must be made to limit the use of vancomycin for prophylaxis to lessen the likelihood of vancomycin-resistant enterobacter infections. neurologic complications following open-heart surgery are dreaded sequelae. the overall incidence of focal deficits is 1-3%. 274, 275 these usually occur intraoperatively and are noted in the first 24-48 h. some 30% of the deficits may develop postoperatively as a result of hemodynamic instability or arrhythmia. 22 risk factors of stroke for the open-heart patient include increasing age (a risk up to 15% in patients older than 75 years), diabetes mellitus, preexisting cerebrovascular disease especially with a history of recent stroke, perioperative hypotension, atherosclerotic plaques and calcifications in the ascending aorta, left ventricular mural thrombus, opening a cardiac chamber, postoperative atrial fibrillation, long duration of cpb, and warm blood cpb. [276] [277] [278] [279] the presentation of neurologic complications depends on the site and extent of the insult. transient ischemic attacks present with focal deficits of hemiparesis or hemiplegia, aphasia, dysarthria, hand incoordination, visual deficits (either retinal or central), and coma. if an interventional neurologist is available, an immediate consultation should be obtained. an evaluation begins with a careful neurologic examination, then a ct scan of the brain with contrast infusion, an echocardiogram (surface or transesophageal) to exclude a cardiac source, and noninvasive carotid studies. if there is no evidence of an intracranial hemorrhage on ct scan, heparin is started, and then warfarin if the stroke is thought to be embolic. if the deficit occurs during surgery, there is some debate as to the need for anticoagulation versus just antiplatelet therapy. other therapy includes the standard measures to reduce intracranial pressure and even a carotid endarterectomy in patients with severe carotid stenosis and transient neurologic deficits. physical therapy is started soon after the event is diagnosed. as regards prognosis, patients with focal deficits have an excellent prognosis. in patients with coma, the prognosis is poor with a mortality rate of 50% and a high percentage of survivors staying in the vegetative state. 22 postoperative encephalopathy and delirium occur in approximately 30% after open-heart surgery. 280 the risk factors include older age, recent alcoholism, preoperative organic brain syndrome, severe cardiac disease, multiple associated medical illnesses, and complex and prolonged surgical procedures on cpb. common causes of delirium are medication toxicity, metabolic disturbances, alcohol withdrawal, low cardiac output syndromes, periods of marginal cerebral blood flow during cpb, hypoxia, sepsis, and a recent stroke. the evaluation of delirium begins with a review of the patient's current medications and drug levels, an 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consideration, and blood conservation methods bleeding complications associated with cardiopulmonary bypass re-exploration for bleeding is a risk factor for increased morbidity and mortality re-exploration after coronary bypass surgery: risk factors, outcomes, and the effect of time delay complement activation during cardiopulmonary bypass: evidence for generation of c3a and c5a anaphylatoxins cytokine responses to cardiopulmonary bypass with merman and bubble oxygenation solute permeability of the alveolar capillary barrier cardiopulmonary bypass significantly reduces surfactant activity in children the influence of pleural and mediastinal chest tubes on respiration following coronary artery bypass grafting (cabg) cardiopulmonary bypass and the lung postoperative phrenic nerve palsy in patients with open-heart surgery the acute respiratory distress syndrome new concepts and therapies of adult respiratory distress syndrome relationship between alteration in renal hemodynamics during cardiopulmonary bypass and postoperative renal function renal arteriography during extracorporeal circulation in dogs with a preliminary report upon the effects of low molecular weight dextran changes in renal blood flow and pah extraction during extracorporeal circulation of short and long duration prevention of supraventricular arrhythmias after coronary artery bypass surgery: a meta-analysis of randomized control trials pulsatile and nonpulsatile cardiopulmonary bypass: review of a counterproductive controversy is kidney function altered by the duration of cardiopulmonary bypass? renal dysfunction after myocardial revascularization intravenous diltiazem and acute renal failure after cardiac operations report of a substudy of warm versus cold cardiopulmonary bypass: changes in creatinine clearance valvular heart surgery is an independent risk for acute renal failure acute renal failure in the patient undergoing cardiac operation. prevalence, mortality rate, and main risk factors 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gastrointestinal complications after coronary artery bypass grafting a comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation hyperbilirubinemia after cardiac operation. incidence, risk factors and clinical significance severe ischemic early liver injury after cardiac surgery blood transmitted and clotting factor transmitted non-a, non-b hepatitis hyperamylasemia after cardiac surgery. incidence, significance, and management acute pancreatitis after cardiopulmonary bypass hypomagnesemia is common following cardiac surgery magnesium inhibits the hypertensive but not the cardiotonic actions of low-dose epinephrine diabetes and coronary artery surgery clinical features of hyperosmolar nonketotic diabetic coma associated with cardiac operations the effect of cardiopulmonary bypass on platelet function and platelet kinetics platelet surface glycoproteins: studies on resting and activated platelet membrane microparticles in normal subjects, and observations in patients during adult respiratory distress syndrome and cardiac surgery mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective a-granule release hypothermia-induced reversible platelet dysfunction heparininduced thrombocytopenia heparin-induced thrombocytopenia the impact of nosocomial infections on patient outcome following cardiac surgery a prospective study of sternal wound complications sternal and costochondral infections following open-heart surgery. a review of 2,594 cases mediastinitis after cardiac valve operations: impact upon survival recent experience with major sternal wound complications major sternal wound infections after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures rigid internal fixation of the sternum in postoperative mediastinitis does bilateral internal mammary artery grafting increase surgical risk? approaches to sternal wound infections occurrence of and microbiological findings in postoperative infections following open-heart surgery. effect on mortality and hospital stay use of computed tomography to assess mediastinal complications after median sternotomy clinical-radiological evaluation of poststernotomy wound infections infectious mediastinitis after cardiac operations: computed tomographic findings leg wound complications associated with coronary revascularization an 11 year evolution of coronary arterial bypass grafting (1968-1978) stroke following coronary artery bypass grafting: a ten year study usefulness of atrial fibrillation as a predictor of stroke after isolated coronary artery bypass grafting differential effects of advanced age on neurologic and cardiac risks of coronary artery operations risk factors for stoke after coronary artery bypass central nervous system complications of open-heart surgery postcardiotomy delirium: conclusions after 25 years? key: cord-335141-ag3j8obh authors: higgins, g.c.; robertson, e.; horsely, c.; mclean, n.; douglas, j. title: ffp3 reusable respirators for covid-19; adequate and suitable in the healthcare setting date: 2020-06-30 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.06.002 sha: doc_id: 335141 cord_uid: ag3j8obh nan "please doctor, could you tell him that i love him?": letter from plastic surgeons at the covid-19 warfront dear sir, how many times have we heard these words in this time? too many. the covid-19 pandemic has completely disrupted our normal surgical and clinical routine. in these days, many colleagues of whatever specialty are regularly employed by their hospitals to face covid-19 emergency in italy, europe and worldwide. we are not plastic surgeons anymore. many of us feel lost, unprepared and inadequate for such an emergency. here in bergamo, the centre of the italian epidemic, we felt small and incompetent at the beginning. 1 however, we must remember that first of all we are doctors, then plastic surgeons. in these weeks we are putting our willingness at the service of our patients and colleagues. the numbers of the covid-19 pandemic in bergamo are impressive: 8664 positive patients and over official 2000 deaths in about one month. at the same time, the reaction of our hospital, papa giovanni xxiii, has been impressive too: over 400 doctors and over 900 nurses entirely dedicated to covid-19 positive patients; 88 intensive (one of the largest intensive care unit in europe) and over 400 nonintensive care beds are set aside for those patients. this huge wave of covid-19 positive patients, forced the hospital management to progressively and rapidly recruit, train and put on ward over 400 physicians of any discipline and 900 nurses from march 6th. several training programs about covid-19 infection and management have been scheduled in order to prepare the entire staff. two plastic surgeons of our team (on a total of six) have been fully dedicated on the shifting in covid medical areas coordinated by a pulmonologist and an intensivist. main activities focus on patient clinical exam, adjustment of oxygen therapy, regulation of cpap systems, hemogasanalysis implementation, blood and radiological exam monitoring and consequent therapy modulation, admission, discharge and deaths bureaucracy. despite these new clinical fields which are new for a plastic surgeon, we are learning how isolation of patients, due to public health reason, is the most devastating aspect of covid-19 pandemic. 2 , 3 every single day we phone and update the relatives of those who, because of the worsening of their respiratory condition, are unable to speak and call home. we are sometimes those who communicate the death of his or her beloved but also those who bring words of hope, words of love: "please doctor, could you tell him that i love him so much?". some of these patients die without the hug of their families. a plastic surgeon is not usually used to face death because in our surgery it is not so frequent. we would say that the death of a lonely patient also takes a part of us away. it acquires a different hint, touching some inner cord, it makes you feel impotent and lost. as plastic surgeons we often take care of the psychological side of patients and, except for some tumours and traumas, the pathologies we treat -like breast reconstruction -are not fatal diseases. if we compare the contribution of plastic surgery department in term of numbers, we are like a drop in the ocean. but as ovid wrote in epistulae ex ponto "gutta cavat lapidem" i.e. "the drop digs the rock". thanks to our support, a clinical physician is able to evaluate a larger number of patients, focusing on the most critical ones. this is why we keep going on. we want to make our part, working with commitment, dedication and professionalism and assisting all our patients to the best of our in-continueupdating knowledge. we are proud to help bergamo community to face covid-19 emergency and trying to make the difference in our wounded city. we hope this letter will help other colleagues not to consider themselves unprepared or unready. the contribute of everyone is crucial to defeat this ongoing pandemic which has not only upset our clinical routine, but it has woken us up from our everyday life. before covid-19 everything was scheduled, now there are no plans and we are not sure about our priorities. only if we behave, as long as necessary, with the awareness of being able to make a difference, we will win this terrible fight against sars-cov-2. only together we will go back to hugging, kissing and loving each other. when the critical phase of this emergency is over, it will be necessary to think deeply about the socioeconomic development strategies to discover new horizons and new opportunities for a better future. we will never give up!…and what about you? are you ready to play your part? none. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. dear sir, covid-19 is a novel coronavirus with increasing outbreaks occurring around the world. 1 , 2 during the past 4 weeks, emergence of new cases has gradually decreased in china with the help of massive efforts from society and the government. in addition to those directly working in the respiratory, infectious, cardiology, nephrology, psychology, and icu departments and covid-19 patients, all members of the general population may encounter the new coronavirus. medical staff in plastics, reconstructive, and other departments also have a responsibility to prevent the disease spreading in our community. in order to protect both patients and medical staff, selective operations and cosmetic treatments were reduced or postponed in the plastic surgery hospital, beijing, china. gloves and medical masks were saved and donated to the doctors and nurses in wuhan as the demand for protective equipment increased significantly. in addition, a standard operation procedure for covid-19 was proposed in local hos-pitals. our hospital recommended online consultations to replace face-to-face interactions. hospital websites and official social media accounts provided updated practical disease prevention information instead of plastic surgery information. other colleagues also conducted publicity campaigns on disease prevention online via their own social media accounts for relatives and friends, especially for older persons who appeared to have developed a serious illness. at the early stages of the covid-19 outbreak in certain areas, the public may not care much about the new disease. as more information about covid-19 becomes available, people without medical background may be anxious to seek diagnosis, which may result in potential risks of cross infection in the crowded fever clinics. thus, proper information and guidance can help reduce their panic and anxiety. moreover, if individuals were exhibiting relevant symptoms with epidemiologic history, they were advised to seek medical care following the directions of local health authority. in general, plastic surgeons are particularly good at introducing novel surgical methods to the public and keeping in touch with a great number of patients. as a result, they may be able to present local health authority advice in the form of straightforward images and accessible videos, as well as promote practical information via personal social media or clinic websites. in addition to local doctors and nurses from other departments helping in fever clinics and isolation wards, 3 42,600 (as of march 8, 2020) members of medical staff from other provinces rushed to help their colleagues in hubei province. 4 plastic surgeons that had completed icu training in beijing and other cities supported wuhan on their own initiative as well. 5 we suggest that measures should be taken by medical staff from all departments to help slow further spread and to protect health systems from becoming overwhelmed. dear sir, as covid-19 spreads quickly from asia via europe to the rest of the world, hospitals are evolving into hot zones for treatment and transmission of this disease. with the increasing acceptance that operating theatres are high risk areas for transmission of respiratory infections for both patients and surgeons, 1 and with our health care systems being generally well-designed to only deal with occasional high-risk cases, there is an obvious need to evolve our practice. although social media campaigns via the british association of plastic, reconstructive and aesthetic surgeons (#staysafestayhome) and british society for surgery of the hand (#playsafestaysafe) are attempting to raise awareness and reduce preventable injuries, we are still seeing a steady stream of patients present to our plastic surgery trauma service. we have had to act immediately so our systems can support essential surgical care while protecting patients and staff and conserving valuable resources. as a department we have developed a set of standard operating procedures which cover the full scope of plastic surgery from the facilitation of emergent life and limb saving surgeries, rationalised oncological management to the management of minor soft tissue and bony injuries. we have been cognisant of the need to reduce footfall to the hospital and the stratification into "dirty" and "clean" areas with attempted segregation of non-, suspected and confirmed covid cases within inpatient clinical areas. this has resulted in displacement of assessment and procedure rooms within the unit. the ward itself has been earmarked as an extended intensive care unit due to its layout and facilities. standards of practise have changed, with an emphasis on "see and treat" as operating theatre availability has been reduced due to the reduced availability of nurses and theatre staff and their conversion into intensive care areas for ventilated patients. there is also an emerging assumption that all patients are covid-19 positive until proven otherwise. 2 the combination of unfamiliar environments, lack of accessible equipment, requirement to reduce time spent with patients and adherence to social distancing has resulted in the need to provide a more mobile and flexible service. in order to support our mobile service, we have found that, as in other disaster situations where specialised bags have been deployed, 3 using a simple bag containing essential equipment and consumables has revolutionised our ability to work at the point of referral and avoid unnecessary trips to theatre. despite their simplicity, bags have been fundamental for the development of human civilization, with the word originating from the norse word baggi and comparable to the welsh baich (load, bundle)!!! 4 our portable "pandemic pack" is now being carried by the first on-call in our department. this pack contains a 10 l ultra dry adventurer tm , polymer dry bag measuring 36 cm (w) × 70 cm (l) as shown in figure 1 . the contents are shown in figure 2 . we have found this adequate for managing most common plastic surgery trauma and emergency scenarios. the bag is easily cleaned with 1000 ppm available chlorine (in accordance with public health england guidance) after each patient exposure. we have found it useful to make up two packs in advance so that one is available at handover whilst the other is replenished by the outgoing team. we are sure that this concept has been used elsewhere, but if it is not common practice in your unit, we would advocate implementing such a toolkit to facilitate management of trauma patients and reduce the amount time frontline staff need to be in a potential "dirty" environment during the covid-19 pandemic. teleconsultation-mediated nasoalveolar molding therapy for babies with cleft lip/palate during the covid-19 outbreak: implementing change at pandemic speed dear sir, cleft lip/palate is among the most common congenital anomalies, requiring multidisciplinary care from birth to adulthood. the nasolaveolar molding (nam) revolutionized the care provided to babies with a complete cleft, with proving its benefits to patients, parents, clinicians, and society. 1 this therapeutic modality requires parents' engagement with nam care at home and continuous clinicianpatient/parent encounters, commencing at the second week of life and finishing just before the lip repair. the rapidly expanding covid-19 pandemic 2 has challenged clinicians who are dealing with nam therapy to fully stop it, or adjust it to protect, both, the patient/parent and the healthcare team. based on the current who recommendation, to maintain social distancing, and the national regulation for the use of telemedicine, 2 , 3 the nam-related clinician-patient/parent relationship has timely been adjusted by implementing the non-face-to-face care model. babies with clefts are consulted individually by clinicians, proactively establishing the initial and subsequent telemedicine consultations, also providing an open communication channel for parents. based on a shared decisionmaking process, all parents have the option to completely stop nam therapy or use only lip tapping. given that each patient is at a particular stage within the continuum of nam care, numerous patient-and parent-derived issues are being addressed by video-mediated consultations. overall, this has helped explain the current covid-19-related public health recommendations and precautions to parents, while addressing patients' needs and parents' feelings, fears, expectations, and answering parents' questions. moreover, clinical support is provided to patients and parents by visual inspection (looking for potential nam-derived facial irritation), and checking parents' hand-hold maneuvers, such as feeding and placement of the lip tapping and nam device, with immediate feedback for corrections. thus, the use of an audiovisual communication tool has considerably reduced the number of in-person consultations. when a face-to-face consultation could not be resolved using the telemedicine triage, an additional video-based conversation had been implemented, focusing on the key steps, established for patient/parent visits to the facility (i.e., frequent hand-cleaning, mask usage, and keeping 1 m social distance) and on the covid-19-focused screening. 5 symptom-and exposure-screened negative parents/babies have been consulted in a time-specific scheduling with minimum waiting time to avoid crowded waiting rooms, by a clinician wearing personal protective equipment (cap, face shield, n95 mask, goggles, gloves, and gowns), and working in an environment with constant surface/object decontamination. 5 parents, who screened positive for symptoms (e.g., fever, cough, sore throat), were indicated to follow to the appropriate self-care or triage mechanism, stipulated by the who guidelines and local authorities. [2] [3] [4] [5] in the covid-19 era, the care provision should be aligned with the latest clinical evidence. 4 in response to the constantly changing needs, clinicians across the globe could adapt the telemedicine-based possibilities to their own environment of national/hospital regulatory bodies, technology accessibility, and the parents' level of technological literacy. as most of the issues addressed in the video conversations were recurrent reasons for consultations prior to the covid-19 outbreak, future investigations could assist in truly defining the key aspects of telemedicinebased clinician-patient/parent relationship in delivering nam therapy, and its impact on nam-related proxy-reported and clinician-derived outcome measures. there are no conflicts of interest to disclose. virtual clinics: need of the hour, a way forward in the future. adapting practice during a healthcare crisis the whole world is gripped by the novel coronavirus pandemic, with huge pressures on the health services globally. within the coming days, this is only going to increase the pressure on the health care services and needs robust planning and preparedness for this unprecedented situation, lest the whole system may cripple and we may see unimaginable mortalities and suffering. 1 the whole concept of social distancing 2 and keeping people in self isolation has reduced footfall to the hospitals but this is affecting delivery of routine care to patients for other illnesses in the hospital and telehealth is an upcoming way to reduce the risk of cross contamination as well as reduce close contact without affecting the quality of health care delivered. 3 at the bedford hospital nhs trust, for the past one year we have been running a virtual clinic for our skin cancer suspect patients, where in after a particular biopsy if the clinical suspicion of a malignancy was low, these patients were not given a follow up clinic appointment and instead they were informed of the biopsy result through post, sent both to their gp and themselves. most patients encouraged this model to not have to come back to an appointment and this took significant pressure off our clinics. in the event we needed to see a patient, they were informed via a telephonic conversation to attend a particular clinic appointment. from an administration standpoint, this resulted in less unnecessary follow up appointments in our skin cancer follow up clinics, which could then be offered to our regular skin cancer follow up patients as per the recommended guidelines, without having to struggle with appointments. virtual clinics have previously shown to be safe and cost effective alternatives to the out patient visits in surgical departments like urology 4 and orthopedics. 5 they improved performance as well as improved economic output. 3 , 4 we have increased the use of these virtual clinics, with the onset of the novel coronavirus pandemic, in order to reduce the patient footfall to our clinics. most patients voluntarily chose not to turn up and with the risk being highest amongst the elderly, it was logical to keep them away from hospitals as far as possible. in order to achieve this, we have started virtual clinics for nearly all patients in order to triage patients that can do without having to come to the hospital for now. the world of telemedicine is the way forward in nearly all aspects of medical practice 3 and this pandemic situation might just be the right time to establish such methods. we propose setting up of more such clinics in as many subspecialties of plastic surgery, which not only will help in the current crises situation, but will also be useful in the future to take pressure of our health care services. none declared not required funding none webinars in plastic and reconstructive surgery training -a review of the current landscape during the covid-19 pandemic dear sir, the covid-19 pandemic has resulted in cancellation of postgraduate courses and the vast majority of elective surgery. plastic surgery trainees and their trainers have therefore needed to pursue alternative means of training. in the face of cross-speciality cover and redeployment there is an additional demand for covid-19 specific education. the joint committee on surgical training (jcst) quality indicators for higher surgical training (hst) in plastic surgery state that trainees should have at least 2 h of facilitated formal teaching each week. 1 social distancing requirements have meant that innovative ways of delivering this teaching have needed to be found. a seminar is a form of academic instruction based on the socratic dialogue of asking and answering questions, with the word originating from the latin word seminarium meaning "seed plot". 2 fast and reliable internet and the ubiquitous nature of webcams has led to the evolution of the seminar into the webinar. whilst webinars have been common place for a number of years, they represent an innovative and indispensable tool for remote learning during the covid-19 pandemic, where trainees can interact and ask questions to facilitate deep and meaningful learning. speciality and trainee associations have traditionally used their websites and email lists to publicise training opportunities. however, the covid-19 pandemic has seen a shift to social media; with people seeking constant updates and information from public figures, brands and organisations alike. surgical education has mirrored this trend, and we have increasingly observed that webinars are being launched through speciality and trainee association social channels to keep up with the fast-paced demand for accessible online content. the aim of this study was to audit cumulative compliance of active publicly accessible postgraduate plastic surgery training webinar frequency and duration against jcst quality indicators. we used the social listening tool brand24 tm ( https:// brand24.com ). this tool monitors social media platforms for selected 'keywords' and provides analysis of search results. we used the search terms "plastic surgery webinar", "reconstructive surgery webinar", "royal college of surgeons", "bapras", "bssh", "british burns association", "plasta" and "bssh". there were 733 mentions of these terms from 6th may 2019 to 5th may 2020 and 727 of these were after 23rd march 2020, the date that lockdown began in the united kingdom (uk). this represents an increase of 12,017% post-lockdown. we supplemented this search strategy by searching google tm and youtube tm with "plastic and reconstructive surgery webinar". these search engines rank results in order of relevance using a relevancy algorithm, we therefore reviewed the first 100 results only. additional webinars were identified through a snowballing technique where the host webinar webpage was searched for advertised webinars at other institutions. we included any educational webinar series aimed at trainees that was free to access, mirroring weekly plastic surgery hst teaching. free webinars which required membership registration were also included. we excluded webinars aimed at patient or parent education, webinars with less than one video, any historic webinar that did not have an accessible link and webinars behind a paywall or requiring paid membership. we systematically reviewed the search results from brand24 tm , google tm and youtube tm and identified webinar series currently in progress ( table 1 ) and historic webinar series ( table 2 ) . seven active webinar series and two historic webinar series were identified respectively. all were consultant or equivalent delivered. of the active webinar series, 3 (43%) related to covid-19, 2 (29%) related to aesthetic surgery, 1 (14%) related to pan-plastic surgery and 1 (14%) related to hand surgery. the weekly total running time for active webinars amounted to 8 h 30 min, with 4 h and 30 min plastic surgery specific. this was a surplus of 2 h 30 min to jcst quality indicators. limitations of this study include us only identifying webinars advertised publicly. we are aware of training pro-grammes in the uk running in-house webinar series to supplement training and therefore the total available for training is likely to be higher than we have identified. we have also not reviewed the quality of educational content. we acknowledge there are good quality webinar series that require paid for membership such as those provided by the british association of aesthetic plastic surgeons and american society of plastic surgeons but it was not the aim of the study to present them here. innovation flourishes during times of crisis. the education of surgical trainees is of paramount importance and should be maintained, even during the difficult times we currently face. while operative skills will be difficult to develop, the use of technology can allow for the remote delivery of expert teaching to a large number of trainees at once. in this study we identify a number of freely available webinar series that provide a greater number of teaching hours than is recommended by the jcst. the training exists, it is up to trainees to make the most of it. none. none. dear sir, salisbury district hospital (sdh) is based in southwest england and provides a plastic surgery trauma service across the south coast, serving six local hospitals and the designated major trauma centre (mtc). prior to the covid-19 pandemic all patients referred to the trauma service, apart from open lower limb trauma, were reviewed in person within the trauma clinic. if surgery was required, it was usual for patients to return on a separate day for their operation and in most instances this was carried out under general anaesthetic in the main operating theatres. after discharge, patients were referred to the hand therapy and plastics dressing services and returned in person for all follow-up visits including dressing changes and therapy. patients with lower limb injuries from the mtc were transferred from southampton general hospital as inpatients to sdh for all complex reconstruction including free tissue transfer. at the start of the covid-19 crisis, it became quickly apparent that reducing patient footfall within our department was necessary to protect both patients and staff from the disease. this included reducing inpatient stays in hospital. we responded to this challenge in the following ways and hope that our experience will be of assistance to other trauma services over the course of the global pandemic. firstly, all patient protocols underwent significant redesign following which changes to the layout of our plastic surgery outpatient facility were made and patient flow through the department was altered and reduced. now, when patients are referred to our hand trauma service from peripheral hospitals, the initial patient consultations are carried out remotely using the 'attend anywhere' video platform. we are following the bssh covid-19 hand trauma guidelines 2 for patient management. all patient decisions are discussed with the trauma consultant of the day. we are managing a greater number of patients conservatively and to aid this we have designed comprehensive patient information leaflets that enable our patients to increase understanding of their own management. patients who need to be seen in person at our department are screened for symptoms of covid-19 and their temperature taken at the department entrance. level 2 ppe is worn by staff at all times. for hand trauma patients requiring surgery, this is provided on the same day to maximize efficiency and reduce the need for multiple visits. we have transformed our minor operating theatres, located adjacent to our clinic, into fully functional theatres equipped with a mini c-arm and all instruments for trauma operating. this reduces the need for our patients to be taken into the main hospital theatre suite. operations are carried out either under local anaesthetic, walant or regional block depending on complexity. all theatre staff wear level 3 ppe and staffing is kept to a minimum. all wounds are closed with dissolvable sutures. immediately post operation, our on-site hand therapists review patients. splints are made on the same day and patients are educated about their post-operative management at this time. all follow-up is subsequently carried out virtually by the hand therapy team using 'attend anywhere'. with our hub and spoke service set up for lower limb trauma patients, we have ensured that there is an on-site consultant at the mtc every day. wound coverage is being undertaken for all patients at the mtc. two plastic surgery consultants in conjunction with the orthopaedic team carry out operating for these patients. all inter-hospital transfers for this group of patients have been stopped. choice of wound coverage for these patients is being designed to minimise inpatient stay and reduce operative time. the changes that we have made to our service in a short period of time have already been beneficial for patients, streamlining their care and reducing time spent in hospital. figure 1 shows the drop in numbers of trauma patients that we have seen during the first four weeks of the uk lockdown ( n = 213 in january 2020 to n = 75 over the first 4 weeks into lockdown). this is in line with reports from other uk units. this has given us time to refine our protocols for an expected upsurge of patients as the lockdown is lifted. furthermore, during this period where we have had extra capacity, our registrars have been trained to carry out new techniques. they now undertake insertion of both mid-lines and picc lines for medical inpatients under ultrasound guidance to support and reduce the burden placed on our anaesthetic and critical care colleagues who previously would have placed these. it is our expectation that many of the changes we have implemented to our service will be continued in the longterm. we will continue to learn and adapt our protocols as this phase of work continues. whilst many of the outcomes of the covid-19 pandemic will be negative, it has also been the catalyst for significant positive change within the uk nhs. dear sir, the covid-19 pandemic has caused unprecedented disruptions in patient care globally including management of breast and other cancers. 1 however, cancer care should not be compromised unnecessarily by constraints caused by the outbreak. clinic availability and operating lists have been drastically reduced with many hospital staff members reassigned to the "frontline". furthermore, all surgical specialties have been advised to undertake emergency surgery or unavoidable procedures only with shortest possible operating times, minimal numbers of staff and leaving ventilators available for covid-19 patients. 2 in consequence, much elective surgery including immediate breast reconstruction (ibr) has been deferred in accordance with guidance issued by professional organisations such as the association of breast surgery (uk) and the american society of plastic surgeons. 3 , 4 this will inevitably lead to backlogs of women requiring delayed reconstructions and it is therefore imperative that reconstructive surgeons consider ways to mitigate this and adapt local practice in accordance with national guidelines and operative capacity. in the context of the current "crisis" or the subsequent "recovery period", time consuming and complex autologous tissue reconstruction (free or pedicled flap) should not be performed. approaches to breast reconstruction might include the following options: 1. a blanket ban on immediate reconstruction, and all forms of risk-reducing, contralateral balancing and revisional/tertiary procedures. where reconstructive delay is neither feasible nor desirable, opting for simple and expedient surgery should be considered e.g.: a) expanded use of therapeutic mammaplasty: as a unilateral procedure in selected cases instead of mastectomy and ibr. b) exploring less technically demanding (albeit "controversial") implant-based forms of ibr: i. epipectoral breast reconstruction (fixed volume implants): this adds about 30 minutes to the ablative surgery as the pre-prepared implant-adm complex is easily secured with minimal sutures. ii. "babysitter" tissue expander/implant: this acts as a scaffold to preserve the breast skin envelope for subsequent definitive reconstruction. 3. during the restrictive and early recovery phase, either a solo oncological breast surgeon or a joint ablative and reconstructive team (breast and plastic surgeon) performs surgery without the assistance of trainees or surgical practitioners. for joint procedures, the plastic surgeon acts as assistant during cancer ablation and as primary operator for the reconstruction. despite relatively high rates of complications for implant-based ibr (risking re-admission, prolonged hospital stays or repeat clinic visits), 5 avoiding all ibr will lead to long waiting lists and have a negative psychological impact, particularly among younger patients. this will also impair aesthetic outcomes due to more extensive scars and inevitable loss of nipples. whilst appreciating the restrictions imposed by covid-19, there is opportunity to offer some reconstructive options depending on local circumstances, operating capacity and the pandemic phase. we suggest that these proposals involving greater use of therapeutic mammaplasty as well as epipectoral and "babysitter" prostheses be considered in efforts to offset some of the disadvantages of covid-19 on breast cancer patients whilst ensuring that their safety and that of healthcare providers comes first. dear sir, the covid-19 pandemic has shifted clinical priorities and resources from elective and trauma hand surgery with general anaesthesia (ga) to treat the growing number of covid patients. at the time of this correspondence, the pandemic has affected over 2 million people resulting in 129045 deaths worldwide, with 12868 uk deaths, with numbers still climbing. this has particularly affected our hand trauma services which serves north london, a population of more than 2 million. we receive referrals from a network of 8 hospitals in addition to 3 emergency departments of the royal free group of hospitals and numerous gp practices and urgent care centres. in the first week following the british government lockdown, which commenced march 23rd, we experienced a 75% drop in referrals, from 25 to 6 a day. subsequently, numbers have been steadily rising to 12-14 a day by 6 th of april. the british association of plastic, reconstructive and aesthetic surgeons, the british society for surgery of the hand and the royal college of surgeons of england, have all issued guidance: both encouraging patients to avoid risky pursuits, which could result in accidental injuries and to members how to prioritise and optimise services for trauma and urgent cancer work. we have adapted our hand trauma service to a 'one stop hand trauma and therapy' clinic, where patients are assessed, definitive surgery performed and offered immediate post-operative hand therapy where therapists make splint and give specialist advice on wound care and rehabilitation including an illustrated hand therapy guide. patients are categorised based on the bssh hand injury triage app. we already have a specific 'closed fracture' hand therapy led clinic, to manage the majority of our closed injuries. we combined this clinic with the plastic surgeons' led hand trauma clinic, and improved its efficiency further by utilising the mini c-arm fluoroscope within the clinic setting. this enabled us to immediately assess fractures and perform fracture manipulation under simple local anaesthesia. we have successfully been able to perform 95% of our operations for hand trauma under wide awake local anaesthesia no tourniquet (walant). 1 prior to the pandemic, we used walant for selected elective and trauma hand surgical cases. in infected cases, where local anaesthesia is known to be less effective, we have used peripheral nerve blocks. previous data showed 50% of our trauma cases were conducted under ga, 33% under la, and 17% under brachial or peripheral nerve blocks. 2 we have specifically modified our wound care information leaflets to minimise patient hospital attendance. afterwards patients receive further therapy phone consultations and encouragement to use the hand therapy exercise app developed by the chelsea and westminster hand therapists. the patient is given details of a designated plastic surgery nhs trust email address, for direct contact with the plastic surgery team: for concerns, questions and transfers of images. we have to date received 39 emails, of which 21 have been from patients directly, and the remainder from referring healthcare providers. the majority of inquiries are followed up via a telephone consultation and only complex cases or complications, attend face-to-face follow-up. this model has successfully combined assessment, treatment and post-op therapy into a one-stop session, which has greatly limited patient exposure to other parts of the hospital, such as the radiology and therapy departments. the other benefit of such clinic is an improved outcome through combined decision making. 3 there is also a cost saving benefit compared to our traditional model of patient care. we have treated 31 patients based on this model so far, who have been suitable for remote monitoring. on average we have saved 2 plastics dressing clinic (pdc) visits for wound checks per patient, as a very minimum. we have previously calculated the cost of pdc at our centre at £155 per visit 4 and for our 31 patients this translates to an approximately saving of £9000 per month just on pdc costs. if 30 patients each month could be identified for remote monitoring, this could potentially lead to an annual saving of more than £110,000. in addition, the estimated cost-saving by converting the mode of anaesthesia from ga to walant has been shown to cause a 70% reduction. 5 the concept of a one-stop clinic has already been successfully implemented in the treatment of head & neck tumours, following introduction of nice guidelines in 2004 3 and the covid-19 pandemic has made us redesign a busy metropolitan service for hand injuries along the same lines. we believe this model is a good strategy and combining this with more widespread use of the walant technique, technology such as apps and telemedicine, as well as encouraging greater patient responsibility in their post-operative care and rehabilitation; is the way forward. we hope sharing this experience will result in improved patient care at this time of crisis. 'this is a saint patrick's day like no other' declared the irish prime minster on march 17th 2020, whilst announcing sweeping social restrictions in a response to the worsening covid-19 pandemic. this nationwide lockdown involved major restrictions on work, travel and public gatherings and signified the government's shift from the suppression to the mitigation phase of the outbreak. the national covid-19 task force produced a policy specifying the redeployment of heath care workers to essential services such as the emergency department and intensive care. 1 with the introduction of virtual outpatient clinics and the curtailment of elective operating lists, the apparent clinical commitments of a plastic surgeon during this pandemic has lessened. trauma is a continual and major component of our practice 2 ; however, a decline in emergency department presentations has fuelled anecdotal reports of a reduction in the trauma workload. with diminishing resources, the risk of staff redeployment and consequences of poor patient outcomes we aim to assess the effect of the current lockdown due to covid-19 pandemic on plastic trauma caseload. we performed a retrospective review of a prospectively maintained trauma database at a tertiary referral hospiduring the first 25 days of the lockdown, 48 patients attended plastic surgery trauma clinic, in which 41 (85.4%) underwent a surgical procedure. as seen in figure 1 , these numbers are comparable over the same time frame for the two previous years. upper limb trauma accounted for the near majority of referrals. frequency and type of surgery performed during the lockdown were similar to the previous two years, as seen in table 1 . the percentage of patients requiring general anaesthesia was 46.3% (19/41) in 2020, 44.2% (19/43) in 2019, and slightly higher in 2018 at 58.9% (23/39). we have refuted any anecdotal evidence proposing a decline in plastic trauma caseload during the covid19 nationwide lockdown. comparing the same time in previous years, the lockdown has produced an equivalent trauma volume. despite, the widespread and necessary restriction of routine elective work, somewhat surprisingly the pattern and volume of trauma remains similar to preceding years. with people confined to their household, it is the 'diy at home' associated injuries which attributes to this trend. and the exemption from regulations of certain industries such as agriculture and the food preparation chain. whilst not every trauma risk may be mitigated, the potential for these diy injuries to overwhelm the healthcare service has resulted in the british society for surgery of the hand (bssh) cautioning the general public on the safety of domestic machinery. 3 as healthcare systems are stretched further than ever before we all must recognise the need for adaptation and structural reorganisation to treat those of our patients most in need during this pandemic. staff redeployment is a necessary tool to maintain frontline services; nonetheless, we wish to highlight the outcomes of this study to the clinical directors with the challenging job of allocating resources. our trauma presentations have not reduced during the first 25 days of this pandemic, resources (staff and theatre) should still be accessible for the plastic surgery trauma team, with observance of all the appropriate risk reduction strategies as documented by british association of plastic, reconstructive and aesthetic surgeons. 4 none. none. in light of the ongoing covid-19 pandemic, the american society of plastic surgeons (asps) has released a statement urging the suspension of elective, non-essential procedures. 1 this necessary and rational suspension will result in detrimental financial effects on the plastic surgery community. given the simultaneous economic downturn inflicted by public health social-distancing protocols, there will be a bear market for elective surgery lasting well past the bans being lifted on elective surgeries. this effect will largely be due to the elimination of discretionary spending as individuals attempt to recover from weeks to months of lost earnings. as demonstrated during the 2008-2009 recession, economic decline was associated with a decrease in both elective and non-elective surgical volume. 2 private practice settings performing mostly cosmetic procedures were particularly vulnerable to these fluctuations and demonstrated a significant positive correlation with gdp. 3 the surgery community must prepare for the economic impact that this pandemic will have on current and future clinical volumes. these effects are likely to be more severe than the previous recession as surgeons are currently indefinitely unable to perform elective surgeries, coupled with the immense strain on hospital resources at this time. given this burden, elective surgery cases may be some of the last to be added back to the hospital once adequate resources are restored. while surgeons are temporarily unable to operate, they do have the potential to use telehealth in order to arrange preoperative consults and postoperative follow-up appointments. this could be accomplished in private practice settings with the use of telehealth services such as teladoc health, american well, or zoom, which allow for live consultation with patients without unnecessary exposure of patients or providers to potential infection. 4 the main limitation of these types of appointments is the lack of an inperson physical exam, so providers have found that billing based on time spent with the patient is more effective with this tool. 5 this could generate revenue and facilitate future surgical cases after the suspension of in-person elective patient care has been lifted. several strategies should be considered by the elective surgery community to minimize financial losses. many financial entities have changed their policies in order to support small businesses. examples include the small business administration offering expanded disaster impact loans and deferment of the federal income tax payments by three months to july 15. 5 another option employers may leverage is temporarily laying off of employees so that employees can apply for and collect an expanded unemployment package by federal and state governments thereby reducing the payroll burden on stagnant practices with no cash flows and providing employees with a steady source of income during the pandemic. the employer's incentive to do this may be reduced with the potential suspension of the payroll tax on employers and loan forgiveness to employers who continue to pay employees wages. 5 once elective procedures are again permitted, plastic surgeons that have retained a reconstructive practice should make a strategic business decision to increase reconstructive surgery and emergent hand surgery bookings as historically these procedures are less fluctuant with the economy. 3 other options to maintain aesthetic case volume include price reductions or temporary promotions. however, it is important that these be adopted universally in order to minimize price wars between providers. as physicians, it is principle that surgeons practice nonmaleficence and minimize non-essential patient contact for the time being. however, this time of financial standstill should be used constructively to prepare for the financial uncertainty in the months to come. none demic advise certain groups to stringently follow social distancing measures. inevitably some health care workers fall into these categories and working in a hospital places them at high risk of exposure to the virus. studies have shown human to human transmission from positive covid-19 patients to health care workers demonstrating that this threat is real 1 , 2 and as in other infectious diseases is worse in certain situations such as aerosol generating and airway procedures 3 , 4 . there is therefore a part of our workforce that has been out of action reducing available workforce at a time of great need. in our hospital a group of vulnerable surgical trainees ranging from ct2 to st8, and also consultants, have been able to keep working while socially isolating within their usual workplace. in light of covid-19 our hospital, a regional trauma centre for burns, plastic surgery and oral and maxillofacial surgery, was reorganized to increase capacity for both trauma and cancer work. as part of this a virtual hand trauma service has been set up. the primary aim of the new virtual hand trauma clinic was to allow patients to be triaged in a timely manner while adhering to social distancing guidelines by remotely accessing the clinic from home. further aims were to reduce time spent in hospital and reduced time between referral and treatment. in brief, patients referred to our virtual hand trauma clinic from across the region receive a video or telephone consultation using attend anywhere software, supported by nhs digital. following the virtual consultation patients are then triaged to theatre, further clinic, or discharged. our group of isolating doctors, plus a pharmacist and trauma coordinator, have been redeployed away from their usual face to face roles and are now working solely in the virtual trauma clinic. they are able to work to provide this service in an isolated part of the hospital named the 'virtual nest.' the nest is not accessible in a 'face to face' manner by non-isolating staff or patients. this allows a safe 'clean' environment to be maintained. the virtual team is able to participate in morning handover with other areas of the hospital via video conferencing using webex software. the nest workspace is large enough to allow social distancing between clinicians and by being on site they benefit from availability of dedicated workspaces with suitable it equipment and bandwidth. it is widely recognised that reconfiguration of hospitals and redeployment of staff has meant that training is effectively 'on hold' for many trainees. we have found that a benefit of the new virtual hand trauma clinic is that trainees can continue to engage with the intercollegiate surgical curriculum programme with work based assessments in a surgical field. while direct observation of procedural skills and procedure based assessment are not feasible, case based discussions and clinical evaluation exercises have been easily achievable due to trainees managing patients with involvement of supervising senior colleagues in decision making. this plus a varied case mix seen has enhanced development of knowledge, decision making, leadership and communication skills. as trainees are unable to attend theatre practical skills may suffer depending on how long clinicians are non patient facing. this has been acknowledged by the gmc in the skill fade review; skills have been shown to decline over 6 -18 months 5 . although it can only be postulated at the current time colleagues who are patient facing but redeployed may face a similar skill decline. the structure of the team is akin to the firm structure of days gone by with the benefits that brings in terms of support and mentorship. patients benefit from having access to a group of knowledgeable trainees, supported by consultants, and a service accessible from their own home. this minimizes footfall within our hospital, exposure to, and spread of covid-19. local assessment of our practice is ongoing but we have found that this model has enabled a cohort of vulnerable plastic surgery trainees to successfully continue to work whilst reducing the risk of exposure to covid-19 and providing gold standard care for patients. none. nothing to disclose. dear sir, a scottish sarcoma network (glasgow centre) special study day on 6th march 2019 at the school of simulation and visualisation, glasgow school of art, with representatives from sarcoma uk, beatson cancer charity and the bbc. traditional patient information leaflets inadequately convey medical information due to poor literacy levels: 16-27% of uk population have the lowest adult literacy level 1 and 40% the lowest "health literacy" level (ability to obtain, understand, act on, and communicate health information). 2 it was hypothesised that an entirely visual approach, such as ar, may obviate literacy problems by faciliating comprehension of complex 3 dimensional concepts integral to reconstructive surgery. we report the first augmented reality (ar) in patient information leaflets in plastic surgery. to our knowledge we are among the first in the world to develop, implement, and evaluate an ar patient information leaflet in any speciality. developed for sarcoma surgery, the ar patient leaflet centred around a prototypical leg sarcoma. a storyboard takes patients through tumour resection, reconstruction, and the potential post-operative outcomes. input from specialist nurses, sarcoma patients, and clinicians during a scottish sarcoma network special study day in march 2019 informed the final content ( figure 1 ). when viewed by smartphone camera (hp reveal studio, hp palo alto, california usa), photos in the ar leaflet automatically trigger additional content display without need for qr codes or internet connectivity: (1) sequential tumour resection ( a 3d alt flap model was developed using body-parts3d (research organization of information and systems database centre for life science, japan) and custom anatomical data. 4 leaflet evaluation by 14 consecutive lower limb sarcoma patients was exempted from ethics approval by greater glasgow and clyde nhs research office as part of service evaluation. ar leaflets were compared with pooled data from traditional information sources (sarcoma uk website patient leaflets (6), self-directed internet searches (5), generic sarcoma patient leaflets (5); some patients used > 1 source). the mental effort rating scale evaluated perceived difficulty of comprehension (or extrinsic cognitive load), 3 as a key outcome measure in comparison to traditional information sources. patient satisfaction was assessed by likert scale (1 was very, very satisfied and 9 very, very dissatisfied). statistical analysis performed with social science statistics, 2019. ar leaflets were rated as 1.57 (very, very low mental effort), traditional information sources as 6.36 (high mental effort) [unpaired t -test p < 0.0001]. likert-scale satisfaction was 1.43, indicating a very, very high satisfaction. when asked "do you think the ar leaflet would make you less anxious about surgery?", 12/14 (86%) patients responded 'yes'. when asked "would you think other patients would like to have a similar ar leaflet before surgery" and "would you like to see further ar leaflets to be developed in the future?", 100% responded "yes". no correlation was found between age or educational level and mental effort rating scale scores for ar patient leaflet (data not shown). subjective feedback analysis found that self-directed internet searches had too much unfocussed information: " (i) didn't want to google as may end up with all sorts" and "(there is) good and bad stuff on the internet, don't know what you're looking at". all patients felt the visual content in ar leaflets helped their understanding: "incredible…that would have made a flap easier to understand", "tremen-dous… good way of explaining things to my family", "so much better seeing the pictures, gives an idea in your head", and "helpful for others with dyslexia". traditional patient leaflets were often difficult to comprehend: "(i) didn't fully understand the sarcoma leaflets", "couldn't take information in from leaflets". feedback recommended adding simple instructions on the leaflet, however the ar leaflet is intended for use by the clinician in clinic, and to be so simple that no instructions are required once software is downloaded to the patient's smartphone (i.e., point and shoot without technical expertise, menus, or website addresses). all patients desired an actual paper leaflet for reassurance, preferring something physical show their family rather than direction to a website or video. this study demonstrates significant reduction in extraneous cognitive load (mental effort required to understand a topic) with ar patient leaflets compared to traditional information sources ( p < 0.0001). ar visualisation may make inherently difficult topics (intrinsic cognitive load), such as reconstructive surgery, easier to understand and process. significant learning advantages exist over tradi-tional leaflets or web-based videos, including facilitating patient control, interactivity, and game-based learning. all contribute to increased motivation, comprehension, and enthusiasm in the learning process. 5 ar leaflets reduced anxiety (86% patients), and scored very highly for patient satisfaction with information, which is notable given increasing evidence of strong independent determination of overall health outcomes. this study provided impetus for investment in concurrent development of other ar leaflets across the breadth of plastic surgery, and non-plastic surgery specialties. chief scientist office (cso, scotland) funding was recruited to aid development of improved, free, fully interactive 3d ar patient information leaflets and a downloadable app. ethical approval is in place for a randomised controlled trial to quantify the perceived benefits of ar in patient education. our belief is that ar leaflets will transform and redefine the future plastic surgery patient information landscape, empowering patients and bridging the health literacy gap. none. dear sir, we investigated if age has an influence on wound healing. wound healing can result in hypertrophic scars or keloids. from previous studies we know that age has an influence on the different stages of wound healing. 1-4 a general assumption seems to be that adults make better scars than children. knowledge of the influence of age on healing and scarring can give opportunities to intervene in the wound healing process to minimize scarring. it could guide patients in their decision when to revise a scar. it could also lead patients and physicians in their decision of the timing of a surgery, if the kinds of surgery allows this. this study is a retrospective cohort study at the department of plastic, reconstructive, and hand surgery of the amsterdam university medical center. all patients underwent cardiothoracic surgery through a median sternotomy incision. all patients had to be at least one year after surgery at time of investigation. hypertrophic scars were defined as raised 1 mm above skin level while remaining within the borders of the original lesion. keloid scars were defined as raised 1 mm above skin level and extending beyond the borders of the original lesion. 5 the scars were scored with the patient and observer scar assessment scale (posas) as primary outcome measure. as secondary outcome measures we looked at wound healing problems and scar measurements. in order to ensure that the results of this study are as little as possible influenced by the already known risk and protective factors for hypertrophic scarring, the patients were questioned about co-existing diseases, scar treatment, allergies, medication, length, weight, cup size (females) and smoking. their skin type was classified with the fitzpatrick scale i to vi. all calculations were performed using spss and the level of significance was set at p ≤ 0.05. 105 patients were enrolled in this study. group 1 contained 53 children and group 2 contained 52 adults. there is a significant difference between the two groups for the amount of pain in the scar scored by the patient. this item was given higher scores by adults than children ( p = 0.025). there is no significant difference between the two groups for the other posas items (itchiness, color, stiffness, thickness, and irregularity), the total score of the scar and the overall opinion of the scar scored by the patient ( table 1 ) . there is a significant difference between the two groups in pliability of the scar scored by the observer. the posas item pliability of the scars of the children was assessed higher, thus stiffer, than in adults ( p = 0.022). there is no significant difference between the two groups for the other posas items (vascularization, pigmentation, thickness, relief, and surface), the total score of the scar and the overall opinion of the scar scored by the observer ( table 1 ) . there is no significant difference between children and adults in the occurrence of wound problems post-surgery. there is no significant difference in scar measurements between children and adults. in children we found three hypertrophic scars and two keloid scars. in adults we found seven hypertrophic scars and three keloid scars. for both groups together that is a percentage of 14.3 hypertrophic and keloid scars ( table 2 ) . patients with fitzpatrick skin type i and iv-vi scored significantly higher, thus worse, in their overall opinion of the scar ( p = 0.024) than patients with skin type ii and iii. observer and patient assessed the overall opinion of the scar significantly higher (worse) in people who had gone through wound problems (respectively p = 0.020 and p = 0.007) than those who had not. we found no significant differences in the primary outcome measure between men and women, cup size a-c and d -g, smokers and non-smokers, bmi < 25 and bmi > 25, allergies and no allergies, and scar treatment and no scar treatment. age at creation of a sternotomy wound does not seem to influence the scar outcome. this is contrary to what is often the fear of a parent of a child who needs surgery early in life. comparing scars remains difficult because of the many factors that can influence scar formation. we found that scars have the tendency to change, even years after they are made. a limitation of the study is the retrospective design. the long follow-up period after surgery is a strength of the study. to our best knowledge this is the first study that compares scars of children and adults to specifically look at the clinical impact of age on scar tissue. in order to detect even more reliable and possibly significant differences between children and adults, more patients should be enrolled in future prospective studies. for now we can conclude that there is no significant difference in the actual scar outcome between children and adults in the sternotomy scar. if we extend these results to other scars, the timing of surgeries should not depend on the age of a patient. none. none. metc. reference number: w18_050 # 18.068. we published a systematic review of randomized controlled trials (rcts) on early laser intervention to reduce scar formation in wound healing by primary intention. 1 while comparing our results with two other systematic reviews on the same topic, 2 , 3 we identified various overt methodological inconsistencies in those other systematic reviews. issue 1. including duplicate data ( table 1 ) : karmisholt et al. 2 included two rcts of which both reported the identical data on five people. the inclusion of duplicate data can bias the results of a systematic review and should be prevented in the quantitative as well as the qualitative synthesis of evidence. abbreviations. id: identity; n.l.t.: no laser treatment; pcs: prospective cohort study; pmid: pubmed identifier; rct: randomized controlled trial. a) listed are rcts which were included by at least one of the three identified systematic reviews. the systematic reviews are ordered by search date from left to right. b) "search date" refers to the searching of bibliographic databases by the authors of the corresponding systematic reviews. c) "publication date" refers to the publication history status according to medline®/pubmed® data element (field) descriptions. d) "n.l.t." means that the authors of the rcts compared laser treatment with no treatment or a treatment without laser. e) "pcs" means that the authors used this term to label the corresponding rct. f) "-" indicates that an rct could not have been identified because the publication of the corresponding rct happened after the search date. g) "missing study" means that an rct could have been identified because the publication of a corresponding rct happened before the search date. h) "excluded" that the authors of the present review excluded the corresponding rct based on the exclusion criteria provided. i) "not analyzed" means that an rct was reported within an article but the corresponding data were not included in the metaanalysis. j) "other laser" means that the authors of the rcts compared various types of laser treatment. 2 attached the label "prospective cohort" to almost all considered studies including 16 rcts and seven nonrandomized studies. in rcts, subjects are allocated to different interventions by the investigator based on a random allocation mechanism. in cohort studies, subjects are not allocated by the investigator but rather allocated in the course of usual treatment decisions or peoples' choices based on a nonrandom allocation mechanism. 4 we believe that 'cohort study' is certainly not an appropriate label for rcts. furthermore, it is known for a long time that the shorthand labeling of a study using the words 'prospective' and 'retrospective' may create confusion due to the experience that these words carry contradictory and overlapping meanings. 5 issue 4. mixing data from various study designs: karmisholt et al. 2 did not clearly separate randomized from nonrandomized studies. combinations of different study design features should be expected to differ systematically, and different design features should be analyzed separately. 4 issue 5. unclear definition of outcomes and measures of treatment effect: kent et al. 3 reported, quote: "the primary outcome of the meta-analysis is the summed measure of overall efficacy provided by the pooling of overall treatment outcomes measured within individual studies." we think that the so-called "summed measure" is not defined and not understandable. the meta-analysis reported in that article included mean and standard deviation values from four rcts. these rcts applied endpoints and time periods for assessment which differed considerably among the included studies. it appears obscure to us which data were transformed in what way to finally arrive in the meta-analysis. we believe that traceability and reproducibility of data analyses are mainstays of systematic reviews. issue 6. missing an understandable risk of bias assessment: kent et al. 3 reported, quote: "the risk of bias assessment tool provided by revman indicated that all studies had 2-3 categories of bias assessed as high risk." the term "revman" is a short term for the software "review manager 5 provided by cochrane for preparing their reviews. the cochrane risk-of-bias tool for randomized trials is structured into a fixed set of domains of bias including those arising from the randomization process, due to deviations from intended interventions, due to missing outcome data, those in measurement of the outcome, and in selection of the reported result. we believe that the risk of bias assessment reported by kent et al. 3 is not readily understandable and presumably does not match standard requirements. systematic reviews of healthcare interventions aim to evaluate the quality of clinical studies, but they might have quality issues in their own right. the identification of various inconsistencies in two systematic reviews on plateletrich plasma therapy for pattern hair loss should prompt future authors to consult the cochrane handbook ( https: //training.cochrane.org/handbook ) and the equator network ( http://www.equator-network.org/ ). the latter provides information to various reporting standards such as prisma for systematic reviews, consort for rcts, and strobe for observational studies. the authors declare no conflict of interest. dear sir, journal clubs have contributed to medical education since the 19th century. 1 along the way, different models and refinements have been proposed. recently, there has been a shift towards "virtual" journal clubs, often using social media platforms. 2 our team has refined the face-to-face journal club model and successfully deployed it at two independent uk national health service (nhs) trusts in 2019. we believe there are reproducible advantages to this model. over 6 months at one nhs trust, 8 journal club events were held, with iterative changes made to increase engagement and buy-in of the surgical team. overall, tangible outputs included 3 submissions of letters to editors, of which 2 have been accepted. following this, the refined model was deployed at a second nhs trust, which had expanded academic support increasing its impact. over 4 months, 6 journal club events were held, with 4 submissions of letters to editors, 3 of which have been accepted. thus, in 10 months of 2019, the two sequential journal clubs generated 7 submissions for publication, with 16 different authors. these tangible outputs are matched by other intangible benefits, such as improving critical appraisal skills. this is assessed in uk surgical training entry selection and is also a key skill for evidence-based professional practice. therefore, we feel this helps our team members' career progression and clinical effectiveness. key aspects of the model include: 1. face-to-face meetings continue to have multiple intangible benefits there is a trend towards social media and online journal clubs. while such initiatives have considerable benefits, maintaining face-to-face contact in a department allows for an efficient discussion, and enhances teambuilding. instead of replacing face-to-face meetings with virtual ones, we use social media platforms, such as whatsapp, to support our events. this includes communications to arrange the event in advance, and for maintaining momentum on post-event activities, such as authoring letters to journals from the discussion. while some articles describing journal club models highlight the benefit of expert input in article selection, 1 we also view it as a learning opportunity. a surgical trainee is allocated to present each journal club, with one of our three academically appointed consultant surgeons chairing and overseeing. trainees are encouraged to screen the literature and identify articles beforehand and make a shared decision with the consultant. the article must be topical and have potential to impact clinical practice. doing this prior to the session allows the article to be circulated to attendees with adequate time to read it. we routinely use both reporting guidelines (e.g., prisma for systematic reviews), and also methodological quality guidance (e.g., amstar-2 for systematic reviews) to guide trainees and structure the journal club presentation. in addition to three consultants with university appointments guiding critical appraisal, a locally based information scientist also joins our meetings. during journal club discussion, emphasis is placed on relating the article to the clinical experience of team members. this provides context and aids clinical learning for trainees. while undertaking critical appraisal may be a noble endeavour, in busy schedules, it is important that it adds value for everyone involved. reviewing contemporary topics can inform clinical practice for all levels of surgeon in the team, presenting the article improves trainees' presentation skills, and publishing the appraisal generates outputs that help trainees to progress. 8. publishing summaries of journal club appraisals can impact on multiple levels journal club does not only contribute to our trainees' development and departmental clinical practice. it benefits our own research strategy and quality, and open discussion of literature in plastic surgery contributes to a global culture of improving evidence. scheduling events on a regular basis increases familiarity with reporting and quality guidance and allows for the study of complementary article types (e.g., systematic review, randomised trial, cohort study). our iterations suggest that the following structure is most effective: joint article selection one week before event, dissemination to audience, set time and location during departmental teaching, chairing by an academic consultant with information scientist and senior surgeons present, presentation led by a surgical trainee, open-floor discussion of article and its implications for our own practice, summary, drafting of letter to the editor if appropriate. as we have used variations of this model successfully at two independent nhs trusts, we believe that these tactics can be readily adapted and deployed by others as well. nil. dear sir, surgical ablation of advanced scalp malignancies requires wide local excision of the lesion, including segmental craniectomies. the free latissimus dorsi (ld) flap is a popular choice for scalp reconstruction due to its potential for mass surface area resurfacing, ability to conform to the natural convexity of the scalp, reliable vascularity and reasonable pedicle length. 1 one of the disadvantages of ld free flap use is the perceived need for harvest in in a lateral position. this necessitates a change in position of the patient intraoperatively for flap raise and can add to the overall operative time. current literature in microvascular procedures on the elderly demonstrates that a longer operative time is the only predictive factor associated with an increased frequency of post-operative medical and surgical morbidity. as most patients undergoing scalp malignancy resection are elderly it is important to reduce this surgical time in this cohort of patients. 2 , 3 we present our experience of reconstruction of composite cranial defects with ld flaps using a synchronous tumour resection and flap harvest with supine approach to reduce operative times and potential morbidity. all patients undergoing segmental craniectomies with prosthetic replacement and ld reconstruction under the care of the senior surgeons were included in the study. patients were positioned supine with a head ring to support the neck; a sandbag is placed between the scapulae and the arm on the chosen side of flap raise is free draped. a curvilinear incision is made posterior to the midaxillary line ( figure 1 ). the lateral border of the ld muscle is identified, and dissection continued in a subcutaneous plane inferiorly, superiorly and medially until the midline is approached. the muscle is divided at the inferior and medial borders, and the flap lifted towards the pedicle. once the pedicle is identified, the assistant can manipulate the position of the free draped arm to aid access into the axilla; the pedicle is clipped once adequate length has been obtained. the flap is delivered through the wound and detached ( figure 2 ). donor site closure is carried out conventionally.the flap inset is performed using a "vest over pants" technique utilising scalp over muscle by undermining the remaining scalp edges. 5 a non-meshed skin graft is used to enhance aesthetic outcome. a total of 11 patients underwent 12 free ld muscle flaps. all were muscle flaps combined with split-thickness skin grafts. the study population included ten male patients and one female. the age range was 47-74 years with a mean age of 69.5 years. the defect area ranged from 99 cm 2 -360 cm 2 . a titanium mesh was utilised for dural cover in all patients fixed with self-drilling 5 × 1.5 mm cortical screws. the primary recipient vessel used was the superficial temporal artery and vein. however, in cases where a simultaneous neck dissection and parotidectomy are necessary for regional disease, the facial artery and vein are used ( n = 1 in this series) or contralateral superficial temporal vessels. the ischaemia time ranged from 48-71 min, with a mean of 61.3 min. there were no take backs for flap re-exploration. the overall flap success rate was 100%. marginal flap necrosis with secondary infection occurred in one patient with a massive defect (at one week post-op). the area was debrided and a second ld flap was used to cover the resultant defect (30%). a further posterior transposition flap was used to cover a minor area of exposed mesh. the scalp healed completely. the total operating time ranged between 210-410 min, with a mean of 289 min. all patients were followed up at 2 and then four weeks for wound checks. the ld flap remains a popular choice due to its superior size and ability to conform to the natural convexity of the scalp compared with other flap choices. 4 also, unlike composite flaps which often require postoperative debulking procedures, the ld muscle flap atrophy's and contours favourably to the skull. 5 however, the traditional means of access to this flap requires lateral decubitus positioning of the patient, which can hinder simultaneous oncological resection. the supine position facilitates access for neck dissection, especially if bilateral access is required. our approach ensures that the tumour ablation and reconstruction is carried out in a time efficient manner in an attempt to reduce postoperative medical and surgical complications. synchronous ablation and reconstruction are key in reducing overall operative time and complication risk and is practised preferentially at our institute. it is important to maintain a degree of flexibility to achieve this -there may be situation where supine positioning overall is more favourable. likewise, there are situations relating to flap topography where a lateral approach to tumour removal and reconstruction is preferred. the resecting surgeon or reconstructive surgeon may have to compromise to achieve synchronous operating but is worthwhile to reduce overall total operative time. none. not required. once established, lymphorrhea typically persists and can present as an external lymphatic fistula. lymphorrhea occurs in limbs with severe lymphedema, as a complication after lymphatic damage, and in obese patients. some cases are refractory to conservative treatment and require surgical intervention. reconstruction of a lymphatic drainage table 1 three patients had primary lymphedema, 4 had age-related lymphedema, 3 had obesity-related lymphedema, and 2 had iatrogenic lymphorrhea. in the 2 cases of iatrogenic lymphorrhea, the lesions were located in the groin and the others in the lower leg. abbreviations: bmi, body mass index; f, female; m, male. three patients had primary lymphedema, four had agerelated lymphedema (aging of the lymphatic system and function is thought to be the cause of age-related lymphedema 1 .), three had obesity-related lymphedema, and two had iatrogenic lymphorrhea ( table 1 ) . one of 2 cases of lymphorrhea in the inguinal region was caused by lymph node biopsy and the other by revascularization after resection of malignant soft tissue sarcoma. compression therapy had been performed preoperatively in 10 cases (using cotton elastic bandages in 6 cases). four patients wore a jobst r compression garment. compression therapy was difficult to apply in 2 patients. the duration of lymphorrhea ranged from 1 to 192 months. the severity of lymphedema 2 ranged from campisi stage 2 to 4 ( table 1 ). the clinical diagnosis of lymphorrhea was confirmed by observation of fluorescent discharge from the wound on lymphography. no signs of venous insufficiency or hypertension were observed in the subcutaneous vein intraoperatively. all anastomoses were performed between distal lymphatics and proximal veins. postoperatively, lymph was observed to be flowing from the lymphatic vessels to the veins. two to 4 lvas were performed in the region distal to the lymphorrhea and 1-4 in the region proximal to the lymphorrhea in patients with lower limb involvement. six lvas were performed in patients with lymphorrhea in the inguinal region ( table 1 ) . all patients were successfully treated with lvas without perioperative complications. the volume of lymphorrhea decreased within 5 days following the lva surgery in all cases and had resolved by 2 weeks postoperatively. the compression therapy used preoperatively was continued postoperatively. there has been no recurrence of lymphorrhea or cellulitis since the lvas were performed. an 86-year-old woman had gradually developed edema in her lower limbs over a period of 2-3 years. she had also developed erosions on both lower legs ( figure 1 ). compression with cotton bandages failed to terminate the percutaneous discharge; about 400 ml of lymphatic discharge through the erosion was noted each day. ultrasonography did not suggest a venous ulcer resulting from venous thrombosis, varix, or reflux. four lvas were performed in each leg (3 distal and 1 proximal to the leak). the lymphorrhea had mostly resolved by 5 days postoperatively. the erosions healed within 3 weeks of the surgery. no recurrence of lymphorrhea was noted during 12 months of follow-up. iatrogenic lymphorrhea occurs after surgical intervention involving the lymphatic system. it is also known to occur in patients with severe lymphedema. obesity 3 and advancing age 1 are also risk factors for lymphedema. most patients with lymphorrhea respond to conservative measures but some require surgical treatment. patients with lymphorrhea are at increased risk of lymphedema. lymphorrhea that occurs after surgery or trauma is caused by damage to lymphatic vessels that are large enough to cause lymphorrhea. lymphorrhea that occurs in association with lipedema or age-related lymphedema indicates accumulation of lymph that has progressed to lymphorrhea. it is possible to treat lymphorrhea by other methods, including macroscopic ligation, compression, or negative pressure wound therapy 4 . however, it is impossible to reconstruct a lymphatic drainage route using these procedures. we hypothesized that lymphorrhea can be managed by using lva to treat the lymphedema. lva is a microsurgical technique whereby an operating microscope is used to perform microscopic anastomoses between lymphatic vessels and veins to re-establish a lymph drainage route. the primary benefits of lva are that it is minimally invasive, can be performed under local anesthesia, and through incisions measuring 2-3 cm. one anastomosis is adequate to treat lymphorrhea and serves to divert the flow of the lymphorrhea-causing lymph to the venous circulation. if operative circumstances allow, 5 or more anastomoses are recommended for the treatment of lymphorrhea complicated by lymphedema. lymphedema is a cause of delayed wound healing, and lva procedures are considered to improve wound healing in lymphedema via pathophysiologic and immunologic mechanisms 5 . lva is a promising treatment for lymphorrhea because it can treat both lymphorrhea and lymphedema simultaneously. the focus when treating lymphedema has now shifted to risk reduction and prevention, so it is important to consider the risk of lymphedema when treating lymphorrhea. none over-meshing 1:1 meshed skin graft we were curious to learn if it's feasible to mesh already meshed skin grafts. we run our skin bank at the department of plastic surgery 1 and used allograft skin that was tested microbiologically positive and thus not suitable for patient use. grafts were cut into 4 cm x 4.5 cm pieces and meshed using mesh carriers to 1:1 and over-meshed with 1:1.5. we used two kind of mesh carriers for 1:1.5 meshes. the meshed grafts were maximally expanded and measured again. the results were expressed as ratios, figure 1 . we found that, over-meshing results in 1.25-fold increase in graft area regardless of the mesh carrier used. figure 2 illustrates close-up picture of the over-meshed graft. in the close-up picture the small 1:1 incisions are still visible. in those undesirable "oh no the graft is too small"or "the graft is too large" -situations this technique has its advantages. we have used over-meshed graft in a skin graft harvest site, supplemental figure, with acceptable outcome. it seems that the tiny extra incisions in the overmeshed skin graft do not deteriorate the aesthetic outcome from the 1:1.5 mesh. what is the clinical value of the tiny incisions, we don't know, but we approximate it to be minimal if even that. to best of our knowledge, only one previous publication has addressed the over-meshing of skin grafts 2 . henderson et al. showed in porcine split thickness skin grafts that overmeshing resulted in increase of 1.5 ratio, a bit larger compared to our results. taken together, the results point to the direction that meshing of already meshed graft is feasible and does not destroy the architecture of the original or succeeding mesh. each author declares no financial conflicts of interest with regard to the data presented in this manuscript. supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.bjps.2020.02. 048 . numerous autologous techniques for gluteal augmentation flaps have been described. in the well-known currently employed technique for gluteal augmentation, it is noticeable that added volume is unevenly distributed in the buttock. in fact, after a morphological analysis, it becomes clear that the volume is added to the upper buttock to the expense of the lower buttock. 1 according to wong's ideal buttock criteria, the most prominent posterior portion is fixed at the midpoint on the side view. 2 additionally, mendieta et al. suggest that the ideal buttock needs equal volume in the four quadrants and its point of maximum projection should be at the level of the pubic bone. 3 we describe a technique of autologous gluteal augmentation using a para-sacral artery perforator propeller flap (psap). this new technique can fill up all the quadrants vertically with a voluminous flap shaped like a gluteal anatomic implant. gluteal examination is done in a standing and prone position. patients must have a body mass index less than 30 kg/m2, an indication for a body lift contouring surgery, gluteal ptosis with platypygia and substantial steatomery on the lower back. when the pinch test is greater than 5 cm this is defined as substantial steatomery. preoperative markings: the ten steps a. standing position 1. limits of the trunk. the median limit (mlt) and the vertical lateral limit (llt) of the trunk are marked. 2. limits of the buttock. the inferior gluteal fold (igf) is drawn. the vertical lateral limit of the buttock (llb) is defined at the outer third between the mlt and the llt. 3. lateral key points. points c and c' are located on the vertical lateral limits: point c is 2 to 3 cm below the iliac crest, depending on the type of underwear. point c' is determined by an inferior strong tension pinch test performed from point c. mhz. this diagnostic tool is easy to access, non-invasive, and above all, reliable in the identification of perforating arteries, with sensitivity and a positive predictive value of almost 100%. 4 usually, one to three perforators are identified on each side and marked. 9. design of the gluteal pocket. the shape is oval, with the dimensions similar to those of the flaps. the base is truncated and suspended from the lower resection line. the width of the pocket is one to two centimeters from the lmt laterally and two centimetres from llt medially. the inferior border of the pocket is not more than two fingers'-breadth above the ifg. therefore, the pocket lies medial in the gluteal region. 10. design of the flap. the flap is shaped like a "butterfly wing" with the long axis following a horizontal line. after a 90 °medial rotation, the flap has a shape similar to an anatomical gluteal prosthesis. the medial boundary is two fingers'-breadth from the median limit of the buttock, and the width is defined by the two resection limits. the patient is placed in a prone position, arm in abduction. the flap is harvested from lateral to medial direction, first in a supra-fascial plane then sub-fascial when approaching the llb. the dissection is completed when the rotation arc of the flap is free of restriction (90 °−100 °), and viewing or dissection of the perforators is usually not required. to create the pocket, custom undermining is done in the sub-fascial plane according to the markings. the flap is then rotated and positioned into the pocket. the superficial fascial system is closed with 0 vicryl (ethicon) and the deep and superficial dermis are closed with a buried intradermal suture and running subcutaneous suture with 3.0 monocryl (ethicon). a compressive garment (medical z lipo-panty elegance coolmax h model, ec/002-h) was worn postoperatively for one month ( figure 1 ). rhinoplasty is one of the most common procedures in plastic surgery and 5-15% of the patients undergo revision. dorsal asymmetry is the leading (65%) nasal flaw in secondary patients. 1 careful management of the dorsum to achieve a smooth transition from radix to tip is necessary. camouflage techniques are well known maneuvers for correcting dorsal irregularities. cartilage, fascia, cranial bone, and acellular dermal matrix were previously used for this aim. 2 , 3 bone dust is an orthotopic option, which is easily moldable into a paste. it is especially useful in closed rhinoplasty, where our visual acuity on the dorsum is reduced. we introduce a new tool, a minimally invasive bone collector, as an effective and safe device for harvesting bone dust from the nasal bony pyramid to obtain camouflage on the dorsum and for performing ostectomy simultaneously. patients were operated for nasal deformity by the senior author (o.b.) with closed rhinoplasty between february 2018 and november 2018. in all cases, a minimally invasive bone collector was used for ostectomy and the harvest of bone dust. included patients were primary cases with standardized photos, complete medical records, and 1-year follow-up. written informed consent for operation and publishing their photographs was obtained and the study was performed in accordance with standards of declaration of helsinki. the authors have no financial disclosure or conflict of interest to declare. patient data were obtained from rhinoplasty data sheets and photographs were used for the analysis of nasal dorsum height, symmetry, and contour. physical examinations were carried out for detecting irregularities. micross (geitslich pharma north america inc., princeton, new jersey) is a bone collector, which allows easy harvest, especially in narrow areas. micross comes with a package containing 1 sterile disposable scraper. it is externally 5 mm in diameter and has a cutting blade tip. a collection chamber allows harvesting maximum of 0.25 cc graft at once. a sharp technique improves graft viability. incisions for lateral osteotomies were used to introduce micross when the planned ostectomy site was nasomaxillary buttress. infracartilaginous incision was used when the desired ostectomy site was dorsal cap or radix. bone dust was collected into a chamber with a rasping movement. the graft is mixed with blood during the harvest, this obtains an easily moldable bone paste (surgical technique is described in the video). after the completion of osteotomies and cartilaginous vault closure, the bone paste was placed on the site of bony dorsum, which is likely to show irregularities postoperatively. a nasal splint was used to maintain contour. the bone graft was not wrapped into any other graft. eighteen patients underwent primary closed rhinoplasty with 1-year follow-up. seventeen of 18 patients were female and one was male. harvesting sites were nasomaxillary buttress in 18 patients, radix in 7 patients and dorsal cap in 5 patients. the total graft volume was between 0.25 and 0.5 cc/per patient. the nasal dorsum height, symmetry, contour, and dorsal esthetic lines were evaluated using standardized preoperative and postoperative photographs. dorsal asymmetry, overcorrection of the dorsal height or residual hump were not observed in 17 of the patients ( figures 1-4 ). only 1 patient had a visible irregularity of the dorsum. physical examination revealed palpable irregularities in 3 patients. none of the patients required surgical revision for residual or iatrogenic dorsum deformity. asymmetries and irregularities of the upper one-third of the nose, lead to poor esthetic outcomes, and secondary revision surgeries. to treat open roof after hump resection; lateral osteotomies, spreader grafts, flaps and camouflage grafts are commonly used. warping, resorbtion and migration, visibility, limited volume, donor site morbidity, and the risk of infection are the main disadvantages of grafts. örero glu et al. have presented their technique of using diced cartilage combined with bone dust and blood. 4 tas have reported results with harvesting bone dust with a rasp and using this for dorsal camouflage. 5 the disadvantages of harvesting with a rasp were difficulty with collecting dust from the teeth of the rasp and losing a certain amount of graft material during the harvest. with using micross, a harvested graft is collected in the chamber, thereby the risk of losing the graft material is resolved. replacing "like with like" tissue concept is important, therefore the reconstruction of a bone gap can be achieved successfully with bone grafts. to limit the donor site morbidity, we prefer to harvest bone from the dorsal cap, which was preoperatively planned to be resected. the preference of lateral osteotomy lines as the donor site facilitates osteotomies by thinning the bone. the device allows us to effectively harvest the bone under reduced surgical exposure. simultaneous harvest and ostectomy contributes to a reduced operative time. operative cost is relatively low in comparison with alloplastic materials. in this series, we did not experience resorbtion, migration, visibility problems, or infection with bone grafts. a new practical, safe, and efficient tool for rhinoplasty was introduced. graft material was successfully used for smoothing the bony dorsum without any significant complications. none. not required. the authors have no financial disclosure or conflict of interest to declare in relation to the content of this article. no funding was received for this article. the work is attributed to ozan bitik, m.d. (private practice of plastic, reconstructive and aesthetic surgery in ankara, turkey) dear sir, early diagnosis of wound infections is crucial as they have been shown to increase patient morbidity and mortality. hence, it is important that such infections are detected early to guide decision-making and management 1 . currently, the most common methods of identifying wound infection is by clinical assessment and semi-quantitative analysis using wound swabs. bedside assessment is subjective, and it is shown that bacterial infection can often occur without any clinical features. on the other hand, swabs have the disadvantages of missing relevant bacterial infection at the periphery of the wound due to the sampling technique as well as delaying diagnostic confirmation which may lead to a change in the bioburden of the wound. although tissue biopsy is the gold standard diagnostic tool, it is seldom used as it is invasive, has a higher technical requirement and is also more expensive. a hand-held and portable point-of-care fluorescence imaging device (moleculight i:x imaging device, moleculight, toronto, canada) was introduced to address the limitations of the other diagnostic methods 2 . this device takes advantage of the fluorescent properties of certain by-products of bacterial metabolism such as porphyrin and pyoverdine. when excited by violet light (wavelength 405 nm), porphyrins will emit a red fluorescence whereas pyoverdine has a cyan/blue fluorescence. the types of bacteria that produce porphyrins include s. aureus, e. coli , coagulase-negative staphylococci, beta-hemolytic streptococci and others whereas pyoverdine which emits cyan fluorescence is specific to pseudomonas aeruginosa. this allows users to localise areas of bacterial colonisation at loads ≥10 4 amongst healthy tissue which instead emits green fluorescence 3 . the benefits of this device are that it is portable, non-contact which means minimising cross-contamination, non-invasive and it provides real-time localization of bacterial infection. all these features allow it to be a useful tool to aid diagnosis and guide further investigation and management. many previous studies that have examined the efficacy of auto fluorescent imaging in diagnosing infections in chronic wounds 3-5 . however, equally important is identifying infections in acute wounds which will help guide antimicrobial management as well as surgical debridement. often, broad-spectrum antibiotics are given where clinical assessment remains inconclusive. this, however, may lead to an increase in antimicrobial resistance. therefore, the use of moleculight i:x to identify infections in acute open wounds in hand trauma was evaluated. we collected data from patients who attended the hand trauma unit over a 4-week period prior to irrigation and/or debridement. wounds were inspected for clinical signs of infection and autofluorescence images were taken using the moleculight i:x device. wound swabs were taken, and the results of these interpreted according to the report by the microbiologist. autofluorescence images were interpreted by a clinician blinded to the microbiology results. 31 patients were included, and data collected from 35 wounds. 3 wounds (8.6%) showed positive clinical signs of infection, 3 (8.6%) were positive on autofluorescence imaging and 2 (5.7%) of wound swab samples were positive for significant infection. autofluorescence imaging correlated with clinical signs and wound swab results for 34 wounds (97.1%). in one case, the clinical assessment and autofluorescence imaging showed positive signs of infection but the wound swabs were negative. to the best of our knowledge, this is the first time the use of autofluorescence imaging in an acute scenario was investigated. in this study, out of 2 of the wound swab samples that were positive, autofluorescence imaging correctly identified both (100%) ( fig. 1 ) . one of the autofluorescence images which showed red fluorescence on the wound and which was clinically identified as infected showed growth of usual regional flora on microbiological studies. the reason behind this could be due to the method of sampling from the centre of the wound. on autofluorescence image, the areas of significant bacterial growth were on the edges of the wound ( fig. 2 ) . this example illustrates the potential of using autofluorescence imaging to guide more accurate wound sampling. this has also been shown in a non-randomised clinical trial performed by ottolino-perry et al. 4 . from a surgeon's perspective, autofluorescence imaging can guide surgical debridement by providing real-time information of the infected areas of the wound. furthermore, because of its portability, this device can also be used in intra-operative scenarios to provide evidence of sufficient debridement. although easy to use, the requirement for a dark environment causes a logistical problem. the manufacturers have realised that this is a limitation of the device and have created a single-use black polyethene drape called "darkdrape" which connects to the moleculight i:x using an adapter to provide optimal conditions for fluorescence imaging. while autofluorescence imaging can help clinicians to decide whether to start antibiotics or not, it does not provide any information on the sensitivities of the bacteria. another limitation with autofluorescence imaging we encountered in our study is the difficulty with imaging acute bleeding wounds where blood shows up as black on fluorescence and therefore may mask any underlying infection. in conclusion, autofluorescence imaging in acute open wounds may be useful to provide real-time confirmation of wound infection and therefore guide management. none declared. none received. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjps.2020.03. 004 . when compared with the two previously published studies, publication rates have improved from 2007 and have not continued to decline. interestingly, the number of publications in jpras has fallen. this may be explained by a rise in the impact factor of the journal, increasing competitiveness for publications as well as an expansion in the number of surgical journals. we observed that journal impact factor for free paper publications was significantly greater and likely reflects the stringency of the bapras abstract vetting process. comparison with other specialties is inherently difficult, primarily due to differences in study design and inclusion criteria. exclusion of posters, inclusion of abstracts published prior to presentation and studies not referenced in pubmed affect the reported publication rates. a large meta-analysis, assessing publication of abstracts, reported rates of 44%. 3 rates from other specialties are shown in figure 2 . although our figures of close to 30% may seemingly rank low versus other specialties, including abstracts published prior to presentation would increase the publication rate to 39%, therefore making it more comparable. however, this would not be a direct comparison to the two previous bapras studies. one may debate that the academic value of a meeting should be judged upon its abstract publication ratio. however, the definition of a publication is itself clouded, with an increasing number of journals not referenced in the previous 'gold standard' of pubmed, including a number of open access journals. 4 most would still argue the importance of stringent peer review as the hallmark of a valuable publication 5 and perhaps this along with citability should remain the benchmark. in an age where publications are key components of national selection and indeed lifelong progression in many specialties, we must ensure that some element of quality control remains so as not to dilute production of meaningful data. we have been able to reassess the publication rates for the primary meeting of uk plastic surgery. the bapras meeting remains a high-quality conference providing a platform to access the latest advances in the field. significant differences in the methodology of available literature make other speciality comparisons challenging. however, when these are accounted for publication rates are similar. within a wider context, with the increase in open access journals, it has become ever more difficult to define a 'publication'. if publication rate is to be used as a surrogate for meeting quality, then only abstracts published after the date of meeting should be included. in order to continually assess the quality of papers presented at bapras meetings, the conversion to publication should be regularly re-audited. none. dear sir, global environmental impact and sustainability has been a heated topic in the recent years. plastics and singleuse items are widely, and perhaps unnecessary, used in the healthcare sector. various recent articles 1 , 2 discuss the negative impacts of this in the surgical world, but can we look at the nhs sustainability as a bigger picture? whilst it is a positive step to be considering how we can reduce the environmental impact of modern operating practice, it risks falling into the trap of being overly focused and not taking an holistic view of how the health service as a whole can become more environmentally focused and reduce costs. in fact, the operating theatre is one of the more difficult places to make change. single use medical devices seem like an obvious item to replace with a more environmentally friendly re-usable alterative, but what about patient safety? such a change would require the implementation of new workflows and supervision structures to make sure patient safety is maintained. these take time to create, will meet resistance in their design and implementation, and may not ultimately be adopted. in order to overcome these challenges, we must take a holistic view of the hospital environment -doing this reveals numerous opportunities for improvement with minimal impact on patient safety. the nhs incurs significant waste through using energy unnecessarily. some examples are readily visibly working in a hospital for a just few weeks: computers are left on standby through the night and at weekend; lights are left on throughout the night; and empty rooms are heated or cooled when left unoccupied. other sources of energy waste are less visible, but it is likely that some machinery (particularly air conditioning units) would show rapid return on investment through energy savings if they were replaced on a more regular basis. in the past, saving energy would have required a sustained campaign to educate staff and still be subject to the vagaries of human management (forgetting to switch the heating off on a friday night could lead to more than two days of wasted energy if not revisited until monday). today, solutions based on internet of things (iot) technology can use sensors to monitor the environment and take action to reduce consumption. with the use of ai and machine learning, these systems are becoming advanced such that they can even monitor and anticipate energy usage allowing rooms to be heated or cooled at times which mean that when staff arrive in the relevant room it is the ideal temperature. the nhs is starting to use such technology, with wigan hospital as the first example to install intelligent lighting. 3 adoption should not be limited to lighting, however, and the nhs needs to adopt best practice from the commercial sector. for example, sensorflow based in singapore, provide an intelligent system that optimises cooling/heating costs for hotels around south east asia, saving the operators up to 40% in energy costs. 3, 4 without doubt, these systems can also apply to hospital infrastructures and can help the nhs further reduce energy consumption. in addition to reducing energy consumption, the reduction of single use plastics has become a key focus in recent years and the nhs has started to address this issue. at least 196 million single use plastic items were purchased by the nhs last year. 5 the target to phase out plastic items used by retailers in the next 12 months is laudable, however there is also a significant amount of disposable plastic items used in staff coffee rooms and hospital canteen. getting rid of such items completely and encourage staff to use reusable coffee cups and metal cutlery can potentially compound the cost-saving and environmental benefits. the nhs has established an early leadership position tackling environmental challenges -the first european intelligent lighting installation and ambitious targets to cut disposable plastic items -but more needs to be done. to maximise impact, the nhs needs to be seen as a whole (not by department) with the most senior executives in the health service driving national level change. we read with interest the recent article 'healthcare sustainability -the bigger picture'. 1 the wider picture of the nhs environmental impact and sustainability clearly needs to be addressed. however, large-scale improvement projects to hospital buildings, such as intelligent lighting and heating systems, are likely to require huge investment in infrastructure and modernisation that the nhs in its current form is unfortunately unlikely to be able to make. we believe that the field of medical academia should similarly be contributing to environmental sustainability. firstly, the shelves of hospital libraries and offices internationally are lined with print copies of journals. we reviewed the 20 surgical journals with the highest impact factors and found that all were still offering the option of a subscription of print copies, with 19 of these printing monthly issues. 2 consumers are able to access all journals electronically through institutional subscriptions or via the nhs openathens platform, which in our view is a more time-efficient way to search for articles, read them and to reference them. as such, we commend jpras for their recent move to online-only publication. additionally, with the increasing use of social media to discuss research and the creation of visual abstracts for articles to encourage readership, this will be likely to encourage this shift further. secondly, the environmental impact of the current academic conferencing culture must be addressed. by the end of training, a uk surgical trainee spends an average of £5411 attending academic conferences, but beyond this personal expenditure, what is the environmental cost? 3 for each conference we attend, the printing of poster presentations, conference programmes and certificates all detrimentally impact our environment. furthermore, consider the conference sponsor bags we receive, filled with further printed material, plastic keyrings, stress-balls and disposable pens, all contributing to the build-up of plastic in our oceans. 4 conferences, such as the british association of plastic and reconstructive surgeons scientific meeting, have now started using electronic poster submissions, with presentations being held consecutively on large television screens -but further measures are possible. a well-designed conference smartphone app forgoes the need for printed programmes and leaflet advertising from sponsors and could include measures to reduce the carbon footprint, such as promotion of ride-share options for venue travel. the concept of virtual conferences has also been explored. organisers of an international biology meeting recently asked psychologists to assess the success of a parallel virtual meeting, with satellite groups organising local social events afterwards. more than 80% of the delegates joined online and there was an overall 10% increase those attending the conference; a full analysis of the success of this approach to conferences is awaited. 5 virtual conferences may enable delegates to sign in from multiple time zones and minimise travel, disruption of clinical commitments and time away from family. this option is being pursued by the reconstructive surgery trials network (rstn) in the uk, whereby the annual scientific meeting will be delivered using teleconferencing technology at four research active hubs across the uk, reducing delegate travel substantially and the conference's carbon footprint in turn. there is a clear but unmeasurable benefit of networking face-to-face for formation of personal connections, exchange of knowledge and opportunities for collaboration. the use of social media, instant messaging applications and modern teleconferencing technology are vital to retain this valuable aspect of academic conferencing. equally, perhaps there is a balance to be found, with societies currently holding biannual meetings moving to include one virtual, or running a parallel virtual event for those travelling long distances. the academic community must play a role in environmental sustainability by reducing the carbon footprint of our journals and conferences. jcrw is funded by the national institute for health and research (nihr) as an academic clinical fellow. none for completion of submission. none. we read with interest the study by sacher et al., who compare body mass index (bmi) and abdominal wall thickness (awt) with the diameter of the respective diea perforator and siea. 1 they found that there was a significant ( p < 0.05) positive correlation between these variables, concluding that this association may mitigate for the increased perioperative risk seen in patients with high bmi. their findings disagree with a previous smaller study by scott et al. 2 reconstruction in the high bmi patient group can be challenging, and is associated with higher complication rates. 3 despite this, satisfaction with autologous reconstruction appears similar across bmi categories. 4 as the authors discuss, perfusion, as a function of perforator diameter, is of key relevance to the safety of performing autologous breast reconstruction in patients with higher bmi. larger perforator sizes relative to total flap weight have been suggested to reduce the risk of post-operative flap skin or fat necrosis. 5 while this is likely an oversimplification, as flap survival will also depend on multiple factors including perforator row compared to abdominal zones harvested, it does suggest that if the high bmi patient group has reliably larger perforators then their risk profile may be reduced. however, we suggest caution regarding reliance on the correlation they found between bmi or awt and perforator size when planning free tissue transfer. while they demonstrate p values suggesting correlation between bmi or awt and perforator diameter, the r (correlation coefficient) values that they determined through pearson correlation analysis are low, ranging from 0.219 to 0.456. the resulting r 2 (coefficient of determination) values are therefore in the range 0.048-0.21, suggesting that only 4.8-21% of the variation in perforator diameter can be related to bmi or awt. it is therefore likely that other variables, such as height and historical abdominal wall thickness, that were not accounted for in the correlation analysis also play roles in determining perforator size, in addition to anatomical variation. in addition, their analysis and results depend on a linear relationship between the variables, which may not be the case. therefore although the authors demonstrate a correlation between abdominal wall thickness and perforator size, there is substantial variation between individual patients and so this relationship cannot be relied upon when planning autologous reconstruction. we read with interest pescarini's et al. article entitled 'the diagnostic effectiveness of dermoscopy performed by plastic surgery registrars trained in melanoma diagnosis'. 1 the article is of great interest in highlighting the potential of plastic surgery registrar training in domains such as dermoscopy, especially for those trainees looking to specialise in skin cancer. training in these experiential skill domains is essential to building a diagnostic framework, and the comparable accuracy in diagnosis to dermatologists reflects this. it would be of great benefit to understand further how diagnostic accuracy evolves along the inevitable learning curve experienced using the dermoscope. pescarini et al. comment briefly on method of training but we believe the timeline is key, as is mentorship and regular appraisal. terushkin et al. found that for the first year of dermoscopy training benign to malignant ratios in fact increased in trainee dermatologists before going on to decrease 2 potentially secondary to picking up more anomalies but not yet having the skill set to determine if these are benign or not. there is no reason to suggest that plastic surgery trainees' learning curves should differ significantly. this of course would skew the data presented in terms of accuracy at the end of the three year study period. more helpful would be a demonstration of how accuracy changes with time and experience, as one would expect, and of course how these rates are comparable to those of dermatologists. this would have implications for training programmes where specific numbers of skin lesions or defined timeframes for skin exposure during training are set as benchmarks for qualification. this is particularly pertinent for uk trainees; the nice guidelines for melanoma state that dermoscopy should be undertaken for pigmented lesions by 'healthcare professionals trained in this technique'. 3 to understand the number of lesions that trainee plastic surgeons have to assess with a dermatosope before their diagnostic accuracy improves -or the time needed to achieve that accuracymight be a key factor for placement duration and numbers required for trainees to become consciously competent dermoscopic practitioners. reproducible training programmes in this regard are therefore vital. it must be pointed out that the role of the dermascope for plastic surgeons is likely to be narrower than for our dermatological colleagues. within the uk, the role of the plastic surgeon is primarily reconstructive, with some subspeciality involvement in diagnosis of melanomas and a range of non-melanomatous skin cancers and skin lesions. the dermoscope is primarily a weapon in the diagnosis of insitu or early melanoma for plastic surgeons where diagnostic certainty is unclear following a referral for consideration for surgical removal. where doubt remains over a naevus, surgical excision is still the normal safe default. dermatologists use dermoscopes for a broad range of diagnostic purposes on a wide variety of skin conditions. the familiarity and expertise with this instrument that they garner is therefore not surprising. we must be clear in resource-limited healthcare systems about what our specific roles are as plastic surgeons and how the burden of patient assessment is shared to appropriately deploy our skills within the context of a broader multidisciplinary framework. accuracy with the dermoscope is essential to safely treating patients in a binary fashion -should the lesion be removed or monitored? comparison with dermatological expertise is helpful as a guide and dermoscopy has an important diagnostic role for plastic surgeons, but we should not strive to be equivalent in skills to dermatologists with dermascopes at the expense of the development of vital surgical reconstructive skills and excellence throughout plastic surgery training. response to the comment made on the article "the diagnostic effectiveness of dermoscopy performed by plastic surgery registrars trained in melanoma diagnosis" we strongly agree with the benefit correlated to understand the learning curve experienced by plastic surgery registrars using the dermoscope. as stated in our article, the limit of our study is its retrospective nature. moreover, the training and the level of competence differed between the three registrars. at the beginning of the data collection, two of them were at their third year of specialist training and were using dermoscope since at least one year while the other one was at his first year. all the registrars attended specific but different dermoscopy courses and all of them completed a 10 h on site training with a competent consultant. for this reason, the expertise partially differed among the three registrars. nevertheless, we believe a 3 years' period should be long enough to truly homogeneously estimate the accuracy in diagnosis of melanoma by them. in fact, townley et al. 1 demonstrate the attendance of the first international dermoscopy for plastic surgeons, oxford, improved the accuracy of diagnosing malignant skin lesions by dermoscopy rather than using naked eye examination. we believe a well-planned prospective study should be of great benefit in term of planning a reproducible dermoscopy plastic surgery-oriented training program. this could help to estimate when a clinician can be considered as competent dermoscopic practitioner. it should be underlined as learning how to use dermoscope is something is not possible to do from time to time but it need effort and self-study. we believed is important to properly plan a formal training in dermoscopy for all the plastic surgery registrars who will use this tool in their practice. vahedi et al. 2 stated, as per their survey, only one of 53% of the plastic surgery trainees that used dermoscope in their practice had formal training. as all trainees perform outpatient appointments dealing with skin lesions, especially for trainees looking to specialize in skin cancer, we believed the expertise gained through specific course and training is not at expense of the development of surgical reconstructive skills, but instead it can lead improvement in performing outpatient appointment. proper use of dermoscope will make the skin cancer specialized plastic surgeon more confident and truthful if not in detecting melanoma at least in leaving evident benign lesions. keeping always in mind a multidisciplinary approach and a close cooperation between dermatologists and plastic surgeon is of paramount importance in skin cancer treatment. there is no conflict of interest for all of the authors. dear sir, as the author mentioned in this publication, the correction of infra-orbital groove by microfat injection did increase the postoperative satisfaction of lower blepharoplasty surgery 1 . in this study, we want to explore whether this procedure can replace the previous fat pad transposition. months after the microfat injection, we have observed that fat continues to be present but its volume gradually disappears, and, with some, it totally vanishes. with fat pad transposition, the fat volume does not decrease, it seems that both have their advantages and disadvantages because the volume of transplanted fat after lower blepharoplasty might disappear gradually by time. survival of transposed fat through fat pad transposition is the best, creating a more natural look at the tear trough. however, the volume of augmentation might not be enough. it would be exceptional if we could combine both advantages; that is, to administer microfat injection after fat transposition. but prior to that, we would like to share the experience of the author. the fat pad is usually transposed to periosteum by two limits: one is the transposition of the medial fat pad to the inner groove and the other one is the transposition of the central fat pad to the center of the infra-orbital groove. as mentioned by the author, we fill the superficial layer (under the skin) and the periosteum layer (deep layer). injection into the deeper layer is not performed after lower blepharoplasty but before the musculocutaneous flap was closed. after fat pad transposition is completed, we would first cover up the musculocutaneous flap before asking the patient to sit up. then, the surgeon assesses whether a further filling of the groove with the fat is needed or not. if necessary, the musculocutaneous flap is opened and more fat is injected in-between the fat pads into the groove, but, definitely, not into the fat pads. the reason why we do the injection before the flap is closed is to accurately perform the insertion and to avoid entering into the intra-orbital fat pad, which may worsen the presence of eye bags. we inject the superficial fat only after the flap wound is closed. this procedure modifies the groove under the eye more accurately. we share with you our surgical methods with the hope that fat utilization and fat pad transposition will greatly improve surgical satisfaction. dear sir, eiben and gilbert are thanked for their comments. they may be correct in the original description of the respective flaps, but the five-flap z-plasty in our experience has always been known colloquially as the jumping man flap. indeed, extra caution is required in burns secondary reconstruction. the skin of these patients is typically thin, often scarred and unforgiving. flaps should never be undermined unless in an area of completely virgin tissue. the modification we presented does result in an apparently thinner base for the 'arm limb' flaps, but traditionally wider based flaps would have been transferred and then trimmed with the same outcome. the tiny sizes involved in paediatric eyelid surgery would not be the best forum to experiment, and certainly mustardé's original design would seem safest in that setting. we had uniquely sought to also measure precisely the geometric gain in length, and felt that the result was impressive. none letter to the editor: evaluating the effectiveness of plastic surgery simulation training for undergraduate medical students 1 we read with interest the recent correspondence regarding the effectiveness of plastic surgery simulation for training undergraduate medical students. we are in wholehearted agreement with the statement regarding medical school curricula lacking exposure to plastic surgery and commend the authors for their efforts to pique the interest of medical students in our specialty. we wish however to point out some vagueness that, unless clarified, could be misleading to your readership. the correspondence states: "the decrease in competition ratios for plastic surgery". we believe that current data supports the opposite view. taking into account published data from health education england over the last 4 years 2 , there has in fact been a 41% rise in the competition ratios from 2016 to 2019 ( fig. 1 .) suggesting an increasing interest in the specialty. highlighting this increase in demand supports the authors' desire for more undergraduate exposure to plastic surgery. this increased input in the uk curriculum would also help all medical students become aware of the support plastic surgeons can provide to other specialties as this is a particular feature of the specialty. in an increasingly specialised medical world, we feel it is important that all doctors are equipped with the knowledge to best serve their patients. no funding has been received for this work and the authors have no competing interest. dear sir/madam, in response to critical personal protective equipment (ppe) shortages during the covid-19 pandemic, medsupply-driveuk was established by ent trainee ms. jasmine ho, and medsupplydriveuk scotland by two plastic surgery trainees (ms. gillian higgins and mrs. eleanor robertson). we applied the principles of creative problem solving and multidisciplinary collaboration instilled by our specialty. since march 2020, we have recruited over 400 volunteers to mobilise over 200,000 pieces of high quality ppe donated from industry to the nhs and social care. we have partnered with academics and leaders of industry to manufacture: surgical gowns, scrubs and visors using techniques including laser cutting, injection molding, and 3d printing. we have engaged with nhs boards and trusts and politicians at local, regional and national level to advocate for healthcare worker protection in accordance with health and safety executive and coshh legislation including: engineering controls and ppe that is adequate for the hazard and suitable for task, user and environment. public health england (phe) currently advise ffp3 level of protection only in the context of a list of aerosol gener-the authors have no competing interests. ating procedures 1 . a surgical mask confers 6x (63%) protection, ffp2/n95 100x (92-98%) and ffp3 100-10,000x ( > 99%) protection ( figure 1 ). as sars-cov-2 is a novel pathogen, evidence is naïve and evolving, and since transmission occurs via aerosol, droplets and fomites from the aerodigestive tract, all 10 uk surgical associations have issued guidance to use higher levels of ppe for procedures that are not included in the phe list (2) . cbs, entuk and baoms have issued statements supporting the use of reusable respirators and power air-purifying respirators, and their use is approved by phe, health protection scotland, public health agency, public health wales, nhs and the academy of medical royal collages 1 . the first author has experienced the need to quote bapras guidance 2 in defense of their use of ppe 2 . medsupplydrive (uk and scotland) hope to empower all healthcare workers to demand provision of adequate (i.e. will protect from sars-cov-2) and suitable (for the task, user and environment) ppe by engaging with their employers directly or through unions, royal colleges and associations. as a nation we must learn from other countries who successfully protected their workforce. data suggests that staff death is avoidable with the use of occupational health measures and ffp3 grade ppe 3 , despite which at least 245 uk health care workers have died of covid-19 4 . the strain placed on systems by sars-cov-2, with reduced access to operating theatres, beds, equipment and staff has the potential for serious detrimental consequences for surgical training 5 . ppe shortages and the subsequent necessity for rationing is causing additional harm. due to global demand and supply chain failures, ffp3 disposable masks for people with small faces are in particularly short supply. the majority of these individuals are female, and they are currently provided with no solution apart from avoiding "high risk" operating if/when this resource runs out; further depriving them of training opportunities. reusable respirators provide superior respiratory protection over disposable ffp3 masks due to design characteristics. they are more likely to provide reliable fit due to increased seal surface area (half face 10mm, full face 20mm). as they are designed to be decontaminated between patients and after each shift they are both economically and ecologically advantageous whilst also reducing fit testing burden and negating reliance upon precarious supply chains. there are factories in the uk which already make reusable respirators and medsupplydrive have been contacted by uk manufacturers looking to retool to meet this demand. although some nhs trusts remain reluctant to use reusable respirators, others have already adopted them routinely, using manufacturer decontamination and filter change advice. one nhs trust has supplied every member of their workforce with a reusable respirator as a sustainable plan for ongoing pandemic waves. it is apparent that healthcare workers are unable to access sufficient quantities of high quality respiratory protection. reusable respirators provide adequate protection from sars-cov-2 as well as being eminently suitable for a wide range of users, tasks and environment. we call on those reviewing decontamination and filter policy for reusable respirators to appreciate the urgency of the situation and expedite the process to enable all health and social care workers to access the respiratory protection that they need. at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation love in the time of corona references 1. world health organization world health organization. who director-general's opening remarks at the mission briefing on covid-19 -12 plastic and reconstructive medical staffs in front line national health commission of the people's republic of china. press conference of the joint prevention and control mechanism of the state council nam therapy-evidencebased results covid-19: how doctors and healthcare systems are tackling coronavirus worldwide governmental public health powers during the covid-19 pandemic: stay-at-home orders, business closures, and travel restrictions a plastic surgery service response to covid-19 in one of the largest teaching hospitals in europe transmission routes of 2019-ncov and controls in dental practice who declares covid-19 a pandemic covid-19: uk starts social distancing after new model points to 260 000 potential deaths telehealth for global emergencies: implications for coronavirus disease 2019(covid-19) prospective evaluation of a virtual urology outpatient clinic virtual fracture clinic delivers british orthopaedic association compliance quality indicators for plastic surgery training available at url: available at url: https: //en.wikipedia.org/wiki/seminar (accessed internet resource: the telegraph. the inflexibility of our lumbering nhs is why the country has had to shut down internet resource: the british society for surgery of the hand. covid-19 resources for members caring for patients with cancer in the covid-19 era maxillofacial trauma management during covid-19: multidisciplinary recommendations asps statement on breast reconstruction in the face of covid-19 pandemic statement from the association of breast surgery 15th march 2020: confidential advice for health professionals blazeby jmbreast reconstruction research collaborative. short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (ibra): a multicentre, prospective cohort study how the wide awake tourniquet-free approach is changing hand surgery in most countries of the world. hand clin hand trauma service: efficiency and quality improvement at the royal free nhs foundation trust one -stop" clinics in the investigation and diagnosis of head and neck lumps the implications of cosmetic tourism on tertiary plastic surgery services the need for a national reporting database references 1. policy on the redeployment of staff trauma management within uk plastic surgery units president of the british society for surgery of the hand. (2020) 24th march highlights for surgeons from phe covid-19 ipc guidance american society of plastic surgery website. asps guidance regarding elective and non-essential patient care the effect of economic downturn on the volume of surgical procedures: a systematic review an analysis of leading, lagging, and coincident economic indicators in the united states and its relationship to the volume of plastic surgery procedures performed telemedicine in the era of the covid-19 pandemic: implications in facial plastic surgery united states chamber of commerce website. resources to help your small business survive the coronavirus transmission of covid-19 to health care personnel during exposures to a hospitalized patient early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia otorhinolaryngologists and coronavirus disease 2019 (covid-19) quantifying the risk of respiratory infection in healthcare workers performing high-risk procedures skills fade: a review of the evidence that clinical and professional skills fade during time out of practice, and of how skills fade may be measured or remediated ad hoc committee on health literacy for the council on scientific affairs training strategies for attaining transfer of problemsolving skill in statistics: a cognitive-load approach use of a virtual 3d anterolateral thigh model in medical education: augmentation and not replacement of traditional teaching? augmenting the learning experience in primary and secondary school education: a systematic review of recent trends in augmented reality game-based learning aging and wound healing tissue engineering and regenerative repair in wound healing duration of surgery and patient age affect wound healing in children investigating histological aspects of scars in children formation of hypertrophic scars: evolution and susceptibility early laser intervention to reduce scar formation in wound healing by primary intention: a systematic review early laser intervention to reduce scar formation -a systematic review effectiveness of early laser treatment in surgical scar minimization: a systematic review and meta-analysis cochrane handbook for systematic reviews of interventions version 6 prospective or retrospective: what's in a name? how to run an effective journal club: a systematic review the evolution of the journal club: from osler to twitter free flap options for reconstruction of complicated scalp and calvarial defects: report of a series of cases and literature review the effect of age on microsurgical free flap outcomes: an analysis of 5,951 cases factors affecting outcome in free-tissue transfer in the elderly reconstruction of postinfected scalp defects using latissimus dorsi perforator and myocutaneous free flaps long-term superiority of composite versus muscle-only free flaps for skull coverage indocyanine green lymphography findings in older patients with lower limb lymphedema microsurgical technique for lymphedema treatment: derivative lymphatic-venous microsurgery lower-extremity lymphedema and elevated body-mass index lymphorrhea responds to negative pressure wound therapy lymphovenous anastomosis aids wound healing in lymphedema: relationship between lymphedema and delayed wound healing from a view of immune mechanisms evolving practice of the helsinki skin bank skin graft meshing, overmeshing and cross-meshing gluteal implants versus autologous flaps in patientswith postbariatric surgery weight loss: a prospective comparative of 3-dimensional gluteal projection after lower body lift redefining the ideal buttocks: a population analysis classification system for gluteal evaluation blondeel and others. doppler flowmetry in the planning of perforator flaps frequency of the preoperative flaws and commonly required maneuvers to correct them: a guide to reducing the revision rhinoplasty rate temporalis fascia grafts in open secondary rhinoplasty the turkish delight: a pliable graft for rhinoplasty bone dust and diced cartilage combined with blood glue: a practical technique for dorsum enhancement the use of bone dust to correct the open roof deformity in rhinoplasty wound microbiology and associated approaches to wound management moleculight _ ix _ user _ manual _ rev _ 1.0 _ english the use of the moleculight i:x in managing burns: a pilot study improved detection of clinically relevant wound bacteria using autofluorescence image-guided sampling in diabetic foot ulcers efficacy of an imaging device at identifying the presence of bacteria in wounds at a plastic surgery outpatients clinic publication rates for abstracts presented at the british association of plastic surgeons meetings: how do we compare with other specialties? are we still publishing our presented abstracts from the british association of plastic and reconstructive surgery (bapras)? full publication of results initially presented in abstracts the true cost of science publishing science for sale: the rise of predatory journals plastics in healthcare: time for a re-evaluation green theatre wigan's hospital organisation is first health trust in europe to install intelligent lighting sensorflow provides smart energy management for hotels in malaysia nhs bids to cut up to 100 million plastic straws, cups and cutlery from hospitals healthcare sustainability -the bigger picture on behalf of the council of the association of surgeons in training cross-sectional study of the financial cost of training to the surgical trainee in the uk and ireland plastic waste inputs from land into the ocean low-carbon, virtual science conference tries to recreate social buzz body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction patient body mass index and perforator quality in abdomen-based free-tissue transfer for breast reconstruction increasing body mass index increases complications but not failure rates in microvascular breast reconstruction: a retrospective cohort study are overweight and obese patients who receive autologous free-flap breast reconstruction satisfied with their postoperative outcome? a single-centre study predicting results of diep flap reconstruction: the flap viability index the diagnostic effectiveness of dermoscopy performed by pastic surgery registrars trained in melanoma diagnosis analysis of the benign to malignant ratio of lesions biopsied by a general dermatologist before and after the adoption of dermoscopy assessing suspected or diagnosed melanoma dermoscopy-time for plastic surgeons to embrace a new diagnostic tool? the use of dermatoscopy amongst plastic surgery trainees in the united kingdom modification of jumping man flap combined double z-plasty and v-y advancement for thumb web contracture plastic surgery in infancy evaluating the effectiveness of plastic surgery simulation training for undergraduate medical students united kingdom mr. b.s. dheansa queen victoria hospital recommended ppe for healthcare workers by secondary care inpatient clinical setting, nhs and independent sector personal protective equipment (ppe) for surgeons during covid-19 pandemic: a systematic review of availability, usage, and rationing covid-19: protecting worker health. annals of work exposures and health memorial of health & social care workers taken by covid-19 nursing notes2020 covid-19 robertson canniesburn plastic surgery and burns unit georope geo-technical and rope access solutions, west quarry none. the authors have no financial interests to declare in relation to the content of this article and have received no external support related to this article. no funding was received for this work. the authors would like to thank catriona graham, sarcoma specialist nurse who helped in the evaluation of this study. the authors kindly thank the beatson cancer charity, uk (grant application number 19-20-001), the jean brown bequest fund, uk, and the canniesburn research trust, uk for funding this study. the sponsors had no influence on the design, collection, analysis, write up or submission of the research. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjps.2020.03. 011 . none. the authors declare no funding. jeremy rodrigues provided data from the two nhs trust journal clubs and invaluable advice. nil. all authors declare that there were no funding sources for this study and they approved the final article. supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.bjps.2020.02. 029 . all authors disclose any commercial associations or financial disclosures. none. none. none. none. all authors agree to the fact there are no conflicts of interest to declare. no funding was provided for this letter. the authors have no financial or personal relationships with other people or organizations, which could inappropriately influence the work in this study. the authors have no financial disclosure or conflict of interest to declare in relation to the content of this article. no funding was received for this article. supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.bjps.2020.02. 034 . dear sir, long has the term 'publish or perish' been considered medical doctrine and this has historically been a prerequisite for progression in research-driven specialties such as plastic surgery. national, or indeed international, presentation is pivotal to disseminating information, but also provides a stepping-stone to future publications. in the uk, bapras meetings have always represented the ideal platform for this. of significant interest is the conversion of accepted abstracts into peer-reviewed publications.previous studies 1 , 2 have assessed abstract publication for bapras meetings and have shown a declining conversion rate. we re-assessed this in order to establish whether this reported downtrend is continuing and how plastic surgery compares to other specialties.all abstracts from bapras meetings between winter 2014 and summer 2016 were analysed. later meetings were excluded to allow adequate lag time for publication. abstracts were identified retrospectively from conference programmes accessible via the bapras website ( www.bapras. org.uk ). pubmed ( https://www.ncbi.nlm.nih.gov/pubmed/ ) and google scholar ( https://scholar.google.com/ ) databases were used to search for full publications. cross-referencing of published papers with abstracts for content was completed to ensure matched studies.abstracts published prior to the conference date were excluded. two-tailed t -testing was used to assess for statistical significance between variables. none. none. dear sir, diver and lewis described a modification of the "jumping man flap". 1 in fact, what they have described is a modification of the 5-flap z-plasty. this was described by hirschowitz et al. 2 it is not a jumping man as it has no body.the true jumping man flap was described by mustarde 3 for the correction of epicanthal folds and telecanthus.we have used the 5-flap z-plasty particularly for the release of 1st web space contractures following burns, the modification of raised curved scars of the trunk and limbs following burns, and for the correction of epicanthal folds in small children.using the diver and lewis modification in burn cases results in thin and less vascular flaps. when correcting epicanthal folds in children the flaps are so small that reducing their size in any way would make it near impossible to suture the flaps correctly. no conflicts of interest. key: cord-015370-4jfgsic7 authors: nan title: 55th annual meeting of the austrian society of surgery: graz, june 25—27, 2014 date: 2014-06-03 journal: eur surg doi: 10.1007/s10353-014-0261-0 sha: doc_id: 15370 cord_uid: 4jfgsic7 nan ren nähten. danach erfolgte die einlage eines kunststoffnetzes mit mindestens 5 cm überdeckung der naht. alle patienten wurden prospektiv in eine datenbank eingebracht und nach einem jahr interviewt. alle patienten mit unklaren beschwerden wurden einbestellt und untersucht. endpunkt waren rezidiv oder tod. ergebnisse: die mediane operationszeit bei den 77 patienten betrug 60 min. postoperativ kam es zu 2 hämatomen (ohne intervention). nach einem jahr konnten wir alle patienten erreichen. wir fanden zwei rezidive (3 %), ein serom (1 %) und bei 5 patienten (6 %) behandlungsbedürftige chronische schmerzen (> vas 4, länger 4 wochen). im verlauf entstand eine trokarhernie (1 %) und eine patientin wurde wegen adhäsionen revidiert (1 %) . weitere probleme fanden sich nicht, insbesondere keine pseudorezidive. schlussfolgerungen: der verschluss der bruchlücke vor der laparoskopischen implantation eines kunststoffnetzes verringert die raten an rezidiven, pseudorezidiven und seromen im vergleich mit den daten in der literatur. die chronischen schmerzen sind im vergleich mit der laparoskopischen versorgung der narbenhernien per ipom nicht häufiger. die naht der bruchlücke stellt die kontinuität der bauchdecke wieder her und sorgt in zusammenhang mit der sicherung der "schwachstelle" narbe durch ein kunststoffnetz für die weitere verbesserung der therapie der narbenhernie. prevention of subcutaneous seroma formation in open ventral hernia repair by using a new lowthrombin fibrin sealant (cox regression) was carried out for parameters known to influence long-term survival. anastomosis time was defined as the time from the start of anastomosis until reperfusion. results: mean at was 30.9 ± 9.6 sd minutes. five year graft survival of allografts with an at > 30 min was 76.6 and 80.6 % in the group with an at < 30 min (p = 0.027). five-year patient survival in the group with an at > 30 min was 86.9 % compared to 85.7 % in patients with an at < 30 min (p < 0.0001). cox regression analysis revealed at, beside recipient bmi < 18.5 kg/m 2 , recipient age, recipient gender, hla-a-mismatch, dgf and hcv-infection, as an independent significant factor for patient survival (hazard ratio, 1.021 per minute; 95 % ci 1.006 to 1.037; p = 0.006). conclusions: as a longer at closely correlates with inferior long-term patient survival, the warm ischemia time has to be considered as a major risk factor for inferior long-term results after deceased donor kidney transplantation. nosokomiale infektionen und erregerspektrum nach elektiven resektionen an pankreas, leber, magen und ösophagus c. chiapponi, f. meyer, p. mroczkowski, c. bruns, o. jannasch otto-von-guericke-universität, magdeburg, deutschland grundlagen: die häufigsten chirurgisch behandelten infektionen sind nosokomiale infektionen (ni). die datenlage zu häufigkeit und ursächlicher erreger in abhängigkeit vom operierten organ ist unzureichend. in dieser studie sollen daher infektionsraten und ursächliche erreger nach elektiven resektionen an pankreas, leber, magen und ösophagus bestimmt werden. methodik: vom 01.01.2005 bis 31.08.2007 wurden alle patienten mit elektiven resektionen von pankreas, leber, magen und ösophagus erfasst. ausschlusskriterien waren: radio-/ chemotherapie < 6 monate zurückliegend, chirurgischer eingriff < 30 tage zurückliegend, notfalleingriff, präoperativ bestehende infektion. die datenanalyse erfolgte retrospektiv. wichtigste untersuchungsparameter waren: behandlungsdauer auf intensivstation (its) und im krankenhaus, sterblichkeit, organbezogene rate an ni und mikrobiologisches spektrum. ni wurden definiert als: wund-und intraabdominale infektionen, harnwegsinfektionen, bakteriämie/katheterinfektion, atemwegsinfektion. ergebnisse: es wurden 358 patienten eingeschlossen -150 (42 %) pankreasresektionen, 91 (25 %) leberresektionen, 105 (29 %) magenresektionen und 12 (3 %) ösophagusresektionen. die mediane its-behandlungsdauer betrug 48, 8 (iqr 24, 8) stunden, die mediane krankenhausaufenthaltsdauer 16 (iqr 13-23) tage und die krankenhaussterblichkeit 4,5 %. bei 120 (33,5 %) patienten konnte mindestens eine ni nachgewiesen werden. intraabdominale (16,5 %) und wundinfektionen (12,3 %) traten am häufigsten auf. bei 27,1 % der patienten konnte mindestens ein positiver mikrobiologischer befund erhoben werden (80,8 % der erfassten ni). häufigste keime waren escherichia coli (12,4 %), koagulase-negative staphylokokken (12,2 %) und enterococcus faecium (9,7 %). schlussfolgerungen: bei patienten mit elektiven resektionen an pankreas, leber, magen und ösophagus fanden sich erhebliche unterschiede bei demographischen faktoren sowie 1910 31 medical schools geschlossen worden. bei den reformen berücksichtigte man erfahrungen aus der wiener medizinischen schule, die an der johns hopkins bereits zum teil verwirklicht waren, getragen von halsted, der sich 1878/79 in wien aufhielt und pirquet, der 1909 der kinderklinik an der hopkins vorstand, bevor er zurückkehrte. außerdem absolvierten geschätzte 10.000 amerikaner von 1870-1915 ihre medizinische ausbildung teilweise in wien. im rahmen der eingeleiteten reformen gründete martin1913 das american college of surgeons, das bis 1928 5 teilnehmer der wien-exkursion zu präsidenten hatte. wann ist denn die aufklärung des patienten rechtzeitig? obwohl die fehlerhafte aufklärung durch ärzte unter juristen schon länger ein "renner" ist, hat sich in der praxis häufig noch nicht herumgesprochen, wie und vor allem wann der patient vor einem chirurgischen eingriff aufgeklärt werden muss. da behandlungsfehler in der regel für den laien schwer nachzuweisen sind, wird oft der umweg über die mangelhafte aufklärung genommen, welcher dann manchmal leider auch erfolgreich ist. gelingt dem arzt, welcher die beweislast für eine ordnungsgemässe aufklärung trägt , der nachweis nicht, haftet er trotz lege artis behandlung! es soll des weiteren auch auf die bestimmungen im neuen ästhetik-op-gesetz eingegangen werden und einige fälle aus der aktuellen rechtssprechung mit konkreten fallbeispielen erörtert werden. the faster, the better: anastomosis time influences patient survival significantly after deceased donor kidney transplantation background: endometriosis is one of the most frequent benign diseases that can affect women in their reproductive age. in severe form, the colon or rectum may be involved. it has been shown that the surgical treatment improves typical symptoms like pain and dyspareunia. we evaluated the functional results and quality of life after laparoscopic colonic resection for endometriosis. methods: a retrospective analysis of thirty women with typical symptoms including pelvic pain, infertility and endometriotic bowel lesions who underwent laparoscopic surgery including colonic resection performed from 2009 to 2012. quality of life and pain was documented postoperatively. results: thirty women (mean age 35.7 years, range 26-53 years) underwent laparoscopic treatment for endometriosis. twenty-three had low anterior resection, three sigmoidectomy and one underwent appendectomy. two patients required a hartmann procedure. conversion rate was 6.7 % (2/30). major complications occurred in one case including an anastomotic leakage, in this case, a hartmann procedure was done consecutively. conclusions: laparoscopic colonic resection for deeply infiltrative endometriosis is technical demanding but feasible and safe and improves the clinical symptoms of endometriosis of the bowel. art und häufigkeit von postoperativen ni. auf grund der auswirkungen von ni auf den postoperativen verlauf sollten präoperative risikofaktoren bei der operationsindikationsstellung sorgfältig berücksichtigt werden. alle beeinflussbaren risikofaktoren sollten präoperativ optimiert werden. diagnose und therapie spontaner lähmungen bei nervenentzündungen der oberen extremität neuropathien der oberen extremität präsentieren klinisch oft mit sehr ähnlichen symptomen, obwohl oft sehr unterschiedliche ätiologien zu einem eng gefassten klinischen zustandsbild geführt haben können. dies kann entweder zu einer glatten fehldiagnose und entsprechender fehlbehandlung führen oder den behandelnden arzt in ein diagnostisches dilemma bringen. bei einer klaren anamnese, welche eine mechanische ursache, wie trauma oder chronische kompression nahe legt, ist natürlich die therapie klar vorgegeben. bei patienten mit unklarer ätiologie und klinischer präsentation sollte auch an den seltenen fall einer isolierten neuritis gedacht werden. diese spontan auftretenden lähmungen können auf unterschiedlicher höhe des armnervengeflechtes und den entsprechenden armnerven auftreten und dem unerfahrenen als nervenkompressionskasuistik imponieren. bei genauer anamnese und diagnostik lässt sich jedoch die neuritis vom nervenkompressionssyndrom abgrenzen, was die wahl der richtigen behandlungsstrategie wesentlich beeinflusst. in diesem bericht möchten wir die typische klinik der häufigsten neuritiden der oberen extremität und deren therapie anhand von fallbeispielen präsentieren und einen diagnostischen und therapeutischen algorithmus vorstellen. any evidence for the benefit of supplementation with b vitamins. despite promising epidemiological evidence, no explanation has been found to date. plasma vitamin b12 concentrations might not accurately reflect intracellular concentrations, as only holotranscobalamin (holotc), the 'active' vitamin b12, is able to enter the cell via a receptor dependent transport. objective: this study aimed to investigate the effect of single and combined baseline concentrations of b vitamins on postoperative survival of vascular surgery patients over a time of 8.5 years in a region without folate fortification. methods: this single-centered, non-randomized, prospective case series comprised 486 consecutive vascular patients undergoing carotid surgery. vitamin baseline concentrations were measured (january 2003 -april 2004 and patients observed for the occurrence of the primary outcome (overall death) until the census date (january 2012). results: single holo-tc and b12 concentrations had only marginal effect on survival. however, the ratio of b12/holo-tc showed a highly significant negative effect on overall survival (hr = 1.04 per unit of ratio, ci 1.01-1.08, p = 0.01). taking into account concomitant folate concentrations increased the significance of predicted risk (p = 0.004). conclusions: the effect of vitamin b12 on overall survival depends on its intracellular form holo-tc and concomitant folate concentrations. low survival rates were associated with a high b12/holo-tc ratio and low folate concentrations. this has to be taken into account in future trials. the occult parathyroid adenoma: a challenge to the surgeon a. bradatsch 1 , g. wolf 1 , e. braun 2 , a. krajicek 1 1 surgical clinic medical university graz, graz, austria, 2 university clinic of otorhinolaryngology, graz, austria background: primary hyperparathyroidism is caused by isolated parathyroid adenoma in 80 to 85 % of all cases. sonography of the neck, scintigraphy or mrt are used to localize the neoplasm prior to surgical intervention. in about 70 % of all cases the studies give positive localization of the adenoma. especially in mild or oligosymptomatic hpt, which occurs in about 30 % in endocrine centers, preoperative localization studies give no evidence of a parathyroid adenoma. as negative localization does not influence the indication for operative treatment of hpt, these patients are referred to the endocrine surgeon without preoperative conclusive imaging. patients and methods: we present our findings in cases of occult parathyroid adenoma or inconclusive or false-positive localization studies (25 % of all hpt-cases) and the strategies we use for these cases. careful exploration of the retrothyroidal space by a minimal-invasive approach is the first step in these patients. 95 % of the adenomas without conclusive preoperative localization studies could be found intraoperatively by the experienced endocrine team. 75 % of these adenomas were located in an orthotopic, 25 % in a cervical ectopic position. of the remaining 5 %, the position of the adenoma could not be cleared in the primary operation and required secondary intervention or continuous medical treatment. grundlagen: neben dem wurzelersatz kombiniert mit biologischer oder mechanischer klappenprothese, stehen als behandlungsmöglichkeiten einer akuten typ-a-dissektion mit aortenklappeninsuffizienz rekonstruktive techniken (yacoub-operation, david-operation) zur verfügung. wir berichten über den einsatz einer modifizierten yacoub-operation (caviaar) mit verwendung eines extraaortalen ringes im akuten setting. methodik: bei zwei patienten (beide 43a) wurde zur vermeidung einer postoperativen antikoagulation eine aortenklappenrekonstruktion mittels caviaar-technik im hypothermen kreislaufstillstand mit antegrader hirnperfusion durchgeführt. dabei wurde die klassische yacoub-operation um die implantation eines extraaortalen ringes (coroneo-ring  ) und die plikatur jeweils eines prolabierenden aortenklappensegels erweitert. ergebnisse: beide patienten konnten erfolgreich operiert werden. die intraoperativen daten sind in tab. 1 aufgelistet. bei patient 1 kam es intraoperativ zu einer neu aufgetretenen höhergradigen mitralklappeninsuffizienz, hervorgerufen durch undersizing des extraaortalen ringes mit konsekutiver verziehung des vorderen mitralsegels. die mitralinsuffizienz konnte mittels implantation eines mitralklappenringes saniert werden. der lange postoperative intensivaufenthalt resultierte aus nicht kardialer ursache. patientin 2 zeigte einen komplikationslosen intra-und postoperativen verlauf. bei beiden patienten zeigte sich echokardiographisch bei entlassung und im intervall eine komplett suffiziente aortenklappe. schlussfolgerungen: die caviaar-technik bietet auch im akuten setting die möglichkeit einer klappenerhaltenden operation, die initialen ergebnisse sprechen für ein stabiles rekonstruktionsergebnis. langezeitergebnisse bleiben allerdings abzuwarten. finally diagnosed. he was brought immediately to the or and replacement of the ascending aorta was performed in moderate circulatory arrest with antegrade brain perfusion. because of the patients history and due to malformation of his sternum, it was closed by sternum-plates. ten days after, the patient developed a mobile sternum, the plates were removed and 1 month after a vac-system, a rectus flap was performed. four months later, the ct-scan showed a significant progression (> 2 cm) of the descending aorta. because of the multiple sternal interventions, an arch rerouting with subsequently tevar was impossible to perform. therefore we decided to proceed with descending aortic replacement through a left thoracotomy with left heart bypass. after surgery, the ct-scan showed still a small collapsed true lumen as well as malperfusion of the left renal artery. tevar with a jo-stent into the descending aorta and stenting of the left kidney artery was performed. result: one month after the final intervention, the ct-scan showed a satisfying postoperative result and the patient could be discharged home regaining his previous mobility. the fate of the visceral arteries after stentgraftimplantation in patients with acute type b dissection 32,8 %. in 50,3 % (offene herniotomie) sowie 50,3 % (laparoskopische herniotomie) wird perioperativ keine antibiose verabreicht. die operation nach lichtenstein (♀: 57,1 %; ♂: 50,8 %) ist bei offener, einseitiger -die tapp (80,2 %) bei beidseitiger sanierung mittel der wahl. bei laparoskopischen verfahren erfolgt eine fixierung des netzes zu 49,7 % mittels tacker. bei offenen verfahren kommen in 71,4 % selbsthaftende netze zum einsatz -eine zusätzliche fixierung durch naht wird in 32,5 % durchgeführt. am 2.-4. postoperativen tag erfolgt in 72 % nach offener, in 65,9 % nach laparoskopischer herniotomie die entlassung, wobei sich im prä-und perioperativen management unterschiede in abhängigkeit zur bettenanzahl der abteilung zeigten. schlussfolgerungen: in österreich orientiert sich die versorgung der leistenhernie in weiten teilen an den evidenzbasierten empfehlungen der european hernia society (ehs). allerdings besteht hinsichtlich des perioperativen managements kein eindeutiger konsens. "offenes abdomen" und "dynamische nähte"zwei wertvolle hilfsmittel in der behandlung von loss-of-domain-hernien grundlagen: hernien -leisten-wie narbenbrüche-bei denen ein großer teil der baucheingeweide über längere bis lange zeit außerhalb der bauchhöhle gelegen ist, lassen sich aus gründen der bauchwand-anatomie, des drohenden abdominellen compartment-syndroms und der atemphysiologie nicht primär verschließen. die alleinige augmentation der dehiszenten bauchwand mit netzen aller art führt nicht zur gewünschten stabilität der rumpfmuskulatur. methodik: wir berichten über drei patientinnen mit derartigen hernien -je einmal nach pfannenstiel-laparotomie bzw. medianer unterbauchlaparotomie und ein mal mit einer primären beidseitigen inguinalhernie: nach medianer laparotomie wurde stets das redundante kolon -zwei mal das sigma, ein mal sigma und ascendens-mit präparatlängen von bis zu 80 cm reseziert, ein vac-abthera  -verband eingebracht und die bauchdecke mit dynamischen nähten der faszienränder aus vessel-loops approximiert. im fall nr. 3 wurden die beiden leistenhernien mit primären nähten der bruchringe von innen provisorisch verschlossen, um einer neuerlichen eventeration vorzubeugen. nach 3 und 6 tagen wurde das vac  -system gewechselt und die elastischen nähte wurden erneuert. ergebnisse: nach 9 tagen konnte der vac  -verband bei allen patienten entfernt und der definitive primäre bauchdeckenverschluss mit pds-fortlaufnaht vorgenommen werden. in 2 fällen haben wir zusätzlich die bauchdecke mit einem sublay-mesh verstärkt. im fall nr. 3 erfolgte in selber sitzung mit dem bauchdecken-verschluss der beidseitige lichtenstein-repair. die wundheilung verlief stets unkompliziert. zum berichtszeitpunkt und im mittel 7 monate postoperativ sind die patienten rezidivfrei. schlussfolgerungen: die vorgestellte technik erlaubt es, innerhalb einer relativ kurzen zeit und ohne präoperative manöver einen annähernd anatomischen bauchdeckenverschluss auch nach riesenhernien zu erzielen. 4 medical university of innsbruck, department of general surgery, innsbruck, austria we present a case of a 33-year-old woman who was diagnosed with bland-white-garland syndrome (bwgs) during her second pregnancy. patient was presented with systolic murmur and frequent ventricular extrasystoles. an echocardiogram showed hypokinesis of all apical segments with mildly decreased global systolic function of enlarged left ventricle (lvef 50 %, lvedd 70 mm), mild mitral insufficiency and blood flow between pulmonary trunk and left coronary artery. as the patient was mildly symptomatic further diagnostics was postponed after delivery. coronary angiogram revealed left anterior descending (lad) artery originating from pulmonary trunk; circuflex artery and right coronary artery (rca) originated separately from the right sinus of valsalva. cardiopulmonary exercise test revealed good exercise capacity. magnetic resonance imaging (mri) confirmed the spatial relation of the vessels. late gadolinium enhancement presented myocardial ischemic scar of the anterior wall and apex (up to the 50 and 75 % of wall thickness, respectively). patient was referred to surgery. takeuchi's repair was performed by making an intrapulmonary baffle connecting the aorta and the origin of lad. both surgery and recovery proceeded uneventful. postoperative echocardiogram showed improvement of systolic function (lvef 55-60 %), hypokinetic apex and adequate blood flow in the baffle. hernienchirurgie): single-port procedure und notes: (nur) benefit für den patienten? leistenhernienchirurgie in österreich: ergebnisse einer online-umfrage 1 krankenhaus der barmherzigen schwestern linz, linz, österreich, 2 wilhelminenspital, wien, österreich grundlagen: die operative versorgung von leistenhernien stellt eine der häufigsten, routinemäßig durchgeführten operationen in der allgemeinchirurgie dar. ziel dieser umfrage war, die gegenwärtigen operationsstandards sowie das peri-und postoperative management in österreich zu evaluieren und mit internationalen guidelines und aktueller literatur zu vergleichen. methodik: in zusammenarbeit mit der österreichischen gesellschaft für hernienchirurgie erfolgte im dezember 2013 eine anonym durchgeführte online-umfrage, bestehend aus 20 single-choice fragen. die aussendung erfolgte an alle abteilungsleiter österreichs sowie mitglieder der österreichischen herniengesellschaft und der aco-asso. ergebnisse: die rücklaufrate betrug bis jänner 189 (36,3 %). in 40,7 % wird unter laufender thrombo -ass medikation keine leistenhernienoperation durchgeführt. eine präoperative coloskopie erfolgt in 66,3 % sowie eine routinemäßige sonographie in in both groups (group a: mean 49 min/31 min, group b: mean 45 min/26 min). no intraoperative or postoperative complication occurred. prolonged pain medication was administered in 1 (2 %) and none of group a and group b patients, respectively. patient satisfaction was optimal in all patients. procedural costs were less in sil-tep. conclusions: this study demonstrates that both procedures provide comparable clinical safety and feasibility but sil-tep benefits from less expenses. antiadhesive agents for intraperitoneal hernia repair procedures-tisseel ® compared to adept ® and coseal ® in an ipom rat model background: adhesion formation remains an important issue in hernia surgery. among others, antiadhesive liquid agents were developed for easy and versatile application, especially in laparoscopy. the aim of this study was to compare the antiadhesive effect of fibrin sealant (fs, tisseel  ), icodextrin (id, adept  ) and polyethylene glycol (peg, coseal(r) alone and in combination. methods: fifty-six sprague dawley rats were operated in ipom technique. one polypropylene mesh of 2 × 2 cm size was implanted per animal and covered by 1: fs, 2: id, 3: peg, 4: fs + id, 5: fs + peg, 6: id + peg (treatment groups; n = 8). meshes in the control group (n = 8) remained uncovered. observation period was 30 days. macroscopic and histological evaluation was performed grading adhesions, tissue integration, dislocation and foreign body reaction. results: severe adhesions were found in group 2 (id), group 6 (id + peg) and the controls. in all other groups adhesions were mostly moderate or mild. best results were achieved with fs alone or fs + id. tissue integration of the treatment groups was reduced in comparison to the control group. all samples featured a moderate foreign body reaction. conclusions: fs alone and in combination with id yielded excellent adhesion prevention. tissue integration of fs covered meshes was superior to id or peg alone or combined. peg did show adhesion prevention comparable to fs but evoked impaired tissue integration. id alone did not show significant adhesion prevention after 30d. tisseel is among the most potent antiadhesive agents in ipom and can be used with any mesh of choice. leistenhernienchirurgie in "reduced port technique": konventionell, mils oder sil? r. h. fortelny 1,2 1 allgemein-, viszeral-und tumorchirurgie, wilhelminenspital, wien, österreich, 2 paracelsus medizinische privatuniversität, salzburg, österreich grundlagen: die entwicklung in der minimal invasiven chirurgie der letzten jahre hat sich neben den verbesserungen von versiegelungstechnologien vor allem in der reduktion des zugangstraumas im sinne der "reduced port surgery" ergeben. die damit verbundenen vorteile in hinsicht auf verminderung postoperativer schmerzen, kosmetisches ergebnis und der trokarhernieninzidenz werden kontroversiell diskutiert. methodik: der klassische "konventionelle" 3 port-zugang in der tapp-technik hat sich in den letzten jahren zur verwendung von einem 10 mm kameratrokar und zwei 5 mm arbeitstrokaren entwickelt. die weitere reduktion des zugangstraumas mit applikation von 3 mm arbeitstrokaren (mils-technik), wie auch mittels eines single ports (sil-technik) mit einem 25 mm zugang im nabel, entsprechen dem allgemeinen trend in der laparoskopischen chirurgie. ergebnisse: die verschiedenen techniken werden kritisch einander gegenübergestellt, vor-und nachteile aus persönlicher erfahrung beleuchtet und wissenschaftliche arbeiten zitiert. schlussfolgerungen: die ergebnisse der reduced port leistenhernienchirurgie sind mit der klassischen tapp-technik bezüglich rezidivraten und komplikationen vergleichbar, der benefit bzgl. kosmesis und narbenhernieninzidenz ist bis dato wissenschaftlich auf grund fehlender rct-studien noch nicht bewertbar. single incision laparoscopic tapp versus single incision laparoscopic tep: a matched pairs analysis 1 patient akute cholezystitis mit cholezytolithiasis, 1 patientin cholangiozelluläres karzinom. schlussfolgerungen: die eswl beim symptomatischen gallensteinleiden erbrachte unbefriedigende kurzzeit und langzeitergebnisse. im lichte zweier todesfälle die unmittelbar mit dem steinleiden zusammenhängen könnten, ist zu bedenken, dass diese möglicherweise durch die bereits damals bestehende standardbehandlung, nämlich die cholezystektomie, verhindert hätten werden können. isolierte magenpolypose oder generalisierte gastrointestinale polypose bei juvenilem polyposis syndrom -ein diagnostisch/ therapeutisches dilemma das juvenile polyposis syndrom ist eine seltene in der normalbevölkerung mit einer häufigkeit von 1:100.000 auftretende krankheitsentität. die 3 untergruppen sind die polyposis coli, die magenpolypose und die generalisierte intestinale polypose. zur entwicklung der polypen kommt es meistens in der adoleszenz beziehungsweise im jungen erwachsenenalter. als primärsymptome treten peranale polypenausscheidung, rezidivierende blutungen, anämisches zustandsbild, colonintussuszeption und dünndarm -bzw. mageninvagination auf. in 40 % der fälle kann durch eine genetischen untersuchung eine subgruppenspezifizierung durchgeführt werden. (bei mutation des smad4 gen -isoliertes auftreten im magen bzw. bei bmpr1a genmutation eine generalisierte intestinale polyposis) die jip zeigt ein altersabhängiges malignes entartungsrisiko von 20 % im alter von 25 jahren bis 68 % im senium. bei gleichzeitigem auftreten von 5 colonpolypen gilt momentan die proktocolektomie als goldstandard. differentialdiagnostisch müssen ein peutz -jeghers syndrom und eine familiäre adenomatöse polypose ausgeschlossen werden. unser fall beschreibt einen 42 jährigen patienten der aufgrund einer chron. anämie und oberbauchschmerzen vorstellig wurde. gastroskopisch zeigte sich eine massive magenpolypose mit vulnerabler schleimhaut. histologisch entsprachen die biopsien einer juvenilen polypose. weiters wurden coloskopisch 3 isolierte colonpolypen und im rahmen einer ballonenteroskopie ein jejunalpolyp diagnostiziert. das ergänzend durchgeführte abdomen ct zeigte keinerlei hinweis auf intestinale begleitpathologien. es wurde eine totale gastrektomie durchgeführt. die 3 colonpolypen sowie der jejunalpolyp wurden abgetragen. eine genetische analyse blieb ergebnislos. mit diesem vorgehen ist der patient gegenwärtig polypenfrei. da es keine literaturempfehlung gibt ob mit zunehmendem alter neuerlich juvenile polypen auftreten können wurde der patient in ein nachsorge schema aufgenommen. laparoskopisches ipom nach laparoskopischem ipom c. pizzera, g. weber, g. rosanelli krankenhaus der elisabethinen graz, graz, österreich die laparoskopische operation einer hernia cicatricaea mittels intraperitonealem onlay-mesh ist mittlerweile bereits zu einer standardoperation geworden. kommt es jedoch zu einem rezidiv wird in den meisten fällen eine konventionelle einer neuerlichen laparoskopischen versorgung vorgezogen. dies insbesondere da sich die schwierigkeiten einer laparoskopischen revision bei massiven intraperitonealen verwachsungen, welche teilweise eine sichere positionierung der trokare erschweren, sowie bei der explantation des bestehenden (teil)integrierten netzes zeigen. das video zeigt den fall eines hernia cicatricaea rezidives wobei das rezidiv infolge eines netzbruches des primär implantierten meshs zustande kam. es wird die laparoskopische explantation des netzes, bei teilintegration des primären netzes, sowie die neuerliche implantation eines ipom veranschaulicht dargestellt. 15 young surgeon forum 2 konservative therapie von gallensteinen mittels eswl: kritische beurteilung der ergebnisse nach 20 jahren verlaufsbeobachtung universitätsklink für chirurgie, salzburg, österreich grundlagen: die eswl (extracorporale stosswellenlithotrypsie) wurde in den 1980er jahren als alternative behandlungsmethode des symptomatischen gallensteinleidens empfohlen. ziel dieser untersuchung war es die ergebnisse dieser behandlungsmethode und das schicksal der patientinnen im langzeitverlauf von über 20 jahren zu untersuchen. methodik: retrospektive studie an 160 patientinnen die wegen symptomatischer cholezystolithiasis mittels eswl einer steinzertrümmerung in den jahren 1989 und 1990 zugeführt wurden. ergebnisse: von 160 patienten welche mittels 217 eswl sitzungen behandelt wurden, konnten 126 (79 %) nachuntersucht werden. in 18 % der fälle konnte mittels einer eswl-sitzung eine symptom-und steinfreiheit erreicht werden. bei 10 % waren weitere interventionen notwendig: bis zu 3 eswl-sitzungen 8 pat, ercp 2 patienten. 72 % der patienten mussten aufgrund von steinrezidiven bzw. persistierender cholezystolithiasis im mittel nach 5,1 jahren operiert werden. im langzeitverlauf kam es bedingt durch komplikationen des gallensteinleidens bei 2 patienten zu todesfällen. in 2,3 % der fälle kam es zu gallenstein-bzw. gallenwegsassozierten todesfällen. 1 patientin gallenblasenkarzinom (46a), tomy is recommended by current guidelines. the objective of this study was to evaluate platelet counts after splenectomy. methods: we performed a retrospective analysis of all consecutive patients undergoing laparoscopic splenectomy for idiopathic thrombocytopenic purpura (itp). primary end-point was any relapse of disease. results: from 06/2007 to 08/2013, twenty-six patients (female: n = 15, 58 %; mean age 49 years) underwent laparoscopic splenectomy for severe thrombocytopenia after immunomodulating therapy failed. median time from primary diagnosis to surgery was 2.45 years [42 days to 16.6 years]. after a median follow-up of 23 months (1.6 to 65.3 months), eleven patients (42 %, female: n = 7) experienced recurrence of their disease with platelet counts below 80 × 109/l. in one patient an accessory spleen was detected on abdominal ultrasound and computed tomography so laparoscopic resection was performed. splenic cell spillage during laparoscopic splenectomy was suspected. thereafter, platelet counts recurred to normal range. in another 5 patients, imaging did not reveal accessory splenic tissue and therefore conservative treatment was continued. in the remaining 5 patients, corticosteroid-therapy was continued with stable platelet counts. conclusions: recurrence of thrombocytopenia following laparoscopic splenectomy is a common phenomenon. in rare cases, accessory splenic tissue can be detected as causal factor. it is highly recommended to avoid splenic cell spillage during laparoscopic surgery to prevent surgical causes of recurrence. inzidentelle malignome der gallenblase nach single incision laparoscopischer (sil) cholezystektomie krankenhaus der barmherzigen brüder, salzburg, österreich grundlagen: das gallenblasenkarzinom (gbk) stellt eine seltene entität dar. bei routinemäßig durchgeführten laparoskopischen cholezystektomien (che) werden bis zu 24 % der gbk erst intra-oder postoperativ diagnostiziert. schlechtere einsehbarkeit und punktion der gallenblase sind mögliche kritikpunkte der sil che. ziel dieser analyse war, die häufigkeit und das outcome inzidenteller gbk nach sil-che zu evaluieren. methodik: zweizentrumsstudie (bhb salzburg, bhs wien) mit einschluss aller konsekutiven sil che (2008) (2009) (2010) (2011) (2012) (2013) (2014) . analyse von patienten, bei welchen das histologische ergebnis ein gb malignom ergab. aufzeichnung von intraoperativen parametern und postoperativem verlauf. ergebnisse: in beiden abteilungen wurde die che routinemäßig in sil-technik angestrebt. bei insgesamt 1310 (960 bhb, 350 bhs) sil che fand sich bei drei (0,2 %) patientinnen (alter 51, 57, 68a) erst in der postoperativen aufarbeitung ein inzidentelles malignom: in zwei fällen ein adenokarzinom der gallenblase (pt3nxm0,l1,v1,pn1,g3,r1 und pt2n1m0,l1,g3,r1), im dritten fall ein invasiv lobuläres karzinom der mammae mit okkultem primum. bei keinem eingriff wurde die gallenblase verletzt. einmal mussten aufgrund von verwachsungen zwei submuköse magenwandtumore -wirklich alles gist? chirurgie kh braunau, braunau, österreich einleitung: die häufigsten mesenchymalen tumore im git sind mit einer inzidenz von 10-20/100.000 gist-tumore, davon finden sich 65 % im magen. soll man somit bei einem submukösen magenwandtumor immer von einer malignität ausgehen oder ist eine open-minded herangehensweise angeraten? kasuistik: eine 69-jährige patientin stellt sich mit thorakalem druckgefühl vor. eine kardiologische ursache kann ausgeschlossen werden. bei der gastroskopie findet sich im antrum ein submuköse raumforderung, die biopsie war nicht zielführend. computertomographisch ergibt sich bei der ca. 2 cm betragenden veränderung der verdacht auf einen gist. vergößerte lymphknoten konnten nicht gefunden werden. zur weiteren abklärung wurde eine endosonographie veranlasst. auch hier ist ein gist als wahrscheinlichste diagnose anzunehmen. es wird schließlich auf grund der guten resektabilität nach präoperativer endoskopische tusche-markierung eine laparoskopische magenvollwandresektion mit ausreichendem sicherheitsabstand durchgeführt. histologisch findet sich schließlich ektopes pankreasgewebe. schlussfolgerungen: von einem gist im magen kann durch die bildgebenden untersuchungsmethoden ohne biopsie nicht ausgegangen werden. trotz einem hohen prozentsatz von malignen submukösen magenwandtumoren ist dennoch eine gutartige veränderung nie außer acht zu lassen. immerhin besteht für ein ektopes pankreasgewebe in der magenwand eine prävalenz von bis zu 13,7 %. the effect of preservation solutions htk, htk-n and tiprotec on various tissue components using a rat-hind-limb-transplantation model zusatztrokare gesetzt werden. es traten keine intra-oder postoperativen komplikationen auf. die bergung erfolgte mittels bergebeutel. die beiden gbk wurden mittels exzision der trokarstellen, konventioneller atypischer leberteilresektion und lymphadenektomie (r0) nachoperiert. schlussfolgerungen: inzidentelle malignome der gb sind selten. ein intrinsisch höheres/niedrigeres risiko bei durchführung einer sil che ist spekulativ aber nicht zu belegen. sentinel node biopsie bei neoadjuvanter behandlung und klinisch/sonographisch negativer axilla: vor oder nach der chemotherapie? grundlagen: abhängig von der molekularpathologischen tumorcharakteristik erfolgt heutzutage bei ca. 15-20 % aller patientinnen mit einem mammafrühkarzinom eine präoperative behandlung. aktuelle studien (sentina-studie und aco-sog z1071) belegen, dass die sentinel node biopsie (snb) nach präoperativer chemotherapie (ptc) bei besiedelten axillären lymphknoten unsicher, die auffindungsrate zu niedrig und die falsch negative rate mit über 10 % zu hoch ist. es stellt sich nun die frage, ob bei geplanter ptc bei klinisch negativer axilla die snb vor oder nach der chemotherapie durchgeführt werden soll. die prätherapeutische snb erwies sich als sicher. was die snb nach der chemotherapie betrifft, bestehen bedenken, dass durch die behandlung der lymphabfluss z. b. durch fibrosierung verändert wird, die snb unsicher und zudem der wahre lymphknotenstatus nicht bekannt ist. die daten für die suche nach einer beantwortung dieser frage wurden prospektiv aufgezeichnet und retrospektiv analysiert. methodik: zwischen 2000 und 2013 wurden bei 127 entsprechenden patientinnen eine wächterlymphknotenbiopsie vor (46 ×) bzw. nach (81 ×) der neoadjuvanten therapie durchgeführt. ergebnisse: in beiden gruppen war die auffindungsrate mit 98 % sehr hoch. in der gruppe 1 fanden sich bei 40 %, in der gruppe 2 bei 35 % tumorbefallene sentinels. background: ischemia/reperfusion (i/r) injury is an early factor damaging grafts and determining patients' outcomes in solid organ and composite tissue transplantation. we herein investigate the effect of the preservation solutions htk, htk-n and tiprotec on tissue preservation and damage in an isogenic rat-hind-limb-transplantation model. methods: orthopic hind-limb transplantations were performed in lewis-rats following 6 or 10 h of cold ischemia (ci). limbs were flushed and stored in htk-n, tiprotec, htk or saline-solution. skin, muscle, nerve, vessel and bone-samples were procured at the 10th post-operative day (pod) for histology, confocal and transmission electron-microscopy. results: live-confocal microscopic imaging of the anterior tibial muscle revealed no significant difference of muscle-cell viability on pod 10 between htk-n (10 h ci: 82.2 %; 6 h ci: 83.4 %), htk (10 h ci: 80.6 %; 6 h ci: 96.0 %), saline (10 h ci: 85.4 %; 6 h ci: 88.2 %) and tiprotec (10 h ci: 61.2 %; 6 h ci: 92.6 %) treated limbs. histopathologic analyses showed that nerve and muscle were most affected by i/r injury, but not the vessels or the skin. histopathological scoring showed a superiority (p = 0.08) of htk in muscle preservation at 10 h ci. at 6 h ci, tiprotec turned out to be favorable (not significant) in tissue preservation in all evaluated tissue types. conclusions: nerve and muscle are most susceptible to i/r injury in vca whereas skin and vessels are relatively unaffected. htk has the best preservation ability for muscle tissue at 10 h ci, which is the major component of a vca. the novel preservation solution tiprotec shows a superiority in tissue preservation at 6 h ci. results: moderate and severe ppm was present in porcine aortic valves (ppm/sppm:m:55/43 %;e: 74/37 %) and in bovine pericardial tissue valves (mf:49/44 %,cep:63/0 %,pm:45/1 %,t f:21/0 %,me:16/0 %). in patients received size 19 valves without ppm, the perioperative mortality was significant decreased in isolated procedures (0 %,lpm:9.97 %;p < 0.01). in contrast the mortality in patients with severe ppm is high and not statistically significant different between isolated and combined procedures (7.4 vs. 10 %;ns). the new generation of bovine pericardial tissue valves (ce perimount  , ce perimount magna  , ce magna ease  and sjm trifecta  ) showed the lowest incidence of moderate and severe ppm in the small sizes. with the use of these pericardial tissue valves, we further improved perioperative mortality in patients with small aortic roots (2.9 vs. 4.3 %, p = 0.029; lpm 8.5 %, p = 0.031) . conclusions: the latest generation of pericardial tissues valves has further improved perioperative outcome and showed the lowest incidence of ppm in the cohort. we recommend these valves as the aortic valve substitute of choice in patients with small aortic roots. single-center-ergebnisse mit der edwards intuity sutureless aortenklappenprothese im rahmen des foundation-trials (multizentrische "post-market"-analyse) background: the vitality tm two-part valve is a bovine pericardial tissue valve prosthesis with an exchangeable leaflet set, designed to simplify and shorten re-do procedures. hemodynamics are equivalent to best-in-class bovine pericardial valves. the two-step implant enables better visibility and procedural confidence and enhances the ability to see and fix potential paravalvular leaks. it offers the possibility for surgical or minimal invasive surgery and in the future, on and off-pump leaflet exchange options. methods: as member of the european ce mark clinical investigators we have implanted this new surgical vitality tm valve in eight patients who underwent aortic valve replacement for aortic stenosis (mean age: 67 ± 4.9 years, female n = 2, male n = 6, size: 19 n = 2, 21 n = 3, 23 n = 3, hemisternotomy n = 7). six month clinical and echocardiographic follow-up was performed in all patients (complete 100 %). results: no morbid event for thromboembolism, bleeding, thrombosis, endocarditis or structural valve degeneration was observed. no patient died perioperative or during follow-up. echocardiographic measurements show significant reduction of peak and mean gradients (ppg, mpg) from preoperative to follow-up (mmhg) : ppg 92.4 ± 22.7 vs. 31.6 ± 4.9; mpg 57.5 ± 17.8 vs. 18.4 ± 3.9 . the mean eoa of the vitality tm valve was 1.6 ± 0.5 cm² (range 1.2-2.4 for size 19 to 23). no patient prosthesis mismatch was observed. conclusions: our first clinical results with the new vitality tm two-part valve support its excellent implant visibility and procedural confidence. echocardiographic examinations confirm the excellent hemodynamic performance. additional design (sutureless vitality-s tm and transcatheter vanguard tm ) are a potentially revolutionary technology extending the indication for tissue valves to a much younger age group. the new generation of stented aortic pericardial tissue valves in patients with small aortic roots: single center experience in 572 patients r. moidl institutional experience with the heartware ventricular assist system in 100 patients background: lvad implantation has become a standard treatment option for terminal heart failure. we present our institutional experience with the heartware ventricular assist system (hvad) in 100 patients. methods: retrospective review of 100 patients receiving an hvad between march 2006 and august 2013, regarding patient demographics, adverse events, length of support and outcomes, such as mortality or successful bridging. results: mean age was 55 ± 13 years, ranging from 13 to 75 years. 82 % of the patients were male, 43 % suffered from ischemic cardiomyopathy. at the time of implantation, 30 % of the patients were in intermacs level 1, 12 % in intermacs level 2, 26 % in intermacs level 3 and 26 % in level 4-7. duration of support ranged from 1 to 1631 days with a mean of 409 ± 319 days. 28 patients (28 %) were successfully bridged to transplantation, explant for recovery occurred in one patient (1 %) , 27 died on lvad support (27 %) and 44 remain still on the device (44 %). 28 patients (28 %) experienced at least one major bleeding event, including surgical bleedings in 43 %, gastrointestinal bleedings in 33 %, and intracranial bleedings in 24 %. one or more thromboembolic complications occurred in 18 patients (18 %) (50 % pump thrombus, 50 % ischemic strokes) and right heart failure in five patients (5 %). 13 % of the adverse events had fatal consequences. 30-day and in-hospital mortality were low with 8 and 15 %, respectively. one-year survival was 80 %. conclusions: in our patient cohort, the hvad has been demonstrated to efficiently support patients in terminal heart failure, providing excellent clinical outcomes. multizelluläre 21 bis 27 mm verwendet. in 9 fällen (39,1 %) wurden zusätzliche eingriffe (acbp, maze, tkr) durchgeführt. die mittlere implantationzeit betrug 12,5 ± 1,6 min. die durchschnittliche dauer der extrakorporalen zirkulation und der aortenklemmzeit betrug 61,8 ± 6,4 min, respektive 37,8 ± 4,1 min bei isolierten aortenklappenersätzen. die mittleren gradienten beim jeweils letzten follow-up betrugen abhängig von der klappengröße: 21 mm = 12,6 ± 5,0 mmhg; 23 mm = 10,8 ± 4,5 mmhg; 25 mm = 9,8 ± 4,7 mmhg; 27 mm = 8,3 ± 2,1 mmhg. hämodynamisch relevante valvuläre oder paravalvuläre insuffizienzen konnten ausgeschlossen werden. conclusions: die implantation der edwards intuity sutureless aortenklappe benötigt nur eine flache lernkurve und zeigt hämodynamisch exzellente ergebnisse. außer bei patienten mit speziellen anatomischen begebenheiten (z. b.: bikuspide klappe, ascendensaneurysma) kann die prothese schnell und sicher implantiert werden. insbesondere patienten mit konkomitanten eingriffen und zu erwartender langer ischämiezeit und/oder reduzierter ventrikelfunktion profitieren von einer solchen implantationstechnik. comparison of two different minimized extracorporeal circulation systems in reference to conventional cardiopulmonary bypass (ccpb) in patients with isolated coronary artery bypass surgery m. harrer, r. moidl, f. waldenberger, p. poslussny, abt. für herz-und gefäßchirurgie, vienna, austria background: the minimized extracorporeal circulation (ecc) system has established in coronary artery bypass grafting. a reduction in blood transfusion-rate and lower 30-day-mortality-rates were reported. the aim of our study was to evaluate the clinical outcome of two different ecc-systems. methods: 1980 patients underwent isolated coronary artery bypass grafting between 04/07 and 12/11 and were compared retrospectively. 1557 patients (370 female, 1187 male, mean age: 66.7 ± 9.7 years) were operated with ccpb and 423 patients (82 female, 341 male, mean age: 67.6 ± 10.8 years) were operated with ecc. in 56.7 % the ecc.o (dideco) and in 43.2 % the roc-safe (terumo) system was used in the ecc-group. the logeuro-scores were similar between the two groups (5.0 ± 6.1 vs. 5.3 ± 6.4; p = 0.8). results: between the two ecc-systems we did not observed a statistically significant difference in the intra-and postoperative red blood cell transfusion rate (p = 0.3) as well as in the ventilation time (p = 0.42), length of intensive care unit stay (p = 0.4), re-exploration for bleeding (p = 0.2), neurological disorders (p = 0.9), postoperative stay (p = 0.9) or 30-day-mortality-rate (p = 0.8). but in the ecc-group the blood requirement (p < 0.001), the ventilation time (p < 0.001), length of intensive care unit stay (p = 0.02) and re-exploration for bleeding (p = 0.001) was significantly reduced compared to ccpb. no statistically significance was observed in the 30-day-mortality-rate (p = 0.05), neurological disorders (p = 0.18) and postoperative stay (p = 0.06). conclusions: the comparison of two ecc-systems did not show a statistically significant difference in clinical outcome, but grundlagen: konventionelle offene kardiopulmonale bypasssysteme (cpb) haben besonders bei pädiatrischen patienten mit angeborenen herzfehlern schädliche auswirkungen. geschlossene perfusionssysteme zeigten bereits in der erwachsenen-herzchirurgie, dass sie mit ihrem reduzierten primingvolumen und der abgeschwächten immunreaktion von vorteil sind. wir berichten über die erste konsekutive patientenserie, die mit einem neuartigen geschlossen, minimal-invasiven extrakorporalen perfusionssystem operiert wurde. methodik: von august 2012 bis oktober 2013 wurden 14 patienten mit einem körpergewicht zwischen 6,3 kg und 18,7 kg und einem mittleren alter von 4 ± 1,7 jahren behandelt. bei 9 dieser patienten wurde ein asd mittels direkter naht oder patchverschluss versorgt, 3 erhielten eine fontan-operation, ein patient mit tga wurde palliativ operiert und ein anderer patient mit partiellem av-kanal erhielt eine modifizierte warden-operation. alle kinder wurden mit dem neu entwickelten, geschlossenen p -mec  -system (pediatric-miniaturized extracorporeal circulation) operiert. dieses system zeichnet sich durch ein durchschnittliches füllvolumen von 274 ± 39 ml und dem einsatz eines miniaturisierten oxygenators aus, bei dem eine sofortige umstellung auf ein offenes system möglich ist. ergebnisse: es sind keine embolischen ereignisse aufgetreten. die mittleren präoperativen hämatokritwerte lagen bei 39 ± 9 %, an der hlm bei 30 ± 6 % und postoperativ bei 33 ± 7 %. der mittlere hämoglobinwert betrug 9,6 ± 2 g/dl während der ekz. intraoperativ sind weder bluttransfusionen noch eine konvertierung zum offenen system erforderlich gewesen. alle patienten hatten einen unauffälligen postoperativen verlauf. schlussfolgerungen: die vorteile des p -mec  -systems sind höhere hämatokrit-und hämoglobinwerte peri-sowie postoperativ, reduzierter transfusionsbedarf und eine abgeschwächte entzündungsreaktion bei erhaltenen sicherheitsstan-grundlagen: na + k + atpase-inhibitoren üben auf multizelluläre muskelstreifen positiv-inotrope effekte mit jedoch geringer therapeutischer breite (arrhythmie-induktion) aus. als vorversuch wurde strophantidin in vitro getestet. methodik: aus insgesamt 6 humanen herzen von neugeborenen mit unterschiedlichen kardiokongenitalen fehlbildungen (ventrikelseptumdefekt n = 3; fallotsche tetralogie n = 3) wurden rechtsventrikuläre muskelstreifen (n = 15) isoliert, optimal vorgedehnt, mit einer modifizierten tyrodelösung (2.5 mmol ca 2 + ) bei 37°c umspült und mit 1 hz stimuliert. die muskelstreifen wurden steigenden konzentrationen von strophantidin (1 µm, 3 µm, 0,01 µm/l, 0,03 µm/l, 0,1 µm/l, 0,3 µm/l, 0,5 µm/l, 1 µm/l) ausgesetzt. entwickelte kraft und kinetische parameter wurden mit hilfe eines force-transducers aufgezeichnet. ergebnisse patients undergoing open heart surgery with the use of cardiopulmonary bypass (cpb) often develop a systemic inflammatory response syndrome (sirs), characterized by the release of inflammatory mediators such as matrix metalloproteinases (mmps). we demonstrated previously that continued mechanical ventilation during cpb reduces postoperative sirs. thus, we hypothesized that this has an impact on mmp release. methods: thirty patients subjected to coronary artery bypass grafting with cpb were randomized into a ventilated (n = 15) and a standard non-ventilated group (n = 15). blood was collected at the beginning and at the end of surgery, and at the five consecutive days. inflammatory markers were measured by elisa. results: serum concentrations of mmp-8, mmp-9 and lipocalin (lcn2) peaked at the end of surgery followed by an increase in timp-1 levels at the first postoperative day. mmp3 showed a sustained elevation starting from the second postoperative day. importantly, all mediators were significantly lower in ventilated compared to non-ventilated patients in at least one of the measured time points (ventilated vs. non-ventilated group: 7.1 (3.5) cadmium: a novel risk factor for cardiac fibrosis and hypertrophy background: cadmium (cd) is a toxic heavy metal found throughout our environment which can accumulate in the human body through smoking or intoxication. cd causes a variety of pathologies in different organ systems and recently it has been shown to be a new and independent risk factor for the development of atheroclerosis. the present study will analyse the effect of smoking induced increase in serum cd levels and its potential role in cardiac hypertrophy and heart failure. methods: a cell culture model using hl-1 cardiomyocytes was analyzed after cd exposure using facs techniques. extensive histological examination of heart sections of apoe-/-mice receiving cd in drinking water and different diets was performed. results: cd exposure of hl-1 cardiomyocytes increased both, the number of apoptotic and necrotic cells in culture. however, a significant change in mitochondria function or increase in ros could not be detected. paraffin-embedded heart sections of cd subjected mice showed large areas of fibrotic tissue compared to healthy heart muscle in control mice. immunofluorescent staining of the heart indicated infiltration of cardiac fibroblasts and immune cells. conclusions: the results confirm a cytotoxic effect of cd even at low dose exposure. cd induced cell death and inflammation could cause cardiac remodelling and fibrotic tissue deposition as seen in the histological analysis and subsequently lead to cardiac hypertrophy and heart failure. we hypothesize that cd is a new and until now unknown risk factor for cardiac fibrosis and hypertrophy however the exact underlying molecular mechanisms need to be further elucidated. continued mechanical ventilation during cardiopulmonary reduces matrix metalloproteinase: tissue inhibitor of metalloproteinase-and lipocalin 2 secretion background: pulmonary metastasectomy is part of the interdisciplinary management of patients with primary colorectal carcinoma (crc) and pulmonary metastases (pm). kras and braf mutations are a common characteristic in crc. moreover, the expression of egfr may play a role in the tumor progression. we hypothesized, that the egfr, braf and kras status might be potential prognostic markers in patients undergoing pulmonary metastasectomy. methods: dna was isolated from tissue specimens of 39 patients with primary crc and pm. rt-pcr was used for braf/kras analysis. egfr expression was determined by immunohistochemistry. results: mutations in braf and kras were detected in 48 and 0 % of the assessed tumors, respectively. egfr expression was evident in 49 %. kras mutations were significantly associated with decreased time to lung-specific recurrence in univariate (p = 0.013) and multivariate analyses (p = 0.035). egfr expression did not correlate with any clincopathologcial characteristic. conclusions: herein we could firstly describe the impact of kras mutations on tumor recurrence after pulmonary metastasectomy. patients with lung metastases harboring mutations in the kras gene should be carefully followed up after surgery. telomere rna expression correlates with proliferating cell nuclear antigen (pcna) in colorectal cancer und das bei der ersten schwangerschaft 26,1 jahre. die schwangerschaft dauerte im schnitt 39,1 wochen und brachte ein im schnitt 3,2 kg und 51 cm großes kind mit sich. es gab 8 kaiserschnitte, 6 erst-und 12 mehrfachgebärende. zweimal traten persistierende foramen ovale als angeborene anomalie in der folgegeneration auf. schlussfolgerungen: die durchschnittliche schwangerschaftsdauer, das schwangerschaftsalter zu beginn, das geburtsgewicht, die tragezeit und der zeitpunkt der operation ist mit denen anderer studien nahezu identisch und sie weisen keine großen abweichungen zur normalbevölkerung auf. in unserer studie ist mit 33,3 % der gebärenden und 27,59 % der erfolgreichen schwangerschaften eine hohe kaiserschnittrate abschliessend lässt sich somit die aussage treffen, dass fallotkorrigierte frauen durchaus eine unkomplizierte schwangerschaft erwarten können. sie sollten allerdings engmaschig durch kardiologen und gynäkologen betreut werden, um frühzeitige komplikationen feststellen zu können. kombination der pfortaderembolisation mit subcutaner hormongabe in der leberchirurgie: eine chance zur verbesserung der leberhypertrophie mit erhöhung der operabilität? points. after sacrificing the mice, organ and blood samples were taken, aortas were harvested, analyzed and statistically evaluated. analyses of blood samples revealed that leoligin significantly lowered serum cholesterol levels as well as low-density lipoprotein cholesterol after five weeks of treatment. the ipgtt after 2 weeks showed lowered postprandial serum glucose levels after intraperitoneal injection of glucose in the leoligin treated groups. further, when compared to the control group, a significantly lower body weight gain in mice treated with 50 μm leoligin was observed. leoligin could be a novel substance to avoid and prevent the impacts of dyslipidemia and postprandial hyperglycemia. the changes in blood lipid profiles, postprandial glucose utilization and body weight indicate that it has a broad effect on metabolism and may therefore reduce the risk of cvd-development. however, its mode of action is still unclear and needs further elucidation. ergebnisse von pierre-robin-patientinnen im jugend-oder erwachsenenalter telomeres are protective caps that prevent chromosome fusions and thus are essential for chromosome stability. despite their heterochromatic state telomeres are transcribed into terra (telomeric repeat-containing rna) molecules known to function as natural telomerase inhibitors. terra transcription is regulated during the cell cycle of tumor cell lines indicating a possible relation to cell proliferation. the main purpose of this pre-clinical study was to examine a correlation of terra expression and the expression of the cell proliferation markers ki-67, c-myc, cyclin d1, cyclin a2 and pcna in colorectal cancer (crc). tumor (t) and matched adjacent non-tumor (n) tissues of 68 patients diagnosed with crc were stored snap frozen after surgical removal. terra expression was analyzed by real-time qpcr. relative quantity (rq) values were related to a reference gene. ratios of rq values from matched t and n tissues were calculated and three groups of patients were formed with low, ~ 1 and high t/n ratio. three patients from each group were selected and the proliferation marker expression was analyzed. preliminary data analyses of 9 patients demonstrated significant differences of gene expression values between tumor and normal samples. importantly, terra expression correlated significantly with pcna, but not with other proliferation markers. our data indicate a positive correlation between terra and proliferation marker expression. further crc cases are required to validate our finding and may allow identification of important correlations with clinical data. leoligin, the major lignan of edelweiss, and its potential role in reducing serum cholesterol levels in apoe -/-mice cardiovascular diseases (cvds) are still the number one cause of death in the world. as dyslipidemia is a major driving force underlying atherosclerosis initiation and progression and subsequent development of cvds, the search for new lipid lowering agents is still a highly relevant task. the present study was designed to investigate the systemic effect of leoligin (a compound isolated from edelweiss) on cholesterol levels and atherosclerotic plaque formation in a long-term treatment mouse model. leoligin was administered orally to 40 female apoe knockout mice over 16 weeks at three different concentrations (1 μm, 10 μm, 50 μm). blood samples and intraperitoneal glucose tolerance tests (ipgtts) were taken and performed at various timebackground: the aim of this single center study was to assess the short term outcome of transapical aortic valve implantation (ta-tavi) at our institution. methods: from april 2010 through september 2013, a total of 101 patients were enrolled in our ta-tavi program. comprehensive clinical testing had been performed on baseline and on 30 day follow-up. as primary endpoints 30d mortality and morbidity had been chosen. results: our patients' median age at time of implantation was 80 years (61-92years; n = 101; 60.4 % female). all of them were considered as high risk patients. the edwards sapien (n = 89) and the symetis acurate (n = 12) prostheses were implanted by transapical access. 6 patients had to undergo a valve-in-valve implantation, whereas one had to be placed in mitral position. median follow-up was 25 months (range, 12-44 months). thirtyday device success was high (pvl ≤ i in 96 %; n = 97). all-cause mortality at 30 days was 4.9 % (n = 5). life-threatening bleeding (7.9 %; n = 8), and acute kidney failure (2.9 %; n = 3) were further major adverse events after tavi. only one patient (0.9 %) showed postoperatively signs of a transient ischaemic attack that resolved completely during follow up. 6.9 % (n = 7) needed a permanent pacemaker device after ta-tavi. conclusions: short term outcomes after tavi were encouraging in this high-risk patient population group, were comparable to literature data and underlined the large potential of this hybrid surgical procedure. it also reflects the fact that ta-tavi showed excellent neurological outcomes despite vigorous calcification of the vascular tree or the valve itself. erste erfahrungen mit der osirix software zur diagnostische datenaufbereitung für transapikale und transaortale tavi-prozeduren background: transapical tavi is a common used therapy options for surgical inoperable patients with aortic stenosis. using tavi for isolated aortic insufficiency in high risk patients is an upcoming therapy option. this is case report presents the first jenavalve implantation for isolated aortic insufficiency after mitral repair. methods: one patient, male, 63-years old developed a severe symptomatic aortic valve insufficiency 2 month after mitral valve repair with an edwards physio mitral ring 34 mm. the patient was considered as high risk because of his low left ventricular function (lvef 35 %), high pulmonary artery pressure (papsys 66 mmhg) and reoperation (jehovah's witness). choosing a left sided mini thoracotomy, a self-expandable, 27 mm jenavalve prosthesis was implanted, without the use of rapid pacing. results: the postoperative echo showed the circularly expanded prosthesis an excellent position of the jenavalve without any paravalvular insufficiency. the patient was extubated within the first postoperative day and on the second transferred back to general ward. ten days after operation the patient was discharged to home. conclusions: transapical tavi with the jenavalve prosthesis in patients with mitral ring reconstruction is technically feasible and shows promising results in high risk patients. methods: between 2008 and 2013 three patients (1 woman, 2 men, mean age 74 years) with severe aortic stenosis and aortic sclerosis, as well as severe cad were rejected for conventional surgery and referred for tavi and cabg. the mean log euroscore was 21.83 % and euroscore ii 4.3 %. in two patients ta-tavi was per-sive austausch der aortenklappe auf eine biologische prothese. postoperativ erfolgte bei großzügig gestellter indikation in 14 patienten (29,17 %) die implantation eines permanenten schrittmachersystems aufgrund eines höhergradigen av-blocks. die 30-tagesmortalität betrug 6,25 % (n = 3), die gesamtmortalität nach einem mittleren beobachtungszeitraum von 14 monaten 8,33 % (n = 4), die todesursache dabei nur in einem fall bei intraoperativer ventrikelruptur unmittelbar mit der aortenklappenintervention assoziiert. als weitere todesursachen fanden sich sepsis nach sigmaperforation, respiratorische insuffizienz nach nosokomial erworbener pneumonie und multiorganversagen nach protrahiertem icu-verlauf. postoperativ konnte bei 22 patienten (45,83 %) keine, bei 20 patienten (41,66 %) eine geringgradige sowie in 2 patienten (4,20 %) eine gering-bis mittelgradige aortenklappeninsuffizienz nachgewiesen werden. schlussfolgerungen: mittels katheter-unterstützten verfahren kann chirurgischen hoch-risiko-patienten mit hochgradiger aortenklappenstenose eine therapieoption nicht nur zur verbesserung von überlebensraten sondern vor allem der lebensqualität geboten werden. graft failure after engager-implantation resulted in successful open-heart surgery background: transcatheter aortic valve implantation is an established treatment option, for high risk patients with severe symptomatic aortic stenosis. the self-expandable medtronic engager transcatheter valve is one of the new generation transcatheter aortic valve prosthesis. methods: a 69 years old female patient (log euroscore 11.56 %, euroscore ii 2.2 %) with severe symptomatic aortic stenosis and ascending calcification referred for transapical tavi underwent a ta-tavi procedure with the medtronic engager 23 mm tavi prosthesis. after implantation the patients developed a severe central as well as two paravalvular aortic insufficiency and the echo shows a not fully circulatory expanded aortic prosthesis. therefore we decided to convert to open-heart aortic valve replacement. results: inspection of the transcatheter valve in situ revealed that the stent frame of the prosthesis was not in shape and not fully expanded. one leaflets were not at the same level, one was restrictive. the stent struts did insure the aortic wall and we could identify to lesion at the aortic wall, which were sealed by 5.0 prolene. after removal of the trancatheter aortic prosthesis as well as the excision of the calcified, native valve and decalcification of the aortic annulus, an edwards magna 21 mm was used for aortic valve replacement. postoperative echo did not show any paravalvular or valvular insufficiency. conclusions: self-expandable transcatheter valve prosthesis are an upcoming tool for ta-tavi. nevertheless in patients with severe aortic calcification, they bear the risk of losing original shape, leading in severe paravalvular or central aortic insufficiency. background: transcatheter aortic valve implantation has emerged as an acceptable treatment modality, for high risk patients with severe symptomatic aortic stenosis. this case report about the first successful implantation of the self-expandable medtronic engager. methods: a 74-years old female patient (logeuroscore 32.58 %, euroscoreii 3.59 %) with severe symptomatic aortic stenosis underwent a ta-tavi procedure with a 23 mm medtronic engager. a 14 french cook-port was used to introduce the balloon-catheter through the apex. the balloon-valvulotomy was performed under rapid pacing, thereafter the port was removed and the engager-introducersheet inserted. while removing the port and inserting the introducersheet, the incision at the apex had to be covered manually. the tavi-prosthesis was implanted on beating heart, without the use of rapid pacing. after successful implantation, removal of the introducer-sheet and closure of the apex with the purse-string suture. results: after successful implantation the patient the angiography as well as the echo did show a correct expansion and position of the valve prosthesis. there was no paravalular or central leak detectable. the patient was extubated on the same day and discharged to home on pod10. conclusions: the self expandable medtronic engager taviprosthesis is one of the new generation transcatheter aortic valve prosthesis. the advantage is the renounce of rapid pacing, which might reduce the risk of hemodynamic decompensation during or immediately after implantation. the disadvantage is that in patients with fragile apex the multiple manipulations at the apex can lead to more easily tearing of the myocardium. endoskopie in der chirurgie): gastrointestinale endoskopie: von der diagnostik zum highend komplikationsmanagement in der viszeral-und transplantationschirurgie the role of routine esophagogastroduodenoscopy prior to laparoscopic cholecystectomy background: cholelithiasis can present with a complex combination of clinical symptoms, which may resemble the manifestation of other gastrointestinal diseases. the evidence formed prior to sternotomy and cabg. in the remaining patient we performed the sternotomy for cabg procedure prior to ta-tavi (lateral thoracotomy). mean procedure time was 423 min. results: performing ta-tavi prior to cabg procedures was successful in both patients. cabg anastomosis could be performed without any complications. luxation of the heart for cabg anastomosis did not lead to a dislocation of the implanted valve or lead to an increase of paravalvular insufficiency. otherwise we could observe a significant longer operation time in case of performing cabg prior to ta-tavi, because of difficulties in adjustment of the apex and performing valve implantation after sternotomy. conclusions: concomitant ta-tavi procedure and cabg represents an excellent option for high risk patients with aortic sclerosis. ta-tavi prior to cabg is recommendable due to the superiority of adjustment of the tav via lateral thoracotomy and the resulting shorter operation time. successful aortic homograft implantation in a 81-year old woman with aortic ring rupture after double tavi procedure a 81-year woman was referred to our institution due to worsening of chronic heart failure. the patient presented with severe aortic stenosis and mitral insufficience. due to high operative risk a tavi approach was indicated. following the fist tavi implantation (sapien xt) a aortic ring rupture with a big paravalvular leakage was diagnosed. hence a second tavi procedure with a core valve 26 mm was performed in order to close the paravalvular leakage. nonetheless leakage remained under worsening hemodynamical parameters. we decided to perform open heart surgery as a bail-out procedure. first tavi prosthesis and the native valve were removed. in respect to the anatomical situation an anatomic homograft implantation was favored. a 21 mm sized aortic homograft was implanted using the root-replacement technique. additionally, mitral valve annuloplasty with physio 28 mm ring was performed. after postoperative weaning from ecc the patient remained three weeks in the icu, followed by two weeks on a general ward. the patient was referred home in good condition, with good left ventricular function and no signs of paravalvular leakage in the aortic position. first successful implantation with the selfexpandable medtronic engager in austria conclusions: both peg techniques are safe and wellpracticed. dislocation of the peg tube occurred, compared to the pull-through-peg, occlusions, however, were frequently observed in the push-peg. the decision which peg tube should be used depends on the individual case. cut and push -endoskopisches komplikationsmanagement nach peg-sonden entfernung -fallbericht hintergrund: peg-sonden werden routinemäßig eingesetzt, um die enterale ernährung bei patienten mit schluckstörungen oder passagehindernissen oral des magens zu ermöglichen. bei dysfunktion der peg-sonde muss diese entfernt werden und entweder eine neuanlage unter endoskopischer sicht oder ein wechsel auf ein tube-system mit cuff erfolgen. die cut-and-push-methode ist eine häufig angewandte technik zur entfernung von peg-sonden. dabei wird die sonde in hautniveau abgeschnitten und nach intragastral gedrängt. der intragastral gelegene anteil geht via naturalis ab und wird mit dem stuhl ausgeschieden. alternativ dazu kann die sonde auch gastroskopisch geborgen werden. weder aus eigener erfahrung noch aus der literatur ist evidenz-basiert einer der beiden methoden der vorzug zu geben. fallberichte über komplikationen der cut-and-push-methode beziehen sich fast ausschließlich auf abdominell-voroperierte patienten. bei diesem kollektiv scheint das obstruktions-risiko erhöht zu sein. fall: im vorliegenden fall kam es nach anwendung der cutand-push-methode bei einem abdominell nicht voroperierten patienten mit einem stenosierenden ösophagus-ca zu einem mechanischen ileus durch verkeilung der abgeschnittenen sonde im bereich der valvula bauhini. die sonde konnte coloskopisch mit hilfe einer polypektomieschlinge geborgen und der ileus behoben werden. conclusions: die cut-and-push-methode stellt eine einfache, kostengünstige und komplikationsarme möglichkeit zur entfernung einer peg-sonde dar. bei abdominell voroperierten patienten sollte die anwendung dieser methode kritisch gesehen werden. liegt eine obstruktion vor, ist ein endoskopischer therapieversuch gerechtfertigt. early endoscopic treatment of biliary complications reduces the need for repeated interventions: a single center experience with 820 liver transplants for routine esophagogastroduodenoscopy (egds) before laparoscopic cholecystectomy is controversial. in our institution all the patients are offered egds prior to cholecystectomy. methods: a retrospective review on the significance of preoperative egds in 4,500 patients who underwent laparoscopic cholecystectomy between january 2003 and december 2013 was conducted. results: we present our preliminary results over the period from 2011 to 2013. egds was performed in 499 (49.9 %) patients before surgery out of a total of 1,000 laparoscopic cholecystectomies. 501 (50.1 %) patients did not receive an egds, either because they were diagnosed with acute cholecystitis (n = 241) or they underwent earlier egds in an out-hospital institution (n = 260). pathological findings were seen in 311 (62.3 %), 37.5 % of the patients had gastritis, 1.2 % gastric ulcera, 0.4 % acute duodenal ulcera, 2.4 % barrett's esophagus, 8 % esophagitis, 0.2 % with duodenal stenosis, 0.2 % portal hypertensive gastropathy and 12 % hiatal hernias. histological testing for helicobacter pylori was done in 147 (29.4 %) patients, a positive test was detected in 44 (29.9 %). conclusions: egsd is not generally required prior to cholecystectomy in patients with typical gallstone symptoms. because of the high incidence of simultaneous upper gastrointestinal diseases, routine preoperative egsd is indicated in patients with nonspecific upper abdominal pain and history of peptic ulcer disease. comparison of 231 patients receiving either "pull-through" or "push" percutaneous endoscopic gastrostomy v. kalcher, g. köhler, o. koch, g. spaun, k. emmanuel background: a percutaneous endoscopic gastrostomy (peg) can be performed as a direct puncture, known as seldinger technique ("push") or a thread pulling method ("pull"). the aim of this study was to compare the final result deriving from the application of the pull-through-peg with that of the push-peg. methods: data of all pull-through and push-peg applications, which had been carried out in our department from 2009 to 2012, were analyzed retrospectively. the patients' demographic data, indication, comorbidities, peri-interventional chemotherapy and/or radiotherapy were collected. the complications were graded according to the clavien-dindo classification. the final results of the two methods were analyzed and compared. results: a total of 231 patients received a peg (131 (56.7 %) pull-through-peg/100 (43.3 %) push-peg). in 165/231 (71.4 %) cases patients suffered from a malignant disease and 94/231 (40.6 %) patients received peri-interventional radio-and/or chemotherapy. overall, in 61/231 (26.4 %) of the cases a complication was documented, of which 52/61 (85.2 %) were classified as grade 1 complications by clavien-dindo. an occlusion of the peg occurred significantly (p = 0.001) more frequently in connection with the push-peg (1/131 (0.8 %) pull-through peg versus 10/100 (10 %) push-peg). a dislocation of the peg tube occurred in 17/231 (7.4 %). the complication rate was not significantly influenced by the type of the peg tube used. docholithiasis mit intraabdomineller luft nach komplizierter, erfolgloser ercp, bei st.p. b ii operation, der von der abteilung für medizinische gastroenterologie des hauses an unsere chirurgische abteilung übernommen wurde. es erfolgte eine sofortige offene operation bei der mehrere serosarisse der zuführenden jejunumschlinge, aber keine perforation detektiert wurden. da, nach cholezystektomie und choledochotomie die papille trotzdem nicht überwindbar war, musste eine offene papillotomie mittels duodenotomie durchgeführt werden. bei gründlicher spülung des extrahepatischen gallenwegsystems konnten konkremente und sludge entfernt werden. komplettiert wurde der eingriff durch die t-drain-einlage. bei der kontroll-t-drain cholangiographie am 10. postoperativen tag wurde ein präpapillär liegendes residualkonkrement von 10 × 10 mm größe festgestellt. in anbetracht des hohen alter des patienten, einer vorausgegangenen komplizierten ercp und kürzlich erfolgten schwierigen chirurgischen revision suchten wir nach einer alternativen therapieoption. schließlich führte eine eswl mit nachfolgendem steinabgang zum erfolg. in der abschließenden cholangiographie prompter kontrastmittelabfluß ins duodenum. eine eswl ist aus unserer sichtweise und in der wenig vorhandenen literatur mit 80 % erfolgsrate ein wenig belastendes alternativverfahren zur steinentfernung aus dem extrahepatischen gallenwegsystem wenn ein endoskopisch interventionelles verfahren nicht möglich erscheint und für eine chirurgische revision eine kontraindikation besteht. cholangiozelluläres background: biliary strictures and leaks are a major source of morbidity following liver transplantation. endoscopic retrograde cholangiography (erc) however, represents an efficient means to successfully treat these types of complications. methods: we reviewed our institutional database of 820 consecutive liver transplants performed within the last 13 years (01/2000-10/2013) at our institution. results: the overall biliary complication-rate as confirmed by endoscopy was 18.4 % (n = 151). incidence of biliary complications was significantly higher in anastomoses with internal draining stents:23.7 (n = 9/38), when compared to anastomoses with t-tube drainage:19.9 (n = 28/141) and en-end anastomoses:18.9 % (n = 104/553) (p < 0.01). mean time from diagnosis to endoscopic treatment was 3.1 days. an average of 4.1 endoscopic re-interventions were necessary to treat 12.3 % (n = 101) biliary stenoses, 4.3 % (n = 35) biliary leaks, and 1.9 (n = 15) combined complications (stenosis & leak). early endoscopic treatment (< 3 days after clinical and radiological diagnosis) significantly reduced the need for repeated interventions (3 days: 4.9 ± 0.8 interventions; p < 0.01). sphincterotomy and partial sphincterotomy was performed in 44.6 and 9.6 % of cases. the amount of plastic stents (62.8 %) used was significantly higher when compared to coated metal stents(11.5 %) and pig-tail stents(10.3 %; p < 0.01). median duration of stent treatment was 43 days (1-265 days) . retransplantation-rate due to persistent complications was 3.8 %. significant risk factors associated with biliary complications were increased cold ischemia times (cit), recipientweight, and body mass index, as well as higher donor age, donorweight and donor-body mass index (all p < 0.01). conclusions: early endoscopic intervention is key to successful treatment of biliary complications after liver transplantation. biliary anastomoses with t-tubes are superior to anastomoses with stents and equal to end-end biliary anastomoses without stents. impaktiertes restkonkrement im ductus choledochus nach komplizierter ercp und chirurgischer revision -interventionellendoskopisch und chirurgisch an der wand gestanden und dann von der welle gestoßen in unserem fallbeispiel handelt es sich um einen 86-jährigen patienten mit symptomatischer cholezystolithiasis und chole-background: gastrointestinal and abdominal bleeding can lead to life-threatening situations. embolization is considered a feasible and safe treatment option. the relevance of surgery has thus diminished in the past. the aim of this study was to evaluate the role of surgery in the management of patients after embolization. methods: we performed a retrospective single center analysis of patients outcome after transarterial embolization of acute abdominal and gastrointestinal hemorrhage between january 2009 and december 2012 at the sisters of charity hospital linz. patients were divided into three groups of upper (ugib) and lower (lgib) gastrointestinal bleeding and abdominal hemorrhage. results: fifty-four patients with 55 bleeding events were included. the bleeding source could be localized angiographically in 80 % and the primary clinical success rate of embolization was 81.8 % (45/55 cases). early recurrent bleeding (< 30 days) occurred in 18.2 % (10/55) and delayed recurrent hemorrhage (> 30 days) in 3.6 % (2/55). the mean follow up was 8.4 months and data were available for 85.2 % (46/54) of patients. surgery after embolization was overall required in 20.4 % of patients (11/54). failure to localize the bleeding site was identified as a predictive factor of recurrent bleeding (p = 0.009). more than one embolization effort increases the risk of complications (p = 0.02) and rebleedings (p = 0.07). conclusions: surgery still has an important role after embolization. one of five patients required surgery in cases of early and delayed rebleeding or because of ischemic complications and bleeding consequences. bodypacking -ein interdisziplinärer fall akh linz, linz, österreich die anzahl der aufgegriffenen bodypacker variiert stark je nach region. so wurden in amsterdam 143 fälle in 5 jahren beschrieben, wohingegen innerhalb von 7 monaten in new york allein 193 fälle dokumentiert sind. im akh linz wurde im jänner 2014 ein 35-jähriger mann aus südamerika in der notaufnahme vorstellig mit sinustachykardie und thoraxschmerzen. nachdem er angegeben hatte, zahlreiche kokainpäckchen in sich zu tragen, wurde nach rücksprache mit dem diensthabenden chirurgen eine abdomen-leer aufnahme angefertigt, die dies bestätigte. unter aufsicht der polizei wurde er dann auf der neurologischen intensivstation überwacht. leider konnte mit abführenden maßnahmen kein spontanabgang beobachtet werden. nach fieberschüben, kammerflimmern und reanimation wurde eine abdomen-ct angefertigt, die einige päckchen im magen, einige im rektum und zahlreiche weitere im kolon zeigte. es wurde eine digitale ausräumung des rektums durchgeführt sowie 4 päckchen gastroskopisch entfernt. bei weiterhin bestehenden zeichen einer kokain-intoxikation wurde der patient laparotomiert, das stark geblähte kolon transversum eröffnet und 49 päckchen herausgeholt. in der literatur wird zu einem konservativem vorgehen geraten, lediglich 2-10 % der bodypacker mussten notfalls mäßig laparotomiert werden. zu einer endoskopischen bergung wird nicht geraten. die sterblichkeit sank von über 50 % in den 80er jahren auf aktuell 2 %, was auf eine verbesserte verpackung zurückgeführt wird. kationsmanagment konnte ein technisch hochriskanter reeingriff verhindert werden. technische aspekte der bergung endoluminaler fremdkörper des d. choledochus dpt. of general, thoracic and visceralsurgery, feldkirch, österreich grundlagen: endoluminale fremdkörper des d. choledochus bieten bei erheblicher lithogenizität einen nicht abschätzbaren klinischen verlauf mit hohem komplikationspotential und stellen somit eine zwingende indikation zur bergung dar. zwei case reports illustrieren die endoskopische bergetechnik. methodik: i. case report einer 69-jährigen patientin, die wegen eines dünndarm-adhäsionsileus operiert werden musste bei 15 jahre zuvor stattgehabter laparoskopischer cholecystektomie. im initial-ct wurde der asymptomatische intraduktale clip detektiert und im postoperativen verlauf per ercp und ept mittels dormia-körbchen extrahiert. ii. case report eines 75-jährigen patienten, der im rahmen der chirurgischen versorgung einer leberruptur zur entlastung des gallengangssystemes eine transzystikus-drainage erhielt, die jedoch beim versuch der entfernung intrakorporal abriss. die endoskopische bergung erfolgte in zweizeitiger vorgehensweise mit 8-wöchigem intervall. im verlauf der ersten ercp erfolgten die ept und ein frustraner transpapillärer extraktionsversuch bei weiterer alveranhebel-bedingter ruptur des fragmentes mit konsekutiver teilluxation ins duodenallumen. diese situation wurde durch einen plastikstent gesichert und gefolgt von einer zweiten sitzung zur vollständigen extraktion. ergebnisse: die größte gruppe endocholedochealer fremdkörper bilden operationsresiduen. die migration von clips stellt keine spezifische komplikation minimal invasiver techniken dar. die möglichen physiopathologisch favorisierende faktoren, die sich aus konventionellem oder minimal invasivem operationsduktus ergeben, sowie therapienotwendigkeit und -optionen auch asymptomatischer intracholedochaler nidus und mögliche intraoperative vorsichtsmaßnahmen zur vermeidung des phänomens der clip-migration bzw. der unbeabsichtigten fixationen von drainagen werden erörtert. schlussfolgerungen: die autoren schließen, dass dieses seltene ereignis im dekurs kompliziert verlaufender cholecystektomien vor allem bei rezidivierender choledocholithiasis differentialdiagnostisch in betracht gezogen werden muß und unterstreichen die präponderante rolle der therapeutischen endoskopie. relevance of surgery after embolization of gastrointestinal and abdominal hemorrhage results: indications for the angiography were heart catheter 65 %, peripheral revascularisation 19.3 % and others 15.7 %. complications were pseudoaneurysms 38.1 %, haematoma 23.4 %, active bleeding 20.1 %, dissection with ischemia 1.5 % and others 16.2 %. the surgical procedure was direct closure and removal of the haematoma 60.4 %, direct closure 15.7 %, removal of the haematoma 7.1 %, implantation of a peripheral bypass 1 %, femoral artery interposition 1 % and others 14.7 %. additionally there are some cases with acute bleeding that did not reach theatre in time. we do not have data of those cases. conclusions: surgical complications after angiography via the common femoral artery are rare, but in case they represent a life threatening situation. any possible effort should be done to reduce the complication rate like extensive guided training with ultrasound support. seltener fall eines v.-poplitea-aneurysmas is the rate of bypass degeneration in the omniflow ii prosthesis higher than we think? from previous studies we know that degeneration of the prosthesis with aneurysm formation can be found in 1-7 %. we suspect that the rate of degeneration may be higher. methods: between 1/2006 and 12/2008 105 omniflow ii tm vascular grafts were implanted in 97 patients. 77 male and 20 female patients underwent revascularization for peripheral arterial occlusive disease. the omniflow ii tm prosthesis was used for 77 supragenicular, 21 infragenicular and 7 crural bypasses, when no saphenous vein was available. follow up was done with colour coded duplex ultrasound. patients' data were collected in a database. results: twelve patients have undergone redo surgery because of bypass degeneration so far. in these patients mean time until diagnosis of graft degeneration was 63 (range, 40-85) months. conclusions: aneurysm formation and degeneration of the omniflow ii tm prosthesis may occur more often than reported in the literature. patients with an omnilow ii tm graft should undergo regular ultrasound follow up to find signs of graft aging as early as possible. acute surgery after minimal invasive access to the femoral vessels background: the common femoral artery is the most common access point for heart catheter and peripheral angiography. we reviewed our data with respect to acute surgery after angiography via the common femoral artery. methods: between january 2002 and june 2012 there were 197 acute surgical procedures in 190 patients. our database and written patient documents were reviewed retrospectively. the need of ptfe hemodialysis shunt explantation: a review with special attention to graft infection g. f. schramayer, p. konstantiniuk, j. fruhmann, universitätsklinik für chirurgie, graz, austria background: graft infection in general is a life-threatening condition and in particular if it occurs in hemodialysis shuntgrafts. we reviewed our ptfe hemodialysis shunt data with special respect to graft infection and explantation. methods: 295 ptfe shunt prostheses were implanted between 1.12.1998 and 31.12.2007 . after exclusion of 17 cases due to several reasons (shunt correction, no proper shunt use…) 278 remained for statistical analysis. results: mean age was 62.5 years, 40.6 % were male and 59.4 % were female. 13.3 % of prostheses had to be explanted, 11.2 % of which due to graft infection, 1.1 % due to aneurysms, 0.7 % due to haematoma and bleeding and 0.4 % after successful kidney transplantation. additionally we found two cases of 'silent deaths' caused by underestimation of the dangerousness of graft infection. conclusions: graft infections of hemodialyses shunts provoke urgent surgery, put the patient in a life-threatening condition with need of prolonged local surgical therapy and implantation of a long term central venous catheter. any effort should be done to generate autologous hemodialysis shunts and reduce the rate of shunt prostheses. wilkie -oder superior mesenteric artery syndrome: komplette heilung durch infrarenale transposotion der a. mesenterica superior w. sandmann 1,2 , m. schröder 1 , k. verginis 1 , d. grotemeyer 2 , j. schlaag 1 , m. duran 2 1 evangelisches niederrheinklinikum duisburg, duisburg, deutschland, 2 heinrich-heine-universität düsseldorf, düsseldorf, deutschland wilkie beschrieb 1921 das krankheitsbild einer hochgradigen stenose der pars horizontalis inferior des duodenums, welche zwischen der im spitzen winkel aus der aorta entspringenden a. mesenterica superior und der aorta komprimiert wird. hoher ileus, erbrechen, gewichtsverlust, kachexie und tödlicher ausgang führten zu kuriosen ernährungsstrategien und in schweren fällen zur gastrointestinalen anastomosen-chirurgie. methodik: wir entwickelten die methode der transposition der a. mesenterica superior (tams) in die infrarenale, nierenarteriennahe aorta zur erweiterung des betreffenden anatomischen raumes (n = 10, 8 frauen, altermittel 29 jahre). in 8 von 10 fällen wurde die diagnose verneint und in 9 von 10 fällen eine psychiatrische therapie auswärts empfohlen (2 patienten erhiel-bildung) das gefäßchirurgische vorgehen. insbesondere bei rezidivierenden lungenembolien ist eine venös-aneurysmatische quelle mit in die differenzialdiagnose einzubeziehen. pseudoaneurysma der arteria rectalis superior eine interventionelle lösungsstrategie -ein fallbericht während die meisten akuten fälle von unteren gastrointestinalen blutungen, durch supportive maßnahmen, spontan sistieren, zeigen sich bei 10-15 % der patienten persistierende blutungen die weitere diagnostische, therapeutische und interventionelle maßnahmen benötigen. die häufigsten ursachen massiver blutungen sind die divertikulose und die angiodysplasie. gastrointestinale blutungen, verursacht durch ein pseudoaneurysma sind äußerst selten und häufig folgen eines zuvor durchgeführten diagnostischen verfahrens. wir berichten über den fall eines 86-jährigen patienten der aufgrund von rezidivierenden rektalen blutabgängen an unsere medizinische intensivabteilung transferiert wurde. neun tage zuvor erfolgte in einem auswärtigen spital eine transrektale prostatastanzbiopsie (high grade dysplasie). während des intensivaufenthaltes setzte der patient mehrmals meläna ab, sodass er transfusionspflichtig wurde. im rahmen des intensivaufenhaltes erfolgten mehrmalige koloskopien sowie eine gastroskopie in der sich keine eindeutige aktive blutungsquelle darstellen ließ. in der anschließend durchgeführten ct angiographie zeigte sich eine hyperperfusion des rektums an seiner ganzen zirkumferenz. aufgrund erneuter hämoglobin abfälle wurde die indikation zu einer operativen versorgung gestellt. intraoperativ erfolgten z-förmige umstechungsnähte im bereich der vorderen rektumwand (eine eindeutige blutungsquelle konnte nicht identifiziert werden). zwei tage postoperativ zeigte sich der patient erneut instabil, darum erfolgte die invasive radiologische abklärung mittels mesenteriographie, wobei sich schließlich im bereich der a. rectalis superior ein pseudoaneurysma im unteren rektumabschnitt darstellen ließ. hier erfolgte ein coiling des zuführenden arterienstammes mit gutem interventionellen ergebnis. in weiterer folge kam es zu keinem blutabgang mehr. zusammenfassend sehen wir die möglichkeit einer selektiven embolisation, bei einem radiologisch gesicherten pseudoaneurysma des rektums, als eine exzellente therapiestrategie um eine komplikationsbelastende rektumresektion zu vermeiden. 29 pancreaschirurgie i: status quowas bringt die zukunft? laparoscopic left sided pancreatectomy -early experience with different technical approaches background: left-sided pancreatectomy is burdened by significant operative morbidity. laparoscopic resection conveys the advantages of a minimal invasive access, however is controversial due to accessibility of the organ, as well as the need for a stapled closure of the pancreas cut surface. methods: starting in 2013, patients with non-carcinomatous lesions confined to the left-sided pancreas were considered for laparoscopic resection. with the patient placed in a right-lateral position, two 12 mm and two 5 mm trocars were used. data are reported as total number (%) or mean ± standard deviation. results: eight patients underwent laparoscopic resection, with four (50 %) spleen-preserving operations (1x warshaw-technique). indications for surgery were net (3), ipmn (2), frantztumor (1) and cystadenoma (2) . identification of the lesion and pancreas mobilization was possible in all patients. the pancreas was transected using purple (85.7 %) or beige (14.3 %) stapler cartridges, with one conversion with open cut surface closure due to a history of pancreatitis (14.3 % conversion rate). mean procedure time was 176.13 ± 27.47 min, mean length of stay 15.29 ± 7.50 days. with 0 % wound morbidity, postoperative complications consisted of one type a fistula and one type b (fistula rate 28.57 %) in the 7 patients with laparoscopic parenchyma transection. conclusions: laparoscopic resection effectively reduced wound-related morbidity, however, careful patient selection seems mandatory due the still high pancreas fistula rate. current status of pancreatic and liver surgery in lower austria. a peer review against the background of a reforming process in austrian health care the study was initiated by the lower austrian krankenanstaltenholding to assess quality of patient management in individuals undergoing any surgical procedure to either pancreas or liver against the background of reform of austrian healthcare. all patients meeting these criteria who were discharged between 1.1. and 31.3.2013 from any of the lower austrian hospitals were included. an external senior surgeon was appointed to peer review patient files which were presented originally and complete by the ten auswärts frustrane zusatzernährung: 11 monate jejunale sonde, jahrelange port-implantation). ergebnisse: alle patienten haben nach tams erheblich an gewicht zugenommen, können nach belieben essen. post-op cta, mra und ögd zeigen aufhebung der duodenalen kompression und in 2 fällen zusätzlich eine begleitstenose linke nierenvene. nachuntersuchungszeit 7 jahre bis 5 monate (komplett). schlussfolgerungen: die tams ist eine elegante, effektive und physiologische methode zur behandlung des wilkie-syndroms und der gastrointestinalen anastomosenchirurgie in jeder hinsicht deutlich überlegen. dunbar-syndrom medical university innsbruck/department of surgery, innsbruck, österreich grundlagen: das dunbar-syndrom wurde erstmals 1965 durch j. david dunbar beschrieben und ist als einengung des truncus coeliacus durch das ligamentum arcuatum definiert, wodurch es typischerweise postprandial zu unterschiedlich ausgeprägten abdominellen schmerzen kommt. das krankheitsbild ist selten, weshalb die meisten patienten bis zur diagnose eine vielzahl von untersuchungen zum ausschluss anderer ursachen durchmachen. methodik: zwischen den jahren 2009 und 2013 wurden insgesamt acht patienten an unserer abteilung wegen eines dunbar-syndrom operiert (sieben mal laparoskopisch, einmal offen). als die diagnose beweisend gelten eine stenosierung im truncus von mindestens 80 % und eine daraus resultierende erhöhung der flussgeschwindigkeit. der nachweis erfolgte mittels angio-ct und duplex-sonographie. die patienten wurden durchschnittlich 23, 3(± 18) monate postoperativ klinisch bzw. telefonisch kontrolliert. ergebnisse: das durchschnittsalter der patienten (drei männer, fünf frauen) betrug 42,6(± 21,9) jahre. die flussgeschwindigkeit betrug präoperativ durchschnittlich 350,3 cm/s (± 127,6). nach spaltung des ligamentum arcuatum verringerte sich die flussgeschwindigkeit um durchschnittlich 145,3 cm/s (± 83.3). ein immunsupprimierter patient starb nach offener oeration an den folgen eines multiorganversagens. sechs patienen waren nach dem eingriff und im rahmen der klinischen verlaufskontrolle bzw. befragung beschwerdefrei. ein weiterer patient steht bei wieder aufgetretenen beschwerden unter reevaluation. schlussfolgerungen: bei unklaren abdominellen symptomen sollte das vorliegen eines dunbar syndroms in erwägung gezogen werden. to assess the impact of readmissions after pancreatic resections at our department. methods: for all n = 356 pancreatic resections (08/03-08/13) patient details, all complications, reinterventions and reoperations were documented in a prospectively maintained database. a query of the hospital billing database (sap inc.) was made and all readmissions within 30 days from the operation were identified. patient charts were reviewed to detect the underlying cause and therapeutic consequence of readmission. for categorical variables we performed chi square tests, numerical data were tested according to distribution with t-or mann whitney u tests. results: there were 7.9 % (28/356) readmissions at a median of 22 days (10-30) after operation and a median of 4 days (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) after discharge respectively. most readmissions occurred after pancreatic cancer resections (39.3 %). readmitted patients median age was 65 years. in 89 % (25/28) there were complications, three patients were scheduled for reimaging or port implant. there were n = 6 intraabdominal collections that were all drained interventionally and n = 5 pancreatic fistulas (n = 2 persisting fistulas, n = 3 late fistulas that were not detected after the index operation). the only patient who was reoperated died because of multi organ failure due to bleeding because of not detected late pancreatic fistula. there were no other deaths. all other complications leading to readmission were only grade i-iia. diagnosis (p = 0.8432) and age (p1 = 0.409 p2 = 0.8181) were no significant risk factors for readmission. conclusions: most readmissions occur after mild complications, interventional drainage of all postoperative collections is mandatory otherwise they harbour a significant mortality risk. die bedeutung von infektionen für die postoperative mortalität nach pankreasresektionen die postoperative mortalität betrug 2,5 % (10/394), die häufigkeit ungeplanter reoperationen und reinterventionen 5,6 % bzw. 8,1 %. die morbidität lag bei 27,7 % (109/394), davon 71,6 % (78/109) infektassoziiert und 28,4 % (31/109) nicht infektbedingt. die häufigste infektlokalisation war intraabdominell, meist bei pankreasfistel (52/78; 66,7 %), gefolgt von oberflächlichen ssi (10/78; 12,8 %). bakteriämie (n = 2), pneumonie (n = 3) und cholangitis (n = 1) waren selten. die mortalität bei infektassoziierten komplikationen betrug 10,3 % (8/78) gegenüber 6,5 % (2/31) bei nicht infektbedingten komplikationen und war nicht signifikant unterschiedlich (p = 0,53). von 8 infektbedingten todesfällen holding. a standardized questionnaire was used for every patient, the questions referring to different steps of patient management. furthermore, as agreed upon with the holding data were analysed in respect to type of operation, morbidity and mortality. 97 patients from 11 hospitals were included in the study. there were 58 pancreatic procedures, among them 29 pdpt, 22 distal, 3 total pancreatectomies, and 39 liver procedures half of them including 2 and more segments and hemihepatectomies. overall hospital mortality was 5.1 and 2.5 %. overall hospital morbidity was more than 30 % in pancreatic but only 8 % in hepatic cases. notable differences to published data could not be found. analyses of the standardized questionnaires led to 16 patients with noticeable deviation from what one expects as unremarkable leaving aside morbidity and mortality in this analyses. peer review of individual courses seems to remain subjective by any means although it was possible to point to critical issues concerning the process of patient care in different hospitals thus leading to proposals for improvement which were discussed with all participants. ergebnisse nach pankreaseingriffen im krankenhaus der barmherzigen schwestern wien von 2011 bis 2013 grundlagen: onkologische operationen mit hoher operativer morbidität oder signifikanter mortalität, wie tumorassoziierte pankreaseingriffe werden sinnvoller weise auf spezialisierte abteilungen konzentriert. ziel dieser untersuchung war es, über das outcome dieser eingriffe im krankenhaus der barmherzigen schwestern wien zu berichten. methodik: eingeschlossen wurden 30 patienten, die im zeitraum von 02.2011 bis 12.2013 wegen einer meist tumorbedingten pankreaspathologie operiert wurden. die demographischen daten, intra-und postoperative komplikationen wurden dokumentiert und retrospektiv analysiert. ergebnisse: im angegebenen zeitraum wurden im krankenhaus der barmherzigen schwestern wien 30 patienten am pankreas operiert. die indikationen waren der dringende verdacht auf eine maligne genese. untersucht wurden die mediane operationsdauer, das tumorstadium, die histopathologische aufarbeitung sowie peri-und postoperative komplikationen. schlussfolgerungen: die pankreasoperation ist unter standardisierten bedingungen mit gutem interdisziplinären setting, mit geringer morbidität und ohne mortalität im krankenhaus der barmherzigen schwestern wien etabliert worden. impact of readmission 30 days after pancreatic resection krankenhaus der elisabethinen, linz, austria tur der fixierten obstruktion bei kindern und jugendlichen mit ujpo dar und ist keinesfalls "zu viel des guten". abscess of the upper moiety of the right sided duplex system by a 10-month-old baby o. renz 1 , l. abbasoglu 2 , m. sanal 1 1 innsbruck uni. department of pediatric surgery, innsbruck, austria, 2 acibadem uni. department of pediatric surgery, istanbul, turkey duplex collecting system is presence of two pylocaliceal system associated with single or double ureter. this report presents a renal abscess by a 10-month-old girl with right sided complete duplication of ureter. she is admitted because of high fever and chills. examinations showed a right sided renal duplication with abscess formation on the upper moiety of duplex system. sonography guided pig tail application for abscess drainage and antibiotherapy performed successfully. scintigraphy of the renal system showed nonfunctional upper moiety of the right sided duplex system and she underwent a right heminephroureterectomy. three years follow up was uneventful and she thrived well. antegrade sklerosierung als option der varikozelenbehandlung grundlagen: zur behandlung der varikozelestehen mehrere methoden zur auswahl. in unserer klinik wird seit 1996 die anterograde sklerotherapie nach tauber verwendet. ziel der studie ist die ergebnisse dieser behandlungsmethode zu analysieren. methodik: alle patienten, die zwischen 2006 und 2013 auf grund einer varikozele mittels antegrader sklerosierung nach tauber behandelt wurden, wurden restrospektiv analisiert. indikation zur antegraden sklerosierung waren varikozele grad ii-iii mit oder ohne skrotalschmerz. ergebnisse: im studienzeitraum wurden 21 patienten mit ausschließlich linksseiten varikozelen an unserer klinik operiert davon 12 patienten mit varikozele grad ii und 9 mit varikozele grad iii. das durchschnittliche alter war 13.9 jahren (10-17 jahre), der durchschnittliche krankenhausaufenthalt war 1,6 tage (1-3 tage). die durschschnittliche operationszeit war 44,9 min (22-82 min range). komplikationen traten bei 6 patienten (29 %)auf. drei patienten entwickelten 0.5-3 jahre postoperativ ein behandlungsbedürftiges rezidiv. alle drei wurden mit der selben technik re-operiert und zeigten keine komplikationen oder rezidiv nachher. bei den weiteren drei patienten zeigte sich eine wunddehiszenz und bei zwei ein selbstlimitierendes skrotalhämatom. eine weitere chirurgische intervention war nicht notwendig. methods: we present the case of 7-year old boy, who presented with recurrent vomiting at our department. diagnostic work up revealed two gastric duplication cysts (3.6 and 2.7 cm in diameter) bulging into the gastric lumen along the greater curvature of the stomach, the larger one in close contact to the pancreatic tail. laparoscopic resection was planned using 3 and 5 mm instruments. results: the operation was performed using two 5 mm ports subxiphoidal and in the left upper quadrant, together with a 3 mm forceps (without port) and an umbilical port for stapler insertion and specimen extraction. both cysts were removed by a sleeve resection with an operation time of 98 min. following an uncomplicated postoperative course, the patient was discharged on pod 6. conclusions: laparoscopic resection using small diameter instruments is safe and feasible for resection of gastric duplication cysts. giant congenital omental cyst in a 2-year old girl presenting with acute abdominal pain introduction: cystic lesions of the omentum majus are extremely rare with an incidence of three to ten times less than mesenteric cysts. the diagnosis is often difficult and most of the times it is made only intraoperatively. we present a case of a child with acute abdominal pain caused of a giant omental cyst. case report: a 2-year old girl presented in our institution with abdominal pain, vomiting and fever since 2 days. the clinical history was negative, except recurrent constipation and a conspicuous distended abdomen. a blood sample showed a exalerated crp (127 mg/l) and normal leukocytes. the abdomen x-ray showed a sub-ileus and the abdomen ultrasound a large pseudoascites with displacement of the bowel loops. she underwent at the same day a magnetic resonance imaging, which confirmed the presence of a giant cystic intraperitoneal tumor. at the laparotomy we found a multilocular giant omental cyst (greater omentum), 20 cm x 30 cm in size, filled with 1.7 liter hemorrhagic-serous infected fluid. the treatment was the completely excision. histopathological examination showed lymphoid tissue with conspicuous inflammation without malignancy. the postoperative recovery was uneventful and she was discharged on 5. postoperative day. discussion: congenital giant omental cysts are very uncommon. they mostly occur from lymphatic tissue and the malignant transformation is rare, only isolate case reports with malignant transformation are reported in adult patients. they usually are lacking of symptoms and signs. they initially can mimicking ascites and the diagnosis is often delayed. the surgical excision is recommended. kindern scheint die antegrade sklerotherapie nach tauber eine mögliche alternative zu anderen behandlungstechniken zu sein mit kurzen aufenthaltsdauer und eine rezidivrate/komplikationsrate die mit der anderen techniken vergleichbar ist. duplikaturen des gastrointestinaltraktes -stellenwert der minimal invasiven chirurgie ergebnisse: insgesamt konnten 14 patientinnen (64 %m, 36 %w) eingeschlossen werden. das alter bei erstvorstellung war durchschnittlich 3,7 ± 5,3 jahre (0-14). die lokalisation der duplikatur war 1 im ösophagus, 7 im magen, 3 im jejunum, 1 im ileum, 1 im colon und 1 im rektum. 12 patientinnen hatten eine zystische und 2 eine tubuläre form der d-git. an klinischen symptomen zeigten die patientinnen schmerzen (4), abdominelle distension (1), erbrechen (4), schluckstörungen (1) laparoscopic resection of 2 gastric duplication cysts in a pediatric patient: report of a case ergebnisse: mit ausnahme von 6 der mädchen mit 32 funktionellen zysten, die konservativ behandelt wurden, wurden alle anderen tumoren nach durchführung einer schnellschnittuntersuchung reseziert, bei 2 mädchen mit malignen tumoren war nur ein tumordebulking möglich. schlussfolgerungen: benigne ovarialtumoren sollen organerhaltend operiert werden. bei den meisten funktionellen zysten ist das kein besonderes problem, wohl aber bei den anderen benignen prozessen, abhängig von ihrer ausdehnung und der sicherheit der intraoperativen schnellschnittuntersuchung. im falle eines histologisch verifizierten malignen tumors ist ein individuell-radikales vorgehen indiziert, bei dem kaum auf residuelles ovargewebe rücksicht genommen werden kann. die erstmalige konzeptchirurgische anwendung der do im mitttelgesicht im rahmen komplexer plastisch-rekonstruktiver eingriffe an "nonsyndromic patients" führte u. a. zur definition der "restorativen chirurgie" da im sinne der einheit von form, ästhetik und funktion zu berücksichtigen ist, dass parallel zur größe des gesichtsdefektes in den meisten fällen dazu eine verformung des gesichtes erfolgt (11, 12) . aus diesem grunde ist die wiederherstellung des fehlenden gesichtsabschnittes durch gewebeidente komplex vorgefertigte transplantate ("like tissues") in kombination mit der korrektur der gesichtsverformung die voraussetzung für die rehabilitation dieser patienten (910). sowohl zur dreidimensionalen formkorrektur des gesichtsschädels speziell in der transversalen ebene, als auch in form des "bone transports" bietet die do als regenerative plastische chirurgie entscheidende vorteile indem sie größere distanzen ohne knöcherne transplantate formstabil überbrückt. die do wird daher als alternative zu vorgefertigten lappen in der noma-chirurgie diskutiert (13). die anwendung der do in der chirurgischen kieferorthopädie erwachsener patienten und der ästhetischen gesichtschirurgie in form des "face sculpturings" ist in entwicklung. anhand historischer und aktueller fakten wird die dynamik des wissenschaftlichen diskurses in der do detailliert dargestellt. ösophagektomie ohne thorakotomie r. roka die entfernung oder ausleitung der speiseröhre ohne eröffnung der brusthöhle wurde vor mehr als 100 jahren angegeben, da die möglichkeit der intubationsnarkose nicht zur verfügung stand. nachdem sie über einige jahrzehnte mehr oder weniger in vergessenheit geraten war wurde sie in der modernen chirurgie wieder aufgegriffen. die zielsetzung bestand darin durch vermeidung der thorakotomie die wundfläche als auch das trauma für die lunge zu reduzieren und somit das operationsrisiko herabzusetzen. dies konnte in der literatur in diversen studien gezeigt werden. es konnte jedoch auch festgestellt werden, dass dieses vorgehen den radikalitätsprinzipien bei der therapie des ösophaguskarzinoms nicht gerecht wird. es betrifft vor allem die mehr oder weniger blinde sogenannte ,,blunt-dissektion", tumor im bereich und über der trachealbifurkation und das plattenepithelkarzinom. hingegen dazu hat sich das transhiatale präpatorische vorgehen unter sicht beim distalen adenokarzinom in speziellen situationen bewährt. und war auch wie dies eigene ergebnisse belegen mit einem nur geringen operationsrisiko verbunden. auch in anderen situationen mit benignen erkrankungen (verätzungen, perforationen) kann die technik als ,,inversion-stripping" gute dienste leisten. werden konnten. durch die verbindung dieser techniken mit distraktionsverfahren konnten weit streckige segmentverlagerungen ohne devitalisierung ermöglicht werden. durch diese osteotomietechnik konnten in zusammenschau mit der verbesserung mikrochirurgischer anastomosierungsverfahren erfolgreich kleinknochentransplantattransfers durchgeführt werden, die als vormalige freie knochentransfers nicht erfolgreich waren. zudem konnte durch die einführung intraoraler anastomosetechniken mikrovaskuläre knochentransfers ohne äußere schnittführung durchgeführt werden. so wurden erstmalig mikrochirurgische knochentransplantationen für defektrekonstruktionen der kiefer außerhalb der therapie von tumorpatienten möglich und zumutbar. die kombination alter traditioneller lappenplastiken mit mikrochirurgischen lappentransfers bedingte die erfolgreiche wiedereinführung alter techniken in der rekonstruktion komplexer gesichtsstrukturen und konnte so neue dimensionen der rekonstruktion des gesichtes bedingen, die die ästhetischen untereinheiten des gesichts überschreiten. durch die möglichkeit zur mikrovaskulären anastomosierung von kleintransplantaten und der umsetzung der perforatorlappentechnik konnten transplantate, die früher frei ohne gefäßversorgung transplantiert wurden und eine geringe langzeitstabilität zeigten, nun auch vaskularisiert transplantiert werden und erweisen sich somit langfristig stabil in form und funktion. neben diesen mikrochirurgischen errungenschaften konnte durch die einführung von miniaturisierten distraktoren und die 3d-distraktion auch diese technik eine renaissance in der mkg-chirurgie erleben. in jedem fall konnten alte op-techniken durch modernisierung eine verbesserung erfahren. zudem konnten alte techniken auch neue moderne verfahren nachhaltig beeinflussen und moderne therapiekonzepte ergänzen und verbessern. dies betrifft innerhalb der mkg-chirurgie vor allem den fachbereich der orthognathen chirurgie, tumorchirurgie, rekonstruktiven gesichtschirurgie, fehlbildungschirurgie und präprothetischen chirurgie. die distraktionsosteogenese im gesichtsbereich: geschichtlicher rückblick und aktuelle bedeutung missed tubal sterilization: a hand-in-hand migration of two filshie ® clips onto the liver introduction: filshie  clips are commonly used devices for female sterilization. these titanium clips are placed laparoscopically on both fallopian tubes, causing mechanical obstruction and localized tissue necrosis. clip detachment and migration in the abdominal cavity, causing pain or abscess formation is a rare complication of this method. case presentation: we herein report on a 51-year-old woman presenting with recurrent right-sided epigastric pain. she had undergone bilateral tubal ligation using filshie  clips 16 years earlier successfully preventing any unwanted pregnancy. minimal invasive chirurgie): videositzung -"rocky horror picture show" -komplikationen in der minimal invasiven chirurgie transvaginal repair of vaginal evisceration of the small bowel: a case report vaginal evisceration is rare in occurrence, and less than 100 cases are reported in journals. in premenopausal women it is precipitated by postcoital vaginal rupture, instrumentation, or iatrogenic injury. it is more common in postmenopausal women with previous hysterectomy or other vaginal surgery. we report a case of a postmenopausal 61-year-old woman who suffered from a small transvaginal bowel evisceration after lifting a weight of 25 kg one hour before she had sex. in her medical history she had an abdominal hysterectomy two years earlier. on examination in the emergency room we found a 50 cm loop of her small bowel prolapsing through the vaginal introitus. in the emergency room the bowel had been checked for lesions, disinfected and repositioned in the peritoneal cavity. after that colporrhaphy, the high closure of the peritoneum, and the insertion of a vaginal drainage in the operating room was necessary. this case report highlights the absence of the transabdominal approach, which has not been reported yet. ösophagusperforation im rahmen einer laparoskopischen myotomie nach heller die achalasie stellt eine erkrankung dar, welche durch zunehmende degeneration von ganglienzellen im plexus myentericus der ösophagusmuskulatur gekennzeichnet ist. neben der botox-injektion sowie der mechanischen ruptur der muskelfasern stellt in der operativen therapie der achalasie die laparoskopische myotomie nach heller eines der standardverfahren dar. hierbei ist die ösophagusperforation als häufigste ursache einer frühzeitigen komplikation zu nennen. in der ersten videosequenz wird der unproblematische minimalinvasive standardzugang gezeigt, welcher in unserem hause routinemäßig angewandt wird. weiters wird einerseits eine aufnahme einer intraoperativ entdeckten und versorgten ösophagusläsion gezeigt und andererseits eine postoperativ klinisch evident werdende ösophagusläsion präsentiert, welche zu einer laparoskopischen reoperation führte. methodik: nach kurzer darstellung der standardisierten operativen schritte der tapp, werden verschiedene pitfalls gezeigt und präventive maßnahmen dazu demonstriert. schlussfolgerungen: nur auf basis eines standardisierten operativen verfahrens sind komplikationen zu analysieren und pro futuro zu vermeiden. operationsvideos bieten sich zur analyse von komplikationen als ausgezeichnete methode an. thoracic x-ray revealed a metallic formation underneath the right diaphragm, at the very top of the liver. diagnostic laparoscopy exposed the encapsulated formation migrating into the liver on top of segment viii. the dissected specimen contained both clips abreast originally placed at the right and left fallopian tube. the patient recovered uneventfully and was free of complaints thereafter. conclusions: bilateral clip detachment and hand-in-hand migration onto the liver is a complication of laparoscopic tubal ligation that is described for the first time. stapling failure in laparoscopic liver resection introduction: major laparoscopic liver resection utilizes almost all technical support that is available in minimal invasive surgery. among those stapling of the parenchyma is regarded a safe strategy. failure of the handling of the instruments may cause critical situations. herein we describe our experience of a misfiring of a stapler resulting in a bleeding of the middle hepatic vein in single incision laparoscopic (sil) liver resection. patient: a 60-year old female patient underwent sil liver resection for a symptomatic hemangioma. via a single port system (gelport) preparation of the pedicles was conducted so that the involved segments were isolated. for the purpose of ease parenchymal dissection was started with a stapler. crossing the staple-line with a clip applied previously led to misfiring of the load. management of the bleeding is shown in the video presented herein. conclusions: awareness of basic rules of safety is mandatory. technical prerequisites allow for escaping dangerous situations. modifizierte sils-ipom bei 4. rezidiv einer paracolostomiehernie [rol 20(27 %) , ml 5(7 %), rul 18(25 %), untere bilobektomie 3(4 %)] und 27(37 %) linksseitig [lol 17(23 %), lul 7(10 %), pneumonektomie 1(1 %), segmentektomie 2(3 %)]. bei 3 patienten wurde zu einem offen-chirurgischen vorgehen konvertiert. die mediane anzahl der dissezierten lymphknoten und lymphknotenstationen war 18(3-49) und 7(5-7). ein nodales up-staging konnte bei 11(15 %) patienten beobachtet werden: n0 zu n1 in 7(10 %) und n0 zu n2 in 4(5 %) fällen. in korrelation zum klinischen t-faktor wurde ein nodales up-staging in 5(10 %) patienten der ct1-gruppe und 6(24 %) der ct2-gruppe beobachtet. schlussfolgerungen: die rate an nodalem up-staging nach video-assistiert thorakoskopischen anatomischen resektionen bei nsclc ist gleichwertig zu bereits berichteten serien von robotik und konventioneller chirurgie. randomisierte studien sind notwendig um diese hypothese zu prüfen. maligne, ösophagotracheale fistel -in seltenen fällen eine operationsindikation? multizentrische ergebnisse der karzinom-chirurgie am ösophagogastralen übergang methods: all mpm patients referred for tmt between 2000-2012 were enrolled in this study. data was collected from patients undergoing at least 3 cycles of induction chemotherapy followed by epp and ihp treatment and postoperative intensity modulated radiotherapy up to 58 grays. results: thirty (24 males and 6 females, mean age = 61 years) patients completed tmt and ihp treatment during the observation period. median follow-up was 18.5 months. histological subtypes were epitheliod in 23, biphasic in 6 and sarcomatiod in 1 patient. 18 patients were in late stage whereas 12 patients were in early stage at the time of diagnosis. 4 (13.3 %) patients experienced major postoperative complications. these complications were: bleeding, patch rupture, bronchopleural fistula. overall median survival was 31 months (95 % confidence interval: 12-48 months). 1-year survival was 80 %, 2-year survival was 55 % and 3-year survival was 45 %. 30 day mortality was nil. conclusions: epp in combination with ihp treatment within a tmt protocol is a well-tolerated and feasible treatment approach. compared to reported classical tmt protocols, morbidity and perioperative mortality rates are lower and median survival is equal or better. rf-ablation von lungenmetastasen: eine alternative zur operativen resektion? results: postoperative pleural effusions evidenced a profound bactericidal effect against gram negative (escherichia coli, pseudomonas aeruginosa) and gram positive (staphylococcus aureus, streptococcus pneumonia and streptococcus pyogenes) pathogens, clearing 83.9, 94.9, 99.3, 31.2, 84.8 % of all colonyforming units. amp (hbd1, hbd2, rnase5, rnase7, s 100a7, calprotectin, cathelicidin) were found in high concentrations in postoperative pleural effusions and were mainly originating from leukocytes and pleural epithelium. although proinflammatory cytokines (il-1, il-6, tnf-α, il-8) were locally heightened in pleural fluids during the postoperative course, amp expression could not be augmented in vitro by toll-like receptors ligands or il1-β and tnf-α. conclusions: herein, we provide first evidence of a high abundance of amp in postoperative pleural fluids. these findings might serve as an explanation of the comprehensive protection against postoperative infectious complications after major lung surgery. posterior stabilization using polypropylene mesh in a patient with severe diffuse tracheomalacia background: diffuse tracheomalacia is a severe condition with limited therapeutic options. patients suffer from a complete airway collapse during forced expiration leading to severe functional impairment. stent implantation is often not successful and results in symptom deterioration due to mucus retention and chronic inflammatory changes. surgical stabilization of the membranous portion using rigid materials has been anecdotally described in the literature. methods and results: herein, we describe the case of patient who suffered from a diffuse tracheobronchomalacia associated with a moderate copd. two attempts of internal splinting using custom made self-expanding nitinol y-stents failed. after removing the second stent a surgically external stabilization was decided. through a right-sided posterolateral incision the posterior aspect of the whole intrathoracic trachea and the right and the left main bronchi were exposed. then a bard mesh (bard medica s.a., vienna, austria) was fixed to the membranous portion of the trachea and both main bronchi with four rows of interrupted sutures. the dilated cartilage sponges were brought into a c-shape again using a one centimeter shorter mash than the width of the membraneous portion. the patient could be immediately extubated at the end of the procedure and discharged home on the 11th pod. a control bronchoscopy revealed a stabilized trachea 9 months after the operation and the patient's symptoms have significantly improved. conclusions: the herein described technique of posterior stabilization using a polypropylene mesh is a valid option with good functional results in patients with severe diffuse tracheomalacia. überganges (aeg 1-3) aus 108 (76,6 %) kliniken werden hier gesondert ausgewertet. rund 60 % der aeg-tumoren wurden in kliniken operiert, die weniger als 11 kardiakarzinome pro jahr im untersuchungszeitraum behandelten. in n = 391 (82,5 %) war eine r0 -resektion möglich. endosonographiert wurde in 283 fällen (53 % high concentrations of antimicrobial peptides in post-operative pleural effusion methods: we collected samples of postoperative pleural effusions after lung operations. antimicrobial activity was evaluated using different gram positive and gram negative pathogens. pleural levels of amp were determined by elisa and pcr. in additional experiments the origin of amp was determined and the impact of proinflammatory signals on amp release was evaluated. current state of laparoscopic colonic surgery: a nation-wide survey laparoscopic and open elective colon resections are divided into ileocecal resection, right-colonic resection, left-colonic resection, sigmoid resection, rectum resection and hartmanns procedure as well as "others". the data are analysed by the imas in linz. results: the survey started in january 2014 and will be completed in february. we will present the current data of lcr, rate of conversion to open approach and open colon resections, as well as the teaching situation at the 55. annual meeting of the austrian society for surgery in graz 2014. conclusions: the nationwide survey of laparoscopic colonic surgery shows the current role of laparoscopic colonic surgery in austria. the influence of elevated levels of c-reactive protein and hypoalbuminaemia on survival in patients with advanced inoperable oesophageal cancer undergoing palliative treatment background: there is evidence that in cancer patients inflammation perpetuates tumour progression resulting in decreased survival. the aim of our study was to evaluate the influence of elevated levels of c-reactive protein (crp) as well as hypoalbuminaemia on patients with inoperable esophageal carcinoma undergoing palliative treatment. methods: the data of 218 appropriate patients with advanced esophageal cancer, who were treated at a single center within 12 years, were evaluated retrospectively. patient's age, gender, body weight, dysphagia, plasma levels of crp and albumin, the glasgow prognostic score (gps) combining both indicators, and survival were assessed for statistical evaluation. results: 39 (18.2 %) had hypoalbuminaemia and 161 (73.9 %) had elevated crp levels. patients with hypoalbuminaemia (p = 0.001) as well as patients with increased crp levels (p = 0.001) showed a significantly shorter survival. weight loss had a significant relationship with elevated crp levels (p = 0.022), with diarrhoea (p = 0.021) and with dysphagia (p = 0.008). increasing gps was significantly associated with poor survival (p = 0.001). conclusions: elevated crp levels and hypoalbuminaemia are significantly associated with reduced survival and are considered to be an appropriate predictor for poor outcome in advanced esophageal carcinoma. the gps provides additional detailed prognostication and should be therefore taken into consideration when the individual palliative strategy has to be scheduled. ergebnisse: die gesamtkomplikationsrate zeigte sich beim laparoskopischen vorgehen signifikant niedriger (p < 0,001), insbesondere in der altersklasse zwischen 60 und 80 jahren. patienten mit kardiovaskulären komorbiditäten wiesen beim minimal-invasivem vorgehen ferner niedrigere pulmonale komplikationsraten auf. ebenso zeigte sich die rate an starkem postoperativen schmerz geringer (p = 0,002). bezüglich der kardiovaskulären komplikationen, der krankenhausaufenthaltsdauer und der kosten bestanden keine unterschiede zwischen offenem und minimal-invasivem vorgehen. schlussfolgerungen: die laparoskopische resektion des rektumkarzinoms bei patienten mit hohem perioperativen risiko, insbesondere solchen zwischen 60 und 80 jahren, scheint im vergleich zum offenen vorgehen mit vorteilen bezüglich postoperativer v. a. pulmonaler komplikationsrate sowie vermindertem postoperativen schmerz assoziiert zu sein und zeigt seine vorteile auch bei diesem hoch-risiko-kollektiv. technical issues in transanal minimal invasive surgery: total mesorectal excision (tamis -tme) methods: between 11.2011-12.2013 we operated on nine patients (female = 3/male = 6, mean age 69a, bmi = 26kg/m 2 ) suffering from malign tumors in the lower rectum. in advance, 5 patients were treated with a neoadjuvant chemoradiation due to their utnm-classification. patients were placed in lithotomy position and the anus was exposed with a lonestar retractor. a sils port (covidien) or a gelpoint (applied medical) was fixed transanally after a circular incision of the rectum about 2 cm above the dentate line. using carbon-dioxide insufflation, two working instruments and a 5 mm 30° camera were delivered through the port to conduct the tme. a sil vessel ligation and mobilization of the left flexure using the incision of the planned ileostoma completed the procedure. the colon was transanally exposed and transected. by using a string suture on the lower end of the rectum the anastomosis could be performed with a circular stapling device. performing an ileostoma completed the operation. results: all but one resection could be completed successfully in a combined tamis tme technique (mean ortime = 243 min); one conversion was necessary due to a complicated tamis maneuver (urethral injury). conclusions: the advantage of this technique seems to be a good exposure of the lower rectum by performing the tme transanally. anatomical and technical prerequisites had to be considered. background: sil aims to reduce the surgical trauma on the abdominal wall. this approach is gaining attraction for colorectal resections. we report on our series of 400 sil colorectal resections. methods: between 2008-2014 we operated on 400 patients with colorectal diseases (49 % benign, 51 % malignant), no matter what bmi or age. using a single port system together with one articulating, one straight instrument, a vessel sealing instrument and a 10 mm optical device, one suspension suture for the uterus if needed, all procedures were performed in a single incision laparoscopic setting. results: all but six procedures (1.5 %) could be completed laparoscopically. additional trocars were used in 6.1 % (5.3 % one, 0.8 % two trocars). starting with left side resections all types of colorectal resections were performed in this series. or time and length of specimen varied according to the type of procedure. malignant cases comprised four patients with r1 resections (three of them operated on in palliative intention). mean number of lymph-nodes in malignancies was 16.8. complications are discussed according to the respective procedure. conclusions: sil represents a valid development of minimal invasive surgery for treating colorectal diseases useful in the routine setting. laparoskopische resektion des rektumkarzinoms bei patienten mit hohem perioperativen risiko: nutzen oder gefährdung? fragestellung: ziel der vorliegenden studie war es, den einfluss des laparoskopischen vorgehens bei der rektumkarzinomresektion bei patienten der asa-klasse 3 im vergleich zu patienten mit offener operation zu untersuchen. methodik: die daten von 1576 zwischen den jahren 2006 und 2010 konsekutiv einer rektumresektion zugeführten patienten wurden retrospektiv analysiert. dabei konnten 248 patienten mit der asa-klasse 3 identifiziert werden. davon wurden 144 patienten laparoskopisch operiert, 104 offen. erstere meist innerhalb der ersten 24 h nach vorausgegangener operation auftreten, sich über die förderung liegender drainagen bemerkbar machen und meist durch unzureichende blutstillung im bereich des resektionsbettes und der anastmosen, bzw. durch gerinnungsstörungen zurückzuführen sind, manifestieren sich gastrointestinale blutungen durch kaffeesatzerbrechen, teerstuhl, farbumschlag der magensonde, usw. häufigste ursachen sind schleimhaut-bzw. nahtblutungen im gastrointestinalen anastomosenbereich die einer endoskopischen therapie meist gut zugänglich sind. blutungen zwischen dem 7. und 80. postoperativen tag sind mit einer mortalität von über 60 % vergesellschaftet und sind meist auf arrosionen im stromgebiet der arteria hepatica zurückzuführen. prädisponierende faktoren sind ausgedehnte lymphadenektomien, neoadjuvante radiochemotherapie sowie septische komplikationen bei anastomoseninsuffizienzen. da es sich dabei meist um massive, lebensbedrohende blutungen handelt, ist die frühzeitige diagnose der schlüssel zum erfolg. in 30-80 % der fälle geht der massiven arrosionsblutung eine nicht bedrohliche indikatorblutung -"sentinel bleed" -stunden bis tage voraus, die sich bei anastomoseninsuffizienzen meist retrograd gastrointestinal bemerkbar macht. stellt die unverzüglich endoskopische abklärung den ersten diagnoseschritt dar, hat bei negativem ergebnis die radiographische abklärung des mesenterico-trunkalen arterienbaumes zwingend mittels angio-ct zu erfolgen, um bei positivem befund in einer therapeutisch interventionellen angiographie mit coiling, stentung oder histacrylklebung der blutungsquelle zu enden. wir berichten über unsere erfahrungen. pancreas transplant alone in a pancreatectomized patient after a long history of chronic pancreatitis methods: a 48-year old male patient with a 9-year history of relapsing severe episodes of acute on chronic pancreatitis became insulin dependent after duodenum preserving pancreatic head resection followed by left pancreatic resection and finally total pancreatectomy because of massive pain. due to brittle-diabetes, pta was performed. the pancreas of a 36-year old donor was transplanted with a cold ischemia time of 9 h 19 min, anastomosed to the common iliac artery and to the inferior caval vein. for pancreatic drainage a duodeno-jejunostomy was carried out. immunosuppression consisted of atg induction (single shot, 4 mg/kg), tacrolimus (thorough level 12 ng/dl), mmf and tapered steroids. results: despite immediate organ function 4 relaparotomies because of graft pancreatitis had to be carried out including intraabdominal vacuum treatment and necrosectomies, however, the patient could finally be discharged in excellent condidown to up-tamis (transanal minimal invasive surgery)-approach to tme-is this the way to go? background: low rectal cancer especially in men with narrow pelvis remains a surgical challenge regarding oncological and nerve preserving tme for open and laparoscopic approach as well. since the introduction of tem system transanal approach to rectal cancer became common for low risk small tumors. single port systems are more flexible, allowing the use of standard laparoscopic instruments to approach the distal part of the rectum, enabling much better view and resectability. this video demonstrates a possibly better approach to low rectal cancer, combining transabdominal and transanal laparoscopic surgery. methods: an open approach at the planned ileostomy site is performed for introduction of the single port system, allowing the use of up to 4 instruments. furthermore the transanal approach is highlighted and the key steps of the procedure are demonstrated. results: starting from the abdominal site a laparoscopic standard medial to lateral mobilisation of the colon is performed, including the left flexure. the dissection is stopped 2 cm above the peritoneal fold and the transanal approach starts with open transection respecting the distance to the tumor. a perstring suture is performed and a single port system introduced. under insufflation down to up dissection starting posterior if ever possible is continued. after completing dissection a stapled or handsewn anastomosis and a loop ileostomy is performed. conclusions: transabdominal and transanal combined laparoscopic tme (tamis-tme) of low rectal cancer allows better view and approach to the lowest third of the rectum and probably better preservation of nerval structures. pancreaschirurgie: status quowas bringt die zukunft? arrosionsblutungen der arteria hepatica nach pankreaskarzinomoperationen -diagnostisch, therapeutisches vorgehen pancreatic neuroendocrine tumours: prognostic factors predicting survival after resection background: pancreatic neuroendocrine tumours (pnets) are mostly associated with good prognosis. yet, a subset of patients suffers from recurrence, requiring further treatment after initial curative resection. compared to other pancreatic malignancies, predictors of recurrence such as lymph node ratio (lnr) or proliferation indices (ki67, etc.) have rarely been investigated due to the low incidence of this tumour entity. furthermore, introduction of recently proposed staging systems (enets/ uicc) requires clinical evaluation for future risk stratification. tion, with a normal c-peptide and without the need of exogenous insulin nor hypoglycemias. no rejection episode occurred. conclusions: pta after total pancreatectomy is a feasible option for patients with uncontrollable glycemia after pancreatic resection. pancreas re-transplantation in the modern era: a high-volume centre experience simultaneous pancreas-kidney transplantation (spk) is the gold standard for type 1 diabetic patients with end stage renal disease. however, pancreas re-transplantation (rept) is controversially discussed. retrospective analysis of 46 rept performed at our institution from 2000 to 2013 included 16 re-spk and 30 re-pancreas transplants alone (pta) . eight procedures were 2nd rept and one was a 3rd rept. induction immunosuppression (anti-thymocyte globuline, alemtuzumab or il-2r antagonist) was followed by maintenance immunosuppression with steroids, tacrolimus and mmf. primary endpoint was 5-year patient and graft survival. median donor age was 31 years (range 12-51) and median donor bmi was 23.2 kg/m 2 (range 17.3-29.4). median recipient age was 47 years (range 23-59), bmi ranged from 16.9 to 33.2 (median 23.7 kg/m 2 ). median waiting time was 55 months (range 0-244), cold ischemia time 14 hours (range 8-22). acute rejection occurred in 11 patients, in six of them resulting in graft loss. morbidity and reoperation rates were 78.3 and 45.6 %. after a median follow up of 67 months (range 1-154) patient and graft survival was 97 and 60 % at 5 years, respectively. following re-spk 5-year patient and graft survival was 100 and 76 %. in re-pta recipients it reached 96 and 53 % (p = 0.4 and 0.09, respectively). five-year patient and graft survival following 2nd, 3rd or 4th pt were not statistically significantly different (97 and 64 %, 100 and 28 %, 100 and 50 %, respectively; p = 0.3). rept is a valuable option for patients with failure of the previous graft and results in outcomes comparable to primary pt. folfirinox als neoadjuvante behandlung des borderline resektablen, lokal fortgeschrittenen pankreascarcinoms laparoscopic spleen-preserving left sided pancreatectomy in a pediatric patient: report of a case background: pancreas tail resection is burdened by significant morbidity due to difficult closure of the pancreas cut surface, as well as the incision size. laparoscopic resection conveys the advantages of a minimal invasive access to pancreas resections. methods: a 14-years old female patient was diagnosed with a solid-pseudo papillary tumor (frantz-tumor) of the pancreatic tail. due to the age of the patient, a spleen-preserving approach was planned. results: after placing the patient in a right lateral position, four trocars (2 × 12 mm, 2 × 5 mm) were placed. after division of the gastro colic ligament, the pancreas corpus and cauda were visualized. after sonographic verification of the tumor, the pancreas was mobilized in a medial-to lateral way and the splenic artery and vein were identified and isolated posterior to the pancreas. after division of the organ using a laparoscopic stapler, the left-sided pancreas was completely freed and removed in a bag through the umbilical port site. the procedural time was 178 min, histology confirmed complete tumor removal with clear surgical margins. following an uneventful recovery, the patient was discharged on pod 19. conclusions: due to the well-encapsulated nature of a frantz-tumor, a laparoscopic approach was possible for tumor removal. gastrostomie: techniken und probleme abteilung für kinder und jugendchirurgie, landes -frauenund kinderklinik, linz, österreich für die anlage einer gastrostomie im säuglings-und kindesalter existieren zahlreiche techniken, von der perkutanen endoskopischen gastrostomie bis zur offenen operation. methods: retrospective analysis of surgically treated pnets between 1997-2013. clinicopathological data were collected from a prospectively maintained database and complemented with immunohistochemical reevaluation of proliferation markers and staining of hormonal activity. factors predicting disease free survival (dfs) and overall survival (os) after pancreatic surgery with curative intent were investigated through univariate and multivariate analysis. results: forty patients (female: n = 24) with a median age of 61 years (14-84) were included, 55 % were graded as g1, 30 % g2 and 15 % g3. r0 resection was achieved in 83 % of cases, 25 % showed lymph node metastasis (n1), while 10 % received minor liver resections for synchronous hepatic metastasis. the median os and dfs were 25.9 and 21.1 months. lnr and ki67-index as well as resection margins, grading, n-and l-status were significant predictors of survival. conclusions: after resection of malignant pnets, besides other known factors of recurrence, ki67 and lnr are powerful predictors that might help to stratify patients for adjuvant treatment in future studies. radical resection with regional lymphadenectomy should be the standard procedure. kinder-und jugendchirurgie ii: strategien und fallbeispiele aus der visceralchirurgie minimal invasive methoden im kindes-und jugendalter -wann gibt es einen benefit? kinder-und jugendchirurgie, smz-ost donauspital, wien, österreich grundlagen: die minimal invasive chirurgie dominierte viele jahre lang die themen bei allen kongressen und publikationen in chirurgischen zeitschriften. vieles ich möglich und machbar, doch die kritische "evidence-based" auseinandersetzung ist in vielen fällen ausgeblieben. wo ist der benefit zum beispiel bei leistenhernien, wenn die narben in summe größer sind, als bei der offenen technik? was bedeutet überhaupt minimal invasiv bei säuglingen und kleinkindern, wenn wir einerseits über einen 1 cm langen hautschnitt in sedoanalgesie mit einem caudalblock die korrekturoperation durchführen können und im falle einer laparoskopischen operation einen erhöhten intraabdominellen druck und eine vollnarkose benötigen? methodik: retrospektiv wurden patienten unserer abteilung in ausgewählten krankheitskollektiven nachuntersucht und mit den eigenen ergebnissen und denen der literatur verglichen. dazu wurden die patienten der jahre 2003 bis 2013 mit den entlassungsdiagnosen inguinalhernien, appendizitis, cholezystolithiasis, unklaren bauchschmerzen, kryptorchismus und trichterbrust herangezogen. ergebnisse: die laparoskopische cholezystektomie und diagnostische laparoskopie ist unumstritten einer offenen technik zugangs. zwar können bei vielen kindern die mechanismen der intestinalen adaption zu einer enteralen autonomie führen, dennoch bleiben manche patienten von einer langfristigen parenteralen ernährung abhängig. diese kinder sind besonders gefährdet lebensbedrohliche komplikationen wie kathetersepsis und leberversagen zu entwickeln. mittels verschiedener operativer techniken wird versucht die resorptionsfunktion des dünndarmes und so die enterale nahrungsaufnahme zu verbessern. damit kann die dünndarmtransplantation aufgeschoben oder sogar ganz vermieden werden. die step operation ist eine technisch relativ einfache möglichkeit der chirurgischen behandlung bei kurzdarmsyndrom mit dünndarmdilatation. mittels step operation kann die abhängigkeit von der parenteralen ernährung durch steigerung der intestinalen resorption reduziert werden. probleme, die durch bakterielle überwucherung von darminhalt bei stase in den dilatierten dünndarmsegmenten entstehen können ebenso mittels step operation erfolgreich beseitigt werden. eine wiederholung der step operation bei redilatation des darmes ist möglich und sinnvoll. komplikationen nach step operation lassen sich in den meisten fällen konservativ beherrschen. motilitätsstörungen nach ösophagusatresie pediatric liver transplantation: an outcome analysis of a 30-year experience in a single center background: the aim of our investigation is to analyze perioperative aspects and the outcome after pediatric liver transplantation. methods: retrospective study of 104 consecutive pediatric liver transplantations performed since 1984. kaplan-meier and log-rank analyses were carried out to assess 5-and 10-year patient and graft survival. results: a total of 54 deceased donor ltx, 15 deceased donor split-ltx, 32 ltx from living donors and 3 multivisceral transplantations performed in children between 3 months and 18 years of age were included. median follow-up was 8.67 years. eleven ltx were retransplantations. median recipient age was 3.47 years, median donor age 23 years. anhepatic period was 55.2 ± 20.6 min, and cold ischemia time (cit) was 6.25 ± 4.05 h. five-year patient and graft survival were 84.3 and 79.4 %, 10-year patient and graft survival were 79.9 and 74.8 %. neither graft type, liver disease, donor or recipient age had an influence on longterm graft survival. patient (p = 0.439) and graft survival (p = 0.354) stratified for an anhepatic period below and above 45 min did not show any significant differences. stratification for cit resulted in significant lower patient (p = 0.007) and graft (0.019) survival for children with a cit above 6 h. in the deceased donor subgroup, however recipients younger than 6 years of age have significant worse 10-year-outcome (patient survival 61.8 vs. 84.1 %, p = 0.038; graft survival 55.2 vs. 81.2 %, p = 0.024). conclusions: excellent long-term results can be achieved with ltx in children. limited cit, detailed surgical planning and close long-term monitoring are critical for good results. chirurgische therapie des kurzdarmsyndromes -step operation abteilung für kinder und jugendchirurgie, landes -frauenund kinderklinik, linz, österreich die behandlung des kurzdarmsyndroms bei kindern ist anspruchsvoll und bedarf deshalb eines interdisziplinären sechs monate postoperativ zeigt sich kein anhalt auf weiterbestehende dysphagie oder reflux-symptomatik und eine adäquate gewichtszunahme. konklusion: auch beim kleinkind kann eine hochauflösende manometrie zur diagnosestellung bei achalasie durchgeführt werden. nach sondenlegung in narkose kann in der aufwachphase eine verwertbare druckkurve abgeleitet werden. die interdisziplinäre zusammenarbeit von anästhesie, kinderchirurgie und ösophagusspezialisten hat sich in innsbruck bewährt. the diagnostic value of interleukin-8 and fatty acid binding proteins in necrotizing enterocolitis background: in recent years several potential biochemical markers have been evaluated to facilitate a reliable diagnosis of necrotizing enterocolitis (nec), but none have made progress to clinical routine. we performed a comparative assessment in premature infants to evaluate the diagnostic value of the routinely available cytokine interleukin (il)-8, and two promising experimental biomarkers, the gut barrier proteins liver-fatty acid binding protein (l-fabp) and intestinal-fatty acid binding protein (i-fabp), respectively, for the diagnosis of nec. methods: il-8, l-fabp, and i-fabp concentrations were analyzed in the serum of 15 infants with nec and compared with 14 gestational-age matched infants serving as control group. results: serum concentrations of i-fabp, l-fabp and il-8 were significantly higher in infants with nec compared with controls. il-8 showed the highest diagnostic value with an area under the curve of 0.99, followed by l-fabp and i-fabp. in addition we found a significant correlation between il-8 and both fabps in infants with nec. conclusions: our results further advocate the possible role of il-8 as a specific marker for nec. the diagnostic value of il-8 seems to be superior to i-fabp, and similar to l-fabp. the routinely availability facilitates il-8 as a possible candidate for further clinical investigations. aet 4,5 % 9,2 ± 7,0 (26) 2,9 ± 3,0 (4)* 6,9 ± 9,0 (3**)* nr > 47 99,1 ± 118,1 46,2 ± 56,5 methodik: eine 32-jährige patientin wurde aufgrund chronischer therapieresistenter obstipation an unserer abteilung interdisziplinär abgeklärt. nach der sanierung eines drittgradigen rektumprolaps mittels laparoskopischer resektionsrektopexie, blieben die obstipationsbeschwerden bestehen. nach einholen einer referenzpathologie zeigte sich das bild einer atrophischen desmose des kolons. die zwillingsschwester der patientin wurde bereits vor jahren wegen ähnlicher symptomatik subtotal kolektomiert, mit deutlicher verbesserung der obstipationssymptomatik im langzeit follow-up. ergebnisse: in einvernehmen mit unserer patientin entschieden wir uns nach erfolgloser konservativer therapie sowie sakraler neuromodulation und aufgrund der voroperation für eine rechts-erweiterte hemikolektomie in sils-technik. nach dem eingriff stellte sich regelmäßiger stuhlgang ein, wodurch für unsere patientin eine immense steigerung der lebensqualität erzielt werden konnte. schlussfolgerungen: im falle einer therapieresistenten obstipation ist eine umfangreiche abklärung und die ausschöpfung aller konservativen therapiemaßnahmen unumgänglich, bevor eine operative behandlung in betracht gezogen werden sollte. seltene morphologische anomalien, wie eine atrophische desmose des darmes müssen mit in der differentialdiagnose berücksichtigt werden. die weitere therapie wird in einem tumorboard festgelegt werden. wahrscheinlich ist eine kombination aus strahlentherapie sowie einer systemischen therapie. schlussfolgerungen: anale schmerzen können auch durch seltene maligne entitäten verursacht werden. fehlende besserung auf konservative maßnahmen sollten zeitnahe durch eine intensivere abklärung ergänzt werden. pilonidalsinus-state of the art und eigene erfahrungen der pilonidalsinus ist ein in den chirurgischen ambulanzen häufig präsentes krankheitsbild. während es in der akuten phase einfache und klare therapeutische strategien gibt, ist die definitive versorgung nach primär erfolgter akutbehandlung komplizierter und aufwendiger. sie erfordert ein radikales und standartisiertes vorgehen, um den patienten bei dieser selten gefährlichen, jedoch äusserst störenden erkrankung einen langen krankheitsverlauf mit rezidivierenden eingriffe zu ersparen. der vortrag bietet eine übersicht über die gängigen chirurgischen optionen und deren evidenz, die eigenen strategien und die retrospektive analyse von 90 patienten mit lappenplastiken aus den letzten drei jahren in bezug auf komplikationen, rezidive und aufenthalts-bzw. krankenstandssdauer. die gluteusfaszienplastik -eine deutliche verbesserung in der therapie bei fistulierendem sinus pilonidalis krankenhaus der barmherzigen schwestern linz, linz, österreich grundlagen: früher beobachteten wir eine hohe anzahl an wundheilungsstörungen, wundinfekten und rezidiven bei patienten, bei denen, bei fistulierendem sinus pilonidalis, eine exzision mit primärverschluss durch einfache naht durchgeführt wurde. die folgen waren eine hohe patientenunzufriedenheit, lange krankenstände und eine aufwendige und lange therapie (meist vac-verbände). dies veranlasste uns dazu, uns eine neue op-technik zu suchen. fündig wurden wir in der gluteusfaszienplastik. methodik: patienten die unter einem nicht infizierten, fistulierenden sinus pilonidalis leiden werden mittels gluteusfaszienplastik (exzision, abpräparation der gluteusfaszie vom m.gluteus maximus, annaht des entstandenen lappens in der medianen und primärnaht mit subcutanem redon) versorgt. ergebnisse: seit anwendung der gluteusfaszienplastik ist die rate der wundkomplikationen (wundheilungsstörung, wundinfekt, rezidiv) auf ca. 10 % (4/35 patienten) gesunken. center im zeitraum 10/2004-10/2012 bei einem mittlerem follow-up zeitraum von 57 monaten (sd 35, 9) limbergplastik als therapie des sinus pilonidalis: ein erfahrungsbericht anhand von über 200 patienten über einen zeitraum von 8 jahren der sinus pilonidalis ist eine für den patienten zumeist stark belastende und häufig langwierige erkrankung. in der therapie des sinus pilonidalis stellt die limbergplastik eine der effizientesten operationsmethoden dar. im vortrag wird die gewählte technik der limbergplastik, wie sie an unserem haus durchgeführt wird beschrieben und mittels fotos anschaulich dargestellt. die von uns erhobenen ergebnisse der letzten acht jahre werden anhand von über 200 retrospektiv, nicht randomisierten patienten dargestellt und hinsichtlich der komplikations-und rezidivrate ausgewertet. diese daten werden mit nationalen und internationalen studien verglichen. dabei kann gezeigt werden, dass durch diese technik die rezidiv-und komplikationsrate, im vergleich zu anderen therapieoptionen gesenkt werden können. minimal invasive chirurgie): videositzung: amic laparoskopische pankreas-links-resektion tipps und tricks in der pankreaschirurgie werden zunehmend minimal-invasive verfahren eingesetzt. insbesondere die laparoskopische pankreaslinksresektion (plr) wird in immer mehr kliniken durchgeführt. eine konventionelle laparotomie für die meist nicht mehr als 2 cm im durchmesser messenden neuroendokrinen pankreastumore bedeutet ein zugangstrauma, welches in keinem verhältnis zur tumorgröße steht. diese situation ist vergleichbar mit der aktuellen operativen therapie der meisten nebennierentumore. in der literatur wird die laparoskopische plr ist im vergleich zur offenen plr mit einem geringeren blutverlust, einer kürzeren krankenhausverweildauer sowie einer geringeren gesamtmorbidität und einer geringen rate an wundinfektionen assoziiert. aufgrund ihrer meist geringen größe eignen sich einige von ihnen gut für ein laparoskopisches vorgehen. anhand dieses videos werden tipps und tricks zur sicheren laparoskopischen pankreas links resektion gezeigt und diskutiert. eine deutliche verbesserung im vergleich zu zuvor beobachteten ca. 60 % (12/19 patienten). schlussfolgerungen: die gluteusfaszienplastik ist eine sichere, komplikationsarme therapiemöglichkeit beim fistulierenden sinus pilonidalis, durch die die krankenstandsdauer gesenkt und die patientenzufriedenheit erhöht werden kann. vom pilonidalsinus zur rektumexstirpation der patient ist derzeit fast ein jahr postoperativ rezidiv -und beschwerdefrei. schlussfolgerungen: strahlen oder chemotherapie hatten in der behandlung unseres patienten keinen stellenwert. bei ausgedehnten lokalen exzisionen ist die kooperation mit der plastischen chirurgie wertvoll, sie ermöglicht das wiedererlangen einer guten lebensqualität des patienten. tive time and dissection time of 156 and 102 min, respectively. via a 2.7 cm incision one articulating instrument, a 10 mm camera and a vessel sealing instrument were deployed. transection of major vessels in the splenic hilus was performed by use of a stapler. specimen retrieval was achieved with the help of extra large bag and morcellation. complications were not encountered. conclusions: single port surgery can be performed safely and feasibly even in patients requiring removal of a giant spleen. laparoskopische fixation des colon ascendens und coecums bei coecalem volvulus der coecale volvolus hat eine inzidenz von 2,8-7,1 pro million menschen pro jahr und ist für 1-3 % aller obstruktionen des dickdarms verantwortlich. die symptome reichen vom zustandsbild eines akuten abdomens bis hin zu chronischen abdominellen beschwerden. im vortrag werden besonderheiten und schwierigkeiten der diagnostik beleuchtet. der fall einer 30-jährigen patientin zeigt, wie mittels laparoskopischer refixation des colon ascendens und coecum eine beschwerdefreiheit erreicht wurde und ihr damit eine konventionelle ileocoecalresektion oder rechtseitige hemicolectomie erspart werden konnte. insbesondere werden videosequenzen der operation sowie bewegliche ct bilder, welche eindrucksvoll die massiv überblähten darmanteile und die drehung um die mesenterialachse darstellen, präsentiert. transrectal specimen retrieval: an option for further trauma reduction in single port combined laparoscopic sigmoid resections background: laparoscopic sigmoid resection for diverticular disease is a standard procedure. single port access leads to trauma reduction to the abdominal wall, whereas specimen retrieval needs incision enlargement. this didactic video demonstrates step by step our technique of combined single port laparoscopic sigmoid resection with transrectal specimen retrieval. methods: an open approach at the umbilical site is performed with an incision < 3.5 cm for introduction of the single port system with integrated protection folie, allowing the use of up to four instruments. the key steps and potential pitfsp transrectal alls inherent to any colorectal resection are demonstrated, while the specifics of single port surgery and the transrectal specimen retrieval are highlighted. results: a standard medial to lateral mobilisation of the colon is performed, adhesiolysis done if necessary using only straight or one articulating instrument additional. the dissection of the specimen is completed intraabdominal. for means of stapling the upper rectum an additional 12 mm trocar in a suprapubic position can be helpful. a retrieval bag is introduced transrectal after distinct cleaning of the rectal stump and transecting the stapling line. the entire specimen is placed in the bag and retrieved, the opened rectal stump is stapled again. anvil placement in the descending colon is achieved transumbilical, anastomosis is performed in a usual manner. conclusions: single port laparoscopic sigmoid resection is a safe and efficient procedure. transrectal specimen retrieval offers further trauma reduction to the abdominal wall and potentially reduces incision related complications as wound infection and hernia. minimal invasiveness combined with maximal resection: single incision laparoscopic splenectomy background: patient with spherocytosis suffer from chronic symptoms including anemia, increased blood viscosity and splenomegaly. herein we present the case of transumbilical single incision laparoscopic (sil) removal of a giant spleen. methods: we report on a 37-year-old male patient with spherocytosis suffering from persisting abdominal pain due to splenomegaly (30 × 21 cm). splenectomy was performed by means of sil after routine preoperative check up. results: the procedure was carried out transumbilically using a sil device and could be completed within a total opera-des linken unterlappens mit konsekutiver infiltration von zwerchfell und dorsolateraler thoraxwand (5 rippen) stellte die rekonstruktion und vor allem der erhalt der funktionalität nach radikaler resektion des linken unterlappen, zwerchfell und insgesamt 7 rippen vor eine große herausforderung. methodik: die resektion erfolgte über die alte thorakotomienarbe, wobei diese großzügig mitsamt der narben der thoraxdrainagen exzidiert wurde. die eigentliche thorakotomie erfolgte ventral wobei der unterlappen zunächst vaskulär und bronchial abgesetzt wurde. in weiterer folge wurden zwerchfell und 7 rippen en-bloc reseziert. das zwerchfell wurde mit einem porcinen patch ,die rippen mit einem kieferorthopädischen plattensystem rekonstruiert. die fixation der platten erfolgte durch schraubenfixierung an der wirbelsäule sowie ventral durch schrauben und drahtcerclagen an den rippenstümpfen. die platten wurden nunmehr mit einem porcinen patch gedeckt. der weichteilverschluß darüber erfolgte direkt. ergebnisse: die funktionalität konnte in anbetracht des resektionsausmaßes zufriedenstellend erhalten werden (fevi post op: 2100 ml). das kosmetische ergebnis war für den patoienten ebenso zufriedenstellend. schlussfolgerungen: die rekonstruktion großer thoraxwanddefekte erfordert oftmals individuelle lösungasansätze. die verwendung des kieferorthopädischen plattensystems der firma medartis ermöglicht eine sowohl funktionelle als auch kosmetisch ausgedehnte lösungsvariante. operatives management bei thoracic outlet syndrome: vorläufige ergebnisse nach supraklavikulärem zugang die initial für solche auxiliären maßnahmen erforderlichen zusatzinzisionen an der haut in der prästernalen region, erforderlich für die subperichondralen partiellen chondrektomien und horizontalen sternotomien wurden zunehmend nach lateral in die submammäre/subpektorale region verlagert, um das ästhetische endergebnis unter betracht des narbenbildes zu verbessern. verbessertes instrumentarium und zuletzt auch refinements der chirurgischen inzisionen als zugang zu den osteochartilaginären relaxationen reduzieren weiterhin deutlich die länge der sichtbaren und stigmatisierenden narben, zum benefit des ästhetischen ergebnisses. durch die weiterentwicklungen des weitgehend narbenfreien autologen lipotransfers werden auch silastikimplantate zur auffüllung von geringen ausprägungen des pe oder auch restdeformitäten zunehmend obsolet. thoraxwandrekonstruktion mittels kieferorthopädischer metallschienen nach extensiver tumorresektion als innovativer lösungsansatz results: data were collected and analysed retrospectively. in our clinic a two-step approach for the management of such patients was developed and implemented. as the first step contact gastrostomy is performed with subsequent reconstructive esophagogastroplasty as a second step. a distinctive feature of this method is the partial mobilisation of the lesser gastric curvature with incision and clipping of the left gastric artery. formation of the gastrostomy as the isoperistaltic tube is provided equidistantly to the lesser gastric curvature. attachment point of the stomach tube for gastrostomy on the anterior abdominal wall matches to the diameter of the opening and the of replacing tube. the distal part of the tube is fixed by sutures to the structures of the anterior abdominal wall. this type of gastrostomy is performed taking into account subsequent reconstructive step of esophagogastroplasty by using of prepared stem from the greater gastric curvature. conclusions: performing of this type of contact gastrostomy makes a good possibilities for performing next step of esophagogastroplasty. antibiotika-prophylaxe in der herzchirurgie -"der grazer weg" tiefe sternuminfektionen (dswi) stellen in der herzchirugie eine lebensbedrohliche situation dar. der antibiotikaprophylaxe kommt hier eine zentrale bedeutung zu. an der herzchirurgie graz wird seit 10 jahren eine kombinierten prophylaxe mit cephalosporin und teicoplanin mit folgenden schema durchgeführt. wir berichten über unsere erfahrungen: vor op auf der station: curocef  1,5 g i. v bei narkoseeinleitung: targocid  10 mg/kg (bei kreat > 1,4 halbe dosis) an der hlm: in die hlm: curocef  1,5 g nach der hlm: targocid  5 mg/kg postoperativ: curocef  1,5 g 6 h nach op-ende nur bei klappenersatz: curocef  1,5 g 3x täglich für 48 h bei penicillinallergie alternativ: tavanic  500 mg an stelle von curocef  . ergebnisse: als ursachen konnten halsrippen (n = 2), hypertrophie des m. scalenus anterior und medius(n = 2), anomalien der 1. rippe (n = 4), verlängerung des processus transversus des 7. halswirbels (n = 1), hypertrophie der costoclavikulären membran (n = 3) objektiviert werden. postoperative komplikationen umfassten nachblutungen (n = 3) und eine persistierende lymphfistel bei linksseitigem tos (n = 1). der stationäre aufenthalt betrug durchschnittlich 5,6 tage (range: 1-24 d).das funktionelle outcome war nach 6-monatiger klinischer kontrolle bei 10 patienten subjektiv sehr zufriedenstellend mit voller remission, bei 2 patienten konnte eine neurologische residualsymptomatik diagnostiziert werden. schlussfolgerungen: der supraclavikuläre zugang erlaubt eine vollständige darstellung des plexus brachialis und erweist sich somit insbesondere bei ntos als bevorzugte option. bei vaskulärem tos jedoch ist eventuell aufgrund der fehlenden manipulation an den nervalen strukturen dem transaxillären zugang der vorzug zu geben. prolonged dilatation by large diameter esophageal stent placement in recurrent achalasia: initial results and evaluation of endolumenal stent suture-fixation background: treatment of esophageal achalasia such as myotomy or pneumatic dilatation appears to be effective in many patients. however, some patients still present with treatment failure. we have started to use short-term implantation of a largediameter self-expandable metal stent (sems) in patients with recurrent achalasia. as stent migration is expected to be high, we further evaluated the use of endolumenal stent suture-fixation (essf). methods: patients diagnosed with recurrent achalasia were allocated for prolonged dilatation and large-diameter fully covered esophageal stents (niti-s stent, pejcl gerhard medizintechnik gmbh) were placed across the esophagogastric junction. to prevent early migration, stents were attached to the esophageal wall with either endoscopic clips (group-a: n = 4) or by essf (group-b: n = 4) using an endoscopic suturing-system (over-stitchtm, hcp-austria). patients were scheduled to have stentremoval after 4 to 7 days. results: eight patients, with an initial median eckardt score of 4 (range: 4-9), were treated by prolonged dilatation. stent placement was performed without complications in all patients. esophagograms on the first day found the esophageal stents migrated into the stomach in three of the four patients in group a (75 %). on the other hand, essf (group b) prevented early stent migration in all patients when endolumenal sutures were used. at the 3-month follow-up eckardt score had improved in all but one patient (median 2, range: 1-5). conclusions: prolonged dilatation of the les might be an interesting therapeutic alternative to treat patients with recurrent achalasia. additionally, essf appears promising to prevent early stent migration. binary logistic regression showed that age at time of surgery, episode of af during hospitalisation and preoperative arterial hypertension were predictors for the recurrence of af. conclusions: minimally invasive mitral valve surgery synchronous with surgical left atrial ablation results in high rates of sinus rhythm at discharge and in the long-term. freedom from af within the first year, however, is not predictive for long-term results. evaluation and comparison of differing techniques may lead to improvement of long-term outcome in surgical patients with af. vergleich zwischen st thomas-und bretschneider-kardioplegie-lösung bei minimalinvasiven mitralklappeneingriffen über anterolaterale minithorakotomie long-term follow-up of minimally invasive left atrial ablation synchronous with mitral valve surgery background: the study investigates long-term efficacy of surgical left atrial ablation for atrial fibrillation (af) synchronous with minimally invasive mitral valve surgery. the resulting data was collected for quality assurance and forms the basis for comparisons with other institutions. methods: the study is based on a single-centre clinical trial with partly retrospective and partly prospective design. 54 patients, who underwent minimal invasive mitral valve surgery with additional radiofrequency left atrial ablation (medtronic cardioblate) at our institution between october 2006 and april 2011 where examined in a long-term follow-up of 45 ± 18 months. cardiac rhythm, echocardiographic parameters and patient characteristics were assessed by single ecg, 24 h holter monitoring, prolonged continuous holter monitoring, telephone interviews with patients, consultation of attending cardiologists or physicians and by retrieving data from the clinical information system. freedom of af in total study population (n = 54) (%) ergebnisse: innerhalb des beobachtungszeitraums entwickelten 53 patienten (10,2 %) mit initial diagnostiziertem rektum-ca (rc) sowie 33 (5,6 %) mit initialem colon-ca (cc) ein lr, median 32,1 monate nach primär-tumor diagnose. die histologische aufarbeitung zeigte meist primär-tumore in fortgeschrittenen tu-stadien (100 % t3/t4-cc; 81,1 % t3/t4-rc) mit positivem lk-befall in 63,6 % (cc) und 64,2 % (rc). in der mehrzahl der patienten wurde nach diagnose eine lr-spezifische therapie durchgeführt (84,8 % cc, 90,65 % rc), häufig mittels einem erneuten chirurgischen ansatz (82,1 %-cc, 56,3 %-rc). das 5-jahres überleben (os) nach lr war 17,4 % (15,1 % rc, 21,2 % cc). in der separaten analyse zeigte sich ein signifikanter einfluss der chirurgie des lr sowie im speziellen der onkologisch radikalen (r0)-resektion (p = 0,003) im vergleich zu den konservativen therapiemodalitäten (chemo-/radiotherapie). schlussfolgerungen: die diagnose eines lr ist im allgemeinen verbunden mit einem deutlich reduzierten 5-jahres patientenüberleben. eine onkologisch radikale (r0)-resektion des lr kann das outcome und patientenüberleben signifikant positiv beeinflussen. lokalrezidive 11 jahre nach neoadjuvanter radiochemotherapie beim rektumkarzinom multiviscerale resektion in der colorectalchirurgie im wandel -entwicklung der letzten jahre anhand der eigenen patientendaten einleitung: durch die entwicklung multimodaler therapiekonzepte sowie hoher chirurgischer standards wurden in der colorektalen chirurgie die grenzen der onkologisch sinnvollen multivisceralen resektionen immer weiter verschoben. um die morbidität und mortalität bei ausgedehnten resektionen auf einem niedrigen niveau zu halten, bedarf es neben der eigenen expertise auch einer interdisziplinären kooperation. methodik: es folgt eine darstellung der entwicklung der onkologischen standards in der colorektalen chirurgie von der einfachen resektion bis hin zur multivisceralen resektion und anschließender hipec. es wird das eigene patientengut der letzten (minimum) 10 jahre eines high volume center hinsichtlich der anzahl der multivisceralen resektionen, der morbiditäten, mortalität und weiterer qulitätsparameter aufgearbeitet und mit der vorliegenden literatur verglichen. das lokoregionäre rezidiv beim kolorektalen karzinom -eine single center analyse wertigkeit der hepatischen metastasektomie bei kolorektalem karzinom bei patienten älter als 70 jahre klinik für allgemeine, viszeral-, transplantations-, gefäß-und thoraxchirurgie, münchen, deutschland die mit der steigenden lebenserwartung einhergehende alterung der bevölkerung in den westlichen nationen und die zunehmende inzidenz der chirurgischen therapie hepatischer metastasen haben zu einer enormen zunahme von patienten in höherem alter mit hepatisch metastasiertem kolorektalem karzinom geführt, die im rahmen des multimodalen therapiekonzepts einer leberresektion zugeführt werden. die chirurgische therapie bei diesem patientengut wird gemeinhin mit höherer perioperativer morbidität und mortalität sowie verringertem langzeit-überleben assoziiert. alters-assoziierte abnahme der leberfunktion und perioperative komplikationen werden hierfür verantwortlich gemacht. patienten: die daten von zwischen 2003 und 2012 einer elektiven leberresektion bei hepatisch metastasiertem kolorekateln karzinom zugeführten patienten, welche zu diesem zeitpunkt 70 jahre oder älter waren (n = 71), wurden retrospektiv mittels multivariater analyse ausgewertet. hierfür wurden demographische daten, leberstatus, ausmaß der chirurgischen resektion samt intraoperativer parameter, perioperative morbidität und mortalität sowie das langzeitüberleben untersucht. ergebnisse: bei der patientenpopulation überwog der anteil an männlichen patienten (68 %), das mittlere alter bei operation lag bei 74,5 (± 4,1) jahren mit einem durchschnittlichen asa-score von 2,7. die mittlere anzahl hepatischer metastasen pro patient lag bei 2,0. bei 45 % der patienten handelte es sich um eine synchrone metastasierung des kolorektalen karzinoms. 63 % der patienten waren zuvor chemotherapiert worden. 13 % der durchgeführten leberresektionen wurden bei rezidivmetastasen durchgeführt, davon bei einem patienten bei zweitem rezidiv. weitere, resektable metastasen lagen bei 14 % der patienten vor uns wurden ebenfalls chirurgisch adressiert. eine asa-score von drei und höher reduzierte das mediane überleben signifikant von 39 auf 27 monate (p = 0,006). ebenso traf dies für die erforderlichkeit der intraoperativen gabe von erythrozytenkonzentraten zu (verkürzung von 41 auf 27 monate, p < 0,001). der body-mass-index (im mittel bei 26,2 kg/m 2 ) hatte im gesamtkollektiv keinen signifikanten einfluss auf das gesamtüberleben. die daten zeigen, dass im höheren alter auch größere leberresektionen bei metastasen eines kolorektalen karzinoms sicher durchzuführen sind. komorbiditäten und der intraoperative blutverlust stellen einen prädikator für das gesamtüberleben der patienten dar. die beachtung dieser sowie weiterer identifizierter risikofaktoren könnte die morbidität und mortalität dieser patientenpopulation weiter senken. daher dürften ausgewählte ältere patienten bei korrekter indikationsstellung auch von ausgedehnten leberresektionen profitieren, so dass das alter selbst nicht als kontraindikation auch für größere leberresektionen anzusehen ist. 2001 nach neoadjuvanter radichemotherapie einer onkologisch radikalen resektion eines rektumkarzinoms zugeführt wurden, wurde ein lokalrezidiv erst im jahr 2012, d. h. 10,5 bzw. 11,3 jahre nach der primäroperation entdeckt. die nachsorge erfolgte bei allen patienten leitliniengerecht. bis 2012 waren diese unauffällig, dann fiel in beiden fällen im rahmen der abklärung eines harnaufstaus ein präsakrales rezidiv auf. eine kurative rezidivtherapie war nicht möglich. auch 11 jahre nach kurativer therapie eines neoadjuvant vorbehandelten rektumkarzinoms treten lokalrezidive auf. ob eine anpassung der nachsorge auf die nach neoadjuvanter therapie zu erwartende verzögerte rezidiventstehung vor dem hintergrund einer evtl. möglichen erneuten kurativen therapie sinnvoll ist, bleibt zu diskutieren. resektion eines colorektalen karzinoms bei patienten älter als 70 jahre -gibt es ein alterslimit? grundlagen: bis zu 30 % der colorektalen carzinome (crc) treten bei patienten älter als 70 jahre auf. die meisten studien inklusive jener multimodale therapien betreffend schreiben als exklusionskriterium ein patientenalter zwischen 75 und 80 jahren vor. aufgrund der demografischen entwicklungen stellt sich aber immer öfter die frage des therapieansatzes jenseits dieser altersgrenze. wir analysieren daher den perioperativen verlauf nach onkologischer colonresektion in dieser altersgruppe. methodik: von 01/2012 bis 12/2013 konnten 110 patienten, bei denen eine onkologische colonresektion durchgeführt wurde, in die studie inkludiert werden. perioperative parameter wie kurativer oder palliativer therapieansatz, crc-stadium, operationsausmaß, multimodalität und perioperative komplikationen wurden altersabhängig analysiert (gruppe a < 70 jahre, gruppe b > 70 jahre). ergebnisse: in gruppe b (n = 66) waren die tumore wie folgt lokalisiert: rektum (n = 23), sigma (n = 21), c. descendens (n = 2), c. ascendens (n = 10), coecum (n = 9), c. transversum (n = 1). die altersverteilung in gruppe b war: patienten > 70 jahre (n = 38), patienten > 80 jahre (n = 23), patienten > 90 jahre (n = 5). die 3-monatsmortalität betrug in gruppe a 2,3 % (1/44) und in gruppe b 3,0 % (2/66), ursächlich dafür waren cardiale ursachen (n = 2) bzw. eine exazerbierte niereninsuffizienz (n = 1). die spätmortalität lag in gruppe a bei 2,3 % und in gruppe b bei 4,5 % mit cardialer todesursache (n = 1) und tumorprogredienz (n = 4). schlussfolgerungen: aus unseren daten leiten wir eine vergleichbare perioperative mortalität bei onkologischer colonresektion bei patienten jünger/älter als 70 jahre ab. weiters wird künftig auch bei geriatrischen patienten ein kurativer therapieansatz immer öfter gerechtfertigt sein. we identified all patients with stage iii adenocarcinoma of the colon and rectum using staging criteria of the american joint committee on cancer. we included 311 patients who had undergone surgical resection, out of these 18 patients (5,8 %) were excluded because of in hospital mortality. results: of 293 patients, 71 were diagnosed with rectal cancer in the middle or lower third. overall 49 (16.7 %) patients did not receive an adjuvant chemotherapy, the median age was 80 years (range 49-96 years), 28 were female. from these 49 patients adjuvant chemotherapy was not recommended in 10 (20.4 %) because of one or more co-morbidities and in 17 (34.7 %) patients the reason was a combination of co-morbidities and age. 14 (28.6 %) patients refused the recommended chemotherapy. postoperative surgical complications led to omission in 5 (10.2 %) patients. conclusions: our findings demonstrate that the most common cause for omission of adjuvant chemotherapy was the presence of co-morbidities and their combination with an older age. furthermore, patients' reasons for refusing treatment need to be systematically assessed. von der maximalresektion zum watchful waiting bei der behandlung des tiefen rektumkarzinoms abt. für allgemein-, tumor-und viszeralchirurgie, wilhelminenspital, wien, österreich grundlagen: die neoadjuvante langzeitradiochemotherapie kann zu kompletten klinischen tumorremissionen beim tiefen rektumkarzinom (− 6 cm ab ano) führen. patienten, die ein stoma strikt ablehnten oder aus anderen gründen nicht operabel waren, wurden nach eingehender aufklärung und interdisziplinärem einverstännis gänzlich konservativ behandelt oder im falle eines tumorrezidives einer transanalen endoskopischen mukosaresektion (tem) unterzogen. methodik: zwischen 2008 und 2013 wiesen 5 patientinnen (3 frauen, 2 männer, medianes alter 78 jahre; 53-83a) mit tie-background: unstable meniscal tears are rare injuries in skeletally immature patients. loss of a meniscus increases the risk of subsequent development of degenerative changes in the knee. this study deals with the outcome of intraarticular meniscal repair and factors that affect healing. parameters of interest were type and location of the tear and also the influence of simultaneous reconstruction of a ruptured acl. methods: we investigated the outcome of 25 patients (29 menisci) aged 15 (4-17) years who underwent surgery for full thickness meniscal tears, either as isolated lesions or in combination with acl ruptures. intraoperative documentation followed the ikdc 2000 standard. outcome measurements were the tegner score (pre-and postoperatively) and the lysholm score (postoperatively) after an average follow-up period of 2.3 years, with postoperative arthroscopy and mrt in some cases. results: twenty-four of the 29 meniscal lesions healed (defined as giving an asymptomatic patient) regardless of location or type. 4 patients re-ruptured their menisci (all in the pars intermedia) at an average of 15 months after surgery following a new injury. mean lysholm score at follow-up was 95, the tegner score deteriorated, mean preoperative score: 7.8 (4-10); mean postoperative score: 7.2 (4-10). patients with simultaneous acl reconstruction had a better outcome. conclusions: all meniscal tears in the skeletally immature patient are amenable to repair. all recurrent meniscal tears in our patients were located in the pars intermedia; the poorer blood supply in this region may give a higher risk of re-rupture. simultaneous acl reconstruction appears to benefit the results of meniscal repair. das stumpfe bauchtrauma im kindesalter outcome of repaired unstable meniscal tears in children and adolescents wundbehandlung bei kindern mit dem cnp-unterdruck-system wundbehandlung bei kindern erfordert bedingungen die eine optimale behandlung der wunde selbst ohne traumatisierung der kinder durch schmerzhafte verbandwechsel gewährleisten. bei 8 kindern im alter von 2, 4, 6, 8, 9 und 12 jahren wurde das cnp-system (kerlix gaze und unterdruck) in verschiedenen indikationen eingesetzt: "klassisch" zur wundkonditionierung nach debridement sowie als "verband" für großflächige wunden sowie lappenplastiken und spalthauttransplantate. der wechsel des systems erfolgte in wöchentlichem rhythmus meist in sedierung. bei allen kindern wurde das angepeilte behandlungsziel, wundkonditionierung nach infektion, reizlose abheilung großflächiger wunden bzw. einheilung von lappen und spalthauttransplantaten problemlos erreicht. das -mobile -system wurde von den kindern gut und ohne wesentliche erfordernis zur analgetikagabe toleriert, die behandlung konnte in allen fällen plangemäß zu ende geführt werden. mit einer verbandwechselfrequenz von 1x pro woche konnte die psychische belastung der kinder im rahmen der behandlung gering gehalten werden. results: twenty patients were included into the study. the gender ratio was 1:1. vms were located only in the region of fingers in 12 patients, in the region of fingers and palm in 5 patients, and only in the palm region in 3 patients. additional vms were present in two patients. five asymptomatic patients did not receive any treatment. in 15 patients (mean age at surgery 11 years; age range 2-17 years) surgical excision and debulking was performed due to pain, and/or functional deficits. in one patient prior to surgical excision an unsuccessful sclerotherapy was performed. at follow-up (mean 5 years; range 1-9 years), 11 patients were in "remission" after one (n = 9) or two (n = 2) surgical interventions, and four patients had "improvement" after two (n = 2) or three (n = 2) surgical interventions. conclusions: due to the dangers associated with sclerotherapy in the region of the hand surgical treatment is an important therapeutic option for patients with vms of the hand, especially when symptoms cannot be managed with conservative therapy. summarized experiences of laryngotracheal reconstruction in 7 children background: the management of pediatric laryngotracheal stenosis is complex and needs a dedicated team, consisting of thoracic surgeons, ent surgeons, speech therapists, pediatricians and anesthetists. the majority of pediatric airway stenosis are a sequelae of prematurity followed by prolonged postpartal intubation/tracheostomy. surgical correction is difficult due to combinations of glottis and subglottic defects in most cases. methods and results: herein, we describe a case series of seven children (age ranging between 15 and 55 months) who were operated by the laryngotracheal team vienna between 03/2012 and 06/2013. six out of the seven children had a combination stenosis involving the glottis (fused vocal cords, fixed arythenoid joints) and the subglottic airway (modified myer-cotton iii/ivc and d). after a thorough preoperative evaluation stenoses were surgically corrected through a cervical incision. laryngotracheal reconstruction using anterior and posterior rib cartilage interpositions was performed in four patients. the three remaining children received an extended cricotracheal resection with a dorsal cartilage graft and coverage with a distal mucosal flap. six out of seven procedures were performed as two-stage interventions using an lt-mold to stabilize the reconstructed airway. all children could be discharged 4 to 15 days after the operation and to date six out of seven patients have been successfully decannulated after mold removal. conclusions: both, laryngotracheal reconstruction and extended circotracheal resection with rib cartilage interposition have been established as safe procedures with good long-time follow-up by the laryngotracheal team vienna. background: treatment of venous malformations (vms) of the hand is particularly difficult due to potential problems related to damage of the blood supply, function, and cosmesis. the aim of this study was to evaluate the outcomes of our patients. methods: we retrospectively reviewed the data of patients treated at our institution from 2003 to 2012. the outcome of patients was classified into four groups: "remission", "improvement", "worsening" and "no change." single incision laparoscopy: the surgeons' perspective after 2,500 cases background: single incision laparoscopic surgery (sil) has become an accepted approach in minimally invasive surgery. however, after an initial hype an increasingly differentiated perception encouraged surgeons to go back to standard multiport laparoscopy for particular procedures. methods: a total of 2,500 consecutive sil procedures performed within five years in a high volume centre were analyzed. all relevant intra-and post-operative data of surgeons who performed more than 100 sil procedures each were compared. the annual status for every procedure was reviewed. surgeons were generator implantiert. im laufe der jahre wurde die indikation zunehmend strenger gestellt, hier spielt der kostenfaktor sicher mit eine rolle. bei 16 patienten traten komplikationen auf, eine explantation wegen infektion, dislokation oder wirkungsverlust war in 13 fällen erforderlich. im follow-up war der großteil der neuromodulationsträger aufgrund der hohen lebensqualität sehr zufrieden mit der therapie. für uns waren die reduktion der inkontinenzepisoden und die abnahme des wexner-scores ein wichtiger erfolgsparameter. schlussfolgerungen: die sakrale neuromodulation stellt nach sorgfältiger evaluierung eine sehr effektive und komplikationsarme methode zur behandlung der fäkalen inkontinenz dar. intersphinktaere gatekeeper(r) implantation zur behandlung passiver stuhlinkontinenz -ergebnisse einer europaeischen multicenterstudie grundlagen: gatekeeper  ist ein selbst-expandierbares, nicht resorbierbares implantat zur behandlung passiver stuhlinkontinenz. primäres ziel der vorliegenden studie war die evaluation der wirksamkeit von gatekeeper  mit berücksichtigung der verminderung der stuhlinkontinenzereignisse, verbesserung der lebensqualität und auswirkungen auf die schließmuskelleistung. sekundäres endziel war die einführung eines einheitlichen protokolls an mehreren europäischen zentren. methodik: in 10 europäischen zentren wurden patienten mit passiver stuhlinkontinenz seit mindestens 6 monaten in die studie eingeschleust. es wurden jeweils sechs implantate pro patient intersphinktär unter endoanaler sonographiekontrolle operativ eingebracht. eine klinische untersuchung, ein stuhltagebuch, der wexner sowie vaizey score, der ams score, qol fragebögen, anomanometrie und endoanaler ultraschall wurden präoperativ, ein und drei monate sowie ein jahr postoperativ durchgeführt. ergebnisse: insgesamt wurden 47 patienten (34 weiblich, ø alter 62, 1 ± 12,8) in die studie eingebracht. es kam zu einer signifikanten reduktion der inkontinenzereignisse für stuhlschmieren, winde und flüssigen stuhl (p < 0,05), nicht jedoch für festen stuhl. der wexner und vaizey score konnten signifikant verbessert werden (13,0 auf 6,6 und 14,7 auf 7,5; p < 0,001). die implantate konnten im follow-up endosonographisch detektiert werden, eine signifikante verbesserung der anomanometrischen parameter konnte nicht beobachtet werden. schlussfolgerungen: gatekeeper  stellt eine minimal-invasive und leicht anwendbare methode zur behandlung passiver stuhlinkontinenz dar. die implantate werden nicht resorbiert und migrieren nicht und können im follow-up endosonographisch exakt detektiert werden. ist die single incision appendektomie (sil-ae) sinnvoll? ergebnisse: in der gruppe der sil-ae gab es -vergleichbar mit den gruppen der multiport und der offenen ae -keine relevanten unterschiede in der op dauer, mortalität und morbidität. die mediane aufenthaltsdauer betrug 2,5 tage in der sil gruppe, wobei sich auch hier keine statistisch signifikanten unterschiede zur multiport technik zeigten, wohl jedoch im vergleich zur gruppe der offenen ae. im beobachtungszeitraum von 2 jahren fand sich keine narbenherniation. die materialkosten waren in der sil gruppe erwartungsgemäß höher als in der gruppe der offenen ae, relativieren sich allerdings durch die kürzere verweildauer. in 4 fällen der sil gruppe wurde ein oder zwei zusätzliche trokare platziert. das subjektiv beste kosmetische ergebnis ließ sich in der sil gruppe erzielen. schlussfolgerungen: die single port appendektomie ist der multiport technik sowohl was das postoperative outcome, die operationsdauer als auch die komplikationen betrifft zumindest ebenbürtig. das kosmetische ergebnis ist besser, da der operationszugang meist gar nicht mehr sichtbar ist. von vorteil erweist sich auch die steile lernkurve, sodass die sil ae an unserer abteilung die standardmethode darstellt. tagesklinische single-port-cholezystektomie im kh der barmherzigen schwestern wien questioned concerning the reasons of performing or not performing a procedure by means of sil. results: sil sigmoid and rectum resection, appendectomies and cholecystectomies gained a wide acceptance by all surgeons. the majority of these procedures were conducted in single port techniques one year after introduction. sil right sided colon resection was initially hampered by the subtile technique to perform the anastomosis. sil groin hernia repair was initially performed by all surgeons but abandoned within 2 years for standard laparoscopy due to technical reasons by two surgeons. after an initial series of sil fundoplications all surgeons went back to a reduced multiport technique due to technical disadvantages. if a minimally invasive access was suitable liver, pancreas, splenic and gastric procedures were conducted in sil technique. conclusions: sil surgery has become the standard approach in many different procedures. personal discomfort or technical disadvantages are reasons for the return to standard multiport laparoscopy. die laparoskopische appendektomie als standard der chirurgischen therapie der appendizitis universitätsklinik für chirurgie, paracelsus medizinische privatuniversität salzburg, salzburg, österreich die chirurgische therapie der akuten appendizitis ist nach wie vor die standardtherapie. neben der konventionellen offenen appendektomie kommen vermehrt auch minimalinvasive techniken zum einsatz. mehrere studien zeigten die vorteile der laparoskopischen appendektomie, sodass das laparoskopische vorgehen als empfehlung für krankenhäuser, in denen das nötige equipment und die expertise der chirurgen zur verfügung stehen ausgesprochen wurde. an der uk für chirurgie in salzburg werden pro jahr durchschnittlich 270 appendektomien durchgeführt. wurden 2008 noch 183 konventionelle gegenüber 105 laparoskopischen appendektomien (36,5 %) durchgeführt, so erfolgten 2013 von insgesamt 251 appendektomien nur mehr 26 in konventioneller und 225 in laparoskopischer technik (89,6 %). die postoperativen ergebnisse decken sich mit der publizierten literatur. die erhöhten kosten von ca. € 150.-werden durch den kürzeren stationären aufenthalt kompensiert. zur 3 port-laparoskopischen appendektomie wird an unserer abteilung auch die mils (minimal incision laparoscopic surgery) technik angeboten, wobei 3,5 mm arbeitstrokare verwendet werden. die mils-technik ist gleich sicher wie das konventionelle 3-port verfahren, die postoperativen schmerzen waren geringer und das kosmetische ergebnisse exzellent. die laparoskopische appendektomie ist nach unseren erfahrungen als standardvorgehen geeignet. die mils-appendektomie stellt eine vernünftige alternative dar, wenn das kosmetische ergebnis eine wichtige rolle spielt. ease related complexity. individualized management is based on experience. single port laparoscopic combined transvaginal colorectal surgery: experience from a single centre s. bischofberger, l. traine, n. kalak, w. brunner the reduction of interventional trauma is considered a main goal in modern surgery. innovative techniques as single port laparoscopy, have been developed to further minimize surgical access trauma. using a transvaginal access suprapubic or umbilical incision enlargement for specimen retrieval can be avoided. method: from march 2011 to december 2013 a total of 104 single-port left hemicolectomies, sigmoid and rectal resection were performed (56 m, 48 f). in 21 females a combined transvaginal access and specimen retrieval was performed (mean age 58y (36-84), mean bmi 25.5). 57 % of females had undergone previous abdominal surgery incl. hysterectomy in 5. indication were diverticulitis (17), malignant intestinal neoplasia (3) and benign rectal polyp (1) . two left hemicolectomies, two rectal resections and 17 sigmoid resections have been performed. data was collected in a prospective single centre-database for single port-procedures. results: transvaginal specimen retrieval was possible in all 21 females. in 6 cases one additional trocar was used. no conversion to open surgery was necessary. severe complication rate (clavien-dindo iiib or higher) was 9.6 %, one reoperated by laparoscopic approach, one required open surgery. no vaginal complications or wound infections occurred. mean discharge was at day 6 (no complications). mean fascia incision length was 2.6 cm (2.1-3.6) . conclusions: single port-access is an innovative and still evolving way towards further reduction of interventional trauma in colorectal surgery. the technique is safe and feasible. transvaginal specimen retrieval offers further trauma reduction to the abdominal wall and potentially reduces incision related complications as wound infection and hernia. die laparoskopische herniotomie der ventralen hernie -sils-ipom: aktuelle lage in österreich methodik: einschlusskriterien galten für patienten mit symptomatischem gallensteinleiden asa i und ii, die gewährleistung der postoperativ häuslichen betreuung durch angehörige und die zu erwartende compliance. alle seit dezember 2013 inkludierten patienten wurden prospektiv eingeschlossen und die ergebnisse der intra-und postoperativen komplikationen, tatsächlicher krankenhausaufenthalt sowie grund für weitere hospitalisierung ausgewertet. ergebnisse: 4 patienten wurden bisher inkludiert (3 frauen, 1 mann), durchschnittsalter 39 jahre (± 11), bei allen vier patienten war cholecystolithiasis als diagnose angegeben. bei einem patient bestand ein z. n. akuter cholezystitis. 3 patienten konnten in single-port-technik operiert werden; einmal war ein zusätzlicher 5 mm-trokar notwendig. bei diesem patient wurde eine drainage eingelegt. im post-op. verlauf zeigte sich eine serombildung im nabelbereich, welche konservativ ausbehandelt wurde. die dauer des tatsächlichen krankenhausaufenthaltes betrug durchschnittlich 1,75 tage (± 0,9), wobei einmal die liegende drainage und einmal das psychische zustandsbild ursache für die stationäre behandlung waren. schlussfolgerungen: die untersuchung konnte zeigen, dass bei präoperativer patientenselektion und hochwertiger chirurgisch-anästhesiologischer zusammenarbeit die tagesklinische laparoskopische cholezystektomie durchführbar ist. defining a standard in 1,000 consecutive single incision laparoscopic cholecystectomies background: the laparoscopic approach for cholecystectomy, either multiport conventional, needlescopic or single port, is currently under debate. we present a series of 1,000 consecutive single incision laparoscopic (sil) cholecystectomies performed in a high volume center. methods: from 2008-2014 a total of 1,000 sil cholecystectomies were performed at the department of surgery, sjog hospital salzburg. from the very beginning the operating strategy, in particular all required steps for safety, was not compromised compared to conventional laparoscopy. exposure and dissection was undertaken using one articulating instrument. a 5 mm optical device was used predominantly and a suspension suture on demand. all parameters were prospectively collected in a database. results: after an initial period of patient selection all procedures with an underlying benign disease were performed in a sil setting. obesity and acute inflammation were found to result in a higher number of additional trocars. the or time yielded in mean 56 min which is not significantly different from the or time spent for conventional multiport cholecystectomy when the learning curve, patient's demographics (obesity, inflammatory state, prior interventions) and procedural parameters (simultaneous ercp, bile duct exploration, etc.) are taken into account. with growing experience various features widened the surgical armamentarium. conclusions: sil has become the standard first approach for laparoscopic cholecystectomy regardless of patient or dis-ergebnisse: alle standardeingriffe der hernienchirurgie können sicher in sil technik durchgeführt werden. es kristallisiert sich der richtige verschluss der portstelle als "pitfall" heraus. eigene ergebnisse werden vorgestellt. die sil-tapp als teaching operation division of general surgery, general hospital kufstein, kufstein, österreich grundlagen: 2008 wurde an unserer abteilung der erste single-port eingriff durchgeführt. seither wurden insbesondere cholezystektomie, tapp und sigmaresektion etabliert und standardisiert. da die tapp in unserem krankenhaus nur noch in single-port technik durchgeführt wird, muß sie den assistenten in dieser form gelehrt werden. methodik: in einer prospektiven single-center, single-surgeon-studie soll die machbarkeit, die sil-tapp als teaching-operation zu etablieren, erhoben werden. dies ohne vorherige erfahrungen des operateurs mit der tapp-oder der sil-technik an sich. neben der operationsdauer wurden das handling des port-systems, der instrumente und das subjektive befinden des operateurs sowie der assistenz beurteilt. ein follow-up wurde nach 4-6 wochen durchgeführt. ergebnisse: im zeitraum von oktober 2013 bis januar 2014 wurden 15 patienten in der studie erfasst. der operateur hatte bislang selbst noch keine erfahrung als erstoperateur mit der sil technik gemacht. alle eingriffe wurden ohne konversion oder komplikationen vollendet, einmal mußte die operation von der assistenz übernommen werden. der operateur entwickelte im verlauf eine gute technik. dies spiegelt sich unter anderem in der zeit zum einbringes des port-systems (12-3 min.), der op-dauer (73-37 min.) und im subjektiven empfinden (3-1) wieder. im follow-up zeigten sich durchwegs zufriedene patienten (vas 1-2), keine rezidive. schlussfolgerungen: aus unserer sicht eignet sich die tapp in single-port technik als teaching-operation. sie ist für den patienten sicher und für den operateur ohne derartige vorkenntnisse mit gutem subjektiven empfinden durchführ-und erlernbar. hinsichtlich op-dauer befinden wir uns im guten internationalen vergleich, die lernkurve scheint mit der konventionellen tapp vergleichbar zu sein. the learning curve in single port laparoscopic transabdominal preperitoneal repair (tapp) for inguinal hernia single port surgery to reduce the trauma to the abdominal wall is most criticized due to technical challenge for the surgeon to perform, especially for non-laparoscopic-skilled junior methodik: durch standardisierte befragungen aller chirurgischen abteilungen in österreich wurden empfehlungen für diese therapieform evaluiert. weiters werden unsere erfahrungen mit dieser op-technik sowie zahlen zur zufriedenheit präsentiert. ergebnisse: zum zeitpunkt der abstracteinreichung stehen die österreichweiten befragungsergebnisse größtenteils noch aus. im zeitraum von oktober 2012 bis jänner 2014 wurden an unserer abteilung 38 sils-ipom durchgeführt. es wurden insgesamt 45 hernien, davon 15 primäre bzw. 30 sekundäre hernien, teilweise simultan vorliegend, operiert. die mittlere größe der bruchlücken betrug 5,5 cm. zwei unterschiedlich beschichtete netze wurden verwendet. die lokalisation der brüche lag bei 17 patienten im oberbauch, bei 7 patienten im nabel, bei 2 patienten im linken mittelbauch (trokarstelle) und bei 7 patienten suprasymphysär. bei 5 patienten waren die brüche auf mehrere lokalisationen verteilt. weiters fand sich bei 4 patienten ein gitterbruch. eine adaptation der bruchränder erfolgte bei 18 patienten (47 %). in unserem kollektiv gab es 3 rezidive (7,9 %). es gab eine revisionspflichtige nachblutung (2,6 %) sowie 2 netzinfekte (5,3 %). die mittlere zufriedenheit der patienten lag bei 8,6 (0-10). schlussfolgerungen: die laparoskopische ipom der ventralen hernie in sils technik wird an unserer abteilung routinemäßig durchgeführt. die rezidivrate bzw. die rate an komplikationen sind mit anderen daten vergleichbar. es besteht eine hohe patientenzufriedenheit. über die österreichweite bedeutung dieser op methode soll im rahmen des vortrages berichtet werden. port reduzierte verfahren (single incision laparoskopie und notes) in der hernienchirurgie -der status quo anhand einer übersicht klinischer literatur und präsentation eigener ergebnisse methodik: das referat soll einen überblick über die wichtigsten, klinischen sil hernienstudien (inguinal-, ventral-, parastomalhernien) bieten und die frage beantworten, ob es auch noch relevante notes aktivitäten gibt. besonderes augenmerk gilt den fragen, ob sil in der hernienchirurgie messbare vorzüge gegenüber der klassischen laparoskopie ermöglicht (z. bsp. schmerz oder lebensqualität) oder vielleicht in manchen punkten sogar nachteile haben könnte (z. bsp. narbenhernieninzidenz in den portstellen). darüber hinaus soll der innovationsschub, den sil und notes bei instrumenten und materialien bewirkt haben, dargestellt werden. conclusions: sp tapp represents a safe and generally applicable surgery technique with high patients satisfaction. adipositaschirurgie: adipositas/ metabolische chirurgie i langzeitergebnisse nach malabsorptiven bariatrischen eingriffen grundlagen: bei der behandlung von patienten mit extremformen der morbiden adipositas stellen malabsorptive verfahren sowohl als geplantes zweizeitiges behandlungskonzept als auch als primärer eingriff eine behandlungsoption dar. der anteil an malabsorptiven eingriffen gemessen an der gesamtzahl aller bariatrischen eingriffe ist mit etwa 2 % gering. eine goldstandard zur richtigen verfahrenswahl gibt es nach gegenwärtiger wissenschaftlicher evidenz nicht. methodik: in diese retrospektiven analyse wurden 37 morbid adipöse patienten, die im zeitraum zwischen 2002 und 2013 in der krankenanstalt rudolfstiftung sowie im sozialmedizinischem zentrum ost operiert wurden, untersucht. eingeschlossen wurden jene patienten die eine bilio-pankreatische teilung nach scopinaro, eine bilio-pankreatische teilung mit duodenal switch, oder einen malabsorptiven magenbypass erhalten haben. erfasst wurden neben dem effektiven gewichtsverlust, die perioperative letalität, langzeitkomplikationen, der mikronährstoffhaushalt sowie die subjektive zufriedenheit der patienten. neben der analyse der daten wurden telefonvisiten zur aktualisierung und komplettierung der daten durchgeführt. ergebnisse: von den insgesamt 37 patienten erhielten 19 patient eine operation nach scopinaro, 12 patienten einen duodenal switch und 6 einen malabsorptiven magenbypass. die mehrzahl der eingriffe erfolgte im rahmen von revisionsoperationen. postoperative major komplikationen traten bei 10 % der patienten auf. zwei patienten mussten später wegen malabsorptionsbeschwerden reoperiert werden. mid-term follow-up evaluation of gastric bypass after failed bariatric procedures background: patients after bariatric surgery (sagb, sleeve, gastric stimulator) may experience insufficient weight loss, intolerance, or other severe complications of their primary opera-surgeons. herein we report the learning curves of laparoscopicskilled senior surgeons and a non-laparoscopic-skilled junior surgeon in single port tapp hernia repair. methods: between july 2011 and january 2014 we recorded and compared operation-times of two laparoscopic-skilled senior surgeons and one non-laparoscopic-skilled junior surgeons starting to learn the sp-tapp. results: in the time period two senior surgeons performed 125 respectively 46 procedures with an average operation-time during first half of 101 resp. 76 min, and the second half with 71 resp. 67 min. the junior surgeon performed 15 sp-tapp procedures with an average operation-time during the first half of 80 min and the second half of operations showed no significant change with 84 min operation-time. looking on the course of procedures operation-times seem to depend on the amount of the performed operations. conclusions: sp-tapp requires a certain kind of familiarization even for the laparoscopic skilled surgeon. it seems that operation times and need for additional trocars depend on the amount of performed operations. sp-tapp seems to need about 30 to 40 procedures to reduce the operation-times as well for the laparoscopic skilled surgeon as for the non-laparoscopic junior surgeons. transumbilical single-port laparoscopic transabdominal preperitoneal repair of inguinal hernia: progress in reducing invasiveness results: 368 single-port tapp procedures (208 unilateral, 80 bilateral, 17 recurrent hernia) were performed in 288 patients (243m/45f, mean age 49.1y, bmi 25). 16.3 % of the patients have had previous abdominal surgery. mean operation time was 62.3 min (unilateral) and 96.1 min (bilateral). mean fascial incision length was 25 mm (± 7 mm), mean skin incision length was 32 mm (± 9 mm). additional trocars were needed in 18.8 % corresponding to the experience of the surgeons. no conversions to open surgery were necessary. no intraoperative complications were observed. according to the follow up, patients are very satisfied with general result (1.45 ± 0.82, 1 = very satisfied, 5 = very unsatisfied) and generally do not suffer from postoperative discomfort (1.60 ± 0.9). moreover the cosmetic result is evaluated very well (1.18 ± 0.48). up to now there was only one recurrence of inguinal hernia, but no trocar hernia. a double challenge transplant: horseshoe kidney meets obesity first case of horseshoe kidney transplantation following laparoscopic sleeve gastrectomy for obesity k. kienzl-wagner, j. pratschke, r. öllinger innsbruck medical university, department of visceral, transplant and thoracic surgery, innsbruck, austria background: the rising prevalence of obesity in pretransplant candidates is a major challenge in solid organ transplantation. in an era of growing organ shortage donor criteria are expanded to kidneys with congenital anatomical anomalities. horseshoe malformation is the most common renal anatomical variation associated with complex vascular and urinary tract abnormalities. methods: we here report the first case of laparoscopic sleeve gastrectomy performed as a first step procedure to achieve rapid weight loss in a morbidly obese renal transplant candidate that was followed by successful transplantation of a horseshoe kidney. results: in our 62-year old female hemodialysis patient sleeve gastrectomy resulted in sustained weight loss from bmi 37.5 kg/m 2 to 33.6 kg/m 2 within 3 months and facilitated access to our kidney transplant waitlist. only 6 months after bariatric surgery the patient was offered a horseshoe kidney. due to a crossing urinary collecting system the horseshoe kidney was transplanted en bloc. vascular reconstruction with extension of the donor distal aorta produced a conduit of adequate length for anastomosis to the recipient's common iliac artery. excessive abdominal wall and skin from profound weight loss (20 kg) facilitated placement of the large volume horseshoe kidney in the right iliac fossa. one year post transplant the patient maintains a bmi of 25.7 kg/m 2 and renal function is excellent with a serum creatinine of 1.1 mg/dl. conclusions: laparoscopic sleeve gastrectomy proved to be an innovative strategy to access the transplant waitlist. due to complex vascular anatomy horseshoe kidney transplantation requires great surgical skills and should therefore remain in experienced hands. therapieoptionen und erfolgsaussichten von reoperationen bei therapieversagern nach magenbypass chirurgische abteilung, bhs wien, wien, österreich grundlagen: mit der magenbypassoperation erzielt man sehr zufriedenstellende ergebnisse hinsichtlich der gewichtsreduktion. problem gibt es jedoch mit primären und vor allem mit sekundären therapieversagern. es stellt sich die frage nach der sinnhaftigkeit und den möglichkeiten einer reoperation. methodik: retrospektiver vergleich der ergebnisse der an unserer abteilung durchgeführten re-eingriffe. wir haben bisher tion. in such a case, revisional gastric bypass is an alternative to manage these complications. aim of this study is to evaluate our experience with revisional gastric bypass. methods: retrospective analysis of 129 consecutive patients (109 females, 124 post sagb) undergoing revisional bypass. follow-up was 40.64 ± 30.3 months. data are reported as total numbers (%) and mean ± standard deviation. results: mean age was 43.9 ± 10.8 years, mean bmi at time of bypass 38.1 ± 7.3. most common indications for revisional bypass were band migration (24.0 %), patient wish (20.2 %), pouch dilatation (13.2 %) and band leakage (8.5 %). operative time was 195.9 ± 61.7 min (including 69 (53.5 %) single stage procedures), length of stay 8.72 ± 12.84 days. 1-year mortality rate was 0 %, 30-day complication rate was 12.4 %, including a 8.5 % wound complication and 3.9 % reoperation rate. bmi at 1, 3 and 5 years was 30.3 ± 5.6, 29.6 ± 4.8 and 29.5 ± 6.2, respectively, ewl at the end of follow-up 30.1 %. conclusions: revisional gastric bypass is a safe and durable alternative for patients with failure of previous bariatric surgery up to five years after the procedure. does pouch size affect outcome in patients undergoing revisional gastric bypass? background: revisional bypass is a valid option for patients with failure of other bariatric procedures. post sagb, the scar post band removal may require either smaller or larger pouches than usual. aim of this study was to evaluate the outcome according to pouch size. methods: one hundred and twenty-six patients undergoing revisional bypass were retrospectively reviewed. pouch size was stratified into large (> 8 cm-group i) or small (< 8 cm-group ii). postoperative gastro-jejunostomy related complications and postoperative bmi were compared using chi-2 and non-parametric tests. p < 0.05 was considered significant. results: twenty patients (15.9 %, 70 % female, age 42.2 ± 10.2 years) had a large (98.3 ± 17.2 mm), 106 (84.1 %, 86.8 % female, age 44.5 ± 10.7 years) a small pouch (48.6 ± 17.0 mm). operative time was 189.0 ± 53 (i) versus 198.6 ± 59.7 (ii). postoperative anastomosis complication rate was 15.0 % (i) vs. 20.8 % (ii) (p = 0.404), including a 0.0 vs. 4.7 % leakage (p = 0.346) and 5.0 vs. 6.6 % stenosis rate (p = 0.628). preoperative and postoperative bmi at 1, 3, and 5 years (ii vs was 38.9 ± 6.6 vs. 37.9 ± 7.42 (p = 0.184), 31.0 ± 6.6 vs. 30.4 ± 5.4 (p = 0.568), 29.6 ± 4.4 vs. 30.7 ± 7.8 (p = 0.978) and 30.9 ± 10.6 vs. 29.5 ± 5.6 (p = 0.476), respectively. conclusions: in this retrospective series, pouch size did not affect anastomosis-related complication rate or postoperative weight loss. rospectively analyzed. all removals were performed under general anesthesia by flexible endoscopy using a special band cutter, with simulations port removal. indications for removal, time from surgery to removal, morbidity, and mortality were analyzed. data are reported as total numbers (%) and mean ± standard deviation. results: endoscopic removal was possible when the band had migrated enough to be passed endoscopically on two sides to allow for installation of the band cutter. the mean interval between sagb implantation and endoscopic removal was 76.4 ± 36.2 (19.0-142.0) months. primary success rate was 100 %, with nil procedural morbidity and no early or late post-interventional complications observed. all patients underwent postoperative abdominal x-ray studies, with extraluminal air visible in some cases, however not resulting in postoperative leakage or peritonitis. all patients underwent successful revisional bariatric surgery after recovery in an interval of 13.6 ± 12.0 (2.0-36.0) months. conclusions: endoscopic band removal is a feasible and safe alternative to laparoscopic band removal in a selected group of patients experiencing failure of adjustable gastric banding caused by band migration. comparison of one-step vs two-step revisional laparoscopic gastric bypass after failed adjustable gastric banding in 129 consecutive patients background: revisional laparoscopic roux-en-y gastric bypass (lrygb) has been advocated as the procedure of choice in patients after failed adjustable gastric banding. little is known whether a one-step procedure (band removal + lrygb) or a two-step procedure (band removal-interval-lrygb) shall be preferred. aim of this study is to compare the peri-operative and midterm results of both methods at our institute. methods: retrospective analysis of 129 consecutive patients (69 one-step procedures, 60 two-step procedures) undergoing revisional bypass. follow-up time was 40.64 ± 30.3 months. indications for one-step or two-step procedures, operation time, peri-operative complications, morbidity, and mortality were analyzed. data are reported as total numbers (%) and mean ± standard deviation. results: mean age at time of bypass was 43.1 ± 10.7 vs 44.8 ± 10.8 years with a mean bmi of 36.9 ± 7.1 vs 39.6 ± 7.4 (onestep vs two-step). most common indication for a one-step revisional bypass was patient's wish (30.4 %) followed by motility disorder (15.9 %), whereas for a two-step procedure band migration was the leading cause (51.7 %) followed by pouch dilatation (13.3 %). operative time differed only marginally 194.2 ± 54.2 vs 197.8 ± 66.0 min, as well as length of in-hospital stay: 8.2 ± 2.8 vs 9.3 ± 6.0 days. one-year mortality rate was in both groups 0 %, 30-day complication rate was 5.4 vs 7.0 %, including a 2.3 vs 6.2 % wound complication rate. 14 pouchverkleinerungen mit anastomosenneuanlage durchgeführt, 3 weitere derartige eingriffe mit bandverstärkung (banded bypass) und 3 malabsorptive umwandlungsoperationen. ergebnisse: die auswertungen sind noch im gange, die ergebnisse werden bis zum kongress vorliegen. schlussfolgerungen: es sollen hinweise gewonnen werden, welche eingriffe in welchen fällen sinnvoll erscheinen, bzw. wo die grenzen der adipositaschirurgie liegen. transit bipartition als "second stage procedure" nach sleeve gastrektomie ein nicht unbeträchtlicher anteil der patienten benötigt jedoch einen zweiteingriff, sei es um das gewicht zu stabilisieren oder wegen ungenügender gewichtsabnahme. methodik: eine form der zweitoperation nach sleeve ist die transit teilung-in anlehnung an die von s. santoro publizierte operation (ann. surg. 2012), bei der eine gastroileoanastomose im antumbereich angelegt wird dabei bleibt die nahrungspassage durch das duodenums erhalten. die biliopankreatische anastomose wird bei 100 cm proximal der ileocoecalklappe durchgeführt. ergebnisse: an unserer abteilung wurden von jänner 2013 bis dezember 2013 7 transit teilungen nach sleeve gastrectomie durchgeführt. ausgewertet sollen peri-und postoperative komplikationen, ewl% und möglich malabsorptive beschwerden werden. schlussfolgerungen: bisher galt der magenbypass als zweiteingriff nach "first step sleeve" an unserer abteilung als methode der wahl. ob die transit bipartition eine alternative dazu darstellt, wollen wir nach unseren wenigen patienten mit kurzem beobachtungszeitraum diskutieren. endoscopic band removal of migrated adjustable gastric bands: a single center experience background: transgastric migration of adjustable gastric banding is a well described cause of band failure, requiring band removal. in this study, we present our experience with an endoscopic approach to band removal. methods: twenty-two patients, who underwent endoscopic band removal between june 2002 and december 2013, were ret-und in manchen fällen ist die amputation der einzige ausweg, wenn auch diese sorgfältig gegen risiko und nutzen einer komplexen rekonstruktion abgewogen werden muss, um im endeffekt dem patienten ein paar jahre mit hoher lebensqualität zu ermöglichen. hand replantation after attempted suicide: technical aspects and outcome results: three patients (2 male, 1 female), mean age 53 years have been treated. complete ischemia at presentation in 2, incomplete ischemia in 1. all injuries were to the left wrist and caused by a kitchen knife. two patients presented with haemorrhagic shock at admission (hemoglobin < 20 mg/dl) with ventilatory support initiated by the paramedic team. drug tests were negative. in all instances nerves and tendons of the volar aspect of the wrist were cut, in one instance incomplete dissection of the radial bone. reconstruction involved a multidisciplinary team with reconstruction of arterial circulation first (3 grafts, 2 direct anastomoses), then tendons and nerves. nerve transplants were necessary in one. secondary plastic coverage was necessary in 2. veins were not reconstructed. in all patients the hand could be salvaged and psychological counseling was offered during rehabilitation. no patient gained full motor function at last follow up. all patients are alive, with no further suicide attempt being observed. conclusions: suicidal attempts with deep structure involvement is usually undertaken with great force causing extensive damage. extensive blood loss and hypothermia impede surgery. usually several procedures may be necessary to salvage the extremity. results are gratifying, yet psychologic counseling seems to be the most important factor for successful long term survival. lebensqualität nach extrem mutilierenden eingriffen am bewegungsapparat eine sehr positive zusammenarbeit zwischen ärzten einzelner fachdisziplinen ermöglicht es maximale eingriffe am bewegungsapparat durchzuführen. es gibt grenzen der wiederherstellungschirurgie, so dass nur sehr selten angewandte, maximal conclusions: both approaches show good comparable results. nonetheless the one-step approach shows shorter operation times, shorter in-hospital stay, as well as a slight trend towards less wound complications with regard to the two-step method. anyhow the decision must be made individually in each patient. grundlagen: das hauptaugenmerk in der behandlung bösartiger knochen-und weichteiltumore liegt auf der onkologischen radikalität. für den erhalt einer betroffenen extremität sind verschiedenste techniken des plastische-chirurgischen spektrums zur defektdeckung und -rekonstruktion erforderlich. mit diesen ist eine erfolgreiche tumorbehandlung mit zufriedenstellender form und funktion der extremität möglich. in dieser arbeit präsentieren wir unsere konzepte zur funktionellen rekonstruktion bei knochen-und weichteiltumoren der oberen extremität. methodik: wir präsentieren ausgewählte patientenbeispiele mit unterschiedlichen tumorentitäten an hand/arm. diese patienten wurden mit der bitte um amputation an unsere klinik zugewiesen. in all diesen patienten konnte ein erhalt der extremität ohne massive einbußen in der handfunktion erreicht werden. das chirurgische spektrum reichte von homo-und autologen knochentransplantaten für ober-und unterarmrekonstruktionen, über freie und gestielte lappenplastiken zur defektdeckung und muskel-und sehnentransfers zur wiederherstellung der handfunktion. ergebnisse: in allen fällen konnte eine weite resektion mit freien schnitträndern erreicht werden. die rekonstruktion der knochen-und weichteildefekte konnte in einer sitzung durchgeführt werden. nach rehabilitation erreichten alle patienten eine zufriedenstellende handfunktion und konnten weiterhin ein unabhängiges leben führen und die betroffene hand zumindest als hilfshand einsetzen. schlussfolgerungen: durch ausschöpfung des plastischchirurgischen spektrums konnten die patienten trotz schwieriger und progressiver tumorerkrankungen vor einer amputation und so vor einer deutlichen behinderung bewahrt werden. die onkologische sicherheit muss allenfalls das primäre ziel sein mutilierende resektionsmethoden das überleben des patienten ermöglichen -wie die intrathorakoskapuläre amputation der oberen extremität, mit und ohne gleichzeitige thoraxwandresektion oder die beidseitige hüftenukleation mit teilweiser beckenresektion. dies kann bei patienten nach unfällen -mit querschnittläsionen, dekubitalulzera, und knochennekrosen, compartementsyndromen, oder schier unbeherrschbaren infektionen -wie nekrotisierenden fasziitiden an den unteren extremitäten, oder zentral an der oberen extremität gelegenen tumoren oder tumorrezidiven nötig sein. es sollen patienten vorgestellt werden die die maximalen eingriffe je nach ausgangsbefund bis zu mehr als 20 jahren überlebten und trotz massiver einschränkungen zu ihrer lebensqualität stellung nehmen. vortrag mit videos! 2nd surgical department -breast cancer center akh-lfkk linz, linz, österreich grundlagen: die sofortrekonstruktion der mamma nach mastektomie kann mit geringen komplikationen und gutem kosmetischem ergebnis durchgeführt werden. erfolgt nach sofortrekonstruktion eine radiatio ist dies mit komplikationen und oft mit verlust der rekonstruktion verbunden. ist eine radiatio nach mastektomie indiziert, wird demgemäß auf eine sofortrekonstruktion verzichtet. das ausdehnen der indikationen zur bestrahlung nach mastektomie machen es für den operateur nicht immer planbar, ob nach rekonstruktion eine radiatio nötig wird. methodik: in den letzten 13 jahren wurde bei 30 patienten nach mastektomien und sofortrekonstruktion (latissimus 8, prothesen/expander 18, tram 3, diep 1) eine radiatio (ungeplant 28) durchgeführt. ergebnisse: bei 17/30 patienten (57 %) kam es zu komplikationen nach bestrahlung, davon in 5/17 (29 %) zu einem implantatverlust. schlussfolgerungen: der zeitpunkt der bestrahlung, die technik der rekonstruktion bestimmen die komplikationen. die verwendung von polyurethanbeschichteten prothesen, azellulärer matrix oder lipomodelling könnten auch bei prothesenrekonstruktion die komplikationen durch radiatio vermindern. ist eine radiatio nach mastektomie geplant sollte auf eine sofortrekonstruktion verzichtet und die spätrekonstruktion mit autologem gewebe geplant werden. die sofortrekonstruktion solltein diesen fällen nur nach eingehender aufklärung der patientin über die zu erwartende höhere komplikationsrate durchgeführt werden. onkoplastische mammchirurgie -ein wesentliches element jeder psychoonkologisch adäquaten brustkrebsbehandlung analyzes in 33 cases of tets and 21 nonneoplastic thymuses. these results were corroborated by systemic measurements (elisa) of serum in 41 patients with tets, 28 patients with th and 48 volunteers. results: rage and hmgb1 are both expressed in tets as well as in regular thymic morphology. we have observed the strongest cytoplasmatic rage expression in who type b2 thymomas and thymic carcinomas (p < 0.001). the nuclear hmgb1 staining was strongest in a and ab thymomas; conversely the cytomplasmatic staining was strongest in b1 thymomas(p < 0.001). in serum the levels of soluble rage (srage) were significantly reduced in tets (p = 0.008) and in invasive tumor stages (p = 0.008), whereas the levels of hmgb1 were significantly increased (p = 0.008). fetal thymuses showed a strong rage expression of subcapsular epithelial cells, which was also found in 50 % of myasthenic patients. further rage was specifically expressed in hassall's corpuscles, macrophages, thymic medulla and in germinal center cells of patients with follicular hyperplasia. conclusions: thus, rage and hmgb1 are involved in thymic malignancies as well as in regular thymic morphology. the different thymic and systemic expression of these molecules may act as diagnostic or therapeutic targets in cancer and autoimmunity. ionizing radiation induced gene expression changes in human peripheral blood mononuclear cells background: damage to the spinal cord affects mainly young, active patients and results in irreversible neurologic deficits in many cases, while therapeutic options are limited. inflammation and micro-vascular obstruction after initial trauma aggravates neuronal loss followed by declined neurologic function. recent data suggest anti-inflammatory, anti-apoptotic and anti-thrombotic properties of secretomes of peripheral mononuclear cells (aposec) in-vitro and in-vivo. methods: the aim of this study was to evaluate possible effects of aposec in a commonly used spinal-cord contusion model in rats using the infinite horizon impactor (precision systems and instrumentation, llc). motor function was assessed by the basso-beattie-bresnahan method on day 3, 7, 14, 21 and 28. neuropathological investigation of inflammation and parenchymal damage was performed with h&e-and luxol fast blue stain and immunohistochemistry for amyloid-precursor-protein on day 3 and day 28 after trauma. results: treatment with aposec lead to improved motor function after spinal-cord injury compared to control group assessed by the basso-beattie-bresnahan method (n = 9 each group, p < 0.001). amelioration of neurological damage in the aposec group was confirmed histologically. conclusions: our data suggest that aposec improves motor function after spinal-cord injury. further studies are required to elucidate mechanisms leading to this improvement. the secretomes of apoptotic mononuclear cells ameliorate neurological damage in rats with focal ischemia the pursuit of targeting multiple pathways in the ischemic cascade of cerebral stroke is suggested to emerge as a possible treatment option. here we examined the regenerative potential of conditioned medium derived from rat apoptotic mononuclear cells, rmnc apo sec , and clinically more relevant, from virus inac-conclusions: in this study we were able to show that (1) ir alters expression of both mrnas and mirnas; (2) a large number of genes coding for secretory proteins are detectable in irradiated pbmc, (3) bioinformatic analysis of these secreted proteins reveals that they have the potential to modulate biological processes of angiogenesis, wound repair, vasodilatation, platelet aggregation, hematopoiesis and tissue repair. tetrahydrobiopterin protects pancreatic isograft from brain death associated damage background: brain death (bd) has been shown to immunologically prime grafts in part by aggravating ischemia reperfusion injury (iri). herein we assessed the effects of bd on iri in an experimental setting furthermore the therapeutic potential of tetrahydrobiopterin (bh4), an essential nos-cofactor was tested. methods: pancreas transplantation was performed using c57bl/6-mice. animals underwent bd induction and were followed for 3 h. experimental groups included: non-treated bddonors, bd-donors treated with 50 mg/kg bh4, ventilated nontreated donors and living donors. following 2 h of reperfusion, microcirculation (functional capillary density, fcd; capillary diameter, cd) and cell viability was assessed by intravital fluorescence microscopy. parenchymal graft damage was assessed by histology, ros were quantified by immunohistochemistry against nitrotyrosin and mrna expression of inflammatory candidate markers was measured by real-time rt-pcr. results: compared with controls, bd exacerbated iri reflected by significantly reduced fcd and cd values (p < 0.05). moreover bd induced il-1ß, tnfa, il-6 and icam-1 mrna expression. in contrast treated grafts displayed significantly higher fcd and cd values (p < 0.05). bd had devastating impact on cell viability whereas treatment resulted in significantly higher numbers of viable cells after reperfusion (p < 0.01). parenchymal damage in grafts from bddonors was significantly more pronounced when compared to controls (p < 0.05). treatment resulted in significantly better histology. nitrotyrosin immunostaining showed significantly higher score values in grafts from bd donors when compared to bh4 treated pancreata. conclusions: our data gain new insights into the impact of bd on pancreatic grafts. donor pre-treatment with bh4 offers a novel option for preventing bd exacerbated iri. rechten gallengangs komplettiert. nach entlassung der patienten wurden engmaschige nachuntersuchungen angeschlossen. ergebnisse: von november 2010 bis dezember 2013 führten wir 22 alpps-resektionen bei patienten mit primären (n = 3) und sekundären lebertumoren (n = 19) durch. das mediane alter betrug 63,6 jahre (46-81). bei 17 von 22 patienten lagen colorektale lebermetastasen vor (rektum/colon: n = 10/7; synchron/metachron: n = 11/6). die mittlere wartezeit zwischen der ersten und zweiten operation betrug 14,5 tage (7-63). in dieser zeit kam es zu einer volumen-zunahme des postoperativ verbleibenden leberanteils von 68, . die postoperative morbidität wurde anhand der dindo-clavien-klassifikation eingeteilt (keine komplikationen: n = 4, grad i: n = 3, grad ii: n = 5, grad iii: n = 6, grad iv: n = 0, grad v: n = 4). zu einem lokalen oder extrahepatischen rezidiv im ersten jahr kam es bei 13/18 (72,2 %) patienten. schlussfolgerungen: alpps stellt eine vielversprechende methode zur steigerung der resektabilitätsraten bei initial irresektablen lebertumoren dar. neben einer höheren morbidität und mortalität muss in diesem besonderen patientenkollektiv mit einer hohen rezidivrate gerechnet werden. single incision laparoscopic liver resection: state of the art background: the laparoscopic approach of the liver, in particular resection of left lateral segments and anterior segments, has become standard in experienced hands. single incision laparoscopy (sil) aims at further reducing the surgical trauma. herein we describe our experience and state of the art in sil liver resection. methods: between 09/2009 -11/2013 for malignant (26) or benign (12) diseases. a single port system (octoport, gelport) was used in all procedures. intraoperative ultrasound completed the staging and allowed for defining the resection planes. all data were prospectively collected and analyzed. results: all but two procedures could be completed by sil (reasons for conversion: 1 anatomical, 1 oncological). thereby a total of 66 segments were resected (comprising 65 % anterior and 35 % posterior segments, respectively). respective procedures were right hepatic lobectomy (1), right lateral hepatectomies (4), left lateral hepatectomies (8), multiple segmentectomies ± rfa (9), single segment or non-anatomical resections (13), fenestrations (3). mean or time of 134 min included simultaneous sil procedures (gastric wedge (1), right colon resection (2), sigmoid resection (1), adnexectomy (1)). skin incision measured in mean(range) 3.9 (2.9-5.7)cm. follow-up was complicated by 1 bilioma and 2 recurrent umbilical hernia. conclusions: awareness of technical prerequisites and responsible patient selection enables safe sil liver resection currently considered as the cream of the crop in liver surgery. tivated human apoptotic mnc, hmnc apo sec , in an experimental stroke model. we performed middle cerebral artery occlusion (mcao) on wistar rats and administered apoptotic mnc-secretomes intraperitoneally in two experimental settings (rmnc apo sec -40 min after ischemia; hmnc apo sec -40 min, and 24 h after ischemia). ischemic lesion volumes were determined after 48 h. neurological evaluations were performed after 6, 24 and 48 h. immunoblots were conducted to analyze neuroprotective signal-transduction in human primary glia cells and neurons. in addition, neuronal sprouting assays were performed and neurotrophic factors in hmnc apo sec as well as in rat plasma were quantified using elisa. administration of both rat and human apoptotic mncsecretomes significantly reduced ischemic lesion volumes by 36 and 37 %, respectively. neurological examinations revealed improvement after stroke in both treatment groups. co-incubation of human astrocytes, schwann cells and neurons with hmn-c apo sec resulted in (i) an activation of several signaling cascades associated with the regulation of cytoprotective gene products and (ii) enhanced neuronal sprouting in vitro. analysis of neurotropic factors in hmnc apo sec and rat plasma revealed high levels of brain derived neurotropic factor (bdnf). our data indicate that apoptotic mnc-secretomes elicit neuroprotective effects on rats that have undergone ischemic stroke. analyse des outcomes der offenen choledochusrevision mit routinemäßiger anlage einer t-rohr drainage background: laparoscopic liver surgery represents a highly regarded method for resections of the left lateral and anterior hepatic segments. single incision laparoscopy (sil) is refined to further reduce the surgical trauma. this video describes our technique in oncologic sil major liver surgery. method: we report on a 74-year-old female patient (bmi 23,4 kg/m 2 ) suffering from a intrahepatic cholangiocellular carcinoma in segments ii, iii with partial contact to segment iv. according to an interdisciplinary tumor board decision initial surgical treatment was indicated. results: the entire procedure was carried out through the umbilicus by means of sil. technical steps comprised intraabdominal exploration, laparoscopic ultrasound, lymph node dissection (group 7, 8, 9, 12a, 12p, 12b) , transection of the left hepatic pedicle, parenchyma dissection (by means of ultrasound vaporisation and clips), stapling of the hepatic vein and removal of the specimen in a retrieval bag. total or time yielded 166 min. skin incision after closure measured 4 cm. no intra-or postoperative complication occurred. conclusions: sil major liver resection represents a challenging procedure with requirements in techniques and skills. first description of sil-right-hemihepatectomy for giant symptomatic hemangioma introduction: due to the potential risk for rupture and live threatening bleeding large and symptomatic haemangioma of the liver represent an indication for surgery. as there is growing expertise in minimally invasive liver surgery, many cases are eligible for laparoscopic resection. in that respect, single incision laparoscopic surgery (sil) represents an evolution in minimally invasive surgery, with potential benefits concerning cosmesis, postoperative pain and patient recovery. case presentation: we herein present a case of a 60-year-old female patient with a four year history of right sided epigastric pain. ct scan revealed a giant haemangioma (28.5-14-12 cm) involving liver segments v, vi, vii and viii. after taking informed consent, transumbilical sil right hemihepatectomy with pedicular preparation was carried out, tissue dissection was accomplished by bipolar and radiofrequency dissection (habib  ). intraoperative blood loss remained minimal and the specimen was extracted transumbilically in a tear proof retrieval bag mor unizentrische ergebnisse der chirurgie des primären hyperparathyreoidismus mit postoperativer langzeitbeobachtung sowie rolle des intraoperativen quick-parathormon-tests c. chiapponi, s. klose, p. mroczkowski, c. bruns, o. jannasch otto-von-guericke-universität, magdeburg, deutschland grundlagen: der intraoperative quick-parathormon-test (iopth) sowie die verbesserte präoperative lokalisationsdiagnostik haben zunehmend zu einem fokussierten vorgehen in der nebenschilddrüsen(nsd)chirurgie geführt. in dieser studie wurden die frühpostoperativen und langzeitergebnisse der chirurgie des primären hyperparathyreoidismus (phpt) sowie der nutzen des iopth beurteilt. methodik: vom 01.01.1996 bis 30.09.2011 wurden alle operationen aufgrund eines phpt erfasst. die datenanalyse erfolgte retrospektiv. verglichen wurden 2 patientengruppen: a) anwendung des iopth; n = 142; ,,iopth-gruppe") vs. b) vergleichsgruppe (ohne iopth; n = 44; ,,vg"). das klinische langzeit-follow-up der prä-und postoperativen symptome erfolgte bei den patienten der ersten 4 untersuchungsjahre (n = 43). ergebnisse: die unterschiede zwischen den gruppen hinsichtlich intraoperativer komplikationen, postoperativer hypo-eingeleitet. die patientin erlag ihrem tumorleiden eine woche postoperativ. schlussfolgerungen: zur prognostischen einschätzung und der sich hieraus ergebenden spezifischen therapie bei papillären schilddrüsenkarzinomen ist eine präzise histologische diagnostik unabdingbar. grundsätzlich sollte bei patienten mit einem hohen erkrankungsalter eine tall-cell variante in betracht gezogen werden, um durch eine aggressive therapie eine lokale kontrolle mit günstigerer prognose zu erreichen. postoperative hypocalcemia: dispensable or dangerous? background: postoperative decrease of serum-calcium is a regular finding after thyroid surgery. hypocalcemia occurs in about 40-50 % of all cases although all four parathyroid glands were identified and left intact during surgery. a multifactorial genesis is assumed for this including devascularisation and capsula edema. intraoperative measurement of pth does not rule out postoperative hypocalcemia because the manipulation of the parathyroid glands can also lead to a transiently increased release of pth. any impaired function of the glands begins only hours after surgery. methods: postoperative measurement of pth and calcium combined, however, can help predict the course of hypocalcemia and help to decide if treatment should be started or not. since hypocalcemia manifests with a delay and reaches its nadir 12 to 24 h after surgery, the morning of the first postoperative day is the best time to measure calcium and pth. in addition, if there are symptoms of hypocalcemia, they would show at this time as well. these three components taken together help to define if postoperative hypocalcemia will be transient and require no treatment or might be or permanent. results: we combined postoperative calcium and pth as well as symptoms of hypocalcemia in our hypot-score, to provide a tool in discerning common transient from permanent hypocalcemia which is much rarer and demands treatment and follow-up. conclusions: serum-calcium and pth are simple and economic tools to predict the course of hypocalcemia. the time of measurement, however, is crucial for successful interpretation of the results. einfluss der kalziumausscheidung auf diagnose und therapie des primären hyperparathyreoidismus p. riss single port laparoscopic surgery (sil) follows the quest of ever less invasive procedures with potential benefits of less postoperative pain, better cosmesis and patient recovery. case presentation: we herein present a case of a 33-year-old woman with the aforementioned genetic disposition. according to an interdisciplinary board decision she was found eligible for sil gastrectomy. the procedure was carried out using a transumbilical approach. gastrectomy was conducted including d1 lymphadenectomy. intraoperative ultrasound of the liver unraveled a small nodule in segment i, iii requiring simultaneous liver wedge resection. stapled esophago-jejunostomy was performed by use of an additional trocar. the entire or time yielded 214 min. no complication occurred. histopathologic diagnosis revealed no malignancy. conclusions: the imposition to undergo preventive major surgery always presupposes a procedure with least invasiveness. sil-gastrectomy has met this criterion for this particular case. single single incision laparoscopic gastrectomy with d1 lymphadenectomy: case report introduction: hereditary diffuse gastric cancer (hdgc) syndrome is a very rare mutation in the e-cadherin (cdh1) gen with a near total probability to develop gastric cancer and a sub-aus über 1500 publikationen, die im jahr 2013 zum thema der übergewichtschirurgie in medline zitiert wurden, wurden die arbeiten evaluiert, die für die diskussion der metabolischen chirurgie besonders wichtig erschienen, entweder weil sie in core journals erschienen, oder weil sie neue aspekte thematisierten. arbeiten die über langzeitergebnisse nach bariatrischen eingriffen fanden besondere berücksichtigung. das update gibt einen überblick über die international relevanten veröffentlichungen zu den themen metabolisches syndrom und diabetes nach bariatrischen eingriffen und bariatrische eingriffe bei patienten mit bmi unter 35 wobei insbesondere kontrollierte oder randomisierte untersuchungen und meta-analysen sowie publikationen, die große prospektiv erfasste datenmengen analysierten, herangezogen wurden. routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary klinikum klagenfurt am wörthersee, klagenfurt, austria background: laparoscopic sleeve gastrectomy (lsg) has gained popularity and acceptance among bariatric surgeons, mainly due its low morbidity and mortality. the purpose of this study was to evaluate the usefulness of early upper gastrointestinal (ugi) contrast studies in detection of postoperative complications. methods: radiographic reports were reviewed from the period of april 2006 to january 2013. during that time 161 patients underwent lsg. all patients were submitted to ugi examination on postoperative day (pod) one. results: of the 161 patients who underwent ugi, no contrast leaks were found on pod 1. three patients (1.9 %) developed a stapler line leakage near the gastroesophageal junction, which was diagnosed on postoperative day 3, 4 and 10. gastroesophageal reflux in 5 patients (3.1 %) and delayed gastroesophageal transit in 10 patients (6.2 %) was detected. conclusions: the results of our study show that ugi series on pod 1 cannot assess the integrity of the gastric remnant. it is our opinion that early ugi series is not required as a routine procedure in all operated patients. it should be performed only in patients who postoperatively develop clinical signs and symptoms of complications such as tachycardia, pain or fever. laparoscopic sleeve gastrectomy: gateway to kidney transplantation diagnostisch richtungsweisend war eine gastroskopie in kombination mit einem körperstamm-ct. über einen transumbilikalen zugang erfolgte nach explorativer laparaskopie und fehlender befunderweiterung die eröffnung der bursa omentalis und präparation der großen cuvatur. in 2 fällen erfolgte eine intrakorporale tangentiale magenteilresektion mittels linearstapler (idrive, fa. covidien) unter simultaner gastroskopischer sichtkontrolle und anschließender präparatbergung mittels bergebeutel via port-system. im zweiten fall konnte der magen nach entsprechenden präparatorischen schritten mit dem gist-tragenden anteil über das port-system nach extrakorporal verlagert, reseziert und händisch vernäht werden. histologisch bestätigte sich die diagnose (cd 117, cd34, nse positiv), in allen fällen erfolte eine r = 0 -resektion. alle patienten (n = 2 > 12 monte beobachtungszeitraum) sind ohne tumorprogression bzw. rezidiv, 2/4 aufgrund einer low/ median risk-situation ohne adjuvante glivec-therapie in unserem interdisziplinären onkologischen nachsorgeprogramm. schlussfolgerungen: bei selektiver indikationsstellung und genauer präoperitver lokalisationsdiagnostik eignet sich die sil-technik in kombination mit dem idrive-device hervorragend für die resektion eines gist des magens. adipositaschirurgie: adipositas/ metabolische chirurgie ii metabolische chirurgie -2014 update die thematik der metabolischen chirurgie war im vorjahr gegenstand zahlreicher publikationen. background: weight loss (wl) after bariatric surgery varies with different techniques. two commonly performed operations are gastric bypass (rygb) and adjustable gastric banding (agb), with superior results for rygb. changes in resting energy expenditure (ree) may be an additional factor supporting the results with rygb. methods: three groups of morbidly obese patients were studied: rygb (n = 12) or agb (n = 8) followed by caloric restriction and equivalent caloric restriction alone (diet, n = 10). studies were performed at baseline and after 14 days in all three groups and at 6 months in rygb and agb groups. participants underwent dexa scan to measure body composition and indirect calorimetry to assess ree. ree was adjusted to body weight (kilocalories per kilogram) in all measures. results: at baseline body composition and ree did not differ between groups. after 14 days, patients had similar percent excess wl (%ewl) (rygb:12.7 ± 2.4 vs. agb:12.0 ± 4.3 vs. diet:10.9 ± 2.8, p = 0.38). ree did not change in either group. after 6 months %ewl was greater after rygb (rygb:49 ± 10 % vs. agb:21 ± 11.4 %, p < 0.05). the percentage change of lean body mass was significantly greater in the rygb group (rygb: + 7.95 ± 3.02 % vs. agb: + 1.58 ± 1.54 %, p < 0.01). ree increased significantly after rygb only (delta ree (kcal/kg): rygb: + 2.58 ± 1.51, p < 0.01; agb: + 0.20 ± 0.70, p = 0.52). there was a significant correlation between changes in ree and %ewl at 6 months (r = 0.670, p = 0.003). conclusions: weight adjusted ree increased significantly 6 months after rygb and correlated with the magnitude of wl. the increase in ree after rygb may be one important factor supporting the superior wl after this procedure. the rising prevalence of obesity in end-stage renal disease patients poses a dilemma in kidney transplant candidate selection. obesity is associated with worse outcomes in terms of dgf, graft failure, surgical site infection, cardiovascular disease, prolonged hospital stay and costs. on the other hand obese patients benefit from kidney transplantation in terms of lower long-term mortality and cardiovascular risk compared with continuing on dialysis. methods: we here report a two step approach for morbidly obese renal transplant candidates. in patients with a bmi of 35kg/m2 or higher with end-stage renal disease laparoscopic sleeve gastrectomy was performed. when bmi was below 35 kg/ m 2 patients were evaluated and listed for kidney transplantation. results: in 5 patients with a mean bmi of 39.4 kg/m 2 laparoscopic sleeve resection was performed. within 3, 3, 6, 9 and 22 months, respectively (mean 8.6 months), bmi dropped below 35kg/m2. excess body mass index loss (ebmil) was 68.8 % at 1 year after bariatric surgery. two patients underwent successful kidney transplantation displaying good renal function with a serum creatinine of 1.8 mg/dl at 3 months and 1.1 mg/dl at 12 months post transplant, respectively. three patients are waitlisted for kidney transplantation. conclusions: laparoscopic sleeve gastrectomy as a first step procedure proved to be an innovative and safe strategy for rapid weight loss and subsequent access to the kidney transplant waitlist. weight regain after gastric bypass: where to go now? background: gastric bypass remains one of the most effective procedures in bariatric surgery, but weight regain is occasionally observed. revisional surgery proves both challenging and controversial. the aims of the procedures are improved restriction (gained with resizing of the gastric pouch or banding) or additional malabsorption (shortening of the common channel). an ideal procedure or combination of procedures still remains to be found and grave secondary complications like malabsorption occur. methods: forty-one patients (6m, 35 f ) underwent reoperations for weight regain (n = 33), insufficient weight loss (n = 5), or hypoglycemia (n = 3) after gastric bypass. more than half of them (n = 22) had had restrictive surgery before gastric bypass. mean bmi at the time of revision was 47,9 ± 9,6 kg/m 2 , the mean time to reoperation was 3.8 years. in 41 patients, 16 bandings of the gastric pouch, seven shortenings of the common channel and three resizings of the pouch were performed. pouch banding was combined with shortening of the common channel in seven patients and with pouch resizing in two. in another two patients, the common limb was shortened together with resizing of the pouch. finally, three patients underwent a combination of pouch resizing, banding and shortening of the common channel. age 43.4 ± 9.2 sd (range 21.0-64.0). at baseline: mean absolute weight (aw, kg), 98 ± 11 (78-123); body mass index (bmi, kg/m(2)), 36.7 ± 3.8 (28-39). a mean 15 suture-anchor plications were placed in the fundus and along the distal body wall. mean operative time, 61.2 ± 26.6 min (35-120); patients were discharged in < 48 h. six-month mean bmi decreased 5.8 to 31.3 ± 3.3 (25.1-38.6) (p < 0.001); ewl was 39.4 %; tbwl, 15.5 % after a mean follow up of 12 months. no mortality or operative morbidity. minor postoperative side effects resolved with treatment by discharge. liquid intake began 12 h post procedure with full solids by 6 weeks. patients reported less hunger and earlier satiety post procedure, even after 3 years. conclusions: at 6-month follow-up of a prospective randomized case series, the pose procedure appeared to provide safe and effective weight loss without the scarring, pain. long-term follow-up and further study are required. background: omega loop bypass is a single anastomosis loop gastric bypass with an anti-reflux plastic to prevent biliary reflux into the gastric pouch. methods: 245 patients (78 male/ 167 female) with a mean bmi of 45.12 kg/m 2 ± 6.28 underwent omega loop bypass from 2/11 to 1/14. six patients underwent conversion from sleeve to omega loop, nine patients laparoscopic removal of a gastric band combined with conversion to omega loop and 12 patients simultaneous cholecystectomy. limb length (ligament of treitz to the gastrojejunostomy) ranged from 150 to 300 cm. results: the mean duration of the operation was 62 ± 20 min for primary operations without simultaneous interventions, 125 ± 23 min for omega loop bypass combined with cholecystectomy (n = 12), 92 ± 26 min for laparoscopic band removal and conversion to omega loop bypass and 81 ± 24 min for conversion from sleeve gastrectomy to omega loop bypass. complications consisted in three strictures at the gastrojejunostomy requiring balloon dilation, while six patients underwent reoperation due to bleeding (n = 1), small bowel leakage (n = 1), anastomotic stenosis (n = 1), suspected leakage at the gastrojejunostomy (n = 1) and leakage at the pouch (n = 2)-both cases were revision surgery (n = 1 after band removal, n = 1 after nissen fundoplication). in two cases laparoscopic conversion from omega loop bypass to roux-en-y bypass was performed due to biliary reflux. we further present weight loss follow-up of up to 3 years. conclusions: omega loop bypass can be performed with short operation time, acceptable complication rates and encouraging short time weight loss. pose-the primary obesity surgery endolumenal (pose) procedure-3-year experience background: we report our initial experience and 6-month outcomes in a single center using the per-oral incisionless operating platform tm (iop) (usgi medical) to place transmural plications in the gastric fundus and distal body using specialized suture anchors (the primary obesity surgery endolumenal [pose] procedure). methods: a prospective observational study and a prospective randomized study were undertaken with governmental ethics board approval. indicated patients were who obesity class i-ii, after informed consent. results: between 2011 and 2014, the pose procedure was successfully performed in 19 patients. 18 female one male; mean grundlagen: ziel der wicvac-studie war die evaluation der effizienz und sicherheit einer kombinationstherapie mit unterdruckwundtherapie (v.a.c.) und polymeren verbandsstoffen (polymem  wic) verglichen mit der v.a.c.-monotherapie. durch eine kombinationstherapie (wicvac) soll ein einwachsen von granulationsgewebe in den schwamm verhindert und dadurch ein vereinfachter wechsel mit geringeren schmerzen gewährleistet werden. die übliche drei-bis viertägige wechselfrequenz kann mittels farbindikator, der den zeitpunkt eines notwendigen wechsels anzeigt, prolongiert werden. dies führt einerseits zu einer einsparung von op-ressourcen und andererseits zu einer geringeren belastung der patienten. methodik: in einer prospektiv randomisierten, nicht-verblindeten, single-center studie wurden revaskularisierte patienten mit chronischen oder postoperativen wunden mittels v.a.c.-monotherapie oder mit einer kombinationstherapie behandelt. in der kombinationstherapie fungierte das rosafarbene poly-mem  wic als direkte wundauflage, dessen farbumschlag die indikation zum verbandswechsel stellte. als covariablen wurden wundbeschaffenheit und -ausdehnung dokumentiert. primäre endpunkte waren die therapiedauer und die anzahl der verbandswechsel bis zum wundverschluß (maximal jedoch bis 30 tage). als sekundärer endpunkt wurde eine schmerzevaluation anhand der visual analogue scale (vas) erhoben. ergebnisse: die differenz in wundgröße, wundgrößenreduktion und -beschaffenheit zwischen den therapieformen war nicht signifikant (p > 0,05). jedoch differierte die anzahl der verbandswechsel bis zur kompletten abheilung entscheidend (thxsingle 4,5 ± 2,9 versus thxcomb 2,9 ± 2,7, p = 0,038). während es keinen unterschied hinsichtlich analgetikabedarf zwischen den gruppen gab, wurden nicht signifikant höhere vas scores unter monotherapie verzeichnet (p = 0,063). schlussfolgerungen: die wicvac-kombinationstherapie stellt eine sichere methode zur behandlung chronischer wunden und wundinfektionen dar. durch eine deutliche reduktion der nötigen verbandswechsel werden lebensqualität sowie nutzung der op-und personalressourcen optimiert. soluble st2 serum concentrations are increased in burn patients and predict mortality burn injury represents a frequent and devastating form of trauma. the systemic immune response after thermal trauma develops in different phases. after trauma, immunosuppression leads to an increased risk of developing infections associated with increased mortality. the interleukin-1 receptor family member soluble st2 (sst2) binds to interleukin-33 (il-33) and functions as a "decoy" receptor for il-33, thereby attenuating the systemic inflammatory effects of il-33. the aim of this study was to evaluate sst2 in burn patients in a time-dependent manner with respect to mortality prediction. serum concentrations of sst2 were measured serially in time course in 32 burn patients and in 8 healthy volunteers. all burn patients were admitted to an intensive care unit (icu) and had > 10 % tbsa (mean, 32 %). fällig zu neurolysieren, andererseits die arterie subclavia darzustellen und zu sichern. weiters konnten die mm. scalenii sowie die halsrippe und die 1. rippe übersichtlich dargestellt werden reseziert werden. die übersichtlichkeit der präparation ist als wesentlicher vorteil im vergleich zum transaxillären zugang zu nennen. huge keloid formation after circumcision associated with a solitary neurofibroma keloid formation on the penis following circumcision has been reported very rarely. in contrast to neurofibromatosis a keloid formation tendency is not known for patients with a solitary neurofibroma. we present the case of a patient with a solitary neurofibroma and a penile keloid formation after circumcision. a 13-year-old boy was complaining of a painless mass on the left shoulder which was present since years. physical examination revealed a 3 × 5 cm measuring tumor on the deltoid area of the left shoulder. during preoperative preparation for the excision of the tumor on the left shoulder a huge keloid formation on the coronal sulcus of the penis was noticed. the patient had undergone a circumcision at the age of 11. as the patient did not complain about it, the parents didn't know anything about the situation. there was no swelling at any other part of the patient's body and no family history of such swellings. the patient did not have any features of neurofibromatosis. an excisional biopsy was carried out from the lesion on the left shoulder. histologic examination showed a neurofibroma. a simultaneous biopsy of the penile lesion provided a keloid. in a second operation the keloid tissue was totally excised. before skin closure a corticosteroid was injected. as a recurrence prophylaxis after finished reepithelialization a silicone gel sheet was applied 24 h daily for 2 weeks. two years following excision there was no recurrence. die wicvac-studie: eine prospektive, randomisierte studie zum vergleich einer kombinationstherapie von polymem ® und unterdruckwundtherapie mit herkömmlicher unterdruckwundtherapie bone grafts release paracrine signals that are considered to support tissue regeneration. however, definitive proof for this concept and the underlying mechanisms has remained elusive. in vitro, paracrine signals can be simulated with bone-conditioned medium (bcm) prepared from porcine cortical bone chips. gene expression profiling of murine st2 and atdc5 mesenchymal cell lines revealed that bcm considerably increased the expression of proteoglycan-4 (prg4; lubricin; superficialzone protein), a mediator of skeletal homeostasis and bone formation. consistent with its effect on mesenchymal cell lines, bcm increased prg4 expression in human primary mesenchymal cells isolated from gingiva, bone and periodontal ligament (p < 0.05). the tgf-β pan specific neutralizing antibody and the tgf-β receptor i antagonist sb431542 prevented prg4 expression (p < 0.05). the smad3 antagonists sis 3 as well as the erk and p38 inhibitors u0126 and sb203580, respectively, reduced the impact of bcm on prg4 expression (p < 0.05). moreover, bcm enhanced phosphorylation of smad3, erk and p38. in support of the suggested tgf-β activity, heat-treated bcm and recombinant tgf-β1 enhanced the expression of proteoglycan-4 (p < 0.05). finally, bcm also stimulated prg4 expression in the presence of the inflammatory cytokines il-1β and tnfα (p < 0.05). these in vitro results support the concept that cortical bone chips release paracrine signals that provoke the expression of prg4 via tgf-β receptor i signaling in oral fibroblasts. early prediction of allograft rejection with cytokines methods: hind limbs were transplanted in an allogeneic (brown norway rats to lewis rats) and a syngeneic setting, n = 10 for each group. tape sampling was performed with commercially available skin patches (d-squame  ) according to our standardized protocol at defined timepoints (immediately post transplantation, 4h postop, postoperative days (pod) 1, 3, 5 and 7). the milliplex rat cytokine/chemokine panel was used to assess the expressed cytokines by luminex  technology. results: most of the selected markers (il-5, mcp-1, il-1b, il-6, gm-csf, gro/kc, ifn-g, il-1a, il-10, il-12p70, il-18, il-2, il-4) were detectable in non-rejecting skin (syngeneic, non-transplanted) and found to be upregulated in the allogeneic group. il-1b was significantly upregulated in the allogeneic transplants at the very early timepoints 0h posttransplantation (p = 0.05) and 4 h posttransplantation (p = 0.02). to consider the interdependence of a cytokine network, we performed one-way anova analysis. as a result, il-1b showed significant (p = 0.0008) die häufigsten erreger sind beta-hämolysierende streptokokken gruppe a (gas). fallvorstellung: eine 57-jährige patientin wurde wegen einer beträchtlichen basedowstruma thyreoidektomiert. der intraoperative verlauf gestaltete sich komplikationslos. am 2. postoperativen tag entwickelte die patientin eine lokale wundinfektion, die mit wundspreizung, offener wundbehandlung und i.v. antibiotischer therapie (aminopenicillin/clavulansäure und metronidazol) behandelt wurde. der wundabstrich zeigte gas. gemäß der resistenzbestimmung wurde die therapie auf clindamycin und penicillin g umgestellt. die computertomographie zeigte eine abszedierung sowie eine deszendiernde mediastinitis. es erfolgten mehrfache operative wundrevisionen eine offene wundbehandlung und schließlich die anlage eines geeigneten cervikomediastinalen vac-systems. der zustand der patientin besserte sich unter dieser therapie jedoch zeigte sich der klinische verlauf protrahiert, sodass die antibiotische therapie erneut umgestellt (levofloxacin, fosfomycin und metronidazol) wurde. nach insgesamt 9-maliger wundrevision und der oben genannten therapie konnte die infektion beherrscht werden. die entlassung erfolgte am 45.postoperativen tag. das screening ergab keinen keimträger innerhalb des krankenhaus-personals. schlussfolgerungen: eine infektion mit gas kann zu einer lebensbedrohlichen mediastinitis nach thyreoidektomie führen. grundsätzlich sollte immer eine gezielte infektions-und umfeldanamnese erfolgen, gegebenenfalls präoperativ prophylaktische nasen-rachenabstriche durchgeführt werden. bei erfolglosigkeit einer konventionellen offenen wundbehandlung sollte zusätzlich zur optimierten antibiotikatherapie an eine cervicale vac-therapie gedacht werden. ein screening des personals ist erforderlich. axo-axialer (neo)sigma-volvulus mit perforation nach laparoskopischer onkologischer sigma-rektumresektion ziel: mittels kasuistik wird, basierend auf einer selektiven literaturrecherche jüngeren datums, über einen 72-jährigen, männlichen patienten mit primärer iliaco-, späterhin mesentericoenteraler fistel auf dem boden eines seit 6 monaten bekannten, infiltrativ wachsenden, pulmonal/hepatisch metastasierenden, palliativ-systemisch chemotherapierten rektumkarzinoms berichtet. patientencharakteristik/verlauf/outcome: stationäre übernahme des patienten wegen akuter reblutung (initial am ehesten avastin  -getriggert) aus angelegtem doppelläufigen descendostoma (unter palliativer intention wegen irresektabilität des rektumkarzinoms bei diagnosestellung angelegt) im 4-wochen-intervall (nach fortgesetzter avastin  -freier chemotherapie). die initiale blutstillung erfolgte mittels interventionell-radiologischem stenting der a. iliaca externa rechts (serviceleistung) und nachfolgend (reblutung) mit coiling eines blutenden a.-mesenterica-inferior-astes. im verlauf traten progrediente sensomotorische einschränkungen des rechten beines auf: mittels erneuter dsa ausschluss zunächst angenommene rmakroangiopathisch-ischämischer pathogenese bei suffizienten kollateralen nahe des inzwischen eingetretenen iliacalen stentverschlusses, eher mikrothrombembolische verlegung der kleineren gefäße. es entwickelte sich zusätzlich ein senkabszess ins rechte bein, der am ehesten vom organüberschreitenden, intraoperativ perforiert erscheinenden rektumkarzinom ausging (das i) entdacht [wegen begleitabszess], ii) fistelexzidiert [incl. iliacal-arterieller stententfernung und gefäßligatur unter schonung der intern-iliacalen kollateralen] und iii) mittels resektion des vom descendostoma abführenden, das karzinom erreichenden sigmaschenkels versorgt wurde), welcher zu gangränbildung und letztendlich notfallmäßiger amputation des rechten beines führte. der patient besserte sich postoperativ zusehends, sodass die nachsorge in der chemoambulanz zur fortführung einer palliativ-systemischem chemotherapie/physischen rehabilitation angestrebt werden konnte. schlussfolgerungen: die iliaco-/mesentericoenterale fistel mit rezidivblutung aufgrund eines infiltrativ wachsenden rektumkarzinoms ist ein seltenes/schweres krankheitsbild mit hoher morbidität/mortalität bei anspruchsvoller interdisziplinär ausgerichteter versorgung. ähnliche fälle wurden in der literatur bisher kaum beschrieben. methods: we present a case of a young male patient, who first admitted with macrohematuria caused by a t4-rcc of the right kidney with complete thrombotic occlusion of the vci. primarily, the tumor was considered unresectable. after extensive multidisciplinary discussion, the patient was then scheduled for multi-visceral resection. results: complete resection of the tumor including a radical nephrectomy, cholecystectomy, resection of the lobus caudatus and subsequent resection of the retrohepatic vci could be accomplished successfully; the vci was resected without graft interposition. after an uneventful postoperative course, the patient could be discharged home in an excellent functional state. conclusions: our case clearly demonstrates that in young patients with locally advanced rcc, multi-visceral resection can be performed successfully after meticulous evaluation. primäre, tumorbedingte rechts-iliaco-und nachfolgend mesentericoenterale fistel bei metastasierendem und organüberschreitendem rektumkarzinom -seltene, induzierende koinzidenz einer unteren gastrointestinalen blutung a. bartella ependymome sind sehr seltene zns-tumoren bei erwachsenen. myxopapilläre formen (who grad i) sind langsam wachsend, werden als benigne eingestuft und machen nur 5 % aller ependymome aus. sie kommen vor allem im lumbosakralen bereich vor. leitsymptome sind lokale oder radikuläre schmerzen und progrediente sensomotorische ausfälle. die tumoren treten in der vierten lebensdekade am häufigsten auf. therapie der wahl ist die totalresektion, die ein sehr gutes prognostisches outcome mit sich bringt. dissemination innerhalb des zns bei der intraduralen und fernmetastasen bei der extraduralen form werden trotz der benignen klassifikation beschrieben. rezidive treten selten, wenn dann vor allem bei extraduralen formen und nach subtotaler resektion auf. eine adjuvante radiatio kann deshalb prinzipiell erwogen werden. anschließend folgt die nachsorge -in den ersten zwei jahren halbjährlich, dann in 12-monatigen abständen. fazit: trotz der seltenheit sollte man differentialdiagnostisch an diese erkrankung mit ihrem -wenn auch geringen -risiko der metastasierung und rezidivierung denken. wir präsentieren den fall eines 61-jährigen männlichen patienten, der mit dem verdacht auf n.recti bei polypoidem tumor knapp oberhalb der linea dentata an unserer abteilung erstmalig vorstellig wird. der histologische befund nach hierorts erfolgter biospie des tumors ergibt den seltenen befund eines exulzerierten, amelanotischen melanoms des rektums. nach vollständiger staging-untersuchung einschließlich mr-schädel und knochenszintigrafie, wie auch besprechung in unserem interdisziplinärem tumorboard, führen wir schließlich die rektumexstirpation mit anlage einer enständigen descendostomie durch. postoperativ wird nach vorstellung in der melanom-ambulanz des landesklinikums st. pölten eine interferon-therapie wir berichten von einem 72-jährigen patienten welcher 2003 an einem malignen melanom an der li schläfenregion operiert wurde. 10 jahre postoperativ kommt es zur entwicklung einer einzelnen histologisch bewiesenen metastase in der rechten lunge. im rahmen des staging wird ein auf metastase suspekter rundherd im segment vii des rechten leberlappen diagnostiziert. die operative strategie bestand in einer posterolateralen thorakotomie rechts mit anatomischer segmentresektion des segment 4 des rechten mittelappen, als auch in einer radiären durchtrennung des zwerchfell mit resektion der metastase im segment vii des rechten leberlappen. die entlassung erfolgt nach unkompliziertem postoperativen verlauf am elften postoperativen tag. chirurgische innovation kann sich auch in der überlegung hinsichtlich eines möglichst geringen zugangstrauma als auch in der durchführung eines möglichst einzeitigen eingriffes wiederspiegeln ohne die bewährten wege der chirurgie -nämlich onkologische radikalität-zu verlassen. auch das rasche soziale wiedereingliedern des patienten steht in unserer schnellebigen zeit immer mehr im vordergrund. thorakale fibromatose -strategien zur rezidivprophylaxe an hand eines fallbeispiels fibromatosen sind äusserst seltene, aggressiv wachsende tumorentitäten mit hohem lokalrezidivrisiko. anhand eines fallberichtes werden die aktuelle literatur und die alternativen nachbehandlungsstrategien vorgestellt. eine 58-jährige patientin kommt aufgrund einer 3,7 cm großen läsion in der submammärfalte links erstmalig an unser zentrum. die durchgeführte diagnostik ergab einen tumor der klassifikation birads v (mammographie und sonographie sowie mrt). eine stanzbiopsie ergibt einen mesenchymalen tumor. es erfolgt eine tumorresektion unter mitnahme der äußeren intercostalmuskulatur und histologischer aufarbeitung mit dem ergebniss einer r0 -resezierten fibromatose. 03/2013 entwickelt sich ein 8 cm im durchmesser grosses lokalrezidiv mit thoraxwandinfiltration und wurde unter mitnahme von 3 rippen im ventralen thoraxwandanteil und rekonstruktion mittels netzaugmentation r0 reseziert. im rahmen engmaschiger nachkontrollen wurde 11/2013 ein erneutes 7 cm im durchmesser haltendes lokalrezidiv an der lateralen thoraxwand li identifiziert. die nun durchgeführte resektion beinhaltete das lokalrezidiv und eine komplette thoraxwandresektion unter mitnahme von 5 rippen links. die unmittelbare rekonstruktion wurde mit einem stratos-system und einer netzplastik durchgeführt und mit einem myokutanem latissimus dorsi lappen gedeckt. der postoperative verlauf gestaltet sich komplikationslos und die pat erhält eine hochdosierte antihormonelle therapie mit tamoxifen. erforderte gallenwegssanierung wegen neuer sludge-basierter cholangiolithiasis via suffizient liegendem axios-stent incl. 6-cm-metallstent in eruierter distaler dhc-stenose. im klinischen verlauf weitere az-stabilisierung und gewichtszunahme bei anhaltender abblassung. eine mrt-verlaufskontrolle (nach ca. 1,5 jahren mit incompliance-bedingten, lediglich kurzstationären aufenthalten) kann zwischen fokaler pankreatitis und dd pankreas-ca nicht differenzieren; eine eus-gestützte punktionshistologie/-zytologie erbringt keinen sicheren malignomnachweis. die indikation zur axios-stentextraktion wird lediglich bei problemen im klinischen verlauf (hausarztbeurteilung) gesehen. diskussion/schlussfolgerung: verfahren und abfolge wurden der befundkonstellation gerecht und trugen dem patientenwillen rechnung. intraoperative and postoperative complications following laparoscopic appendectomy y. chan, s. nakhai, z. sow, c. beran, a. tuchmann background: laparoscopic appendectomy has been increasingly considered as the gold standard in the case of appendicitis. we aimed to further investigate its intraoperative and postoperative complications according to their histological types. methods: four hundred and seventy consecutive laparoscopic appendectomies between january 2008 and june 2013 were retrospectively compared in blood test results, appendectomy timing, intraoperative and postoperative complications. results: among 154 chronic, 60 acute, 218 phlegmonous and 38 perforated appendicitis, only patients with chronic appendicitis had a delay in appendectomy timing (median 7 h, range 1.5-114.8), compared to patients with phlegmonous appendicitis (median 5.5 h, range 1-101.8, p = 0.015). following the appendectomy, patients with perforated appendicitis showed a significant higher leukocyte count (mean 13 g/l ± 5.7) and crp (mean 23.8 mg/dl ± 11.7), compared to patients with phlegmonous appendicitis (mean 10 g/l leukocytes ± 3.9 and mean 11.7 mg/dl crp ± 9.8, p < 0.001 respectively). also there was a significant longer length of hospital stay in patients with perforated appendicitis (median 7 days, range 1-114), compared to patients with phlegmonous appendicitis (median 4 days, range 2-59, p < 0.001). the total intraoperative conversion rate was 1.7 %. in a mean postoperative observation time of 35 months, the total postoperative complication rate was 8.3 %, with ileus as the most frequent cause. there was no difference in complication rate between patients with different appendicitis histological patterns. conclusions: patients undergoing laparoscopic appendectomy with perforated appendicitis have higher inflammation sign in their postoperative blood test and longer length of hospital stay, with no significant higher complication rate. b, n = 204, bmi > 50 kg/m 2 ) these findings remained. for group a the timepoint 3 months (p = 0.001) postoperatively and for group b the timepoint 3 months (p = 0.039) postoperatively was significantly higher regarding nt-probnp than preoperatively. conclusions: laparoscopic roux-en-y gastric bypass leads to significantly higher nt-probnp levels in the early postoperative period. choledochobulbostomie mit antegrader drainage -spezielles und anspruchsvolles eucd-verfahren im interventionell-endosonographischen management eines mittelfristig bestehenden, am ehesten chronische-pankreatitis-bedingten ikterus bei gegebenem op-unwillen und nach scheitern konventioneller ercp f. meyer 1 , f. füldner 2 , c. bruns 1 , u. will 2 1 universitätsklinikum magdeburg a.ö.r., klinik für allgemein-, viszeral-und gefäßchirurgie, magdeburg, deutschland, 2 srh waldklinikum gera ggmbh, klinik für allgemeine innere medizin, gastroenterologie und hepatologie, gera, deutschland darstellung einer anspruchsvollen fallkonstellation soll, basierend auf einschlägiger interventionell-endoskopischer erfahrung zur angezeigten minimal-invasiven versorgung und selektiven literaturangaben, das individuelle, falladaptierte und letztlich mittelfristig erfolgreiche management des komplexen krankheitsbildes eines/r chronischen ikterus/cholestase bei chronisch-kalzifizierender pankreatitis und entzündlichem pseudotumor im pankreaskopf mit rezidivierenden akuten, teils subklinischen schüben (exo-und endokrine pankreasinsuffizienz) und portocavernöser transformation (basis: lienoportale hypertension), bulbus-und gallengangsstenose, konsekutiver cholangiolithiasis im intervall (nebenbefund: tourette-syndrom) sowie gescheiterten initialen ercp-gestützten stentplatzierungsversuchen bei grenzwertiger patientencompliance und unwillen zur operation(op) umrissen werden. fallmanagement/therapie/verlauf/outcome: aufgrund eines über 3 monate bestehenden ikterus war ein primäres operatives management nicht zu favorisieren neben nicht gegebenem patienteneinverständnis zur im intervall anzuratenden op (pankreaskopfresektion) -re-ercp-versuch (mitberichtende zweiteinrichtung) ebenso nicht erfolgreich wegen nicht gegebener endoskopischer passier-/platzierbarkeit des endoskops duodenal bei inflammatorischer bulbusstenose trotz bulbärer ballondilatation und precut-papillotomie. daher entschluss im ca. vierteljährlichen intervall nach mäßiger klinischer besserung zu eus-geführter, besonders anspruchsvoller choledochobulbostomie mit antegrader drainage (verfahren aus eucd-spektrum: punktion mit 19g-nadel, drahtvorschub, ringmesser, ballondilatation, axios-stenteinführung in dhc) zur gallenwegsentlastung, abblassung und normalisierung der leberfunktion. kontrollvorstellung im mehrwöchigen intervall cystoscopy with 4.7 ch instrument was performed on 4. day and with 200 microns. holmium laser probe, continuous mode, 0.5 j and 10 hz frequency ,ureterocele incision accomplished successfully. postoperative sonography showed complete decompression. no urinary tract infections and no de novo vesicoureteral reflux developed in the follow up period. individuelle maximaltherapie beim fortgeschrittenen oesophaguskarzinom -eine falldarstellung bei einem 60-jährigen patienten wurde wegen gewichtsabnahme und schluckstörung ein oesophaguskarzinom im stadium ct3n2m1 mit fraglicher infiltration der tracheabifurkation von extramural diagnostiziert. das m-stadium ergab sich wegen eines unklaren, histologisch nicht gesicherten herdes im linken lungenunterlappen. in der tumorkonferenz wurde leitliniengerecht die entscheidung zur palliativen chemotherapie getroffen und ein oesophagusstent zur beseitigung der schluckstörung implantiert. (02/2011) noch während der chemotherapie kam es zur stentperforation mit mediastinitis und pleuraempyem. dieses wurde zunächst offen debridiert und eine spülbehandlung eingeleitet. nach ablehnung der oesophagektomie nach zweit-und drittmeinung wurde aber auf dringenden und verständlichen wunsch des patienten doch die entscheidung zur vermeintlich palliativen operation getroffen. zweizeitig erfolgte die oesophagektomie mit speichelfistelanlage (02/2011) und magenhochzug. (04/2011) die vermeintliche lungenmetastase ließ sich bei der thorakotomie nicht sichern, ebenso wenig die infiltration der trachea oder hauptbronchien. das staging musste nachträglich korrigiert werden: pt3n0m0. in der postoperativen phase war der patient mehrfach wegen rezidivierender pneumonien vital bedroht. dennoch hat man sich entsprechend dem patientenwunsch zur maximaltherapie entschieden. der patient lebt nun seit 3 jahren rezidiv-und beschwerdefrei. schlussfolgerungen: in einer einzelfallentscheidung kann man durch den krankheitsverlauf gezwungen werden, die leitlinien zu verlassen. bei negativem ausgang wird eine solche entscheidung expost oftmals kritisiert. viel wichtiger als diese kritik ist, dass während der kritischen phase alle beteiligten zu der gemeinsamen entscheidung stehen, auch wenn sie wie hier gegen viele wohlmeinende ratschläge aber mit kompetenter beteiligung des patienten getroffen wurde. methodik: anhand fallspezifischer aspekte werden erfahrungswerte des anspruchsvollen und erfolgreichen gefäßchirurgischen managements eines monströsen a.-hepatica-aneurysmas direkt im leberhilus unter reflexion einschlägiger referenzen der literatur mittels wissenschaftlichen fallberichts zu vermitteln. ergebnisse: ein 70-jähriger mann wurde wegen blutdruckschwankungen (abdomen klinisch frei) einer diagnostik mit transabdominaler sonographie (leberzyste, cholezystolithiasis, splenomegalie, verdacht auf teilthrombosiertes arterielles aneurysma am leberhilus), oberbauch-ct mit kontrastmittel (aneurysma der a. hepatica propria -größe: 4,7 × 5,7 cm subhepatisch im ligamentum hepatoduodenale), duplexsonographie und dsa (aneurysma-ø: 6,5 cm; gefäßsegment: a. hepatica propria, variation des truncus coeliacus [michels-typ ix, entsprechend truncus hepatomesentericus]) unterzogen. op-indikation wegen größe und lokalisation sowie fehlender verankerungsoption des stent-"halses" für ein endovaskuläres vorgehen: daher offen-gefäßchirurgische aneurysmaresektion und interposition einer 8 mm durchmessenden und 3 cm langen silver-graft-prothese (b/braun aesculap ag, tuttlingen, deutschland) zwischen a. hepatica propria nach a.-gastroduodenalis-abgang und a.-hepatica-bifurkation (jeweils end-zu-end-anastomose; histologie: teils atrophisierte arterienmedia und -adventitia, aufgelagert konzentrisch geschichtetes thrombotisches material). postoperativ lagen regelrechte leberperfusionsverhält[[unsupported character -codename &shy;]]nisse in der kontroll-mra vor (komplikationsfreie rekonvaleszenz, ebenso unauffälliger klinischer jahresverlauf ). schlussfolgerungen: die versorgung operationspflichtiger vaa stellt eine herausforderung dar, insbesondere in der vorgestellten operationspflichtigen situation eines monströsen a.-hepatica-propria-aneurysmas direkt im leberhilus und variation des truncus coeliacus, die die ausgewiesene gefäß-und viszeralchirurgische expertise in einem zentrum für ein komplikationsarmes outcome als auch adäquate maßnahmen im komplikationsfalle erfordert. ureterocele is cystic dilatation of the terminal part of ureter. in the majority of cases, it is accompanied by a duplex system and affects females in ratio 6:1. in this report 3500 g boy, with antenatally diagnosed right sided hidronephrosis was born (sectio) at 39th week of pregnancy. postnatal us revealed right sided hidronephrosis-duplex system and orthotopic ureterocele. background: thymomas represent a rare and heterogeneous group of intrathoracic malignancies requiring different treatment regarding the individual tumor stage. the objective of this study was to review our experience with the treatment of thymoma in order to analyse both, the efficacy of our therapeutic algorithm and the outcome after therapy. methods: this is a single-center, retrospective study of 50 patients with thymoma treated between 2003 and 2013. results: there were 29 women (58 %) and 21 men (42 %), mean aged 58.3 years. 29 (58 %) had clinical symptoms, 14 (28 %) had myasthenia gravis. 45 patients (90 %) underwent thymectomy, complete resection was done in 42 cases (93.3 %). the masaoka staging system detected 20 stage i, 18 stage ii, 6 stage iii and 6 stage iv. 2 patients had neoadjuvant therapy and 25 received postoperative treatment. 5 (20 %) had intrathoracic tumor recurrence, treated with re-resection. 5-year disease-free survival was 91.6 %. 2 patients died of tumor progression, six died of other causes. the 5-year overall survival was 89 % and median survival time was 92.1 months. the median survival of patients with thymectomy was 92.1 months as compared to 18.3 months in patients without surgery (p = 0.001). masaoka stage iv was significantly associated with reduced survival (p = 0.012). the 5-year survival rate after complete resection was 93.7 % and was considered significantly better than non-surgical treatment (p = 0.006). conclusions: surgery still remains the mainstay in the treatment of non-metastatic thymoma. therefore, complete resection especially in case of early masaoka's stage, is essential for disease control and long-term patient survival. remote accesses for surgical treatment of nonmalignant mammary neoplasms methods: researches are based on analysis of treatment of 38 patients with non-malignant mammary neoplasm which were treated in the si "v.t. zaitsev iges namsu". results: for patients with a single neoplasm of breast (size 1.5-2.5 cm) before surgery had been performed mammography, ultrasound of the breast, needle biopsy of education followed by histological examination. benign process (fibroma, fibroadenoma) had been observed in all cases. ultrasonography had determined the distance from the tumor to the skin of the breast and the projection of the tumor. these data determined the choice of operative access for patients. 20 patients had been operated with using radiar access. 18 patients had been underwent remote surgical accesses: periareolar access-in 13 patients, access on submammary line-in 3 and access from axillary area-in two patients. time of the operation with radyar access and the pain after operation are the same with traditional methodics. all accesses is completely accord to principles plastic surgery. patients had no cosmetic complications. in the early and late periods sensitivity of the area of the remote accesses was saved and cosmetic effect was better after surgery compared to traditional accesses. conclusions: during the surgical intervention in patients with benign tumors of the breast performing of remote access is the method of choice. erste erfahrungen mit der unico ® -drainage zur therapie des pneumothorax univ.-klinik für visceral-, transplantations-und thoraxchirurgie, innsbruck, österreich grundlagen: ein pneumothorax wird standardmäßig mittels bülaudrainage entlastet, um die rasche wiederausdehnung der lunge zu gewährleisten. ziel dieser studie ist, die erfolgsrate eines neuen drainagesystems zu evaluieren. methodik: zwischen jänner und oktober 2013 wurden 9 pneumothorax-patienten mit dem redax unico  -drainagesystem behandelt. merkmale dieses systems sind eine veres-nadel, ein ventil das ein einströmen von luft verhindert, sowie ein adapter zum anschluss einer konventionellen bülauflasche. eingeschlossen wurden patienten mit einem pneumothorax > 3 cm apikal oder > 2 cm lateral ohne komplett kollabierter lunge. 6 patienten hatten einen primären spontanpneumothorax, 3 patienten einen iatrogenen pneumothorax (port-/zvk-anlage, the aim of the study was to evaluate changes in splanchnic blood vessels in patients with acute necrotizing pancreatitis. methods: in 26 patients with acute necrotizing pancreatitis investigated changes in the visceral vessels in angiography, computed tomography and magnetic resonance imaging. results: in acute necrotizing pancreatitis observed various splanchnic vascular spasm. we classified the degree of ischemic changes during angiography: mild ischemic changes: vasospasm limited intrapancreatic branches; moderate ischemic changes: local vasospasm in extrapancreatic arteries around the pancreas (splenic artery, common hepatic artery or gastroduodenal artery) and intrapancreatic branches; severe ischemic changes: diffuse narrowing of the large extrapancreatic blood vessels and disturbance imaging division into branches. necrotizing pancreatitis, in particular, is characterized hypovascular and avascular type, a chaotic, breakage and defects in artery walls, delayed venous phase and lack splenoportography, splenic vein thrombosis. conclusions: in patients with acute necrotizing pancreatitis observed various changes in extra-and intrapancreatic arteries, which leads to marked microcirculatory disorders and determines the severity of the disease process. two case reports of massive bleeding from pancreatic pseudocysts eine schwere arterielle blutung von pankreaspseudozysten stellt eine lebensbedrohliche seltene komplikation einer chronischen pankreatitis dar. wir berichten über zwei männlichen patienten, die uns zur akuten operativen versorgung von einem benachbarten klinikum überstellt wurden. beide litten unter rezidivierenden pankreatitisschüben nutritivtoxischer genese mit akuter verschlechterung des allgemeinzustandes und beginnendem hämorrhagischen schock. die patienten konnten nach operativer versorgung mittels pankreaslinksresektion rasch stabilisiert werden und nach unkompliziertem postoperativem verlauf entlassen werden. die operative therapie ist bei instabilen patienten die methode der wahl und kann sicher angewandt werden. das procedere und gängige interventionelle alternativen werden in der literatur diskutiert und hier gegenüber gestellt. the interplay of homocysteine and internal carotid artery stenosis in carotid surgery background: upper gastro-intestinal surgery is associated with high rates of morbidity and the post-operative complications may have a detrimental impact on patients' quality of life (qol). therapeutic endoscopy is a less invasive procedure with a high 5-year survival rate but is only suitable to a specific group of patients. this study aims to evaluate and compare the qol in patients with gastro-oesophageal cancer who underwent surgical or endoscopic intervention. methods: the european organisation for research and treatment of cancer (eortc) qol questionnaires c30 and og25 were used to assess qol in both treatment groups at 6 weeks, 6 months, 1 year and 2 years post intervention. results: 68 out of the 131 patients (52 %) completed the questionnaires. at 6 weeks after surgery, the functional scale reported lowest score in role function and the higher scores on symptom scale were fatigue, insomnia and loss of appetite. at 6 months after surgery, the main symptoms affecting qol were fatigue, anxiety and weight loss. the overall functional, symptom and global qol score improved at 1 to 2 years after surgery. in comparison, patients who underwent endoscopic intervention reported having worse abdominal pain and discomfort but still achieved an overall higher functional score and lower symptom score. conclusions: the adverse impact of surgery on qol was apparent particularly in patients at 6 weeks and 6 months after surgery. from this study, patients are better informed regarding their qol, the potential functional limitations and symptoms at various times post intervention. changes in the visceral vessels in patients with acute necrotizing pancreatitis regional clinical hospital, lviv, ukraine background: treatment of patients with acute pancreatitis (ap) is difficult, because the key mechanisms of the pathogenesis of the disease are not yet fully understood. one of the important mechanisms of ap is microvascular disturbances. ischemia of the pancreas with vasospasm, which precedes necrotic changes of the pancreas at the early stage of acute necrotizing pancreatitis, and increased blood clotting, which accompanies severe acute pancreatitis, can play a key role in the development of pancreatic necrosis. ausmaß des primärtumors und des lk status wurde eine neoadjuvante radio/chemotherapie mit anschließender op nach etwa 6 wochen oder eine primäre operative versorgung durchgeführt. für die rekonstruktion wählten wir in 32 fällen einen retrosternalen magenhochzug mit zervikaler anastomose nach akijama kirschner und in 22 fällen einen intrathorakalen hochzug mit intrathorakaler anastomose nach ivor lewis, zum teil mittels hybridverfahren mit laparoskopischer technik des abdominellen parts. im rahmen unseres qualitätsmangements wurden die patientendaten auch hinsichtlich der postoperativen anzahl an endoskopischen interventionen bedingt durch anastomosenstenosen evaluiert. dabei zeigte sich ein deutlicher vorteil zugunsten der rekonstruktion nach ivor lewis. in dieser patientengruppe kam es nur bei 4 % zum auftreten einer interventionspflichtigen dysphagie, während bei rekonstruktionen nach akijama kirschner bei 13 % der patienten eine bougierung notwendig wurde. für uns stellt daher im bezug auf postoperative lebensqualität die rekonstruktion nach ivor lewis die bessere option dar. hat die septische thoraxchirurgie ihren schrecken verloren? erfolgreicher einsatz von vac instill bei empyema necessitatis abteilung für chirurgie, lkh leoben, leoben, österreich die septische chirurgie des thorax stellt eine der großen herausforderungen der thoraxchirurgie dar. das empyema necessitatis per definitionem ein spontandurchbruch eines pleuraempyem durch den zwischenrippenraum in die subcutis fordert eine solche chirurgie, die für den patienten sowohl eine physische als auch psychische belastung darstellt, da die therapie sowohl langwierig als auch entstellend ist. wir präsentieren einen fall wo uns mit hilfe des vac instill eine erfolgreiche therapie eines solchen septischen geschehen gelang. es handelt sich dabei um eine 72 jährige patientin mit z. n. operierten bronchuscarzinom. im rahmen der nachsorge wurde der verdacht eines lokalrezidivs sowie einer pleuracarzinose geäußert der mittels minithorakotomie histologisch gesichert wurde. die patientin kam daraufhin an die onkologie unseres hauses zur einleitung einer chemotherapie. am aufnahmetag klagte die patientin über starke schmerzen und rötung im bereich der thorakotomienarbe, über hohes fieber und das aktuelle labor zeigte stark erhöhte entzündungsparameter. das daraufhin durchgeführte ct bestätigt die verdachtsdiagnose eines empyema necessitatis. unsere therapie bestand in der sofortigen operativen versorgung mit eröffnung der pleurahöhle, soweit möglich nekrektomie und einleiten einer vac therapie. an einen verschluß der pleurahöhle war in dieser situation nicht zu denken. mit hilfe des vac instill gelang es uns jedoch innerhalb von 10 tagen die wundverhältnisse so zu säubern das ein erfolgreicher thorakotomieverschluß gelang und die patientin ihrer chemotherapie zugeführt werden konnte. für uns stellt diese therapie eine sehr vielversprechende option dar in solchen situationen einen definitivverschluß der pleurahöhle zu erreichen. die qualität des schluckens! optionen der operativen versorgung bei ösophaguscarzinomen sowie carzinomen des gastroösophagealen überganges mit besonderem augenmerk auf die postoperative lebensqualität für patienten mit carzinomen des ösophagus sowie des ösophagogastralen überganges bedeutet die dysphagie eine hochgradige einschränkung der lebensqualität. bei patienten mit palliativem therapieansatz steht die sicherstellung der schluckfähigkeit im mittelpunkt unseres managements. aber auch patienten mit kurativer operativer versorgung leiden postoperativ unter dysphagie bedingt durch anastomosenstenosen. wir möchten anhand unseres eigenen patientenguts der letzten 5 jahre die möglichkeiten der operativen versorgung und ihre postoperative lebensqualität aufzeigen. in den letzten 5 jahren wurden bei uns 54 patienten einer ösophagusresektion unterzogen. es handelte sich dabei um 12 frauen und 42 männer zwischen 46 und 84 jahren. abhängig von universitätsklinikum magdeburg a.ö.r., klinik für allgemein-, viszeral-& gefäßchirurgie, magdeburg, deutschland rezidivierende ödematöse veränderungen im darmtrakt mit folgender obstruktion, rezidivierendem erbrechen/reflux oder stuhlverhalt mit ileusausbildung können breit differenzialdiagnostisch begründet sein. insbesondere bei unklaren, teils heftigen und wiederkehrenden abdominellen beschwerden können erkennung, adäquate einstufung/deutung und der angemessene therapeutische ansatz schwierig sein, die nicht selten eine herausforderung darstellen. ziel: des vorliegenden fallberichts besteht darin, anhand eines ungewöhnlichen kasus und basierend auf der einschlägigen literatur jüngeren datums die differenzialdiagnose dieser anspruchsvollen klinischen konstellation mit diagnosefindung und erzielter therapieerkenntnis hinsichtlich einer adäquaten versorgung im klinischen alltag zu beschreiben. fallbeschreibung/verlauf/outcome: 46-jährige patientin stellte sich aufgrund rezidivierenden erbrechens (intermittierend nach dem essen) mit konsekutiver gewichtsreduktion (30 kg in 5-6 monaten) vor. die ct ergab eine wandverdickung im jejunum. aufgrund von leidensdruck und verschlechterungstendenz wurde eine jejunumsegmentresektion durchgeführt. intraoperativ sah man einzig die bereits in der ct beschriebene wandverdickung an drei aufeinander folgenden lokalisationen (je drei cm länge) mit geleeartiger struktur und lumeneinengung, letztlich inkompletter ileus (histopathologie: submuköses, teils transmurales segmentales ödem, vergleichbar mit angineurotischem ödem -ausschluss amyloidose/malignität; c1-esterase-inhibitor-diagnostik: physiologische befunde). weitere ursachenforschung erbrachte bei hypertonie eine ace-hemmer-medikation, die dann ab der op abgesetzt wurde. eine einheimische sprue konnte weder klinisch, endoskopisch noch histologisch bestätigt werden. diskussion: trotz simpel erscheinender versorgung sind adäquate klinische diagnosestellung und angemessene therapeutische entscheidungsfindung beim angioneurotischen ödem äußerst anspruchsvoll, da es die klassische konstellation einer morphologisch bedingten, neoplastisch anmutenden, letztlich op-pflichtigen gastrointestinalen passagebehinderung nicht exakt erfüllt, jedoch einige merkmale dessen aufweist. letztlich führte die dünndarmsegmentresektion und histologische untersuchung ,,erst" zum letztendlichen diagnostischen beweis, der zur angezeigten zusatzmaßnahme (optimierung laufender medikation) verhalf. perforierte "subhepatische appendicitis"seltener fall in der zugänglichen literatur, basierend auf einer intestinalen malroration mit letztendlich subhepatischer coecumlage grundlagen: eine perforierende divertikulitis oder ein mechanischer ileus bei akut entzündlichem darmgeschehen mit begleitender peritonitis stellen notfälle in der chirurgie dar, die jederzeit operativ versorgt werden sollten. die oben vorgestellte methode lässt sich als akutoperation auch in einem grundversorgungskrankenhaus durchführen, die definitive versorgung erfolgt nach einem intervall mit vakuum assistierter wundbehandlung des abdomens im rahmen des routineprogramms. methodik: ziel dieses mehrzeitigen vorgehens ist eine schnelle entfernung des entzündlich veränderten darmabschnittes und das kontinuierliche absaugen von sekret mit der vakuumassistierten wundbehandlung. bei der primären laparatomie wird zunächst der makroskopisch veränderte darmabschnitt im sinne einer marginalen resektion mit dem linearstapler oder gia reseziert, danach erfolgt eine ausgiebige peritoneallavage zur minimierung der keimlast innerhalb der peritonealhöhle, der entscheidende vorteil dieser methode ist die, im vergleich zur konventionellen methode, kurze op dauer. anstatt des pimären verschlusses der bauchdecke wird mit der vakuumassistierten unterdrucktherapie über maximal 72 h eine weitere intraperitoneale keimreduktion erreicht. in diesem intervall erfolgen die vorbereitungen für den second look, wo unter zusammenschau des lokalbefundes, des histologischen ergebnisses und der laborparameter die indikation für das weitere procedere getroffen wird. schlussfolgerungen: bis dato wurden an unserer abteilung drei patienten mit dieser methode in allgemeinnarkose unter konsekutiver anastomose und bauchdeckenverschluss versorgt. die bislang erhobenen befunde sprechen für eine minimierung der intensivmedizinischen betreuung, einen verminderten einsatz an antibiotika, eine verringerung der mortalität und eine erhöhung der patientenzufriedenheit. diese methode ist auch in einem grundversorgungskrankenhaus mit gutem erfolg durchzuführen. angioneurotisches ödem bei c1-esteraseinhibitormangel versus ace-hemmer-/ at1-blocker-medikation oder einheimische sprue -ungewöhnliche, aber zutreffende differenzialdiagnose unklarer, rezidivierender abdominalbeschwerden durch morphologisch auffällige jejunale wandveränderungen mit inkomplettem ileus c. lerche, c. wex, c. bruns, f. meyer background: continuous bleeding after the unsuccessful use of conventional haemostatic methods, involving energy, sutures, or clips, is a serious and costly issue during surgery. many topical agents have been developed to promote intra-operative haemostasis, but improvement is needed in both decreasing time to haemostasis and increasing ease of use. herein we tested the novel veriset tm haemostatic patch, which is 100 % free of human or animal components and has been proven to be efficient in liver surgery, for hemostasis during esophagectomy, gastrectomy, colectomy, and lower anterior rectum resections. methods: subjects (n = 30) scheduled for non-emergent soft tissue surgery, with an intra-operative bleeding site, were treated with veriset tm haemostatic patch after traditional means of achieving haemostasis were not successful. bleeding severity grundlagen: anatomische varianten können das klinische bild einer erkrankung so verändern, dass die diagnosestellung von häufigen pathologien wie einer appendizitis zu einer herausforderung wird. unter diesen varianten findet man zum beispiel die malrotationen, defekte der physiologischen drehung des darms während der embryonalentwicklung. unter "zökums maldescensus" versteht man zum beispiel die fehlende wanderung und fixation des zökums in den rechten unterbauch. wenn das zökum samt appendix im rechten oberbauch subhepatisch bleibt, kann eine banale appendizitis zu den differenzialdiagnosen der rechtsseitigen oberbauchschmerzen zählen. in der literatur findet man ungefähr 15 beschriebene fälle von subhepatischer appendix. die größte chirurgische serie von subhepatischen appendizitiden sind sechs fälle, von denen einer perforiert war (palanivelu). fall: hier beschreiben wir das diagnostische management, therapeutische entscheidungsfindung, eigentliche operative therapie und den posttherapeutischen verlauf eines 43-jährigen, der mit dem verdacht auf cholezystitis sonografiert wurde. dabei zeigte sich im oberbauch eine entzündlich-tumoröse struktur, die ct-morphologisch weitercharakterisiert und als appendizitis erkannt wurde. die laparotomie bestätigte die diagnose einer gedeckt perforierten gangränösen appendizitis retrozökal in einem nicht diszendierten, suhepatisch gelegenen zökum. der patient wurde daraufhin einer ileozökalresektion mit ileotransversostomie unterzogen, überstand den eingriff ohne komplikationen und konnte am 8. postoperativen tag entlassen werden. schlussfolgerungen: ungewöhnliche appendixlagen können zu verzögerungen und fehlern in der behandlung von häufigen chirurgischen erkrankungen wie der appendizitis führen. der chirurg muss insbesondere die möglichkeit der anatomischen varianten im hinterkopf behalten, um alle möglichen differenzialdiagnosen zu erfassen. mirizzi-syndrom typ neu ii (cholezystocholedochale fistel) -seltenes, aber repräsentatives und lehrreiches fallbeispiel zum management interner biliärer fisteln interne biliäre fisteln im allgemeinen und das mirizzi-syndrom im besonderen stellen seltene, erworbene gallengangsanomalien dar, bedingt durch eine chronische, meist lang andauernde, entzündliche reaktion des biliären systems oder dessen benachbarter strukturen, sind jedoch mit einer erhöhten perioperativen mortalität/morbidität verbunden. methodik: mittels systematischer aufarbeitung des fallberichtes über einen patienten mit mirizzi-syndrom typ ii soll, basierend auf einer begleitend-selektiven literaturrecherche, ein überblick über klassifikation, hinweisgebende symptomatologie/klinik, diagnostischen algorithmus und operative strategien in der behandlung dieser komplikationsbehafteten entität aufgezeigt werden. fallkonstellation/verlauf/therapie/outcome: 76-jähriger patient wurde 4 sitzungen einer therapeutischen ercp (i. s. des 4/9 patienten waren weiblich. das mediane alter der patienten lag bei 24 jahren monaten telefonisch kontaktiert und standardisiert befragt. ergebnisse: es kam zu keiner intraoperativen komplikation die postoperativen schmerzen an den tagen 1, 2, 3 und 4 lagen im median bei 4, 3, 2 und 1 nach vas. zwei monate nach anlage der drainage berichtet keiner der patienten über schmerzen im bereich der drainaustrittsstelle. schlussfolgerungen: das system erwies sich einfach und komplikationsfrei in der handhabung. 88,9 % der patienten konnten mit dem system erfolgreich therapiert werden. postoperative schmerzen waren gering therapeutischen splittings") wegen sonografisch gesicherter choledocholithiasis (incl. klinisch sicherer cholangitis) unterzogen mit folgender indikation zur cholezystektomie letztlich erfolgte die i) konventionelle cce (+ lösen der adhärenten gb am ductus hepaticus mit übernähung der fistelöffnung), ii) cholangiografie (katheter via cysticusstumpf: regelrecht) und iii) t-drainage (sukzessives abklemmen/verschluss ab 8./ am 11. postoperativen tag). die kontrastmittel-gestützte röntgendurchleuchtung zwei monate postoperativ ergab v klaus krankenhaus der barmherzigen schwestern wien 05.04, 49.05, p13, p33 p14 chiapponi p08 m mach 05.08, 15.02, 27.05, p04, p07, p08 54.02 n nagel p03 rényi -vámos 30.02, 30.05, 30.08 30.02, 30.05, 30.08 p14 author index 05.08, 15.02, 16.06, 27.05, p07, p08 30.01, 30.03, 30.04, 30.06, 36.06 30.03, 30.06 ci (l/min/m2) 2.5 ± 0.1 5.0 ± 0.3 *** 4.7 ± 0.3*** *** infarct % 12.6 ± 1.4 9.8 ± 0.6 8.2 ± 1.7 n.s. grundlagen: immer sensitivere diagnostische verfahren erlauben heute die diagnose von mammakarzinomen in frühesten krankheitsstadien. damit ist eine brusterhaltende behandlung an unserem haus für weit mehr als 80 % der frauen möglich geworden.gleichzeitig verbessern sich die chancen auf langzeitüberleben stetig. daraus resultiert der anspruch nicht nur an das onkologische, sondern auch an das kosmetische ergebnis der operation: es ist einer onkologisch geheilten patientin nicht zuzumuten, täglich vor dem spiegel schmerzlich an eine bösartige erkrankung erinnert zu werden, die viele jahre hinter ihr liegt! methodik: wann immer wir einen brusterhaltenden eingriff vornehmen, beschränken wir uns nicht auf die selbstverständlich zu fordernde radikale tumorektomie nach den üblichen kriterien, sondern bemühen uns stets um das bestmögliche kosmetische operationsergebnis: round-block -technik, batwing-incision, grisotti-plastik, local glandular flap und peri-areoläre raffnaht sind einfache und leicht zu erlernende manöver, deren beherrschung zu ausgezeichneten ergebnissen führt.ergebnisse: wir stellen fälle aus unserem chirurgischen alltag vor , darunter auch solche, bei denen die operation keine sichtbaren spuren hinterlassen hat. lediglich bei kleinen und sehr kleinen mammen lassen sich mit den genannten methoden größenunterschiede im seitenvergleich nicht gänzlich vermeiden. doch selbst dann sind die patientinnen in über 90 % sehr zufrieden, die verbleibenden zu mindestens zufrieden mit ihrem aussehen.schlussfolgerungen: auch allgemeinchirurgen haben die ethische verpflichtung, neben dem onkologischen ein angemessenes kosmetisches operationsergebnis anzustreben. unter bedachtnahme auf das ohnehin mit der diagnose verbundene trauma, das die patientinnen erfahren, ist der routinemäßige einsatz einfacher onkoplastischer methoden zu fordern. background: conditioned media obtained from cultured cells has been shown to exert in vitro and in vivo cytoprotective effects. our group has recently shown that paracrine factors secreted from apoptotic peripheral blood mononuclear cells (pbmc) exert pro-angiogenic, anti-aggregative, vasodilative and immunomodulatory effects.the aim of the study was first to analyze radio responsive biological processes in pbmcs and second to characterize the secretome of irradiated and non-irradiated cultured human pbmcs using global gene expression profiling.methods: human pbmcs from 4 donors were irradiated with 60 gy of g-rays. 2, 4 and 20 h after radiation the rna was isolated and prepared for gene expression evaluation. bioinformatic algorithms were used to detect genes coding for secreted proteins and selected transcripts were validated with rt-pcr.results: ir induced changes in mrna and mirna expression profiles as a function of time. gene ontology analysis revealed that initial radiation responsive genes associated with the biological process "p53 signaling pathway" were enriched after 2 h. bioinformatics based classification of secreted proteins confirmed their involvement in the biological processes "positive regulation of angiogenesis", "vascular wound healing", "regulation of coagulation" and "regulation of cell proliferation".background: heat-shock proteins (hsp) 27 and 70 are associated with anti-apoptotic and pro-angiogenic mechanisms. moreover, their expression is related to rapid tumor progression. lung metastases (pm) occur in a subset of patients with primary colorectal cancer (crc) and metastasectomy is routinely performed in these patients. we sought to investigate the prognostic value of hsp27 and 70 in patients undergoing pulmonary metastasectomy.methods: pulmonary metastases of forty-four patients with primary colorectal carcinoma (crc) were assessed by immunohistochemistry. furthermore, corresponding primary crc of thirty-two patients were available. expression of hsp27, hsp70 and alpha-smooth muscle actin was correlated with clinical parameters.results: hsp27 and hsp70 were evident in 90.6 and 96.9 % of primary tumors and in 72.7 and 95.5 % of paired pulmonary metastases. lung-metastasis free survival was significantly shorter in patients with high levels of hsp70 and low levels of hsp27 in tumor cells of pm. interestingly, co-expression of hsp27 and alpha-smooth muscle actin in tumor-associated myofibroblasts was associated with both, decreased lung-metastasis free survival and lung-specific recurrence free survival in univariate analysis.conclusions: this study provides first evidence of hsp 27 and 70 in tumor cells and tumor-associated myofibroblasts in pm of primary crc. our data indicate an association between cellular stress of and early pulmonary spreading and lung-specific recurrence. in the future, hsp27 and hsp70 might also pose promising therapeutic targets in patients with pulmonary metastases of crc. the local and systemic role of rage (receptor for advanced glycation endproducts) and its ligand hmgb1 (high mobility group box-1) in thymic epithelial tumors, thymic hyperplasia and regular thymic morphology aposec is the secretory product of apoptotic peripheral blood mononuclear cells (pbmc). in preclinical studies aposec has proven effective in attenuating tissue damage and improved hemodynamics after acute ischemic injury or chronic post-myocardial infarction left ventricular dysfunction. due to the range of possible applications and the necessity of an immediate treatment in case of traumatic injury or disease, aposec has to be produced in an allogeneic fashion for the possibility "of the shelf utilization" (multiple pbmc donors are recruited for production, pooling of product). this manufacturing process has to overcome strict regulatory affairs, besides gmp facility, in order to be mandated for clinical trials in humans. for the product to be safe, the production process must include steps to inactivate and/or remove possible virus contamination. taking into consideration the nature and characteristics of aposec we have chosen a system using methylene blue and subsequent gamma irradiation for viral reduction. we sought to determine if the pathogen reduction system has any effect on the drug compound or clinical potency of the product.although screening for protein alterations showed significant changes of measured chemokines and cytokines (egf, ena-78, il-8, mif, tgf-ß and vegf; p < 0.05) in conditioned media after pathogen reduction treatment, aposec kept its clinical potency in a porcine closed chest reperfused acute myocardial infarction model (table 1) .3 and 30 days after ischemia/reperfusion injury, mri was conducted and parameters of cardiac function were obtained from pigs treated with aposec + /-pathogen reduction (pr) and from control animals.burn patients had an in-hospital mortality of 18.75 % (26 survivors vs. 6 decedents). sst2 was higher in burn patients compared to healthy volunteers at admission to the icu (mean, 2333 pg/ml vs. 126 pg/ml; p = 0.002) and the day after (mean, 3574 pg/ml vs. 136 pg/ml; p < 0.001). calculating areas under the curve (aucs) with in-hospital mortality as the classification variable, sst2 obtained at admission to the icu was a significant predictor of death (auc of 0.867). other markers of inflammation were also related to outcome (c-reactive protein, auc of 0.545; il-6, auc of 0.833; and procalcitonin, auc of 0.757). in conclusion, sst2 serum concentrations are markedly increased in burn patients and predict in-hospital mortality. these data suggest an involvement of the sst2/il-33 pathway in the immunosuppression seen after burn trauma. we try to create a living replacement material with regeneration and growth capacity made of homologous cells as patch materials for aortic valve repair in congenital heart surgery.methods: myofibroblasts harvested from umbilical cord of a lamb are isolated, cultivated and expanded for 14 days, seeded on a scaffold. seven days static cultures are followed by cultivation in a bioreactor (14 days). then the tissue engineered patch (tep) is implanted in the sheep (59-70 kg). the acoronary leaflet is explanted and the tep tailored to implant it as leaflet substitute. echocardiography and ct scans were performed; 6 h later the animal is sacrificed.results: so far, we operated on seven sheep (median sternotomy [n:6], right lateral thoracotomy [n:1]). one sheep developed ventricular fibrillation (vf) due to unknown reason right after sternotomy another developed vf refractory to medical or electrical treatment after weaning from ecc and died also before planned scarification. nevertheless, the operation was finished in all seven attempts. mean follow-up time after chest closure was 3.2 h. postoperative echocardiography revealed excellent function of leaflet substitute with good coadaptation of the aortic valve leaflets without signs of relevant aortic valve stenosis (none) or regurgition (none or trivial). in one case an angiogram was done demonstrating a sufficient valve. ct scan was done in 3 cases demonstrating none to trivial aortic valve regurgitation. obtained histologic samples at sacrification showed cell migration (red blood cells as well as lymphocytes) into the scaffold. histological alterations in dogs after creation of composite urinary reservoir increase in the allogeneic group for the very early timepoints (immediately, 4 h postop and pod1). for samples taken on pod 3 and pod5, both markers il-1b and il-1a showed a significant increase (p = 0.01 and p = 0.006, respectively) in the allogeneic group.conclusions: our results demonstrate a clear correlation between cytokine expression in the skin and acute rejection. especially for the markers il-1b and il-1a, a significant increase in the allogeneic group could be detected very early after transplantation, and importantly, prior to any visible signs of rejection. tenascin-c in the murine geriatric heart after myocardial infarction background: aging is associated with a higher incidence, mortality, and complication rate of myocardial infarction (mi). tenascin-c (tnc) is a glycoprotein produced in the infarction border zone. previous studies correlated high tnc expression with unfavorable outcome in patients with mi.methods: in male geriatric (om, 18 months) and young (ym, 11 weeks) of1 mice mi was induced by lad ligation. thirty-two days after mi, cardiac mri was used for hemodynamic evaluation. the tnc expression 3, 7, and 32 days after mi was illustrated by immunohistochemistry and assessed by digital image analysis.results: mri examination showed significant effects of age and of mi vs. sham on ejection fraction (age: p < 0.001; mi: p < 0.001), stroke volume heart weight ratio (age: p < 0.001; mi: p < 0.001), cardiac output heart weight ratio (age: p < 0.05; mi: p < 0.05), end-systolic (age: p < 0.01; mi: p < 0.001), and enddiastolic left ventricular volumes (age: p < 0.05; mi: p < 0.001). moreover, mi had a significant effect on stroke volume (age: n.s.; mi: p < 0.05). no significant interactions between the two factors were found in any parameter.tnc concentrations peaked on the third day after mi. om with mi showed an increased tnc concentration 3, and 7 days after mi induction by tendency. in sham groups no specific staining was detected.conclusions: we found significant hemodynamic differences between mi and sham groups, and also between om and ym. increased tnc expression in geriatric hearts after mi may be a reason for impaired cardiac function.ergebnisse: von diesen 43 artikeln waren insgesamt sechs nicht in deutscher oder englischer sprache verfasst und wurden deshalb nicht berücksichtigt. weiters wurden 18 arbeiten ausgeschieden, deren hauptfokus nicht im therapeutischen bereich angesiedelt war (z. b. epidemiologische, molekularpathologische, radiologische, veterinärmedizinische oder einzelfallstudien). insgesamt konnten schließlich 19 publikationen berücksichtigt werden.schlussfolgerungen: während das akute management bestimmter komplikationen außer streit steht (z. b. abszessinzision), ist im gegensatz dazu die erforderliche radikalität der behandlung in den unterschiedlichen stadien der bronj immer noch gegenstand kontroverser diskussionen. das spektrum der therapeutischen optionen reicht von rein konservativen maßnahmen (z. b. prothesenanpassung zur vermeidung von druckstellen, spülungen mit chlorhexidin, etc.) bis hin zu ausgedehnten resektionen befallener unter-bzw. oberkieferanteile. auch über ein jahrzehnt nach erstbeschreibung dieses erkrankungsbildes besteht somit nach wie vor kein allgemeiner konsensus bezüglich der nötigen therapeutischen invasivität und des geeignetsten behandlungsprotokolls. erkennung von plattenepithelkarzinomen mit einer neuen substanz im in vitro -versuch und im in vivo -tierversuch klinische abteilung für mund-, kiefer-und gesichtschirurgie, graz, österreich grundlagen: weltweit leiden 7,6 mio. menschen an krebs und in 13 % der fälle aller erkrankungen ist dieser die todesursache. in österreich sind 9,8 % aller neuen krebsfälle pro jahr karzinome des kopf-hals-bereiches.ziel: der arbeitsansatz der studie ist, dass nach intravenöser gabe zweier neuen substanzen, diese eine neue fluoreszenzdiagnostik und therapiemöglichkeit in der tumorchirurgie ergeben.methodik: für die mausexperimente werden 2 substanzen in vitro zellen der exponentiellen wachstumsphase verwendet. die identität der zellen wurde mittels str (short tandem repeat) überprüft.der tierversuch wird an nmri-nacktmäusen in vivo durchgeführt. das experiment beinhaltet 2 gruppen mit je 50 tieren: eine kontrollgruppe (20 tiere) und zwei versuchsgruppen (insgesamt 50 tiere) mit induzierten oralen plattenepothelkarzinomen.ergebnisse: tumorzellen in vitro und in vivo tumore der nmri-nacktmäuse konnten durch zwei neue substanzen eindeutig nachgewiesen werden, wobei bei der reinen substanz keine abgrenzung zum gesunden gewebe nachgewiesen werden konnte. die auswertung der tierversuche in vivo ergab insgesamt 120 tiere.schlussfolgerungen: die verdachtsdiagnose wird durch eine inspektion der mundhöhle und durch palpation der halsorgane gestellt und parallel zur radiologischen diagnostik histologisch gesichert. eine solche methode und diagnostik kann tumoren in seinem sicherheitsabstand, als auch die resektionsränder des pec zum gesunden gewebe einen neuen einblick in die größe der tumorgröße und resektionsausweitung geben werden. the best option for augmenting the urinary bladder remains yet obscure. both gastro-and enterocystoplasties have their complications, amongst which malignancy is the gravest. a new animal model was designed to see whether the risk of malignancy decreases if gastric and colonic segments are used simultaneously for bladder augmentation (composite urinary reservoir).methods: composite urinary reservoirs were created using gastric-and colonic segments simultaneously in eight 3-monthold female beagle dogs by replacing half of the native bladder. two dogs with gastrocystoplasty and two with colocystoplasty served as controls. biopsies were taken from the native bladder, the gastric and colonic segments at the time of operation (zero biopsy) and endoscopically at 4, 8 months postoperatively. dogs were sacrificed and open biopsied 12 months postoperatively. tissue specimens were examined with routine (he) and immunohistological staining (pcna).results: zero biopsies showed normal histology. tumor formation was found in 2 dogs 12 months after composite urinary reservoir formation. one animal had an invasive micro carcinoma in the gastric segment, and one had a colonic adenoma in the colonic segment. at 12 months postoperatively, dysplasia was found in 1 gastric segment, in 2 native bladders and in 3 colonic segments in the composite reservoir group. in the control groups, 1 colonic segment and 1 native bladder dysplasia were detected at the end of the 12-month-follow-up.conclusions: composite reservoir did not diminish premalignant changes in dogs during follow-up. further investigations are necessary to approach the question of malignant alterations following augmentation cystoplasty. für mund-, kiefer-und gesichtschirurgie minimal versus maximal -invasivität der bronj therapie im wandel der zeit universitätsklinik für mkg-chirurgie, innsbruck, österreichgrundlagen: in seinem 2003 publizierten artikel über eine mit bisphosphonaten in zusammenhang stehende avaskuläre nekrose im kieferbereich hat robert e. marx erstmals auf ein bis dahin noch unbekanntes erkrankungsbild hingewiesen. die bisphosphonat-assoziierte kiefernekrose (bronj: bisphosphonateassociated osteonecrosis of the jaw) zog in den darauf folgenden jahren jedoch zunehmende aufmerksamkeit auf sich. im laufe des vergangenen jahrzehnts wurden unterschiedliche therapiekonzepte evaluiert, die von minimal invasiven behandlungen bis hin zu ausgedehnten kieferresektionen reichen.methodik: eine pubmed literatursuche anfang jänner 2014 ergab für die schlüsselwörter "bronj" oder "bisphosphonate osteonecrosis" im titel oder im abstract 288 treffer. der zusatz des filters "review" reduzierte diese anzahl auf 43 publikationen, von denen die abstracts gesichtet und auf ihre relevanz hin überprüft wurden. the increase of morbid obesity has propagated the evolution of complex surgical procedures aiming for efficient long-term weight loss through restrictive and malabsorptive approaches.methods: a retrospective review of data collected from 1139 morbidly obese patients, who qualified for either roux-en-y gastric bypass (rygb), sleeve gastrectomy (sg) or adjustable gastric banding (agb) was performed from 01/2003 to 12/2013. results: in 10 years a total of 369 rygbs, 146 sgs and 624 agbs were performed in our center. whereas the incidence of agbs continuously decreased within this decade, due to insufficient long-term outcomes (esophagitis: 28.8 %; pouch dilation: 15.3 %; esophageal dilation: 12.5 % band leakage: 6.5 %), numbers of rygbs simultaneously increased and became the procedure of choice. rygb surgery is associated with a different spectrum of complications (anastomosis ulcers 12.3 %, anastomosis leakage 2.1 %, internal hernia 3 %, bleeding 2.7 %), however, it provides the patient with substantial excess weight loss results (1 year ewl: 60 %) when compared to sg (1 year ewl: 57 %) and agb (1 year ewl: 40.4 %). sg, (performed by single incision laparoscopic surgery in 26.1 %) resulted in increased postoperative gastroesophageal reflux, requiring a secondary rygb in 3.3 %.conclusions: over the last decade a shift from sole restrictive bariatric-(agb) to both restrictive and malabsorptive procedures (rygb) was observed. weight loss was almost equal for rygb and sg followed by adjustable agb. recent technical improvements including single access may have resulted in a transient higher number of sg performed. gastric bypass: long term follow-up a. geberth, m. poglitsch, r. kefurt, s. shakeri-leidenmüller, g. prager background: nt-probnp is an important risk factor for predicting cardiac insufficiency and perioperative cardiovascular complications. however, changes in the nt-probnp levels following bariatric surgery remain controversially discussed.methods: 708 consecutive bariatric surgery patients (78 % female, 22 % male, mean bmi 46 kg/m 2 preoperatively) underwent laparoscopic roux-en-y gastric bypass between 2005 and 2012 and were retrospectively evaluated for changes in their nt-probnp levels at the timepoints preoperatively, at 3, 6, 9, 12, 18, 24, 36, 48, 60, 72, 84 and 96 months postoperatively (mean follow-up: 27 months).results: the mean nt-probnp level was 149 ng/l preoperatively, 230 ng/l at 3, 242 ng/l at 6, 419 ng/l at 9, 148 ng/l at 12, 171 ng/l at 18, 239 ng/l at 24, 158 ng/l at 36, 190 ng/l at 48, 185 ng/l at 60, 230 ng/l at 72 and 118 ng/l at 84 months postoperatively. applying a paired t-test revealed significantly higher homocysteine levels at 3 (p = 0.0001) postoperatively than preoperatively. after subdividing the study population in morbidly obese (group a, n = 504, bmi < 50 kg/m 2 ) and superobese (group initiiert. nach fallpräsentation dieser seltenen tumorentität erfolgt diskussion und aufarbeitung des therapeutischen vorgehens anhand rezenter literaturdaten. the receptor for advanced glycation endproducts (rage) has been shown to be involved in several inflammatory and immunologic conditions, such as diabetes, atherosclerosis, tumors and transplantation. we hypothesized that rage and its ligands might be regulated by exercise such as marathon events. we enrolled 35 probands running a marathon (m), 35 running a half-marathon(hm) and 30 subjects, who did not participate in any competition. we employed immunosorbent assays to determine the serum concentration of soluble rage (srage) and the rage ligands high mobility group box-1 (hmgb1) and advanced glycation endproducts (age-cml) before the marathon (day1), immediately post-marathon at the finish area (day2), and two to seven days after the marathon (day3 es gab keine intra-oder postoperativen komplikationen, sodass der patient am 6. postoperativen tag in gutem allgemeinzustand nach hause entlassen werden konnte. nach einem monat war der patient vollkommen beschwerdefrei und die narbe im nabelbereich war fast nicht mehr zu erkennen. schlussfolgerungen: die transumbilikale sil-sigmaresektion ist für den erfahrenen laparoskopischen chirurgen mit konventionellen laparoskopischen instrumenten sicher und effektiv durchführbar. the rage axis in marathon and half-marathon runners ziel, patienten und methoden: über einen definierten zeitraum wurden alle konsekutiven patienten mit cilostazolmedikation (pavk-stadium iib) eruiert und im 1/4-jahres-abstand nachuntersucht, um den therapieeffekt an einem repräsentativen spezifisch gefäßchirurgischen patientenklientel im rahmen einer prospektiven, unizentrischen beobachtungsstudie zu analysieren. es wurden maximale gehstrecke, subjektive (semiquantitative) einschätzung der lebensqualität, einfluss der nebenerkrankungen sowie auftreten von nebenwirkungen und deren einfluss erfasst.ergebnisse: von den 146 eruierten patienten mit initiierter cilostazoltherapie waren 93 nach studienvorgabe auswertbar. 3 monate nach initiierung der cilostazoltherapie verbesserte sich die maximale gehstrecke, ausgehend von 181 m, um 108 m (159,7 %). nach 6 bzw. 9 monaten wurde eine gehstreckenverbesserung um 181m (200 %) bzw. 168m (192,8 %) ermittelt. nach 12 monaten war zwar kein weiterer zuwachs der gehstrecke mit 126m (169,6 %) im vergleich zum 6. und 9. monat zu verzeichnen, aber noch mit hoch-signifikantem unterschied zum ausgangswert. die gehstrecke verbesserte sich vom 3. zum 6. monat tendenziell (p = 0,1055), zwischen 3. und 9. monat bestand wiederum ein signifikanter unterschied (p = 0,0094; keine signifikanten differenzen zwischen 3./12., 6./9., 6./12. und 9./12. monat. während die subjektive lebensqualitätseinschätzung nach 3 monaten in 76 % der fälle ,,besser" ergab, schwankte die rate nach 6/9/12 monaten zwischen 61/46/59 %. es gab keine sicherheitsbedenken bezüglich schwerer nebenwirkungen, insbesondere blutungsereignissen. subgruppenanalysen von nebenerkrankungen wie diabetes, hyperlipidämie oder nikotinabusus fanden keine signifikante affektion der gehstrecke.schlussfolgerungen: auch im erstmals systematisch untersuchten spezifisch-gefäßchirurgischen patientenklientel führte die cilostazolmedikation zu einer hochsignifikanten maximalen gehstreckenverbesserung (p < 0,0001) mit steigerung bis zu einem jahr (effekt abschwächend), begleitet durch eine überwiegende verbesserung der lebensqualität (effekte reichen über meist berichtete 3-6 monate hinaus). erfolgreiche offen-gefäßchirurgische versorgung eines monströsen aneurysmas der a. hepatica propria im leberhilus ergebnisse: nach der laserresektion besteht eine etwas bessere pneumostase. der unterschied ist aber klein und statistisch nicht signifikant. nach der laserresektion beträgt die mittlere luftfistel 120 ml/min/cm 2 , nach resektion mit der bipo-jet-wasser-schere 160 ml/min/cm 2 . die wasserirrigation bei der resektion mit bipo-jet-wasser-schere verhindert eine erhitzung des gewebes über 100°c und somit die karbonisation des gewebes. die bipo-jet-wasser-schere hat folgende vorteile: einfache handhabung (kein neues instrumentarium), kein instrumentwechsel, "all in one" schneiden-koagulieren-dissezieren, keine personalschulung, keine schutzmaßnahmen, geringe kosten, freies op-feld durch spüleffekt.schlussfolgerungen: die lungenparenchymresektion, z. b. bei der metastasenresektion, mit der bipo-jet-wasser-schere ist einfacher und der laserresektion gleichwertig. das wird nicht nur im experiment, sondern auch bei der lungenmetastasenresektion bestätigt. das auftreten einer aortoduodenalen fistel ist ein zwar seltenes, aber doch immer wieder vorkommendes ereignis nach operativer aortenrekonstruktion, mit extrem hoher perioperativer mortalität und morbidität. eine fistel stellt immer eine ausgesprochen komplexe situation mit dem problem einer schwierigen intestinalen als auch arteriellen rekonstruktion dar. im vorliegenden fallbericht handelt es sich um einen 70-jährigen patienten, der abends mit einer vermeintlichen colonblutung stationär aufgenommen wurde. er war kreislaufstabil und unauffällig. in der anamnese stellte sich heraus, dass 8 jahre zuvor eine aortenbifurkations prothese bei aortenverschluss implantiert wurde. in der tags darauf durchgeführten gastroskopie zeigte sich eine duodenale arosion durch die aortenprothese. anhand des fallberichtes sollen prophylaktische maßnahmen zur verhinderung einer fistel und verschiedene möglichkeiten der rekonstruktion diskutiert werden. prospektiv-systematische beobachtungsstudie zur anwendung von cilostazol (pletal ® ) in täglicher klinisch-gefäßchirurgischer praxissignifikante verbesserung von gehstrecke und lebensqualität bei patienten mit peripherer arterieller verschlusskrankheit (pavk) stadium iib auch im gefäßchirurgischen klientel the clinical impact of thymectomy in the treatment of thymoma background: plasma homocysteine concentrations are independently associated with cardio-and cerebrovascular adverse events, which might bias the efficacy of carotid surgery. this study aimed to investigate the quantitative effect of preoperative plasma homocysteine concentrations on the clinical presentation of patients with carotid artery stenosis (icas, primary outcome) and postoperative overall death after carotid surgery (secondary outcome).methods: single-centered, non-randomized, prospective case series (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) in a tertiary care center (wilhelminenspital, vienna, austria) of 488 consecutive patients with high-grade icas (214 asymptomatic, 164 transitory ischemic attacks (tia), 110 strokes) undergoing carotid surgery.results: the degree of contra (p = 0.012) and thus bilateral carotid stenosis had a significant effect on the clinical presentation of patients (or for occurrence of stroke per 1 % of bilateral stenosis = 1.01 ci 1.00-1.02, p = 0.003). after adjustment for degree of bilateral stenosis, increasing homocysteine concentrations were associated with a significantly decreased likelihood of presenting with a tia (or per 1 micromol/l = 0.96, ci 0.92-1.00; p = 0.038) compared to asymptomatic or stroke patients. tia patients showed higher postoperative survival rates than asymptomatic or stroke patients (p = 0.003).conclusions: plasma homocysteine concentrations affect the clinical presentation of patients with icas, thereby predicting postoperative survival. high homocysteine concentrations identify patients with asymptomatic icas at high risk of stroke, rather than of tia. these patients require immediate carotid surgery and intensive medical care. the contralateral degree of carotid stenosis should be taken into account when scheduling asymptomatic patients for carotid surgery. evaluation of a haemostatic patch in soft tissue surgeries background: abdominal cocoon syndrome is a rare cause of intestinal obstruction. it is characterized by a thick, fibrotic membrane, which totally or partially encases the small bowel. the etiology of this entity is relatively unknown.methods: a 55-year-old male patient presented with symptoms of bowel obstruction. ct and mri showed congregated small bowel loops encased by a capsule-like membrane. synopsis of these findings seemed suspect of a complex internal her-was assessed, time to haemostasis was monitored, and adverse events were recorded up to 90 days post-surgery.results: haemostasis using veriset tm haemostatic patch occurred within 5 min in 29/30 (96.7 %) subjects and within 1 minute in 21/30 (70.0 %) subjects. the median time to haemostasis was 1 minute. no device-related serious adverse events were recorded up to 30 days post-surgery, and no reoperations for device-related bleeding complications were performed up to 5 days post-surgery.conclusions: in this study population veriset tm haemostatic patch is safe and effective in obtaining haemostasis during soft tissue procedures. in der bakteriologe zeigen sich grampositive stäbchen. am folgetag wird der patient wieder instabil. es wird daraufhin eine sofortige operation mittels medianer laparotomie mit freilegen aller intestinalen logen durchgeführt. während der operation langt der bakteriologische befund ein. es handelt sich um eine infektion mit clostridium perfringens. die antibiotische therapie wird entsprechend umgestellt.es erfolgt die transferierung in das lkh graz zur hyperbaren therapie. im lkh graz erfolgen insgesamt 10 hbo therapien und regelmäßige chirurgische revisionen mit vac anlage.der patient kann nach einem 28-tägigen aufenthalt an unsere abteilung transferiert werden.in einem weiteren 4 monatigen aufenthalt an unserer intensivabteilung muss das abdomen bei neuerlichen abszessbildungen und der entwicklung einer dünndarmleckage noch 3x revidiert werden. der patient entwickelt eine dünndarmfistel in der laparotomiewunde die mittels vac therapie versorgt wird. nach 6 monatigen spitalsaufenthalt kann der patient an das heimatkrankenhaus rücktransferiert werden.der abdominelle gasbrand ist mit einer hohen letalität verbunden. nur durch entsprechend schnelle diagnosestellung, entsprechende antibiotikatherapie, chirurgischer therapie in kombination mit der hyperbaren oxygenierung und entsprechender intensivtherapie besteht eine überlebenschance. der postoperative verlauf war durch eine anastomosendehiszenz mit lokaler peritonitis, einen leberabszess und eine wundheilungsstörung protrahiert.schlussfolgerungen: ein bezoar kann in seltenen fällen zu einer lebensbedrohlichen komplikation wie einer kolonperforation führen, insbesondere bei riesigen steinen oder wenn distale darmstenosen vorliegen. ein baldiges operatives vorgehen ist das mittel der ersten wahl. nia. at explorative laparotomy no hernia was found but the entire small-bowel was encased by a dense fibrous membrane. this membrane was incised and separated from the visceral serosa. the bowel was freed and viable so no further surgery was necessary. the postoperative period was uneventful and the patient was discharged from hospital fully recovered.results: patients with acs present with features of recurrent acute or chronic bowel obstruction secondary to compression and captivation of the intestine within the encapsulating membrane. ct is the diagnostic technique of choice. characteristic findings include fixed dilated small-bowel loops and the encasement by a soft-tissue density mantle. surgery remains the cornerstone in management of acs. incision of the membrane and lysis of the intestine normally lead to complete recovery. histological examinations of the membrane reveal fibro-collagenous tissue with nonspecific inflammatory reaction.conclusions: a high index of clinical suspicion in combination with appropriate use of radiologic studies may facilitate preoperative diagnosis and prevent surprise upon laparotomy. treatment of choice is dissection of the membrane and release of the intestine. prognosis after surgery seems excellent. case report of a patient with 5 different tumors in genetic verified lynch-syndrom background: lynch-syndrome is an autosomal dominantly inherited disorder and is the most common inherited colorectal cancer syndrome. it is caused by mutations in dna mismatch repair gens, mainly "mlh1 and msh2 but also msh6, pms", and epcam. carriers of these typical gene mutations are at higher risk developing several different types of extracolonic cancers compared with general population. these extracolonic malignancies are described in previous studies to occur more frequently in preferred organs (ovary, upper urological tract, gastric, small intestine, pancreas, skin and brain), however a context of lynch-syndrome to thyriodal or pharyngeal neoplasms are not described.methods: we present the case of a 54-year-old male with a history of 5 different consecutive malignancies (colon, jejunum, thyroid, skin and hypopharynx), thus led to genetic analysis for mutation in mismatch repair genes. in pedigree analysis stomach cancer, esophageal and breast cancer was revealed, so s the bethesda criteria for the revised guidelines were fulfilled. detection for msh2 microsatellite instability resulted in diagnosis for lynch-syndrome.results: based on developing two nontypical malignancies according to lynch-syndrome as in our patient we present this case. following research should determine whether microsatellite instability is detected in thyroidal respectively hypopharyngeal tumor.conclusions: if microsatellite instability is detected in thyroidal respectively hypopharyngeal tumors especially in this case, continuative genetic research on more patients will be conducted. a goal of this study should reveal, if more extracolonic malignancies belong to lynch-syndrome and should be considered in bethesda criteria. key: cord-005881-oswgjaxz authors: nan title: abstracts: 11(th) european congress of trauma and emergency surgery may 15–18, 2010 brussels, belgium date: 2010 journal: eur j trauma emerg surg doi: 10.1007/s00068-010-8888-z sha: doc_id: 5881 cord_uid: oswgjaxz nan introduction: frequently fractures of modern sport disciplines are fractures of the clavicle. most of them are uncomplicated and still treated without operation. therefore there is a lack of bigger studies about the treatment of clavicle fractures by elastic stable intramedullary nailing (esin). nevertheless this method becomes more and more popular, especially for young and active people. intention of this investigation was to analyze risks and results of this method to check the indication for operative treatment of simple fractures in this group of patients. material and methods: this study is a retrospective analysis of 33 patients whose fractures of the clavicle were treated by intramedullary nailing. crucial for the decision for operation was the individual request of the patient after information of the relative indication. included were 26 patients with fractures of the middle third, 4 fractures of the lateral third and 3 fractures with concomitant shoulder injuries from 2004 to 2008 . the duration of operation, intraoperative radioactive loading and complications were analyzed from the medical file. the functional outcome was measured by the constant-score. the anatomical reduction was proved by measuring the difference of the length of both clavicles (3 -48 month after operation). results: the average duration for the middle third was 66 min (22-163), for the lateral third 73 (59-100) minutes and for fractures with concomitant injuries 65 min . the mean radioactive surface dose was 1,19 cgy/cm 2 . four complications (12%) cause revision operations: one secondary dislocation which leads to pseudarthrosis and two imminent penetrations of the medial end of the nail. one patient had developed a painful pseudobursa due to lateral penetration of the nail. additional there were two prematurely nail extractions because of medial irritation of the soft tissue. altogether we documented complications in 18% of the operations. overall an open reduction was necessary in 37%. after healing there has been no significant shortening of the fractured clavicle in comparison of both sides. the constant-score showed good postoperative results (average: 96, median: 100, lowest 75/100). conclusion: esin with titan nails is an alternative method of treatment with good results. nevertheless we documented complications in 18%. in the literature complication rates from 4 -31% has been described. the complication rate of esin seems to be comparable to the conservative treatment. in our opinion the relevant intraoperative radioactive dose is an often underestimated factor. the operation time is often longer than thought before starting and often an open reduction is necessary. because of these reasons the conservative therapy should still be the standard. esin can be an alternative especially for young athletic ambitious patients after a detailed information about the risks. disclosure: no significant relationships. introduction: the optimal management of clavicle fractures is still controversial, although the nonoperative treatment remains the standard in most fractures. recent studies have reported a higher nonunion rate and unsatisfactory functional results after nonoperative treatment. therefore, there is an increasing interest in the primary operative management of displaced midshaft fractures. however, no treatment-consensus exists at this moment. the goal of the present study was to compare plate fixation with nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of 24 weeks follow-up. material and methods: in a multi-center prospective clinical trial patients with a fully displaced midshaft clavicle fracture were included within one week after the injury. after a standard information procedure, patients were asked if they wanted to have a operative or a nonoperative treatment. outcome analysis included standard clinical follow-up, the constant shoulder score, the disability of the arm, shoulder and hand (dash) score and complication rate at 6 and 24 weeks after the injury. results: between january 2008 and october 2009 a total of 93 patients were included: 41 patients were treated operatively (90.2% men, mean age 41.5 years) and 52 patients were treated nonoperatively (82.7% men, mean age 40.9 years). constant and dash scores were significantly higher in the operative group compared with the nonoperative group at 6 weeks (92 vs 78 and 13.1 vs 26.5). there was no significant difference at 24 weeks (97 vs 95 and 5.6 vs 6.4). in both groups two patients developed pseudartrosis, all four required surgery. in the nonoperative group symptomatic malunion was more frequent: twelve patients at 24 weeks (23.0%) versus none in the operative group. other complications in the operative group were mostly hardware related: pain and irritation requiring plate removal after consolidation in four patients (9.8%), two broken plates due to the earlier mentioned pseudartrosis (4.9%), one early outbreak of the plate (2.4%) and one woundinfection (2.4%). furthermore, patients with heavy professional work activities returned to their jobs at an average of three weeks after injury in the operative group compared with seven weeks in the conservative group. at 24 weeks after the injury, the patients in the operative group were more satisfied compared to those in the nonoperative group (56% vs 46%). conclusion: operative fixation of a displaced midshaft clavicle fracture results in improved functional outcome at 6 weeks after injury and in a higher satisfaction rate at 24 weeks. this study shows that patients with heavy jobs restarted their professional activities sooner if they were treated operatively. furthermore, higher satisfaction with the appearance of the shoulder may be a reason for surgery. introduction: the unstable shoulder girdle with a fracture of the clavicle (floating shoulder, ipsilateral serial rib fractures) is a classical indication for a plate osteosynthesis of the clavicle. despite a relatively high complication rate (5-30%), such as implant failure, non-union and refracture after implant removal, open reduction and internal plate fixation (orif) has been the gold standard for many years. this open procedure with direct reduction maneuvres might be blamed for at least some of the complications due to iatrogenic damage of the blood supply of the fracture fragments. our hypothesis is that a closed method with indirect reduction might reduce some of the complications. the goal of our study was to test the practicability of the mipotechnique in clavicle fractures in unstable shoulder girdles. material and methods: between 2001 and 2009 we included, out of internally fixed 130 shaft fractures in total (66x plate, 64x elastic nail), 18 patients with either a floating shoulder (n = 8) or a clavicle fracture in combination with ipsilateral serial rib fractures (n = 10), in this study. operative technique: a locking compression plate (lcp) 3.5 with 10-12 holes was anatomically shaped to the anterior (-caudal) contour of the contralateral clavicle and then inserted percutaneously from lateral to medial using a short incision at the anterior border of the lateral end of the clavicle. using mainly indirect maneuvres, the fracture was reduced and then fixed in a pure bridging technique never using interfragmentary lag screws. free unloaded rom was allowed immediately after the operation with full loading 6-12 weeks later. follow-up examination was performed 1 to 4 years later with clinical (dash-score, shoulder function, length measurement) and radiological (fracture healing, length measurement) examination. results: 17/18 fractures healed without complications. clinical and radiological length measurement showed no significant differences to the contralateral side (range: +5 mm to -5 mm). in all patients a very good functional result was achieved with an average dash score of 4.2 (0-18). one implant failure occured two years after the initial trauma in a road workman. at reoperation only a partial consolidation of the original fracture was observed. restabilization and bone grafting led to an uneventful healing. conclusion: the mipo technique is feasible even in clavicle fractures and can lead to good functional and cosmetic results. the advantage might be its low invasiveness which better preserves the vascular supply of the fracture fragments. however it is technically demanding mainly due to the small size of the fractured bone. therefore in our opinion it requires a surgeon experienced in the mipo technique of treating fractures of larger bones as tibia and femur. introduction: there are some reports on the difficulties of removing the locking compression plate in clavicle fractures, due to problems of removing the self tapping locking screws. we retrospectively investigated if this was also the case in our institution in removal of lcp plate of the clavicle and if this was incidential or becoming a trend. material and methods: from october 2004 till october 2009, we have removed 30 locking compression plates after claviclefracture stabilization. all of the locking screws were inserted by trauma surgeons with the use of the torque limiting srewdriver according to the manufacturer's recommendations. a total of 171 screws where removed. they consisted of fifty-one 3.5 mm self tapping cortical screws and hundred and twenty 3.5 mm self tapping locking screws. results: from the 30 locking compression plates that where removed after claviclefracture stabilization, in eleven patients (37%) a problem with removal of the plate arised. this was caused by a total of 17 self tapping locking screws. in all 17 cases jamming of the screwheads in the plate was found to be the reason. there was ''cold welding'' between the threaded head of the locking screw and the locking plate. for removal four different strategies were used. in two screws the head was drilled off and the plate removed and subsequent the rest off the screw removed with forceps. five times the plate was bend around the screw and by rotating the plate (helicopter) both were taken out. in eight screws the recess of the head of the screws were enlarged and a conical extraction screwbit 3.5 was used to remove the screws. two times a combination of cutting the plate and helicopter tecnique was used succesfull. in comparison the fifty-one 3.5 mm selftapping cortical screws were removed without any problem. conclusion: the locking compression plate is a usefull attribute in fracture treatment of the clavicle. however in one-third of the patients removal of locking compression plates and especially the 3.5 mm self tapping locking screws from the clavicle, becomes an increasingly challenging procedure. we find this an unacceptably high percentage. number of mri studies it was possible to describe the intraarticular disc. until now there was no in vivo verifying of one of these mri protocols. the introduction of a high resolution mri protocol using a superficial coil (3d wats and t2ffe) that has been developped in an ex-vivo model allows the visualisation of the intra-articular structures. the aim of this study is to ascertain the significance of the mentioned mri protocol and the applicability in the clinical practice in a limited patients cohort with instability of the ac-joint. the mri findings are compared to the arthroscopic findings. material and methods: in a one year period 16 patients with chronic acromioclavicular-joint dislocation rockwood type ii and iii were seen in the outpatient clinic the major symptom was pain followed by loss of power. inclusion criteria where a history of more than three month the exclusion of subacromial pathologies, age over 18 and the indication for arthroscopic revision of the ac-joint. the radiological examiner was blinded to the clinical findings. the mri-scan was performed on both sides. at the time of the operation the surgeon was blinded to the mri reading. the surgical procedure was performed by arthroscopy in beach chair position. the surgical findings have been documented by video and also in a descriptive manner. the examination was performed on a 1.0 t mri-system . results: throughout the radiological examination, in 9/13 patients a rupture of the intra-articular disc was suspected. in 3/13 cases degenerative alterations were described. in one case the reading was negative (e.g. ,,no rupture of the intra-articular disc''). during the surgical examination 12/13 patients showed ruptures of the intraarticular disc. in one patient no signs of macroscopical disintegration of the disc could be detected. in the case with negative radiologiocal reading, the disc was verified as intact during surgery. in all other cases the disc was disintegrated, including those with the radiological reading ''alterations without clear signs of rupture''. the significance of the described mri protocol was 75%. introduction: cancer of the colon is a common disease. the choice of treatment after diagnosis is surgery, in an elective setting, to remove the tumor. however, a large number of patients present with colonic obstruction requiring acute surgery before the diagnosis is known, or before the set date for elective surgery. previous studies have shown a worse outcome for patients who undergo surgery in the acute setting compared to patients in scheduled care. the aim was to establish characteristics and prognosis in patients with acute obstructing colon cancer compared to patients who underwent elective colon cancer surgery. material and methods: all patients diagnosed with colon cancer during 2000-06 in the linkoping area were identified through the swedish colorectal cancer register (n = 438). a retrospective analysis of patients with colonic obstruction (n = 88) was done using various criteria from the medical records. exclusion criteria were acute surgery due to reason other than obstruction (n = 57), non-surgical treatment (n = 44), other diagnosis (n = 13), or missing medical records (n = 11 conclusion: acute surgery due to colonic obstruction of colon cancer is common. tumor stage seems to be more advanced in patients with obstructing disease than in patients scheduled for elective surgery and consequently the rate of complications is higher and the outcome is worse. however, when stratified for different tnm-stages, the worse outcome in 2-year survival for patients with acute obstructing colonic cancer still remains. the explanation for this difference is to be elucidated in further studies. disclosure: no significant relationships. introduction: acute colonic obstruction due to malignancies is often a surgical emergency. hartmann's procedures or one stageresection with primarary anastomosis (with or without ileostomy) have been the treatment of choice. however these procedures are associated with a significant morbidity and mortality rate. self expanding metallic stents (sems) have shown their efficiency as palliative treatment in colonic cancer. colonic stenting has been advocated as a''bridge'' towards surgical procedures in potentially resectable diseases. the aim of this study is to evaluate the efficacy of colonic stenting in the emergency treatment of large bowel occlusion either for palliation or to enable to planned surgical procedure. s. tamulis, e. v. gaidamonis 1 1 surgical, vilnius unuversity emergency care hospital, vilnius, lithuania introduction: to evaluate the results of the treatment of patients with the small bowel obstruction due to intestinal adhesions. material and methods: medical records for the patients treated with small bowel obstruction due to adhesions from 1995 to 2005 were reviewed. the patient's age, gender, previous abdominal operations, method of the treatment and outcomes were analyzed. results: there were 1594 patients admitted to the vilnius university emergency hospital during 10 years period. appendectomy as a previous operation was recorded in 40% of cases. surgery was required in 457 of the cases (28.7%). strangulated small bowel was found in 197 patients (43,1%). in 404 cases (88,4%) the surgical procedure was limited to adhesiolysis, whereas in 53 cases (11,6%) an intestinal resection was performed. enterodecompresion tube was used in 156 cases (34,1%). the operative mortality was 4,8% (22 cases). mortality after the treatment due to strangulation was 3,9% (18 cases). conclusion: there were 29% of surgicaly treated patients. main reasons of adhesions formation was previous performed apendectomy and midline lower laparotomy. the criteria of uneffective conservative treatment were absent of the positive results of the physical, laboratory, rentgenological and ultrasound examination. mortality after the strangulated small bowel resection was higher. operative enterodekompresios reduces the risc of the postoperative complications and mortality. disclosure: no significant relationships. introduction: hartmann's procedure (hp) still remains the most frequent performed procedure in diffuse peritonitis due to perforated diverticulitis. [1] [2] [3] nevertheless it is associated with high morbidityand mortality 1 . the aim of this study was to assess feasibility, morbidity and mortality of resection with primary anastomosis (pa) with or without diverting loop ileostomy versus hp in case of diverticular peritonitis. 2,3. material and methods: we retrospectively reviewed our prospectively collected database from 1/95 to 12/08 of patients who were operated in the emergency department of bellvitge university hospital. only patients operated on generalized diverticular peritonitis (hinchey iii-iv) were included. data on patients' demographics, asa classification, hinchey score, peritonitis severity score (pss), surgical procedure, post-operative morbidity, mortality and post-operative hospital stay were studied. results: a total of 87 patients [median age 66 (34-94) years], female 39.1% were included. sixty (69%) had undergone hp and 27 (31%) pa. only in 5 patients (5.7%) a diverting ileostomy was performed. overall post-operative morbidity was 74.7%, most frequent complications were wound infection 33.3%, respiratory complications 20.7% and sepsis 17.2%. overall mortality was 33.3% (29 pt). these patients had a mean pss of 11.1 while the survival group 8.6. there was an overall reintervention rate of 17.2%, after pa 11.1% and after hp 20.0%. significant differences were found in the hp versus pa group in asa score (asa i-ii: 20% v 81%, asa iii-iv: 80% v 18%) and the median pss (11 versus 8) . 62% (21/34 pt) with pss £ 8 underwent pa, but none (0/31) with pss ‡ 11. the post-operative morbidity was significantly higher for hp (86.2%) compared to pa (48.1%). focusing on hospital stay there was a significant difference between pa (mean 15.1 days) versus hp (mean 27.9 days). in the stratified analysis considering patients with hinchey iii peritonitis we found a mortality of 45.7% (21/46 pt) in the hp group versus 7.7% (2/26 pt) of the pa group. the mortality rate stratified for asa and surgical procedure shows no difference in asa i-ii, but in asa iii-iv a lower postoperative mortality for hp (20.2%) versus pa (40.0%). including only patients with pss less than 11 (56 patients) there is a significantly lower morbidity in pa (80.1%) versus hp (89.7%). conclusion: our data show that pa can be performed safely with lower morbidity and mortality for diverticular peritonitis in patients with asa i-ii, hinchey iii peritonitis grade or pss less than 11 respectively to hp. these findings are supported by a shorter hospital stay in favor to pa. y. arlettaz 1 1 orthopaedics and trauma, chcvs hô pital du valais, sion, switzerland introduction: one of the most demanding steps of intramedullary nailing is the distal locking. most of young surgeon are ''affraid'' to treat a long bone fracture by a nail because of the distal locking. the aim of this study is to evaluate a new frendly radiation free targeting device on cadavers. material and methods: the study was conducted on fixed cadavers. 25 femurs were available. the method consists of the following steps: determining the zero position of the device; opening the tip of the great trochanter; introducing the nail (sirus nailò 12x400 (zimmer inc.)); introducing an emitter inside the nail to be positioned in the distal holes; adaptation of the guide on the standard handle with a receptor; moving the receptor to be aligned to the emitter; changing the receptor for the sleeve and performing the drilling and the locking. for the second or even third screw, the targeting device needs a little adjustment. results: on the 25 distal locking procedures (50 screws), we observed only one failure due to the breakage of the prototype. this translates as a 98% success rate for two screws with a mean time of 8.2 min. two surgeons conduct this study. not only the inventor but also a inexperimented surgeon tested the new device with the same succes. conclusion: this new device has the advantage to be fully mechanical, to be solidly linked to the patient and to be totally radiation free. it can be used in any hospital, by any surgeon. the procedure is easy to learn and reproducible. it could be adapted to any nail system and does not need external power supply. introduction: anterior knee pain is one of the most frequent complication of tibial nailing. its aetiology remains unclear, potentially being a multifactorial event. the aim of this prospective study was to evaluate if anterior knee pain has any negative influence on: bone healing(the hypothesis is if the patient has anterior knee pain he or she will not put weight on the affected leg and this will not stimulate the bone healing), ability to return to work and quality of live. material and methods: 3 european level 1 trauma center was involved in this study. methods: between januari 2003 and december 2004, 102 patients with a tibia fracture was admitted to the trauma departments we used a standard t2 tibia nail(stryker) with the possibility of proximal and distal fixation with 3 screws the approach was trans or parapatellar. results: at 4-6 weeks, 4 months, 12 months follow-up we had 11, 13, 14 patients with anterior knee painthe vas decreased from 3,1 to 2,3, bone healing was 100% and for 70% of patients it was possible to do their previous full time job after 12 months. the quality of life (walking up and down stairs normally without any help, putting on shoes and socks, sitting/standing from a chair, total weight bearing,) was improving. conclusion: we conclude that anterior knee pain in this study is mild, that the two different method of patellar tendon approach(trans or paratendinous approach) have no relevance and it does not have a negative influence on bone healing, ability to return to work and the quality of live. introduction: the aim of this study was to see if there is any difference between manual traction and fracture was applied in one step. twenty-seven femurs and thirthy-three tibias were treated. the mean distraction rate was 1.6 mm (range 0.8-1.8 mm) for the femur and 1.3 mm (range 1.25-1.3 mm) for the tibia. the necessary pressure to advance the distraction in the tibia was average of 27 bar (range 20 -42 bar), to distract the femur, 46 bar (range 28 -82 bar). results: bone healing index for tibia 1.1 and femur 0.7 months/cm distraction. implant failure five cases; infections three cases. nonunion of the distraction site or docking site four cases. we did not encounter major stiffness of the adjacent joints. conclusion: although the presented technique is a semi-closed distraction procedure, we find this system appealing because of it simplicity in use, low cost and the ability to immediate weight bearing. introduction: bone transport for treatment of segmental bone defects as a salvage procedure is related to a high complication rate. posttraumatic soft tissue problems and callus insufficiency are to be dealed with especially in posttraumatic conditions. the ilizarov ringfixator allows a stable external bone fixation enabling full weight bearing. in bone defect reconstruction bone transport is commonly used. a major problem is the skin cutting wires for bone fixation. a new method of the cable transport with intramedullary cable passing avoids skin cutting thus reducing skin problems. material and methods: 15 patients with a metaphyseal and diaphyseal bone defect of the tibia after open trauma and posttraumatic infection were treated with debridement, bone resection and soft tissue coverage by local and free flaps. after soft tissue healing the monolateral external fixation was replaced in each patient by a four ring ilizarov fixator with a proximal percutaneous tibia osteotomy. for bone transport a flexible cable was placed around the distal part of the segment and passed intramedullarly through the distal segment out of the tibia and onto the ilizarov fixator and the transport clickers. the bone segment was transported after a delay of 7 days anterograd by the intramedullar placed cable one mm per day. results: in all patients the bone defect was closed by the bone transport. in one patient early consolidation of the regenerate occurred and a rupture of the cable. two patients had an insufficiency of the callus. the distal docking site was augmented in all patients after the segment transport with iliac bone graft for consolidation. the one patient with early consolidation was treated by a second osteotomy; the two patients with insufficiency were augmented during the docking operation with iliac bone graft. conclusion: the intramedullar cable transport is a new modification of the bone transport with the ilizarov ringfixator. the main advantage is the soft tissue spearing and protecting transport mechanism enabling bone transports after free flap soft tissue coverage with micro vascular anastomosis. therapeutical course before and after amputation (number of operations before and after amputation) in relationship to co-morbidities and bacteria which caused the infection. results: hospital data from 63 (15 female, 48 male) patients were available for 64 septic amputations in the lower extremities on account of non-manageable infections. the average age was 56.6 years (27 to 88 years). the first age peak lies with 46, the second with 78 years. in 15 cases infected endoprostheses were found (3 total hip arthroplasties, 12 total knee arthroplasties) in 49 cases osteomyelitis was diagnosed. before amputation the patients underwent an average of 7.5 interventions (between 0 and 28) in oder to control the infection. the average treatment period before the amputation was 39.76 days (from 1 to 117 days). post amputationem an average 2.5 interventions were necessary (from 0 to 9). the average period of treatment was about 36.81 days (from 3 to 99 days). the analysis of the co-morbidities showed that hypertension was the most frequent, 19 cases (19.58%), followed by diabetes in 15 cases (15.46%), coronary desease in 8 cases (8.24%), obesity in 5 cases (5.14%) and copd in 4 cases (3.88%). conclusion: a statistical relevant risk-assesment based on these data (correlation of microbiological findings co-morbidities and risk of amputation) cannot be carried out due to the relatively small number of patients. however, a trend may be estemated: combination of mrsa, diabetes and cardial disease in combination with a great number of operations leads to an increased amputation-risk independent to the individuals age. introduction: maggot debridement therapy (mdt) as an ancient method is succesfully used for the treatment of acute and chronic wound infections in trauma surgery 1 . the underlying mechanisms of action of mdt are unknown, but could provide information for a novel treatment modality against infection, which is important in these times of increasing antibiotic resistance. therefore, in this research the effect of living maggots on planktonic cells was investigated. furthermore, the influence of maggot excretions on planktonic cells and on bacterial biofilms was tested. material and methods: sterile tubes were filled with living maggots in a bacterial suspension and every two hours samples were cultured and compared with controls. a turbidimetric assay was performed to test the susceptibility of six bacterial species to maggot excretions. bacterial biofilms were formed in vitro on polyethylene, stainless steel and titanium and maggot excretions were added to test their influence. results: the results show that living maggots as well as their excretions stimulate the bacterial growth of s. aureus, e. faecalis, cns, s. pyogenes and k. oxytoca (all p-values £ 0.0002). only p. aeruginosa had a decrease of bacterial growth (p = 0.002). the strongest biofilms in vitro were formed by s. aureus, s. epidermidis and p. aeruginosa in contrast to the weak and inconsistent formed biofilms by e. faecalis, e. cloacae and k. oxytoca. for p. aeruginosa, stainless steel was the best biomaterial with respect to biofilm formation and for s. aureus and s. epidermidis, the best biomaterial was titanium. maggot excretions were added to the strongest biofilms, named above, and reduced these on all biomaterials. the maximal biofilm inhibition by maggot excretions was seen on polyethylene: 82% for p. aeruginosa (p < 0.0001), 61% for s. aureus (p < 0.0001) and 92% for s. epidermidis (p < 0.0001). conclusion: this study shows that nor living maggots, neither maggot excretions have direct antibacterial properties. however, maggot excretions do reduce biofilms formed by different bacterial species on commonly used biomaterials. future research will focuss on the exact mechanism and the substance(s) that cause biofilm reduction. furthermore, possible indirect antibacterial activity will be investigated and the potential role herein of the immune system. introduction: tetanus is an acute disease caused by a neurotoxin produced by the bacterium clostridium tetani, characterised by generalised rigidity, muscle spasm and fatality. open orthopaedic injuries are at particular risk of developing infection from tetanus spores found in the environment. the uk department of health has established guidelines for the prevention of tetanus infection. we assessed the adherence of these guidelines on the initial pre-operative management of tetanus prone open orthopaedic injuries in trauma patients admitted for surgery. material and methods: a retrospective case note review was conducted on 53 patients admitted to the orthopaedic department for intervention with a tetanus prone wound between february 2009 and june 2009. tetanus prone injuries included open fractures, soft tissue injury requiring surgical intervention that is delayed for > 6 h, wounds with significant devitalised tissue, wounds in contact with soil and open injuries containing foreign bodies. we assessed to what extent these patients had their immunisation status ascertained, application of wound irrigation and appropriate dressing, correct tetanus prophylactic cover (tetanus toxoid booster versus human tetanus immunoglobulin) and appropriate administration of antibiotics. results: of the 53 patients included in the study, 32 (60%) of patients were considered to have a 'high risk' tetanus prone injury and 21 (40%) patients were deemed as having a 'low risk' clean wound based on the nature and extent of injury. performance within the high risk category showed that 59% of patients had their tetanus immunisation status ascertained, 72% correctly received wound irrigation and betadine dressing, 75% of patients were appropriately given prophylactic antibiotics. only 9% of patients with a high risk tetanus prone wound received tetanus immunoglobulin and 72% of patients were given a tetanus toxoid booster as a method for prophylaxis. conclusion: our study showed that a large proportion of patients correctly received supportive wound care and antibiotics. we also demonstrated that patients with open tetanus prone orthopaedic injuries are not adequately receiving correct tetanus immunoglobulin as the indicated prophylaxis. a large number of patients were given tetanus toxoid instead, which does not protect immunity early enough to cover the acute injury period, thus posing a major risk of developing a devastating and largely preventable infection. the orthopaedic and trauma doctor attending these patients must adhere closely to the correct initiation of simple measures in the management of tetanus prone orthopaedic wounds. all patients were irrigated and debrided, before the application of vac system. required debridements were maintained during vac therapy. time elapse between the injury time and vac application time was 5 days on the average (min 0, max 10). when the granulation tissue became sufficient to cover the bone, these wounds have been closed secondarily with several methods. time elapse between the start of vac and wound closure or formation of sufficient granulation tissue for grafting was 12 days on the average (min 8, max 17). results: distribution mean postinjury time for the osteosynthesis was 44,5 hours. three of these wounds were closed spontaneously without any need for other wound closure procedures. split thickness grafting is applied in 8 patients, free flap to 2 patients, full thickness grafting to 3 patients, secondary suturing was applied in 1 wound to close it. there was no infection in any extremities that we had osteosynthesed by internal or external methods. conclusion: wound care is as much important as osteosynthesis in open fractures. even if osteosynthesis is successful, failures in wound care may result in loss of extremity. vac alone does not suffice for wound closure. expectation in this therapy is to obtain ideal granulation tissue and to prevent infection development via appropriate wound care. the greatest disadvantage of vac therapy at the time being is its high economic cost. introduction: surgical haemostasis in trauma patients can be difficult and hazardous. commercial products are promoted to accomplish this task at a reasonable cost. in this study we compared the effectiveness of two topical gelatin-based haemostatic agents, flosealò and surgifloò in a porcine liver trauma model. material and methods: we compared the activity of flosealò (with human or bovine thrombin), surgifloò and surgifloò with added bovine thrombin in two porcine models. one anesthetised piglet mimicked ''normal'' conditions, while the other was kept in a status of hypotension, hypothermia and haemodilution, necessitating inotropic support (''critically ill''). laparotomy was performed, after which we inflicted five identical stab wounds on each liver lobe. each wound was treated with one of the four agents, while one wound was kept as a control. haemostasis was evaluated clinically. after euthanizing the piglets, the pathologist performed a macroscopic, microscopic and electron microscopic evaluation, blinded for which agent was used in which wound. results: clinically, surgifloò was able to produce a clot in some of its applications in the healthy piglet (''normal'' conditions), which was not the case in the critically ill animal, not even with the added thrombin. flosealò induced clotting in every wound. both microscopic (hematoxylin and eosin and mallory stain) and electron microscopic examination of the stab wounds confirmed that flosealò created a stable and dense agglomerate of gelatin and fibrin, firmly attached to the adjacent liver tissue, whereas with surgifloò, the gelatin contained more air bubbles, there was a lot less fibrin included in the clot and the clot was not strongly adherent to liver tissue. conclusion: it would seem that flosealò is a superior haemostatic agent, creating a dense and stable blood clot, even in a critically ill animal, hence ensuring haemostasis. disclosure: no significant relationships. introduction: bleedings stemming from splenic traumas are still among important causes of morbidity and mortality. aim of this study is comparison of fibrin glue with hemostasis effectiveness of ankaferd blood stopper lower lob resections on spleen of rats. material and methods: the study was performed at the animal laboratory of istanbul university after obtaining an approval from the ethics committee. twenty-four rats were randomly divided into three groups, namely, fibrin glue group (n = 8), abs group (n = 8) and control group (n = 8). a wedge resection was performed on the lower lobe of the spleen. in fibrin glue group, spleen was hemostasis with fibrin glue (tisseel), while abs was administrated on the lower lobe surface in abs group. chronometric measurements were made to determine bleeding times. blood samples from the tail and vena cava were used for whole blood count and blood chemistry. histopathological scores were measured postoperatively on day 5 th. results: in abs group, chronometric bleeding period is 11,5 s. whereas in fibrin glue group it takes 10,8 secods (p > 0,05). it was noted that the hemogramme test results, hemoglobin and hematocrit levels on the 5 th days of abs and fibrin glue groups did not show sensible differences from one another (13.5 vs 13.9) p = 0.022 (41,63 vs 42,50) p = 0,879. conclusion: there are no differences between the hemostasis speed and effectiveness of ankaferd blood stopper and fibrin glue as an applied material in bleeding stemming from experimental partial lower lob resections on spleen of rats. of the hemoperitoneum in right iliac fossa was performed 6 and 7 days after trauma, resulting in drainage of 2600 and 4200 cc of blood. patients were discharged 1 month later and follow up was successful. conclusion: in selected hemodynamically unstable patients and upon availability of appropriate facilities, nom can be safely challenged over the usual limits. the indicators of tissue perfusion such as ph and be seems to be more reliable and sensitive prognostic parameter than hemodynamic instability evaluated by blood pressure and heart rate, in selecting the patients needing surgical control of hemorrhage. a moderate iah in young patients able to tolerate an increased intra-abdominal pressure, can allow a mechanical compression of the injured parenchyma achieving the arrest of hemorrhage, and extend the indications for nom in selected hemodynamically unstable patients, without signs of severe tissue hypoperfusion. material and methods: our case describes a 51 year old male who fell 7 m and landed on the right side of his torso dislocating a rib through the diaphragm, causing a transecting grade 5 liver injury to liver lobes iv and vii, the right hepatic artery and a lesion of the retrohepatic vena cava (vc). the patient presented alert, hemodynamically stable with normal breath sounds. ct scan showed right sided hemothorax and a grade 5 liver injury. a right sided chest tube drained 600 ml of blood. the patient became unstable and was transferred to the or. profuse haemorrhage from the liver was encountered and massive blood transfusion protocol was initiated. the right hepatic artery showed to be injured and was ligated. pringles manoeuvre and packing of the liver were not enough to control the bleeding. an injury to the retrohepatic vc was suspected and manual compression was not sufficient to gain control. endovascular assistance was called for and using a bilateral femoral vein approach two occlusive balloons were placed and inflated under x-ray and open view in the vc to gain proximal and distal control. the patient stabilized and the injury to the vc could be sutured and covered with a topical haemostatic agent. the balloons were deflated but were left in place as a security measure. the liver was then again packed. the pringle manoeuvre had intermittently been used for approximately 2 h in total. two vessel loops were left tension free around the hepatodoudenal ligament and brought out through the midline incision as a security measure. 60 units of rbcs, 30 units of ffps and 2 units of platelets were given. angioembolization of the right hepatic artery was performed after the first surgery. during the second operation, the haemostats, vessel loops and occlusion balloons could safely be removed. 15 days after the injury the patient showed increasing signs of liver failure. the patient was accepted for liver transplantation 22 days after the injury; this procedure was carried out successfully. the combined open and endovascular approach in this case was crucial. the nature of the injury, the pringle manoeuvre, packing of the liver and arterial embolization caused permanent damage to the liver which had to be managed with liver transplantation which was successful. the use of endovascular occlusive balloons might also have had a role in the permanent damage of the liver, but had great benefit in saving the patients life. introduction: the incidence of pulmonary failure in multiple trauma patients is postulated to be influenced by several factors such as thoracic trauma and liver injury. the incidence of pulmonary failure increases in patients with an abbreviated injury scale thorax ‡ 3 (ais) and they are more likely to face poor outcome. thus, the aim of the present study was to test the hypothesis that patients sustaining significant thoracic trauma (ais thorax ‡ 3) in combination with a relevant liver injury (ais liver ‡ 3) are more likely to develop pulmonary failure when compared to patients which sustained thoracic trauma without additional liver injury. material and methods: records of multiple trauma patients documented in the trauma registry of the german society for trauma surgery were analyzed using uni-and multivariate analyses. patients were subdivided into four groups according to their liver and thoracic injury: group 1 (ais thorax < 3; ais liver < 3); group 2 (ais thorax ‡ 3; ais liver < 3), group 3 (ais thorax < 3; ais liver ‡ 3) and group 4 (ais thorax ‡ 3; ais liver ‡ 3). potential relevant variables were subjected to univariate analysis between groups using the chi square test to predict the probability for pulmonary failure rate. subsequently, multivariate logistic regression analysis was performed, employing pulmonary failure as the dependent variable. differences at the level of p < 0.01 were considered statistically significant. results: 12,585 patients with a mean age of 40.8 ± 10.7 years and a mean iss of 28.6 ± 11.1 points fulfilled the inclusion criteria and were enrolled in this study. the overall rate of pulmonary failure was 21 ± 40%. 12% of the patients in group 1, 26% in group 2 and 16% in group 3 developed pulmonary failure. the largest proportion of patients (36%) who developed pulmonary failure was found in group 4. those factors which proved to show a significant correlation with the incidence of pulmonary failure were included in a subsequent multivariate analysis. however, the presence of relevant lung injury, male gender, pre-existing medical conditions (pmcs), transfusion of more than 10 packed red blood cells (prbcs) as well as iss and age played a significant role. in contrast to our hypothesis, liver injury did not proof to be associated with the incidence of pulmonary failure. conclusion: pulmonary contusion and significant liver injury seem to have a synergistic effect on the incidence of pulmonary failure. however, multivariate analysis with adjustment of further relevant factors reveal, that liver injury is not a predictive factor for the incidence of pulmonary failure. rather male gender and reported pmcs together with relevant lung injuries are more likely to develop pulmonary failure following multiple trauma. nethertheless, patients with combined pulmonary and liver injury are at higher risk for pulmonary failure with critical outcome. disclosure: no significant relationships. introduction: thoracic trauma is the leading death cause in 25% of politraumatised patients and contributes to the death of another 25% of these fatalities. identifying the determining causes, assessing their severity, early and qualified intervention in a multidisciplinary team may improve outcome of these patients. the goal of this paperwork is to assess the effects of thoracic trauma on clinical management, morbidity, mortality and outcome. material and methods: retrospective study of 740 politraumatised patients admitted in the emergency department of st. pantelimon hospital between jan 2001 and jun 2005. the followed parameters were most common injuries, severity, mortality, survival rate correlated with iss and rts, using data from emergency charts, hospital charts and anatomopathologic exams. results: out of 740 patients, 445 associated thoracic trauma, with a survival rate of 79,1%. 410 patients had blunt trauma. injuries that claimed early surgical intervention and had the highest death rate were: massive haemothorax 15 patients (100% mortality rate), aortic and great vessels injuries 6 patients (100% mortality rate), open pneumothorax 1 patient (100% mortality rate), tension pneumothorax 10 patients (50% mortality rate), flail chest 30 patients (53% mortality rate). conclusion: thoracic trauma is often associated to politrauma and may increase significantly the mortality rate of these patients. lifesaving surgical procedures must be immediately performed, on patient arrival. it is important to adopt intervention protocols for multiple trauma, with a leading role of the emergency department medical staff. disclosure: no significant relationships. introduction: to evaluate treatment modalities of penetrating and/or contusive hemothorax, we reviewed our experience with patients admitted for traumatic hemothorax to our center for thoracic surgery. material and methods: from january 1998 to we treated 135 consecutive patients (mean age, 47 + 22 sd years; m/f, 111/24) presenting traumatic hemothorax: 122 patients had contusive hemothorax (cont) following car accident (28%), fall (27%), motorbike accident (25%), crushing trauma (7%), bike accident (3%); 13 patients had penetrating trauma (pen) following stab wound (6.5%), gunshot (2%) and impalement (1.5%). we recorded demographic data, injury severity score (iss) at admission, endo-and extrathoracic injuries, method of treatment and outcome. results: there were no statistically significative differences between cont group and pen group regarding mean age (47 vs 45 years), gender (m/f = 100/22 vs 11/2), mean iss (30 vs 28) and icu admission rate (51% vs 54%). the cont group however presented a higher rate of extrathoracic lesions (bone, visceral, cns) than the pen group (71.3% vs 31%: p < 0.005). in all patients a chest tube was immediately inserted, as the definitive treatment in 75% of cont pts and in 46% of pen pts (p < 0.05). surgical introduction: evaluation of penetrating injuries to the chest presented at a level 1 traumacenter. the main study question was to see whether there was an increase in incidence in time. material and methods: in this retrospective study fifty-nine consecutive patients were included with penetrating injuries of the chest during the period of june 2004 until june 2008. the penetrating injury had to be caused by gunshot or stab incident. statistical analyses of the data was performed using spss 16.0. results: the study group consisted of fifty-nine patients. ninety percent were male with a mean age of 36 years (range 17-64). the mechanism of injury were stab (79,9%) and gunshot wounds (20,3%). sixteen patients required a thoracotomy. in four other cases a laparotomy was performed. twenty-two (37,3%) patients were admitted to the icu. the number of patients treated in the first year of the study period ( of the patients with a shotwound 25% died of their injuries and mortality rate of the patients with a stabwound was 10.7%. in the last year of the study period the mortality of gunschot wounds was 9.5%. conclusion: there is an increase in incidence of penetrating injury of the thorax for both stabwounds and gunshot wounds. the increase of gunshot wounds was especially large in the period july 2007-june 2008. the risk of suffering a gunshot or stabwound to the chest in our traumaregion is gender related. with the increase in the number of gunshot wounds, and thus experience, the mortality seems to decrease. introduction: rib fractures and more specific the flail chest are currently treated conservative. in our level one trauma centre we have on average 90 patients with rib fractures and 5 flail chests/yr. until recently we mainly treated the patients conservative. according to the literature the morbidity and mortality increases twofold with 4 or more ipsilateral rib fractures and an age > 45yrs old. 1, 2 some studies have also shown that operative fixation of rib fractures may reduce the morbididity significantly 3 with this data and the recent development of specific dedicated osteosynthesis material for rib fractures we devised a pilot study in order to analyse the efficacy of this new matrixò rib fixation system (synthesò) and the effect on the morbidity/mortality of the patient. material and methods: during a 6 month period we included all patients with the before mentioned criteria(4 rib fractures, > 45 yr) or with a flail chest. we analysed operation details, lenght of icu stay, hospital stay and recorded complications. the results were compaired with a matched control group from 2008. results: 12 patients were included with an average age of 59 yrs and a m:f distribution of 9:3. 5 patients had a flail chest and 7 patients had 4 or more rib fractures. on average all patients were operated within 2 days (0-5). on average 4 (2-6) rib were stabilized with an operating time of 77 min (40-150). no implant failures were seen. 8 patients had an average icu stay of 8 days (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) . total hospital stay for the whole group was 18 days (6-38), specific for flail chest it was 22 days and for the ipsilateral rib fractures it was 16 days. one patient sustained an extra rib fracture due to the procedure and one patient sustained an iatrogenic pneumothorax. one patient died due to neurologic complications. one patient had a superficial wound infection. no deep infections, pneumonia or chest related mortality occurred. compared to a matched control group of 2008, the overall length of stay was not significant different. 18 vs 15 days. the length of stay for the ipsilateral fractures was not significantly shorter, 16 vs 15. however the length of stay for the flail chest was significantly shorter in the study group 22 vs 48 (p < 0.05) the control group had significant more pneumonia, 5 vs 1 (p < 0,05). conclusion: the new matrixò system is easy and safe to work with. the system has good stabilizing capabilities. operative treatment reduces pneumonia and length of stay with flail chest. these results warrant a randomised study, comparing operative treatment vs conservative treatment. introduction: severe thoracic wall injuries can result in long time icu stay with ventilatory support substantial morbidity and even death. if the patient recovers persistent thoracic wall pain, restricted respiratory capacity and/or non union of the rib fractures can be the consequence. in a systematic review of literature we demonstrated that there is some evidence that early internal fixation can shorten the on-ventilator time, the icu stay and lower the short time morbidity. long term pulmonary function is not altered by internam fixation, however the rate of rib nonunion and chest wall pain is decreased. however high quality evidence is lacking. in order to evaluate the feasability of rib osteosynthesis with a new plating system: the synthes matrix system a preliminary study is performed and its results presented. this study preceeds a randomised controled trial comparing plate ad screw osteosynthesis and conservative treatment. material and methods: 10 consecutive patients with flail chest and or serial rib fractures involving at least five ribs necessitating measures other than analgetics to maintain pulmonary function are included and prospectively documented. exlusion criteria: *hemodynamic instability necessitating a damage controle approach *intrathoracic injuries necessitating surgery *normal pulmonary function *patient refusing surgical treatment *patient not available for follow-up all patients are operated upon with use of the matrixrib system. postoperative icu stay, on-respirator time, pain at defined moments of follow-up, healing of the rib fractures and complications are recorded prospectively. patients grade their rate of satisfaction (functional and esthetical) on a scae of 0 to 10. the results in these patients concerning on-ventilator time, icu stay and morbidity are compared to a historical series of patients with comparable iss. prospective case series with historical control group.(level iii) results: preliminary data indicate: *a shorter time on ventilator than anticipated (based on comparisson to historical data) * a shorter time on icu * less pneumoniae * no intra-operative complications * good healing results of the rib fractures * no implant failures * acceptable pain scores * good overal satisfaction * acceptable cosmetic results conclusion: internal fixation of rib fractures (flair chest or multiple sequential fractures with pulmonary function compromise) results in a earlier recuperation of pulmonary function with shortened icu stay. the overal satisfaction of the patient after operative treatment is good, with acceptable cosmetic results. there were no implant related complications. these results form the basis for a randomised control trial comparing operative fixation with the matrix rib system to conservative treatment. disclosure: no significant relationships. a. e. elsherif 1 , m. fawzy 2 , n. badr 1 , m. marashda 3 1 surgery, tawam hospital/johns hopkins international, abu dhabi, uae, 2 surgery, tawam hospital, abu dhabi, uae, 3 surgery, tawam hospital/johns hopkins international, abu dhabi, uae introduction: acute airway emergencies result from a wide variety of malignant and benign diseases. for both the patient and the clinician, the presentation can be frightening, and advanced interventional pulmonary/endobronchial techniques are required to achieve prompt relief of symptoms. general anesthesia is sometimes prohibited in these situations with complete loss of airway. we report our initial experience with these patients in a tertiary referral center. material and methods: three patients (two males) with acute proximal airway emergencies were included. two patients presented with acute stridor. the third presented with massive bronchial air leak and purulent drainage after an acute traumatic event. all patients were treated emergently with bronchoscopy and placement of an ultraflex bronchial stent under local anesthesia. all patients were followed up after discharge. results: there was no perioperative mortality or morbidity. the median age was 51. one patient had anaplastic thyroid cancer obstructing the trachea and was denied treatment elsewhere. the second patient had a malignant tracheoesophageal fistula. the third patient had an acute bronchopleural fistula following pneumonectomy for a gunshot wound. complete symptom relief was obtained after stenting under local anesthesia in all patients. median length of stay was 3 days for the patients with malignancy. on a median follow up of 11 months; two patients were symptom free, one patient died from malignant disease progression. conclusion: stenting under local anesthesia is feasible with acute airway emergency. obstruction of the central airways by malignant tumor is associated with poor prognosis.the alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life the primary goal rather than cure. introduction: on april 6th 2009 an earthquake measuring 6.3 on the richter scale stuck a large area of the abruzzo region in central italy. the first notice suggested a lot of injured people and destroyed structures, incuded the main hospital of the area, the san salvatore hospital. material and methods: the national civil protection immediately send the field hospital (fh) of the marche regional government, the neighbouring region, together with a large amount of medical staff and personnel by the non governmental organization ares (regional association sanitary emergencies). this association, already involved during other national and international disaster situations and relief efforts, sent professionals volunteers (md and nurses) whit disaster knowledge and specific medical specializations. the international literature demonstrated that a fh is a complex structure and often the time required to be completely functionally is very long, indeed longer than the affected people needs. results: from april 6 th , june 6 th when the mission ended, the fh provided medical treated to almost 6000 patients, and the ares personnel (167) where backed by the sanitary personnel of the san salvatore hospital. conclusion: a well planned medical response is very important to provide health assistance during a disaster, yet it is very hard to substitute a damaged hospital in the hearth of the disaster area. a modular sanitary structure, very light at the beginning, with specific and restricted medical supplies, with a little number of specialists in disaster medicine and disaster logistics, could improve the already good results obtained in the l'aquila abruzzo mission. disclosure: no significant relationships. around 100,000 people died, twice as many were injured, and almost 3million people were made homeless. in any situation of disaster, both natural and complex, may be produced a large number of victims that defeat the ability of local health resources to provide adequate health care. on one hand, the system may be overwhelmed with a high number of casualties. on the other hand, hospitals and other health care facilities generally may be compromised heavily: buildings may be destroyed or damaged and the supply of water, electricity, medical gasses, etc. may be limited. the transportation infrastructures may be severely damaged, creating problems for both people and equipment arriving at the hospital. damage to the health care infrastructure will further compromise the delivery of health services. material and methods: italian government responded immediately to this emergency after the official request for international relief efforts from the president of pakistan. two days after the impact, the first italian evaluation emergency team was already arrived in pakistan and the initial field structure was already fully operative, offering medical care, especially advanced trauma care and life support intervention, provided by specialists. later, when the structure had been completed and became larger provided also hospitalization, and surgical abilities, appropriate treatments and essential drugs. all the medical activities of the responding italian mission team field hospital in manshera were recorded and evaluated. results: a total of 20,212 patient contacts occurred at the field hospital during the 83 days it operated, 620 patients were admitted in the field hospital with a total number of 6949 nursing days with a average length of stay per admission of 11,2 days and with the occupancy rate of 95,2%. a total number of 365 major operations were performed. introduction: mass casualty incident's (mci) management is a present problem which is now more frequent because of iraki, afghan wars and terrorists actions. numerous new plans are evolved in each emergency association or military organization. nato as built a ''masscal'' plan to help teams in role ii in afghanistan to take care mci. through two experiences of mci in french role ii in afghanistan (kaboul) and through the litterature, we discuss the different ways of taking in charge mci. material and methods: the french role ii is located in kaboul near helicopter area. there are 3 surgical teams (50 pax, 3 nationalities), 3 emergencies boxes, 4 icu beds and 3 operating theatres. we have a pool of 42 blood units, an echograph, a first generation ct-scan and all materials for traumatologic surgery. for mci, we use nato triage classification. each trauma undergoes ressucitation room, has needing x-ray exams, fast echography and intensive care if necessary. patient who needs urgent surgery runs immediately to operating theatre. iss score is calculated. the first mci concerns 6 patients involved in a suicid bomber's explosion near the role ii. all were taken in charge 15 min later. the second concerns an attack against a french coy occured 50 km in the east of kaboul. there were 22 casualties and 10 soldiers died. they were taken in charge belatedly between 7 to 12 h later. results: fisrt mci : 4 surgical interventions, one 90%burned, and a blast injury. second mci : 7 surgical interventions, 15 injuries with no surgery, 6 blast injuries. we organize for these second mci a stratevac in france for 10 casualties in less than 24 h. mean iss score is 8 for alive injuries and 40 for the died soldiers. through these 2 mci, we analyse the litterature and discuss about presents concepts in mci management. conclusion: the contemporary history of war, especially in iraqi and afghanistan constrains military surgical teams to improve their way of management of mci. training is necessary. first of all we have to define clearly each place of each actor, the conditions of triage, wich priority for which surgery and the possibility of modern communications and fast and efficient transports. the lower extremity (38%). 19% suffered multiple severe injuries, 9% upper extremity injury, 7% upper extremity and head/neck injury, 7% back injury, 6% head/neck injury, 6% upper and lower extremity injury, 4% abdominal injury and 4% miscellaneous. 7 patients (10%) underwent an primary amputation of one or more extremities. 3 (4%) patients underwent secondary amputation. all primary amputated limbs were shortened later. 1 patient (1%)died one day after arrival in the cmh because of multiple severe injuries. conclusion: this single-center, and therefore complete dataset of the repatriated military personnel demonstrates the impact of participating in a nato mission for a small european country. it puts a high and challenging burden on the shoulders of the medical personnel in our hospital. further it shows, in contrast to studies from owens and dougherty, a higher prevalence of lower extremity injuries than upper extremity injuries. data regarding admission time, infection rate, disposition and quality of life will be presented. a lot of medical-ethical decisions had to be made about continuation of medical threatment or to decide whith patient will be treated and with patient will not be treated. as war surgeon you have to do operation for which you were not educated. because there is no other surgeon you have to the operation or the patient will die. it gives the opportunity to learn and gives a lot of surgical experience. this can be useful in civilian circumstances also. conclusion: the period as war surgeon in afghanistan has been of a forse impact. i had to take a lot of medical-ethical decisions and to do operations in which i was not trained. but i have learned a lot about war surgery and on human aspects also. introduction: there are a lot of unique challenges for the medical personnel which are assigned to the combat environment in afghanistan. especially the medical groups are in contact with patients from different nationalities and with different characteristics under special and difficult war circumstances. this article evaluates the effectiveness of the co-operation between a german and a greek surgical team during a 2-month period in a role ii hospital in north afghanistan. material and methods: from 21st july 2009 through 20th september 2009, 764 patients were admitted. there were 718 male (94%) and 46 female (6%). we reviewed the type of diseases, mechanism and location of injuries, management, type of surgical procedures performed, blood supply and outcome. results: 72.9% of the patients were international security assistance force (isaf) personnel. most of the patients were men in a percentage of 94%. four children were included among the local patients. 37.6% of the patients had surgical diseases while the rest 28.9% were of orthopaedic interest patients. 35 (4.6%) patients underwent a surgical operation; 26 (74.3%) of them were operated immediately. gunshots were the main mechanism of injury for local patients whereas isaf personnel were usually presented with burns after improvised explosive devices (ieds) and rocket attacks. conclusion: the co-operation between medical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in order to manage war casualties. introduction: in the emergency caused by natural and social disasters there are evident deficits between the health needs of affected population and the local health system capacity. the causes of disasters are various and not predictable, usually the health structures can not face up to the population needs. knowing that disaster medicine has different protocols and materials from ordinary medicine structures and that improvisation during the disaster's acute phases is not a good practice, it has been created an emergency operating health group, the non-profit ares association. (regional association sanitary emergencies) material and methods: the ares, whose members are about 600, all over the nation, is configured as an extraordinary health resource, activated by the national civil defence operations centre, in according with the regional centre of marche, in disater situations results: the main objectives of ares are training and organization of medical staff and structures and its growth crosses several missions including: ae earthquake in molise, 2002 introduction: cephalomedullary nails rely on a large lag screw that provides fixation into the femoral head. there is an option to statically lock the lag screw (static mode) or to allow the lag screw to move within the nail to compress the intertrochanteric fracture (dynamic mode). the purpose of this study was to compare the biomechanical stiffness of static and dynamic modes for a cephalomedullary nail used to fix an unstable peritrochanteric fracture. material and methods: thirty intact synthetic femur specimens (model #3406, pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron 8874 (instron, canton, ma). a long cephalomedullary nail (long gamma 3 nail, stryker, mahwah, nj) was then inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and the cephalomedullary nail was reinserted. mechanical tests were conducted for axial, lateral, and torsional stiffness with the lag screws in: 1) static and 2) dynamic modes. a paired student's t-test was used to compare the two modes. results: the axial stiffness of the cephalomedullary nail was significantly greater (p < 0.01) in the static mode (484.3 ± 80.2 n/mm) than in the dynamic mode (424.1 ± 78.0 n/mm) (fig 2a) . similarly, the lateral bending stiffness of the nail was significantly greater (p < 0.01) in the static mode (113.9 ± 8.4 n/mm) than the dynamic mode (109.5 ± 8.8 n/mm). the torsional stiffness of the nail was significantly greater (p = 0.02) in the dynamic mode (114.5 ± 28.2 n/mm) than in the static mode (111.7 ± 27.0 n/mm). a post hoc power analysis with a = 0.05 and ß = 0.20 revealed that the paired t-test on 30 samples was sufficiently powered to determine a difference in mean axial stiffness of 33.0 n/mm (6.8% of static stiffness), a difference in mean lateral bending stiffness of 3.6 n/mm (3.2% of static stiffness) and a difference in mean torsional stiffness of 3.4 n/mm (3.0% of static stiffness). conclusion: our results show that there is a 60 n/mm reduction in axial stiffness of the cephalomedullary nail when the lag screw is changed from static to dynamic mode. this represents a 12.4% reduction in axial stiffness with a change from axial to dynamic modes which may be clinically significant. the differences in lateral (4.4 n/mm, 3.9%) and torsional (2.8 n/mm, 2.4%) are small enough that they are likely not clinically significant. we felt that a difference of greater than 10% in axial stiffness and a difference of greater than 5% in lateral or torsional stiffness would be clinically significant. our study was adequately powered to detect these differences. given the significant reduction in axial stiffness with dynamization of the cephalomedullary nail construct, we recommend use of the static mode when treating unstable peritrochanteric fractures with a cephalomedullary nail. disclosure: no significant relationships. introduction: minimizing tip-apex distance has been shown to reduce clinical failure of sliding hip screws used to fix peritrochanteric fractures. the purpose of this study was to determine if such a relationship exists for the position of the lag screw in the femoral head using a cephalomedullary device. material and methods: thirty intact synthetic femur specimens (model #3406, pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron 8874 (instron, canton, ma). a long cephalomedullary nail (long gamma 3 nail, stryker, mahwah, nj) was inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and repaired using one of 5 lag screw placements in the femoral head: 1) superior (n = 6), 2) inferior (n = 6), 3) anterior (n = 6), 4) posterior (n = 6), 5) central (n = 6). mechanical tests were repeated for axial, lateral and torsional stiffness. all specimens were radiographed in the anterioposterior and lateral planes and tip-apex (tad) distance was calculated. a calcar referenced tip-apex distance (caltad) was also calculated. anova was used to compare means of the five treatment groups. linear regression analysis was used to compare axial, lateral and torsional stiffness (dependent variables) to both tad and caltad (independent variables). results: anova testing proved that the mean axial (p < 0.01) and torsional stiffness (p < 0.01) between the five groups was significantly different, but lateral stiffness was not statistically different (p = 0.494). post hoc analysis showed that the inferior lag screw position provided significantly higher mean axial stiffness (568.14 ± 66.9 n/mm) than superior (428.0 ± 45.6 n/mm; p < 0.01), anterior (443.2 ± 45.4 n/mm; p = 0.02) and posterior (456.7 ± 69.3 n/mm; p = 0.04) lag screw positions. there as no significant difference in mean axial stiffness between inferior (568.14 ± 66.9 n/mm) and central (525.4 ± 81.7 n/ mm) lag screw positions (p = 0.77). post hoc analysis revealed significantly less mean torsional stiffness for the superior lag screw position compared to other lag screw positions (p < 0.01 all 4 pairings). there were no significant correlations between tad and axial (r = -0.33, p = 0.08), lateral (r = -0.22,p = 0.24) or torsional (r = 0.08, p = 0.69) stiffness. there were significant correlations between caltad and axial (r = -0.66, p < 0.01), lateral (r = -0.38, p = 0.04) and torsional (r = -0.38, p = 0.04) stiffness. conclusion: our results suggest that placement of the lag screw inferiorly in the femoral head when using a cephalomedullary nail to treat an unstable peritrochanteric fracture results in the stiffnest construct in axial and torsional biomechanical testing. a simple radiographic measurement, caltad, provides an intraoperative method of determining optimal cephalomedullary nail lag screw position to achieve greatest construct stiffness. introduction: a potential of polymethylmethacrylate (pmma) augmentation to increase the purchase of cephalic implants in the treatment of intertrochanteric hip fractures has been proven in sev-eral biomechanical studies [1] [2] [3] [4] . the aim of this study is to compare the cut-out ratio of pmma augmented helical blades to not augmented ones in human cadaveric femoral heads. material and methods: six pairs of osteoporotic cadaveric femoral heads were instrumented with a proximal femoral nail antirotational (pfna) blade in a standardized manner. within each pair, one blade was augmented using 3 ml of pmma cement. cyclic loading was performed at 2 hz. starting at 1000 n, the load was monotonically increasing by 0.1 n/cycle until failure of the construct. x-rays were taken at 250 cycle increments to monitor the movement of the blade with respect to the head. paired nonparametric test statistics were used to identify differences between groups. results: a significant higher number of cycles to cut-out was found for the augmented group (p = 0.028). a significant correlation was observed between bone mineral density and cycles to cut-out for the non-augmented specimens (p < 0.001, r 2 = 0.97), whereas no correlation was found for the augmented group (p = 0. introduction: when treating distal tibial deformities or fractures with the ilizarov external fixator the ankle joint and foot is often transfixed within the ring construction. for some patients full weight bearing can only be achieved in assembling a walking device on the distal ring. the biomechanical effect of the indirect loading on the fixator stiffness, the osteotomy and the wire tension is still unkown. material and methods: on the basis of a standarized ilizarov external fixator (4 rings, 160 mm diameter) with two 1,8 mm wires per ring applied in anatomical position on composite tibiae (3 rd generation sawbones) direct and indirect loading was analyzed using a universal testing machine (model 10, uts germany). a middiaphyseal osteotomy of 3,5 mm was performed. the following parameters were recorded: micromotion at the osteotomy, relative movement between bone and rings, compressive forces at the osteotomy and strain of the wires. each experimental setup was tested ten times with 100 kg maximal axial loading. results: the osteotomy gap closure occurred at 275 n at direct loading and at an average of 730 n at indirect loading. the compressive forces at the osteotomy were almost double as high at direct loading. regarding the relative motions between rings and bone the amplitude of motion was higher at indirect loading. the stress on the wires was up to four times higher when the walking device was applied on the distal ring for indirect loading. conclusion: the indirect loading using a walking device has a substantial influence on the mechanical characteristics of the ilizarov fixator which determine the biomechanical environment of the osteotomy/fracture. the results showed a higher mechanical load while achieving less compressive forces at the osteotomy. in the need of the walking device we suggest to apply additional half-pins at least in the distal fragment. 9) . three randomized groups of 6 pairs were formed. after the osteosynthesis with the implants was done the fracture (a2.2) was made with a jigsaw. for further destabilsation the troch. minor was removed. the femura were fixed in the testing machine and tested under dynamic condition with a physiologic load for normal walking (2.5x bodyweight) under 25 000 cycles. we measured the load on the implant, the migration and rotation of the bone around the implant. the data was dokumented with lab view, results: the intramedulare implants showed significant lower migration rates (mean 2.7 mm) of the head compared to the extramedular implants (mean 9.6 mm). the rotation of the head around the lag screw startet earlier within the dhs an showed higher rates (mean 32â°) followed by the gamma 3 (mean 23â°) until the end of the 25 000 cycle. the best stabilisation against rotation was documented for the pfn a (mean 13â°). the post x-rays showed a significant migration and sintering process of the femoral head with lateralisation and fracture of the lateral wall. this was even higher in probes with a low bmd. introduction: excising part of an implant through the femoral head is a rare but severe complication of osteosynthesis of proximal femoral fractures. there is little evidence in the literature about incidence and management of this complication. according to opinion leaders in an recent international user meeting most cases end up in total hip arthroplasty (tha). the value of re-osteosynthesis remains unclear. most patients that suffer an excision are geriatric and multimorbid patients, rather suitable to less invasive revision surgery. to assess the incidence and management of cutting out of the pfna blade (proximal femoral nail antirotation by synthes gmbh international) was the aim of this multicenter study. material and methods: the incidence and management of excision of the pfna blade in trochanteric femoral fractures was assessed retrospectively in 3092 cases in 15 participating hospitals all over europe in a time period between 2003 and 2009. all implantations were screened for this complication. the preoperative, follow up x-rays and patients' medical records including the surgical reports were collected and analysed with a special focus on revision surgery until union or tha. results: the incidence of excision of the implant was 1.3% (41/3092). the mean age of patients was 80 years. 76% of mostly female (86%) patients sustained an unstable 31a3 fracture according to the ao classification. final revision surgery was performed with tha in 19 cases (48%). in 21 cases re-osteosynthesis led to union (52%). reosteosynthesis was either exchange of blade with or without cement augmentation alone or re-nailing. in 8% of tha revisions additional revision was necessary. in 45% of revisions with exchange of blade additional revision was required (all tha). 83% (5/6)of revision cases with cement augmented blades healed. in 20% of revision with re-nailing, additional surgery was inevitable. on average 2.5 operative procedures were performed after excision of the pfna blade. conclusion: cutting out of the blade of the pfna is a rare complication. nevertheless the management after removal is challenging as indicated by the high number of surgical revisions. revision with total hip arthroplasty showed a lower rate of reoperations compared to re-osteosynthesis. nevertheless 52% of all revision cases were managed successfully with a minimally invasive osteosynthesis. this gives a rationale for osteosynthesis in managing this complication in geriatric multimorbid patients with a high risk for operation. references: 1. simmermacher, r. k., j. ljungqvist, et al. (2008) . ''the new proximal femoral nail antirotation (pfna) in daily practice: results of a multicentre clinical study.'' injury 39 (8) in a prospective series of subtrochanteric fractures with or without involvement of the pertrochanteric region and in revision procedures of this area the pf lcp was applied. in 4 out of 14 patients a fixation failure was observed. this paper reports on these fixation failures. material and methods: all patients with a multifragmented subtrochanteric fracture with or without involving the trochanteric or the femoral neck region which where judged to present a compromised nail entry point from may 2007 until may 2008 were stabilized using the pf lcp. the plates were applied in a minimally invasive manner through soft tissue windows (mipo). intrinsic stability of the fixation was increased by excentric drilling or applying the tensioning device. all patients were followed up to fracture healing. intraoperative and postoperative complications were noticed. intraoperative and postoperative x-rays were analysed using the ccd angle and the gardens alignment index. results: we report 4 out of 14 patients who sustained a fixation failure with secondary varus collapse requiring 3 revision surgeries until healing. revision consisted in a reosteosynthesis in one, a plate exchange to a 95 o blade plate in the second and a dhs in the third patient. in all our reported cases of implant failure the posteromedial buttress was missing [two ao 31 a2 and two seinsheimer type v], and all patients were not able to restrict wheight bearing due to different reasons like, noncompliance (alcohol abuse, limited force, advanced age) leading to increased axial bending forces and finally to breakage of the femoral neck screws with varus collapse of the fracture. conclusion: in conclusion the pf lcp proximal femoral plate 4.5/5.0 due to its guide wire technique allows for straightforward plate application and reduction also in very complex fractures of the trochanteric region, including fractures with extension into the greater trochanter or reverse oblique intertrochanteric fractures. however in fracture patterns with missing posteromedial support and limited ability to restricted weight bearing (e.g.: advanced age, additional handicap or mal-compliance) an alternative fixation device should be considered, e.g. the hook plate extension of the lcp proximal femoral plate to apply higher intrinsic stability of the fixation when using the tensioning device. further clinical and biomechanical studies are needed to evaluate the potentiality and limitation of this device for the treatment of these challenging fractures of the trochanteric region. the majority of the the former fixation was replaced by a blade plate. in 25% we performed a total hip prosthesis. in these cases we saw an overproportional tend to prosthesis-luxations. conclusion: we conclude that mechanical complications like cut out are a little more frequent after dhs-implantation and should be treated by change to a blade-plate-osteosynthesis. this allows a fracture consolidation in that the minor trochanter becomes that stable, that a regular total hip replacement becomes possible. this seems to be the best prevention of mechanical complications after posttraumatic hip replacement like luxations. disclosure: no significant relationships. introduction: hip fractures often concern elderly patients with a high degree of co-morbidity and therefore susceptible for the associated postoperative morbidity and mortality. according to the literature, several factors have an influence on the amount and severity of postoperative complications after hip fractures. low preoperative haemoglobin levels (hb) in elderly patients seem to be associated with increased short-term morbidity and even mortality after surgery. the aim of this study was therefore to establish the impact of anaemia and blood transfusion on postoperative recovery of hip fracture patients. results: there were 16 women and 44 men with medium age of 24,2 years (18-45 years) and with medium follow-up of 2 years (1-6 years). the lesions occur in 8 sports, 50% of the fractures occur while practicing soccer. the fractures were bimalleolar (n = 30), medial malleolus (n = 11), lateral malleolus (n = 10), with sindesmotic lesion (n = 6) and trimalleolar (n = 3). 6 months after surgery 22% of the patients returned to sports activity ant at 12 months 43%. at 12 months the younger patients (p = 0,0001) and men (p = 0,001) returned earlier to sports activity. at one year 80% of the amateur and 20% of the professional athletes, had returned to sports practice. fractures of the lateral malleolus returned earlier in 16,2 weeks than medial malleolus fracture in 59,5 weeks. the smfa and aofas scores were high in all types of fracture. conclusion: correct treatment of instable ankle fractures in athletes, with anatomic reduction and preservation of the integrity of the articular surface, is crucial to the return to sports practice. the fractures that influence an earlier return were younger age, male sex and less severe fracture, and negative predictors were older age and female sex. athletes submitted to open reduction and internal fixation with adequate and precocious programme of physical rehabilitation, can return to the same level of sports practice, despite the seriousness of the fracture without pain and functional limitation(4). results: in all cases anatomic reduction could be achieved. no secondary dislocation was observed and all fractures healed uneventfully. conclusion: indirect reduction of the volkmann triangle from anterior makes an image intensifier mandatory and has potential of not achieving anatomic reduction due intercalated tissue. in larger fragments the fixation with a lag crew from anterior, the buttressing effect might not be sufficient to avoid secondary displacement. with the use a postero-lateral approach and dorsal plate for fixation of the volkmann triangle, it is possible to reliably obtain an anatomical reduction of the dorsal articular surface of the tibia, thus potentially minimizing the risk of posttraumatic osteoarthtitis. introduction: after ankle-and hindfoot fractures, edema often delays surgery and postoperative mobilisation. therefore effective treatment of edema is of great importance. the aim of this study was to evaluate the efficacy of the continuous lymphological multi-layer compression therapy and of the av-intermittent impulse compression (avi) in reducing ankle-and hindfoot edema. material and methods: randomized, controlled, single-blinded, clinical trial. 64 patients (40 ± 15 years, 41 m, 23f) with unilateral fractures of the ankle or hindfoot pre-or postoperatively were randomized into a) the control group (elevation and cold packs), b) the continuous multi-layer compression therapy group (cct) or c) the av-impulse compression group (avi). primary outcome was the pre-respectively postoperative reduction of edema as measured with the figure-of-eight methode 20 . results: pre-and postoperatively the continuous lymphological multi-layer compression therapy (cct) showed a significant better edema reduction when compared to the control group. after three days of intervention the mean preoperative edema reduction in the control group was -3.8 ± 10.4 mm (11.1%) figure-of-eight methode20 vs. -13.5 ± 6.7 mm (39.5%) in the cct group (p < 0.01) and vs. -5.7 ± 9.3 mm (17.6%) in the avi group. three days postoperatively the mean edema reduction was -3.9 ± 9.8 mm (12.6%) in the control group vs. -11.6 ± 6.5 mm (34.5%) in the cct group (p < 0.05) and -5.1 mm ± 15.6 (19.4%) in the avi group. pre-and postoperatively the cct group shows moderate effect sizes after two days of intervention and large effect sizes after three days. avi is more effective when combined with elevation during off-session periods. conclusion: continuous lymphological multi-layer compression therapy leads to a clinical relevant and significant better reduction of ankle-and hindfoot edema as compared to the standard treatment with elevation and cold packs. av-intermittent impulse compression shows a tendency towards a better edema reduction compared to the standard treatment. continuous lymphological multi-layer compression therapy reasonably can be applied when edema delays operation or postoperative mobilisation. considering the avi application we strongly recommend to elevate the leg during off-session periods. introduction: the objective of the study is to define the global hospital costs of a group of patients that suffered from severe trauma. additionally we identify the distribution of the expenses between the different services and the different procedures fulfilled to the patient. (2), season (4), moon phases (4), times on duty (2) and weather condition (2) . the observed mortality was adjusted with the risc based prognosis and the smr calculated. results: the selected collective had an average age of 40.4 years and 73% of the patients were males. the mean iss was 26.1 and the mean hospital mortality was of 17.6%. for the time of day the highest rate of admission was between 6:00 and 7:00 p.m., with the highest numbers on saturdays. in the times of on-call duty (weekend, public holiday, weekday between 5:00 p.m. and 8:00 a.m.) twice as much trauma patients were delivered to trauma centers as within the regularly working hours. in summer, the admission rate was highest (29.2%) and lowest in winter (21.3%), with more victims of car accidents in autumn and winter as in the warm season and more victims of motor-and bicycle accidents in spring and summer as in the cold season. but none of the mentioned factors showed an effect on survival (smr between 0.98 and 1.00). the moon phases had no influence either on frequency of accidents nor on outcome. the effects of temperature was similar to this of the seasons: with warm temperatures/month less car accidents and more bike accidents occurred (and the opposite for cold temperatures). in the subgroup with temperatures under zero degree the mortality was 4% higher (21.5%) than in the subgroups with temperatures above zero (17,0 to 17,6, even though a similar iss (26,4 vs. 25,9 to 26,2) . in a second step a multivariat analysis was done in order to improve the predictive power, but none of the external factors could improve the prognosis. conclusion: there are large variations in the incidence of severe accidents due to time of day, day of week and time of year. but there is no effect of patient's outcome in regard to medical care in german trauma centers. the quality of medical trauma care is consistent around the day, the week and throughout the year. additionally, we observed an increasing difference between mortality rate and risc prediction rate from -0,1% to -5,2%, means less deceased polytraumatized patients than predicted. within the late secondary transferring patients with spinal cord injuries were leading (35%), followed by patients with pelvic injuries (26%), infections (16%) and complex extremity injuries (16%). conclusion: with this investigation, we tried to characterize the influence of the new mapping of germany on patient data using the example of the regional trauma network ''saar-(lor)-lux-west-rhineland-palatinate''. although, knowing a lot of interferences, we noticed an abrupt rise of primary admittances of trauma patients in our level-1 hospital since starting networking. among the load rejection for smaller hospitals this fact leads to a distinct concentration of the treatment of polytraumatized patients in specialized trauma centers. the improved routine by increased quantity could be responsible for the improvement of process and outcome quality in the treatment of severely injured patients. but, the enormous quantity of emergency patients also reflects a future challenge in dealing with emergency operations besides routine operations as well as seldom icu-beds in these trauma hospitals. the role of the nlfc is to work in parallel to doctor led clinics, assessing and treating uncomplicated musculoskeletal injuries with a favourable natural history. since its inception, throughput in this clinic has increased and with greater clinical exposure and training, the spectrum of referred injuries has also broadened. the aim of the present study was to determine patient satisfaction with the nlfc using a validated questionnaire with a specific emphasis on how patients viewed being seen by a nurse rather than a doctor material and methods: 173 consecutive patients were prospectively recruited in the nlfc in january 2008. patients were referred by their resepective consultants after reviewing the presenting history, examination findings and radiographs. after their consultation with the nurse, each patient was asked to fill in a 37 item questionnaire consisting of 6 different domains related to patient satisfaction based on a validated patient satisafction questionnaire adapted for use in the fracture clinic setting. results: there were 173 respondents, 79 men and 86 women, with a mean age of 35 years (range 2-82 years). 35 questionnaires were completed by parents, 4 by carers and the remainder by the patients themselves. the most common treated injuries were distal radial, metatarsal and metacarpal fractures. 97% of patients felt they received the best care from the staff working in the clinic with greater than eighty percent of patients registering satisfaction with the nurse's assessment of their injury, their bedside manner and the treatment and information given. only 9% of patients felt that they would rather be seen by a doctor for their injury. the highest rates of dissatisfaction related to the building and seating comfort. conclusion: generally, over 85% of patients were satisfied with their clinic visit with the vast majority of patients not having any objection to seeing a nurse rather than a doctor. patient satisfaction with treatment remains the ultimate outcome measure by which healthcare interventions should be assessed. the results of this study demonstrate the nlfc to be an effective method of managing selected patients in a clinic setting thus reducing the workload of patients which would traditionally be reviewed by the doctor. this has significant implications for improving opportunities for doctors training as well as reducing clinic waiting times. [1] [2] [3] [4] . the aim of this study is to evaluate the anatomical correlation between the lateral end of the clavicle and the attachment area of the supraspinatus tendon. material and methods: using a mathematical model based upon ct-scan data performed on healthy individuals, the 3 dimensional correlation between the lateral and of the clavicle and the rotator cuff is analyzed. each individual is examined in supine position, using 3 different positions of the arm (maximum external rotation, maximum internal rotation and maximum abduction and external rotation (''aber position''), respectively). for every position the contact area of the lateral end of the clavicle and the spupraspinatus tendon is calculated. results: six healthy individuals (12 shoulders) could be included into the study. the average contact area between the lateral end of the clavicle and the supraspinatus tendon (%) is 51.9% for maximum external rotation, 61.7% for maximum internal rotation, respectively. in the aber position only 4/12 shoulders showed a contact area > 1% (av. 1.6%). conclusion: according to these morphological findings the contact area between the lateral clavicle and the supraspinatus tendon is less than 62%. this contact zone is located in the dorsal aspect of the clavicle. therefore the additional resection of an osteophyte, especially at the anterior part of the lateral clavicle should not have a significant influence on the outcome after subacromial decompression. and good to moderate outcome in the cs (mean 69), one patient had a moderate dash score of 57 with a poor cs of 41. irrespective of treatment strategy the majority of the patients regained normal range of motion and grip strength in the affected shoulder. the most common complication was impingement of the shoulder, which occurred three times in the conservatively and four times in operatively treated patients. all but one conservatively treated patient with a non-union healed without complications. conclusion: minor ( £ 5 mm) and moderate (6-10 mm) displaced greater tuberosity fractures can successfully be treated conservatively with good to excellent long-term rehabilitation of function with a low risk of complications. whereas there is no doubt that major displaced fractures (> 10 mm) should be treated operatively, special attention must be paid to moderate (6-10 mm) displaced fractures, as the degree of displacement may be misinterpreted on plain standard radiographs. disclosure: no significant relationships. introduction: a recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. we studied impairment and disability an average of twenty-one years after injury in a cohort of dutch patient, with the hypotheses that 1) objective measurements of impairment correlate with disability, 2) depression and misinterpretation of nociception correlate with disability; and 3) patients injured when skeletally mature and immature have comparable impairment and disability. material and methods: seventy-one patients were evaluated an average of 21 years after injury. the majority of the 35 skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the 36 skeletally mature patients were treated with plate and screw fixation. objective evaluation included radiographs and measurements of range of motion and grip strength. questionnaires were used to measure arm-specific disability (disabilities of the arm, shoulder and hand: dash), misinterpretation or over interpretation of pain (pain catastrophizing scale-pcs-), and depression (ces-d). multivariable analysis of variance and multiple linear regression were used to analyse the ability of the independent variables to account for variation in the dash-score. (spss 17.0, spss inc., chicago). results: there were 44 men and 27 women with a an average age of forty-one at time of follow-up (range, 20 to 81). fractures were classified as ao/ota-type a3 in 46 patients (simple), b3 in 18 (including wedge fragment) and c fractures in 7 patients (comminuted). the average dash score was 8 points (0 to 54) and 72% reported no pain. both rotation and wrist flexion/extension were 91% of the uninjured side; grip strength was 94%. there were small, but significant differences in rotation (151 versus 169 degrees, p = 0.004) and wrist flexion/extension (123 versus 142 degrees, p = 0.002), but not disability between skeletally mature and immature patients. the best predictors of dash score were pain catastrophizing, pain, ipsilateral injury and grip strength, explaining 55% of the variation in dash scores. pain alone accounted for 40% of variation in dash scores. conclusion: twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over 90% motion and grip strength) and disability after non operative and operative treatment respectively. patients that were skeletally immature at the time of injury had better motion, but comparable disability. disability correlated with pain and pain catastrophizing rather than motion. results: the mesenteric injuries vizualized on initial ct-scan were mesenteric vascular beading or extravasation in 6 cases, and mesenteric infiltration or hematoma in 13 cases. associated abnormalities of the gastrointestinal tract (thickening, abnormal enhancement, perforation) were present in 11/19 cases (58%). nine patients underwent surgery (26%), 6 patients in the early hours, and 3 others after a delay of more than 24 h. indication for surgery was hemodynamic instability in 4 cases and suspicion of bowel perforation in 5 cases. in total, intestinal perforations were found in 8 patients. three patients (15.8%) died of associated injuries. no false positive scan has led to unnecessary surgery. however, the negative predictive value of initial ct was 75% for intestinal associated lesions. conclusion: the mesenteric injuries in blunt polytrauma patients are uncommon but serious. the whole body scanner is a powerful tool for the diagnosis of these mesenteric lesions. conservative treatment is feasible but a clinical and paraclinical reassessment is essential for early detection of intestinal lesions initially undiagnosed, or aggravation of initial lesions. disclosure: no significant relationships. introduction: drug smuggling by gastrointestinal concealment, body-packers, is an increasing problem in developed countries. although conservative treatment is usually successful in most cases, some of these patients suffer complications such as obstruction, gastrointestinal perforation or massive drug intoxication due to a leaking package. despite an urgent surgery and a careful management in the icu, morbidity and mortality remain high. our aim was to assess the outcomes of conservative and surgical management of these patients in our hospital, the referral centre for this entity in madrid. (1996) (1997) pre-hospital fatalities were more frequent (although not statistically significant), which may reflect improvement of trauma organization in recent years (1998) (1999) (2000) (2001) . domestic (may related to delay due to victim's solitude) and urban environment (inexperienced personnel, delay due to referral to another hospital) incidents lead more frequently in pre-hospital death. age and iss as indicators of physiologic reserve and severity of injury were independent predictors of fatality before the victim reaches hospital. introduction: the triad of the elbow is a complex traumatic injury. these injuries have traditionally been considered a poor prognosis for the consequences that arise as a secondary instability, stiffness and loss of functional ability. the objective of this free paper is to review from a clinical and radiological perspective our experience with 24 cases. material and methods: we retrospectively reviewed 24 patients with this type of injury. in 8 patients was not carried out a comprehensive treatment of all existing lesions. the coronoid process was not addressed specifically and fractured radial head was removed or and an osteosynthesis was performed. in the remaining 16 were treated by a treatment protocol trying to repair all the damaged structures (coronoid synthesis, radial head arthroplasty/orif and ligament repair, at least in the external lateral ligament complex). the median followup was 18 months (12-24).the results were evaluated by the scale of may elbow performance score (meps), range of mobility, radiographic parameters and complications during follow up. results: patients treated according to protocol in a systematic manner trying to repair all damaged structures had better outcomes in both the radiological point of view as functional, as well as a lower rate of complications. meps in these patients the average was 85 points (vs. 62 the other group), the arc of 95º flexoextensió n (vs. 60º) and the arc pronosupinació n 150º (vs105º). conclusion: despite being an injury traditionally associated with poor results, which have been established treatment protocols that try to treat all manner of injured structures involved in the injury outcomes have improved significantly. we think it must be performed a radial head artroplasty/orif (not resection), anchorage/ osteosynthesis coronoid process and a ligament repair at least of the external lateral ligament complex. if residual instabilty results it may be repaired the medial colateral ligament complex and a temporal external fixator may be used. disclosure: no significant relationships. tion. 14 patients received a secondary implantation including 6 chronic luxations, 5 nonunions, 2 failed osteosynthesis and 1 reimplantation after deep prosthetic infection. the mean follow up was 14 ± 7 months. the functional outcome was measured by using the mayo elbow performance score. results: we had 14 female and 7 male patients with a mean age of 69 ± 6 years. all 21 patients achieved very good results based on the ,,mayo elbow performance score'' with a postoperative mean of 97 points (range between 90 and 100 points) with a maximum performance of 100 points. the mean range of motion concerning extension and flexion was 94 degrees (55 to 115 degrees), concerning pronation and supination 144 degrees (100 to 160 degrees). the mean flexion deformity was 19 degrees (10 to 50 degrees), the mean maximum flexion was 113 degrees (90 to 130 degrees). we had two partial ruptures of the triceps tendon, one treated by operative refixation and one conservative, one temporary lesion of the ulnar nerve with complete recovery and one postoperative hematoma which needed surgical treatment. one patient needed revision surgery and resection arthroplasty due to a deep infection, but received a new prosthesis after two months. we recorded no radiographic loosening or other mechanical problems so far. conclusion: according to the used ''mayo elbow performace score'' all patients achieved a very good functional outcome. eventhough they all had severe injuries of the elbow. with modern types of elbow prosthesis the rate of complications and revision surgery is quite low. ô ur findings indicate that total elbow arthroplasty should be considered as an additional treatment alternative. patients with a lower functional demand and of higher age benefit most from a prosthesis. for younger patients preservation of the joint should be achieved as far as possible. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. however secondary overload of the lateral facet of the humero-ulnar joint (with consequent arthritis), instability (especially in the presence of medial collateral ligament injury), painfull anteroposterior instability of the radial stump, and radial shortening (in essex-lopresti lesions) with wrist pain can be the result. radial head arthroplasty widely is proposed as prevention of these complication. however as we demonstrated in a systematic review of the litterature, radial head arthroplasty has equally high secondary arthritis rates as radial head resection. the complex anatomy of the radial head, articulating both with the capitellum and the proximal ulna is not reproduced by most contemporary radial head prostheses. material and methods: we describe the complex radial head anatomy based upon an analysis of 20 mriâ e tm s of the elbow performed in healthy volunteers under standardised situations. we describe the next variables: â e¢radial head shape and diameter at the most proximal part of the pruj (proximal radio-ulnar joint) â e¢radial head shape and diameter at the midpoint of the pruj â e¢radial head height medial and lateral â e¢depth of the radial head through â e¢offset of the radial headâ e tm s through relative to the center of the radial head â e¢offset of the radial headâ e tm s through relative to the axis of the radius â e¢offset of the radial head relative to the axis of the radius â e¢angulation of the radial neck to the axis of the radius we compare these parameters to the available radial head prostheses. results: there is a high variability of the different parameters and no relation between all of the parameters could be determined. the existing radial head prostheses do only reproduce the anatomy to a limited extend. conclusion: the high rates of post arthroplasty arthritis can be related to the non-anatomical shape of the existing designs. as the proximal radius articulates both with the capitellum and the proximal ulna, a precise reconstruction of both joints is a necessity to avoid maltracking and/or edge contact in both joints. given the high variability this only can be realised using a theoretic modular prosthesis that allows for reconstruction of the synchronisation between both joints. we found no significant differences (p > 0.05) in the deficit of the range of motion. flexion: screws 6 ± 10°, prosthesis 12 ± 13°, plate 8 ± 13°e xtension: screws 7 ± 11°, prosthesis 13 ± 10°, plates 16 ± 18°p ronation: screws 17 ± 19°, prosthesis 10 ± 14°, plates 25 ± 32°s uppination: screws 6 ± 16°, prosthesis 13 ± 19°, plates 27 ± 30°a ccording to elbow functional evaluation criteria by broberg and morrey, we found excellent and good results in 60% of all patients treated with screws, in 58% of all patients treated with prosthesis and in 50% of all patients treated with plates (p > 0.05) the average dash score of patients treated with screws was 11 ± 17 points, of patients treated with prosthesis 19 ± 17 points and of patients treated with plates was 16 ± 18 points (no significant differences, p > 0.05). the physical and mental component of the sf-36 score was at the time of follow-up within the normal range at all patients (physical component: screws 51 ± 9.7, prosthesis 46 ± 8.3, plate 52 ± 6.2; mental component: screws 54 ± 7.9, prosthesis 56 ± 6.6, plate 56 ± 4.5). in the subcategory of physical functioning, screws performed better than prosthesis (p < 0.05). no other items of sf-36 were significantly different (p > 0.05). conclusion: according to our results osteosynthesis with only screws seem to be the best of the three studied methods. radial head prosthesis replacement yields better functional results than treatment with plates. it must be considered that prosthesis replacement of the radial head has the long-term risk of loosening, especially in young and active patients. plates showed worse clinical results especially in rotation of the forearm even after removing the plate in 7 patients. disclosure: no significant relationships. s111 is angular stable osteosynthesis of the olecranon more economical than traditional treatment? n. spaepen 1 , k. govaerts 1 , s. nijs 2 , p. broos 3 1 trauma surgery, uz leuven, leuven, belgium, 2 department of traumatology, university hospitals leuven, leuven, belgium, 3 traumatology, university hospitals leuven, leuven, belgium introduction: although tension band wiring is considered as the gold standard in the treatment of simple olecranon fractures and olecranon osteotomies, the complication rate is high (delayed healing in up to 15% of cases, hardware migration 13%). in an historical series using anatomical preshaped lcp plates, we could lower the rate of healing disturbances, but the volume of the implant did make hardware removal necessary in the majority of patients. the lcp 3,5 mm hook plate is a low volume angular stable compression plate, designed for the treatment of simple fractures and osteotomies of the olecranon. in this study we want to evaluate the early results of using this new device for the treatment of acute fractures and osteotomies at a level 1 trauma centre. material and methods: we prospectively include all patients treated by lcp 3,5 mm hook plate between and. 6 months results considering range of motion (as measued by), meps (mayo elbow performance score), complications and radiographic results are presented. we perform a cost analysis of primary operation using the different implants available, length of stay and time off work. we also perform a cost analysis for reoperation because of delay in union results: we included 21 patients. average age is 55,6 years (range 17-83). there were 11 female and 10 male patients. at 6 months average extension deficit was 12â°, the average flexion 130â°. there was no substantial loss of pro-supination. all factures but one united anatomical (early loss of reduction, but patient refused reoperation). there were 3 complications: 1 early loss of reduction (treated conservatively), 1 crps (complex regional pain syndrome) and 1 arthrofibrosis necessitating implant removal). because of symptomatic hardware two additional hardware removals have been performed. according to the mayo elbow performance score all but 1 patient scored good to based upon the cost analysis the predicted average cost per patient is significantly lower in the hook plate group as compared to the tension band and anatomical preshaped plate group. conclusion: although still a limited series, the early results of this implant are very promising. we document ranges of motion witch are comparable to those described previously in tension band wiring or anatomical plating, but at lower complication and reoperation rates. based upon an analysis of the cost of treatment and of reoperation we advocate the routine use of the olecranon hook plate in the treatment of simple olecranon fractures and osteotomies. disclosure: no significant relationships. material and methods: dutch surgeons (n = 23) were asked to draw two incisions for an olac on embalmed human specimen (n = 46). they also filled out a questionnaire of their experience. all incisions were photographed and digital measurements were taken. each incision was compared to the gold standard on 4 criteria. incisions should not be closer than two-thirds of the distance between: 1) distal tip of the lateral malleolus and the achilles tendon. there was no correlation between number of mistakes and number of procedures per year or years of experience (spearman correlation: 0.03 and -0.04 respectively) the median of the mistakes for l-shaped incisions was 1 (iqr = 2) and 2 (iqr = 2) for j-shaped incisions (p = 0.017, mann-whitney). the spearman correlation between the mistakes for the two incisions drawn by each surgeon was 0.55. conclusion: conclusions: inter-surgeon variation of incision lines was high and since the number of mistakes per incision was not correlated to the surgeon's experience, casam can be useful in two ways: 1) pre-operative planning using casam, might assist the surgeon in determining a 'tailor made' safe zone in each patient. 2) for educational purposes casam is able to compare a student's incision with the gold standard or the computed location of the sural nerve, thus providing personal feedback. introduction: a precise sustentaculum tali screw placement is crucial for the fixation strength of operatively treated calcaneus fractures, as shown in biomechanical studies. due to the complex anatomic shape of the calcaneus and the limited visualization of the sustentaculum tali fragment via the common lateral approach, the exact screw positioning is demanding and a bright knowledge of the surgeon is mandatory. with the introduction of navigation procedures an increased precision of implant positioning could be achieved for different applications, as reported for pedicle-and iliosacral screw placement. the aim of this study was the evaluation of different navigation procedures compared to the conventional technique for the placement of the sustentaculum tali screw. material and methods: 32 sustentaculum tali screws were placed via a standard lateral approach in artificial calcanei with a prefabricated soft tissue envelope. we used different navigation techniques: group i: 2d-based fluoroscopic navigation group ii: 3d-based fluoroscopic navigation group iii: fluoro-free navigation compared to the standard procedure without navigation (group iv). for each screw the time of procedure and time of fluoroscopy was measured. the precision was evaluated in postoperative ct scans. results: no x-ray exposure was necessary for the standard procedure and the fluoro free navigation, whereas 17 ± 1.03 and 66.8 ± 0.9 s of fluoroscopy time were needed for the 2d-and 3d-based fluoroscopic navigation. significant differences were observed for the mean procedure time: 1.26 ± 0.05 (group iv), 3.49 ± 0.26 (group iii), 13.5 ± 0.49 (group i) and 19.04 ± 1.41 min (group ii). no significant differences were seen for the precision with one mal-placed screw in each group. whereas for the image based navigation procedures wide experience in computer assisted surgery was necessary, the fluoro free navigation procedure could easly used without that experience, due to a simplified and self-explanatory workflow. conclusion: all three navigation procedures increase the intraoperative orientation for the placement of the sustentaculum-tali screw, but significant differences of precision compared to the standard technique could not be observed in our experimental set up. potential reasons are a visual and tactile memory effect, despite a randomized order of drillings and a better visualization of the osseous structures in the used artificial model. in clinical situations a lack of surgical routine for this rare injuries and a limited display of anatomic landmarks exist, making all of the evaluated navigation procedures to a helpful tool. if the fracture reduction is controlled intraoperatively by an 3d fluoroscopic scan, we recommend the 3d navigation, otherwise we use the fluoro free navigation. disclosure: no significant relationships. overall satisfaction of functional status was measured using a visual analogue scale (vas; range zero to ten). results: four-hundred metatarsal fractures were identified in 322 patients. the distribution of fractured metatarsals was: first metatarsal 5%, second 12%, third 14%, fourth 13%, and fifth 56%. multiple metatarsal fractures were seen in 15.6%. most fractures were caused by an inversion injury or fall from height (75%). more than eighty percent of fractures were undisplaced or minimally displaced, and most fracture patterns were transverse or oblique/spiral. a total of 166 patients (67.2%) returned the questionnaire with a median follow-up of 33 months. responders were female in 56% and had a median age of 47 years (p 25 -p 75 32-58). in 51.2% of cases the left side was affected. the median aofas-score was 100 points (p 25 -p 75 87-100), the median vas was 9 points (p 25 -p 75 8-10). in the univariate analysis the aofas and vas score were inversely dependent of the body mass index (r s = -0.409 and -0.305; p < 0.001). patients with known diabetes reported lower vas (p = 0.010) and aofas scores (p = 0.020). female patients reported a lower aofas (p = 0.034). an increase in dislocation (> 2 mm) resulted in a decrease in vas (p = 0.017). no correlations were identified with outcome and which metatarsal was affected, number of fractured metatarsals, fracture type and location, articular involvement, and smoking habits. in the multivariate analysis the bmi correlated with the aofas (p < 0.001) and vas (p = 0.011) and the dislocation with the vas (p = 0.013). conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at 33 months. outcome is dependent of bmi, diabetes, gender, and dislocation at the fracturesite. disclosure: no significant relationships. introduction: incidence of fracture non-union is increased after severe trauma. the systemic inflammatory response syndrome (sirs) resulting from major trauma appears to play a role in this healing impairment. especially the cellular reaction associated with sirs influences the inflammatory response, which is of vital importance in fracture healing. we hypothesize that systemic inflammation may impair healing through an altered interaction between neutrophils and stem-or osteoprogenitor cells within the fracture hematoma. we therefore investigated the effect of neutrophils on differentiation of mesenchymal stem cells (mscs). material and methods: osteogenic differentiation of mscs was assessed using an alkaline phosphatase colorimetric assay on the adhered cell lysate after culturing mscs for 7 days in the presence of different quantities of neutrophils. chondrogenic differentiation of mscs was assessed within the same samples using a glycosaminoglycan colorimetric assay in the cell medium. proliferation was measured within the same samples using a picogreen(r) dsdna fluorescent assay. to assess whether any effect was mediated through release of soluble factors or through direct cell-cell contact, supernatants of stimulated neutrophils were used. stimulation of neutrophils was achieved during 24 h with tnf-alfa. tnf-alfa in the supernatant was subsequently blocked with humira prior to interaction with mscs. results: low neutrophil concentrations resulted in increased alkaline phosphatase concentrations compared to control levels. high concentrations of neutrophils resulted in increased glycosaminoglycan concentrations and decreased alkaline phosphatase concentrations. introduction: angiogenesis is a cue element in the early wound healing and is considered most important for tissue regeneration. in addition to aiding research in understanding the regulatory mechanisms of angiogenesis and vasculogenesis, the concept of co-cultures has helped to better understand the mechanisms of interactions between osteoblasts and endothelial cells focusing on new therapeutic approaches for critical size bone defects. here, we describe in detail the cellular and molecular interaction between human osteoblasts (hob) and human endothelial progenitor cells (epc) in a complex 3d-environment. material and methods: we investigated endothelial differentiation and morphological organization of human epc in cocultures with hob using methylcellulose sphaeroids as well as collagen biomatrices. cocultures of human umbilical vein endothelial cells (huvec)/ hob were used as controls. epc were tracked with cell tracker red, whereas hob were transduced using a lentiviral egfp-vector to allow direct cell visualization using confocal laser microscopy and analysis of cell-specific gene expression. we studied the survival of both cell types and formation of vessel-like sprouts as a criterion of endothelial activity of epc. expression of several relevant angiogenic and osteogenic markers, as well as different extracellular matrix proteins was investigated using quantitative rt-pcr. results: using the hybrid coculture technology we could clearly show that hob regulate the survival, proliferation, and spouting of epcs. concordantly, expression of endothelial cell markers cd31 and vwf was significantly up-regulated by cocultivation with hob. by contrast, epcs did neither proliferate nor did they form any apparent vessel-like structures when cultured in a monoculture. using the lentiviral egfp-reporter transduction method the expression of osteoblast marker genes was also estimated accurately. we could clearly show that epcs inhibit the terminal differentiation of hob by interfering with expression of specific transcription factors runx2 and sp7. in contrast, cell proliferation and expression of the early osteoblastic differentiation marker alp were induced in cocultures. conclusion: in the present study we demonstrate that human endothelial progenitor cells interact with human osteoblasts on the cellular level. we have identified a complex regulatory mechanism which accounts for endothelial cell survival and cell differentiation of both cell types. this study provides new insight into regulatory mechanisms of bone regeneration and may unveil potential applications in bone tissue engineering and fracture healing. introduction: failure of fixation is more common in osteoporotic than in other fractures. early treatment of osteoporosis as well as early stimulation of the fracture healing may improve the later clinical outcome. bisphosphonates are effective in osteoporosis treatment, and bone morphogenetic proteins (bmps) stimulate fracture healing, although several studies show less effect in estrogen deficient models. in order to determine the effect on early fracture healing of bisphosphonates and bmps in osteoporotic fractures, these treatment modalities were applied in estrogen deficient rats. material and methods: fourty rats underwent an ovariectomy (ovx), followed by low calcium diet during six weeks. ten rats underwent a sham operation, followed by normal diet. after six weeks, a closed femoral fracture was induced in all animals. the ovx animals were then assigned to four different groups: ovx alone, injection of bisphophonate, injection of bmp-7 in the fracture gap, or the combination of these. all animals received a normal diet after the fracture. after sacrifice at two weeks, fracture healing was evaluated using radiographs and four-point bending stiffness andstrength. results: radiographs showed a higher score in the bmp-7 treated animals, with or without the bisphosphonates (p = 0.002, kruskal-wallis test). no delay in healing was seen in estrogen deficiency as compared to the sham group. bending stiffness was higher in the bmp-7 treated groups compared to the others (p = 0.004, kruskal-wallis), as was the strength (p = 0.015, kruskal-wallis). no significant improvement was found by the injection of bisphosphonates conclusion: early fracture healing is significantly stimulated by injection of bmp-7 in the fracture gap in estrogen deficient rats. early treatment with bisphosphonates showed no effect on fracture healing. introduction: traumatic brain injury (tbi) is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly due to humoral factors. however, the pathophysiological mechanism of heterotopic ossification after tbi is still not fully understood. this study investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with tbi. material and methods: blood was collected from 17 patients with severe tbi as well as ten control subjects. primary skeletal muscle cell cultures were isolated from orthopedic surgery patients and characterized using immunohistochemical techniques. proliferation and osteoblastic differentiation were assessed using commercial cell assays, western blotting (for osterix protein) and the villanueva bone stain. results: all serum-treated cell populations expressed osterix after one week. cells treated with serum from both study groups in mineralization medium had increased alp activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks. serum from patients with tbi induced a significant increase in the rate of proliferation of these cells compared to the controls (p < 0.05). introduction: the current gold standard to establish the diagnosis of osteoporosis and to follow the pharmacological treatment is the measurement of the bone mineral density (bmd). with a growing number of predicted fractures due to osteoporosis the expenses for bmd-measurement will increase. it was therefore the objective of this study to determine parameters that possibly allow a laboratory follow-up of these patients. material and methods: since 2008 we operated 166 patients (ø 74.8 y, 84% female) with an osteoporotic fracture (group1). all of them were more than 65 years old and underwent a laboratory screening including the serum levels of vit-d 25-oh, vit-d 1.25-oh, calcium (s-ca), phosphate (s-pho), p1np, b-cross-laps, intact pth, osteocalcin, tsh and sex hormones as far as the urine concentration of calcium (u-ca) and phosphate (u-pho). in vit d 25-oh insufficient patients without treatment a therapy with alandronat 70 lg once a week and daily calcium and vitamin d3 substitution was started. 37 patients (ø 68.3y, 54% female) of the orthopedic department underwent the same screening and served as a control (group2). these patients did not sustain a fracture or relevant surgery within at least 6 months. in a second part we checked the evolution of group1-patients laboratory screening at a 3, 6 and 9-months postoperative interval. results: group 1 and 2 displayed significant differences with regard to s-ca, u-ca, u-pho (p < 0.001), osteocalcin (p < 0.02) and vit-d 25-oh level (p < 0.01). after separating male and female patients significant serum concentration differences of testosteron (p < 0.02) in the male patients and of fsh (p < 0.01) and oestradiol (p < 0.001) in the female patients could be observed. during the follow up at 3, 6 and 9 months we could demonstrate a significant elevation of s-ca (p < 0.001), s-pho (p < 0.03), osteocalcin (p < 0.03) and vit-d 25-oh (p < 0.04) concentration. further we found a significant elevation of fsh-(p < 0.001), lh-(p < 0.02) and testosteron (p < 0.01) concentration as well as a significant decrease of the oestradiol (p < 0.001) concentration. as former studies showed we confirmed by comparing group 1 and 2 a deficiency of vit-d 25-oh, s-ca and an elevation of u-ca in patients with osteoporotic fractures. we could also show a significant difference of the concentration of osteocalcin. by following these blood parameters during treatment we found an improvement or normalization of these differences as a result of the treatment. therefore we believe that vit-d 25-oh, s-ca, u-ca and osteocalcin could serve as follow-up parameters in the treatment of osteoporosis. further our preliminary results suggest that under the treatment there is a decrease of the testosterone level in male patients and a decrease of the fh-and increase of the oestradiol-concentration in female patients which has not been reported in the literature yet. in 20 consecutive cycli an alternating traction of 40 newton was exerted on the subscapularis and infraspinatus, while a continuous force was applied for the supraspinatus. the motion of the tuberosities and the shaft were recorded by 2 high-speed cameras. the following parameters were investigated: failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. results: group 1: cable fixation was significantly more stable for intertuberosity motion and tuberosity-shaft motion. furthermore we found 2 failures for the lesser tuberosity in the suture group. we found no significat difference for the metaphysis-shaft motion. group 2: the greater tuberosity-shaft motion was significantly lower using two cables. all other parameters showed no significant difference. we found no failures. group 3: since the tuberosity-shaft motion and the intertuberosity motion were significant higher using fibre-wire, this series was abandoned after 6/8 pairs. conclusion: cable fixation is significantly more stable than suture fixation for tuberosities in shoulder arthroplasty. double-cable fixation does not improve intertuberosity stability. we found tendencies for an enlarged tuberosity-shaft stability. introduction: the results following prosthetic treatment of primary humeral head fractures present great variability. dissolving of tuberosities leading to dysfunction of the rotator cuff with limited motion, pain and instability are often reported. the short term results on inverse prosthesis on the one hand are promising, whereas scapular notching turns out to be a major problem leading to a high failure rate in the long run. high complication rates are also reported. material and methods: in an ongoing prospective and consecutive multicentre study until today,199 cases with an inverse shoulder prosthesis system are documented. in this series we analyse the results of the cases treated for primary fracture as indication. in all cases the affinis ò fracture inverse prosthesis has been used. this implant was specially designed as a reversed treatment option for selected fracture cases. mechanical and biological notching should be reduced due to the special design features of the prosthesis. patients were asked to describe pain and satisfaction for the injured shoulder one week before the trauma and also to fill in the ases score. the constant score for the healthy shoulder was measured whenever possible. postoperatively constant and the ases score were assessed. the x-rays were evaluated for notching and the healing of the tuberosities. results: from february 2008 until today a total of n = 35 cases (29 females and 6 males) were treated for primary fracture with the fracture prosthesis. mean age at operation was 79.4 years (range 63.4 -95.5). according to the neer classification we treated 28 patients with a 4-part fracture, 5 with a 3-part fracture and 2 cases with a head split fracture. after a mean of 9 months (range 1 -20) the cs reached 55.8 points. active forward elevation was 114.5°and passive 128.4°. the active lateral elevation (abduction) was 108.0°for the active movement and 112.5°passive. the ases score was 68.2 points at the latest follow-up and the value for pain and satisfaction were 1.9 and 7.6 respectively. we found no notching in this series and the tuberosities were judged as anatomically healed in 50% of the cases. we found no difference in the clinical outcome between patients with healed tuberosities compared to the group with non visible tuberosities. postoperatively two complications occurred one fracture of the clavicula and one fracture of the acromion. so far we did not have any luxations or implant disconnections. introduction: the purpose of this study is to evaluate the survival and function of splenic autotransplants using spleen imaging with tc 99m labeled heat-damaged erythrocytes. material and methods: 40 patients with splenic rupture underwent spleen imaging with tc 99m labeled heat-damaged erythrocytes at 1 to 2 months after splenic autotransplantation (early scans); also, 15 of them underwent the same imaging technique at 3 to 6 months after operation (follow-up scans). results: on early scans, splenic autotransplants were faintly and the intensity of radioactivity in autotransplants was lower than in liver. the increase of intensity of tracer accumulation in autotransplants was significant higher on follow-up scans. one week after operation the levels of cd 4 , cd 8 and cd 4 /cd 8 ratio were significantly lower than those of controls and returned to normal 3 months later. conclusion: the spleen imaging with tc 99m labeled heat-damaged erythrocytes is a valuable and effective method for evaluation of the survival and function of splenic autotransplants. , respectively 20/ 17 in the group ''skiers''(59%) and 6/12 in the group ''snowboarders''(50%). the aast grade of injury was: aast 1 1 case; aast 2 11 cases; aast 3 10 cases; aast 4 6 cases; aast 5 1 case. 3 of the 19 ''skiers''(17%) and 6 of the 12 ''snowboarders''(50%) showed a high grade (aast > 3) splenic injury. 8 patients has an injury severity score > 15 (4/19 skiers and 4/12 snowboarders): 2 cases of severe brain injury, 2 case of associated liver injuries, 3 cases of associated left renal injuries. 1 patient had associated colonic and pancreatic injury. four patients were not stables at admission and had immediate laparotomy with 3 splenectomies. 25 patients were elected for nonoperative management. results: 6 splenectomies was performed with a splenic salvage rate of. 79%. there was no mortality and morbidity was 15%. for thr three patients who had immediate splenectomy the recovery was uneventfull. in te group nonoperative management three patients had angioembolization and four had delayed laparotomy (3 for delayed splenic rupture at post injury 4,5 and 9 resectively; 1 for sirs). in the 26 patients with availables data, mean hospital stay was 10 days (3-88), 7.7 days (3-88) for the group skiers and 12-25 days (5-47) for the group snowboarders. 14 patients(54%) were recovered less than 10 days. 16 patients were admitted initially in icu ward(from 1 h to 46 days). conclusion: ski accidents are in cause for more the one-third of all splenic injuries admitted to grenoble university hospital. the mean age is lower and male incidence is higher than splenic injuries admitted for others causes (road traffic accident, falls, other mountain accidents). an high number of snowboarder's' accidents was observed and pattern of injury is poor in these patients. the incident of polytrauma cases was the same in two groups and this observation confirm that snowboard practice is at higher risk than skiing for severe splenic injuries. in france, if number of raod traffic accidents is decreasing, the number of sport accidents is imcreasing in the last years. a better comprehension of mechanism, epidemiology and hystological findings of splenic injuries resulting from skiing and snowboarding is necessary to improve trauma preventiin programs. introduction: management of splenic injuries has evolved over the past three decades. prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of the concern about ongoing hemorrhage and/or missed intraabdominal injuries. in children the nonoperative management (nom) of splenic injuries rapidly gained interest because of the significant incidence of post-splenectomy sepsis as well as the complications associated with non-therapeutic laparotomies. the last decade has witnessed a proliferation of reports of nom in adults with injuries to the spleen. inclusion criteria for nom in adults, which have been a source of controversy, continue to evolve. moreover we noted that most publications focused on isolated splenic injury and not on patients with multiple injuries. this study was conducted to summarize the indications for the nom of blunt splenic injury with special attention to the multiply injured patient. material and methods: we conducted a medline search. the search was designed to identify english language citations between 1974 and 2009: using the keywords: blunt splenic injury, conservative management, multiply injured patients and blunt abdominal trauma. the bibliographies of the selected references were examined to identify relevant articles not identified by computerised search. one hundred articles were identified. a cohort of three trauma surgeons selected 50 articles for review and analysis. we used the methodology developed by the agency for health care policy and research of the united states department of health and human services to group the references into three classes. reviewing all data showed that the nom of blunt splenic injury is a save treatment modality in isolated cases but also the multiply injured patient. conclusion: currently the non-operative management of blunt injury to the spleen is the treatment modality of choice. important is a haemodynamically stable patient, with no signs of peritonitis on physical examination. patients who only maintain their blood pressure by the constant infusion of crystalloid or blood products are not haemodynamically stable and need surgical intervention. ct scan findings and grade of injury are not, in themselves, criteria for laparotomy. these criteria are applied to isolated injuries to the spleen but can also be applied to the multiply injured patient. age itself is not a contraindication. the general condition of an individual patient needs to be decisive. and finally hospitals with a low trauma incidence can safely use these guidelines in their management protocol. introduction: the treatment of trauma patients with solid organ injury has changed over the last 15 years towards a less invasive treatment. still our algorithms especially in dealing with trauma patients with ongoing internal abdominal haemorrhages is still based on fast control en stopping of the bleeding by any means. the use of ct-abdomen and subsequent performing angiography and embolization takes time. we analyzed the time path involved in angiographic control of the bleeding spleen. material and methods: a retrospective study. the study group consisted of ten patients presenting at our institution with a traumatic spleen injury in the period november 2006 till november 2008. all patients were managed according to the principles of atls. data were analyzed using spssò 16.0. results: the study group consisted of seven men and three women. average age was 25 years (range 15 till 39). the iss was on average 26 (range 20 -40). all patients in the study group received an angiography after ct-abdomen which showed an active bleeding focus in the spleen. organ injury score were eight grade 4 and two grade 3 spleen injuries. average time from admission to angiography was 139 min. time to control of bleeding by embolization took average 50 min. time loss between ct and angiography was on average 88 min. conclusion: the time paths involved in managing this group of trauma patients with spleen injuries by embolization are much longer than expected. the time involved after diagnoses to actual control of the bleeding spleen injury is much longer than anticipated. logistic changes to limit the time loss in interpretation of data from the ct-a, transfer of the patient, preparation of the angio-suite and less time consuming technique to actual embolization are needed. articles were eligible if they reported the failure rate of nom with or without angio-embolization (ae) in pediatric patients with splenic and/or liver injuries with a contrast blush on ct and included two or more trauma patients. two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. interrater differences were resolved by discussion. results: nine studies were included describing 117 pediatric patients. the median sample size was five (range 2-44). seven studies (including 71 patients) reported a total of 16 patients with failure after nom without ae. failure rates across these studies ranged from 4.5 to 100%; the pooled percentage was 28.2% (95% ci: 8.9%-61.3%). the failure percentages after nom with or without ae ranged from 0 to 100%; the pooled percentage was 21% (95% ci: 7.5%-46.8%. two studies (including 46 patients) reported a total of 3 patients with failure after nom with primary ae: a percentage of 6.5%. conclusion: despite the current low level of evidence on failure rate of nom when a contrast blush is present on ct we emphasize that there is a significant amount of patients in whom nom fails. we therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiological response but also when a contrast blush is present on ct. results: primary blast injury: this form of injury results from the deleterious effects of the blast wave passing through the body. these waves have little or no effect on solid organs but have their major destructive potential in air containing organs, especially lungs. secondary blast injury refers to the impact on a patient's body of projectiles usually inert. the addiction of destructive metal fragment, nails and other such objects to bombs increase the severity of injury and lethality. tertiary blast injury refers to the deceleration and impact with the ground, wall or other inanimate object of the patient whose body is displaced by the blast. quaternary blast injury refers to the miscellaneous forms of injury by-products of explosions, burns, inhalation of dust, contamination in case of ''dirty bombs'' or penetration of allogenic body parts shrapnel. this last one asks the question of contamination by hepatitis or hiv and modalities of surveillance and treatment. conclusion: blast injuries are complex and require the expertise of surgeons for their evaluation, treatment and longterm recovery. the victims of this form of terrorism sustain unusually severe and complex multidimensional forms of trauma not typically encountered in routine surgical practice. surgeons must be leaders and active participants in disaster planning and management; they are uniquely qualified to manage the physical trauma that results from most forms of mass casualty events, including blasts. disclosure: no significant relationships. a. s. dogjani 1 1 general surgery, military university central hospital, tirana, albania introduction: as the risk of terrorist attacks increases in the world, disaster response personnel must understand the unique pathophysiology of injuries associated with explosions and must be prepared to assess and treat the people injured by them. the explosions at the army depot in gerdec village, some 10 km north of tirana, were heard more than 50 km (30 miles) away. introduction: during the last decades there is a debate concerning the fact if the facial fracture can cause further damage or somehow to protect the brain parenchyma from a more severe injury. the aim of our study is to analyze the effects of facial trauma exerted upon brain parenchyma. material and methods: a series of 500 patients with craniofacial fractures was studied. the injuries were separated into five grades of severity based on neurological examination including cranial ct. the injuries was also grouped into three categories based of facial regional involvement ct -facial reconstruction results: the control group included 383 patients with head trauma but without any facial fracture or brain injury. in group a included 82 (16,4%) patients with both facial fracture and brain damage.among them 30 diagnosed with temporal-mandibular fractures accounting for 36,5%, 6 patients(7,31%) had lower mandibular fracture, 34 patients (41,4%) diagnosed with nasal fractures and 12 patients (14,6%) had orbital fractures. in group b were categorized 35 patients with only brain damage accounting for 7%. conclusion: the data demonstrated that patients with upper facial fractures were at greatest risk for serious closed head injury (chi).injuries to both the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild chi with a modest likelihood of no neurological deficits. trauma to only the mandibular region or to only the midfacial region was least likely to involve chi disclosure: no significant relationships. introduction: post-traumatic stress disorder (ptsd) is a psychiatric disorder that results from exposure to a traumatic event. the individual may develop symptoms of three distinctive types: intrusive and unwanted recollections, avoidance followed by emotional withdrawal, and heightened physiological arousal. people who are exposed to traumatic events may also have somatic symptoms and physical illnesses, particularly hypertension, asthma and chronic pain syndromes. hospitalized victims of suicide terror attacks are unique due to the circumstances and severity of their injuries which could have possibly affected the occurrence of ptsd and delayed the recognition of ptsd development. our objectives were to evaluate the prevalence and severity of ptsd among hospitalized victims of suicide bombing attacks and to assess variables of physical injury as risk factors for the development of ptsd. material and methods: forty-six hospitalized victims of suicide bombing attacks were evaluated for ptsd using the pss-sr questionnaire by phone. demographic and medical data considering the severity of injury, type of injury and medical treatment were collected from the medical files. injury severity scale (iss) was used to assess severity of physical injury. results: the prevalence of ptsd among hospitalized victims of suicide bombing attacks was 52.2%. presence of blast lung injury was significantly higher in the ptsd group compared with the non-ptsd group (37.5% vs. 9.1% respectively, p < 0.04). there was no significant difference in iss values between ptsd and non-ptsd groups. blast lung injury and intracranial injury were found to be predictors of ptsd (odds ratio 125 and 25, respectively). no correlation was found between length of hospital stay, length of icu stay or severity of physical injuries to the severity of ptsd. conclusion: hospitalized victims of suicide bombing attacks are considerably vulnerable to develop ptsd. they should be evaluated with a high level of suspicion in order to identify ptsd symptoms and treated as soon as possible in conjunction with physical treatment. blast lung injury and intra cranial injury are predictors of ptsd. victims suffering from these conditions should be monitored closely and treated in conjunction with their physical treatment. conclusion: from the use of the smart adopted for the evaluation of the code of entrance in emergency department, we have deduced and confirmed the facility and the speed of use of this new model of triage. the triage smart typically holds not only besides in consideration the traumatic pathologies but also internists that, it is an usable advanced triage both on the territory and in the hospital. we can classify the model smart triage as a valid system in case of a disaster as is reliability and sensibility of assessment of patients result to be more appropriates in comparison to the other models of triage taken in examination. conclusion: we showed that alcohol, massive bleeding needed blood transfusion and age were risk factor of trauma and japanese emergency medical technician attendance was effective for trauma care. we suggested the reason of detachment by the injury form was that japanese penetrating wound include many stub wound not gun shot wound. introduction: rapid aging of japanese population is causing numbers of emerging problems in trauma patients care which consists of trauma in elderly people and increased pre-existing co-morbidities such as cardiovascular diseases, neoplasms and organ failures. nevertheless, little is known about the relationship between co-morbidities and trauma. the aim of the study was to clarify the influences of co-morbidities on the trauma mortality, using data from the japan trauma data bank (jtdb), a multicenter, nationwide and prospectively recruited trauma registry in japan. material and methods: we selected the records from jtdb which fulfilled the requirements to estimate trauma injury severity score (triss) system. logistic regression analysis after adjustment for baseline trauma severity based on triss system assessed the risk of in-hospital trauma death for following co-morbidities: hypertension (ht), diabetes (dm), psychotic disorders (pd), dementia (de), stroke (st), chronic obstructive lung diseases (cold), bronchial asthma (ba), coronary diseases (chd), congestive heart failure (chf), liver cirrhosis (lc), chronic hepatitis (ch), chronic renal failure on dialysis (crf) and active cancer (acn). we conducted a couple of analysis which were adjusted or unadjusted by age in consideration for confounding between co-morbidities and elderly in age. introduction: monitoring the quality of trauma care is frequently done by analyzing the preventability of trauma deaths and errors during trauma care. in the academic medical center traumatic deaths are discussed during a monthly morbidity and mortality meeting. in this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a dutch level-1 trauma center for (potential) preventability. material and methods: all patients who died during or after presentation in the trauma resuscitation room in a two year period were eligible for review. all information on trauma evaluation and management was summarized by an independent physician. an external multidisciplinary panel individually evaluated the cases for preventability of death. disagreements in classification were resolved during two consensus meetings. potential errors or mismanagements during the admission were classified for type, phase and domain. overall agreement on (potential) preventability was compared between the panel and the amc consensus. results: of the 62 evaluated trauma deaths one was judged preventable and 17 were judged as potentially preventable by the review panel. overall agreement on preventability between the review panel and the amc consensus was moderate (kappa 0.51). the classification of the panel was more favourable than the amc consensus. the interobserver agreement between the review panel members was also moderate (kappa 0.43). the panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. most frequently mentioned errors were related to choice or order of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. conclusion: the preventable death rate in the present study was comparable to the available literature. external review does not seem necessary to improve our current internal reviewing system. however, multidisciplinary reviewing of our trauma deaths provided us potential insights to optimize trauma care. disclosure: no significant relationships. arab emirates (uae). the aim of this paper is to report on the long term effects of our early analysis of this registry. material and methods: data in the early stages of this trauma registry were collected for 503 patients during a period of 6 months in 2003. data was collected on a paper form and then entered into the trauma registry using a self-developed access database. descriptive analysis was performed. results: most were males (87%), the mean age (sd) was 30.5 (14.9). uae citizens formed 18.5%. road traffic collisions caused an overwhelming 34.2% of injuries with 29.7% of those involving uae citizens while work-related injuries were 26.2%. the early analysis of this registry had two major impacts. firstly, the alarmingly high rate of uae nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. second, the equally alarming high rate of work-related injuries led to collaboration with a preventive medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention. conclusion: analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention. disclosure: no significant relationships. as a result of injuries related to skating on natural ice. we analysed epidemiological aspects, diagnostically examinations, prevalence of injuries per anatomical location as well as the necessary therapeutic interventions and costs for national health services. results: injuries related to skating on natural ice accounted for 47% of all 259 attendances. the mean age for man and women did not significantly differ (43,2 and 42,5 years resp.; p < 0.05), but adults aged 41-60 years are more prone to injuries. women were affected in 60%. radiological examinations were requested in 94% (87% xrays; 7% ct-scans). the upper extremity was affected in 75%, with the wrist accounting for 64% of those injuries. fractures accounted for 79% of all ice-skating related attendances. an operative therapy was indicated in 23%. the mean costs for national health services were e1416 per patient. conclusion: fractures, especially those of the upper extremity, were the predominate type of injury as a consequence of collectively performed skating on natural ice. this incidence is >2 times higher compared to fractures occured during skating on artificial ice-rinks [2] . wearing wrist guards is an effective tool in protecting skaters against injuries. we recommend wearing wrist guards during skating on natural ice [1, 4] . especially (employed) adults aged 41-60 years are very prone to injuries resulting in a high loss of work days [2] . in contrast to children, adults might be more accessible for wearing protectors [3] . in future it seems reasonable for national health services to provide steps to increase public awareness on the benefits of prophylactic safety measures. this might result in a substantial reduction of costs for health care and society. introduction: liver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. we therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients. material and methods: using the multi-center population-based trauma registry of the german society for trauma surgery, we retrospectively compared outcome in patients (iss > = 9, > = 18) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis means were compared using student's t-test and analysis of variance (anova) and categorical variables using chi 2 (p < 0.05 = significant). results: overall 13,527 patients met the inclusion criteria and were, thus, analyzed. 713 (5.3%) patients had a documented alcohol abuse and 91 (0.7%) suffered from liver cirrhosis. patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. more specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted (31% vs. predicted 19%) and increased single-and multi organ failure rates. while alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality. of note, alcohol abuse significantly decreased 24-hour mortality. conclusion: patients suffering from liver cirrhosis are at maximised risk for impaired outcome after multiple injuries. pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile. introduction: early in-hospital treatment of severely injured patients has been internationally standardized by the implementation of algorithms such as the atls ò -concept. however, due to lack of time, the instability of the patients and the complexity of injuries, there is a risk that some lesions will be missed at this stage. the purpose of our study was to evaluate the incidence and significance of these missed injuries. material and methods: retrospective chart analysis (in-hospital and follow-up as outpatient) of data prospectively collected via an accessò-based documentation system was performed. missed injuries were determined as injuries not found during primary and secondary survey. introduction: complication registration is important for monitoring the quality of health care. aim of this article was to describe the incidence, type and impact of complications occurring within 6 months after the initial trauma in multitrauma patients. second, we assessed potential risk factors for the occurrence of complications. material and methods: during a 2-year period all trauma patients presented to the academic medical center and having an injury severity score of ‡ 16 were included. patients who were directly transferred to other hospitals were excluded. we used the prospective dutch national surgical complication registry of the amc, a level-1 trauma center, to assess complications within 6 months after the initial trauma. for verification we additionally performed a chart review and searched the decubitus specialists-and icu registration. complications were graded 0 (no real health loss) to 4 (lethal). identification of risk factors associated with an increased risk of complications was performed by univariate analysis. we also analyzed an autopsy findings of these patients and found that 7 of 19 (36.8%) had a difference between clinical and autopsy iss. the most frequent missed injury were rib fractures. six of these 7 patients were hospitalized in a period when we did not use msct routinely in multiple injured patients. conclusion: triss is not a clinical prognostic tool but is used retrospectively for clinical and epidemiological research, performance evaluation, and resource allocation. it is required as a basis for quality assessment and improvement. in combination with autopsy findings, triss methodology can be an valuable tool for recognition of unexpected trauma deaths and further analyze of possible treatment errors. patients had to be operated 5,3 times and were treated 23 days in the icu and stayed 73 days in hospital. mortality rate was 36% and rate of multi-organ failure 28%. 15% demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. 25% recovered well or at least moderately. 29 out of 56 survivors answered the polochart. a personal interview was performed with 13 patients. the state of health was at least moderate in 72% of patients. in 48% interpersonal problems and in 41% severe pain was observed. in 57% problems in working ability concerning duration, as well as quantitative and qualitative performance were observed. symptoms of post-traumatic stress disorder were found in 41%. the more distal the lesions were located (foot/ankle) the more functional disability affected daily life. in only 15%, working ability was not impaired. 8 out of 13 interviewed patients demonstrated complete work disability. conclusion: even severely injured patients after polytraumatization have a good prognosis. the iss is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. introduction: one of the most common cause of preventable deaths in severe trauma is represented by delay in diagnosis and treatment of injuries, therefore a good teamwork aimed to reduce time consumption and errors is essential. there is in fact good evidence that the outcome of trauma care depends on effective trauma team performance (ttp). critical points during trauma management are represented by lack of leadership, information sharing, difficult communication and decision making. to improve ttp, advanced simulators with full scale realistic patients (1) and trauma crew resource management (crm) educational programmes are increasingly being used. material and methods: we made a survey among health care professionals (hcp) from 9 different level i and level ii trauma centers in the milan area that confirmed that difficulties in communication and conflictual behavior during trauma action is perceived as a barrier to ideal management. after a focus group interview to establish the need to improve performance we tested in our hospital a tailored trauma teamwork course using an advanced human patient simulator. the peculiarity of this course is the recreation of the same location of the trauma bay using same trauma team components and teamwork laboratory conducted by a professional coach as facilitator for the teamwork. this role is particular important since with this facilitation hcp can reach the awareness of wrong attitudes that lead to errors and bad performance. in particular, the tasks of the facilitator were the following: to help people understand their common goals to assists the trauma team to plan to achieve common goals to assist the group in achieving a consensus of any disagreements that preexist or emerge in the meeting so that it has a strong basis for future action a second survey few months after the course was made among hcp of our institute to evaluate the possible improvement of the ttp. results: the second survey confirmed a perceived benefit among hcp who started to work in a proactive manner. in particular 78% of hcp reported the feeling of a better ttp and 86% suggested regular practice with advanced simulation. conclusion: integration of a tailored advanced simulation and a facilitator assisted teamwork could be a powerful method to improve quality of treatment in trauma patients. a score index to evaluate the improvement of the ttp during the course and in reality is although needed and is under evaluation. introduction: our university hospital is one of the only two national university hospitals in tokyo and our emergency medial center is one of the busiest emergency center in japan that receives 25 to 30 ambulances per day. japan has a quite unique emergency medical system in the world. in japan, emergency patients are stratified into 3 tiers, minor-primary, moderate-secondary, severe-tertiary. japanese emergency doctor, that is not same as the emergency physician in the usa, take care only for the most severe emergency cases, tertiary level emergency patients. and if they find out the patient who needed an emergency operation, then they do the surgery by themselves. if the patients need to admit to icu, they take care the patient in icu by themselves. this unique system was installed in mid-1970 s. japanese emergency doctors do not only trauma cases, but also nontrauma severe emergency cases. for talking about trauma, they do not only the initial management of trauma patients but also do emergency surgery and trauma critical care. the mou came into effect with the signatures of the appropriate representatives, acknowledging that four courses had been run in portugal prior to its signature and that all future courses would be conducted in accordance with the essential requirements established by iatsic. in practical terms, the first two courses run after signing the mou must be of the form and nature as laid down by iatsic. thereafter, variations as determined by the nsc may be allowed. the slide material will be provided ''locked''. after the two initial courses, the ''unlock'' code will be provided. details of all modifications must be lodged with the iatsic. nsc will be responsible for ensuring the maintenance of high standards in the conduct of all courses and the selection of participants, ensuring that they meet the minimum standards as laid down by iatsic. nsc is entitled to appoint two representatives at international subcommittee meetings. introduction: clinical skills must be to the fore of medical occupation, especially in surgery, where the mastery of basic skills is of great importance for the young learner. the acquisition of basic clinical skills during surgery clerkships has been shown to be inadequate. this work presents an analysis of different teaching methods in a standardized training program for basic clinical skills in surgery. material and methods: the program is part of a four week surgical rotation for 4 th year medical students, consisting of the one-week training program in basic surgical skills and a three-week clerkship on surgical ward. during the skills training, a maximum of 6 students per group rotate through 12 modules. in a randomized study, the effects of different teaching modalities as skills lab, simulation and role play, as well as different teaching methods as four-step-approach, short-lecture, video were tested on their effect on theoretical and practical skills acquisition. results: a total of 60 students participated on a voluntary basis. the theoretical and practical examinations revealed significant differences in the acquired skills comparing the different teaching modalities and methods. the use of video as part of the 4-step approach was effective for training the basic skills such us suturing and wound care. least effective for all skills were short-lectures. conclusion: the choice of teaching modality and method has a significant impact on students' skills acquisition and its long term retention. disclosure: no significant relationships. training in trauma center: where to pay attention to? l. handolin 1 1 traumatology, helsinki university hospital, helsinki, finland introduction: systematic trauma team simulation training was started in helsinki university hospital in 2003. in terms of getting the optimal advantage of training and maintaining the justification of resource allocation, an advantageous balance in various team training principles has to be applied. the aim of the present study was to analyze the standardized written feedback given by trainees after training sessions. material and methods: the study period was three years (2006) (2007) (2008) . the collected data consisted of a subjective self-assessment on the level of knowledge, skills, and team work in traumaresuscitation. also a selfassessment on the effect of training on decision making, communication, skills, team work, and leadership, as well as a general rating of training session were collected. self-assessment was done using five step scoring system from one to five. results are presented as means. conclusion: the actual evaluated interspinous devices led to a significant reduction of rom during flexion-extension, but to a significant increase of rom for the whole specimen (l2-l5) during lateral bending and rotation, which increases the risk of adjacent level degeneration. therefore the decision for the optimal individual treatment should be made on the knowledge of the biomechanical effect of each device and the underlying disease of the patient's symptoms. introduction: gait analysis is a powerful tool to monitor the degree of convalescence in fracture care after fracture fixation and during bone healing. because of the availability of a large array of monoclonal antibodies and gene-targeted animals, the mouse has become the preferred species for molecular studies on fracture healing. of interest, gait analysis after fracture fixation and during the bone healing process has not been performed in mice yet. we present a novel technique for dynamic gait analysis in mice and report the change of motion pattern after femur fracture and fixation. materials and methods: all animal procedures were performed according to the national institute of health guidelines for the use of experimental animals and were approved by the german legislation on the protection of animals. ten cd-1 mice were divided into two groups: fracture group (n = 5) and control group (n = 5). all mice were anesthetized by an i.p. injection of xylazine (15 mg/bw) and ketamine (75 mg/bw). a standardized closed midshaft fracture according to ao-classification a2-a3 was stabilized by a common pin. the non-fractured tibia was additionally marked with a pin, allowing a measurement of the tibio-femoral angle by a digital videoradiography system recording 30 images/s. for the control group, one pin was inserted into the femur and one into the tibia without producing a femoral fracture. dynamic gait analysis was performed at day fourteen after surgery in a x-ray compatible running wheel and the following gait parameters were determined: the minimum and maximum tibio-femoral angle, the stride frequency, the stride time, the stride length and the stride velocity. eighteen representative strides per mouse were analyzed. all measurements were done using osirix imaging software and the open source program imagej. all data are given as means ± standard error of the mean (sem introduction: single distal locking screw insertion had been accepted as an option in clinical practice of femoral nailing. however, effect of number and location of the screw on rotational stability of the construct was still doubtful. therefore, this experimental study was conducted to compare rotational stability of the femoral nail construct among three different conditions (two distal screws, single distal screw in different locations). materials and methods: eight right femoral sawbones were selected for this study. each of which was implanted with gk femoral interlocking nail (11 · 400 mm) and a static proximal locking screw follow by single distal screw insertion in the most distal screw hole. then, transverse osteotomy was performed at the mid-shaft to simulate simple fracture. after the femur was stabilized on the custom holding jig, rotational force was applied to the femoral condyle by using a torque wrench connecting to the distal part of the jig starting from 2 to 8 nm in 2 nm increment. total rotational angle in each situation was measured by modification of navigation system. thereafter, testing protocol was repeated to the same specimen but two distal locking screws and single distal locking screw in the most proximal screw hole, sequentially. different angle in each testing condition was compared among the different constructs by using paired t-test. results: rotational stability was significantly better in the group of two distal locking screws in every testing condition (p < 0.05). single distal screw in the most proximal screw hole provided more rotational stability than that in the distal screw hole at 8 nm (p = 0.003). conclusion: this study demonstrated that two distal locking screws provide more rotational stability than single screw in the case of simple mid-shaft femoral fracture stabilized with interlocking nail. if single distal screw was considered, insertion in the most proximal hole would be a better option in term of rotational stability than that in the most distal hole. introduction: the exothermal reaction of pmma leads to an extensive interaction between the bone cement and the plastics of the application system. this chemical reaction changes the structure of the bone cement and especially makes air pockets. it is necessary to develop application systems with a special composition of the plastics so that there is no interaction between the cement and the application system. in this study a new application system is presented for the first time which does not interact with the bone cement. materials and methods: two different application systems for bone cement were tested in this study. one popular and frequently used system made of polyethylene and a new system made of polypropylene. a special testing unit, in which the application systems were mounted, was used. the testing unit worked with a certain pressure so that a defined amount of bone cement was injected. the resistence data and the time were digitally collected and statistically evaluated. in all 60 procedures were carried out. after the injection all application systems and the injected bone cement were microscopically analyzed. results: two groups, old versus new application systems, were divided. both groups showed significant differences. when using the old application systems made of polyethylene the time frame for injection of the cement was 4 min while the time frame with new system made of polypropylene was 10 min. microscopically there is a significant interaction between the plastics and the cement in the old systems with massive air pockets. in contrast there is no interaction, no air pockets and a homogeneous pattern of the cement when using the new systems. conclusion: the new application system made of polypropylene showed a significant longer time frame for application of the cement as well as no interaction with the plastics. it is possible to treat more than one localization with one application system which makes it financially rewarding. additionally there are no air pockets reducing the danger of infection und increasing the structural stability of the bone cement. introduction: femoral neck fractures are common fractures. despite the frequency of this fracture and the consequences associated with it, little is known about the functional changes that can be expected during and after rehabilitation. the aim of this study was to identify prognostic factors for functional outcome, using a modified harris hip score, after a femoral neck fracture treated with an arthroplasty. materials and methods: we included 252 patients who sustained a displaced femoral neck fracture treated with an arthroplasty. functional outcome after surgery was assessed using a modified harris hip score, and was evaluated after 1 (hhs1) and 5 (hhs5) years. we analyzed the following prognostic factors for functional outcome of patients after treatment of femoral neck fractures with an arthroplasty: age, pre-operative co-morbidity, asa-score, type of arthroplasty (hemi-or total hip replacement), surgeon experience (resident or attending surgeon), interval between trauma and operation, blood loss, direct (associated with the arthroplasty) peri-and post operative in-hospital complications related to the arthroplasty and general post operative in-hospital complications. to challenge the outcome of the analyses we used the cronbach's alpha coefficients for testing the internal consistency. results: after one year the existence of co-morbidities ( ‡ 1) was a significant predictor for a poor functional outcome. with and without co-morbidities the mean hhs1 was 71.8 and 80.6, respectively. after 5 years all potential prognostic factors did not have significant influence on the functional outcome. to further analyse this outcome, internal consistency of the hhs was assessed. when pain and function of the hhs were analysed together the internal consistency was poor (hhs 1: 0.38 and hhs 5: 0.20). the internal consistency of the harris hip score solely in function (without pain) improved to 0.68 (hhs1) and 0.46 (hhs5). when the potential prognostic factors were analysed with only the functional aspect, age and the existence of co-morbidities could be defined as a predictors for the functional outcome of femoral neck fractures after 1 and 5 years (r 2 24 and 19% resp). conclusion: pain has such a dominant position in the harris hip score that even immobile patients without pain can obtain a reasonable hhs score. the hhs, with the omittance of pain, is therefore a more reliable score to estimate the functional outcome. after using the hhs in this modification, age and the existence of preoperative co-morbidities appeared to be predictors of the functional outcome after 1 and 5 years. many studies have shown that delay to theatre beyond 48 h has an associated increased risk of morbidity and mortality in this cohort. our data revealed that there is certainly room for improvement regarding treated more patients within the 24 h guideline however, there will always be a group of patients whom medical input is required prior to surgical management. lack of theatre time appears to be a significant administrative reason for delay. this is an area of potential improvement however it must be noted that any system of this nature will carry an intrinsic delay in processing. . x-rays and post-op data were analyzed on displacement, postoperative reduction, loss of reduction, and avascular necrosis (avn) and revision rates. high volume surgeons were defined as surgeons who performed > 10 fixation procedures for proximal femoral fractures annually. results: mean age (72 vs. 70 years) and percentage of fracture displacement (55 vs. 58%) were equal in both groups. re-operations following loss of reduction or infection was seen in 21 (17%) patients. less frequent complications were avn (8%), coxarthrosis (2%) and pain due to screws bulging out (6%) led to a total conversion rate to arthroplasty in 33%. displaced fractures show a higher rate in loss of reduction (27%, p < 0.05) and revision (40%, p = 0.05) than non-displaced fractures (3.7%; 20.4%). patients > 70 years showed 19% loss of reduction, 14% avn and taking the reoperations due to coxarthrosis and pain into account, a total revision rate of 40% was seen compaired to 16, 5, and 29% in younger patients. radiological analyses revealed that the lack of medial support lead to revisions in 52% of the cases, dorsal angulation in 50%. low volume surgeons did not perform worse than high volume surgeons. the latter group showed 19% loss of reduction, 14% avn and total revision rate 40%, compared to 16, 5 and 29% in the low volume group. we found no differences in the outcome of treating displaced fractures. conclusion: the outcome of fixation of femoral neck fractures is poor. especially displaced fractures, inadequate fracture reduction and high age were associated with poor outcome. therefore, arthroplasty should be considered in patients older than 70 years with displaced fractures that cannot be reduced anatomically. we could not demonstrate that high volume surgeons performed better in this group but we are convinced that further specialization of care is mandatory to improve results of this unsolved fracture. (1) (2) (3) (4) . internal fixation has shown to provide minor results. the majority of these patients are therefore treated by a hemiarthroplasty of the hip. since the primary goal is to regain the pretraumatic level of mobility as soon as possible(3;5), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss (6), postoperative pain(7;8) and thus postoperative mobility (9) . material and methods: in a randomised controlled trial, 48 patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within 72 hours after trauma(10). apart from parameters like age, asa-score or body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. all data collected were compared between groups to detect statistical significant differences. additionally the same parameters were checked for significant differences comparing patients with or without complications within their group. results: a significant difference between groups was found for postoperative pain within the first 72 hours and for operation time, both to the disadvantage of the minimal invasive approach group. within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at 48 hours was rated higher in patients with complications in the lateral approach group. these results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up. conclusion: despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. still, the operation time was significantly linked to postoperative complications. in this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results. of the 512 patients, 350 (68.3%) received a formal assessment for antiresorptive therapy. the outcomes of this assessment is as follows: 4.6% did not require any antiresorptive therapy, 0.9% awaiting bone clinic assessment on discharge, 5.4% awaiting a dexa scan, 73.7% of patients were started on antiresorptive therapy and 14% were continued on antiresorptive therapy from pre-admission. conclusion: our study highlighted that in our trust only 68.3% received this assessment formally. we can conclude that when this assessment occurs the guidelines and hence subsequent fragility fracture secondary prevention is addressed. we have then presented this data locally and amended our integrated neck of femur documentation pathway to include a section on antiresorptive therapy assessement. to follow this up we plan to re-audit from 1st january 2010 to 1st january 2011. in the upper thoracic spine 216/297 (73%) could be placed with navigation, 157/297 (53%) were controlled intraoperatively. occasionally, scan-setup was problematic, in addition, we experienced technical problems. correct placement was seen for each screw, thus correlating well with theintraoperative findings. conclusion: the application of the combination of intraoperative 3d-imaging and navigation for posterior instrumentation of the cervical and the upper thoracic spine is technically feasible and reliable in clinical use. user-and software-dependant sources of error could be solved during the first course of the series. image-quality at the cervical spine is depending on individual bone density, and possible metal artifacts. with undisturbed visibility of the vertebral body, the reliability of 3d-based navigation at the cervical spine is comparable to that of ct-based procedures. additionally, it has the advantage of skipping preoperative acquisition of data as well as thematching-process. furthermore, exposure to radiation is reduced due to the possibility of sparing pre-and postoperative ct. disclosure: no significant relationships. the average lka measurements in order were: 12.63°, 0.21°, 6.92°( p < 0.001), and for aca: 14.13°, 5.83°, 6.25°(p < 0.001). while a significant difference between the averages of lka, e/f of group 2 and group 3 (p < 0.05), no statistical difference was found comparing the average aca angle (p = 0,753). while there was no significant change in e for all groups (p > 0.05), the increase in f after surgery was considered significant (p < 0.05), and no difference was observed between the averages of group 2 and group 3 (p > 0.05). vas was 2.73 (0-5). conclusion: at the end of an average 8 year follow up period of posterior tl fractures no difference was found between the early and late period measurements of aca and anterior height although lka showed a statistical loss in height the correction degree achieved in the late period was found to be significantly higher than preop. (8 cases), crushing without skeletal injuries (4 cases) in all these cases, pulse was present at the first evaluation, and the onset of acute post-traumatic ischaemia was at 8-49 hrs after trauma . tha diagnosis, based on clinical suspicion, became definite after doppler evaluation and arteriography. the anatomical base of ischaemia was late thrombosis (42 cases) and compressive hematoma (4 cases). thrombosis was due to obstruction of the big arteries (39 cases) and microcirculation, due to overrun compartment syndrome-3 cases.vascular restoration and fasciotomy was performed whenever muscles were viable, but amputation was necessary in 3 cases results: the patients were analysed from the point of view of the corelation between the moment of onset of the ischaemia, the type of injury, the status of the muscular structures, the algorithm of diagnosis, the type of the treatment, and the clinical outcome. the study revealed that the clinical outcome was better when the time between trauma and ischamia onset was less, since the muscular ischaemic had less time to develop. in the same time, there were 4 cases in which clinical symptomes were not corresponding to the imagistic evaluation. conclusion: high energy trauma affect all the structures of the limbs. clinical suspicion has particular importance especially when trauma affects one of the regions which is known as establishing a dangerous environment between the arteries and the bones / joints. in all the cases that authors analyse, complete and early diagnosis and treatment of acute post-traumatic ischaemia, based on the close monitoring of the patient and '' clinical alarm signs '' seemd to be the conditions for the favourable outcome of the patients. introduction: the aim of presentation is to demonstrate the surgical treatment and postoperative period of a patient who was caught on a fence-pole and suffered severe injuries of perineal region and lower extremity. material and methods: after a long time of technical rescue the patient arrived to our department with a one meter long portion of fence in his perineal region. after the urgent extraction of metal fence we performed an intraoperative rectoscopy. during the debridement and exploration of deep perineal injuries we realised a heavy swelling around the punctated wound of the left leg. we made a femoral incision and exploration and recognised the several injury of the femoral vein and artery. we provided the 4 cm long injuries with stitches. results: in the postoperative period we made a second-look and debridement because of lymhphatic retention and small skin necrosis around the incision. no real vascular or circular lesions were recognised during the control period of the patient. injuries were totally improved. conclusion: the edification of this case is that it's never sure that the major wound makes the biger trouble to the patient or to the surgeon. in our presentation we plan to demonstrate the intra -and postoperative pictures and the results of controll period. results: the incidence of various types of trauma were blunt in 13 patients (31%), gunshot wounds in 3 patients (7%), and stab wounds in 26 patients (62%). only 15 (36%) patients were hemodynamicaly stable. isolated abdominal vascular trauma was detected in 9 patients (21%). vessels injured included aorta 1 (2,4%), inferior vena cava 7 (16,6%), named visceral arteries 2 (5%), named visceral veins 8 (19%), iliac arteries 1 (2,4%), and iliac veins 1(2,4%), epigastric, hypogastric, intercostal arteries 6 (14,3%), epigastric, hypogastric, intercostal veins 2 (5%), gonadal vessels 2 (5%), renal veins 3 (7%), non-named mesenteric vessels with segmental bowels necrosis 14 (33,3%). two or more vascular injuries were found in 6 (14,3%) patients. according to organ injury scaling, 1 st grade injuries were found in 17 (40%), 2 nd -in 11 (26%), 3 rd -in 8 (19%), 4 th -in 5 (12%), and 5 th -in 1 (2,4%) patients. the most frequent associated injuries were small bowel -12, liver -8, colon -5, stomach 4, duodenum -4, diaphragm -3, pancreas -2, spleen -1, with an incidence of 29%, 19%, 12%, 9,5%, 9,5%, 7%, 5% and 2,4% respectively. all injuries were managed according to injury score. infrarenal v. cava ligation was performed in all cases of hemodynamic instability. minor named abdominal vessels were ligated in all cases. segmental intestinal resection was performed in all patents with 5 th grade of intestinal injuries due to devascularisation. overall mortality rate was 21%. the vessels with the highest mortality rates were inferior vena cava (71% -5/7). there were no mortalities in isolated abdominal vascular trauma patients and in cases of 1 st grade of injury. mortality rate in accordance to ois was: 2 nd -3 patients (27%), 3 rd -3 patients (37,5%), 4 th -2 patients (40%), 5 th -1 patient (100%). no differences in mortality rate were found according to type of trauma (blunt or penetrating). the associated injuries with the highest mortality rates were pancreas (2/2 -100%), diaphragm (2/3 -66,6%), liver ( (8), a rupture of the heart (4) or a aneurysma dissecans with a rupture of the aorta (3). in addidtion to the detailed forensic examination and autopsy, we took the anthropometrical measurement of all corpses in 3 dimensions, so that we were able to create a biomechanical simulation of the accidents with ''finite element models''. there the shear forces affecting the aorta can be calculated. as three forces (frontal impact, side impact and deceleration) are the most important, we will present three comprehensible example accidents. the reason of death is always the ''aortic rupture'', but every time the biomechanical way of application of the force was completely different. in detail they are a car accident (frontal collision of a small car with a wall); a downfall from the height of 25 meters in suicidal purpose and a compression of the thorax of a eight year old boy with a shovel of an excavator. results: although all three accidents have completely different course of crash, we were able to see the same reason for death: a rupture of the aorta at the onset of the ligamentum arteriosum botalli. by using the numerical simulation, it can be shown that three main directions of force are important in an accident: the frontal impact, the side impact and the deceleration. in all these examples, it was able to simulate the reaction of the aorta in relation to the development of the force. the simulation will be presented as well as all clinical treatement made by the medical stuff. conclusion: although the rupture of the thoracic aorta is a frequent cause of death, the injury mechanism has not been comletely known. a database with several victims of aortic ruture was created and 3 special accident types will be presented and simulated. introduction: overlooked compartment syndrome represents a catastrophic complication for patients and orthopedic surgeons. invasive compartment pressure measurement continues to be the gold standard. however, repeated measurements in uncertain cases can be difficult to achieve. we, therefore, developed a model for a noninvasive technique to assess tissue pressure by ultrasound based elastography. material and methods: a perforated plastic tube filled with saline was surrounded by a silicone sealed plastic cover, mimicking the shape of the tibial compartment. a pressure transducer inside the compartment was installed. a second pressure transducer was installed on the ultrasound probe to allow simultaneous monitoring of the pressure inside the compartment and the tissue deformity. for calibration, ultrasound images were generated at 0 and 130 mmhg. the plastic cover to tube distance was measured before and after compression (delta d). subsequently, increments of 5 mmhg pressure increases were used to generate a standard curve (0-60 mmhg), thus mimicking rising compartment pressures. the intra-observer reliability was tested by using 10 subsequent measurements. a correlation was determined between the skin to bone distance (delta d) and the pressure measurement (p). the pearson correlation coefficient was calculated, and a regression analysis was performed. (2), better antibiotics and computed tomography-guided percutaneous drainage (3). however, when everything else has failed, the burder of decision making the choice of a 'last resort' operation will be shifted again to the surgeon. we here described our recent experience with 10 such cases treated by abbreviated laparotomy using the bogota bag technique (4). results: for the seven first patients, we performed colon resection with colostomy. after extensive debridement, lavage and drainage, the peritoneal cavity was closed with a sterile gastric bag sutured on the rectus aponeurosis according to the so-called bogota-bag procedure (5). the mean operative time was 75 minutes. a second look laparotomy was planned after 48 hours: one patient required one reexploration, four patients required two and two required three. the decision of re-exploration was based on the visual aspect of the peritoneal content, the clinical evolution and the bacteriologic results. for the last three cases, we elected perform colon resection without colostomy followed by anastomosis in two patients in the second look laparotomy and colostomy in one because of two relaparotomies. none of the ten patients required further percutaneous drainage. two patients died in multiple organs failure (one with perforated diverticulitis and one with ischemic colon after aneurysm repair). conclusion: abbreviated laparotomy with temporary closure of the abdominal wall associated with planned re-exploration of the peritoneal cavity is a simple and effective way to treat patients with severe abdominal sepsis. introduction: pelvic fractures usually are the result of high energy trauma and such patients often have many associated injuries. long term outcome data of pelvic injury patients is sparse, we present our information with special emphasis on poly-trauma patients, with consideration for the combined involvement of associated injuries on functional outcome. material and methods: general functional outcome and clinical outcome were determined with an examination by a physician and patient assessment at a minimum of 10 years after the injury. pelvic fracture patients that had suffered poly-trauma were categorized by fracture location: acetabular, pelvic ring, or a combination. results: the long term outcome in the patients with pelvic ring fractures (exclusive of acetabular fracture) was the worst clinically, as evidenced by evaluation of pain(29.3%), increased use of special medical aids(37.4%), a poor merle d'aubigne score(13.1%), and worse sf-12 and haspoc scores. patients with acetabular fracture had poorer general functional outcomes than those with combined pelvic acetabular fractures and were noted to have higher incidence of associated injuries such as type iv pipkin fractures. further subcategorization of pelvic ring fractures into anterior, posterior or combination showed specifically those patients with combined anterior posterior pelvic ring fractures had the worst long term outcome. conclusion: a combined anterior posterior pelvic ring injury accounts for the worst long term outcome of pelvic injury poly-trauma patients. we found that bilateral pelvic injury and particular associated injuries greatly influence long term functional outcome. disclosure: no significant relationships. material and methods: 99 canulated screws were placed in 15 human semi-cadaver models and 9 plastic pelvis models in 3d navigated, 2d navigated and conventional matta technique. aim of this study was to evaluate intraoperative time, intraoperative radiation dose (fluoroscopy time, area dose product and images per screw) and accuracy (amount of exactly placed screws, mean deviation of tip placement and misplaced screws per group). results: the accuracy of 3d navigated procedures is significantly higher (p < 0,05) than in the conventional technique. there is a significant lower radiation dose in the navigated procedures (p < 0,0001) for the operation team. the intraoperative radiation dose is increasing significantly from conventional method to 2d navigated to 3d navigated procedures for the patient (p < 0,01). there is a significant higher time per screw necessary for navigated procedures (p < 0,001). conclusion: the usage of flatpannel technology seems promising in 3d navigation. our data shows a benefit from using navigated procedures in transilliosacral screw placement. the higher precision and lower radiation exposure for the operation team show that 3d navigation is superior to 2d navigated procedures. the higher accuracy of the 3d navigated procedures renders a postoperative routine ct scan obsolete thus lessening the total radiation exposition of the patient. introduction: the purpose of this biomechanical study was to determine whether locking screws or smooth locking pegs optimize fixation of ao a3 distal radius fractures. material and methods: 8 pairs of fresh-frozen human distal radii were used. ao a3 extra-articular distal radius fractures were created by removal of a 1-cm-wide dorsal wedge of corticocancellous bone centered 2 cm from the articular margin of the distal radius and were fixed using palmar locking plates. the radii were divided into 2 matched-paired groups for comparison. the side order, the fixation order and the testing order were randomized. the distal fragment in group i was stabilized with 7 angular stable screws. the distal fragment in group ii was fixed with 7 locking pegs. the proximal fragment in both groups was fixed with 3 screws. the probes were tested with 1.5 nm for torsion and with 100 n axial load for 1000 cycles each. stiffness was measured from the first 6 cycles regarding torsion and axial load. then the differences of the stiffness were recorded during the remaining cycles. the wilcoxon test was performed, a value of p £ 0.05 was considered statistically significant. results: there were no statistically significant differences in the first 6 load cycles within the eight matched pairs. after 1000 cycles the constructs with locking screws (group i) showed statistically higher stiffness values (p = 0.008) compared to the constructs with smooth locking pegs (group ii introduction: plate fixation of the odontoid process without c1-c2 arthrodesis appears to a practicable option for the management of odontoid fractures that are not suitable for conventional screw fixation. although previous biomechanical works have evaluated the effectiveness of different odontoid screw fixation techniques, no study has quantified the mechanical stability of odontoid fixation by a plate device. the purpose of this study was to measure the mechanical stability of odontoid plate fixation using a specially designed plate construct, and to compare the results to those after odontoid single-and double screw fixation. material and methods: the second cervical vertebra was removed from fifteen fresh human spinal columns. the specimens were fixed to the experimental apparatus, with the load cell at the articular surface of the odontoid process. in a first test series, stiffness and failure load of the intact odontoid were measured. type ii odontoid fractures were created by 45°oblique extension loading at the articular surface of the odontoid process. afterwards, the specimens were randomly assigned to one of the following three groups: in group i (n = 5) the fractures were stabilized using a specially designed plate construct, in group ii the fractures were fixed using two 3.5 mm cortical screws, and in group iii we used one regular 4.5 mm cortical screw. in a second test series, stiffness and failure load of the stabilized odontoid fractures were assessed for comparison and statistical analysis. results: group i (plate device) showed a significantly higher mean failure load than group ii and group iii. the mean failure load of group i after fixation of the odontoid fracture was 84% of the mean failure load that was necessary to create a type ii odontoid fracture, initially. comparing group ii (double screw technique) and group iii (single screw technique), there was no significant difference regarding the mean failure load. in both groups the mean failure load after odontoid fixation was approximately 50% of the mean failure load of the intact odontoid. statistical analysis also revealed a significantly higher stiffness of the stabilized odontoid after plate fixation, than after single or double screw fixation. conclusion: plate fixation of the odontoid process as an alternative procedure in certain fracture patterns provided a significantly higher biomechanical stability than the technique of odontoid screw fixation. using a specially designed plate construct fixed with two cancellous screws into the body of c2 and an additional cortical screw inserted in the odontoid process, 84% of the original stability of the intact odontoid was restored. single or double screw fixation of the odontoid only restored approximately 50% of the original strength. results: extension and flexion were not influenced of all implants significantly. all dynamic implants and also the rigid implant led to a significant increase of the mobility during side bending and rotation in the area of the adjacent segments. conurrently the cephaled adjacent segment (l2/l3) showed a significantly higher mobility than the caudal adjacent segment (l4/l5). conclusion: dynamic implants such as the interspinous spacer enlarge the mobility of the adjacent segments during side bending and rotation in a comparable size as the rigid implant. to this extent is to be assumed that reinforced adjacent degeneration cannot be prevented by the use of the interspinous spacer substantially. introduction: osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and disrupted microarchitecture of bone tissue. the most severe consequence of osteoporosis are osteoporotic fractures. these are mainly low-energy fractures, which anamnestically, clinically and radiologically differ from fractures in healthy bone. we tried to find the answer to a queston, whether it is possible, that osteoporotic compression fractures are single events, or if they represent a gradual, progressive vertebral collapse in patients with osteoporosis. we evaluated the forces, necessary for vertebral fractures, regarding the bone mineral density. material and methods: 14 cadaver vertebrae were isolated with the approval of ethics committee. we mesured their bone mineral density and then subjected them to the stress-test. we used the computer-controlled hydraulic press and stress vertebrae to the fracture point and beyond, monitoring the deformation and the load. a sigma-epsilon diagram was constructed from the data. results: with the loading of vertebrae the pressure grew exponentially as a function of deformation to the breakage point. then we observe a plateau of saw-like shape, which corresponded to the progressive vertebral collapse. further deformation led to gradual compacting of vertebrae and we observed once again an exponential increase in pressure. this bone compaction is therefore the first mechanisms of fracture repair. the saw-like plateau form suggests progressive collapse of vertical trabeculae and their jaming into the horizontal, which then with the increasing deformation and load also fail. a similar phenomenon can be observed in the collapse of buildings during the demolition. (the 9-11 phenomenon). conclusion: unlike a high energy vertebral fractures, the osteoporotic fractures are presented as a gradual vertebral collapse. they take place parallel with the processes of bone reparation and remodelation. from this standpoint, osteoporotic fracture is unique. vertebral collapse increases the bone mineral density in the broken vertebrae, what is observed radiologically and densitometrically. repair of medium to large, but reparable, rotator cuff defects, augmented with a restore patch or not. patients have been randomly assigned to receive standard repair augmented with the restore implant or to receive non-augmented standard repair as the repair procedure is exactly the same in both patient groups, and the implantation of the restore implant does not necessitate any additional incision or measures, neither the patient nor the assessors are aware of the fact an implant has been used. the ethical committee of the university hospitals leuven has approved the study. all patients get full information and are enrolled in the screening program after written consent only. clinical evaluation, both pre-operatively and at 6 months post-operative is performed by the same, independent physiotherapist trained in shoulder evaluation using the constant score structural evaluation is performed by ultrasonography, performed by a radiologist specialised in musculoskeletal radiology and sonography. unpaired two-tailed t tests, performed with prism 5 software for mac osx, were used to compare the results of the scores in the control group with those in the xenograft group. fisher exact tests were used to evaluate the significance of differences in the proportions of retears in the patients for whom a sonography was obtained. results are expressed as the mean and standard error and significance was set at p < 0.05. results: we included 20 patients. there were 7 female and 13 male patients. in the non-augmented group there were 3 females and 7 males. in the restore group there were 4 female and 6 male patients. the average age of patients was 66 years of age. in the non-augmented group the average age is 65,2y (+/-2,7) years of age, in the restore group 66,8y (+/-2,2). the mean pre-operative constant score of the non-augmented group was 46,8 +/-6,2 points whereas it was 42 +/-5,6 points for the restore augmented group. post-operative the functional outcome 6 months after surgery again was scored using the constant score. the mean score in the non-augmented group was 86 +/-4,0 points; in the restore group it was 82,1 +/-4,5 points in the non-augmented group we documented a retear in 1/10 patients, in the restore group we had a retear in 3/9 patients (2 small tears, 1 massive tear). introduction: it has been estimated that up to 30% of adults suffer from rotator cuff tears [1] , which can impair their ability to work or perform household tasks [2] . management of rotator cuff tears is difficult as a large proportion of technically correct surgical repairs re-rupture, estimated between 13-68% [3] . it has been estimated that thousands of extracellular matrix repair grafts are used annually [4] to augment surgical repair of rotator cuff tears and act as temporary scaffolds to support tendon healing. the only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus [4] . as the shoulder is subject to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. we used dynamic shear analysis (dsa), which is a form of rheology and allows the study of flow and material deformation. material and methods: the shear properties of four different commercially available rotator cuff repair grafts were measured (restore, graftjacket, zimmer collagen repair and sportsmesh). 3 mm punch biopsies were taken from the grafts and subjected to oscillatory deformation under compression. the bulk storage modulus (g') was calculated [5] and used as an indicator of mechanical integrity. to assess how well the repair grafts were matched to torn and normal rotator cuff tendons, the storage modulus was calculated for 79 human rotator cuff specimens obtained from the edge of rotator cuff tears during surgery, from patients aged between 22 and 89 years. 14 age and sex matched normal controls were also obtained during shoulder hemiarthoplasties and stabilisations. results: we report a significant difference in the shear moduli of all four rotator cuff repair grafts (p < 0.001, 1 way anova). 2 of the repair grafts (restore and graftjacket) had a significantly lower storage modulus when compared to human rotator cuff tendons (p < 0.01, dunn's multiple comparison test). only the zimmer collagen repair and sportmesh had a storage modulus which was comparable to that of normal rotator cuff tendons (p > 0.05), and thus were most closely matched. conclusion: with increasing numbers of repairs of rotator cuff tears, and augmentation of these repairs, there is a need to understand the mechanical and biological properties of the both repair grafts and the tendons they are designed to augment. there is no clear definition of the ideal mechanobiological properties. current rotator cuff repair grafts display a wide variation in their shear mechanical properties, and how closely they are matched to the mechanical properties of human rotator cuff tendons. it is hoped that this study, in conjunction with others, will help to guide surgeons in deciding on the most appropriate repair graft. three-dimensional computed tomography reconstructions also improved the average intraobserver reliability for all fracture characteristics, from j 2d = 0.624 (substantial agreement) to j 3d = 0.687 (substantial agreement). the addition of three-dimensional images had limited influence on the average interobserver reliability for the recognition of specific fracture characteristics (j 2d = 0.488 versus j 3d = 0.485, both moderate agreement). three-dimensional computed tomography images improved interobserver reliability for the recognition of coronal plane fractures from fair (j 2d = 0.398) to moderate (j 3d = 0.418) but this difference was not statistically significant. conclusion: three-dimensional computed tomography is helpful for; 1) individual orthopaedic surgeons for preoperative planning (improves intraobserver reliability for the recognition of fracture characteristics), and for 2) comparison of clinical outcomes in the orthopaedic literature (improves interobserver reliability of classification systems). disclosure: no significant relationships. introduction: in recent years, 3d fluoroscope has used increasingly in orthopaedic surgery because it offers some advantages such as generation 3d data without anatomic registration requirement. previous studies have focused on the clinical use of 3d fluoroscope in surgical procedures such as calcaneus or acetabular fracture reduction, or placement of screws in spinal surgery. there are no reported data on radiation exposure of 3d flu to orthopaedic theater staff. we want to correlate radiation exposure and distance concerning the patients and members of surgical team during using three-dimensional fluoroscope and study how far is enough until radiation exposure can not be measured. material and methods: an isocentric c-arm fluoroscope (siremobile isoc 3d) was used for the study. human cadaveric extremity was used for target. digital dosimeters (mydose mini pdm-117, aloka) were used to measure radiation exposure at specific distances. dosimeters were systematically exposed by the following protocol. represented positions were direct contact and every 25-cm. radius from the center of the beam. the distances were increasing until the dosimeters could not detect the radiation. each radius distances were designed to record 4 different positions; top, bottom, left and right side. dosimeters were exposed and removed (4 dosimeter positions at a time from each radius). first we used low resolution scan technique to obtain the images. after all radiation exposure records were collected, we changed to use high resolution scan technique and repeated the protocol. each technique was repeated in 3 times to obtain the mode of data. results: radiation dose at ground zero is 49 lsv in high resolution and 21 lsv in low resolution. radiation in high resolution technique can not be measured beyond 1 meter from the center of the beam at the top, bottom, and right direction and 1.5 meters at the left direction. in low resolution, radiation cannot be detected farther than 75 cm. in the top, bottom and right direction and 1.25 meters at left direction. conclusion: radiation dose measurements in each direction are decreased during increasing distance and dose in left direction is higher and farther than others. beyond 1.5 meters is safe from radiation in knee application. high resolution gives higher radiation and farther than low resolution. introduction: tibial plateau fractures with impression are often associated with poor outcomes and a high rate of complications. the current guidelines advocate anatomic reduction, re-establishment of tibial alignment, stable fixation, and filling of the sub-articular defect. we hypothesized that fixed-angle liss-plates provide adequate stabilization with less need for void filling, minimal complications and good radiological outcome. material and methods: retrospective evaluation study. in the period 2004-2008, we operated 55 patients with an intra-articular tibial plateau fracture. forty were treated with a liss-plate. mean age was 57 years, 14 were male. all fractures were classified as ao type b or c; 16 were schatzer type ii, 2 type iv, 2 type v, and 20 type vi. five patients were initially treated with external fixation. mean time until definitive surgery was 9 days (range, 1 -47 days). in 12 fractures, the subchondral void was filled with either hydroxy or bone graft, in the other 28 cases no graft was used. demographic data and fracture classification were equal in both groups. articular impression was measured by 3 independent evaluators pre-operatively, post-operatively and 6 months after surgery on plain x-rays. results: mean pre-operative impression was 6.9 mm (with void filling 8.0 mm, without 6.5 mm, ns). thirty-four fractures were additionally stabilized with k-wires or screws. the post-operative impression was on average 2.8 mm. evaluation criteria included the lysholm and tegner activity score. all fractures were stabilized post primarily. the surgical main approach was strictly medial. exposure of the entire medial condyle fracture was first performed anteromedial following the fracture line to the articular border. the posterolateral impaction was addressed directly through the main fracture gap. small fragments were removed, larger reduced and preliminarily fixed with separate kwire(s). the posteromedial part of the condyle was then prepared for main reduction and application of a buttress t-plate in a posteromedial position, preserving the pes anserinus and medial collateral ligament. in addition a parapatellar medial mini-arthrotomy through the same main approach was performed for reduction and pds-suture-fixation of the anterior eminence (acl and anterior horn of lateral meniscus). results: we treated 28 patients with 29 fractures. median age was 48 years (20-77). we could evaluate 25 patients (89%), 3 patients were lost to follow-up due to foreign residency. the fractures were treated post primarily at an average of 4 days, 18 of them in a twostaged procedure with initial knee-spanning external fixator. all fractures healed without secondary displacement or infection. 24 patients showed none to moderate osteoarthritis after a median of 4 years. one patient showed a severe osteoarthritis after 8 years. all patients judge the result as good to excellent. the lysholm score reached 95 (75-100) and the tegner activity score 4 (3-7). all patients have achieved a minimum flexion of 100°. conclusion: in our view it is crucial to recognize this increasingly observed type of knee injury in winter sport areas. with our strategy we achieved good results in nearly all patients. the described larger medial approach allows addressing most of the injured parts of the tibial head (medial condyle with posteromedial buttressing, tibial spine, posterolateral impaction). material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator (sif). there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to 119 metaphyseal fractures of distal femur and proximal and distal tibia. the age of patients was from 18 to 86 years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. for opened fracture it has been used high mobile external fixation system as temporarily (39 fractures) or definitive (49 fracture) method. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the 2.5-4 months. it has been allowed to patients early full weight bearing, if fractures not intraarticular. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with 3d configuration resulted in unexpectedly quick fracture healing. follow up was 19 months (6-60). when used external fixation system, axial dynamisation has been regularly activated. conclusion: according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site if no intraarticular dislocation. it can be used as primary method or soon after external fixation if damaging control concept used. introduction: disaster, is the disproportion between the need for medical care and the means available in the community. this discrepancy of needs /means is the major problem in every step of the rescue chain, when a disaster situation is present. this is more obvious at the end of the chain, which is the hospital and especially, the bottleneck of the entire disaster's management system, the emergency department. material and methods: in greece, the most common and frequent disaster situation is the earthquake. and so, the most expected pathology of the victims is trauma. because of the lack of 1. special organization of emergency medicine and 2. independent modern emergency departments in greek hospitals, their directors did not give the appropriate attention to organize a disaster plan (internal or external introduction: accurate response to major incidents requires accurate decisions on all levels, from command level to the care of the individual patient. development, evaluation and training of the process of decision-making requires standardized models providing complete and accurate information as a base for the decisions; a decision based on incomplete or incorrect data can not be properly evaluated. the aim of the present project was to design a simulation model that could be used both for evaluation of different methods in the response to major incidents and for training and evaluation of skills in making correct decisions. material and methods: a system was created providing the information required for this process in the whole chain of management and performance: scene, transport, hospital response, co-ordination and command. input data were based on real scenarios and real resources. for evaluation of methodology, all parameters except the one studied, in this study triage, were standardized. the results from (a) physiological and (b) anatomical triage, performed by staff on different levels of competence and experience, serving as their own controls, were compared. for training, the system was used in courses in medical response to major incidents with training of the whole chain of management and performance, from prehospital patient management to over all co-ordination and command. results: the methodological evaluation showed differences in priority and outcome between anatomical and physiological triage related to the level of experience and to the position in the chain of response, providing a base for choice of method related to those factors. the results from training with the use of the system, so far only evaluated by the participants own ranking, showed high percepted improvement of relevant skills. conclusion: a methodology for simulation of major incident response designed for scientific evaluation of methodology also provides a very good educational tool, since correct and complete data as a base for decision making also gives an effective and realistic training. disclosure: one of the authors, sl, has the copyright to the mac-sim system, a non-commercial system intended mainly for scientific use. equipment for training can be produced by users, but also purchased for production costs. introduction: interhospital referral of traumapatients for reasons of special (most neuro-)surgical competencies to a specific level 1 traumacenter, is common practice in the netherlands. these traumapatients are sometimes admitted directly through specialized intensive care units and therefore do not enter the emergency department (ed). therewith the standard assessment according to the atls guidelines is bypassed in these cases. this withholds the risk of an incomplete assessment. we therefore consistently coordinate the assessment of all transferred traumapatients. in this study we analysed the number of newly found injuries in referred polytraumatized patients and the clinical consequences in terms of extra treatment, permanent damage or death to the patient. we also analysed possible risk factors for missing injuries. introduction: synchronous admission of large numbers of patients into the hospital requires a perfect coordination of activities of designated teams in the process of reclassification at the entry to the hospital and subsequent continuous provision of medical care for the patient in the course of examination and treatment, up to his hospitalisation at the target department, in accordance with the characteristics of the injury and seriousness of his medical condition. this process cannot be accomplished through improvisation but only with creating a uniform organisational scheme, defining the recommended structure of medical teams and their activities during a multiple admission of casualties into the hospital. in this article, we present a proposal of such consensual organisational scheme, partially verified in practice. the organisational scheme is defined in the following areas: -space arrangements -places of admission and organisation of work -creation of mini trauma teams (anaesthesiologist, traumatologist and surgeon or another traumatologist take over the most serious patients, the teams are accompanied by consulting specialists of relevant specialities (neurologist, neurosurgeon, radiologist), the whole teams or at least parts of them, accompany the patients for the whole period up to the definite treatment at operating theatre, or his placement at a destination department -the continuity of care is secured in this way, without the need to pass on any findings and information -placement of patients into individual hospital departments (follows certain rules, it is necessary to direct all the admitted patients into as few departments as possible (one or two), and thus keep the best possible view over the priorities during their treatment -entry corridors -,,green corridor'' -patients are immediately transported through this area by transport teams into the ''green'' designated area, the ''red'' and ''yellow'' entry area does not have to be extremely large, however it requires an adequate equipment from the material and technical point of view results: multiple admission of patients must be well-organised and managed, most often by a head-physician of the ua department, or another authorised specialist (in hospitals without the ua department). the idea of the traumanetwork d dgu is to built up regional networks of various trauma centers with the objective to standardise and optimise the treatment of severely injured patients -with the additional involvement of rescue services, physicians and competent facilities and centres for the treatment of specific injuries as severe burn or spinal cord injuries etc. to assure that all participating hospitals meet the criteria needed for the treatment of trauma patients, a certification firm (diocert) was assigned to accomplish the audits and to control the process of certification. thus, every hospital has to pay a sum of nearly 6 000 eur for audit, certification, benchmarking, yearly quality reports and the use of special it-tools which were designed for the traumanetwork d dgu. material and methods: coordination of traumanetwork implementation coordination of audit and certification process results: since the beginning in the year 2006 actually 781 hospitals are participating the traumanetwork d dgu. these hospitals are organized in 48 regional traumanetworks. 26% of the hospitals are preliminary categorized as local trauma centers, 28% as regional trauma centers and 11% as over-regional traumacenters (the highest category). 33% still aren¢t categorized. 407 hospitals have already signed the contract with the german trauma society and paid the participation fee. 250 hospitals meet the criteria for audit and 153 hospitals are already audited by the firm. in october 2009 the first regional trauma network (trauma network east bavaria / tno) was certificated with a total of 25 participating hospitals. conclusion: in the past 3 years the number of participating hospitals increased year by year. the nationwide acceptance and the high level of participation in the traumanetwork d dgu in germany show that the treatment of severely injured patients is one of the main topics and exercises for trauma surgeons in germany. if the expected improvement in treatment quality and the decline in trauma mortality is only wish and fiction or reality and fact has to be proven by studies in the next years. therefore a working group with focus on quality improvement, changes in mortality, improvement in rehablitation results etc. was founded. introduction: one of the challenges in trauma care is diagnosing all injuries. any delay in treatment can lead to increased morbidity, prolonged length of hospital stay, costs, and even mortality. despite the use of standardized guidelines for initial evaluation such as atls, the incidence of missed injuries in the literature is considerable. the aim of this study was to assess the rate of missed injuries in trauma patients evaluated in two dutch level-1 trauma centers and to determine potential factors that contribute to injuries being missed. we assessed all radiological reports during initial admission and operation records of the 1124 patients included in the prospective randomized react trial. this study was part of a randomized trial conducted in two dutch level-1 trauma centers investigating the role of ct scanning in the trauma room. missed injuries were defined as not diagnosed during initial radiological evaluation in the trauma room. we assessed all missed injuries and the phase in which these injuries were diagnosed. second, we assessed potential contributing factors by univariate analysis. results: there were a total of 129 total calls performed with real patients and 328 test calls. of the actual calls, 111 (86%) were performed while moving and 18 (14%) were done from a stationary position. initial video quality in was rated good in 98 cases (76%) and initial audio quality was rated good in 97 (75%) cases with actual patients. 107 of the actual calls (83%) experienced some sort of temporary video drop during the entirety of the call and 93 calls (72%) experience some sort of temporary audio drop. these drops were a result of the setup of mesh wifi and the need to jump from router to router. users in the hospital found the program to be a very useful trauma and emergency medicine tool, but adjustments need to be made to improve the network. conclusion: the use of telemedicine in a pre-hospital setting may play a significant role in the management and treatment of trauma and critically ill patients as hospital medical staff can intervene in real time during transport. patients can be evaluated in real time which allows the necessary staff and resources to be available on arrival. initial user feedback has been encouraging with users acknowledging its usefulness as a pre-hospital tool. (1) in the elective setting it is logical that a lower egfr reflects poor renal function and low overall physiological reserve. the same is not obviously true for emergency patients who may have an ''artificially'' low egfr merely as a reflection of acutely altered fluid balance. change in egfr from admission to hospital to itu admission was also significantly different between survivors and nonsurvivors. this would suggest that egfr reflects a response to treatment as well as renal function. this study supports the use of egfr in the decision making process when trying to predict outcome in emergency general surgery patients. introduction: the surgical medium care (smc) in our hospital is a 6 bed ward with monitoring facilities, and is used critical ill patients from the trauma and other surgical wards. over the last years there has been an increase in the number and severity of trauma patients admitted to out hospital, as well as there has been an increase in patients undergoing major elective surgery. the aim of this study was to verify if these trends are reflected in an increase in patient-and workload on our smc. in this study we describe the patient-and workload on the smc between 2000 and 2008 using the tiss-28. the modified therapeutic intervention scoring system (tiss-28) is a validated score of therapeutic activities and an alternative approach to evaluate outcome of critically ill patients (1) (2) (3) . material and methods: a prospective cohort study of all consecutive patients admitted to the smc between 01/01/2000 and 31/12/2008 was performed, using the tiss-28 database. of all admitted patients a daily tiss-score was performed. besides the tiss data, patients demographics, referring ward, discharge destination, length of stay, and hospital mortality were retrieved from the database. results: there were a total of 5455 admissions of 4667 patients in the study period. 64% of patients were male, 36% were female. the median length of stay was 3 days (0-97). the overall hospital mortality rate was 6,4%, with no significant differences over the years. 40% of the patients admitted to the smc came from the icu, 15% came from the emergency department, 1,5% came from home, 5,5% came from the recovery ward, and 38 % came from the trauma and surgical ward. these percentages did not change over time. the average tiss score during the study period was 20 and did not significantly differ during the study period. there was, as expected, no significant difference in tiss score between patients who survived and the non survivors. introduction: the demands placed on systems and organisations that protect the general population are constantly growing. the reasons for this include, among other things, circumstances altered by the threat of inter-national terrorism and the increasing frequency and magnitude of mass public events and natural catastrophes. crisis situations such as these present unique, often completely unprecedented chal-lenges to those affected and to all actors with responsibility for crisis management and the protec-tion and rescue of people.with regard to effective interdisciplinary crisis management, both germany's security and rescue forces and its general population suffer from widely acknowledged and scientifically proven deficits. impact on people and the society. in this context, all natural and man-made threats will be considered (''all hazards approach''). elearning and virtual reality modules based on these scenarios will be offered to target groups via the internet on an individualised basis. results: the aim of this project is to develop a platform to prepare security and rescue forces, doctors, caregiv-ers and the general population for terrorist attacks, crises and disasters. an online platform with a modular structure (employing teaching methods such as e learning, blended learning etc) will offer innovative and specialised instruction and advanced training to all users. conclusion: experts agree that the modern teaching methods and computer-based simulations mentioned here (such as virtual reality methods) are excellent tools to help train people efficiently to respond to events that cannot be planned, such as terrorist attacks and other catastrophes. the use of these innovative methods and com-pletely novel, userfriendly, web-based instruction and information modules is designed to address -to a heretofore unprecedented degree -all security and rescue forces concerned as well as the general population in particular. ultimately this will signifi-cantly improve security and rescue operations in the event of terrorist attacks, crises and disasters. conclusion: in a proper setting, laparoscopic emergency is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients. the diagnostic and therapeutic versatility afforded by the laparoscopic approach avoids extensive preoperative studies, averts delay in operative intervention and minimize morbidity and shorten the postoperative hospitalization. we do think that laparoscopy should be incorporated into general surgeon's armamentarium for the management of patients with acute abdomen as just as another tool to be used selectively when indicated. laparoscopy, however, must not be used as an alternative to good clinical judgment. about our algorithm in patients with acute abdomen: if there aren't any contraindications to laparoscopy, obtained an informed consensus, in presence of a well trained surgical team in minimally-invasive surgery, excluded any major gynaecological diseases (about which we and our gynaecological colleagues haven't a skilled experience with a laparoscopic approach), we always approach laparoscopically. introduction: stable patients with thoracoabdominal penetrating or blunt injuries resulting in diaphragmatic injuries represent a difficult and challenging management dilemma. although laparoscopy and thoracoscopy have now emerged as the most reliable and efficient diagnostic and treatment modality of these injuries, a conversion to laparotomy for mere evidence of peritoneal penetration and or diaphragmatic injuries is common for most trauma surgeons. we hypothesized that laparoscopically-assisted mini-thoracotomy for repair of diaphragmatic injuries will be as effective as open laparotomy or thoracotomy and will prevent the morbidity associated with open technique and should be used in hemodynamically stable trauma patients. we designed a minimally invasive technique that combines laparoscopic exploration of the intraperitoneal cavity and existing injury site as an entrance to the injured site or organ. open hassan technique, using vertical midline incision is used to create the pneumoperitoneum. additional two to three 5 or 10 mm ports are placed to enable thorough examination of the peritoneum, running the small bowel and examining other abdominal viscera. diaphragmatic lacerations are repaired by extending (3-4 cm) the existing thoracic stab or gunshot wound. the diaphragm is grasped with two graspers and brought to the operative field. continuous or interrupted suture are used for repair. we applied this technique to 8 hemodynamically stable trauma patients (la group) treated over a 4 year period at the university level i trauma center and compared to 10 trauma patients requiring laparotomy (og) for isolated diaphragmatic injury repair . all laparoscopically assisted procedures were performed by the senior author (rl). length of stay, morbidities and complications were studied in both groups. both groups were matched for iss, age, and gender and mechanism of injuries. results: there were 8 patients (five with stab, two with gunshot wound and one with blunt trauma and chronic diaphragmatic injury) in the la group. introduction: acute small bowel obstruction is mostly due to adhesions (83%), while internal hernia can cause acute small bowel obstruction in 2% of cases. this clinical condition has been considered for many years a relative contraindication for laparoscopic surgical treatment. with the introduction of ct-scan in the diagnosis of this clinical situation and the experience in laparoscopic techniques, more surgeons are now attempting laparoscopic management for this indication. the advantages of laparoscopy in abdominal surgery are now well defined, such as a shorter intestinal function recovery, a shorter hospital stay and less post-operative pain complained by the patients. in our presentation we want to analyse the importance of laparoscopy in the diagnosis and the treatment of acute small bowel obstruction, in order to underline advantages and limits of this technique. material and methods: in san raffaele hospital milan (italy) a total of 136 patients underwent a surgical intervention for small bowel obstruction from january 2007 to december 2008. 98% of the obstructions was due to adhesions, 2% to internial hernias. all the patiens underwent preoperative abdominal x-ray and ct-scan. results: of the total of patients, 30 have been operated on with a laparoscopic approach, with a conversion rate of 33.3%. postoperative morbidity was 0% in the laparoscopic group and 1.22% in the traditional surgical approach, with a shorter hospital staying in the first group. conclusion: the analysis of our data suggests us that the selection of patients that can benefit from a laparoscopic approach to acute small bowel obstruction has to be made accurately, better with the use of ct-scan, in order to limit the percentage or useless laparoscopy and to diminish the conversion rate and to give the patient the better curative option. introduction: intestinal obstruction has remained one of the most common surgical emergencies. the aim of our study is to evaluate the feasibility, safety and palliative role of laparoscopic bowel surgery in the management of large bowel obstruction. material and methods: in a period of 2 years, 15 patients were subjected to loop sigmoidostomy. in 12 patients the diagnosis was bowel obstruction due to rectal cancer. in 3 patients the obstruction was attributed to ovarian cancer. from those 12 patients with rectal cancer, 10 patients had contominant liver and lung metastases and 2 had an unresectable liver lession. in that period 2 lapassisted ileo-transverse anastomosis were performed due to obstruction from cecum carcinoma together with mlitple liver and lung metastases. single surgeon-performed pocus in the evaluation of acute appendicitis led to a correct diagnosis in 87,6% (177/202). surgeons trained in us ordered a ct scan in 8,9% of cases and ratio of negative appendectomy was 1,5%. surgeons not trained in us ordered a ct scan in 61,5% and their ratio of negative appendectomy was 28,2% (including pts that underwentent surgery on clinical investigation basis only). conclusion: surgeon-performed pocus has a high sensitivity in the assessment of acute appendicitis and it is a powerful tool that minimize the use of ct scan and ratio of negative appendectomy with reduction of hospital and social costs; furthermore an advantage for the patients in terms of radiation exposure can be achieved. moreover, to reduce additional costs, laparoscopic approach should be indicated only when the appendix cannot be perfectly visualized and localized. introduction: severe bleeding is, besides head injury, the most important predictive factor in severe trauma. therapy of hemorrhagic shock starts already at the scene of accident. however, the best strategy regarding preclinical volume therapy is controversially discussed. the traumaregister of the german society for trauma surgery (tr-dgu) observes the routine management of severely injured patients since many years. this registry will be used to describe the behaviour of preclinical volume administration as well as the consequences in early hospital care and its changes during the last ten years. material and methods: the tr-sdgu is a voluntary anonymous documentation of severely injured patients for the purpose of quality management. data collection started in 1993. about 100 parameters are collected per patient. for the present investigation only adult patients (age >=16) admitted directly from the scene to one of the participating hospitals during the past ten years (1999-2008) were considered. a minimum injury severity of iss > = 9 and available data for volume administration and blood transfusion were required. means and prevalence rates were analyzed on a yearly basis. results: a total of 25,935 patients injured between 1999 and 2008 were analyzed. mean age was 44.2 years, and 73% of patients were males. in 95% of cases there was a blunt trauma mechanism, and 30% of cases were unconscious at the scene (gcs £ 8 years that required presentation in one of the two level-1 trauma centers (amc or vumc) were eligible. in the amc the ct scanner was located in the trauma room (intervention group) and in the vumc the scanner was located in the radiology department (control group). randomization was performed prehospitally at the time of dispatch from the scene. primary outcome measure was the number of non-institutionalized days within the first year following trauma. secondary outcomes were mortality, length of initial admission and transfusion requirements. preplanned subgroup analyses consisted of multitrauma patients and severe traumatic brain injury (tbi) patients. results: in total, 1124 patients were included for analysis of which 264 were multitrauma patients and 121 had severe traumatic brain injury (tbi). demographic data were comparable between both groups except that there were more multitrauma patients evaluated in the amc. introduction: the effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of common injury patterns, incidence, mortality, and consequences. the needed inital radiological imaging remains controversial and should be adapted to the expected injury pattern. material and methods: in this retrospective study, the injury patterns of 56 polytraumatized paediatric patients (age £ 16 years) in the period from december 2001 to may 2009 were evaluated. all children were initially diagnosed with a whole body ct scan. the cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. the ais (abbreviated injury scale) and iss (injury severity score) were used to classify the severity of injuries in different body regions. moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated. results: the mean score of the iss was 30 ± 13 in 38 boys and 18 girls with a mean age of ten years. the lethality was 11% and only 4% in the first 24 hours. the most severe and most frequent injury was craniocerebral trauma in 89% with an ais ‡ 3 in 80%. surgical intervention of the head was done in 41%. thorax injuries were found in 63% with 57% with an ais ‡ 3 and in 11% a thoracic drainage was needed. abdomial trauma was found in 34% (surgery 4%) with an ais ‡ 3 in 32%. fractures of the spine occured in 14% (surgery 5%) with an ais ‡ 3 in 4% and pelvic injuries were diagnosed in 16% (surgery 4%) with an ais ‡ 3 in 14%. injuries of the upper extremity were found in 23% (surgery 11%) with an ais ‡ 3 in 5% and of the lower extremity in 32% (surgery 16%) with an ais ‡ 3 in 13%. conclusion: especially because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery the authors recommend a whole body ct scan in children who are potentially polytraumatized. not only in adults but especially in children the authors suggest the initial use the quickest imaging with a high sensitivity-the whole body ct scan. introduction: patients who suffer physical injuries following a traumatic event are at risk for developing posttraumatic distress. care workers in hospitals treating polytrauma patients are in an optimal position to screen and identify patients developing posttraumatic stress disorder (ptsd). to start early intervention procedures and possibly lower the prevalence, a screening instrument to identify patients at a higher risk is needed. aims of this study were to determine if the severity of injury is related to the prevalence of ptsd and to review the personality traits of patients with ptsd. with these results a screening instrument might be developed. to simulate an unstable extraarticular distal radius fracture, an osteotomy with a 5 mm gap was made. axial loads of -10 to -100 n and torque loads of -1,5 to 1,5 nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. after that, 1000 cycles of dynamic torque load alterations of 0,5 to 1,5 nm (or -0,5 to -1,5 nm convenient to side) at 0,5 hz with a preload of -10 n were performed. in the specimens that were still intact after 1000 cycles, loading in torque was continued until failure occurred. axial and torque stiffnesses of the osteosynthesis system were calculated. results: with a median of 136,0 n/mm axial stiffness of xscrewòfixed specimens was higher than of dnpò-fixed specimens with a median of 69,5 n/mm but did not reach statistical significance. with a median of 0,163 nm/°torque stiffness of xscrewò-fixed specimens was significant higher than of dnpò-fixed specimens with a median of 0,068 nm/°. the xscrewò-group reached 33% of the axial stiffness and 49% of the torque stiffness and the dnpò-group reached 14% of the axial stiffness and 20% of the torque stiffness of the intact radii. conclusion: fixation of unstable extraarticular distal radius fractures with a xscrewò provide biomechanically more stability than a fixation with a dnpò. disclosure: no significant relationships. after distal radius fractures occur in 4% to 7% of fracture cases. the resulting deformity resembles madelungs deformity and is also called pseudo-madelungs deformity. this deformity leads to ulnocarpal impaction and dorsal dislocation of the distal radioulnar joint (druj). several treatment options such as lengthening of the radius and shortening of the ulna or epiphysiodesis of the distal ulna have been described. the taylor spatial frame (tsf) is a hexapod based external ring fixator, which is widely used to perform six-axis deformity corrections of the lower limb. tsf-planning is web based (www.spatialframe.com) but its use is only available for lower extremities. the purpose of this study was to apply the tsf to the upper extremities to correct pseudo-madelung deformities. material and methods: defining the nomenclature to correct bony deformities with the tsf, one must determine the deformity parameters, the frame parameters, and mounting parameters for the web based planning program. the six deformity parameters and the four mounting parameters use the anatomic nomenclature for the lower extremities. to use the tsf on the forearm, one must transfer the nomenclature of the deformity parameters and the mounting parameters to the nomenclature of the forearm with the transferred nomenclature, one can correct forearm deformities with the correction mode long bone of the planning program for the lower limb. patients two boys (patient 1, 13 years, patient 2, 14 years old) and two girls (patient 3, 8 years, patient 4, 7 years) were seen in our clinic with progressive pseudo-madelung deformities after an epiphysial fracture of the distal radius at age 12 in the boys and 6 in the girls. skeletal maturity (rus, tw3 method) was equivalent to the patientâ e tm s age. results: in the four patients, the multiplanar deformitiy of the distal radius could be corrected anatomically with the tsf. there were no frame changes or frame modifications necessary for deformity correction. patient 2 was slightly overcorrected because of some growth in the distal ulnar growth plate. during the distraction, each patient had two low-dose ct scans for better visualization of the radiocarpal and radioulnar joint. the web-based planning program was adjusted twice until total deformity correction was achieved. no further immobilization after frame removal was required. the one-year follow-up showed an anatomic aligned forearm/hand relation with increased pronation and supination compared to the preoperative range of motion in all patients. the wrist and especially the druj were stable and reduced at the one-year follow-up examination. the patients did not complain about any pain or functional deficits in the hand. conclusion: in conclusion, the power of the tsf with the ability to move two fragments precisely can be transferred to the forearm. this allows for the correction of multiplanar radial deformities simultaneously without the need for frame modifications of rotational and translational deformities, as is necessary with the standard ilizarov system. material and methods: thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent ct and mri within ten days after trauma. ct-reconstructions were made in planes defined by the long axis of the scaphoid. the reference standard for a true fracture of the scaphoid was 6-week follow-up radiographs in four views, based on current available evidence in the literature. a panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. we calculated sensitivity, specificity and accuracy as well as positive (ppv) and negative predictive values (npv) for both imaging modalities. results: according to the reference standard there were six true fractures of the scaphoid (prevalence 18% both mri and ct are better at ruling fractures out than in ruling them in and both were subject to false positive and false negative interpretations. the best reference standard for a true fracture is debatable, but for now it is not clear when bone edema on mri and small unicortical lines on ct represent a true fracture. we advice ct because costs are lower and overall availability is higher. introduction: the scaphoid bone is the carpal bone most commonly fractured in wrist trauma. traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. conversely, displaced fractures are recognised as unstable, with a significant risk of non-union if not treated surgically. there is a current trend in orthopaedic practice, however, to treat non-or minimal displaced fractures also with early open reduction and internal fixation. this trend is not evidence based. in this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarise the best available evidence. material and methods: fourty fresh frozen cadaver scaphoid bones have been sampled at our disposal for testing of screws. the bone density measurement of all specimens has been performed using a qct scan. a transverse osteotomy will be performed at the waist of each scaphoid simulating a b2 fracture according to the herbert classification. a load cell will be interposed, in an already established method, between the proximal and distal pole of the bone to measure compression force while introducing the screw. the screws will be applied as recommended by the manufacturer using original instruments. the intrascaphoid compression will be recorded at the peak during insertion of the screw, and after 30 and 60 seconds, 2, 10, 30 and 120 minutes. results: preliminary results determined that a greater compression can be sustained over a time by headless compression screws with significant differences between those screws. the tests will be finished at the end of january and we will present the final results. conclusion: in more than 50% of our cases a fracture was missed with the initial radiograph. bone scintigraphy is still a good choice to detect an occult fracture around the wrist. introduction: operations in trauma patients represent a second insult and the extent of the surgical procedures influences the extent of the inflammatory response. the aim of this study was to evaluate the operative burden related to femoral intramedullary nailing. our hypothesis was that a reamer-irrigator-aspirator (ria) system would cause lesser inflammatory response than traditional reaming (tr) due to a lesser intramedullary pressure increase and thereby reduced intravasation of bone marrow content. material and methods: coagulation, fibrinolysis and cytokine responses were studied in norwegian landrace pigs during and after intramedullary reaming and nailing with the two different reaming system; the tr (n = 8) and the ria (n = 7) reaming system, and compared to a control group (n = 7). the animals were followed for 72 hours. simultaneously arterial, mixed venous and femoral vein blood were withdrawn peroperatively and until two hours after the nail was inserted for demonstration of pulmonary, systemic and local activation. results: significantly procedure-related increased levels were found for tat, t-pa and il-6 in the tr group and tat in the ria group. the local and the pulmonary activation of coagulation, fibrinolysis and cytokine response was more pronounced in the tr than in the ria group, but the difference did only reach significance for il-6 (femoral vein) and pai-1(arterial). the arterial levels of il-6 and tat exceeded the mixed venous levels indicating an additional pulmonary activation. these differences, however, did not reach significance. two animals in the tr group, who died prior to planned study end point, demonstrated higher inflammatory response compared to rest of the tr group. conclusion: the inflammatory response to the reaming and nailing procedure was modest, and the response was lesser in the ria group than in the tr group. introduction: approximately 1.5 million joint arthroplastic operations are performed annually worldwide. implant failure due to massive bone loss and aseptic prosthesis loosening, however, is a major complication of joint replacement. it is generally accepted that small particles (''wear debris'') and activated macrophages play a key role in aseptic loosening. but also the prosthesis loosening fibroblast (plf) plays an important role. material and methods: between 1992 and 1998 208 abg-1-hip arthroplasties were implantated. after a 7 year analysis 40% had to be removed because of massive wear of polyethylene (pe) and consecutive acetabular osteolysis. we analysed the influence of patient and surgeon, the implantdesign incl. pe-thickness, anchorage coupler, material roughness i.e. and the material i. medtronic) the application of the cements was done according to the specifications of the manufacturer. after extrapedicular kyphoplasty on cadaveric lower thoracic spine vertebrae (th 6-12), the intervertebral distribution pattern was investigated by microtomography (â lct). besides creating high resolution 2d and 3d reconstructions, the mathematic calculation of the porosity of the vertebra, the bone substitute material and the relative part within the different compartments was performed. of special interest were the characterization of the bone substitute material -spongiosa -interface and the penetration of the calcium phosphate cement into the adjacent spongiosa. the following parameters were investigated: 1. trabecular structure, porosity and hydroxylapatite concentration of the native vertebrae 2. structure (homogeneity, distribution of pores) of the bony substitute material 3. characterization of the bone-bone substitute-interface a. central located, filled kyphoplasty defect b. transition zone with spongiosa and bone substitute material c. solitary spongious bone results: the investigation of the native spongiosa yielded a comparable trabecular structure, porosity and hydroxylapatite concentration in the intra-individual comparison of the vertebrae of the lower thoracic spine. between the cements differences in the solitary structure as well as distribution pattern during kyphoplasty were observed. especially the analysis of the ability to penetrate into the spongiosa adjacent to the centrally located kyphoplasty defect yielded significant differences. the main influencing factor of the ability to penetrate into the spongiosa is the different viscosity of the -according to manufacturer specification -used calcium phosphate cements. the cements differ in their native structure as well as in their distribution pattern during kyphoplasty. the differences in micro-morphology of the calcium phophate cements have a high probability to influence the degradation of the sedimentation products and later osseointegration. disclosure: this research was funded by a grant of ao germany. introduction: it is difficult to predict the long-term clinical outcome in the early period following an acetabular fracture. introduction: the tremendous increase of acetabular fractures in the elderly provides new challenges for the surgical treatment of acetabular fractures. surgical reduction of the acetabular joint represents the most reliable possibility to prevent the development of premature arthrosis even in the elderly. biomechanical studies showed, that plates with periarticular long screws result in an increased stability of the osteosynthesis, it has to be considered that the insertion of these screws always bears the risk of penetrating the joint the aim of this study was to evaluate the biomechanical properties of these standard plates and newly developed minimal invasive osteosynthesis techniques for stabilization of an anterior column combined with posterior hemitransverse fracture type (acphtf), which represents a typical acetabular fracture in the elderly. material and methods: using a single-leg stance model we analyzed 3 different implant systems for the stabilization of acphtfs in synthetic pelvises (standard reconstruction plate, new developed prototype and definitive repofix ò (adi -ao foundation, switzerland). applying an increasing axial load in a biomechanical testing machine, fracture dislocation was analyzed with a multidirectional ultrasonic measuring system (zebris, germany). differences in change of center of gravity are statistical analysed by man-whitney-u -test. results: analog to a long bow, the repofix ò supports the quadrilateral surface sufficiently and reconstructs the surface of the pelvic brim from the inner side of the pelvis. in synthetic pelvises, the new repofix ò is associated with a significantly less pronounced dislocation (center of gravity) of the fractured quadrilateral surface when compared to prototype and the standard reconstruction plate. the biomechanical results could be seen at a measuring point at the quadrilateral surface and in the rotation around the x -axis (angle y results: we collected data on 68 acetabular fractures. a conventional image intensifier was used in 37 cases (group a), 3d-navigation was used in 31 cases (group b). in group a the kocher-langenbeck-approach was used in most of the cases (59%), followed by the maryland-approach (27%). in group b, the kocher-langenbeck-approach and the ilio-inguional-approach were used in an almost equal number of patients (32% / 35%), but extended approaches were only used twice. in 28% of the cases in group b fractures were stabilised by navigated placement of percutaneous lag screws. when we excluded the percutaneous operations in group b (n = 8), the difference in or-time between navigated (n = 23, 365 ± 129 min) and conventional treatment (n = 37, 264 ± 100 minutes) was significant (p < 0,001). in group a we detected relevant postoperative complications in 35% of patients. the complication rate was significantly lower in group b (4%, p < 0,006). the postoperative radiological analysis revealed a better qualitiy of reduction in group b (n = 23) with an average post-op fracture gap of 0,34 mm vs 1,58 mm in group a (p < 0,025). conclusion: by using a navigation system and a 3d image intensifier we found a significant increase in the or-time in the navigated group. however, in the postoperative radiological analysis, we detected a better quality of fracture reduction in the navigated group. navigation in combination with the 3-dimentional pictures of the iso-c 3d led to a better visualisation of the acetabulum, therefore the need for extended approaches was reduced. to our opinion, this explains the significant reduction of postoperative complications in group b. we conclude that navigation and a 3d image intensifier should always be used for orif of acetabular fractures. disclosure: no significant relationships. introduction: the traumatism is the first cause of the mortality in patients under 40. it means a serious incapacity in 1 of 4 trauma patients. the initial management in trauma patients is essential to improve these results material and methods: this is a prospective and multicentric study with the participation of 10 hospitals in catalunya (spain). the objectives are to improve the evaluation and the initial management of trauma patients, and to improve the knowledge of the frequency, the magnitude and the approach of these trauma patients. we defined 7 points to improve which are: to intubate patients with glasgow < 8 (1); to not remove the cervical collar without clinical or radiologic cervical exploration (2); to move trauma patients monitorized (3); to not move haemodinamically instable trauma patients (4); to use two thick intravenous cannulations (5); to take thorax and pelvic simple radiographies in the trauma box (6); to fix pelvis fracture with a grassland before moving the patient (7) we took more thorax and pelvic radiographies in the trauma box (from 45.2% and 27% in the first period to 62.3% and 50.5% in the second period, p < 0.05). and we also fixed more pelvis fracture with a grassland before moving the patient, from 24% in the first period to 48.6% in the second period. conclusion: the registration of the information about trauma patients allows the identification of the points to improve. we improved the evaluation and the initial management of the trauma patients, especially in the monitorization of trauma patients and in the management of the thoracic and pelvic traumatism introduction: there is wide evidence about the importance of having good protocols for assisting trauma patients and a teaching system for the personnel involved in this assistance is needed. it is also well known that the formation for assisting trauma patients in spain is not very much spread in general. material and methods: we describe how we have arranged the care for this type of patients in a level ii center and a teaching system for our staff and we prospectively analyze the impact of this specific formation by means of a questionnaire and analyzing how correctly the trauma team is activated. results: from november 2006 through october 2008 (23 months), 5 editions of our course have taken place and 54 people have participated (29,5% of the staff for whom the course is aimed to). we found a clear improvement on the results of the test (prior and after the course: 55% of improvement for physicians and 85% for nurses, p < 0.001) and the qualification of the final exam was superior. the incidence of rightly activated trauma team improved as the staff was completing the course. conclusion: we conclude by enhancing the importance of having adequate protocols for treating these patients and the correct means for teaching the personnel because they can improve the care of these patients. (tonk) score. this system is specialty specific and tries to eradicate the weaknesses in a previously published scoring system, which was generic. material and methods: a total score of 100 is assigned to each firm from the beginning and marks are deducted for missed documentation. 2 sets of notes are randomly selected from discharged patients for each firm, one from trauma and one from elective surgery, each having at least 2 entries. each case note is given 50 marks and the total deduction for both case notes are then subtracted from the total score of 100 to give the resultant score. the tonk score has four major parts comprising initial clerking, subsequent entries, discharge letter and legibility. an objective system of scoring the legibility of medical notes is part of the tonk score. this scoring system is easily reproducible and it's been validated using the kappa statistic. introduction: despite the increasing mechanization in medicine, clinical skills must be to the fore of medical occupation and consequently must have a main focus in medical training. especially in surgery, the mastery of basic clinical skills is of great importance for the young learner as it besides the knowledge of elementary principles substantially contributes to the understanding of the subject, the development on the wards, the operation theatre and the ambulance. in order to assure a standardized training using reliable, effective modern teaching methods, a ''train-the-teacher''-course was developed. material and methods: in an 8-hour training, the important teaching modalities and methods for surgical skills as skills lab, simulation, role play, 4-step approach are presented and trained in small groups with a maximum of 6 participants per group. furthermore, the training focuses on ,,giving adequate feedback'' and examining practical skills. the training is evaluated using a standardised evaluation form. furthermore, the teachers are evaluated by their students after each of their teaching sessions before and after the training. results: a total of 32 surgeons participated in the training program (5 chief physicians, 10 senior physicians). overall, the training was rated to be very good (54%) or good (46%). in students' evaluation, there was a significant increase in positive ratings for teachers' didactical compentencies as well as for their overall training after the participation in the training program. introduction: sports injury risk management and prevention is a very complex challenge that must be addressed 1 . one of the basic tasks is to perform epidemiological studies to estimate the risk in different types of sport. up to now many studies were conducted on injury rates in specific organised sports 2 . just a few taking into account any physical activity (pa) 3 . therefore only for specific sports data about the influence of higher sport skills on injury risk can be found 4 . the goal of our study was to investigate the relevance of motor skills and sport education on injury risk, including the total pa and the occurrence of any injury in any type of sport. material and methods: in two austrian secondary schools (gymnasien) fifty-five of 63 classes were asked to fill out a two sided questionnaire regarding pa and sports injuries within the last year. demographic data and information about the types of sport, the intensity and the occurrence of injuries was collected. 1090 pupils, 469 from a ''normal'' school (ng) and 621 from a ''sports-school'' (sg) filled out the questionnaire. in the sg every child has to pass an entrance exam containing basic coordinative and motor tasks as well as complex motion sequences in different types of ballgames. in the educational program of this school a strong emphasis is placed on sports. in the ng just the basic sport lectures are held. results: the total physical activity (pa) containing organised, unorganised sports and leisure time activities was significant higher in the sports-school (sg), 9.9 hours per week vs. 7.6 h/w (p < 0.01). the most performed types of sport were similar: in the sg soccer (n = 202, 43%), riding bike (n = 197, 42%) and running (n = 176, 38%); in the normal school (ng) riding bike (n = 260, 42%), soccer (n = 191, 31%), snowboarding (n = 171, 28%) and running (n = 154, 25%). proportionally there were more boys than girls in both schools: 64% boys, 36% girls vs 51% boys, 49% girls. boys (11.3 h/w, 9.5 h/w) were more active than girls (9.1 h/w, 5.5 h/w) in both schools. the rate of injury was statistically significant higher in boys (0.60) than in girls (0.47) (p < 0.01). the mean age was higher in the normal school 14.0 vs 13.4 years. the proportion on injured children was at the same highest level (34%) in 10 and 11, 12 and 13, and in 14 and 15year-olds. the ratio of injury per pupil is statistically significant higher in the sg (0.62) than in the ng (0.49) (p < 0.01). but including the extension of activity the injury risk is a little bit lower in the sg: 1.20 injuries in 1000 hours of pa vs 1.24. conclusion: it seems that better motor skills and intense sport education have no effect on the population risk 1 . the individual risk has to be investigated more extensively in future studies. references: 1 fuller, 2 spinks, 3 spinks, 4 schwebel disclosure: no significant relationships. introduction: pain is one of the main complaints of trauma patients in emergency medical care (1). in the netherlands, a third of all prehospital emergency medical systems (ems) rides concern trauma patients and yearly 860.000 patients are treated in the accident & emergency department (ed) due to an injury. significant deficiencies in pain management in emergency medicine have been identified (2) . as a consequence, patients unnecessarily suffer from pain, and also recovery and healing are delayed. furthermore, chronic pain is reported one year after trauma (3). there is no appropriate systematic approach to acute pain management in the chain of care for trauma patients in prehospital ems and the ed. aim: the aim of the research project is the development of a national evidence-based guideline for the management of acute pain in adult trauma patients in prehospital ems and the ed. during the open reduction we applied a incision allowing to remove soft tissues and to set fragments of fractured bone correctly. in 2 patients we performed close reduction of the fracture without the fixation because of a patient's age. results: xr 3 month after surgical procedure was done and in all cases we achieved consolidation of the ulnar fracture and good of radial head reduction. complication after the treatment was the paresis of the median nerve, neurosurgical procedure needed. the nails were remove 6,5 month after procedure (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) . after obtaining the union of the fracture and rehabilitation of the limb we removed the nails (3-6 month after procedure). conclusion: featured way of the operative treatment doesn't claim wide opening region of the fracture and reduces possibility of complications. dislocated radial head after close reduction and immobilization period shows full stability. years. data and x-rays were retrospectively gathered and analyzed. all fractures were scored according to the ao-pediatric classification. 58 patients were treated with solely closed reduction and cast immobilisation and 42 patients were additionally treated with k-wire fixation. spss version 15.0 was used for all statistical analysis. results: incidence of recurrent dislocation was significantly higher in patients treated solely with closed reduction (41%) compared to patients treated with additional k-wire fixation (19%) (p 0.018). the proportion of patients requiring a second surgical intervention was also higher in patients treated with closed reduction: 21% versus 5% of patients treated with additional k-wire fixation (p 0.023). additional k-wire fixation results in a relative risk reduction of 54% and 77% for recurrent dislocation and secondary surgical interventions respectively. complications of k-wire fixation comprised local infection (n = 2) and k-wire migration (n = 2). conclusion: additional k-wire fixation might reduce the incidence of recurrent dislocation and secondary surgical interventions after closed reduction of displaced distal forearm fractures in children. larger and randomized studies will have to be obtained to confirm the results from our data. radiographic controls were planned after one and six month and until the removal of the intramedullary nailing. we documented all peri-and postoperative morbidity, further operative procedures, the radiographic findings as classified by capanna and the time till removal of the nails. results: a cohort of 10 children (four girls, six boys) was recruited. mean patient age was 12,4 years (9-15 y). the bone defects included eight juvenile and two aneurysmatic bone cysts. four patient suffered earlier unsuccessful treatment after pathologic fracture. the other six presented with acute pathologic fractures (five humeral, one femoral). no postoperative complications occurred after the treatment combination of elastic intramedullary nailing, curettage, artificial bone substitute and autologous platelet rich plasma (gps ò-system). the radiographic findings showed at six month a total resolution of the cysts in eight cases (capanna typ i), in two cases a tiny residual cyst remained (capanna typ ii). the removal of the nails was possible after six to nine month. one fourteen year old boy (typ ii capanna) wished a further gps application to reach a total resolution. all patients showed very good functional results and no refracture occurred. conclusion: the gpsò-system enhances the treatment of bone cysts in children. it is a save method without additional perioperative complications. by this, total treatment time can be shortened and secondary procedures as difficult changes of the elastic nails will be lessened. technically the decisive factor is the debridement of the . albumin values were significantly lower in patients with two or three complications than those with zero complications (zero and two complications p = 0.001, zero and three complications p = 0.004). no significant difference in levels was found between one and zero complication (p = 2.94). admission albumin was not significantly lower in patients with wound infection than those without (30.20 ± 2.58 g/l versus 34.95 ± 5.47 g/l, p = 0.064). patients with a dry and intact wound had a higher mean albumin value than those with wound healing complications (mean albumin 38 ± 4.24 g/l versus 31 ± 4.23 g/l, p = 0.0001). conclusion: our study findings support the hypothesis that lower preoperative albumin levels are associated with a more adverse inpatient post-operative recovery. these patients can be identified and optimised early in preparation for adverse events likely to occur in the post-operative period. material and methods: the targon fn is a new kind of side plate with six locking screw ports. the two distal holes are used to fix the plate to the lateral cortex of the femur with angle stable 4.5 mm cortical screws. the proximal holes allow the implementation of up to four ''telescrews'' which cross the fracture site. these 6.5 mm screws are dynamic and allow therewith the collapse of the fracture at the femoral neck. we present a prospective study on 30 patients with a comparative 30 patients case control with a total hip cementless arthroplasty for the same indication at the same period. results: this new device show a lower incidence of complications on the first 3 weeks than with the total hip group. wereas the 3 month control show no difference between the two groups. there are an x rays neck collapse one year folow up in osté oporotic patients with singh 1 an 2 stade with no significant consequences on the functional score. conclusion: targon fn is a good alternative for older and multimorbid patients with less surgical burden and reduced early access morbidity in comparison to the prosthesis group. conclusion: the number of re-interventions and the mortality within one year after hip fracture surgery is sizable. nonetheless, our numbers are not unfavourable in comparison with international literature. the percentage of re-interventions in the cannulated hip screw group is significantly higher than in the other subgroups. on the contrary, the mortality in this group is low. this is undoubtedly an expression of our attempts to preserve the femoral head in vital, active patients. possibly, the combination of the two standardsnamely the re-intervention and mortality-is a new accurate performance indicator. informed. the operative treatment with lcp and tension bandages shows small morbidity regardless the comorbidities and the geriatric cohort. it remains standard procedure for periprosthetic fractures of the femur at our institution. we are expecting the number of periprosthetic fractures to be increasing rapidly. introduction: periprosthetic femoral fractures are rare but severe complications following total hip-or knee-arthroplasty. the incidence for of these fractures are increasing, caused by a raising frequency of total arthroplasty for both younger and elderly patients as well as by a higher life expectation. so far there are very little long-term results regarding this issue. material and methods: 25 patients (15 female, 10 male) with a mean age of 76 years (56-92) were clinically and radiologically examined on average 30 months after surgery. we investigated the prosthesis (total hip arthroplasty vs. total knee arthroplasty) and compared the treatment (revision arthroplasty vs. osteosynthesis) in this study. for the clinical examination we used the harris-hip-score (hhs), oxford-hip-score (ohs), the oxford-knee-score (oks), the sf-36 and the funktionsfragebogen hannover (ffh) which measured the functionality of patients in his daily routine in his environment. results: tha + osteosynthesis (n = 8) 25% of the patients had fair or better results with an average hhs of 61. 38% of this group had a good or excellent result with an average ohs of 33 and 12% had a ffh score of ‡ 50%. 50% of the patients had a possible hip flexion of ‡ 100°and (66% ‡ 90°). the average sf-36 score for this group was 28. tha + revision arthroplasty (n = 12) 50% of the patients had fair or better results an average hhs of 70. 58% of this group had a good or excellent result with an average ohs of 29 and 45% a mean ffh score of ‡ 50%. 75% had a possible hip flexion of ‡ 100°(100% ‡ 90° the results of the scores are mainly caused by the high age, the common multimorbidity and the low overall functionality of the patients and confirm the severity and importance of these kinds of fractures. most authors suggest a treatment of these fractures according to the classification by using osteosynthesis to treat stable fractures and revision for unstable fractures. however we see a slightly better outcome of the revision arthroplasty compared to the patients that were treated with osteosynthesis. we suggest more studies with a higher number of patients regarding this issue. introduction: fracture dislocation of the proximal humerus is a rare but challenging situation for the orthopaedic surgeon. if a closed attempt to reduce the dislocation fails, a demanding surgical procedure is required and the emergency setting is not always the best situation to face difficult cases. as a matter of fact a proper approach to this fractures involve an experienced surgeon, more than one assistant and a variety of instrumentation that often lack in emergency. fracture dislocation of the humeral head is related with a significant increase of the risk of the humeral head necrosis and it is widely accepted that these lesions are best treated in emergency, but there are no reports on the influence of the dislocation time on the results of the surgical procedure. with this study we wanted to determine if a delayed procedure could affect the outcome of these lesions and if there is a rationale in postponing the procedure to allow a better organisation of the surgical time. material and methods: we retrospectively analysed the clinical and radiological records of 22 patients admitted at out institute for fdhh between jan 2005 and jan 2008. ten out of them were operated in emergency while 12 with a minimum delay of 24 hours. all the patients underwent open reduction and fracture fixation with locking plates. results: the results of the two groups were similar and influenced mainly by the bone quality and age of the patient. it seems that a delay in the procedure do not alter the result in terms of rate of necrosis of the humeral head or influence a worse clinical outcome conclusion: on the basis of these results we do not consider these fractures as emergencies anymore: our preference is still an immediate operation provided the presence of an experienced surgeon, assistant and nurse and the availability of the proper instrumentation, conversely we believe that the risks of an immediate procedure overwhelm its benefits. introduction: minimal invasive plate osteosynthesis (mipo) should belong nowadays to the armentarium of each trauma surgeon. applied correctly, mipo not only meets the criteria of a ''biological'' osteosynthesis by minimizing invasivity as well as iatrogenic soft tissue damage caused by the operation, but can also provide adequate reduction and stability for fracture healing and early functional aftertreatment. up to date, only few publications report on mipo of humeral shaft fractures mainly using the antero-lateral deltopectoral approach for plate insertion 1-3 . material and methods: in this present study, we evaluated 29 patients (mean age 77 years, range 48-95) with displaced metadiaphyseal fractures of the proximal humerus treated in mipo technique using an angular stable long philos ò -plate. a lateral deltoid-split approach was used proximally and a brachialis/ brachioradialis intermuscular approach with exposure of the radial nerve was used distally. there were 23 acute fractures including two periprosthetic as well as one pathological fracture. three patients were operated after failed conservative treatment, one for delayed-union and two cases were revision surgeries. results: there were no infections and no iatrogenic injuries to the axillary and radial nerve, respectively. all the 29 patients were immediately allowed active shoulder and elbow movement. one patient had to be reoperated ten weeks postoperatively for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. this patient was successfully operated using the same method and implant. whereas one patient refused follow-up, 28 patients showed entirely healed fractures and satisfactory shoulder and elbow function after a mean follow-up of 8 months (range 3 -12 months). conclusion: minimal invasive long philos ò -plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe and viable procedure for the treatment of metadiayphyseal fractures of the proximal humerus with low morbidity and good functional outcome. introduction: plating for reduction and stabilization of proximal humerus fractures is a common orthopaedic procedure. however, angular and rotational malalignment is not an infrequent result, and extensive use of fluoroscopy is commonly involved. we checked the accuracy of a computerized navigation system(vector vision trauma navigation system, brain lab) to enhance multiplanar fracture reduction and to decrease the requirement for fluoroscopy. material and methods: 5 men and 7 women aged 36 to 78 (mean, 56) years underwent philos plate fixation for proximal humeral fractures. all fractures were closed with no associated injuries and classified as 11-a3 (n = 7), 11-b1 (n = 4), and 11-b2 (n = 1), according to the ao classification. the cases were assessed operation time, radiation time. and accuracy measurements were taken. results: patients were followed up for 6 to 37 (mean, 16) months. all the fractures united and occured no avascular necrosis. the mean operation time and radiation time were 74 minutes (range, 56-91) and 3.2 minutes (range, 1-7). the mean distance between fluoroscopy and navigation of reduction accuracy at the fracture site were 1.5 mm (range, 0-5). conclusion: the fluoroscopic operation using pilos plate was troublesome, but navigated operation was easy to reduce the fracture because of the 2 direction visualization at the same time. and computerized navigation has the potential for increasing precision in fracture reduction while minimizing fluoroscopic requirements at proximal humerus fractures. introduction: the proximal humerus fracture is a frequent fracture in the elderly people. the lower density of the bone with increasing age is one of the main reasons for implant failure after osteosynthesis with a range of 10-50 %. the options of therapy are including the screw-, platelet-or nail-osteosynthesis or the endoprosthesis.belonging to failure rates and the demand for early activity there is a tendency to be seen for early and strong stabilisation. material and methods: since august 2006 114 proximal humerus fractures were operated with the retron-humerus-shortnail. the average of age was 73,6 +-15,4 (28-96) years. the demographic data, bone quality and fracture classification were documented including procedure of reposition, details of the implants, complications and postoperative course. results: there were 8,3% a3 fractures, 52,1% c1, 27,1% c2 and 8,3% c3 fractures (ao-classification). the reposition was done in a closed mannor with a direct percutaneous assistance respectively. intraoperatively 2 secondary dislocations and 1 corticalis brake was to be seen. there have been 2 insufficient nailing procedures. 6 screws had to be exchanged. the gymnastic began immediately after operation or with a delay of 1-2 weeks depending on the fracture classification. the evaluation of the constant score is on the way. the results show a good stability of the nail especially in osteoporosis. comparing with platelets or antegrade nailing it is a minimal invasive procedure. the exraarticular access avoids any damage to the shoulder structures, especially to the rotator muscles. therefore early gymnystic of the shoulder is possible. shoulder impingement, screw dislocation and problems with the shoulder are avoided principally. the learning curve is short. shoulder score was used to evaluate functional outcomes. anova was used for statistical analysis, with significance set at p < 0.05. results: 307 files were available on 302 patients. failure rate was 15.6% at mean follow-up of 4.3 years and a mean ases-score of 75.3. there was a reoperation rate of 23.8%. mean age at operation was 62.4 years. mean operative delay was 4 days (range 0-98). delay did not influence outcome. young age at operation was associated with better results. when evaluating fracture characteristics significant better outcomes were evaluated with ao type aand b-fractures, valgus or neutral fracture type, the presence of impaction and less displaced fractures. quality of reduction and fixation of the fracture was evaluated with significant better results with anatomic reduction of the medial cortical border, less residual displacement and a ccd-angle that was corrected or in residual valgus. osteosynthesis failed significantly more in c-type fractures, in fractures with an avascular head fragment, in varus displaced fractures and in fractures where an anatomical reposition was not obtained. introduction: fractures of the proximal humerus are responsible for 4-5% of all fractures.the most extensive used operative treatments are the plate osteosynthesis and the intra-medullarry nail fixation with proximal locking nailsscrews. especially the latter technique can give iatrogenic injury of the axillary nerve. in this study, we define a safe-zone by using radiological parameters material and methods: the following procedure was performed in ten shoulders of embalmed specimen. first, the deltoid muscle was dissected from the clavicle. then the axillary nerve was identified together with its branches and was marked with clips and radioopaque wires. the muscle was then re-attached to its anatomical position.standard ap radiographs were made with the forearm in neutral (anatomical) position and exorotation. on these radiographs, the distance between the cranial side of the humeral head and the axillary nerve and its branches was measured. results: the median distance from the head of the humerus to the axillary nerve is 52 mm (sd = 4.5 mm, range 48-58 mm) measured on the ap radiograph in 90 degrees exorotation. the mean number of branches to the deltoid muscle is 3 three. the distances vary from 23 to 78 mm. the median distance from the first proximal branch measured from to the humeral head is 36 mm (n = 10, range 24-48 mm), to the second branch 54 mm (n = 10, range 40-66 mm), to the third branch 47 mm (n = 6, range 45-52 mm) and to the fourth branch 73 mm (n = 3, range 58-78 mm). conclusion: there is a great variation in the course of the axillary nerve and its branches. with the insertion of an intra-medullar nail from the proximal side or by placing locking-screws nails the surgeon has to reckon with the course of this clinically important nerve. it is unsafe to place the locking-screws nail in the zone between 24 mm and 78 mm from the humeral head with the arm in exorotation. the greatest risk to damage the main branch of the axillary nerve is in the zone between 48 and 58 mm. this study provides distances to avoid damage to the axillary nerve. in contrast to the existing literature these distances are measured from the humeral head. there are several reasons to use the humeral head instead of the acromion are: first, the distance between the humerus and the acromion can vary due to the preceding trauma, relaxation of the deltoid muscle or by manipulation of the arm. second, from an anatomical perspective, the position of the axillary nerve is determined by the position of the humerus due to the connection to the deltoid muscle. results: 15 emg/eng records were without pathologic variances of the axillary nerve. 5 of them pre-operatively showed pathologic variances. 2 of these 5 continued to show variances 3 months after the operation, which indicates a chronic lesion. just one patient showed a pathologic eng after surgery which was not seen before. the constant score was as expected. introduction: patella recurrent dislocation and patellofemoral pain syndrome is a common cause of instability in young patients and especially athletes. in the present study we present the results of the extension mechanism realigment throughout the fulkerson oblique osteotomy of the tibial tubercle and soft tissue balancing. material and methods: during the last two years 11 patients (7men, 4 women, mean age 29.6/ range 20-39) were treated operatively for recurrent dislocation of the patella using the fulkerson procedure. all our patients had as onset a traumatic dislocation of the patella that developed to recurrent. all patients were underwent knee arthroscopy for the treatment of potential chondral trauma or loose bodies removal and lateral retinaculum release. after that, we performed oblique osteotomy of the tibial tubercle, medialization and internal fixation with two cortical screws. this oblique osteotomy provides additionally to the medialization, anteriorization of the tibial tuberosity as we move it medially. moreover we perform medial plication. all patiens used functional brace locked in 0â º immediately after the operation and gradual rom increase untill the 8th p.o. week. results: the patients had no initial or long term complication. during their last follow up examination had a painless knee with full rom and marked improvement of the patella tracking. the mean lysholm score was improved from 63.2 to 90.5. no patella dislocation was referred. conclusion: our findings show that fulkerson procedure of the tibial tubercle osteotomy and anteriomedialization, with additional intervention on the lateral and medial patella retinaculum is an excellent option for the treatment of recurrent patella instability and relief of patellofemoral pain. disclosure: no significant relationships. introduction: injuries to the knee involving the anterior cruciate ligament (acl) are very common related to sports especially in soccer and skiing. more than 50% of those with acl injury will develop radiographic osteoarthritis (roa) within 15 years of injury although it is not known if return to sports is a risk factor for longitudinal roa development. in this retrospective study, we evaluated the long term radiographic and clinical results of acl reconstruction by comparing the injured knee with the contralateral knee in athletes returning to pre-injury sports. material and methods: twenty-eight patients (20 men and 8 women, mean age 20 years at the time of acl surgery, bmi 24.9 ± 2.9 kg/ m2) were studied. patients returning to previous sports and without meniscal injury at baseline were selected. acl reconstruction was performed using patella tendon or hamstrings tendon graft. radiological assessments using x-ray and a 3-t mri of both legs were obtained at a mean follow up of 8 years after acl reconstruction. roa was determined according to the classification of bohndorf. the ikdc score and tegner activity index were used for clinical evaluation and the knee injury and osteoarthritis outcome score (koos) for evaluating self-reported knee function. results: the 3-t mri revealed positive signs of roa on the operated knee in 36% and on the non-operated knee in 25%. these changes were however limited to small localized areas of the knees. the statistical difference of morphological and clinical outcome of acl reconstructed patients 4 weeks after injury vs. replacement after this period showed no significance (p = 0,09-1.0). the total ikdc score was 89.2 ± 9.3 points and the total koos was 92.7 ± 7.8. the median pre-injury tegner score was 8 (range 3-9) corresponding to 7 (range 3-9) at follow up. in 68% of the patients the tegner score was unchanged from pre-injury to follow up. according to the ikdc score 61% had type a symptoms, 36% type b, 3% type c, and none type d. conclusion: eight years after acl reconstruction in athletes returning to pre-injury sports, the risk of developing knee roa in the injured knee was not higher than the risk of developing roa in the contra lateral knee. disclosure: no significant relationships. radiographs and a mri of the knee were available for all patients. all patients were followed prospectively and lysholm, tegner and ikdc score were surveyed before treatment and after at least 12 months. after diagnosis, a brace immobilization with tibial supporter with full extension of the knee was applied for 6 weeks followed by another 8 to 12 weeks of pcl brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. all patients received concomitant physiotherapy. after at least 6 weeks, stress radiographs were taken for evaluation of the pcl. the further treatment depended on the harner classification based on the stress radiographs. in cases of grade a or asymptomatic grade b injuries, conservative treatment was continued. in cases of symptomatic grade b, grade c or d injuries, operative treatment with arthroscopic transtibial pcl reconstruction using single bundle hamstring tendons was performed. results: 27 patients were treated conservatively (group i), 18 patients had an arthroscopic pcl reconstruction (group ii). mean patient age was 30.7 years (range 17 -50 years). the mean tegner score in group i raised from 2.5 before treatment to 5 at follow up, in the operative group from 2.4 to 4.6. the mean lysholm score ascended in the conservative group from 49 to 83, in group ii from 42. introduction: the virtual reality (vr) 3d arthroscopy surgical simulator provides arthroscopy training on knees in a controlled, stressfree, and virtual-reality environment. it is unknown whether better visomotoric three-dimensional (3d) condition will facilitate arthroscopic training. therefore, our objective was to evaluate the visomotoric condition to novice individuals and assess whether visomotoric abilities ameliorates arthroscopic performance within a 2d surgical environment. material and methods: 164 medical students without any knee arthroscopic experience were investigated. both groups received a fixed protocol of simulator based arthroscopic skills training and a visomotoric skills test. this consisted of an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator. . their learning curve was assessed objectively using motion analysis. time taken, path length and roughness for probe and camera were recorded. results: motion analysis demonstrated objective improvement in performance during simulator training, if visomotoric skills performed better. conclusion: better condition of visomotoric skills lead to subsequent improvement at an arthroscopic vr skills training simulator. this may assume that visomotoric skills training before arthroscopic vr skills training is a useful tool. however further studies are necessary to find preliminary practice exercises to get a better performance at an arthroscopic vr skills training simulator. -ii and c-iii after tscherne § open fractures o-ii and o-iii after gustilo o urgent operative treatment § first stabilisation with miniosteosynthesis and external fixation § soft tissue debridement and their temporary closure o second look after 48 -72 hours, next looks after the soft tissue condition o delate treatmentdefinitive stabilisation -osteosynthesis conversion in 7 -10 days after injury. o type of osteosynthesis § orif with lcp distal tibia platesmedial or anterolateral § imterlocked intrtamedullary nail § external fixation -in cases of serious soft tissue defects we prefer fracture stabilisation ae serious soft tissue defects closing with rotation or microsurgery stem lobs. introduction: fractures of the distal tibial metaphysis account for 7.2% of fractures over the distal end of the tibia. many of them are high-energy injuries causing extensive articular damage and compromise the soft tissues. managing these fractures continues to challenge most orthopaedic surgeons, as soft tissue injury could be further compromised by unjudicious surgical technique. aim of the treatment is to restore physiological alignment of the distal tibia and stabilize the fracture with minimal damage to soft tissues. material and methods: we designed an implant for the stabilization of distal tibial metaphyseal fractures, and gave the name ''angle stable''. the features of the implant are: precontoured plate with holes above the distal metaphysis providing positioning of screws with angular stable characteristics. the screws are self tapping and self cutting at the threaded part (far end) and have a cylindrical shape with a rim at the near end, that tightly fits into the holes at a special angle, guided by a targeting device. the distal screws penetrate the opposite cortex, and when they are tightened, compression is achieved. the plate is introduced through a small incision and guided onto the surface of distal tibia. 4 screws can be inserted distally, proximal screws are inserted through stab wounds. biomechanical tests of this system were performed on cadaver bones. since 2005 the ''angle stable'' system has been used in 41 patients in 35 cases as a primary stabilization, and in 6 cases as conversion of external fixation. follow-up time was 18 months. outcome was assessed with regard to function, pain and alignment. introduction: the fracture of the distal lower limb with or without participation of the ankle joint remains a challenge to the surgeon. due to the high energy released at the time of fracture, these injuries are usually accompanied by a severe soft-tissue damage. the success of the surgical therapy of tibial pilon fractures depends largely on the extent of the soft tissue damage as well as the quality of reconstruction of the tibial joint surface. a problem of the minute anatomical reconstruction is an increase in soft tissue problems and bone infection. aim of this study was to investigate the results gained by a primary stabilization by external fixator followed by a multidirectional locked plate osteosynthesis after soft tissue consolidation. material and methods: setting is a level 1 trauma centre, the design a consecutive series with a retrospective data evaluation. between 2002 and 2005, 42 patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: 1. the fracture was stabilized with an external fixator immobilizing the ankle joint. 2. after stabilization of the soft tissue situation (mean 9.2 days) internal fixation with a locked-screw plate was performed. the implant used was a multi-directional locking internal plate fixator (tifix, litos, hamburg/germany), made of pure titanium with locking holes for titanium screws which can be fixed in different angles and is available in seven different lengths (3-7 holes in the diaphyseal area). the mean follow-up time was 27.8 months. all follow-up examinations were supervised by a specialized orthopedic trauma surgeon. the examination consisted of a set of standardized questions, clinical evaluation, the aofas score and radiographs. results: superficial wound-necrosis was noted 3 times, conservative treatment led to complete wound healing. dvt of the injured leg occurred in 2 cases. in 2 cases autologous bone graft was necessary after 2 and 3 months. deep wound infection or postoperative osteomyelitis was not observed. the definitive treatment was performed after an average of 9.6 days. in 9 cases an autologous bone graft was used. in a further 2 cases a later autologous bone graft was performed for delayed union at 9 and 13 weeks after orif. full weight bearing was reached after an average of 11.8 weeks. bony union was achieved in all cases after an average of 4.1 months as determined by conventional radiographs. in 6 cases range of motion (rom) of the ankle did not show any restriction compared to the opposite side. in 18 cases the range of motion was reduced by less than 1/3 compared to the opposite side, of up to 2/3 in 14 patients and restriction of > 2/3 was not noted in 4 cases. the mean aofas score was 73.4. conclusion: a twostage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result. disclosure: no significant relationships. introduction: the internal fixation for complex distal tibial fractures is sometimes challenging. nowadays, successful outcome were reported about osteosynthesis through medial and anterior approaches including minimally invasive plate osteosynthesis (mipo). however, there are cases in which such methods are not indicated because of their soft tissue problems or their fracture pattern. in this presentation, the new posterior plating procedure using the mipo technique is reported. material and methods: this procedure was indicated only when no other internal fixation methods were present, which includes intramedullary nailing or medial/anterior plating, were found. so the indication for this procedure was extremely rare. from 2005 to 2009, 34 cases of ao classification 43-a and c type fractures were treated operatively in our institution. 2 cases met the criteria. both of them were female and aged 66 and 37. the follow up period was 24 and 12 months. the procedure was as follows; before the operation, the spanning external fixator was applied and the alignment was reduced as properly as possible. the patient was in the supine position and the knee was flexed at about 90 degrees. the distal window for mipo was positioned between the distal fibula and achilles tendon, which is called a ''posterolateral approach.'' blunt dissection was performed, and exposed the edge of the flexor hallucis longs muscle (fhl). the tunnel over the periosteum at the posterior surface of the distal tibia was made and the plate was inserted. then an incision was made at the posteromedial border of the tibial shaft and exposed the proximal part of the plate (proximal window). the plate was placed properly under the image intensifier and fixed with screws. the wounds were irrigated and sutured in layers. postoperative rehabilitation included a range of motion exercise and non-weight bearing gait and use of crutches immediately begun. full weight bear was permitted around twelve weeks post operatively. time to union, complication and final ambulatory ability were evaluated. results: bony union was uneventfully completed within three months in both cases. there were no complications such as infection, skin problems, or plate irritation/impingement. free gait was achieved within four months in both cases. conclusion: posterior plating using the mipo procedure for complex distal tibial fractures can be a good option, although our experience is very limited. however, this procedure should be indicated only when no other osteosynthetic methods are found because irritation/ impingement of the fhl or the achilles tendon or some other complications may arise, which has already been reported in open reduction and internal fixation through posterolateral approach. references: hayes ag, nadkarni jb. extensile posterior approach to the ankle. j bone joint surg 1996;78b:468-470. disclosure: no significant relationships. introduction: even the most modern technology has failed to induce satisfactory functional regeneration of traumatically severed peripheral nerves. delayed neural regeneration and in consequence slower neural conduction seriously limit muscle function in the area supplied by the injured nerve. this inferiority study aimed to compare a new nerve coaptation system involving an innovative prosthesis with the classical clinical method of sutured nerve coaptation. besides the time and degree of nerve regeneration, the influence of electrostimulation was also tested. material and methods: the ischiatic nerve was severed in 14 female gö ttinger minipigs with an average weight of approx. 35-40 kg. the animals were randomized electronically to four groups: group i: nerve prosthesis without stimulation; group ii: nerve prosthesis with stimulation; group iii: microsurgical coaptation without stimulation; group iv: microsurgical coaptation with stimulation. in groups iii and iv, the nerve was sutured microsurgically, while the animals in groups i and ii received the new nerve prosthesis. postoperative monitoring and the stimulation schedule covered a period of 9 months, during which axonal budding was evaluated monthly. results: preliminary data indicate that results with the nerve prosthesis are comparable to those with conventional coaptation. the results of this pilot study indicate that implantation of the nerve prosthesis allows good and effective neural regeneration. this new and simple treatment option for peripheral nerve injuries can be performed in any hospital with surgical facilities as it does not involve the demanding microsurgical suture technique that can only be performed in specialized centers. disclosure: no significant relationships. in mean there were 5,6 previous operations. in 166 cases a change of osteosynthesis was neccessary. in 42 cases bmp 7 was used alone. in 223 cases bmp7 was expanded by autologeous bone grafting. in 21 cases the bmp was extended by autografts or ceramic scaffolds. results: divided in a healing group and a not healing group we found in the healing group a excellent clinical result by 8.9 points (able for sports) for the atrophic non unions and a good result of 8.1 points (walking long distances) for the post infected non unions. the radiological score is as high 8.1 / 7.9 (3 cortices healed and bridging callus). in the non healing group the clinical rate was 5.5 /4.9 (walking with splint) and the radiological rate was 4.9 / 3.4 (two cortices healed) the overall healing rate was 79%. divided in several groups the healing rate increases from 68% (infected non unions not tibia) to 93% (atrophic aseptic non union tibia). overal the secondary intervention rate was 14%. the healing time is 6.5 months in the middle. we see only mild side effects in 6%, like swelling. the most serious complication was the bony reinfection in 9%. there were 2 amputations. conclusion: compared to the literature the healing rate of non unions could be increased using a strong concept in the treatment. as a part of the treatment the bmp treatened group increases the healing rate from 81% (friedlä nder) to 93%. the results are similar to the papers from kanakaris or zimmermann. there were no significant side effects noticed. material and methods: methods: at our level i trauma institute, from july, 2007 to september, 2008 each patient who presented with a clavicle fracture that was deemed operative received plate fixation alone or supplemented with bioresorbable calcium phosphate cement or autogenous bone grafting. patient records and radiographs were retrospectively reviewed. follow-up included standard radiographs to evaluate union at a minimum of 6 months. all complications were also reviewed. results: results: two different clavicle plating systems, smith and nephew (smith and nephew, memphis, usa) (23 clavicles) and implant technology systems (i.t.s., lassnitzhohe, austria) (30 clavicles), were used with orif alone (11), autogenous bone graft (14 patients), or bioabsorbable calcium phosphate (28 clavicles). of 53 patients treated with open reduction internal fixation, 6 complications have occurred at a minimum of 6 month follow-up. three prominent hardware occurrences necessitated plate removal. one nonunion, one distal screw cut-out and one hardware breakage have been treated successfully with revision plating. using fisherâ e tm s exact test, no statistical significance was seen between the orif alone, autogenous bone grafting (2) and bioabsorbable calcium phosphate (4) in regard to overall failure incidence (p = 0.66). complications necessitating revision orif with bioabsorbable calcium phosphate (2) and bone graft (1) were not statistically significant either (p = 0.73). conclusion: there appears to be no statistically significant difference between union and complication rates between orif alone, or orif augmented with bioresorbable calcium phosphate cement or autogenous bone graft in this retrospective study. introduction: the purpose of the present study was to determine the effect of two anti-osteoporotic treatments on fracture healing in osteoporotic ovx rats, 28 days after fracture occurrence. pth which has been proven to influence fracture healing in ovx rats, was taken as a control treatment. strontium ranelate is acting on both resorption and formation. we combined the rat model of a closed, standardised diaphyseal fracture of the femur with the model of a post-ovariectomy osteopenic rat, mimicking post-menopausal bone loss. material and methods: forty-five animals were ovariectomised at the age of 12 weeks and a further 15 were sham operated. at the age of 24 weeks, osteopenia in the ovx rats was diagnosed. then, in all animals, a standardised mid-diaphyseal fracture was induced. at the time of fracture, the animals were divided into four groups. group 1 was the sham control group, groups 2, 3 and 4 were the ovx treatment groups. groups 1 and 2 were treated with nacl 0.9% s.c. daily, group 3 was treated with 600 mg/kg/d strontium ranelate p.o. daily and group 4 received 20 lg pth 1-34 3x/ week s.c. the animals were killed after 28 days and the fractured femur removed. the samples were scanned using microct 80 by scanco medical, zurich, switzerland. the evaluation of the data focused on outer callus contour, cortical contour and marrow contour as well as cortical thickness. torsion testing on the bones was carried out using the axial-torsional 8874 system by instron (darmstadt, germany). results: treatment with strontium ranelate significantly improved the mechanical properties of the callus when compared to the ovx control group, while the improvement induced by the treatment with pth 1-34 did not reach significance. pth 1-34 and strontium ranelate both showed a significant increase in bone volume of the callus when compared to ovx control rats with no significant difference between the two treatments. as for the callus tissue volume, the increase induced by strontium ranelate was significant compared to ovx whereas pth induced no change and the difference between both drugs was significant . in both the pth 1-34-and strontium ranelate-administered animals bv/tv was significantly increased compared to the ovx control rats . the bv/tv of the pth-treated rats was even higher than in the sham rats. conclusion: this is the first report on the enhancement of fracture healing with strontium ranelate. the callus in strontium ranelatetreated animals is even more resistant to torsion in comparison to ovx and sham-untreated animals and even to those treated with pth 1-34. pth did not significantly enhance the resistance of the callus versus ovx, despite a significant increase in bv/tv within the callus. the superior results obtained with strontium ranelate compared to pth could be the consequence of a better quality of the new bone formed within the callus. introduction: recent clinical and animal studies suggest an elevated homocysteine serum concentration to be a risk factor for osteoporosis and fragility fractures (1) . in vitro studies showed that increasing homocysteine concentrations stimulate the activity of human osteoclasts (1). however, there is no data demonstrating that circulating homocysteine is related to structural and biomechanical properties of human bones. this study aimed to investigate the relation between morphological as well as biomechanical bone properties and homocysteine serum concentrations in humans. material and methods: fasting blood samples and femoral heads were obtained from 94 males and females who underwent hip arthroplasty. bones were assessed by dual energy x-ray absorptiometry (dxa), biomechanical testing (indentation method), and histomorphometry. blood was sampled to measure homocysteine, folate, vitamin b6, and vitamin b12. according to their homocysteine serum concentration, subjects were classified as hyperhomocysteinemic (> 12 lmol/l, n = 47) and normohomocysteinemic (< 12 lmol/l, n = 47). results: folate and vitamin b6, but not vitamin b12, were significantly lower in hyperhomocysteinemic subjects when compared to controls. however, dxa, biomechanical testing, and histomorphometry did not reveal significant differences in bone quality between hyperhomocysteinemic subjects and controls. the results of the present study do not indicate a significant relation between circulating homocysteine and morphological as wells as biomechanical bone properties. introduction: sometimes fractured bones heal poorly with standard treatment and sometimes a bone defect is a major problem. although the bone grafting technique is considered a standard, there is a need for enhancement of this procedure. healing of the cancellous bone is a complex process in which many inflammatory and signaling molecules take part. to improve the outcome of the healing process, one can influence it by applying platelet rich plasma gel locally, thereby releasing cytokines and growth factors (1). cancellous bone is rich with mesenchymal stem cells that produce new bone when stimulated. material and methods: we enlisted 8 patients with hard to heal fractures and fractures that demonstrated poor healing in the study. five of the patients had osteomyelitis in the fracture and all fractures resulted in a bony defect as a serious complication after treatment. we designed a protocol for the preparation of allogeneic platelet rich plasma gel with suspended autologous cancellous bone, based on laboratory experiments in vitro (2) . cancellous bone was harvested from iliac bone crest. we used standard ab0 and rhd identical, leukocyte depleted and irradiated platelets from a blood bank. activation of the platelet gel was achieved by using a cacl2 and thrombin mixture. we accepted patients after fulfilling the inclusion criteria and they were operated on in a standardized manner by their elected surgeons under technical supervision. in their follow-up, the ingrowths of bone grafts were measured by using x-ray analysis (3). results: in 6 patients the transplant was sufficiently incorporated in the fracture to give a limb full function. there were no major complications related to the platelet rich plasma additives. in one patient a nerve paresis was observed, which resolved spontaneously. in 2 patients bone graft was not sufficiently incorporated, once because of poor compliance and the other time because of complex nature of distal tibia fracture. the clinical outcome of the operated patients (75%) is satisfactory and encouraging. conclusion: the preliminary clinical results show that using platelet rich plasma and cancellous bone in the treatment of large bone defects has a promising therapeutic potential. (1) marx re. platelet-rich plasma: evidence to support its use. time from injury to reduction and to surgical intervention was noted. apoptosis was verified by microscopy with tunel, hematoxilin and eosine stained specimens after decalcification of the samples, a time consuming process. the number of live, apoptotic and necrotic chondrocytes were counted. the patients are followed with harris hip score, merle de aubigne score and radiographs for two years. results: 7 patients were admitted directly to our hospital, the rest transferred from other hospitals. 18 patients had their hip reduced after a mean time of 276 minutes. 2 had femoral traction applied and 3 patients were not reduced. mean time from trauma to operation was 6 ± 3.8 days. three patients received total hip arthroplasty. the results of will be presented at the congress. conclusion: the conclusions will be given at the presentation. introduction: distal inter-locking using free-hand technique in intramedullary nailing is always a time consuming procedure. the use of xray amplifier is mandatory and the exposure to radiation is rarely modest. if we use navigation devices we rarely trust the device completely and that is why we check the position with x-ray amplifier more than we need to. that is why we did laboratory testing of the new system using the electromagnetic navigation with the use of micro sensors for free-hand interlocking technique in laboratory without the use of x-ray amplifier to ensure the use of system in the operating theatre. material and methods: three residents with little experience in distal interlocking and no experience with this device were testing the electromagnetic navigation system with the use of micro sensors for free-hand interlocking technique. 100 interlocking holes were drilled by the use of guiding star platform in lidis module, ekliptik, slovenia. the system producer had 20 minutes of introduction time, afterwards drilling was done. distal locking was done on utn synhes nail and instead of bone, cannulated hard wood rods were used. we measured time needed for calibration and time needed for reaming and weather we were successful or not. introduction: percutaneous catheter drainage (pcd) is a useful method to manage pericardial effusion. however, pcd is not always effective in a case of hemopericardium due to clot. to perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method following finger dissection by subxiphoid approach, which was preliminary reported in 2005. we present the final data to report the usefulness of blind subxiphoid pericardiotomy (bsp) for emergency cases with acute hemopericardium. material and methods: we designed a study to determine a favorable management for cardiac tamponade due to hemopericardium. emergency 148 patients with acute hemopericardium secondary to trauma (n=12), acute aortic disease (n=122) and cardiac rupture following acute myocardial infarction (n=14), were the subjects. board certified surgeons performed bsp (n=16) and other emergency physicians performed pcd (n=67) for patients with cardiopulmonary arrest (cpa) or near cpa due to cardiac tamponade from 2000 to 2004. since 2005, bsp (n=37) or pcd (n=28) has been performed at the physicians' discretion. results: bsp was effective to relieve cardiac tamponade in all 53 cases but pcd was ineffective in 12 cases (12.6%, p=.008) because of clot in pericardium (n=10) or right ventricular puncture (n=2). in addition to ineffective drainage, acute occlusion of percutaneous drainage tube (n=4) were observed and resulted in 2 deaths in the pcd group. procedure-related complication rates of bsp and pcd and survival rates of bsp and pcd were 0% and 16.8% (p=.001), 18.9% and 6.3%, respectively (p=.018). sixteen patients (bsp, 10; pcd, 6) could discharge following emergency surgery (n=13) or conservative treatment (n=3). conclusion: blind subxiphoid pericardiotomy was safe and could be performed quickly in an emergency situation. percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clot in pericardium in some cases. disclosure: no significant relationships. introduction and objectives: heart trauma, mostly penetrating, is not common in our community, but carries a significant morbidity. its clinical presentation can be variable. our objective was to asses the incidence, clinical presentation, associated injuries and mortality of our patient population with trauma to the heart. material and methods: observational, descriptive, retrospective analysis of patient with heart trauma included in our trauma registry between 1993 and 2007. we reviewed demographic characteristics, mechanism of injury, associated injuries, injury severity score (iss) and new injury severity score (niss), mortality, triss probability of survival (ps), and hospital length of stay. results: we found 17 (1.1%) patients with cardiac traumatism out of 1.575 patients included in our registry, 6 (35%) with associated injuries and 11 (65%) isolated; 13 (76.5%) were from penetrating trauma, and only 4 (23.5%) were from blunt trauma. mean iss and niss were of 28 (+/-12) and 35 (+/-14), respectively. three patients presented ''in extremis'' (agonal status), nine presented with hemodynamic ''stability'' (sbp> 90 mmhg) (33% of them with a hr> 120 bpm), and five patients presented with hemodynamic instability. only 30 % of the patients presented with cardiac tamponade, without hemothorax. two pericardiocentesis (12%), 3 pericardial windows (18%), and 4 emergency room thoracotomies were done (23.5%). the most frequent location was in the left ventricle, followed by right atrium and right ventricle. the most frequent associated injuries were in the lungs (53 %), followed by the abdomen and vascular injuries (44.4 %). fifty-nine percent required icu admission, with a median length of stay of 25 days. ten patients died (59%), and three of them (17.6%) were dead on arrival. two patients (22.2%) died with a ps > 0.50. conclusion: heart trauma is not frequent in our community, and displays great variability in its clinical presentation, with a high mortality. over half of the patients presented with hemodynamic ''stability''. disclosure: no significant relationships. approach of two cases of secondary aortoesophageal fistula results: the 1 st patient was a 57-y-old man in which fistula was secondary to a fish-bone ingestion, 10 days before the admission. in the 2 nd cause, a 66-y-old man, fistula was secondary to rupture in oesophagus of a known thoracic aortic aneurysm. diagnosis was made by a contrast-enhanced ct scan; a gastrografin x-ray in the1 st and an endoscopy in the 2 nd case completed the examination. in both cases the lesion consisted of a few-mm-diameter defect of the oesophageal wall. in the i case an emergent endovascular repair of thoracic aorta by bolton relay 28·110 mm stent graft was per-formed; in the ii case, endovascular repair of thoracic aorta (by bolton relay 28x145 mm) was associated to an endoprosthesis placement for primary treatment of a preexisting infrarenal abdominal aortic aneurysm. postoperatively tpn was administered. definitive treatment of fistula was performed in both cases by an explorative right thoracotomy (in v and vii post-operative day respectively): oesopagus was primarily repaired and reinforced by a pedicled intercostal muscle flap and a nutritional jejunostomy was associated. subsequent post-operative course consisted in ne administration, prolonged nasogastric suction, resuscitation with fluids, antibiotics. hemorrhagic complications or infections were excluded by repeated ct scan. oral feeding was in 19 th and 7 th postoperative day, after exclusion of a persistent fistula at a gastrografin x-ray of oesophagus. hospital stay was of 30 days in both cases. no late complications were registered at follow-up. conclusion: when an aortoesophageal fistula occurs (if consists of a small oesophageal lesion), emergent treatment of endovascular aortic repair can be successfully associated to a second-step primary repair using a pedicled intercostal muscle flap via a right thoracotomy. results: case 1: a 51-year-old male is taken to our hospital after a car crash. on ct scan there was a periaortic hematoma from isthmus to diaphragm, multiple rib (flail chest) fractures, and a pelvic fracture. the aorta was repaired with an endograft with good immediate results. case 2: a 55-year-old male, injured in a frontal car crash. on ct scan a mediastinal periaortic hematoma was seen, with a pseudoaneurysm at the origin of the descendent thoracic aorta, distal to the sublavian artery. the aorta was repaired with an endograft, which was replaced at day 16th because of a leak. on follow-up he is doing very well. case 3: a 26-year-old male, injured in a car crash. ct scan findings were as follows: a left diaphragamatic herniation, bilateral lung contusion, traumatic laceration of the descending aorta, pelvic fracture and spleen laceration. he underwent an emergency laparotomy with splenectomy and diaphragmatic repair. on the 2 nd postop. day an endograft was placed at the descending thoracic aorta, without complications. case 4: a 68-year-old male, injured in a frontal car crash. on ct scan there was a thoracic aortic laceration, distal to the isthmus, and an aortic endovascular repair was undertaken at day 10 th , after complete hemodynamic normalization. the patient died at day 58 th from multiple organ failure. conclusion: traumatic thoracic aortic injuries are frequently associated to severe thoracic, abdominal and orthopaedic injuries. traditional early surgical aortic repair through thoracotomy, with single lung ventilation and, occasionally, extracorporeal circulation carries a high morbidity and mortality. that is the reason why aortic repair has classically been delayed, but this carries an additional mortality rate of between 6% and 9%. endovascular treatment allows for an early management in severely traumatized patients who otherwise wouldn't stand such a risky surgery. it has also revealed lower rates of paraplegia after 10 years of follow-up. introduction: injuries in zone i of the neck are rare and difficult to manage particularly in environment of war. this area gathers aerodigestive, vascular, lymphatic and nervous elements. all the difficulties lie in diagnosis of the lesions, in the decision of a surgical exploration and in the way of repair if necessary. in that situation, fistula between carotid artery and jugular vein is very uncommon, accounting for 4% of all arterial injuries. through one case, which has occurred in afghanistan, we discuss the various possible solutions to repair such a lesion. material and methods: we report one case of a french soldier, 30 yo, who was wounded by a rocket splinter on left side of the area i of the neck. he was transported immediately in french role ii in kaboul. respiratory tracks are not injured, there's no neurologic lesions. he had a huge haematoma of the area with a tracheal back pushing (xray exam). during an effort of cough, a haemorrhage through the wound occurred requiring an oro-tracheal intubation and a surgical exploration by a cervicotomy. no obvious vascular lesions were found but just a thrill at the base of the neck. the patient was hemodynamically stable. he was transferred by medevac to france in the night. an angioscanner showed a fistula between carotid and jugular vein (2 photos). results: he was re-operated 24h after. the fistula was just behind the first rib requiring an enlarging by sternotomy to control the origine of left carotid. there was a section of left pneumogastric nerve. after exclusion of the fistula and the vein, we interposed an allograft on carotid artery (3 photos). the patient discharged from the hospital one week later without lateral damage except a bitonal voice with no need of re-education. conclusion: arterio-veinous fistula is an uncommon consequence of carotid injury. the taking in charge of this patient and the decision of the kinds of repair are difficult. stenting has also been used to repair distal internal carotid injuries that are not easily approached surgically. the favorable outcome of this case illustrates that surgery is a reasonable alternative when an endovascular approach is not feasible in patients with trauma-acquired arteriovenous fistulae. allograft or vein graft, if possible, is also a good solution for this kind of injuries. introduction: we report 3 cases of subclavian artery injury caused by traffic accidents. in all cases, surgical vascular reconstruction was undertaken. in 2 of the cases, the subclavian artery was obstructed by intimal dissection caused by falling down from a motorcycle. in the remaining case, subclavian artery aneurysm caused by seat belt injury occurred. material and methods: case 1: 59-year-old male while driving a large motorcycle, the patient collided with a car and the left side of his body was trapped in the car. this resulted in traumatic pneumothorax and severe ischemia of his left upper limb, and he was transported to our level 1 trauma center for surgical treatment. bypass surgery using a 6mm diameter ptfe was performed. postoperative arteriography showed good patency of the graft and the patient was discharged. recovery from the motor dysfunction caused by brachial plexus injury took 7 months. case 2: 19-year-old male for this case, the patient ran into a wall while driving a 50 cc motorcycle. bypass surgery and clavicular orif were undertaken simultaneously for right clavicular fracture and ischemia of the right upper limb. postoperative arteriography showed good patency of the graft and the ischemia improved. however, rehabilitation was needed for the motor dysfunction caused by brachial plexus injury. case 3: 68-yearold female the patient ran into a tree while driving a car resulting in hemorrhagic shock caused by bilateral femoral and humeral fractures. she was transported to our center by helicopter. a scar from seat belt injury was found in the right cervical area. she presented with an expanding mass around the subclavian artery with accompanying pulsating pain. arteriography detected a 5 cm-diameter pseudoaneurysm and aneurysmectomy was undertaken. postoperative computed tomography confirmed the disappearance of aneurysm and she was discharged. results: these 3 cases showed favorable outcomes with surgical vascular reconstruction. conclusion: traumatic subclavian artery stenosis is caused by crushinduced local dissection and is frequently complicated with brachial plexus injury. subclavian artery aneurysm caused by seat belt injury occurred. disclosure: no significant relationships. results: case description: 40 years old male patient who was brought in after receiving a large stab wound below the mid-portion of the left clavicle. severe external bleeding was prevented by manual compression in transit to the hospital. three foley catheters introduced through the wound at the ed failed to temporarily control the bleeding due to its large size, and he was rushed to the or. an emergency left antero-lateral thoracotomy allowed for the blind manual compression of the bleeding vessel from within the thoracic cavity, and was very successful in stopping the external bleeding. a long supra-and infra-clavicular incision was done, and the clavicle was divided. this failed to expose the bleeding vessel, due to the large muscle mass of the patient. a decision was taken to split the sternum in a ''trap-door'' approach, which nicely exposed a large laceration of the subclavian vein. this was suture-ligated, and the incision closed, in a surgical field with profused oozing from coagulopathy. he was taken to the icu, and then back to the or two hours later because of persistent bleeding through the chest drains. the ''trap-door'' incision was reopened and careful haemostasis was performed. the patient had a protracted course in the icu but eventually recovered. as a striking and very uncommon sequel he developed severe blindness from bilateral ischemic optic neuropathy attributed to hypotension and use of vasopressors. he is free of pain at the incision and with good cosmetic results conclusion: ''trap-door'' incisions are very infrequently used nowadays, but should be kept in mind in the armamentarium of trauma surgeons. disclosure: no significant relationships. conclusion: mortality in patients with ivc injuries can be well predicted by hemodynamic parameters on arrival and intra-operative findings .hemodynamic instability and intraoperarive findings of expanding hematomas and active intra-peritoneal bleeding are associated with high mortality. introduction: vascular complications due to intravenous drug abuse pose significant challenges to vascular surgeons and no standardized surgical management of the resultant infected pseudoaneurysm was established. material and methods: we present our successful management of a case of an expanding retroperitoneal haemathoma due to external iliac artery pseudoaneurysm caused by self inflicted trauma (heroin administration). mri showed an external iliac artery pseudoaneurysm surrounding by an infected old haemathoma, venous thrombosis (external illiac and femoural) and multiple muscular abscesses of the left thigh. a self-expandable stent-graft was deployed across the pseudoaneurysm after crossing the lession with an exchange glide wire through the left brachial artery route. post-stenting angiography showed complete exclusion of the pseudoaneurysm with no residual stenosis. we decided local surgical debridement; after haemathoma evacuation we identified external illiac artery presenting a stent graft and reinforced it by double layer of tissue sealing surgical patch. results: postoperative course was favorable under complex general and local therapy. conclusion: endovascular treatment of arterial pseudoaneurysms has become feasible as natural extension of the endovascular techniques. ct, mri, sonography and angiography may all be valuable in the imaging working of pseudoaneurysms. prompt diagnosis and treatment are necessary to avoid the morbidity and mortality secondary to hemorrhage and rupture. although endovascular stent-grafting is not considered a standard therapy for infected aneurysms, our case suggest that stent-graft deployment, secondary surgical debridement and major antimicrobial therapy may be the most favorable treatment option for patients unfit for major surgery. introduction: the incidence of traumatic vascular injuries (tvi) has increased significantly in the last decades, with penetrating trauma as the most frequent mechanism. our aim was to estimate the incidence, management by interventional radiology, and the preventable death rate in our patient population. material and methods: a retrospective observational study based on our trauma registry covering a 14-year period (july 1993 to july 2007) . we have assessed the demographics, severity, diagnostic and therapeutic approaches, outcome, and triss probability of survival (ps). results: 76 patients (80% males, with a mean age of 37 years) suffered a tvi located at the head (2), neck (7), thorax (20), abdomen (4), upper extremities (19) and lower extremities (24), respectively. 39 (51.3%) were caused by a blunt mechanism, and 37 (48.7%) by an open one. the average time spent before being taken to hospital was 60 minutes. upon arrival to hospital, 20 were in shock, 22 required orotracheal intubation, and 2 a cardiac massage. the diagnostic methods used were a ct scans in 54, dpl in 1, fast in 7, angiography in 16, echocardiogram in 4 and duplex-doppler in 1. 69 (90.8%) patients underwent emergency surgery and 8 (10.5%) were treated with interventional radiology (7 of them associated with surgery). only 6 (7.9%) were treated conservatively. overall mortality was of 12 patients (15.8%) (6 of them died upon their arrival to hospital or in the operating room, all of them with an aortic injury), out of which 5 (6.6%) had a triss ps > 0.5. the incidence of tvi increased from 15 cases in the 1993-1997 period to 30 in 1998-2002, remaining stable in 2003-2007 (31) . however, the mortality rate has shown a steady decline over the years (from 33% in 1993-1997, to 16% in 2003-2007) . conclusion: the incidence of traumatic vascular injuries has increased considerably during the last years in our hospital. these injuries are most commonly located in the lower extremities, followed by the thorax. 10% of patients could be managed by interventional radiology techniques. introduction: the tip apex distance (tad) is a simple measurement that predicts screw cut out in the femoral head in peritrochanteric fractures treated with a fixed angle sliding hip screw device. we wanted to assess whether the tad measurements in our centre were comparable to previously published results, how reproducible these measurements were between observers and how accurate we were at reducing the fractures. material and methods: a retrospective review was conducted of 102 consecutively treated peritrochanteric fractures over a 12 month period. 11 patients were excluded because they did not sustain a peritrochanteric fracture, had treatment of a pathological fracture or because of incomplete radiographic data. three observers used a standardised method to measure the tad (from 2 orthogonal projections with a correction for magnification). the stability of the fracture patterns and the accuracy of reduction were measured according to criteria from the original baumgaertner paper 1 introduction: distal locking screw insertion of the short gamma 3 nail is normally performed by using a targeting device attached firmly to the proximal part of the nail. generally, the accuracy of targeting device should be promising. however, missing the target in the process of drilling might be a potential risk. we report 5 cases of such condition in term of early radiographic finding, method of solving and the result of treatment. material and methods: the patient records, operative notes and intraoperative c-arm images of the patients underwent short gamma 3 nailing for unstable pertrochanteric fractures during october 2008 to october 2009 have been reviewed in order to identify an error of distal locking screw insertion via a targeting device. the intraoperative radiographic finding, solving procedure and the outcome has been analyzed. results: there were 64 cases of short gamma 3 nailing over the past one year in our institute. five of which had an error during distal screw insertion even using the targeting device. an error occurred in the drilling process in all cases. intraoperative images showed that the drillbit missed its target posteriorly after perforating the near cortex of the femur. all has been corrected by using a free-hand technique under c-arm guidance. no any serious complication afterword and all fractures healed in an appropriated time. conclusion: distal screw insertion during gamma 3 nailing can be missed even though using the targeting device. therefore, radiographic confirmation on the lateral view after perforation the near cortex is recommend in all cases in order to obtain early detection prior to bicortical perforation. freehand technique can be carried out in order to correct the error. . systemic antibiotics were used in 36 patients (92%). ten different types of antibiotics were used after wound exploration for a period between 1 and 12 weeks. in-hospital mortality was 15%. sixty-nine percent (n=27) was finally discharged from follow-up. conclusion: we conclude that our infection rate was higher than reported in literature and the infections classified initially as superficial required a prolonged treatment as well. moreover, the treatment of this disastrous complication showed no uniformity whatsoever and should be the topic of further research, resulting in a clear protocol to increase survival and decrease morbidity. introduction: allograft meniscal transplantation is known as a possible procedure to solve pain and loss of function in the knee of patients with a history of subtotal or total meniscectomy. medium-term and long-term results after meniscal allograft transplantation in the knee are scarce. in this study patients who received an arthroscopically assisted meniscal allograft transplantation with a follow-up between 5 and 15 years were evaluated using subjective questionnaires, a clinical and a radiographical evaluation. material and methods: demographic data of all patients were collected and pre-operative results, using the koos (knee injury and osteoarthritis outcome score), the lysholm score, the tegner score, the sf 36 and the vas (visual analogue scale) for pain were compared with actual results of those questionnaires to evaluate the therapeutic effects of allograft meniscal transplantation in the knee during medium-term follow-up. patients were evaluated with a standardized clinical examination of the knee to objectivate knee related symptoms. standard weight bearing radiographs and a full leg standing radiograph were performed to evaluate the evolution of osteoarthritis and malalignment. results: for all questionnaires (vas, koos, lysholm, sf 36) there is a significant (p<0,0001) and clinically relevant increase in postoperative score. this improvement stays consistent during the followup period. the more severe the osteoarthritis, the lower the improvement. despite the meniscal transplantation, there is still a significant (p=0,0006) increase in osteoarthritis. an increase in osteoarthritis grade was seen in 42% of the patients, as scored following the kellgren-lawrence classification. when strictly respecting the indications, there is no significant correlation between preoperative cartilage damage, pre-operative osteoarthritis, alignment deviation, gender and body mass index on the one hand and outcome scores or improvement on the other hand. conclusion: meniscal allograft transplantation results in important pain relief and functional improvement in patients with a history of (sub)total meniscectomy and pain localized in the affected compartment. strictly following the indications, meniscal transplantation can give good and predictable results. introduction: intramedullary nailing of the tibia has become the conventional therapy for tibial shaft fractures. one of the most common complaints associated with this procedure is chronic knee pain. incidence rates between 10% and 86% have been reported and a significant number of patients have problems in kneeling, affecting professional and recreational activities. surgical damage to the infrapatellar nerve is one possible causative factor for post-nailing knee pain. the infrapatellar nerve is exclusively sensory and runs subcutaneously almost perpendicular to the patellar tendon just below the patella. the purpose of this study was to determine the prevalence of chronic knee pain in our institute and its relation with sensory disturbances in the knee area. material and methods: a chart review was conducted. all patients between 15 and 65 years with healed traumatic tibial shaft fractures treated with an intramedullary nail between 1998 and 2008 were included. exclusion criteria were: fracture lines extending into the knee or ankle joint, any other fracture in the affected leg, lacerations in the knee area, pre-operatively existing knee pain and loss of follow-up. chronic knee pain was defined as persisting pain in the knee area 6 months after tibial nailing. sensory disturbances were defined as hyperesthesia or anesthesia at the nail entry site. introduction: femoral nailing causes an influx of fat in the circulation. in the multiply injured patient, especially in the patient with concomitant lung or brain contusion, this can lead to ards, fat embolism syndrome and multiple organ failure. the timing and kind of fixation of femoral fractures in patients with multiple injuries is controversially. the advantage of damage control orthopaedics (external fixation) would be less fat embolisation but some authors report more problems of infection and delayed healing. the aim of our study was to investigate the effect of external fixation on healing and infection rates of femoral shaft fractures in the multiply injured patient. material and methods: between january 1998 and januari 2008, we treated 230 femoral shaft fractures. in this group there where 122 polytrauma patients with a total of 137 fractures. we compared the rate of infection and delayed union in the group treated by damage control external fixation to the group primarily treated by intramedullary nailing. results: no significant difference in infection or union rates could be demonstrated between the damage control external fixation and the primary nailing group. we also noted that there's a correlation between the complexity of the fracture and the percentage of prolonged healing. and although not statistical significant there seems a tendency of less healing problems with the reamed femoral nail in comparison with the unreamed femoral nail. introduction: the diagnostic information power of a level one emergency room has risen excessively within the last years. the need for quality control, judicial regulations, insurance claims and forensic reasons still lead to a high number of autopsies being performed in patients not surviving the first 48 h after admission to the er. however, the number of autopsy clarification featured in a level one trauma centre after trauma related deaths considerably vary and also the rate of deathly diagnoses missed within er assessment of early stage deceased patients differ in the literature. the aim of this study was to assess the value and necessity of autopsy after modern er assessment with a multi-slice ct-scan as an integrated part of the diagnostic algorithm. material and methods: prospectively reviewing our emergency database, case histories, laboratory values and radiological findings compared to findings in autopsy between jan 2004 and sep 2007, we charged for missed deathly diagnoses in 87 early stage deceased trauma patients (<48h). patients were classified into two groups: group 1: patients with limited diagnostic assessment (conventional xray, sonography). group 2: patients with full er assessment (msct). all patients in group 1 could not be sufficiently stabilised in terms of circulation patterns and therefore did not receive full assessment. non-trauma patients and patients reaching the er under cpr were excluded. results: the autopsy rate of all included patients was 86%. the overall incidence of missed deathly diagnoses was 9.2%. in terms of missed deathly diagnoses, groups varied significantly (group 1: 35.7%;group 2: 4.1%).the iss after autopsy increased significantly in group 1 from 25 to 37.5. in group 2 there was no difference of iss between status emergency room and after autopsy. the most concerned region of missed deathly injuries was thorax with 62.5% of all patients with autopsies followed by pelvic (25%) and spine injuries (12.5%). conclusion: in spite of complete and nearly ideal conditions within a modern emergency room assessment nowadays, detecting all diag-noses is still challenging. overall, our findings show that almost every tenth early stage deceased patient showed at least one missed potential deathly diagnose in a level one trauma centre. regarding the insufficient assessment performance in group 1, the relative high rate of missed diagnoses seem explicable. nevertheless, even having acquired full assessment power (group 2), still 4.1% deathly diagnoses were missed. for this reason, autopsy is still the most powerful and indispensable tool in finding the ''whole'' diagnosis. completeness of autopsies after trauma related death therefore is essential referring a continuous gain of quality. introduction: in a physiological environment metallic biomaterials undergo corrosion through a variety of mechanisms. this study investigated whether, beside the well recognized electrochemical aspect of corrosion, human osteoclasts are able to directly corrode titanium alloys, uptake and finally release corresponding metal ions into their environment. the released ions are believed to cause inflammatory reactions and activate osteoclastic differentiation and activity, which most likely play a role in the pathophysiological mechanisms of aseptic loosening [1] . material and methods: human monocytes and in vitro generated osteoclasts were seeded onto titanium and aluminum (positive control) foils. after 21 days scanning electron microscopy analysis was performed in order to assess whether monocytes were able to grow and differentiate on the metals. in order to visualize uptake and distribution of intracellular metal ions, a novel protocol using confocal microscopy analyses with newport greentm dcf diacetate ester staining was developed [2] . additionally, the concentrations of metal ions released into the culture supernatant were measured using atomic emission spectrometry. ). nine bre-gfp mice were used. mice were allowed unrestricted activity. a mini-external fixator fixed to the proximal and distal tibia was applied under general anesthesia on day 0. the animals were permitted full weight baring and unrestricted activity after awakening from anaesthesia. the gfp signal of tibia and fibula in bilateral limbs was measured on days 1, 3, 7, 10 and 14 after application of the external fixator. results: baseline measurements of the gfp-signal ranged from 6.8x10e9 photons to 3.1x10e10 photons between individual mice. after application of the external fixator, the gfp signal of the unloaded tibia and fibula decreased in all mice to on average 87% of baseline on day 1 (sd ± 23%, p = 0.07), 71% on day 3 (sd ± 31%, p < 0.05), 71% on day 7 (sd ± 41%, p < 0.05), 80% on day 10 (sd ± 41%, p = 0.09) and 71% on day 14 (sd ± 23%, p < 0.01). in the contra-lateral non-operated limb, the gpf signal increased to an average 129% on day 1 (sd ± 88%, p = 0.17), 154% on day 3 (sd ± 85% p < 0.05), 164% on day 7 (sd ± 105%, p = 0.05), 150% on day 10 (sd ± 58%, p < 0.05) and 172% on day 14 (sd ± 82%, p < 0.05). introduction: the aim of the present study was to assess the effect of antibiotic loaded fresh-frozen allografts and compare it with antibiotic loaded acrylic bone cement in staphylococcal tibia osteomyelitis and to combine the effects of bone repair and eradication of infection in one stage surgery. material and methods: a unicortical 6.5-mm-diameter defect was created in the proximal tibial metaphysis of thirty-six new zeland albino rabbits. after contamining the wounds with 2x10 8 colony forming units of staphylococcus aureus, we divided the animals into four groups. the negative control group received no treatment, the positive control group received teicoplanin-impregnated polymethylmethacrylate beads, the allograft group received fresh-frozen allografts and the experimental group received teicoplanin-impregnated fresh-frozen allografts. histopathological evaluation with light microscope were made and intraosseous tissue cultures were performed on postoperative day 28. clinical evaluation in a daily-routine were made. results: the cultures showed no evidence of intramedullary infection in the experimental or the positive control group in eight of the nine rabbits, but they were positive for staphylococcus aureus in one of the nine rabbits in the experimental group, one of the nine rabbits in the positive control group and all of the rabbits in the negative control and allograft groups. the experimental group and the positive control group has similar effects in eradication of the infection. conclusion: teicoplanin-impregnated allografts was effective in preventing intramedullary staphylococcus aureus infection in a staphylococcal tibia osteomyelitis model. this combination therapy could potentially eliminate the need for surgical removal of cement beads. using an antibiotic-graft compound, eradication of pathogens and grafting of bony defects may be carried out in a one stage procedure. introduction: we first report a case of an infection in humans by streptococcus pluranimalium, a new streptococcal species that has been isolated in the genital tract and tonsils of cattle, tonsils of a goat and a cat, and from the crop and the respiratory tract of canaries. according our knowledge there are a few reports in the literature reporting infections by this strain of streptococcus in animals, but never since now in humans. a 57 year old farmer, fit and well, nonimmunocompromised has been treated in our department, for a close tibial plateau fracture (schatzker vi), with a circular external fixator. postoperatively, i.v antibiotics -cefuroxime 1500 mg every 8 h was administrated for 24 hours. radiological and clinical healing of the fracture achieved successfully within 11 weeks of the fracture. the frame removed and the patient was followed up as an outpatient. six days after the removal of the frame, the patient turned up to the a&e department, systematically unwell, complaining for a swollen painful knee, and a discharging abscess in one of the proximal pin sites near by the joint line.fluid samples from the abscess and the knee aspiration, obtained and revealed streptococcus pluranimalium in all samples. debridement of the abscess and an arthroscopic wash out was performed twice, followed by i.v antibiotics according to the sensitivity test (levofloxacin (500 mgx2) ceftriaxone (2grx2)) for six weeks, and p.o antibiotics (clarithromycin 500mg every 12 h and levofloxacin 500 mg every 12) for another two weeks. results: symptoms were settled and the patient is free of infection for the last 12 months. conclusion: we hypothesized that the bacterium was settled on the wires of the circular fixator and was inoculated in the patient during the removal of the frame. according our knowledge, it is the first case of infection in a human individual by this specific strain of streptococcus. disclosure: no significant relationships. introduction: post traumatic knee joint contracture is the most difficult complication of the lower limbs traumas, considerably limits the functional abilities and make the patients invalids. besides, the frequent consequence of knee joint injure is gonarthrosis, and kinesitherapy is one of the element of the complex treatment. the basis of the procedure is the joint relief, leading to adjoining muscles tonus lessening, and paraarticular tissues general tense lessening and infrajoint hydrostatic pressure, joint tissues nourishing improvement. the introduction: ilizarov frames are still removed in the operating theatre in a lot of centers. this is due to a variety of reasons, the main one being that it is a painful procedure. we decided to evaluate patient satisfaction and pain experienced on removal of ilizarov frames in an outpatient setting, using oral analgesia and entonox. material and methods: seventy consecutive patients, who had their frames removed in the out patients department, had their level of pain scored using a visual analogue score (vas) and a simple questionnaire. results: the mean score for frame removal was 4.7 on the vas. there was no difference between male and female scores. the age of the patient does make a difference in the pain score, the pain score decreases with the age of the patient. pain increases when there are 4 or more olive wires to be removed conclusion: removal of ilizarov frames in the outpatient department is a moderately painful but well tolerated procedure. introduction: the proximal metaphyseal tibial fractures are difficult to treat due to their frequent association with tibial plateau fracture and due to their aspect, which is often comminuted and has a significant impact on the function of the knee. surgery has to restore local anatomy and to allow early rehabilitation, meaning proper evaluation and stabilization of the fracture. material and methods: 24 cases, operated between 01.01.2005 -01.06.2007 (mean age 22-59 yrs) with proximal metaphyseal tibial fractures, were analysed. pre-operative planning using ct scan was used. the fractures were complicated with compartment syndrome (4 cases) which needed additional fasciotomy.the fractures were stabilized with : plates and screws (16 cases) or external fixation (8 cases) depending on the soft tissue status. bone graft was used in 2 cases. the patients were monitorised at 1,2,6,12 and 24 months postoperative, concerning: bone healing, restoring of the axis of the knee, joint mobility, septic complications. results: the axis of the knee were completely restored in all the cases. bone healing appeared in all the patients (starting from 2 months-8 cases, at 3 months in the rest of the fracture) depending on the initial aspect of the fracture. flexion of the knee was limited in 6cases (25% of the pactients) and extension was affected in 4 patients, depending, also, on the initial characteristics of the fracture. the frequency of the complications depended on the initial aspect of the fracture, initial stabilization, time from intial stabilization to final fixation. conclusion: results after surgery for tibial plateau fractures depend on the initial aspect of the fracture, but also on the results of surgery . the method proposed by the authors, which allows the suspension of the articular surphace, is valuable especially when the fracture is cominuted and has small fragments. the double plate fixation (medial and lateral) with single anterior incision is the best, effective and simple procedure in treatment of complex proximal tibial fractures (type v and vi of schautzker classification). introduction: compartment syndrome is one of the most frequent complications after proximal metaphyseal tibial fractures, due to the anatomical characteristics of this area. the importance of the problem is that the compartment syndrome radically changes the local and general and especially the type of fixation of the fracture. the purpose of this study is to evaluate the impact of the compartment syndrome on the outcome of the patients with this type of fracture, when recognized and treated early and complete. material and methods: the authors analyse 52 cases of proximal metaphyseal tibial fractures treated in the emergency hospital, bucharest, between 01.06.2004-01.06. 2008 . from these, in 28 cases, compartment syndrome was diagnosed. in all these cases, the patients were operated and the fracture stabilized (with plates and screws in 36 cases and external fixation in 16 cases). decompressive fasciotomy was performed in all the 16 cases with installed compartment syndrome and intra-compartimental pressure was monitored post-operative in all the other 12 cases. frome these, in 3 cases secondary compartment syndrome developed and fascitomy was necessary 24-48 hours after surgery the patients are analysed concerning: the moment of surgical treatment, and the characteristics of the patient in that moment, post-operative treatment, the postoperative local and general outcome, local and general complications. results: the incidence of the complications was influenced by the time between trauma and complete surgery. there were 4 cases of superficial infection and 1 case of deep infection, without needing implant removal. all the fractures healed, the interval proved to be longer when external fixation was first used. there were no systemic definitive complications after these trauma. conclusion: compartment syndrome is frequent after proximal metaphyseal tibial fractures and the incidence of this complication was significant in the group of patients we studied, and the outcome was good when the treatment was early and complete . the compartment syndrome influenced the local and general prognosis, due to the importance of microcirculation in healing after trauma. results: a ct pulmonary angiogram illustrated a metallic density, which appeared to lie in the lumen of the main pulmonary artery just proximal to the pulmonary valve. conclusion: in this case, the respiratory symptoms and signs were due to a metallic pulmonary embolus rather than fat or thrombus. formal anticoagulation was initiated and the patient's clinical condition consistently improved without the need for cardiothoracic surgery, although this is described in the literature with retained catheter fragments. eight months after the injury, the fracture has consolidated with the patient returning to work. toid is often necessary to obtain adequate exposure. as an alternative to this we promote the minimal invasive transdeltoid approach. material and methods: the operative technique of the minimal invasive transdeltoid approach is explained in a first section. this approach has the advantage of direct access to the fracture site with more opportunities for adequate reduction and good plate placement without extensive distraction of the muscles. an important step in the procedure is the palpation of the axillary nerve. in a second section the results of a prospective cohort of the first 14 patients treated with this technique will be presented. the neer criteria were used as guidelines for operative treatment. fractures were classified according to the ao-classification. the ases shoulder score was used to evaluate functional outcomes. preoperative xrays were used to evaluate displacement, vascularity of the humeral head (according to the hertel criteria) and ao fracture type. postoperative x-rays were analyzed for quality of reduction of the ccd angle, reconstruction of the medial hinge and reposition of the tuberosities. follow-up x-rays were evaluated for healing, avascular necrosis, loss of reduction and implant related failures of osteosynthesis. the 67-year-old male patient was taken to hospital after a traffic accident. he was a pedestrian hit by a car. he suffered comminuted proximal humeral fracture on the dominant right side. the fracture was closed. the glenoid cavity was damaged and acromion was broken. the fractures of the v-vi th ribs were found without complication. otherwise the patient's condition was good. he had only a controlled hypertension. for preoperative planning ct scan was performed. as pieces of the humeral metaphysis wedged into the glenoid cavity insertion of glenoid component seemed uncertain. an early shoulder replacement was done on the 7 th day. the denudated fragments were removed. the tubercles with the muscle attachments were preserved. as a long bone defect remained in the metaphyseal zone normal stem would have been insufficient. a 220 cm long stem used in tumor cases was implanted. the length of the arm and size of the humeral head were compared to the intact side. the tubercles were attached to the prosthesis by non absorbable sutures. after the operation long bone defect remained which was filled up by heterotopic bone visible on x-ray. the postoperative period was complication free. fever, severe pain, hematoma did not occur. the arm was in rest for 6 weeks, only controlled pendulum exercises were done from the second week. active physiotherapy was started on the 7 th week. after 5 months the patient finished the follow up treatment. he was pain free and self-sufficient. conclusion: for three-or four-part displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment/1,2/. in trauma cases short prosthesis stem is usually sufficient but in comminuted fractures involving the metaphyseal zone long stem has to be used for certain bone-prosthesis contact. introduction: there is a trend to apply plate and screw fixation directly medial and lateral (so-called parallel plating), and many implants designed specifically for the distal humerus extend more laterally to improve fixation. this may risk injury to the origins of the common extensor and flexion musculature and the collateral ligaments either via operative dissection or by damage to the blood supply. internal plate and screw fixation is often accomplished with subperiosteal elevation of muscle attachments and tight apposition of the plate to the bone, but this should not be done over the epicondyles. plates applied to the medial and lateral aspects of the lateral and medial epicondyles should be placed directly over the soft tissues without elevating or disturbing them. damage to the collateral ligaments could cause elbow instability. material and methods: in order to emphasize these important technical aspects, we report three patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle led to post-operative instability after open reduction and internal fixation of a fracture of the distal humerus. results: while the cases are very complex and the exact cause of elbow instability by necessity somewhat speculative, our concern is that the operative dissection performed to apply implants to the lateral side of the elbow contributed to the ulnohumeral instability. injury to the lcl is the most common cause of recurrent elbow dislocation. attempts to place a direct lateral implant directly on the bone by elevating soft tissues will put the origin of the lcl at risk. it is preferable to place implants directly over the soft tissues, although there is a risk of interfering with blood supply leading to soft tissue insufficiency. it seems safe to assume that the operative treatment contributed in some way to the instability in each patient. patient one in particular had osteoporotic bone noted intraoperatively, so that one would expect failure to occur through bone with any subsequent trauma. the failure through the ligamentous structures seems to implicate the operative technique. conclusion: in any case, these three patients establish that instability of the ulnohumeral joint is an uncommon complication or sequel of the operative treatment of a bicolumnar fracture of the distal humerus. our intention in reporting these cases is to increase awareness of these potential complications and we encourage others to report any similar cases so that we can learn enough to limit the risk of this complication. introduction: orif of comminuted distal humerus fractures carries a high risk of complications such as secondray loss of reduction, pseudarthrosis and heterotopic ossifications. especially elderly patients with osteoporotic bone quality are struck by these complications. therefore total elbow arthroplasty (tea) is gaining more and more in importance as it has proven to achieve good results in elderly patients with poor bone quality. the latitude total elbow system (tornier inc., stafford, usa) is a modular, convertible implant that allows not only linked and unlinked tea with or without radial head replacement but also hemiarthroplasty. the aim of this system is to reproduce the patient's anatomy to reconstitue the elbow's physiologic kinematics. therefore the latitude prosthesis is offered in four different sizes, respecting the flexion-extension axis and three different humeral offsets based on anatomical findings. the purpose of our study was to evaluate the short-term results after elbow arthroplasty with the latitude system. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. other authors propose radial head arthroplasty as an alternative to radial head resection to avoid the complications of radial head resection. different concepts of radial head prostheses are available: silicon prosthesis, monopolar prosthesis (loose fit and cemented/thight fit) and bipolar prostheses. evidence is lacking on the exact place for arthroplasty as opposed to radial head resection. to answer this question we performed a systematic review of litterature. material and methods: inclusion criteria are clinical studies reporting on radial head resection or radial head arthroplasty, published between 1995 and today in english, french, german or dutch language. a search has been performed using the pubmed and embase databank. a secondary search has been performed based upon the reference list of the included publications. exclusion criteria are: â e¢cadaver or animal studies â e¢biomechanic studies â e¢clinical studies with a follow up of less than 2 years â e¢clinical studies with less than 10 patients data extraction â e¢elbow function â e¢complication rate â e¢arthritis rate data are reported according to the moose guidelines. results: only low evidence studies are available. we did not find any randomised controlled trial comparing resection to radial head arthroplasty. there is evidence that radial head resection results in high complication rates (including arthritis) and poor function in case of elbow instability and/or essex-lopresti lesions. the rate of complications in these indications is higher than for radial head arthroplasty. in cases without instability or essex-lopresti lesion there is a trend to better function in radial head resection. complication rate is higher in the prosthesis patients. the rate of post-traumatic arthritis is not significantly differing between the resection and the arthroplasty group, and remains very high (+/_ 70%). conclusion: complex radial head fractures remain difficult to treat. based upon the findings of this systematic review we suggest: â e¢that adequate level of evidence studies are a necessity â e¢that in case of fracture without evident instability or essex lopresti lesion resection results in better function and less complications than arthroplasty â e¢that in case of fracture with evident instability or essex lopresti lesion resection results in worse function and higher complication rates than arthroplasty â e¢as secondary arthritis rate remains 70%, further therapeutic optimisation is a must. often, mortality. a new pelvic stabilizer (t-pod ò ) provides secure and effective simultaneous circumferential compression of the pelvis. material and methods: in this study we have managed fifteen patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the t-pod ò . before and 2 minutes after applying the t-pod ò , heart rate and blood pressure were measured. an x-ray before and after applying the t-podò was made to measure the effect on reduction in symphyseal diastasis. results: application of the t-pod ò reduced the symphyseal diastasis with 60% (n=12; p=0.01). the mean arterial pressure (map) increased significant from 64.7 to 81.2 mmhg (n=10; p=0.04) and the heart rate declined from 106 beats per minute to 93 (n=10; p=0.04). in ten patients of whom circulatory response before and after the t-pod ò was recorded, there were seven good responders, one transient and two poor responders. conclusion: in the acute setting, the t-pod ò device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. the t-pod ò is therefore an easy to use and effective way of (temporarily) stabilizing the pelvic ring in an acute setting. introduction: thoracolumbar and lumbar fractures treated with surgical methods aim to decompress the spinal cord and correct the deformity. we aimed to compare the effects of anterior, posterior and anterior-posterior surgery on the local kyphosis angle in thoracolumbar and lumbar vertebral fractures. material and methods: thoracolumbar and lumbar, burst or compression fractured and surgically treated 62 patients were evaluated retrospectively. preoperative, postoperative and follow-up local kyphosis angles were measured on the x-rays and changes in these angles were compared according to the applied surgical treatment methods. results: early application of surgical treatment following trauma decreases the correction loss suffered after surgery. the increase in correction loss continues after removal of the hardware. it is observed that laminectomy applied in the course of posterior surgical interventions has no effect on the correction loss. the length of the implantation, fusion and the addition of a hook to the lamina of the vertebra which is located one segment lower than the transpedicular screw applied vertebra do not affect the loss of correction. conclusion: in the surgical treatment of thoracolumbar and lumbar vertebral fractures, different degrees of correction loss are observed after each surgical treatment modality. considering the corrective effect of combined anterior-posterior surgery on the correction of kyphotic derformity due to trauma and the preoperative local kyphosis angle, follow-up correction achievement is higher when compared with anterior and posterior surgical approaches. domain questionnaire (eq-5d), the 10 point self-rated back pain (vas) and device and/or procedure related adverse events. the ethic committee of the hospital did not accept a randomized study because of the results in this proof of concept, they accepted the study with a minimum of 69 patients (based on the results of a previous proof of concept). the incidence of missed injuries without the application of the tertiary survey was 45% and this incidence has been reduced to 4% with the application of the tertiary survey (it means a reduction of the 91.1% in the incidence of missed injuries). the incidence of clinically significant missed injuries without the application of the tertiary survey was 23% and it has been reduced to 0% with the application of the tertiary survey (it means a reduction of the 100% in the incidence of missed injuries). the tertiary survey is an essential task in the management of the trauma patients to reduce the incidence of missed injuries and clinically significant missed injuries. introduction: knee-arthroscopy is a complex surgical ability. it is a combination of factors like anatomical knowledge, hand-eye coordination, three-dimensional mental activity and operating experience. surgeons as well as students were not able to train knee arthroscopy before. parts of these abilities were trained by playing video games. former studies indicated a correlation between a better performance in virtual reality (vr) laparoscopy simulation and video game experience. the aim of this study is to show that experienced video gamer perform better in a virtual arthroscopy simulation. material and methods: 164 medical students did an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator (the insight arthro vr ò gmv, madrid, spain). the students completed a questionnaire asking for their game experience: none (n = 123), monthly (n = 20) weekly (n = 17) daily (n = 6) before they did the arthroscopy. the simulator assessed 4 different parameters: time, distance moved and roughness both for probe and camera and a global score (combination of all metrics). results: students with game experience (n = 43) performed significantly (p <= 0,05) better than not experienced students (n = 123). there is a tendency that the performances get better with more game experience. conclusion: gamer performed better in a vr knee arthroscopy than not gamer. these result correlates to the laparoscopic simulator training. there is a tendency of achieving a better performance in vr arthroscopy simulation due to a higher frequency of playing games. extensive training on the simulator improves the abilities of nongamers with respect to their arthroscopy skills. we will evaluate these dates in the future. ) and mostly injuries of tendons (n = 10) and/or vessels / nerves (n = 6). buzzsaws of different manufacturers and different price ranges were used. the work conditions were well in all cases, the saws were placed firmly on the ground and the lighting was sufficient. most injuries appeared on the week-end (friday n = 9, saturday n = 8). a break or a meal, taken shortly before the accident, had no influence on the injury risk. all patients had a several years lasting experience in dealing with buzzsaws, half of the patients even for at least 20 years. the safety device of the saw was folded back in most cases (n = 25), only few patients (n = 15) had correctly put on the saw safety device at the accident time, 4 patients provided moreover no information. the accident had entered in 12 cases shortly before working end, mostly with the last cut. in 10 cases a wooden piece had become stuck in the saw and the patient had tried to solve it. conclusion: a many years' routine in dealing with buzzsaws can lead to the fact that necessary safeguarding measures are not followed any more and so cause an increased injury risk. in particular shortly before working end the attention decreases and the injury risk rises. an especially injury-laden situation is becoming stuck of wooden parts in the saw. the attempt to solve these parts without switching off the saw before bears a high injury risk. the patients showed predominantly heavy injuries. this might be the result of our clinic as a university clinic. patients with less severe injuries are concerned to be treated in smaller clinics next to their residence . ethibond was then used to anatomically oppose the ends of the sleeve fracture. the construct was reinforced with a circlage wire with the wire twisted so that it could be retrieved later through a small lateral incision post operatively the legs were immobilised in lightweight casting material for a period of 6 weeks followed by an unlicked hinged knee brace for 4 weeks. the circlage wires were removed at 6 months. the child now has full, pain free range of motion. the knee is stable and he has no functional problems. conclusion: we report a rare case and emphasize the timing of diagnosis as being crucial in outcome. early operative intervention with accurate open reduction will yield good results. this publication serves to educate and refresh those who deal with general and paediatric lower limb trauma. introduction: the purpose of this study was to evaluate the effect of electromagnetic fields in healing progression of delayed union of long bones in the lower extremities. we defined delayed union, as failure of expected healing progression and nonunion when a minimum of nine months has elapsed since injury and failure or halting of healing progression was observed in three successive monthly radiographs (infection ruled out results: an average of 4.7 x-rays were performed on each patient from the time of diagnosis to discharge from clinic. none of these fractures displaced on follow up x-rays. conclusion: stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources. (1). we aim to describe the rate of postoperative complications after calcaneal plate osteosynthesis in relation to the hospital fracture load as a means to increase insight into the clinical audit data. material and methods: a search was performed using the disease code for intra-articular calcaneal fractures and operative code for orif for the period 2000-2009. the medical records of all included patients were obtained. as postoperative complications we included superficial and deep wound infection, mobilisation problems with need for orthopaedic shoes or walking aid and secondary arthrodesis. current complication rate of deep infection and arthrodesis rate from the clinical audit were compared with the mean logarithmic correlation coefficient relating complication rates with the institutional fracture load data, reported earlier in the literature (1) . results: over a period of 108 months a total of 53 intra-articular calcaneal fractures were reconstructed with a calcaneal plate using orif (mean institutional fracture load = 0.49 fractures per month). eight patients had a wound infection, six of them were treated with antibiotics and two of them needed surgical debridement. thirteen patients have mobilisation problems, 5 patients suffered from pain when walking, 7 patients used orthopaedic shoes and one patient mobilised using a wheelchair. two patients had an secondary arthrodesis (n = 2, 3.8%). in seven patients the osteosynthesis was removed due to pain. both deep infection rate and arthrodesis rates related to the institutional fracture load were below the 95% ci reported in the literature. the outcome of open reduction and internal fixation of intra-articular calcaneal fractures is known to be determined not only by factors related to patient and the fracture, but also to the institutional fracture load (1) . the complication rate regarding deep wound infection and arthrodesis is below the data reported in the literature, related to the institutional fracture load. clinical audits studying the complication rate should take the institutional fracture load into account. introduction: toe fractures are the most common fracture of the foot. there is little data on demographics and no studies on functional outcome of toe fractures. material and methods: the initial radiographs of all consecutive patients with toe fractures treated between january 2006 and september 2008 at the reinier de graaf groep in delft, the netherlands were re-evaluated; patient and fracture characteristics were collected. all patients in aged 16 to 75 (264 patients) were sent a questionnaire concerning pain, activity and functional limitations, footwear, walking distance, and gait (aofas midfoot score). overall satisfaction was measured using a visual analogue scale (range zero to ten). results: a total of 339 patients with 368 digital and 370 phalangeal fractures of the foot were identified. the distribution of fractured toes was: first 38%, second 11%, third 7%, fourth 14%, and fifth 30%. multiple digital fractures were seen in 5.9%. most fractures were caused by stubbing the toe or a crush injury (75.6%). more than 95% of the fractures were undisplaced or minimally displaced and most fracture patterns were transverse or oblique/spiral. a total of 141 patients (53%) returned the questionnaire with a median follow-up of 27 months. responders were female in 57.4% and had a median age of 45 years (p25-p75 31-58). in 46.8% of cases the left side was affected. the median aofas-score was 100 points (p25-p75 93-100), the median vas was 10 points (p25-p75 8-10). no correlations were identified with outcome and which toe or phalangeal bone was affected, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and diabetes. in the univariate analysis a trend was found for dislocation and aofas score (p = 0.058). in the multivariate analysis the vas was dependent of age (p = 0.047) and gender (p = 0.049). the aofas midfoot score was not influenced by any of the parameters. conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome. almost all toe fractures were healed without complaints at 27 months. patient satisfaction is slightly less in younger female patients. the appendix has been one of the most common site of carsinoid tumors(1). carsinoid tm is seen incidental in appendectomised cases(0,3-0,9) and frequently in female(2,3). mean diagnosis age is between 39-49 in literature, whereas in our serise it is 32(4). postoperative living prognosis is good in incidental carsinoid tumors of appendix (5) .in our cases, additional surgical procedure was not applied because tumor is less than 2 cm, mesoappendix is healthy, and vascular invasion was not seen in hystopathologic examination. introduction: for clinical importance, two cases are presented who were operated with diagnosis of acute apppendicitis. intraoperatively,appendixes were normal, for this reason meckel's diverticulas were explored and diverticulitis were seen. material and methods: two cases are explored retrospectively results: case 1:the case is 40 years old male patient.he admitted to emergency department with abdominal pain for 2 days.there were defans and rebaund on the right inferior quadrant of the abdomen. leucocytosis(15,0x10 3 /mm 3 ), aperistaltic intestinal ans in ultrasonografic examination were seen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at 80th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen case 2:the case is 32 years old male. he admitted to emergency departmant with abdominal pain for 3 days because his pain increased last 2 days. he has nausia, vomiting, fever(38,3°c), leucocytosis(16,0x10 3 /mm 3 ), defans and rebaund on the right inferior abdomen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at 100th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen. conclusion: meckel's diverticula is the most congenital anomalies of the gastrointestinal anomalies and it was found 2% in autopsy ser-ies. (1) .it is asymptomatic generally. risk of complication is 4-6%(2). preoperative diagnosis may not be done frequently, so to delay of operation may be serious complication.(3)in our clinic, we explore meckel's diverticula, over(in female) and duodenum, if we do not see pü rü lant material on the appendix. results: patients with abdominal tb were diagnosed by laparoscopy and peritoneal biopsy in 9 cases and by laparotomy in 2 cases. from these 11 patients we observed peritoneal tb in 8 cases, intestinal tb in 2 cases, mesenteric lymph nodes tb in 1 case. at admission 5 patients presented complications: 2 cases with perforations and peritonitis, 1 case with intestinal obstruction and 2 cases presented as ileo-cecal ''tumors'' (solved by right colectomy); other surgical procedure performed was enterectomy with either entero-entero-anastomosis, either ileo-colic anastomosis. in abdominal tuberculosis ascites was present in 8 cases. other common findings were weight loss (6 cases), weakness (4 cases), abdominal pain (10 cases), anorexia (8 cases) and night sweat (2 cases). only 2 patients had chest radiography suggestive of a new tb lesion. in those patients with peritoneal tuberculosis subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white ''miliary nodules'' or plaques, enlarged lymph nodes, ascites, ''violin string'' fibrinous strands, and omental thickening. biopsy specimens revealed granulomas, while ascitic fluid showed numerous lymphocytes. postoperative management was applied by the tb medical system. all patients were treated for 6 months by specific drug therapy, with favorable evolution. pcr of ascitic fluid was positive for mycobacterium tuberculosis (m. tuberculosis) in all cases. introduction: abdominal trauma represents an important cause of morbidity and mortality in children. conservative management is preferred in blunt trauma with hemodynamic stability although there is a risk of intestinal damage when free fluid without solid organ injury is found in image studies. early laparotomy may be unnecessary in most cases but a delay in diagnosis of bowel perforation could lead to increased rate of complications. on the other hand the presence of a penetrating abdominal trauma is considered an absolute indication of laparotomy. we present five cases of abdominal trauma treated in our department in which laparoscopy proved to be an optimal diagnostic and therapeutic tool. material and methods: chart review of our cases and literature review results: three cases of blunt abdominal trauma underwent laparoscopy. we found a small bowel perforation in one case that was repaired by externalization of the jejuna loop by one of the ports. in the other two cases we found intestinal and mesenteric contusions that were treated by peritoneal drainage. two cases of penetrating trauma underwent laparoscopy. one of them presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. conclusion: in our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure in blunt abdominal trauma in stable children with abnormal abdominal examination and moderate free fluid and no solid organ injury in image studies, and it could be a first and sometimes definitive approach to minimal penetrating abdominal trauma. 3%) patients, biliary tract injury in 3 (13.04%) patients, multiple stones in the abdomen due to perforation in 2 (8.6%) patients, inadequate technical equipment in 2 (8.6%) patients, liver injury in 1 (4.3%) patient, intraoperatively detected umbilical hernia in 1 (4.3%) patient, uncontrollable bleeding in trocar entry site in 1 (4.3%) patient, insufficient insufflation in 1 (4.3%) patient, and unstoppable bleeding of arteria cystica in 1 (4.3%) patient, respectively. conclusion: although laparoscopic cholecystectomy is the golden standard of treatment in cholecystectomy, it involves the risk of conversion to open surgery. the rate of conversion to open surgery has been reported to be between 2-20% in many series and is considered to be 5% on average. in our study, we found it as 6.2%, a rate which is close to the rate reported in the literature. chief reasons for conversion from laparoscopic to open cholecystectomy include the difficult dissection of callot's triangle due to obscured anatomy and adhesions, gallbladder perforation, bleeding, the failure to produce pneumoperitoneum, gallbladder cancer, and injury in main biliary tracts and neighboring organs. the presence of pericholecystic adhesion and liquid in acute cholecytitis cases and the presence of edema in the tissue affect regional anatomy and complicate dissection, which increases the risk of gallbladder perforation. in our study, changes due to acute cholecytitis and difficulties in the preparation of callot's triangle ranked first among the indications for open cholecystectomy with a rate of 47.8% (11/23 introduction: the most difficult decision in the management of the patients with severe necrotizing pancreatitis is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. recently a great deal of data has emerged suggesting that a pulsating irrigation stream delivered at high pressure and with a high flow effectively decreases bacteria, foreign bodies, and necrotic crushed tissue in wounds and decreases the incidence of resultant wound infection. this study evaluates the effect of inter pulse jet irrigation, used for the first time in open abdominal surgery. material and methods: twelve patients presenting proven infected/ non-infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological or laparoscopic drainage were prospectively offered necrosectomy using itner pulse jet irrigation. open necrosectomy and subsequent jet irrigation were performed using a midline laparotomy. in all patients, 1 to 3 tube drainages were placed during necrosectomy for continuous closed lavage. temporary abdominal closure using modified mesh-foil laparostomy was applied for relief of abdominal compartment syndrome. results: no intraoperative complications were recorded with a median operative time of 112 +/-34 minutes. in 7 cases two sessions of necrosectomy were sufficient to completely clear the necrotic tissues. another 5 patients with extended retroperitoneal necrosis required 3 irrigation procedures. necrosectomy using inter pulse jet irrigation was successful in all patients, and none required complementary surgical or radiological treatment. introduction: intra-abdominal hypertension (iah) and abdominal compartment syndrome (acs), have been described often in patients with abdominal trauma or after emergency abdominal surgical operations. we present 3 patients with vomiting, meteorism, acute abdomen and acute respiratory insufficiency provoked by phytobezoars. aetiopathogenesis, symptoms and differential diagnosis are analyzed and a brief report of the literature is discussed. material and methods: three patients, were admitted to the emergency department of our hospital during the last year. all patients were presented with acute respiratory failure, abdominal pain, discomfort, meteorism and vomiting. the first patient, a 57 years old man, alcoholic was admitted with meteorism, acute abdominal pain and discomfort. a 26 fr nasogastric tube was introduced and the symptoms were remitted after gastric evacuation. the second patient suffered from bowel obstruction after closure of colostomy as a result of traumatic injury of sigmoid colon. a laparotomy was performed and a phytobezoar was revealed at the level of anastomosis. the last patient was presented with meteorism, vomiting and dyspepsia, as a result of enlarged gastric mass, revealed after endoscopy. results: gastric evacuation in the first patient revealed 5 lt of fluid mixed with a smelly gas under pressure (iap = 33 cmh2o after evacuation) followed by washouts. laparotomy was performed in the second patient revealing a large phytobezoar at the level of anastomosis. mini laparotomy and gastrotomy in the third patient (after two unsuccessful gastroscopies) revealed large phytobezoars. introduction: the objective was the substantiation of using dcs tactics in wounded with ctmi. material and methods: in case of cranial injuries dcs tactics implied treating superficial wounds of skin, arrest of exterior bleeding and subsequent evacuation of the wounded within the first hours after getting trauma. in case of extremity injuries, dcs tactics implied first of all the operations on the occasion of gunshot injuries, including the arrest of bleeding, application of the external fixation apparatuses, application of temporary shunts for injured vessels. the burn wounds treating were carried out after helping the patient out of shock. in case of the wounded with chest injury in the presence of hemo-and pneumothorax, drainage of pleural cavity of silicone tubes with active air aspiration was fulfilled. in case of abdomen injuries after laparotomy abdominal cavity was cleaned and inspected including examination of the most probable sources of bleeding: liver, spleen, magistral vessels. on the background of unstable hemodynamics the abdominal cavity tamponage along the right and left side canals, supraliver and underliver space and small pelvis. results: thus, in accordance with dcs principles in case of ctmi, operations regarding gunshot injuries were made in the first turn, and operations connected with burns -in the second turn. the first were urgent operations. then, intensive therapy in the conditions of resuscitation unit. conclusion: the repeated operation of the second stage -final removal of lesions -was carried out after the condition of the wounded had been stabilized. introduction: the aa highlight the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. material and methods: man, age 78, 3 rd pod after total gastrectomy with precolic reconstruction for gastric cancer (t2n2mxr0) in another institution. no significant past diseases. mechanically ventilated, in septic shock, with purulent drainage from right hemithorax and blue drainage from right abdominal upper quadrant, after ''methilene blue'' swallow. distended abdomen. relaparotomy with median frenotomy (pinotti) and damage control procedures for oesophagojejunal and cardiophrenic pleural sinus perforation by an esophagojejunal tube, with right pleural empyema, mediastinitis and peritonitis: primary closure of the perforation, washing and drainage of the pleura, mediastinum and peritoneum, delayed abdominal closure (dac, rotondo and schwab) and intensive care unit (icu). on 5 th pod, revision of the mediastinum and peritoneum, no evidence of fistula: internal pleural drain retired, fibrin glue and collagen placed to protect the anastomosis, dac and icu. on 8 th pod, anastomotic leak: a ttube (kehr) has been placed as a minimal drainage procedure; dac and icu. on 10 th pod, descendent feeding jejunostomy and abdominal closure. on 14 th pod, subfrenic abscess on ct scan: surgical drainage through the upper third of the previous closed laparotomy. on 32 nd pod, intestinal suboclusion: drainage jejunostomy above the feeding one. on 41 st pod, right pleural drainage: oesophagoscopy, t-tube removed and expansible silicon covered oesophageal prosthesis inserted, covering the anastomotic fistula. on 62 nd pod, patient left the icu. results: on 77 th pod, patient sent back to the institution where he has been operated first. on 99 th pod, endoscopical removal of the prosthesis with baritated swallow control, with patient sent back home. conclusion: this case highlights the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. disclosure: no significant relationships. y. el-ashaal 1 , a. hefny 1 , y. saadeldinn 2 , f. m. abu-zidan 3 1 al-ain hospital, department of surgery, al-ain, united arab emirates, 2 al-ain hospital, department of radiology, al-ain, united arab emirates, 3 surgery, department of surgery, uae university, al-ain, united arab emirates introduction: acute gastric dilatation due to superior mesenteric artery syndrome in healthy subjects is extremely rare. herein we report its sonographic findings and highlight the value of point of care bedside ultrasound in such a case. material and methods: a 17-year old female was admitted to al-ain hospital complaining of epigastric pain of two days duration following excessive eating. she was nauseated but could not vomit. succussion splash was positive. bedside ultrasound has shown a hyperactive duodenum, a distended stomach compressing on the ivc, and a narrowed angle between the superior mesenteric artery and the aorta. these findings were confirmed by abdominal ct scan. the angle between the aorta and superior mesenteric artery was only 8 â -p p . gastrographin follow through has shown complete obstruction of the third part of the duodenum. nasogastric tube immediately drained 3500 ml of yellowish fluid. results: five days later gastrographin follow through has shown free passage of the dye to the small intestine with significant reduction in the stomach size. the patient was discharged home in a good condition. conclusion: bedside ultrasound has proven extremely useful for both the diagnosis and management of this rare case. introduction: a rare and potentially lethal complication during right hemicolectomy material and methods: a 75 year-old male, underwent a right hemicolectomy due to malignancy in the cecal region. during the operation the relatively constant venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas was injured, resulting in excessive haemorrhage. in the effort to manage the bleeding, the superior mesenteric vein (smv) was torn, and after multiple unsuccessful efforts to repair the vein, we finally had to ligate the smv. the operation was completed by typical right hemicolectomy and the abdomen was closed. five hours later the patient showed acute distention of the abdomen together with respiratory distress. due to increased abdominal pressure (> 35 cm h 2 o), the patient was taken back to the or. the small bowel was edematous, bluish but viable. the abdomen left open and was closed by using the vac. the patient was taken to the icu. six days later the small bowel returned to normal colour and thickness, but the generalized edema made the closure of the abdomen impossible. by day ten the patient was on full enteral feeding, and was taken to the or, where free partial thickness skin grafts were used to close the abdomen. results: the patient was extubated by day sixteen and was taken to the rehabilitation center. conclusion: accidental injury of the venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas, may prove a potentially life threatening condition. we present this case in order to point out this rare complication of right hemicolectomy. aimed to explore the influence of different surgical diagnosis groups on long term health status and to make comparisons with general population norms. material and methods: qol was measured in all surviving surgical icu patients admitted to a dutch teaching hospital between 1995 and 2000. patient-reported data on qol were collected with the euroqol-5d + after a mean follow up of 8 (range 6-11) years. patient characteristics, surgical diagnosis group, length of icu stay and survival were prospectively registered. eq-utility scores (eq-us), eq visual analoge scales (vas) and prevalences of domain-specific health problems were calculated. the effect of surgical diagnosis group on eq-us/eq-vas was assessed by multivariable generalized linear regression analysis. logistic regression was used to explore the influence of surgical diagnosis group on domain specific health problems. long term quality of life of surgical icu patients was compared to an age-and sex-matched general dutch population using the t-test analysis. results: 834 patients survived the icu and were available for follow up. in 598 (72%) patients the health-related qol was measured. for all surgical groups combined, after 6-11 years nearly half of all patients still suffered from problems in the dimensions mobility (52%), usual activity (52%), pain (57%) and cognition (43%). compared to the age-and sex matched general dutch population hrqol was worse with a difference of 0.11 on the eq utilities score (range 0-1). oncological surgery patient had the best (eq-us 0.83) and vascular patients had the worst (eq-us 0.72) hrqol. trauma (odds ratio between 2.47-3.47) and vascular surgery (2.27-5.37) showed significantly increased prevalences of problems in mobility, self-care, usual activities and cognition. conclusion: more than 6 years after a surgical icu admission, quality of life of this patient population is largely reduced. many patients still suffer from a variety of health problems, including decreased cognitive functioning. treatment advances should be made to reduce the current health deficit of surgical icu survivors compared to the general population. disclosure: no significant relationships. u. sekmen 1 , g. altaca 2 , s. aktas kalayci 3 , g. moray 2 1 general surgery, baskent university, ankara, turkey, 2 general surgery, baskent university, ankara, turkey, 3 internal medicine and division of gastroenterology, baskent university, ankara, turkey introduction: predicting the prognosis in severe acute pancreatitis is cruciate in order to constitute effective treatment strategies. material and methods: thirteen consecutive patients admitted with the diagnosis of severe acute pancreatitis according to glasgow or ranson criteria were evaulated. we searched the prognostic values of age, gender, etiology of pancreatitis, comorbidity and labarotory values and their affects on complications and length of hospital stay. results: mean age was 57,6 years (range: 27-83 yrs). etiology was biliary in 9 patients (2 after ercp). acute cholecystitis was also present in 7 patients. 4 patients had diabetes mellitus. two patients had percutaneous cholecystestostomy. five patients had ercp at a mean of 2,5 days after admission. cholecystectomy was performed in 8 patients, either at the first admission (n:4) or after 6-8 weeks. mean wbc, alt, ast, and ldh values on admission and mean highest hscrp levels and mean lowest serum calcium (ca) levels in the first 48 hours were 14750/mm 3 , 205 u/l, 190 u/l, 438 u/l, and 106 mg/l and 8 mg/dl, respectively. pancreatic necrosis (30,8%) was diagnosed by computerised tomography in 4 patients (2/4 in diabetics, 2/9 in nondiabetics); a total of 5 patients (38%) had systemic complications. mean ldh (594 u/l vs 360 u/l) and lipase levels (4503 u/l vs 2952 u/l) were higher in patients who developed necrosis, though not statistically significant. other parameters were similar in patients with or without necrosis. two patients who had pancreatitis due to ercp underwent pancreatic necrosectomy. median hospital stay was 9 days (range: 3-75 days). all patients survived. mean highest hscrp and lowest ca levels in the first 48 hours correlated significantly with the hospital stay (r: 0.65 p: 0.041 for hscrp, and r: -0.689 p: 0.04 for ca). conclusion: although we have a limited number of patients, we may conclude that high levels of ldh, lipase, hscrp and low levels of ca can be used as predictive factors for severe pancreatitis. pancreatitis seen after ercp and in diabetic patients tend to be more severe. abdomen. abdominal imaging reveals persistent bleeding and multiple bone lesions compatible with bone hemangioma with low blood platelets count -kasabach-meritt syndrome. patient is transferred to a central hospital for arterial embolization of the right hepatic artery that is not effective. the authors describe surgical control of the bleeding without liver resection. second look surgery was undertaken with removal of hepatic packing and pringle's manoeuvre with temporary control of the haemorrhage with haemostasis and ligation of the right hepatic artery. it was needed several surgery's more with additional packing, haemostatic mesh and haemostatic products in order to control the bleeding. the patient was proposed for liver transplant during the process but was not accepted. introduction: management of splenic injury has evolved over the past 25 years. nonoperative management has gained currency, first in children and after in adults. material and methods: we present a case of a 60 years-old man who falled for 2 m, haemodinamically stable, presenting pain on the left part of thorax and upper abdomen. results: the patient fall for 2 m 4 hours before the arrive in our er; he was haemodinamically stable (bp=130/70 mmhg, av=95 bpm) and presented pain on the left thorax and left hypocondrium. laboratory showed 12,3 g/dl haemoglobin. radiologic test: laterally 10 th left rib fracture. ct scan revealed iv grade spleen injury and perisplenic hemoperitoneum. we choosed non-operative managementafter 7 days ct scan showed reduced dimensions of dilacerated spleen injury and no hemoperitoneum. the patient status was stable during the 10 days hospitalisation. imagistic control after 1 month: homogenous spleen structure. conclusion: the haemodinamic status of the patient is the most reliable criteria for non-operative management, not ct aspect of the injury. 27 years old) submitted to upper partial splenectomy for blunt trauma. residual spleen after surgery was 1/3 and 2/5 respectively. ceus was preceded by standard b-mode us with color flow mapping in all cases; videoclips of each exam were stored for forensic medicine issue too. mean time for ceus exam was 5-7 minutes. results: ceus allowed to recognize regular perfusion of the residual spleen in both patients. conspicuity of ceus imaging was high and impressive. homogeneous complete distribution of the contrast medium in the parenchyma was observed on day 5 in both pts. ceus follow-up on day 10 and 30 did not add any supplementary information. pts were discharged on day 7 and day 11 respectively, without indications for vaccinations or antibiotic prophylaxis. conclusion: ceus is an effective method for assessing perfusion of the residual spleen after partial splenectomy. ceus can be performed bedside by the surgeon in the early po period or on an outpatient basis. imaging interpretation is immediate and distribution of the contrast medium assure about viability of the splenic tissue. ceus imaging allowed us to omit prophylactic vaccinations. it is the first description of the use of ceus in this particular setting. introduction: injuries to the abdominal visceral vessels are uncommon but devastating entities that incur extremely high rates of mortality.the rarity of these injuries prevents many trauma centers and trauma surgeons from developing a significant knowledgement learning curve. the authors describe a case with abdominal visceral vascular abdominal blunt trauma, presented with laceration in the confluence of inferior mesenteric vein and splenic vein, laceration of the hepatic artery associated with hepatic hematoma, periduodenal and peripancreatic hematoma. the routine principles of vascular surgery were applied to the management of these visceral blood vessels injuries :adequate exposure, proximal and distal control, dé bridement of the vessel wall,meticulous arteriorraphy and venorraphy with fine monofilament vascular sutures and early instituition of damage control resulting a successfull repair. material and methods: the authors made a review of several large series in the literature wich are also consistent with a low incidence of visceral vessel injuries. vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment a broad spectrum of surgical specialities are involved in the ressuscitative phase of trauma care including general, trauma, thoracic and vascular surgery . despite a relatively low incidence of vascular trauma in portugal, the results are satisfactory because of active and early management by surgeons on call, weather with vascular training or not, treating all kinds of vascular surgical emergencies. a trauma and emergency surgical speciality is a challenge. results: little information describing the first repair or ligation of any visceral vessel injuries can be found in the literature. visceral vascular injuries carry a significant mortality rate. vascular injury poses a small but significant challenge in portugal trauma care. opportunities such as better practise guidelines and minimum standars will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. training in the management of vascular trauma surgery with integration of vascular and general surgeryin trauma care should optimize outcomes. conclusion: from reviews of large series dealing with the management of abdominal vascular injuries, the incidence can be estimated to be between 0.01% to 0.1 %of all vascular injuries. few data are available describing the mortality rate for patients with portal veins injuries. te author's vision is that all vascular and general surgery trainees would eventually undertake the definitive surgical trauma care course and improve outcomes and reduce mortality. introduction: high rates of intra-abdominal pressure, has been proved to increased mortality, especially in multi-trauma patients followed laparotomy. multiple organ failure syndrome (mofs), derived by intra-abdominal hypertension, has been called abdominal compartment syndrome (acs), the epidemiology and the characteristics of which, have not been thoroughly determined. introduction: intercostal pulmonary hernias are rare and mostly resulting from complications related to the chest trauma.the authors report a case of traumatic intercostal pulmonary hernia in a 35-yearold man. he was admitted to the hospital as a traumatic patient after a motor-cycle accident . material and methods: beside multiple polytraumatic injuries the patient had a blunt injury to the left chest.physical examination revealed a bulge on palpation of the left chest wall.computed tomography (ct) scan of the chest revealed the protrusion of lung tissue outside the intercostal space.size of hernia, incarceration and respiratory insufficiency mandate immediate surgical intervention.postoperative course was uneventful, and there has been no sign of recurrence of hernia. results: post -traumatic lung herniation through a defect in chest wall is an uncommon injury .various methods of tratement and repair have been described, including both purely thoracoscopic to full open techniques.the authors repaired a case using a minithoracotomy. conclusion: lung hernia is an uncommon entity defined as the protrusion of pulmonary tissue and pleural membranes through defects of the thoracic wall.chest trauma is the most common cause.timely surgical intervention is critical to favorable patient outcomes.effective management, surgical approaches and repair of thoracic injuries are discussed and the available literature. of the hernia from the outside, dé bridement and closure layer-bylayer with maxon-0 was performed. the postoperative course was uneventful. conclusion: a tawh after blunt trauma is a rare entity. the reported incidence of acute hernia ranges from 02,%-3,6% 1 . in our case the tawh was already diagnosed in the trauma room. mahajna et al. 2 reported the case of herniation of the right colon with vessel strangulation, which wasn't seen in the primary survey. a right hemicolectomy had to be performed on the 2 nd posttraumatic day. in our case we decided intraoperatively to perform a primary reconstruction of the abdominal wall without mesh repair. the potential advantage of a mesh implantation lies in the augmentation of the abdominal wall, thereby potentially lowering the risk of incisional hernia. however, the benefits of such augmentation should be cautiously weighed against the risk of foreign body contamination when resecting bowel during the same operation. introduction: impalement is an uncommon and spectacular injury, which combines aspects of both blunt and penetrating trauma. impalement injuries from falls are rarely seen, because most of the patients die at the scene of injury. we present an unusual case in which a patient survived a perineal impalement after a fall.with reference to our latest case and discuss the initial management and the operative treatment of this rare injury according to a literature review. material and methods: a young man was working on a construction site when he suddenly lost his footing and fell 7 m off a scaffold. he orientated such that he landed in a sitting position on a vertical aluminium u-tube, which penetrated his perineal region and stucked. upon arrival at the emergency room he was in stable condition, intubated. after the initial treatment and diagnosis according to atls a ct of the abdomen was performed; it showed a penetrating tube perianal left, from caudal into the cavity of the pelvis, the point of the tube stucked in the sacrum -in the hole of neuroforamina s1. there was no intraabdominal or laceration. the patient was taken to the operating room in stable condition. the laparotomy was performed. there was no laceration detected, explorating the praesacral cavity brought out a profuse bleeding of the main pelvic vein. after the active bleeding was stopped the tube was removed from the outside. after lavage and positioning of drains, a protective loopileostoma was placed to avoid further contamination. the perineal wound was carefully debrided, drains were inserted and the wound was not completely closed by adapting stitches. a wash-out of the colon was performed, he received antibiotics and the perineal wound was rinsed daily. he was dismissed 18 days post-trauma. results: impalement injuries result when a solid object pierces a body cavity or extremity. the object often remains fixed within the body. this case report showed a positive outcome. impalement injuries are impressive but also rare, so it is important to show an algorithm in management of such injuries. the object should be in situ during transport. in large or immoveable objects, the impaling device should be cut just above the skin. the management of the injuries depend on the particular body region of penetrating. perineal impalement often appear quite complex. these injuries may need the assistance of gynecology and urology surgery praesacral drainage and distal rectal washout is recommended. wound care is essential in the care of impalement injuries. the skin should generally left open. even uncomplicated wounds have to be treated with antibiotics. conclusion: impalement injuries are rare and treating is a challenge for the surgeon. the degree of the injury determines the functional result. strict adherence to the transportation and management principles outlined in this paper are necessary to decrease morbidity and mortility disclosure: no significant relationships. introduction: the insertion of foreign objects into the anus and rectum is a well-known phenomenon. rectal foreign bodies can present a difficult diagnostic and management dilemma. . a foreign body may be inserted by a doctor for diagnosis or treatment like rectal thermometer, enema tubes or anal packs, by the patient for self eroticism or by a third party as a result of assault or sexual activity, but the most common cause for insertion of a foreign body is sexual stimulation. 1,2,3 . anorectal foreign bodies are more common in men than in women . they can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, rectal bleeding and can be associated with perforation or delayed injury. material and methods: in this study, in the ten years from 1999 to 2009, we used the medical records of 7 patients with foreign bodies in the rectum have been diagnosed and treated,at izmir teaching and research hospital,izmir. results: all patients were men.they ranged in age from 33 to 68 (mean age 48).two of these 7 patients had impulse body spray, two patients had bottle, one patient had eggplant,one patient had brush and one patient had wishbone (after oral ingestion) in the rectum. five objects were removal transanally extracted by anal dilatation under general anesthesia.two patients required laparotomy.one patient of these the object was high lying in the rectosigmoid and performed laparotomy.the object was removal transanally extracted by abdominal manuplation.one patient had a intraperitoneal rectosigmoidal perforation.the perforation was treated by primer suture, proximal colostomy and appropriate antibiotic therapy. routine rectosigmoidoscopic examination is performed after removal.one patient had perforation of the rectosigmoid and 4 had lacerations of the mucosa. no patient had a mortality. conclusion: foreign bodies in rectum should be managed in a wellorganized manner. the diagnosis is confirmed by means of plain abdominal radiographs and rectal examination. manual extraction without anaesthesia is usually only possible for very low lying objects. patients with high lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction.open surgery should be reserved only for those patients with perforation, peritonitis and impaction of the foreign body. results: definitive pathological examination confirmed the diagnosis of pancreatic pseudocyst. the patient postoperative outcome was unremarkable and was discharged from the hospital at the seventh postoperative day. conclusion: retroperitoneal and ''well protected'' location implies that a high energy traumatism is needed to injury the pancreas. the fact that in this case a non-classical injury mechanism has occurred, makes the diagnosis more difficult to reach. pancreatic pseudocyst is the most frequent complications in this type of traumatisms. effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch uncomplicated mason type-ii and iii fractures of the radial head and neck in adults. a long-term follow-up study surgical treatment of intra-articular fractures of the distal part of the humerus. functional outcome after twelve to thirty years disclosure: one or more of the authors received funding from the small bone innovations (dr) fractures of the neck of the talus. long-term evaluation of seventy-one cases tuberosity malposition and migration: reasons for poor outcome after hemiarthroplasty for displaced fractures of the proximal humerus tuberosity osteosynthesis and hemiarthroplasty for four part fractures of the proximal humerus abdominal 64-mdct for suspected appendicitis: the use of oral and iv contrast material versus iv contrast material only socioeconomic factors, medicolegal issues, and trauma patient transfer trends: is there a connection? are patients being transferred to level-i trauma centers for reasons other than medical necessity? the delaware trauma system: impact of level iii trauma centers improving outcomes in a regional trauma system: impact of a level iii trauma center jupiter -metaanalysis: nondisplaced scaphoid fractures. operative vs. nonoperative management(update to nov dodds -minimally invasive management of scaphoid nonunions chess -a biomechanical analysis of intrascaphoid compression using the herbert scaphoid screw system. an vitro cadaveric study is the mortality rate for septic shock really decreasing? systemic inflammation after trauma in vivo effects of a synthetic 2-kilodalton macrophage-activating lipopeptide of mycoplasma fermentans after pulmonary application alveolar macrophages from septic mice promote polymorphonuclear leukocyte transendothelial migration via an endothelial cell src kinase/nadph oxidase pathway macrophage inflammatory protein-1 alpha mediates lung leukocyte recruitment, lung capillary leak, and early mortality in murine endotoxemia fracture-dislocation of the hip joint. the nature of the traumatic lesion, treatment, late complications, and end results cervical spine trauma in the pediatric patient spinal injuries in children and adolescents long-term clinical and radiographic outcomes after open reduction for missed monteggia fracture-dislocations in children elastic stable intramedullary nailing as alternative therapy for pediatric monteggia fractures unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing delayed radial paralysis after monteggia fracture-a case report, unfallchirurg a simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures a fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation an analysis of different types of surgical fixation for avulsion fractures of the anterior tibial spine modified arthroscopic suture fixation of a displaced tibial eminence fracture tibial spine fractures in children fractures of the tibial spine in children seventeen-year follow-up of a reattachment of a nonunited anterior tibial spine avulsion fracture arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method the mechanism of clavicular fracture: a clinical and biomechanical analysis functional outcome following clavicle fractures in polytrauma patients evidence-based orthopaedic trauma working group. treatment of midshaft clavicle farctures: systemic review of 2144 fracturese: on behalf of the evidence-based orthopaedic working group harnroongroj t, vanadurongwan v. biomechanical aspects of plating osteosynthesis of transverse clavicular fracture with and without inferior cortical defect autologous bone versus calcium-phosphate ceramics in treatment of experimental bone defects iliac crest autogenous bone grafting: donor site complications clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation augmented with iliac crest aspiration literature review of current techniques for the insertion of distal screws into intramedullary locking nails a new fluoroscopy-free navigation device for distal interlocking screw placement disclosure: we all are surgeons at gregorio marañ ó n hospital, madrid. dr. turegano is the chief of the emergency surgery department. references: 1-nandapalan and al factors related to mortality in inferior vena cava injuries: a 5 year experience disclosure: we certify that all our affiliations with or financial involvement (employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending) with any organization or entity with a financial interest. references: 1. blaisdell, f.w. the pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. references: robinson cm evaluation of 238 consecutive patients with the extended data set of the standardised audit for hip fractures in meniscus allograft transplantation: a current concepts review homologous meniscus transplantation: experimental and clinical results cell survival after transplantation of fresch meniscal allografts: dna probe analysis in a goat model freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale meniscus replacement with bone anchors: a surgical technique meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations clinical evaluation of arthroscopic-assisted allograft meniscal transplantation knee joint biomechanics following arthroscopic partial meniscectomy an evaluation of a shockroom located ct scanner: a randomized study of early assessment by ct scanning in trauma patients in the bi-located trauma center north-west netherlands (react trial) overlooked spine injuries associated with lumbar transverse process fractures frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal ct in patients with trauma traumatic lumbosacral dislocation: report of two cases references: prevalence of suicide ideation and suicide attempts in nine countries uptake and intracellular distribution of various metal ions in human monocyte-derived dendritic cells detected by newport green dcf diacetate ester biomechanical analysis of bicondylar tibial plateau fixation:how does lateral locking plate fixation compare to dual plate fixation? operative treatment of 109 tibial plateau fractures.:five to 27 years follow-up results treatment of high energy tibial plateau fractures with half ring external fixation combined with minimal internal fixation. nan fang yi ke da xue xue bao disclosure: no significant relationships de smet l, debeer p, degreef i. fixation of a periprosthetic humeral fracture with ccg-cable system results of non-operative and operative treatment of humeral shaft fractures. a series of 104 cases complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. surgical technique the anteromedial facet of the coronoid process of the ulna ring d, doornberg jn. fracture of the anteromedial facet of the coronoid process. surgical technique broberg ma, morrey bf. results of treatment of fracture-dislocations of the elbow disclosure: one or more of the authors received funding from the small bone innovations (dr perilunate and axial carpal dislocations and fracture dislocations evaluation of the spanish versió n of the dash and carpal tú nel síndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability philadelphia: w. b. saunders company; 1992. p. 645-63. 2. meyer pr. complications of treatment of fractures and dislocations of the dorsolumbar spine no significant relationships. references: 1. general medical council. consent: patients and doctors making decisions together is informed consent effective in trauma patients is informed consent in trauma a lost cause? a prospective evaluation of acutely injured patients' ability to give consent factors affecting the quality of informed consent the impact of objective assessment and constructive feedback on improvement of labrascopic performance in the operating room united arab emirates, 2 medical education at the main trauma hospital. results: 2573 patients were studied (86.6% males) having a mean age of 31.4 years. 50% of patients were from the indian subcontinent and 18% were uae nationals. 99% of patients presented immediately following injury. ambulances brought only 34% of the patients. 40% of trauma took place in the street or highway, 29% in work places and 20% at home. the mechanisms of injury were road traffic collision in 41% and falls in 34%. 45% of injuries were to extremities, 27% to head, face and neck, and 12% to chest. the mean iss was 5.6. the mean (range) hospital stay was 9.2 (1-150) days; 202(8%) patients needed icu admission of whom 28 (13.9%) died. the mean icu stay was 5.8 days (range 1-35). overall mortality was 56 (2.2%). conclusion: road traffic collisions and falls are the main cause of trauma admissions in al ain city. extremities, head, neck, face and chest are the main body regions sustaining injuries. disclosure: no significant relationships hip fractures in the elderly: a world-wide projection disclosure: no significant relationships. references: d. ring et al.: predictors of acute carpal tunnel syndrome associated with fracture of the distal radius pm047 non-surgical treatment of the distal radial fracture. is there an advantage in immobilization in 20 degrees dorsiflexion compared to immobilization in a neutral position? janzing 3 , l. horta 1 1 emergency department, viecuir medical centre the netherlands introduction: according to the literature immobilization of collespoints where radiological (dorsal dislocation, radial inclination), functional, the necessity for surgical intervention a comparison of 2 methods of plastic cast fixation in treatment of loco classico radius fracture. a prospective, randomized study, unfallchirurg pm048 buzzsaw injuries: mechanisms of damages and predisposing factors r. ziegler 1 , w. knopp 1 woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools references: beasley ls, vidal af. traumatic patellar dislocation in children and adolescents: treatment update and literature review long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum 5-year follow-up mri of traumatic patellar dislocation in children reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children injuries to the inferior pole of the patella in children disclosure: no significant relationships pm055 results of electromagnetic fields in healing progression of delayed union in the lower extremities the effect of low-frequency electrical fields on osteogenesis references: complex trauma of the limbs with vascular injuries-olivera lupescu, mihail nagea carcinoid tumour of the appendix:an analysis of 1485 consecutive emergency appendectomies tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy. dig. liver dis at perforated ulcer treatment, suture of the place of prefotation was used at 205 (94,91%) people, billroth ii stomach resection at six (2,78%), suture of the place of prefotation with psv at three (1,39%), and billroth i stomach resection at one (0,46%) patient. postoperative complications were noticed at 14 (6,48%) people. we had postoperative mortality at four (1,85%) patients. recidive ulcer was registred at 10 (4,63%) patients who were surgically treated for perfored ulcer before. conclusion: ulcer perforation is an acute complication of the ulcer disease that appears most frequently after bleeding and which usually requires surgical treatment. references: 1. behçet disease complicated by a perforated ileal ulcer presenting as an acute abdominal emergency gastro-duodenal ulcers with perforation caused by short-term acetylsalicylic acid ingestion: case report culafiä à d, matejiä à o perforated gastroduodenal stress ulcer melinte c, dragomir c pubmed -indexed for medline] spontaneous rupture of the spleen as immediate complication in autologous transplantation for primary systemic amyloidosis delayed splenic rupture as a cause of haemoperitoneum in a capd patient with amyloidosis boluda garcã a f, calvo catalã ¡ j, campos fernã ¡ndez c, parra rã 3 denas jv, gonzã ¡lez cruz mi laparoscopic cholecystectomy for acute cholecystitis disclosure: no significant relationships. references: 1. pokorný j. et al. urgentní medicína, 1. st edition: praha, galé n 2004 2. stetina et al. medicína katastrof a hromadný ch neštä >stí pt018 perforation of oesophagojejunal anastomosis by venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in 58 cadavers pt021 validation of fournier's gangrene severity index score (fgsis) general surgery dobrzanska l, newell r. readmissions: a primary care examination of reasons for readmissions of older people and possible readmission risk factors pt025 spontaneous rupture of giant cavernous hemangioma of the liver in a patient with systemic hemangiomatosys and kasabach-meritt syndrome. an interactive and multidiscipline case b general surgery general surgery portugal introduction: hemangiomas are frequent benign tumors of the liver nonoperative management of blunt splenic and liver injury is ct grading of splenic injury useful in the nonsurgical management of blunt trauma? management of blunt splenic trauma: ct contrast blush predicts failure of nonoperative management references: 1. ochsner mg. factors of failure for nonoperative management of splenic injuries associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management introduction: aim. to establish the diagnostics and management trauma, 193(65,2%) -head trauma, 96(32.4%) -limbs injuries, and 74(25%) -severe shock. in cases the splenic injury was initially manifested -223(75.3%), and in 73(24,7%) cases the clinical signs developed later (p < 0.001) practice management guidelines for the evaluation of blunt abdominal trauma: the east practice management guidelines work group diagnostic accuracy of surgeonperformed focused abdominal sonography (fast) in blunt paediatric trauma surgeon-performed bedside organ assessment with sonography after trauma (boast): a pilot study from the wta multicenter group disclosure: no significant relationships. pt035 incidence of abdominal compartment syndrome in patients with multiple injuries. a single institution experience koulas 1 , o. mousafiri 2 hatzikosta general hospital, ioannina, greece, 2 intensive care unit, g. hatzikosta general hospital intensive care unit, g hatzikosta general hospital delayed presentation of traumatic parasternal lung hernia management of retained colorectal foreign bodies:predictors of operative intervention disclosure: no significant relationships. treatment. disclosure: no significant relationships. references: 1.demetriades d, velmahos g. technology-driven triage of abdominal trauma: the emerging era of nonoperative management management of high grade renal trauma: 20-year experience at a pediatric level i trauma center pt045 blunt abdominal trauma. 5 year experience in our department greece (4,4%), without spinal fractures. resection/anastomosis was permorbidity. in first group, there were 3 deaths (16,6%), 2 cases due to intestinal injuries. the second group (without seatbelt sign) had 8 deaths (8,8%), none due to intestinal injuries but related with multiple thoracic and cranial lesions. conclusion: in this study we found a consistent evidence that ''seatbelt sign small-bowel and mesentery injuries in blunt trauma mortality reduction with air bag and seat belt use in head-on passenger car collisions disclosure: no significant relationships. references: management strategies in isolated pancreatic trauma disclosure: no significant relationships. references: enterocutaneous fistula complicating trauma laparotomy: a major resource burden the american surgeon staged management of giant abdominal wall defects injured patients -documentation of black spots j. heinzmann 1 , u. culemann 2 , t. pohlemann 3 1 universitä tsklinik des saarlandes, klinik fü r unfall-, hand-und wiederherstellungschirurgie, homburg, saar, germany, 2 trauma-, hand and reconstructive surgery, university of saarland, homburg, saar, germany, 3 klinik fü r unfall-, hand-und wiederherstellungschirurgie, universitä tsklinikum des saarlandes, homburg, saar, germanyintroduction: nonunions of the tibia represent a complex problem, particularly if they occur at the distal third of the tibia. the aim of the study was to evaluate a standardized treatment concept to manage different types of nonunions of the tibia with regard to their location within the tibia. material and methods: prospective, non randomised study (01/03-06/08); nonunions of the diaphyseal and metaphyseal tibia (ao type 42/43); standardized treatment concept: diaphysis: reamed intramedullary nailing; dia-metaphyseal junction and pilon: lcp with a minimal invasive approach or an open approach plus bone grafting from the iliac crest; infected nonunions: external fixator. analysis parameters: demographic data, fracture type (ao classification), primary surgery, healing process, time to union (radiographic), complications. results: forty-eight patients (39 m, 9 f; mean age 45,2 y) with 15 hypertrophic (primary surgery: 13x nail, 2x external fixator) and 33 atrophic nonunions of the tibia (primary surgery: 13x nail, 13x plate, 4x screws and 3x external fixator) were included in the study. fifteen tibial nonunions had been primary treated in our department, 33 patients had been admitted from other hospitals. seventy-three% of all nonunions were located at the distal third of the tibia (45% at the diaphyseal-metaphyseal junction, ao-classification type 42; 55% at the pilon, ao-classification type 43). seventy-five% of the dia-metaphyseal fractures and 10% of the pilon fractures were primary treated with an intramedullary nail. the mean time between injury and nonunion-surgery was 10,3 (6-39) months. follow up: 41/48 patients (85%) for an average time period of 22,2 months; union-rate: 37/41 (hypertrophic nonunions 11/13; atrophic nonunions 26/28: 2 re-nonunions each). complications: 1 death by lung embolism, 1 re-nonunion (united after second surgery), 1 implant (plate) loosening with the need of reosteosynthesis, 2x varus malalignment, 1x valgus malalignment, 1x peroneal nerve lesion. conclusion: especially the distal third of the tibia still represents a high risk area for nonunions. impaired perfusion, thin soft tissue coverage, as well as the rising number of nailing even of distal tibial fractures 1 are some of the causes. we think that the herein introduced treatment concept is effective to manage tibial nonunions. thus, the union-rate in this study population was 90% 2,3 . an adequate primary osteosynthesis as well as the prevention of extensive soft tissue damage during surgery are mandatory to improve the outcome of tibial fractures. besides, new therapy options as e.g. the application of growth factors and ultrasound have to be considered also for the treatment of tibial nonunions. g. heinrichs 1 , a. p. schulz 2 , e. wilde 3 , r. oheim 4 , c. jü rgens 4 1 trauma&orthopedics, university lü beck, lü beck, germany, 2 trauma&orthopaedics, university lü beck, lü beck, germany, 3 trauma + orthopaedics, university lü beck, lü beck, germany, 4 trauma&orthopedics, university lü beck, hamburg, germanyintroduction: high energy tibial head fractures with bicondylar involvement have a much poorer outcome compared to the other forms of tibial head fracture. soft tissues are almost allways compromised. bilateral plating carries the risk of soft tissue and bone infections. due to loss of reduction, steps or gaps might remain in the joint surfaces. aim of this study was to evaluate the clinical and radiological outcome of schatzker 4, 5 and six type fractures treated with locked osteosynthesis plating. material and methods: between january 2003 und january 2005 we treated 97 patients suffering from a tibial head fracture. in 26 cases osteosynthesis was performed with the use of an angular stable implant, this group forms the study population. indication for locked screw plates were bicondylar fractures treated unilateral to avoid bilateral approach with double-plate osteosynthesis and tibial head fractures with a shaft involvement (schatzker 6). follow-up was performed after an average of 7.5 months after surgery. we treated 16 male and 10 female patients with an average of 52.5 years of age (17 to 73 years). there were no patients with open fractures or primary nerve injury included in this study. operative treatment was performed after an average of 1.7 days after trauma. we used an angular stable plate fixator made from pure titanium (tifixò, litos, hamburg/ germany). the plate is consisting of the softer titanium grade 1; the screws are made from harder titanium grade 2.results: there was one case of a postoperative peroneal nerve lesion with spontaneous regression after two weeks. no postoperative wound necrosis or infection occured. all patients showed bony consolidation after a mean of 8.4 weeks as judged by radiographs. additional autologous bone transplantation was not necessary. we did not observe any secondary loss of reduction or loosening of the internal plate fixator when comparing direct postoperative radiographs to those at follow up. rom of the knee did not show any restriction compared to the opposite side in 9 patients. 13 cases showed mild and 4 cases a remarkable restriction of rom compared to the not injured side.applying the rasmussen score, 17 cases achieved a good and very good result. 6 patients had to be judged as moderate and 3 as poor conclusion: unilateral plate fixation for the treatment of bicondylar tibial head fractures seems to offer advantages in particular concerning infection rate and implant failure in the treatment of tibial head fractures. results: the adjacent level th-l fracture was found in 6.5% (3/46 patients) in kyphoplasty group and in 7% (2/27 patients) in vertebroplasty group. we did not found any serious complication but established postoperative bmd loss. we did not found any intradiscal cement leakage in cases with adjacent level fractures. intraoperative correction of kyphosis was better achieved in kyphoplasty group; pain relief was similar in both groups.conclusion: natural process of further bone loss seems to be the most influent factor for future compression fractures in elderly patients. trauma patients represent a challenge in terms of obtaining informed consent as they are often in significant pain and maybe under the influence of strong medication at the time of the consent process. we designed a prospective, randomised un-blinded control study to test the hypothesis that there would be no difference in the ability of trauma patients to recall details of the consent process whether the patients were given verbal compared with verbal and written information.material and methods: a consecutive cohort of trauma patients presenting to a major teaching hospital were recruited and randomised into two groups. group a received structured verbal information only. group b received structured verbal information and written information about the proposed procedure. all patients were interviewed within the first post operative week (mean 3.2 days) and scored on their ability to recall key facts given in the original consent interview. results were analysed using the mann-whitney u test.results: 119 patients have been recruited. information recall was significantly improved in the group receiving written information (mean questionnaire score 64% vs 41% for verbal information alone, p=0.0014). patient satisfaction with the consent process was also significantly improved in the group receiving written and verbal information, with 97.9% of patients reporting they understood the risks of surgery when they signed the consent form, compared to 83.2% who received verbal information alone (p=0.01).conclusion: written information improves patient recall of the consent process. it is a simple, cost-effective intervention with high patient acceptability. introduction: survivorship of second hip fracture patients is worse than initial hip fracture patients. however, previous studies included in-hospital mortality. the actual survivorship of initial hip fracture patients with subsequent second hip or major long bone of extremity or vertebral body fracture by exclusion of in-hospital mortality patients have not been studied. we aim to compare the actual survival of initial hip fracture patients with and without second hip or subsequent major fracture. in addition, risk factors, mortality causes, and hazards ratio of each fracture groups were studied. material and methods: in 2000-2008, after exclusion of in-hospital mortality patients, 1038 initial hip fracture patients were reviewed and divided into four groups. group i, ii, iii, and iv were initial hip fracture patients with second hip, subsequent major long bone of extremity, vertebral body fracture, and without any subsequent fractures, respectively. we set group i, ii, and iii as study groups comparing the data with group iv (control group). age, gender, mobility-status, co-morbidity, causes of death, and survival years after hospitalization of last fracture treatment of each group were recorded. actual survival rate and risk factors difference between initial hip fracture with and without subsequent fracture were analyzed by chi-square test. hazards ratio differences among the groups were analyzed by cox regression models.results: there were 34 (3.3%), 71 (6.8%), 160 (15.4%), and 773 (74.5%) subjects in group i, ii, iii, and iv respectively. at one-year and one-to-five year mortality of group i were 8.8% and 5.9%, group ii were 5.6% and 1.4%, group iii were 1.3% and 1.9%, and group iv were 4.7% and 1.4% respectively. statistical analysis by using chi square test of one-year mortality and one-to-five year mortality rate showed no significant difference among four groups (p > 0.05). but from cox regression analysis, second hip fracture produced significant hazards ratio as 7.98 (p = 0.02). the actual survivorship of initial hip fracture patients with second hip or other subsequent fracture were not different from patients who have only one hip fracture. however, special care should be focused in patients with second hip fracture which produced significantly highest hazards ratio for mortality.reduction or redislocation after one week of treatment. due to the lack of sufficient patient data a statistical analysis was not carried out. it was obvious that the dorsal dislocation after reduction was worse in the dorsiflexion group. there was no obvious difference in radial inclination or functional outcome between the two groups. conclusion: mainly the dorsal inclination was worse in the 20 degrees dorsiflexion group. a possible explanation for these results is the technique used when modeling the plaster cast. in our hands immobilization in dorsiflexion yielded poorer results then immobilization in a neutral position. due to the poor results the study was terminated prematurely. the traumatic patellar luxation in adult patients is operatively treated with medial reefing and lateral release. the value for the treatment of adolescents is still discussed controversially in literature. the aim of the present study was to evaluate the efficacy of the minimal-invasive treatment of traumatic patellar luxation in adolescents. , that was treated with acute angular shortening using a monolateral ao fixator followed by gradual correction using the taylor spatial frame (tsf). the conversion in the tsf was achieved in exchanging only two half-pins. results: the deformity was anatomically corrected without any soft tissue complications. the fixator was worn for 12 weeks under full weight bearing while the actual correction took only 14 days. we did not see any typical external fixator complications like pin trac infection. conclusion: acute angular shortening can lead to direct soft tissue closure without any additional plastic surgery. the accuracy the the fixator allows the gradual anatomical reduction of the fracture and simplifies the correction of the mostly multiplanar deformities. when the surgeon is familiar with the tsf even a primary treatment of such fractures could be recommended. the image control (plain x-rays, ct) revealed and definitively determined whether a two-part or three part triplane fracture in the distal tibial physis were present, the amount of the displacement, and the co-existed fracture of the fibula. the principal goal must be the anatomical reduction of the fracture initially closed and in failure opened. an open reduction and fixation with 3 steinmann via anterior approach followed. a long-leg cast worn for initial 4 weeks, followed by a short-leg cast for 2 weeks. results: at a minimum of fourteen months of clinical follow -up all patients lacked complaints and had full range of motion in ankle.conclusion: these injuries occur in the adolescent age group generally slightly younger than the child with a tillaux fracture, needed good image control (ct) and must reduced anatomically and fixed. disclosure: no significant relationships. it is necessary in 15-25% of patients. to provide dynamisation using conventional methods, it is necessary to perform one additional surgery. in this presentation it is shown one new method of selfdynamisation. material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to 1,349 patients in treatment of femoral fractures. the age of patients was from 14 to 88 years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the 3-4 months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept (in 24% of patients), which probably all together with 3d configuration resulted in unexpectedly quick fracture healing. follow up was 20 months (6-61 the severity of injury was measured by the injury severity score (iss). the outcomes for categorical variables were tested using v 2 test and a significance level at p < 0.05 was maintained. delayed complications were defined as any complication directly attributable to the splenic injury that occurred more than 48 hours after injury. the following data was retained: age, sex, mechanism of injury, iss, number of icu days, overall length of stay, number of blood units transfused, day of operation and discharge status. results: our study found 10,4% incidence of delayed complications after nom. these complications include delayed hemorrhage (4 cases), splenic artery pseudoaneurysm (1) and splenic abscess (1 case). the need for operation due to ongoing bleeding was retained in following situations: more than 4 u of blood to maintain a hb higher than 10 g/dl, systolic pressure to less than 90 mm hg despite resuscitation and evidence of peritoneal signs. of the 6 patients failing nom, 67% failed between days 3 and 5 and 83% in the first week. in all cases a splenectomy is performed with no mortality rate. the results of this study indicate 2 independent risk factors of failure of nom: a high ct grade of splenic injury (grade iii and above) and a transfusion with more than 3 u of blood. results: results : out of the 14 patients suffering of liver injuries 10 patients had grade 1,2 and grade 3 liver injuries and were treated conservatively. 4 patients had grade 4 and 5 liver injuries and were operated. 1 patient who was initially managed conservatively was operated due to inability to control the blood loss. out of the 10 patients suffering injuries of the spleen, 4 were grade 4 and grade 5 and were successfully operated and 6 were grade 1 and 2 and were treated conservatively. all patients suffering of injuries of the retroperitoneal space, unilateral kidney injuries and injuries of the hypogastrium were managed conservatively. conclusion: blunt abdominal injuries can be managed successfully and safely by conservative treatment whenever it is allowed by the circumstances. the ct scan is a very sensitive diagnostic scanning, capable of diagnosing intrabdominal haemorrhages retroperitoneal lesions as well as the extent of the organ injury and is a necessary tool for the physician in order to diagnose accurately any abdominal injury. disclosure: no significant relationships. introduction: more and more hepatic injuries are treated non operatively if the hemodinamic's and lesion's stability is confirmed. the count and the scaling of lesions doesn't directly influence surgical indications. we report about 6 cases of blunt trauma with serious hepatic and renal lesions treated successfully with a non operative management material and methods: we treated 6 liver and renal injury associated in a period from 2007 to 2009. patients were admitted to tor vergata -roma and hospital universitario clínico san carlos-madrid. data collected were: age, sex, comorbidities, sequence of events, type and number of associated lesions, management, morbidity and mortality. all liver and renal organ's injuries were evaluated by abdominal ct scan with contrast and classified according to ct-based scale results: middle age was 36 ± 11 sd years. patient were male in (66,6%) of cases. ct scale of liver lesion was 3°for 4 (66,6%) patient and 4°for two (33.3%) patients. renal lesions were i°category in 5 cases (83,3%) and ii°category in 1 patient. no ureteral or major vessels rupture were founded. all patients have been treated non operatively. a ct based follow up of lesions was planned (at admittance, after 48 hours, after a week and after a month). the mean length of hospitalization was 12 ± 6 sd days. during hospitalization, patients were monitored by clinic and labs daily. all patients were dismissed in good conditions and are in in health on a 6 months follow up. at ct follow up, one patient presented an intra-hepatic biloma, that was successfully treated with ct-guided drainage conclusion: this work support the hypothesis that the association of liver and renal lesions in a blunt abdominal trauma, doesn't necessarily influences indications for an explorative laparotomy. if an ureteral rupture is suspected, a more aggressive treatment is necessary, in order to prevent peritonitisintroduction: the aim of this study is to analyze the most frequent mechanisms of injury, the evaluation in the emergency department and the period of increase of the blunt abdominal trauma incidence. material and methods: during the last 5 years (2005-2009) 147 patients were admitted to our department for blunt abdominal trauma.the most frequent mechanisms of injury were: traffic accidents (automobile crashes and motor vehicle collisions)110(74,8%) work accidents 26(17,6%) 3. others (fall from high altitude, beating) 11 (7,5%) we analyzed the most frequent injuries observed, the final treatment for these patients and the period of increase of blunt abdominal trauma.results: the peak incidence occurs in persons aged 18-42 years. the male/female ratio was 7:3. the most frequent abdominal injuries regarded: spleen 113(76,8%), liver 24(16,3%), large bowel 5 (3,4%), small bowel 3 (2%), pancreas2 (1,35%).134 patients underwent surgical treatment (91,15%). the incidence of missed injuries is quite low, one case with pancreatic injury and one with small bowel injury. during summer period a significant increase in blunt abdominal trauma incidence occurs because of the increase of population due to tourism. the initial physical examination, after appropriate primary survey and initial resuscitation with the help of diagnostic studies such as ultrasonography, abdominal ct scan, is essential for the final treatment for these patients, operative or not operative. abdomino-throcal injuries were found in 23(17%) patients.abdominal organ injuries were found in decreasing frequencies in small bowel(29%),liver (26%),large bowel (21%), spleen (18%), major vasculer, stomach and others. thoracal injuries were found in lung and heart in 21 and 2 cases.one organ injury was found in 39(30%) patients,mostly small bowel,and these group had a good haemodynamic status.thirty-two(25%) patients had two organ injuries which 6 of them associated with lung injury.three,4 and < 4 organ injuries were found in 13, 2 and 3 patients. haemodynamic unstability at presentation,and shock was found in five patients(1,2 and 3 organ injury in 2,1 and 2 cases). the overall mortality was found in 8(6%) patients.mortality from gun injury was 50% from major vascular injury 2,lung,pancreas and large bowel 1,lung and large bowel one.mortality from penetrating trauma was 40% from lung and multipl abdominal organ injury 1,heart 1,lung,spleen and stomach injury 1 and major vasculer injury from blunt trauma in one (10%) patient. five patients who remain haemodynamically unstable after resuscitation died intraopreoperative period.these group was not received some resuscitation, and they referred to our hospital later than 8 hours of injury. introduction: retroperitoneal location of the pancreas makes the diagnostic of any traumatism to be difficult, especially when this is not suspected. we report on a case of blunt pancreatic trauma with 6 months delayed diagnosis, after injury due to maneuvers in a difficult birth. material and methods: we report on a case of a twenty-nine year-old female who consulted at the emergency department for constant right upper quadrant pain that didn't ease with any analgesic prescribed by the general practitioner. these symptoms started after a birth six months before and loss of 15 kg of weight was associated. after reviewing the previous history of the patient, the birth had been difficult and forceps, suction pad and repeated abdominal pressure maneuvers were needed. abdominal examination showed a painful non-pulsatile mass located at epigastrium and both right and left upper quadrants. abdominal ultrasonography and enhanced ctscan were performed and demonstrated the presence of multicystic 15x14x11 cm mass located between the stomach, spleen and left kidney. the high density content seemed to be blood. the mass was pushing the stomach anteriorly and no communication between both of them was shown. the splenic vein was pushed superiorly and thinned and plenty collateral circulation was evidenced. the tail and the body of the pancreas were not identified in any of the studies. the first choice diagnosis was posttraumatic complicated (with bleeding) pancreatic pseudocyst. the patient underwent emergency operation and a big cystic pancreatic mass was encountered, with plenty of collateral circulation. intraoperative biopsy confirmed that it was a pseudocyst and therefore, the majority of the cyst was removed and roux-en-y pancreatojejunostomy was performed. cholecistectomy was also done. introduction: unnoticed traumatic injuries produce avoidable morbidity, mortality and a higher medical cost. we present a special case of the reconstruction of a catastrophic abdomen with several intestinal fistulae and giant abdominal wall defect. material and methods: we present the case of a 26 year old woman with blunt thoraco-abdominal trauma secondary to a road traffic accident. several lower left rib fractures, a fast echo with free fluid without solid organ injury and fractures of l1 and l2 were seen in the initial assessment. on the third day surgery was required due to septic shock with diffuse peritonitis due to a jejunal laceration and section of the body-tail of the pancreas. simple suture of the jejunal laceration, distal pancreatectomy, and abdominal packing without closure of the abdomen was performed. she developed several intestinal and colonic fistulae. over 40 surgical procedures were performed on her and she was discharged 9 months later with night parenteral nutrition, a closed abdomen by secondary intention and intestinal fistulae. she was readmitted a year later for reconstruction. we performed monoblock resection of the abdominal wall and the fistulized loops, subtotal colectomy and bowel transit reconstruction with three enteroenteric and an ileosigmoid anastomosis, leaving 1,8 m of small bowel. abdominal plastia with permacol mesh was also performed. results: surgical time was of 420 minutes and oral tolerance was initiated on the 7th postoperative day. she was discharged on the 14th day postop. the only complication was a fever secondary to infection a central venous catheter on the 3rd day. key: cord-015369-72cjogxz authors: nan title: 50th annual meeting of the austrian society of surgery. vienna, june 18–20, 2009. guest editors: albert tuchmann, erhard schwanzer, benedikt walzel date: 2009 journal: eur surg doi: 10.1007/s10353-009-0461-1 sha: doc_id: 15369 cord_uid: 72cjogxz nan die transinguinale präperitoneale hernioplastik wurde in ihren grundzügen bereits in den 1960er jahren beschrieben. im deutschsprachigen raum erfuhr das verfahren durch die arbeiten von schumpelick eine gewisse bedeutung. pelissier entwickelte basierend auf diesen grundlagen einen patch, welcher mit einem memory-ring armiert wurde und alle 3 hernienkompartimente der leiste abdeckt. basierend auf 909 durch die autoren seit oktober 2004 durchgeführten hernienreparationen wurden die daten prospektiv erfasst und unter anderem die komplikationen und rezidive analysiert. hinsichtlich der intraoperativen komplikationen ergaben sich 1,1 % probleme wie blasenläsion und verletzung der epigastrischen gefäße. postoperative komplikationen wurden in 8 fällen (0,88 %) beobachtet. insgesamt wurden 12 rezidivhernien diagnostiziert (bis 25 monate nach implantation), wobei die verteilung der rezidive uneinheitlich ist. es besteht bislang kein signifikanter unterschied zwischen fixierung mit resorbierbarem oder nicht resorbierbaren nahtmaterial. ungeschlitzte netze zeigen häufiger rezidive. die beschaffenheit des patches begü nstigt im einzelfall wahrscheinlich die rezidiventstehung. 2 netze wurden wegen einer schmerzsymptomatik im bereich des schambeines entfernt (2-4d post op), 1 netz wegen schmerzen am netzoberrand 39 m nach implantation. bezü glich der allgemeinen komplikationen unterscheidet sich das verfahren nicht von den gängigen hernienreparationen, die rezidivrate ist auch im längeren beobachtungszeitraum gering. es werden die problemzonen des patches diskutiert. klinisch diagnostizierte hernien ohne peritoneale ausstülpung c. hollinsky, s. sandberg kh floridsdorf, chirurgische abteilung, vienna, austria grundlagen. bei der laparoskopischen transabdominalen präperitonealen meshplastik (tapp) kö nnen leistenoder femoralhernien hinter einem intakten peritoneum verborgen sein. methodik. in einer prospektiv kontrollierten studie wurden alle laparoskopischen hernienoperationen der letzten 15 jahre analysiert. präoperativ wurden alle hernien vom operateur klinisch untersucht und bei unklarem befund wurden ergänzend ultraschall sowie in seltenen fällen ein mrt durchgeführt. intraoperativ wurden alle suspizierten hernien auf das vorliegen eines peritonealen herniensacks untersucht sowie die im präperitonealraum eingesehene pathologie dokumentiert. in einer multivariaten regressionsanalyse wurden eventuelle risikofaktoren auf deren zusammenhang mit einer hernie ohne peritonealdefekt ermittelt. ergebnisse. bei 6,2 % der hernien war intraoperativ kein peritonealer herniensack ersichtlich. dabei handelte es sich in erster linie um femoralhernien sowie durch präperitoneales fett ausgefüllte inguinalhernien. bei der multivariaten regressionsanalyse zeigte sich neben der femoralhernie sowohl die bruchpfortengröße als auch das alter als signifikante risikofaktoren für hernien ohne peritonealbeteiligung. schlussfolgerungen. aufgrund dieser ergebnisse sollte bei klinisch diagnostizierten hernien der inguinalregion intraoperativ der präperitonealraum inspiziert werden. feasibility and potential advantages of transporous mesh fixation by a laparoscopic spray system (lss) in inguinal hernia repair excellent fixation accompanied by a reduction of the amount of fs required. investigation of a new self-gripping mesh for hernia repair in a rat model in der modernen hernienchirurgie verdrängen netzbasierte therapien zunehmend die klassischen nahttechniken. in dieser untersuchung haben wir ein neues selbstfixierendes netz (parietene progrip) im tiermodell ratte im vergleich zu einem standardnetz (parietene light) erprobt. ziel war der vergleich der zugfestigkeit 5 tage und 2 monate nach aufbringen der netze auf die bauchmuskulatur. die fixierung erfolgte bei dem progrip-netz nur durch mikrohaken, bei dem parietene light mittels titanklammern, gewebekleber oder ohne fixierung. im zugversuch wurde die scherfestigkeit ermittelt. außerdem erfolgte eine histologische untersuchung auf entzü ndliche reaktionen sowie eine elektronenmikroskopische untersuchung auf materialdegradation. nach 5 tagen zeigten progrip-und stapler-fixierung ähnlich gute zugfestigkeiten (3,2 n/cm 2 ; 2,7 n/cm 2 ), wohingegen mit gewebekleber fixierte netze genauso wenig halt hatten wie unfixierte netze (0,9 n/cm 2 ; 1,5 n/cm 2 ; p < 0,05). nach 2 monaten waren die progrip-netze signifikant besser auf dem gewebe fixiert verglichen mit stapler, kleber und ohne fixierung (14,8 n/cm 2 vs. 11,7 n/cm 2 ; 11,4 n/cm 2 und 8,7 n/cm 2 ; p < 0,05). die histologische untersuchung zeigte nach 5 tagen entzündliche reaktionen im fremdkörperbereich bis in das umgebende bindegewebe. nach 2 monaten ist diese gewebsreaktion deutlich zurückgegangen, es sind kaum noch entzündliche zellen zu finden. stattdessen ist das netzmaterial vermehrt von riesenzellen umhüllt. die progrip-mikrohaken reichen deutlich in die muskulatur und sorgen dort für eine gute verankerung. die elektronenmikroskopische untersuchung konnte keinerlei materialveränderungen nach 5 tagen oder 2 monaten im vergleich zu neuem netzmaterial feststellen. schlussfolgerungen. das progrip netz zeigte eine deutlich bessere fixation im gewebe als der hernienstapler oder der fibrinkleber und ist zu diesen vergleichsfixationen eine kostengünstige alternative. grundlagen. der verschluss von trokarinzisionen ü ber 10 mm wird empfohlen aufgrund des risikos einer narbenhernienentstehung. insbesondere bei adipösen patienten ist dieser verschluss mit herkömmlichen methoden oft schwierig oder nicht durchfü hrbar. in der literatur finden sich hinweise auf eine deutlich erhöhte narbenhernieninzidenz im bereich von trokarstellen nach laparoskopischer narbenbruchoperation. methodik klinik für allgemein-und visceralchirurgie, bassum, germany grundlagen. sonographisch lassen sich präzise befunde zur pathologie der leiste als auch zur postoperativen situation resp. komplikationen erheben. fragestellung. bringt der routinemäßige postoperative einsatz der sonographie zusätzliche relevante befunde zur verlaufskontrolle? methodik. 600 leistenhernien wurden nach transinguinaler präperitonealer hernioplastik (tipp) versorgt und im rahmen der routinemäßigen postoperativen kontrolle nach 7-15 tagen zusätzlich sonographisch standardisiert nach netzlage, hämatomen/seromen und samenstrangdurchblutung untersucht. ergebnisse. in allen fällen fand sich eine korrekte netzlage, es fand sich kein rezidiv. in 43 fällen lag eine vermehrte netzwellung vor (7,16 %), meist medial, selten lateral. in 19/600 fällen (3,1 %) fanden sich hämatome/serome > 1 cm schichtdicke, deutlich häufiger > 5 mm (94/600), kleinere hämatome noch häufiger. keines der tiefen hämatome musste revidiert/punktiert werden, 2 oberflächliche hämatome wurden revidiert, 19 patienten wurden ein-oder mehrfach punktiert. 4 postoperative hydrocelen wurden beobachtet. die durchblutung von samenstrang oder hoden war sonographisch in allen fällen intakt. schlussfolgerungen. die routinemäßige sonographie-kontrolle nach leistenhernienoperation (hier tipp) hat nur gelegentlich therapeutische konsequenzen fast immer zusammen mit dem klinischen befund. aufgrund der ergebnisse sollte daher ein on-demand-vorgehen als ausreichend angesehen werden. in hinblick auf die bestätigung des frühen postoperativen befundes wird die routinemäßige sonographische kontrolle von den meisten patienten aber als positive bestätigung angesehen. das video zeigt eine neue onkoplastische technik beim mammakarzinom. die tumorquadrantektomie wird dabei im rahmen einer reduktionsplastik mit superior gestieltem pedikel durchgefü hrt. der inferiore pedikel, der normalerweise reseziert wird, wird dabei zur defekdeckung genutzt. ist eine resektion des tumors mit darü berliegender haut nötig wird der inferiore pedikel nicht komplett de-epithelisiert, sondern mit hautinsel in den defekt eingeschwenkt. die technik erlaubt rekonstruktion auch von kleinen und mittelgroßen brü sten, sowie von defekten im inneren quadrant der kontralateralen brust. oncoplastic surgery: the use of a breast reduction to improve cosmetic outcome for breast conserving surgery (video) oncoplastic techniques have increasingly been used in the last 20 years in europe and the united states. several techniques have been described. beside the use of local and free flaps after mastectomy the use of breast reduction techniques solved several problems for breast conserving surgery. this video demonstrates one possible technique to improve breast symmetry during breast conserving surgery. skin-sparing mastektomy and immediate reconstruction of the breasta videopresentation grundlagen . die erhaltung der kosmesis im rahmen der chirurgischen therapie des mammakarzinomes ist von zentraler bedeutung. trotz der vielfachen möglichkeit einer brusterhaltenden therapie, zwingen spezielle indikationen auch heutzutage noch zu einer kompletten entfernung des brustdrü dengewebes. dabei kommen immer häufiger hautsparende techniken bis hin zur erhaltung der areola oder sogar der mamille zur anwendung. im rahmen einer videopräsentation soll die technik der skin-sparing mastektomie und sofortrekonstruktion der brust veranschaulicht werden. methodik. von 345 patientinnen, die seit mai 2000 an unserer abteilung eine brustrekonstruktion erhielten, konnten in 38 fällen hautsparende techniken angewendet werden. zur präsentation der technik der skin-sparing mastektomie mit sofortrekonstruktion der brust wurde ein operationsvideo angefertigt. ergebnisse. die im video präsentierte technik führt zu einem kosmetisch ansprechenden ergebnis für die patientin. schlussfolgerungen. um fü r die patientinnen optimale postoperative resultate erreichen zu können, sollte die vorgestellte technik einen integralen bestandteil des therapiekonzeptes des mammakarzinoms darstellen und den patientinnen schon nach der diagnosestellung offeriert werden. the treatment of nonhealing and infected sternotomies following cardiac surgery is a challenging task, with increased rates of mortality and morbidity, as well as high costs. local vacuum therapy (v.a.c. system) permits the treatment of deep sternal infections due to continuous aspiration and a sealed dressing which stimulates granulation tissue formation. aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the speed of potential rewiring. after some weeks of v.a.c.-therapy a complete preparation of the substernal structures is necessary. in this context laceration of the right ventricle is a rare, but lifethreatening complication. we describe a new technique for sternal closure after vacuum-assisted wound treatment using nitinol clips which can prevent these severe complications. without any preparation of the substernal tissue the clips can be inserted in the parasternal space with consecutive proper stabilization of the sternum. this new method represents an easy, low-cost and complication-free procedure. der gelegentlich oder ungelegentlich angemahnte ,,hippokratischer eid'' ist kaum wegweiser für chirurgie, keineswegs weltweite norm, operationen werden ausdrücklich verboten. chirurgie muss also auf die praktische ethik zurückgreifen und daraus gültige moralische und wissenschaftliche (cochrane; 1972) prinzipien ableiten. diese prinzipien beruhen heute auf partnerschaftliche arzt-patient-beziehung, schadensvermeidung, dem bewusstsein und der daraus folgenden demut, dass der eingriff als schwere körperverletzung, unter dem aspekt der möglichen heilung, durchgeführt wird und gerechtigkeit -handeln ohne ansehen der person. darauf basierend wird in der neuzeit gelehrt. dies sollte auch mitverantwortlichen spitalsökonomen vermittelt werden. grundlagen. immer wieder ist man in der ärztlichen tätigkeit mit den begriffen offlabel, offlicence, compassionate use, orphan drug, individueller heilversuch und experimentelle behandlung konfrontiert. leider gibt es für die wenigsten dieser begriffe gesetzliche definitionen im österreichischen recht, sie werden deshalb oft widersprüchlich und manchmal falsch verwendet. ziel dieser arbeit ist es diese begriffe klar darzustellen und ihre gesetzlichen grundlagen aufzuzeigen. methodik. identifikation der gesetzlichen grundlagen mit hilfe des österreichischen rechtsinformationssystems, pubmed suche und google suche. diese daten werden verknüpft und zur begriffsbestimmung verwendet. es werden die jeweiligen rahmenbedingungen zur anwendung dargestellt und die auswirkungen auf die ärztliche haftung aufgezeigt. ergebnisse. auflistung der entsprechenden österreichischen gesetze sowie eu verordnungen und richtlinien. die begriffe offlabel und offlicence sind im österreichischen recht als rechtsbegriffe fremd, dennoch finden sich im arzneimittelgesetz entsprechend anwendbare rahmenbedingungen, dem jedoch zum teil die bestimmungen im allgemeinen sozialversicherungsgesetz gegenüber stehen. die begriffe compassionate use und orphan drug sind durch eu verordnungen und richtlinien geregelt. experimentelle behandlung ist nach dem arzneimittel-und medizinprodukte gesetz nur im rahmen klinischer prüfungen zulässig. schlussfolgerungen. alle angeführten modalitäten sind unter bestimmten rahmenbedingungen, vor allem die qualifizierte einwilligung, in ö sterreich zulässig. allerdings kann dabei die haftung vom hersteller vollständig auf den behandelnden arzt/ ä rztin übergehen. grundlagen. abseits von klassischen arzneimittel-(amg) und medizinprodukt-(mpg) studien gibt es immer wieder unklarheiten ob die ethikkommission zu beschäftigen ist oder nicht. die vorliegende arbeit analysiert dazu die gesetzlichen grundlagen ö sterreichs, der eu und internationaler organisationen, sowie zusätzliche bestimmungen der österreichischen medizinuniversitäten. methodik. identifikation der gesetzlichen grundlagen mit hilfe des österreichischen und eu-rechtsinformationssystems, pubmed suche und google suche. die ergebnisse werden nach rechtlicher bindung vom nationalen recht bis zu internationalen empfehlungen dargestellt. es werden die strafbestimmungen im zusammenhang mit studien analysiert. ergebnisse. in ö sterreich gibt es drei arten von ethikkommissionen: forschungs-, klinische-und bio-ethikkommission. für die klinische forschung beschränkt sich die weitere analyse auf die forschungs-ethikkommission. die österreichischen gesetzlichen grundlagen reichen vom arzneimittelgesetz (amg) bis zum universitätsgesetz (ug), hinzu kommen die universitären gsp bestimmungen und zahlreiche sonderfälle von anwendungsbeobachtungen bis zu biodatenbanken. auf eu ebene ist die rl 2001/20/eg und rl 2005/28/eg maßgeblich, international die ich, gcp und who richtlinie für ethikkommissionen. fü r die publikation können zusätzliche anforderungen wie z.b. von wame (world assocation of medical editors) und icmje (international committee of medical journal editors) gestellt werden. die strafbestimmungen im österreichischen recht werden aufgezeigt. schlussfolgerungen. die dargestellte rechtliche situation ist überaus komplex, deshalb wird es notwendig sein an universitäten aber auch extrauniversitär entsprechende beratungsstellen einzurichten. die zunehmenden anforderungen werden zu einer ü berhäufung der ethikkommissionen mit anträgen führen. ein möglicher ausweg ist die trennung in begutachtungspflicht (für amg/mpg studien) und beratungspflicht wie in deutschland sowie die einführung von institutional review-boards als filter zwischen forscherinnen und ethikkommissionen. background. egfr-targeted therapies are a novel and very effective chemotherapeutic approach for advanced nsclc. how-ever, the predictive factors for therapeutic response are not entirely known. one of the reasons of therapy failure might be the change of egfr status during the course of disease, or an altered egfr status in metastases as compared to the primary tumor. using autopsy material, we compare here systematically the egfr status of nsclc metastases with the primary tumor. methods. autopsy cases from our institution with metastatic nsclc have been retrieved from the archive. the specimens of primary tumor and of all metastases have been stained by anti-egfr and re-evaluated by two independent observers. in addition, basic clinical parameters have been retrieved from the charts. the egfr status in primary tumor and metastases has been compared by statistical means. results. we examined a total of 40 patients. the mean age at death was 67.5 years; the male:female ratio was 3:1. most patients suffered from adenocarcinoma (62.5%). most patients were in stage iv with multiple metastases at 19 different body sites. while all primary tumors were egfr-positive, only in 2 cases metastases were egfr-negative. both egfr staining intensity and extension of egfr-positive cells were in most cases identical. thus, statistical analysis failed to detect a significant difference in staining behavior between primary tumor and metastases. conclusions. the expression of egfr in metastases of nsclc is almost identical to egfr expression in the primary tumor. thus, in egfr-positive advanced nsclc egfr-targeted therapy is reasonable. grundlagen. es erfolgte eine retrospektive analyse der stationär und operativ behandelten handinfekte an unserer abteilung der letzten 9 jahre. methodik. die krankengeschichten aller patienten die an unserer abteilung wegen eines handinfektes zwischen 2001 und 2008 operiert wurden sind retrospektiv ausgewertet worden. die patienten wurden in 3 gruppen eingeteilt (panaritien, spritzenabszesse und phlegmonen) und miteinander verglichen. ergebnisse. es wurden 131 patienten (72 männer, 59 frauen) mit einem durchschnittsalter von 41 jahren operiert. am häufigsten zeigten sich panaritien (58) gefolgt von phlegmonen (40) und spritzenabszessen (33). die jüngste patientengruppe war mit durchschnittlich 28 jahren bei der operation jene der spritzenabszesse. ä tiologisch dominierten traumata bei den panaritien und phlegmonen bzw. drogeninjektionen bei den spritzenabszessen. als grunderkrankung zeigte sich bei den panaritien und phlegmonen eine häufung von diabetes und immunsuppression. 19 von 33 patienten mit spritzenabszess waren hepatitis c positiv, 3 von 33 patienten hiv ipositiv. es wurden bis zur vollen abheilung bzw. rekonstruktion insgesamt 224 operationen durchgefü hrt. dies entsprach einer durchschnittlich erforderlichen op-anzahl von 1,25 bei panaritien, 2,05 bei phlegmonen und 2,09 bei spritzenabszessen. die durchschnittliche aufenthaltsdauer war mit 8 tagen bei den panaritien am kürzesten (phlegmone 10 tage, spritzenabszesse 13 tage). insgesamt waren 8 lappenplastiken und 12 amputationen notwendig. schlussfolgerungen. an unserem stark vorselektionierten krankengut zeigte sich das panaritium als die häufigste infektion an der hand mit der geringsten anzahl an notwendigen eingriffen und der kürzesten aufenthaltsdauer. phlegmone mussten wegen des teilweise sehr ausgedehnten befundes bis zu 5x operiert werden. durchschnittlich sind 2 operationen bis zur völligen abheilung bzw. rekonstruktion nötig. in der gruppe der spritzenabszesse fanden sich in 33 % staphylokokken, 40 % streptokokken, 9 % andere grampositive und gramnegative keime, 3 % anaerobier, 18,2 % mischflora und in 25 % kein wachstum. in der gruppe der phlegmonen fanden sich in 53 % staphylokokken, in 12 % streptokokken, in 20 % andere grampositive und gramnegative keime, in 15 % fand sich mischflora und in 15 % zeigte sich kein wachstum. schlussfolgerungen. die kenntnis des keimspektrums ermöglicht eine adäquate kalkulierte therapie bis zum eintreffen des abstrichergebnisses. im rahmen unserer untersuchungen zeigten sich deutliche unterschiede zwischen den keimspektren von patienten mit panaritien, phlegmonen und spritzenabszessen. diese erkenntnis sollte bei der wahl des geeigneten antibiotikums berücksichtigung finden. grundlagen. grundprinzip der plastisch-chirurgischen infektchirurgie ist seit jeher das radikale chirurgische debridement, gefolgt von anfänglicher offener wundbehandlung. seit jahren kommt das v.a.c.-system zur wundkonditionierung erfolgreich zur anwendung. der defektverschluß erfolgt erst bei beherrschung des infektes durch auffüllung des totraumes durch gut durchblutetes gewebe, meist lappenplastiken, bei reiner weichteilbeteiligung auch durch einfache spalthauttransplantate. problematisch wird es, wenn aufgrund der anatomischen situation ein radikales debridement nur bedingt möglich ist bzw. eine keimpersistenz zu erwarten ist. methodik. das v.a.c.-instill + ermöglicht ein 3-stufenprogramm: instillation -einwirkzeit -vakuumtherapie kommen zyklusartig zur anwendung. bei unseren patienten kam ausschließlich ein lokales antiseptikum zur anwendung. das patientengut hatte eines gemeinsam: debridement und geplante defektdeckung schienen für eine infektsanierung unzureichend. wir berichten über 2 patienten, die wegen hämatogenem handgelenksempyem mit beteiligung aller handwurzelknochen an unserer abteilung in behandlung waren. zur anwendung kam der polyvinylalkoholschwamm. die instillationsdauer war unmittelbar von der wundgröße abhängig. die therapiedauer betrug maximal 1o tage, der v,a,c,-wechsel wurde drei-bis viertägig durchgeführt. die defektdeckung erfolgte durch lokale oder gestielte lappenplastiken. ergebnisse. in allen fällen konnte trotz eingeschränkter radikalität eines chirurgischen debridements eine infektsanierung erzielt werden. schlussfolgerungen. das v.a.c.-instill + stellt für uns ein wertvolles instrument zur infektsanierung in anatomisch problematischen zonen und eingeschränkter möglichkeit eines radikalen chirurgischen debridements dar. grundlagen. handinfektionen wie panaritien und phlegmone stellen eine große gefahr fü r die integrität der hand dar. der schritt zur chirurgischen sanierung muss sorgfältig gestellt werden und richtet sich nach klinischen sowie radiologischen gesichtspunkten. trotz hohen inzidenzen sind nur wenige daten zum langzeitoutcome von chirurgischen eingriffen bezü glich der verbleibenden funktionalität der hand vorhanden. methodik. um das effektive outcome von solchen eingriffen evaluieren zu können wurden alle patienten chirurgisch sanierter handinfektionen an unserer abteilung im zeitraum von 2002-2008 erhoben und anschließend zu einer nachuntersuchung eingeladen. im rahmen der nachuntersuchung wurden sensibilität, kraft und bewegungsumfang der betroffenen extremität untersucht. mittels eines fragebogens wurden subjektive parameter bezüglich der betroffenen region dokumentiert. ergebnisse. von den 49 ausgehobenen patienten erschienen 20 patienten (41 %) zur nachuntersuchung. die durchschnittliche patientenzufriedenheit auf einer skala von 1-5 lag bei 1,7, eine deutliche einschränkung der bewegungsfreiheit war nur bei 2 patienten evaluierbar (18 %). eine objektivierbare bewegungseinschränkung ging stets mit einer verminderung der kraft, sowie sensibilitätsstörungen im bereich der finger einher. generell kann gesagt werden, dass eine weit fortgeschrittene entzündung, die meist durch zuwarten der patienten zustande kam, das outcome verschlechtert. schlussfolgerungen. je nach ausprägung zeigt sich einerseits eine herausforderung an die chirurgische sanierung, anderseits verlängert sich bei zunehmender schwere der infektion die rekonvaleszenzzeit deutlich und eine restitutio ad integro ist meist nicht mehr möglich. immunhistochemische untersuchungen zur pathogenese posttraumatischer und postinfektiöser sehnenadhäsionen logischer narben. ziel dieser studie war, die rolle des immunsystems bei der entstehung von sehnenverwachsungen zu beleuchten. untersucht wurde sehnenscheidengewebe von 10 patient-innen, die sich einer tenolyse unterzogen. sehnenscheidengewebe von 10 frischen leichen diente als kontrolle. immunsuppressive therapie, neoplastische oder infektiöse erkrankungen sowie chronisch entzündliche erkrankungen waren in beiden gruppen ausschlusskriterien. an gefrierschnitten wurden mit hilfe von monoklonalen antikörpern gegen t-lymphozyten und makrophagen immunhistochemische untersuchungen durchgeführt. dabei wurden die t-lymphozyten subtypisiert und ihr aktivierungsgrad bestimmt. im vergleich zur kontrollgruppe zeigte sich eine statistisch signifikante erhöhung von t-lymphozyten im patientengewebe. auch die zahl der zytotoxischen t-lymphozyten war signifikant erhöht, während die erhöhung der zahl der helferzellen nicht signifikant war. auch die zahl der aktivierten t-lymphozyten war signifikant erhöht. im patientengewebe fanden sich auch vermehrt makrophagen, wobei diese erhöhung nicht statistisch signifikant war. die ergebnisse unserer untersuchungen weisen auf eine zentrale rolle der t-lymphozyten bei der entstehung von sehnenverwachsungen hin. weitere untersuchungen zum aktivierungsweg, zur interaktion zwischen makrophagen und t-lymphozyten sowie zur rolle dendritischer zellen in diesem geschehen sollen zu einem weitergehenden verständnis dieser vorgänge führen. der tiefe infekt der hand -diagnostik und therapie am beispiel zweier fallberichte j. erhart, v. vécsei univ.-klinik für unfallchirurgie, wien, austria grundlagen. der tiefe handinfekt ist vital bedrohlich und beinträchtigt die funktion der hand. diese hängt von einem adäquaten therapeutischen konzept ab. methodik. anhand zweier fallberichte wird das management der tiefen handinfektion dargestellt. fall 1. nach einem bagatelltrauma ohne hautläsion kommt es zu einem tiefen infekt der hand eines mädchens. aufgrund der unklaren ä tiologie wird ein mrt der hand angefertigt, alle möglichen ursachen ausgeschlossen, die hand der patientin dorsal und palmar debridiert und mit einem vacuumverband behandelt. im abstrich finden sich dorsal und palmar ß-hämolisierende strektokokken. es wird lediglich ein revisionseingriff zum sekundären weichteilverschluss benötigt. zur durchführung der ergotherapie bedarf es eine maximale schmerzausschaltung unter psychotherapeutischer betreuung. sie erlangt eine sehr gute funktion der hand. fall 2. ein ausgedehnter defekt der weichteile und knochen der handwurzel und des handrü ckens ist nach 3 tagen septisch. die wunde wird debridiert, die defekthöhlen mit septopalketten gefü llt, mit einem radialislappen gedeckt und zur ausheilung gebracht. nach infektsanierung wird das handgelenk arthrodetisiert, die streckfunktion aller langfinger durch interposition von adduktorensehnen wiederhergestellt. schlussfolgerungen. durch die präsentation des ersten falles weisen wir auf das seltene auftreten eines spontanab-szesses der kindlichen hand hin. trotz der dringlichkeit der operation sollte eine sorgfältige abwägung der lokalisation der inzisionen erfolgen, um eine rasche infektbeherrschung durch radikales, in diesem fall beidseitiges debridement zu erzielen. wir weisen auf die extrem aufwändige nachbehandlung hin. der zweite fall ist wegen der doppelfunktion der regionalen lappenplastik zur gleichzeitigen weichteildeckung und infektbeherrschung erwähnenswert. er zeichnet sich durch einen sicheren erhalt der hand und die vollständige wiederherstellung der fingerfunktion aus. free tissue transfer for complex infections of the handa retrospective analysis grundlagen. schwere infektionen im handbereich bedürfen nach ausgedehntem radikalen débridement und bannung der infektion häufig einer komplexen defektdeckung. diese retrospektive analyse umfasst 5 patienten (4 männlich, 1 weiblich), welche zwischen juni 2006 und märz 2008 mit ausgedehnten infektionen an der hand operiert worden sind. ergebnisse. infektursache war in drei fällen ein hundebiss und in zweien ein bagatelltrauma. in zwei fällen war der hautweichteilinfekt auf den handrü cken, in einem auf die hohlhand beschränkt. zwei patienten zeigten einen kombinierten dorsalen und palmaren infekt. bei einem patienten fand sich neben einer ausgeprägten streck-und beugeseitigen infektlokalisation auch ein handgelenksempyem mit bereits stattgefundener knochenzerstörung. 4 der 5 patienten wurden vor der einweisung in die spezialklinik auswärtig durch stichinzisionen mit drainagen und/oder begrenzte nekrosektomien chirurgisch vorbehandelt. bei drei patienten wurde nach einmaligem débridement, bei zweien nach mehrfachdébridements die indikation zur mikrochirurgischen defektdeckung gestellt. diese wurde mit 2 splited-lat.-dorsi-lappen, 2 serratus-ant.-lappen und 1 lat.-oberarm-lappen durchgefü hrt. alle lappenplastiken zeigten einen unkomplizierten primären heilungsverlauf; in zwei fällen erfolgte eine operative nachkorrektur im sinne von kontrakturauflösung, lappenausdü nnung und liposuktion. 4 der 5 patienten verzeichneten nach intensiver postoperativer ergo-und physiotherapie bereits ab der 12. postoperativen woche einen vollständigen aktiven faustschluss, sowie spitz-und schlü sselgriff. die rom an hand-und sämtlichen fingergelenken betrug zu diesem zeitpunkt 80 % der nicht betroffenen hand. schlussfolgerungen. der mikrochirurgische transfer von fasziokutanen-oder muskel-lappenplastiken stellt eine zuverlässige methode der defektdeckung bei ausgedehnten handinfekten dar. abhängig von ausdehnung und lokalisation des defektes steht die lappenauswahl zum erreichen eines zufriedenstellenden funktionellen und ästhetischen ergebnisses im vordergrund. background. oncolytic viral therapy may offer a promising alternative in highly aggressive tumors such as malignant pleural mesothelioma (mpm), that are insensitive to established chemotherapy and radiation regimes. in the following study, the oncolytic efficacy of newcastle disease virus (ndv (f3aa)-gfp) on mpm is tested and investigated by bioluminescence imaging. methods. ndv(f3aa)-gfp was tested for viral cytotoxicity at different multiplicities of infection (moi) against several mesothelioma cell lines in vitro. for in vivo studies, msto 211h cells were transduced with firefly (photinus pyralis) luciferase (fluc)encoding cdnas (msto td 211h). tumor-bearing animals (1e 7 cells injected intrapleurally) were treated with either single or multiple doses of ndv(f3aa)-gfp (1e 7 plaque-forming units pfu should be given as log 10) at different time points (days 1, 3, and 10) and followed by bioluminescence imaging. results. mesothelioma cell lines exhibited susceptibility to ndv lysis in the following order of sensitivity: msto 211h > msto td 211h> h-2452 > vamt > jmn (no effect in the cell lines h-2052, h-2373, and hmeso) . in vivo studies with msto td 211h cells showed complete response to viral therapy in > 75% of the animals, resulting in eradication of tumor detected by bioluminescence. 72% of the virally treated animals survived > 50 days after tumor injection. no signs of toxicity were observed in the treatment group. in addition, multiple treatments showed a significantly better response compared with single treatment (p ¼ 0.005). conclusions. ndv appears to be an efficient viral oncolytic agent in therapy of malignant pleural mesothelioma in a murine model, and warrants further investigation as a potential therapeutic agent. university clinic for surgery, graz, austria; 2 institute for pathology, graz, austria background. isolation by size of epithelial tumour cells (iset) is an innovative method for the detection of circulating tumour cells in blood. we want to report our preliminary experiences with this method. methods. blood of 20 patients with liver metastases from colorectal cancer and of five patients with benign liver lesions was analyzed for the presence of circulating tumour cells. therefore blood samples were filtrated through a translucent polycarbonate filter. epithelial cells were retained on the filter due to their large size and thus separated from smaller blood particles. afterwards the filter was stained and evaluated by light microscopy. tumour cells were identified by cytomorphological criteria's. results. no patient with a benign liver lesion had detectable tumour cells in blood, but eight of the twenty patients with liver metastases. see the following table. the difference concerning the recurrence rate between the two groups was statistically significant (p < 0.05). conclusions. it is possible to detect circulating tumour cells in blood on basis of their size. the most important advantage of this method is the ability to isolate the tumour cells without damaging their morphology. so the isolated cells can be used for further analysis. grundlagen. höhere konzentrationen im tumorgewebe durch drug targeting erhöhen die responserate sowie das gesamtüberleben. einen neuartigen experimentellen ansatz stellt die applikation von in erythrozyten verkapselten chemotherapeutika (5-fu) dar. im lebertumortragenden modell sollten in erythrozyten verkapseltes 5-fu erstmals appliziert werden. zielsetzung war die technische machbarkeit einer verkapselung von 5-fu, die bestimmung der biokompatibilität der 5-fu-erythrozyten sowie die messung der 5-fu-konzentration im tumorgewebe. methodik. als tiermodell dienten 60 wag-ratten, denen cc531-tumorzellen der leber subkapsulär appliziert wurden. nach ausbildung makroskopisch fassbarer solitärtumoren folgte die applikation von verkapselten erythrozyten der ratte, die nach einem hypoosmotischen dilutionsprozeß mit 5-fu beladen worden waren. es erfolgte die unterteilung in vier gruppen und 4 zeitpunkten, wobei die applikation von unverkapseltem und verkapseltem 5-fu systemisch und lokal via arteria hepatica erfolgte. tumorgewebskonzentrationen wurden mittels hplc (high performance liquid chromatography) bestimmt. ergebnisse. es konnte eine ausreichende beladung der erythrozyten mit 5-fu erreicht werden. der nachweis gelang durch zentrifugieren der erythrozyten und anschließender lyse der erythrozytenmembranen. der ü berstand wurde dann per hplc gemessen. die tumorkonzentration war signifikant (p < 0,01) gesteigert durch die verkapselung in erythrozyten sowie durch lokoregionäre applikation. die tumorkonzentration wurde als konzentrationszeitkurve (area under the curve auc) vom zeitpunkt 12-44 h dargestellt. freíes 5-fu 5-fu verkapselt 86,6 mg/ml á min 126,3 mg/ml á min systemische appl. 338,3 mg/ml á min 411,8 mg/ml á min arterielle appl. schlussfolgerungen. die chemische verkapselung von 5-fu in erythrozyten der ratte ist möglich, wobei ein hoher grad der beladung der erythrozyten erreicht werden kann. es zeigten sich signifikant höhere 5-fu-tumorkonzentrationen bei der lokoregionären gegenüber der systemischen sowie bei der verkapselung in erythrozyten. expression of integrin-linked kinase and the progression of early-stage nsclc: a pilot study background. although radical resection of early-stage nonsmall cell lung cancer (nsclc) should warrant cure in almost every case, clinical experience teaches that recurrences appear in up to 40% of cases. therefore, the prognosis is probably codetermined by additional risk factors, which are not described by the tnm scheme. integrin-linked kinase (ilk) is a known molecular risk factor for metastatic progression. in this study we attempt to verify its role in the progression of early-stage nsclc. methods. all stage ia pulmonary adenocarcinoma patients operated until 2001 in our institution have been retrieved from the clinical archive, and a follow-up has been conducted. the pathological specimens of the primary tumor have been stained against ilk, two blinded observers have scored the ilk expression. the results have been compared with the clinical data adopting a basic kaplan meier statistics. results. we examined a total of 32 patients (20 males, 12 females) with a mean age of 62 years. median follow-up was 7.2 years. twenty-eight patients (88%) were ilk-positive, only four (12%) were ilk-negative. eleven ilk-positive patients experienced a recurrence within five years; from those patients, ten died. this corresponds to a 5-years recurrence-free survival of 67 ae 9% and a 5-years overall survival of 74 ae 8% in ilk-positive cases. conversely, none of the ilknegative patients had a recurrence nor died within five years. conclusions. ilk-negative stage ia nsclc patients have apparently a better tumor-related prognosis than ilk-positive patients. however, these observations have to be extended unto a larger patient cohort. biliverdin reductase: a crucial enzyme in bile pigment mediated tumor inhibition? background. maximization of liver regeneration represents a promising strategy to improve outcomes after extensive liver resection. here, we investigate the role of lipocalin 2 in liver regeneration. methods. lcn2 þ=þ , lcn2 þ=à and lcn2 à=à mice were subjected to 2/3 partial hepatectomy. hepatic proliferation was measured by brdu and pcna immunohistochemistry. hepatic lcn2 expression was analyzed by qrt-pcr and western blots. serum levels of lcn2, il-6, and tnf-were determined by elisa. results. hepatic regeneration in lcn2 þ=þ mice was analyzed at 24, 48, 72 and 96 h after partial hepatectomy. the peak of hepatic proliferation as indicated by the number of brdu-and pcna-positive cells was confirmed to be at 48 h post surgery. analysis of hepatic lcn2 expression showed a 140-fold upregulation only 24 h after liver resection in lcn2 þ=þ animals with a stepwise reduction during the observation period (48 h 15.7-fold, 72 h 5.5-fold, 96 h 5.8-fold). western blots confirmed significant lcn2 protein over-expression 24 h after partial hepatectomy. also, serum lcn2 levels were significantly elevated upon liver resection. to determine the biological relevance of lcn2 induction on liver regeneration, hepatocyte proliferation was analyzed in lcn2 þ=à and lcn2 à=à mice 48 h after partial hepatectomy. the number of brdu-and pcna-positive cells did not differ significantly between the groups. however, lcn2 à=à animals exhibited a significantly elevated baseline liver regeneration (6.6-fold lcn2 à=à vs lcn2 þ=þ , p < 0.05). conclusions. up-regulation of lcn2 after murine partial hepatectomy is striking but without significant impact on hepatocyte proliferation. our results imply that lcn2 induction upon liver resection either constitutes a redundant pathway or simply displays an epiphenomenon. effect of the probiotic mixture vsl#3 on epithelial barrier function, tight junction protein expression, and apoptotic ratio in a murine model of colitis background. changes in epithelial tight junction protein expression and apoptosis increase epithelial permeability in inflammatory bowel diseases. the effect of the probiotic mixture vsl#3 on the epithelial barrier was studied in dextran-sodium-sulphate (dss)-induced colitis in mice. methods. acute colitis was induced in balb/c mice (3.5% dss for 7 days). mice were treated with either 15 mg vsl#3 or placebo via gastric tube once daily during induction of colitis. inflammation was assessed by clinical and histological scores. colonic permeability to evans blue was measured in vivo. tight junction protein expression and epithelial apoptotic ratio were studied by immunofluorescence and western blot. results. vsl#3 treatment reduced inflammation (histological colitis scores: healthy control 0.94 ae 0.28, dss þ placebo 14.64 ae 2.55, dss þ vsl#3 8.43 ae 1.82; p ¼ 0.011). a pronounced increase in epithelial permeability in acute colitis was completely prevented by vsl#3 therapy (healthy control 0.4 ae 0.07 (ext./g), dss þ placebo 5.75 ae 1.67, dss þ 3 0.26 ae 0.08; p ¼ 0.003). in acute colitis, decreased expression and redistribution of the tight junction proteins occludin, zo-1, claudin-1, -3, -4, and -5 were observed, whereas vsl#3 therapy prevented these changes. vsl#3 completely prevented the increase of epithelial apoptotic ratio in acute colitis (healthy control 1.58 ae 0.01 (apoptotic cells/ 1000 epithelial cells), dss þ placebo 13.33 ae 1.29, dss þ vsl#3 1.72 ae 0.1; p ¼ 0.012). conclusions. probiotic therapy protects the epithelial barrier in acute colitis by preventing (1) decreased tight junction protein expression, (2) increased apoptotic ratio. background. to prospectively compare the accuracy of liver fat quantification using chemical shift imaging and h1 mr-spectroscopy at 3.0 tesla field strength in patients undergoing major hepatic surgery. methods. the study was approved by our local irb and a total of 13 patients, planned for metasectomy, were prospectively included after signing informed consent. preoperative 3.0 tesla mri (trio, siemens) of the liver included t1w 2d gre single breath hold in-and opposed phase sequences (te 2.46/ 3.69 ms) and a single breath hold single voxel h1 mr-spectroscopy (voi 9 cm 3 ; te 30 ms). with chemical shift imaging liver fat was quantified with the relative loss of the liver-to-spleen signal intensity ratio on the opposed-phase images compared to the inphase images. with h1-spectroscopy liver steatosis was quantified by calculating the integral of the water and fat spectra. the standard of truth was defined by histopathological analysis of the surgical specimens according to a five-point scale (1 -no steatosis; 5 -severe steatosis). spearman's rank correlation was used for statistical analysis. results. both h1-spectroscopy and chemical-shift imaging showed a high correlation of the liver steatosis grading compared to the histopathological analysis (r ¼ 0.83 and 0.75). the difference between both techniques was not significant (p > 0.05). conclusions. both, h1 mr-spectroscopy and chemical shift imaging at 3.0 tesla, allow for a noninvasive preoperative assessment of liver steatosis with high correlation to histopathology. the addition of bevacizumab to xelox/folfox is concidered as standard in the neoadjuvant treatment of colorectal cancer liver metastases. since bevacizumab does not exert direct cytotoxicity, the concept of tumor response as indicator of efficacy upon neoadjuvant therapy containing bevacizumab is being challanged. cytotoxic therapy of liver metastases results in pathologic response of various grades, however the effect of bevacizumab on pathologic response is unclear. we retrospectively analyzed specimen of liver metastases of patients treated with xelox/folfox or xelox plus bevacizumab. we report that bevacizumab, when combined with xelox/folfox, increases the extent of necrosis and decreases the amount of fibrosis in colorectal liver metastases compared to xelox/folfox alone. however, bevacizumab does not change the radiologic response according to recist. we conclude that bevacizumab improves pathologic response which has no counterpart in radiologic response. role of hepatic lymph node involvement within the hepatic pedicle in patients with colorectal liver metastases background. hepatic lymph node involvement in patients with colorectal liver metastases is an important prognostic factor, but the role of lymphadenectomy, especially of the hepatic pedicle, is still unknown. methods. at the medical university graz 262 patients, who underwent liver resection because of colorectal liver metastases between 1991 and 2008, were retrospectively reviewed. results. out of 262 patients 46,6% (122 patients) underwent combined hepatectomy and node dissection of the hepatic pedicle, whereas 140 patients underwent hepatectomy only. 15,6% (19 of 122 patients) were microscopically node positive within the hepatic pedicle and 84,4% (103 of 122 patients) were node negative. the 5-year survival rate for the whole group (262 patients), for the node positive group (19 patients) and the node negative group (103 patients) was 50,4%, 18,1% and 65,1% with a median survival time of 1906 days, 765 days and 2966 days respectively. the difference was significant (p ¼ 0,0017). tumor recurrence was found in 172 patients (65,6%) with a disease free survival (dfs) of 620 days in the whole group, 286 days in the node positive and 517 days in the node negative group. conclusions. patients with positive lymph nodes in the hepatic pedicle are at high risk for a shorter dfs and a decreased 5-year survival rate and can be safely identified by lymphadenectomy in this area. grundlagen. das kolorektale karzinom führt in 25 % der fälle zu einer synchronen leberfiliarsierung -weitere 25 % der patienten entwickeln vornehmlich in den ersten beiden jahren nach operation des primärtumors metastasen. die radikale chirurgie der lebermetastasen stellt bis dato die einzige chanche auf heilung dar mit 5-jahres ü berlebensraten von 30-50 %. die rezidivrate nach leber-erstresektionen beträgt 60-70 % und nur 20 % dieser patienten sind einer weiteren radikalen leberresektion zugänglich. methodik. die eigenen ergebnisse wurden retrospektiv analysiert und mit den daten der gängigen literatur verglichen. im zeitraum von 1/1997 -12/2008 erfolgten an 40 patienten insgesamt n ¼ 57 leberteilresektionen wegen metastasen eines kolo-rektalen karzinoms; n ¼ 29 patienten wurden einmal und n ¼ 11 patienten mehrfach reseziert. ergebnisse. bei den patienten handelte es sich um 22 männer und 18 frauen in einem durchschnittlichen alter von 62 jahren. bei n ¼ 11 patienten erfolgten eine oder mehrere -bis maximal 6 re-resektionen, wobei in allen fällen eine r-0 situation erreicht wurde. mortalität und morbidität waren hierbei gering (0 bzw.27 %) und führten zu einem durchschnittlichen stationären aufenthalt von 7.5 tagen. inzwischen sind n ¼ 5 patienten -bei einem mittleren ü berleben von 28 monaten (min 22, max 76 monate) -verstorben; n ¼ 6 patienten, bei einem mittlerem ü berleben von 58 monaten (min 16, max 84 monate) sind tumorfrei am leben. schlussfolgerungen. auch wiederholte leberteilresektionen bei metastasen eines kolo-rektalen karzinoms sind mit einer niederen mortalität und morbidität durchführbar; entscheidend für das langzeitüberleben ist die r-0 resektion. background. laparoscopic liver surgery has been proven feasible and safe for the treatment of benign and malign liver diseases. however, the complexity of resections and the limitations in instrumentation hamper broad acceptance for advanced liver surgery. herein we describe different technical procedures for minimally invasive liver surgery adding safety to major laparoscopic hepatic resections. methods. three patients (2 female, 1 male; age: 66, 70, 84) underwent laparoscopic major hepatic resections for primary and secondary liver malignancy, respectively. the entire operation was guided by laparoscopic ultrasound to define the resection planes. vascular control of the hepatic inflow and outflow was achieved for the impaired part of the liver. dissection of the parenchyma was carried out utilizing in particular laparoscopic radiofrequency ablation, the harmonic scalpel and laparoscopic staplers. specimen were retrieved in a bag through an enlarged trocar incision. the technique is discussed. results. laparoscopic liver resection was completed in all patients. the operative time was 125-170 min. no intraoperative adverse events were observed. blood loss yielded insignificant in 2 and 300 ml in one patient, respectively. specimen were retrieved in a bag through a widened trocar incision. no significant perioperative complication was noticed. histological evaluation revealed sufficient resection margins to the malignant tumours. oral diet was resumed on the first postoperative day. patients were discharged on day 16, 23 and 45 (due to additional surgery not related to the liver resection). conclusions. we present our technique for laparoscopic major hepatic resections by use of standard laparoscopic instrumentation. comparison of preoperative indocyanine green clearance in patients with colorectal liver metastases pretreated with systemic chemotherapy background. preoperative systemic chemotherapy has become an essential tool in downsizing colorectal liver metastases (clm), helping to render patients with initially irresectable disease resectable and to prolong progression free survival in initially resectable patients. histopathologic examinations of resected non-tumoral liver tissue have raised concerns about chemotherapy-associated liver injury, which might impair the function of the remnant liver. we therefore tried to evaluate whether indocyanine green plasma dilution rate (pdr, % á min à1 ), which can easily be measured preoperatively, helps to assess chemotherapy-induced liver damage. methods and results. data of 135 liver resections for clm performed between january 2004 and december 2007 were analyzed. onehundred-fifteen patients were treated with chemotherapy prior to surgery, 20 patients were resected without pretreatment. patients who received preoperative chemotherapy had a significant lower pdr (19.3 ae 5,4 versus 23.4 ae 3.8; p ¼ 0.02) reflecting an impaired liver function. the percentage of subjects with an abnormal pdr (pdr 18) was significantly higher among those who were treated with chemotherapy prior to liver resection (48.7% versus 5%; p < 0.001). patients with a pdr 18 stayed longer in the intensive care unit compared to those with a pdr > 18 (2.0 ae 2.0 versus 0.9 ae 0.9; p ¼ 0.03) and had a significantly longer postoperative hospital stay (10.0 ae 5.7 versus 7.4 ae 2.9; p ¼ 0.009). the incidence of postoperative complications was increased in those with an abnormal pdr (34.1% versus 8.3%; p ¼ 0.01). conclusions. assessing the pdr preoperatively may help to indentify patients with an impaired liver function after preoperative chemotherapy. grundlagen. die radiofrequenztherapie ist mittlerweile ein etabliertes verfahren zur lokalen tumorkontrolle bei nicht oberflächennahe lokalisierten primären und sekundären lebertumore mit einer maximalen größe von 3 cm. wir 2005 eine technik entwickelt, die es ermöglicht große tumore oberflächennahe und damit in unmittelbarer nachbarschaft zu anderen organen, wie magen, colon, niere oder zwerchfell laparoskopisch so zu isolieren, so dass sie anschliessend computerunterstützt abladierbar sind. die ergebnisse und komplikationen werden hier präsentiert. methodik. alle patienten, die im zeitraum von 12/2005 bis 12/2008 nach laparoskopischem liver packing radiofrequenzabladiert wurden, wurden eingeschlossen und retrospektiv analysiert. patientendaten, komplikationen, und follow-up sind dokumentiert worden. ergebnisse. 42 patienten (f ¼ 15, m ¼ 27) mit einem mittleren alter von 65.5 jahren sind im beobachtungszeitraum wegen eines ccc (n ¼ 3), hcc (n ¼ 19) und metastasen (n ¼ 21, colon, rektum, mamma, neuroendokrines karzinom, melanom, rcc) operiert und abladiert worden. die perioperative mortalität betrug 2,4 % (n ¼ 1) aufgrund eines postoperativen leberversagens. die beobachtete morbidität betrug 35,7 % (n ¼ 15) und beinhaltete pulmonaembolien, dü nndarmverletzungen mit intraoperativer ü bernähung, mods, ards, durchgangssyndrom, cervikale plexusläsion, intraparenchymatöse blutung mit angiographischer blutstillung, par-tielle pfortaderthrombose, spätabszess und ein erysipel am unterarm. leichtes fieber und transienter transaminasenanstieg trat bei allen patienten auf. bei 2 patienten wurde wegen eines rezidivs eine neuerliche rft mit liver packing notwendig, 5 patienten wurden ohne packing ein zweites mal abladiert und ein patient unterzog sich einer linksseitigen hemihepatektomie nach rechtsseitiger ablation. schlussfolgerungen. das laparoskopische liver packing ermöglicht eine ablative therapie der leber in patienten, die mit den herkömmlichen möglichkeiten nicht lokal therapierbar sind. die technik ist mittlerweile standartisiert mit geringer mortalität und morbidität durchführbar. grundlagen. ablationsverfahren nehmen einen festen platz in der therapie von lebermetastasen ein. entscheidend fü r den onkologischen erfolg einer ablation ist die erzeugung einer ausreichend großen thermoläsion, die die metastase mit einem ausreichenden sicherheitsabstand vollständig zerstört. ziel dieser studie war es, bei patienten die aufgrund von kolorektalen lebermetastasen eine ablative therapie erhielten mögliche faktoren herauszuarbeiten, die eine unvollständige thermoablation verursachen. methodik. patienten mit irresektablen kolorektalen lebermetastasen. ab 1996 erhielten die patienten eine laserinduzierte thermotherapie (litt), ab 2003 eine bipolare radiofrequenzablation (rfa). ausschlußkriterien: metastasenanzahl >5, metastasendurchmesser >5 cm, extrahepatische tumormanifestation. bei den offen-chirurgischen ablationen erfolgte eine sonografische punktionskontrolle, die perkutanen ablationen erfolgte ct-oder sonografiegestützt in lokalanästhesie. zur kontrolle der vollständigen ablation (,,r0'') erhielten alle patienten 24-48 h postinterventionell eine km-gestützte mrt. in abhängigkeit der erreichten ,,r0-ablation'' erfolgte die einteilung der patienten in zwei gruppen: gruppe i: ,,r0-ablation'', gruppe ii: keine ,,r0-ablation''. ,,r0-ablation'' ¼ sicherheitsabstand von allseits 1 cm in der postinterventionellen mr-untersuchung. ergebnisse grundlagen. die chirurgische versorgung der leistenhernie galt lange zeit als wenig interessanter standardeingriff und wurde nicht selten dem jungen ausbildungsassistenten überlassen. in den letzten jahren hat sowohl die wissenschaftliche auseinandersetzung als auch das interesse an ergebnisorientierter qualitätssicherung deutlich zugenommen. methodik. in zusammenarbeit mit dem zürser hernienforum wurde an unserer abteilung ein herniendokumentationssystem entwickelt. als basis diente ein software-programm, das für die qualitätssicherungsstudie des bö c im jahr 2000 geschrieben wurde. dieses wurde im expertengremium auf heutige anforderungen adaptiert und von der hausinternen it in das krankenhaussystem sap integriert. die eingegeben daten können über eine access-datenbank analysiert und ausgewertet werden. ergebnisse. das system ist an unserer abteilung seit 1.1.2007 in betrieb. die dateneingabe erfolgt zu 3 zeitpunkten (im op, nach entlassung, bei follow-up kontrolle) und ist an einer abteilung eines ordenskrankenhauses mit limitierter mitarbeiter-zahl gut zu bewerkstelligen. schlussfolgerungen. nach erfolgreichem testbetrieb kann das herniendokumentationssystem anderen interessierten abteilungen zur verfügung gestellt werden. die anwendungsmöglichkeiten reichen von der eigenen qualitätskontrolle bis zur häuserübergreifenden analyse neuer medizinischer produkte oder op-methoden. laparoscopic ventral hernia repair with ipomexperience from the first 100 cases abteilung für chirurgie, bruck/mur, austria grundlagen. bereits 1993 wurde von k. leblanc erstmals ü ber den verschluss einer bauchwandhernie in laparoskopischer ipom (intraperitoneales onlay mesh)-technik berichtet. erst mit der entwicklung verschiedener kunststoffnetze, die immer besser die speziellen anforderungen fü r eine intraabdominelle platzierung erfü llen, kam es zu einer zunehmenden verbreitung dieser technik. es wird ü ber unsere erfahrungen aus den ersten 100 fällen berichtet, wobei das besondere augenmerk den rezidiven und ihren möglichen ursachen gilt. methodik. verwendet wurde in allen fällen ein dreidimensionales, multifaser polyestermesh mit resorbierbarer beschichtung. die eingriffe wurden von 2 operateuren durchgefü hrt. je nach operateur erfolgte die befestigung entweder mit spiraltacks oder einer kombination aus spiraltacks und transfaszialen nähten. ergebnisse. unsere ergebnisse bestätigen, dass in erster linie eine ausreichende ü berlappung der bruchlücke das rezidivrisiko niedrig hält. dies ist ein grund warum die laparoskopische technik derzeit hinsichtlich bruchlückengröße und lokalisation der hernie noch grenzen aufweist. schlussfolgerungen. unsere erfahrungen mit den ersten 100 durchgefü hrten operationen zeigen, dass mit ausreichender minimal invasiver erfahrung und entsprechender patientenselektion die laparoskopische ipom-technik einen wichtigen platz in der optimalen versorgung von bauchwandhernien einnehmen kann. erfahrungen mit 118 konsekutiven laparoskopischen narbenhernienoperationen grundlagen. die reparation von narbenhernien stellt einen der häufigsten eingriffe dar. in letzter zeit kommt die laparoskopische intraperitoneale onlay mesh technik (lap. ipom) vermehrt zum einsatz. unsere erfahrungen mit dieser methode werden dargestellt. methodik. in einer single center studie wurden patienten, die von august 2002 bis november 2006 einer lap. ipom unterzogen wurden, retrospektiv untersucht. (demographische daten, comorbiditäten, art und größe der narbenhernien und netze, art der fixation, operationszeiten, stationärer aufenthaltsdauer, komplikationen, rezidive.) ergebnisse. es wurden 118 patienten in die studie eingeschlossen. das durchschnittliche alter der patienten betrug 63 jahre; der mittlere bmi lag bei 28. 16 % aller patienten litten an diabetes, während 9 % eine copd aufwiesen. die mittlere operationszeit betrug 102 minuten. in 71 % aller patienten wurde ein polyester netz verwendet, in 25 % ein eptfe netz. bei 33 patienten traten insgesamt 38 komplikationen auf. die häufigsten komplikationen waren serome (16,5 %) und hämatome (9 %). 2,5 % aller patienten wiesen postoperativ länger andauernde schmerzen auf. in 2,5 % kam es zum auftreten eines ileus aufgrund von adhäsionen oder inkarzeration. netzinfektionen und netzausrisse traten jeweils bei 1,7 % aller patienten auf. netzinfektionen fü hrten stets zum operativen ausbau der implantate. ein patient verstarb am vierten postoperativen tag an einem multiorganversagen aufgrund einer darmperforation. nach einem medianen follow-up von 40 monaten kam es bei 9 % der patienten zu einem rezidiv. schlussfolgerungen. die komplikations-und rezidivrate in dieser ersten serie ist mit den in der literatur angegeben vergleichbar. wir erachten die lap. ipom technik für eine interessante alternative zu herkömmlichen verschlusstechniken. comparison of different fixation elements for the ipom procedure in a rat model background. long-time complications after the laparoscopic ipom techniques are adhesion formation and recurrence. because of the intraperitoneal position of the foreign body, adhesions could lead to severe complications like ileus or fistula formation. equally insufficient fixation produces recurrent hernias. study design. forty sprague-dawley rats were used in this two-phase, prospective randomized study. polypropylene mesh (parietene composix) samples were positioned intraperitoneal bilaterally to the midline. the randomized mesh fixation groups were suture (su), protack (pt), absorba tack (at) and i-clip (ic). half of the rats in each group were sacrificed and analyzed one week after implantation while the second half were sacrificed and analyzed after two months. measured parameters were strength of incorporation (soi) and adhesion formations. results. after one week the soi of the su fixation was significantly higher than for all other groups. between pt and at the soi was equally and significantly higher than in the ic group. after two months again the soi from the su was significantly stronger than the two fixation groups pt and at. ic was poorly incorporated resulting in few soi. inflammatory reactions were considerably more severe after one week than after two months. adhesion formations were significantly stronger in the groups su and pt compared to at and ic. conclusions. ic showed unacceptable soi and should not be used for mesh fixation. at leads only to few adhesions compared to the nonabsorbable su and pt. to have a good fixation and less adhesions, a combination of different fixation systems should be used. background. research in hernia repair has targeted new atraumatic mesh fixation techniques like surgical adhesives to reduce major complications like chronic pain and adhesion formation. the efficacy and safety of two adhesives, e.g. artiss + fibrin sealant (fs; 4 iu thrombin, baxter, austria) and bioglue + (bg; cryolife, usa) were evaluated in this study. study endpoints were tissue integration and foreign body reaction. adhesion formation formed the secondary outcome parameter. methods. twelve rats were randomized to 3 groups (n ¼ 6). 2 groups of onlay hernia repair -mesh fixation with fs (group 1) or bg (group 2), one group of ipom repair -mesh fixation with 4 sutures and bg (group 3). follow up was 30 days. native rat tissue served as control. macroscopical and histological assessment was performed. results. onlay meshes fixed with fs showed excellent results in all evaluation criteria (group 1). samples fixed with bg (group 2, 3) showed extensive scar formation. no dislocation and no seroma formation was seen. all of these samples showed moderate to severe signs of inflammation with abscess formation in all samples of group 2. adhesion formation was scored moderate to severe in all samples of group 3. histological signs of a moderate foreign body reaction as well as detritus and remnants of bg were seen in all samples fixed with bg (group 2, 3). conclusions. artiss + showed excellent mesh fixation and biocompatibility in onlay hernia repair. bioglue + yields high adhesive strength, but our macroscopical and histological results indicate a reduced biocompatibility. treatment of mesh graft infection following abdominal hernia repair -risk factor evaluation, role of the v.a.c. system and influence of the type of mesh useda retrospective analysis of 476 operations background. commonly, mesh graft infections after hernia repair are treated by rapid removal of the mesh causing high morbidity. new materials of mesh grafts and new procedures of wound management now further challenge the need for mesh removal. risk factor based choice of patients selected for initial hernia repair might partially avoid such complications. methods. four hundred and seventy-six mesh grafts implanted for hernia repair were retrospectively analyzed to determine risk factors for development of a graft infection. we further evaluated the outcome of infected mesh grafts (n ¼ 31) treated by best supportive care including vacuum assisted closure system. results. risk factors for mesh graft infection were body mass index (bmi), operation time for hernia repair and the size of the hernia. 55% of infected mesh grafts could be preserved by conservative means. preservation was possible for 100% of polyglactin/polypropylene mesh as compared to 20-23% for non-absorbable types of meshes (p < 0.0001). preserved mesh graft showed no recurrent hernias at the site of infection. conclusions. conservative treatment is a valid option for mesh graft infection. polyglactin/polypropylene mesh grafts might be preferentially used for open hernia repair. hernia repair should be preferentially performed when hernias are still small and when high bmi is reduced. biomeshes in experimental ipom repairan overview of own trials background. biomeshes (bm) are a new family of implants designed for the reinforcement of ventral hernias. their use is gaining widespread attention in the usa and some european countries. despite the recommendation to use them specifically in contaminated wound fields and giant hernias, experimental data on their biocompatibility and tissue integration is still scarce. our study group has investigated several biomeshes and tested new methods to possibly enhance the tissue integration (additional perforations; fibrin sealant bm fixation). methods. porcine small intestine submucosa (sis), porcine collagen (pc) and bovine pericard (bp) implants have been tested (n ¼ 6 per group) in a model of open ipom repair. bm were 2 â 2 cm in size and fixated with 4 non resorbable sutures (synthofil, ethicon, germany) to the peritoneum. observation period was 30 days in all groups. primary outcome parameters were adhesion formation, tissue integration and dislocation. foreign body reaction was a secondary outcome parameter assessed in histology (he staining). results. sis, pc and bp showed controversial results when indirectly compared with the established standards of synthetic meshes in ipom repair. problematic findings were obtained for tissue integration and foreign body reaction. conclusions. different bm differ distinctively in terms of important outcome parameters. in our hands they were not superior to synthetic meshes. the potential for improvement for the use of bm will be presented by the authors. mesh coating with vital human amniotic membrane reduces early adhesion formation in experimental ipom repair background. the laparoscopic intraabdominal peritoneal onlay mesh repair (ipom) is an increasingly popular technique for the repair of incisional hernias. the intraabdominal use of synthetic meshes cavity often leads to adhesions between bowel and the implant or fixation devices. this study was designed to assess the impact of vital human amniotic membrane (ha) to cover polypropylene meshes in order to prevent adhesion formation (vitamesh + , vm, proxy biomedical, ireland) in experimental ipom repair. vitality of this biomatrix is considered to preserve its desired physiological characteristics. avital ha has been suggested for this purpose by other study groups. methods. thirty-two rats were assigned to the implantation of vm fixated with 4 non resorbable sutures (synthofil, ethicon, germany) to the peritoneum. vm was covered with with ha. vm was 2 cm in diameter and implanted in open ipom by a laparatomy. the observation period was 7 and 17 days (n ¼ 14/18). adhesions were rated with the score by vandendael. histology was performed. results. ha markedly reduced adhesions when compared to a historical control group (vm w/o coating). adhesions were found at structures which were not fully covered by ha (protruding sutures, mesh fibers at the edges of vm). ha formed a highly effective barrier preventing adhesions. tissue integration in histology was good. conclusions. vital ha yields anti-adhesive efficacy and showed good biocompatibilty in a xeno model. further research has to elucidate a potential clinical application. biological mesh in complex abdominal wall repairlong term results of use of permacol tm (porcine dermal collagen) in a single institution r. d. pullan, d. j. devon torbay hospital, torquay, uk background. abdominal wall repair (awr) if poor tissues, contamination, intestinal fistula, anastomosis, stoma and mesh impingement on bowel represent formidable surgical challenges. synthetic mesh or suture repair is inappropriate. biological meshes are biocompatible, offer resistance to contamination, minimal adhesion or fistula formation but retain strength. we use permacol tm -crosslinked porcine dermal collagen -in these cases and present data with long follow up. methods. retrospective review of patients treated with permacol tm for: 1. recurrent incisional hernia ae mesh; 2. post laparostomy; 3. enterocutaneous fistula; 4. contamination by anastomosis; 5. parastomal hernia. results. twenty-nine patients were identified. 19 with acute or chronic abdominal defects; 10 with parastomal hernia. defects sizes from 80 to 200 cm 2 . median age 56 (range 28-84) years and follow up 51 (36-67) months. eleven cases awr -4 with anastomosis, 1 paracolostomy hernia. eight enterocutaneous fistula with deficient abdominal wall; 3 with fistula associated with mesh, all with anastomosis. four recurrent of 10 parastomal hernias. repairs by onlay, inlay and sublay. sixteen cases had no complications. major complications in 6 patients -2 early deaths (myocardial infarct and multiorgan failure); 2 recurrent hernia, 1 colonic ischaemia requiring relaparotomy and 1 intra abdominal abscess requiring percutane-ous drainage. seven minor complications comprised 4 wound infections, 1 sinus and 2 seroma. there were no mesh rejections and no further complications. conclusions. in difficult anterior abdominal wall repair permacol tm is effective, biocompatible, resistant to infection, contamination and can sit in contact with bowel. background. rectoanal repair (rar), a combination of mucopexy and haemorrhoidal artery ligation (hal), is proposed an ''anorectal lifting'' alternative to stapled haemorrhoidopexy. we retrospectively investigated efficacy and safety for this technique in our center. methods. rar was performed under general anaesthesia in 32 patients (5 female, 27 male) with symptomatic haemorrhoids iii (78%) or haemorrhoids ii-iii with simultaneous mucosal prolapse (22%) from march 2007 to october 2008. previous anal surgery was recorded in five patients. mucopexy was performed using a conventional anal dilator and vicryl 2-0 absorbable sutures at the prolapse sites (median 3, range 1-4, sutures) with secondary hal (median 4, range1-6) according to the arterial signal detected by a commercial ultrasound device. all patients were discharged on postoperative day 2 with stool softeners and pain medication on demand. median follow up was 22 weeks (range 7-38). results. the most common adverse event was pain in the first postoperative month, but no severe bleeding complication was reported. persisting pain due to perianal thrombosis was observed in six patients (19%) . two patients (6%) showed residual haemorrhoids ii , one requiring further intervention (rubber band ligation). in eight patients (25%) marginally hyperptrophied but asymptomatic haemorrhoidal piles were still visible. fecal continence did not deteriorate postoperatively. conclusions. rectoanal lifting is a safe and effective and minimally invasive technique for haemorrhoids ii-iii with simultaneous rectal mucosal prolapse. future prospective, randomized studies should investigate the particular benefit of a specially designed doppler-guided proctoscope in rar. therapie der komplizierten rektovaginalen fistel mittels modifizierter martiusplastik ergebnisse. insgesamt traten 10 (0,25 %) infektionen auf. 6 (0,15 %) dieser infektion waren rein oberflächlich die haut betreffend, ohne dass eine weitere chirurgische intervention nötig war. in 4 (0,1 %) fällen kam es zu einer tiefen den patch (dacron 3, polyurethan 1) betreffenden infektion. die tiefen infektionen traten in einem zeitraum von 1 monat bis 6 jahre nach der primären operation auf. in allen fällen wurde eine explantation des kunststoff-patches durchgefü hrt und dieser durch einen venen-patch ersetzt. bei diesen revision traten weder interoperativ noch postoperativ weitere komplikationen auf. keinerlei infektionen zeigten sich in der gruppe der carotiseversionen. schlussfolgerungen. in der carotischirurgie sind infektionen seltene komplikationen. infektionen traten bei uns ausschließlich bei operationen mit durchgeführter patchplastik auf, wobei der polyurethan patch vorteile gegenüber dem dacron patch zu haben scheint. standardtherapie bei einer patchinfektion ist die explantation und der ersatz durch einen venen-patch. die wertigkeit homologer spendervenen in der shuntchirurgie bei ausoperierten dialysepatienten ergebnisse. der erhalt des gefährdeten beines gelang bei 6 patienten (85 %), bei 5 konnten durch die urokinasinfusionen ursprünglich nicht dargestellte gefäße zumindest teilweise wiedereröffnet werden. dadurch ergaben sich endovaskuläre therapieoptionen, die vor urokinase nicht möglich waren. lediglich bei einer patientin wurde eine unterschenkelamputation notwendig. die ergebnisse bei diabetikern waren erwartungsgemäß besser. schlussfolgerungen. die systemische urokinasetherapie stellt für bisher als austherapiert eingestufte patienten eine erfreuliche zusätzliche therapieoption dar. unsere ergebnisse insbesondere die beinerhaltungsraten von über 80 % und komplikationsraten sind mit den in der literatur beschriebenen vergleichbar und insgesamt als erfreuliche alternative zu sehen. wir haben aber auch gesehen, dass mit einer solchen ,,induktionstherapie'' wieder neuen optionen einer invasiven therapie möglich werden. die vorteile der urokinasetherapie sind in der guten verträglichkeit den überschaubaren kosten sowie in einer erweiterung der multimodalen gefäßtherapie zu sehen. background. pulmonary retransplantation remains the only therapeutic option in some cases of severe primary-graft-dysfunction (pgd), advanced bronchiolitis-obliterans-sydrom (bos) as well as in some cases of severe airway problems (awp), mainly cicatriceal stenosis. however its value has been questioned due to overall scarcity of donor organs and reports on unsatisfying outcome. we analysed our institutional experience with pulmonary retransplantation to evaluate its value for different indications. methods. we retrospectively analysed all 46 patients undergoing retransplantation out of 567 consecutive primary lung or heart-lung transplantations performed in our department from 8/1995-8/2006. we stratified patients according to indication for retransplantation and analysed the outome. results. forty-six patients (mean age 41 ae 16 years, 18 male, 28 female) underwent retransplantation (14 bltx, 32 sltx) for pgd (n ¼ 23), bos (n ¼ 19) and awp (n ¼ 4). mean time to retransplantation was 26 ae 27 days in the pgd-group, 1069 ae 757 days in the bos-group and 220 ae 321 days in the awpgroup. thirty days, 1-year and 5-years-survival after retransplantation were 52.2%, 34.8 and 29.0% in the pgd-group and 89.2%, 72.5 and 61.3% in the bos-group. all 4 patients in the awp-group are still alive (p bos/pgd ¼ 0.02; p bos/awp ¼ 0.27; p pgd/awp ¼ 0.06). conclusions. retransplantation for bos offers long-term survival-rates in the range of primary lung transplantation for selected patients. long-term survival-rates for retransplantation due to pgd are significantly lower, warranting restrictive use in this indication. in our experience with a limited number of patients, retransplantation for awp has excellent results. pulmonary retransplantation for chronic problems is a worthwhile effort, provided that patients are carefully selected. retransplantation for pgd should be avoided. ecmo support in extended thoracic procedures background. for extended pulmonary resections and complex tracheo-bronchial reconstructions cpb is the standard way for extended cardio-respiratory support. given the extensive experience with ecmo support in lung transplantation in our department, we introduced ecmo also for selected cases of general thoracic surgery (gts). methods. all patients undergoing gts on ecmo support in our institution between may 2001 and january 2009. results. nine patients (2 female and 5 male with a median age of 55 years, range 21-68) underwent extended procedures using ecmo. both central (n ¼ 4) and peripheral (n ¼ 5) cannulation was used. in two cases, ecmo was introduced under emergency conditions due to life-threatening tracheobronchial injury, and was prolonged into the postoperative period after trachebronchial reconstruction. in seven cases the procedure was elective for surgery of bronchogenic carcinoma. ecmo bypass was performed for aortal resection (n ¼ 1), for pure carinal resection (n ¼ 3), or in combination with central resection of left pulmonary artery (n ¼ 1), with reinsertion of left main bronchus to trachea (n ¼ 1), and with upper bilobectomy and reinsertion of right lower lobe into the left main bronchus (n ¼ 1). no deaths occurred during the first 30 postoperative days. conclusions. this study confirms the safety of ecmo in gts instead of cpb. avoiding cross-table ventilation facilitates visibility and precision. the closed ecmo circuits prevent tumour cell spilling from the operating field. full heparinisation can be avoided, and bleeding complications can be prevented. ecmo support can also be prolonged into the postoperative period. background. the aime of this retrospective study is to underline that a surgical tool respective videothoracocscopy helps to find diagnosis quick! methods. one hundred and ten patients were included in the study 78 male and 42 female, mean age 49.7 a (range from 28 to 91a). indication for inclusion in the study effusion under monitoring, multiple punction without any result. causes for effusion was in all cases unknown before intervention. patients transferred to the surgical unit for diagnosis and therapy were origin in all cases from pulmologists or conservative departments. patients were treated the day after admission by videothoracoscopy combined with sampling, frozen section and if available following therapy immediately intraoperative or the following days. discharge from hospital was done after removal of chest tube and aftercare was in the outpatient department. results. diagnosis was possible in all cases, the gap in between admission on the surgical department and beginning of treatment range from 1 to 32 days mean 2 days. gap in between symptoms, multiple punction and suction without diagnosis range from 1 to 886 days mean 42.2 days. in comparison early surgical intervention as videothoracoscopy helps to achiev quick diagnosis and therapy. conclusions. in conclusion we emphasize that early surgical intervention after short conservative try show up with diagnosis and successful therapy. first series of robotic pulmonary lobectomy background. surgical resection is the primary treatment for early stage non-small cell lung cancer (nsclc). different minimally invasive approaches are currently under investigation: in addition to conventional video-assisted thoracoscopic surgery (vats), the robotic technology with the davinci system has emerged over the last 10 years. methods. twenty-seven patients (12 women, 15 men; mean age 64.48 years) underwent a robotic lobectomy for early stage nsclc (clinical stage ia or ib). results. distribution of resected lobes were left upper lobes 4, left lower lobes 6, right upper lobes 8 and right lower lobes 9. there were 4 intraoperative conversions to open thoracotomy (one major bleeding, two minor bleedings, one variant course of the pulmonary artery). postoperative complications included prolonged air leak (6) , colonic perforation (1), and intermittend atrial fibrillation (1) . length of hospital stay was median 11 (7-53) days. 30-day mortality was one (3.7%). overall median operative time was 3 h and 28 min (range 2:15 h to 6:30 h, mean 3:45 h). after the first seven patients the initial posterior approach was switched to an anterior one, thus enabling an easier hilar dissection. another technical modification during this first series was the introduction of a new vessel-sealing device (hem-o-lok + -clip) instead of ligation/stapling of the major pulmonary vessels. conclusions. robotic lobectomy has been proven to be feasible and save in our initial series in a learning curve setting. longer follow up and randomized controlled trials are necessary to evaluate a potential benefit over open and conventional vats approaches. background. acute post intubation laceration of the trachea is a rare, but serious complication. we report our experience with the transcervical approach and direct correction of the tear through a t-shaped anterior tracheotomy. methods. in a retrospective study we analyzed the course of 10 patients (9 female, 1 male; median age 53.4, range 16-79 years). in eight patients the tracheal injury was due to emergency intubation and in two patients it occurred during percutaneous tracheostomy. the lesions were located in the membranous part of the trachea and the mean length was 6,5 (range 5-10) cm. all patients underwent surgical repair immediately after diagnosis. the repair was carried out through a cervical transversal and longitudinal t-shaped tracheotomy allowing the exposure of the laceration in the posterior wall of the trachea which was mended by intraluminal running suture with 4-0 pds. results. all patients recovered well and were discharged from the hospital. the endoscopic follow-up at 1, 3 and 6 months shows no evidence for tracheal stenosis or fistula. conclusions. transcervical t-shaped tracheotomy is a minimally invasive approach for the repair of postintubation tracheal injury. this technique allows exposure of the entire length of the trachea and direct suturing of the tracheal wall with excellent results. we recommend this approach for repair of iatrogenic postintubation tracheal lesions requiring surgery. totalrekonstruktion der trachea (1980) mit thoraxtrauma nach 28 jahren the importance of risk management for patient safety in surgery s. kriwanek background. although the concept of risk management is rather new in surgery it is gaining importance to ensure increased patient safety. methods and results. the process of risk managements consists of evaluation, assessment, and reduction of different risks. different analytic procedures as the 3-f method (3 factors method) or the fmea (failure mode and effect analysis) help to stratify risks and classify the urgency of risk-reducing actions. the first and most important application of risk management in surgery must concern operative procedures. conclusions. the concept of risk management represents a new and interesting approach in order to increase patient safety in surgery. grundlagen. mit der kostenreduktion bestehen im krankenhauswesen tendenzen zur verkürzung der stationären verweildauern. bei der bedarfs-und ressourcengerechten aufnahmeund belegungsplanung haben sich in der chirurgie patientenmanagement systeme etabliert und bewährt. die umsetzung eines patientenorientierten entlassungsmanagements ist häufig nicht ohne probleme; beispielsweise ist die aktionsfähigkeit innerbetrieblicher sozial-und medizinischer dienste wegen administrativer und externer reglementierungen blockiert. kann eine anspruchs-und zeitgerechte qualitativ abgesicherte poststationäre häusliche nachversorgung nicht gewährleistet werden, bedeutet dies für patienten egal welcher chirurgischer disziplin ,,krisenmanagement''. methodik. auf der grundlage der konzeption von hospitalto-home + -mobile gesundheitsservices und in zusammenarbeit mit der regional zuständigen kassenärztlichen vereinigung wurde ein klinik-und mobilitätsgestützter gesundheitsservice für das stationäre entlassungs-und poststationäre ,,home-care'' management an der chirurgischen klinik eines universitätsklinikum, hier unter der projektbezeichnung ,,medmobil'' evaluiert. ergebnisse. die zeitgerechte klinikentlassung unter abgesicherter poststationärer weiterversorgung kann mit diesem konzept selbst in komplizierte umständen, wie z.b. bei postoperativen wundheilungsstörungen erfolgen. die fragmentierung von ökonomischer und medizinisch chirurgisch erforderlicher ,,in-time'' leistungserbringung und postoperativer gewährleistung häuslicher versorgungsnotwendigkeiten kann so am ende der prozesskette in übergreifendem interesse gestaltet werden. schlussfolgerungen. unter klinikbedingungen ist das konzept der projektgruppe von hospital-to-home + -mobile gesundheitsservices eine patientenorientierte konsequenz auf die anforderungen des drg-system; insbesondere auch seitens der patienten. interessen der medizinischen leistungserbringer, der krankenhaus-und der versicherungsträger werden auch vor dem hintergrund eines patientenseitigen ,, return-to-invest'' reflektiert. background. skin rejection in composite tissue allotransplantation (cta) is the pace-limiting obstacle for wider adoption in clinical practice. this study aims to identify cytokine network dynamics mediating acute rejection in cta, with focus on skin. methods. using a brown-norway to lewis rat hind-limb allotransplant model, syngeneic [n ¼ 10] and allogeneic [n ¼ 10] transplants without immunosuppression were studied. 120 skin and muscle biopsies were taken at defined time points between day 0 and 11. protein levels of 14 cytokines known to be relevant in cellular inflammatory responses were assessed by luminex tm . expression (ápg/ml) was read by measuring significant differences among pairs of slopes (w/matlab) for characterization of a cytokine network profile. results. in syngeneic transplants, il-1a and il-18 were expressed in skin throughout the period of observation, with highest levels on pod 5 at an average il-1a concentration of 10811 pg/ml (>4 â á from biopsy control (bc), standard deviation (sd) ¼ 6.5%) and il-18 at 8256 pg/ml (>3.77â ábc, sd ¼ 18.5%). in allogeneic transplants, il-1a and il-18 levels were similar to the syngeneic. at pod 7, allogeneics expressed il-1b at 6029 pg/ml (>65.5 â ábc, sd ¼ 21.96%), il-6 at 3145 pg/ ml (>19.41 â ábc, sd ¼ 10.58%) and gro/kc at 813 pg/ml (>15.8 â bc, sd ¼ 15.59%). conclusions. most prevalent cytokines at different time points during skin rejection were identified. this analysis helps understand the pathogenesis, provides a basis for early detection of rejection, and identifies novel targets for therapeutic intervention. disclosure. none. project funded by the austrian science fund (fwf). targeting e-and p-selectin for treatment of skin rejection in limb transplantation background. skin rejection episodes are a frequent problem seen after human hand transplantation. we therefore investigate the expression of e-þp-selectin in skin of human hand allografts and the effect of efomycine-m, a special inhibitor of selectin in a rat limb-transplant-model. methods. 104 skin biopsies from three bilateral hand transplants were assessed by h&e-histology and immunohistochemistry (anti-e-þp-selectin-antibody). efomycine-m was investigated for its effect on skin rejection in an orthotopic rat hind-limb-allotransplant-model (bn-lew). animals received either efomycine-m alone (5 mg/kg/weekly s.c. into the graft) or in combination with als (0.5 ml, pod0 þ 3) and tacrolimus (0.3 mg/ kg/day for 50 days). untreated animals and animals receiving als þ tacrolimus alone served as controls. skin rejection was assessed by daily inspection and he-histology. results. e-and p-selectin expression in the vascular endothelium were significantly upregulated and correlated well with severity of rejection in human hand allografts. in the experimental trial animals receiving efomycine-m alone rejected on day 7 ae 1. these animals didn't show prolongation of graft survival in contrast to untreated animals. animals receiving als and tacrolimus rejected on pod 61 ae 2 and histology showed necrosis and massive infiltration of lymphocytes in all tissues. additional treatment with efomycine-m resulted in long term (150 days) allograft survival. histology on day 150 showed a lymphocytic infiltrate in the dermis and epidermis and a myointimal proliferation consistent with rejection grade 2. conclusions. selectins are upregulated upon skin rejection after human hand transplantation. local administration of a selectin-blocker in combination with als þ tacrolimus results in significant prolongation of graft survival but doesn't prevent chronic rejection in a rat limb-transplant-model. xenotransplantation of microencapsulated porcine islet cells in diabetic rats background. xenotransplantation of microencapsulated porcine islet cells might be a possibility to overcome the shortage of human donor organs for pancreas transplantation. several materials for microencapsulation of cells are described in literature which all show severe disadvantages. nacs is easy to produce, does not show any cytotoxicity and cell lines survive for a nearly unlimited time-spam after microencapsulation. however, this material has not been tested for microencapsulation and xenotransplantation of porcine islet cells. methods. porcine islet cell isolation and purification was performed according to a newly modified ricordi method and microencapsulated with nacs. diabetes was induced in sprague dawley rats by intraperitoneal injection of stz. microencapsulated porcine islet cells were transplanted under the kidney capsule of the animals. blood sugar levels were monitored on a weekly basis, porcine c-peptide levels and insulin levels were measured using elisa. after 4 months, the animals were sacrificed, the kidney containing the microencapsulated porcine islet cells was retrieved and processed for histological and immunohistochemical examination. results. after xenotransplantation of microencapsulated porcine islet cells diabetes was reversed in rats. animals stayed normoglycaemic up to four months. functionality of transplanted porcine islet cells was detected by insulin measurement and detection of c-peptide. viability of microencapsulated porcine islet cells after explantation was proven by immunohistochemical viability stains. conclusions. rats stayed normoglycaemic until the end of the study period. no signs of fibrosis could be detected in the surrounding tissue. nacs seems to be a promising material for microencapsulation of porcine islet cells in order to treat diabetes. introducing the cuff technique for hind limb transplantation in rats background. current models for orthotopic hind limb transplantation traditionally utilize a time-consuming, technically demanding micro-vascular suture technique for vascular anastomoses. our objective was to introduce a new simplified vascular ''cuff technique'' which substantially accelerates the surgical procedure and is well suited to study ischemia/reperfusion injury in reconstructive transplantation. methods. syngenic hind limbs were transplanted orthotopically using lewis rats employing either the conventional microsuture technique (n ¼ 10) or the new ''cuff technique'' (n ¼ 10) for vascular anastomosis. results. all grafts in the microsuture technique and 9 out of 10 grafts in the ''cuff technique'' group survived the endpoint of the study (postoperative day 10). microangiography on postoperative day 10 showed no stenosis or occlusion of anastomoses, skin and muscle histology demonstrated normal appearing tissues. conclusions. our newly introduced cuff technique enables for significantly reduced operating time (cuff group: 49 ae 5 min, vs conventional group: 118 ae 5 min), low postoperative morbidity and mortality (10%) and excellent functional results after orthotopic hind limb transplantation. a quantitative analysis of the sensory and sympathetic innervation of the human pancreas the delineation of pancreatic nerve innervation during fetal life may contribute to our understanding of pancreatic pain modalities after birth. to define the peripheral sensory and sympathetic fibers involved in transmitting and modulating pancreatic pain, immunohistochemical detection was used to examine the sensory and sympathetic innervation of the head, body and tail of the normal human fetal pancreas using specimens from 15 fetuses (13-36 weeks of gestation) following intrauterine death or legal interruption of pregnancy. myelinated sensory fibers were labeled with an antibody raised against neurofilament (nf) and post-ganglionic sympathetic fibers were labeled with an antibody raised against tyrosine hydroxylase (th). choline acetylase (chat) at cholinergic synapses was labeled with a conventional antibody. nf. th, and chat immunoreactive fibers were present in parenchyma of the head, body and tail of the pancreas at variable density, but the relative density of both nf and chat expressing fibers seemed to be increasing head > body > tail, whereas for th, a relatively even distribution was observed. in addition to this set of sensory and sympathetic nerve fibers that terminate in the pancreas, there were large bundles of en passant nerve fibers in the dorsal region of the pancreas that were associated with the superior mesenteric plexus. these data suggest that the pancreas receives a significant sensory and sympathetic innervation during fetal life. understanding the factors and disease states that may alter the distribution of nerve structures can be of significance for the development of therapies in pancreatic disorders of child and adulthood. background. electrospinning of polymers offers an interesting approach to fabricate nanostructured vascular substitutes which match the biomechanical and structural properties of native vessels. in this study we investigated the in-vivo behaviour of electrospun, small diameter conduits in a rat model. methods. vascular grafts with an inner diameter of 1.5 mm were fabricated by electrospinning polyether-urethane. prostheses were implanted into the abdominal aorta of 40 rats for either 7 days, 4 weeks, 3 or 6 months. retrieved specimens were evaluated by conventional histology, immunohistochemistry and scanning electron microscopy. results. the overall patency rate of the electrospun conduits was 95%; neither foreign body-type reactions nor gross evidence of degradation were observed. within 1 month after implantation, midgraft regions were completely covered with endothelial cells. immunohistochemistry revealed a significant immigration of cd 34þ cells from the luminal side of the graft into the prosthesis wall. within 6 months, vascular specific smooth muscle cells (actin þ , desmin þ ) repopulated half of the conduit wall. conclusions. nanostructured electrospun polyurethane conduits offer biomechanics and bioinertness comparable to native vessels and promote the immigration and differentation of vascular specific cells in-vivo. diskussion. die coloskopische mukosektomie hat den nachteil des meist fragmentierten präparates, gefahr des hinterlassens von kleinen adenomresten, implementierung mehrfacher sitzungen und der narbenstenose durch die fehlende naht. die tem ermöglicht im gegensatz zur coloskopischen mukosektomie die zusätzliche resektion von submukosa und muskularis und somit eine entfernung des adenomrezidivs in toto mit primärer naht. die transanale excision nach parks hat eine 5-10 fach höhere rezidivrate als die tem, weshalb der tem unbedingt der vorzug zu geben ist. mit der laparoskopischen vorderen resektion kann wie mit der tem das adenomrezidiv sicher komplett entfernt werden, sie hat aber den nachteil der höheren morbidität, letalität und der schlechteren funktionellen spätergebnisse. im eigenen krankengut hat sich die tem als optimales therapieverfahren zur behandlung von rektumadenomrezidiven bewährt. schlussfolgerungen. die tem ist bei der behandlung des rektumadenomrezidivs alternativen therapieverfahren ü berlegen. the impact of computed tomography in acute appendicitis and obese patients m. von der groeben, v. neuhaus, o. schöb background. acute appendicitis is diagnose by clinical examination, ultrasound and laboratory tests. however, ultrasonography may not be sufficient for a definite diagnosis in obese patients and in the case of meteorism. in this study, the clinical relevance of computed tomography to diagnose acute appendicitis, especially in obese patients, was evaluated in a retrospective study. methods. patients suffering from acute pain in the right underbelly were examined for appendicitis by means of clinical examination, ultrasound imaging and laboratory tests. in case of definite diagnostic findings (n ¼ 160), appendectomy was accomplished by laparoscopy. in case of negative ultrasonography findings (n ¼ 38), patients were reexamined by ct the same day (n ¼ 20) or by ultrasound imaging and laboratory tests the next day after admission (n ¼ 18). results. patients with negative initial ultrasonography findings (n ¼ 38), duration of anamnesis ranged from 12 to 120 h and 14 (36.8%) of these patients were considered as obese due to their body mass index (bmi ! 30 kg/m 2 ). in comparison, only 7.3% of the patients with positive ultrasonography findings were obese. among the 20 patients further examined by ct, 17 (85.0%) showed a bmi ! 30 kg/m 2 . duration of anamnesis ranged from 12 to 48 h. in contrast, among the 18 patients reexamined by ultrasound imaging, only two showed a bmi ! 30 kg/m 2 . conclusions. to enhance diagnosis of acute appendicitis in patients with increased bmi ( ! 30 kg/m 2 ) suffering from acute pain in the right underbelly and short duration of anamnesis, it is advisable to directly perform ct of the abdomen instead of ultrasound imaging. outcome of emergency bowel resection for acute mesenteric ischemia background. due to vague early symptoms and lacking specific laboratory values, acute mesenteric ischemia (ami) is often detected late when bowel necrosis has occurred. methods. in a 75-month period, all consecutive patients with clinical symptoms of mesenteric ischemia were screened for inclusion in this retrospective study. patients with secondary causes for ischemia (strangulation ileus/post resection) were excluded. results are reported as mean ae sd or total number (%). results. sixty-two patients (54.8% female; mean age 72.34 ae 15.71 years) were enrolled. twenty-two patients (34.4%) had preoperative arrhythmia. lactate levels upon diagnosis were 40.67 ae 25.06 mg/dl, leucocyte count 15.15 ae 7.85 g/l and creactive protein 9.09 ae 3.32 mg/dl. fifty-one patients (79.7%) underwent a ct scan, 22 (34.4%) an ultrasound and 6 (9.8%) an angiography, which diagnosed mesenteric vessel occlusion in 26 (41.94%). fifty-five patients (88.71%) underwent surgery, five patients (8.06%) were managed non-operatively, and two patients (3.23%) died before surgery. revascularization was only possible in 2 patients (3.23%). forty-five patients (81.82% of operated patients) underwent bowel resection, with primary anastomosis in 20 and stoma creation in 25 patients. second look operation was performed in 9 patients (14.80%). in-hospital mortality was 38.71% (24 patients). preoperative arrhythmia (p ¼ 0.005), renal failure (p ¼ 0.006), vasopressor demand (p ¼ 0.005), intraoperatively instable patients (p ¼ 0.011), diffuse bowel ischemia without resection (p ¼ 0.02), and bowel resection during second look operation (p ¼ 0.025) were associated with mortality. conclusions. despite modern diagnostic tools, acute mesenteric ischemia is still often diagnosed late. mortality remains high in unstable patients, or when no resection of necrotic bowel is possible during primary surgery. background. intrahepatic cholangiocellular carcinoma (icc) accounts for 10% to 20% of primary liver cancer cases. aggressive resection is the mainstay of treatment. methods. between 2001 and 2007 total 25 patients (68% male, mean age 62.5 (ae7.4) years) operated for icc at our department were followed up postoperatively. eleven right hemihepatectomies (eight extended), seven left hemihepatectomies (three extended), one segmental resection, two bisegmentectomies (ii iii), and four non-anatomical resections were performed. the median observation period was 2.7 (range: 0.2-6.9) years. analysis focused on age, sex, tumor size, operating time, histologic resection margin, tumor-node-metastasis (tnm) stage, reoperations, postoperative complications, tumor recurrence, survival rate. we also assessed p53 protein accumulation, ki67 index and muc1 positivity. results. median operating time was 4.5 h. mean diameter of the resected tumor was 7.55 (range: 2.5-17) cm. histology showed r1 resection for three patients. eighteen patients (72%) underwent lymph node dissection. major postoperative complications occurred in ten patients (40%). there was one in-hospital death from liver failure. seventeen patients (68%) showed tumor recurrence. median time to tumor recurrence was 6.7 (5.7-15.4) months. total 12 patients (48%) died. median time from operation to death was 14.6 (7.4-30.9) months. survival rate after one year was 84%, after three years 57% and after five years 45%. we found no correlation between p53 accumulation/high ki67 index counts/muc1 positivity and icc prognosis. conclusions. our study shows that outcome after icc is generally poor and only a small number of patients are really cured. lymphknoten-ratio als prädiktiver faktor nach kurativer resektion wegen intrahepatalem cholangiokarzinom für die lymphknotenchirurgie, es konnte auch bisher kein ü berlebensvorteil für diese eingriffserweiterung gezeigt werden. methodik. zwischen 1997 und 2007 wurde 93 patienten an unserer institution wegen eines icc operiert. aus dieser kohorte wurden 46 patienten ermittelt, die mit kurativer resektion und lymphadenektomie behandelt wurden. aus diesem kollektiv wurde eine uni-und multivariate analyse prognostischer faktoren für rezidiv (rfs) und ü berleben (os) durchgeführt. ergebnisse. sowohl tumorgröße als auch uicc stadium waren sowohl für rezidiv als auch ü berleben prognostisch. ein erhöhter quotient von positiven zu gesamt entfernten lymphknoten (lymph node ratio, lnr) war für die patientengruppe mit positiven lymphknoten prognostisch für rezidiv und ü berleben (hr für os ¼ 8.9, 95 % ci 1.5-32.5; hr für rfs ¼ 8.8, 95 % ci 2.0-39.2). in der multivariaten analyse bestätigte sich lnr als ebenso starker prognostischer faktor (adjusted hr [lnr] für os ¼ 9.8, 95 % ci 1.5-43.4; hr für rfs ¼ 8.3, 95 % ci 1.7-40.9). die anzahl der entfernten lymphknoten hatte keinen einfluss auf ü berleben oder rezidiv. schlussfolgerungen. lnr ist ein neuer prognostischer faktor für ü berleben und rezidiv nach kurativer resektion wegen icc. die therapeutische relevanz dieser beobachtung sollte in einer prospektiven untersuchung geklärt werden. background. patients with advanced cholangiocarcinoma have a poor prognosis and until now, no standard palliative chemotherapy has been defined. the purpose of this prospective single-centre phase ii study was to investigate the therapeutic efficacy, safety and k-ras status dependence of cetuximab in combination with gemox in the palliative first line treatment of these patients. methods. patients with locally advanced, metastatic cholangiocarcinoma or gallbladder cancer were treated with cetuximab 500 mg/m 2 followed by 1000 mg/m 2 gemcitabine (day 1) and 100 mg/m 2 oxaliplatin (day 2) every second week. results. from october 2006 until july 2008 thirty patients (15 male, 15 female) with a median age of 68 were enrolled. the overall response rate of evaluable patients (30) was 63,3%, including three patient with a complete radiological response. 5 patients (16.7%) achieved stable disease and only 6 patients (20%) progressed under chemotherapy. nine initially unresectable patients underwent a curative resection after major response was observed (30%). five patients are currently without evidence of disease after a median follow-up of 16,3 months post curative liver resection. k-ras mutation was detected in 3 patients (12%). all three patients did not progress under chemotherapy. neither pfs nor os were affected by k-ras status. the median pfs of all 30 patients was 8.3 months and median os was 12.7 months. conclusions. cetuximab in combination with gemox induces impressive response rates which were unrelated to kras status. pfs and os were remarkably improved and therefore cetuximab in combination with gemox deserves further evaluation in prospective randomized trials. methodik. es wurde eine retrospektive analyse anhand einer pro-spektiv geführten datenbank an der abteilung für unfallchirurgie durchgeführt und jene patienten ermittelt, die im anschluss an ein ausgedehntes trauma im bereich der oberen extremität neben einer knöchernen versor-gung mit einer freien lappenplastik versorgt wurden. der erfasste zeitraum lag zwischen 1. jänner 2008 und 14. jänner 2009. ergebnisse. die auswertung der datenbank ergab 10 patienten (3 weiblich), bei de-nen eine solche freie lappenplastik durchgeführt wurde. jede operation wurde gemeinsam mit einem kollegen der plastischen chirurgie und der unfallchirurgie durchgeführt. in 2 fällen kam es zu einem lappenverlust, wobei daraus in einem fall ein zweiter erfolgreicher freier lappen resultierte und in dem anderen fall eine amputation des betroffenen daumens. im rest der patienten wurde mit der initialen operation das operative ziel erreicht. schlussfolgerungen. die implementierung mikrochirurgisch-rekonstruktiver verfahren an einer großen unfallchirurgischen abteilung führte zu einer deutlichen steigerung in der versorgungsqualität bei patienten mit komplexem trauma im bereich der oberen extremität. trotz eines mitunter sehr aufwändigen operativen verfahrens konnte die zeit bis zur kompletten abheilung deutlich verkürzt werden. facial edema and petechiae, subconjunctival hemorrhage, and occasionally neurological symptoms. case report. a 46-year-old men was admitted to the emergency department after the heavy metal door had fallen on his chest. his head, neck and upper chest were cyanotic and edematous with subconjunctival hemorrhages. computer tomography of the thorax revealed multiple fractures of the ribs on the left side and signs for pulmonary contusion. on the eight day the facial cyanosis and petechiae almost disappeared, only subconjunctival hemorrhage persisted. discussion. the symptoms are attributed to thoracoabdominal compression or to forceful compression of the thoracoabdominal muscles against a closed glottis. a reflux of blood from the heart through the valveless great veins of the head and neck occurs, the increased pressure is transmited to the capillaries. the blood stagnates and desaturates. characteristic appearance and the patient's history are the most important elements for diagnosis. laryngeal swelling can be severe enough to make the endotracheal intubation difficult. tinnitus or temporary deafness, transient or permanent vision disturbances and lethargy may occur. conclusions. morbidity and mortality are usually determined by the presence and severity of associated injuries. treatment should be directed toward associated injuries. any sign of airway compromise requires early intervention. grundlagen. in dieser retrospektiven studie wird der frage nachgegangen, ob die klinischen und radiologischen langzeitergebnisse den prothetischen ersatz des radiuskopfes in fällen von nicht rekonstruierbaren radiuskopffrakturen sowie von komplizierten luxationsfrakturen des ellbogengelenkes rechtfertigen. methodik. innerhalb eines zeitraumes von 7 jahren (1998) (1999) (2000) (2001) (2002) (2003) (2004) wurden 13 patienten mit derselben bipolaren metallprothesentype (tornier sa, fr) in zementierter technik versorgt. die indikationen waren: isolierte radiuskopftrümmerfrakturen (mason iii; 4 fälle, gruppe 1), ellbogenluxationen mit begleitenden radiuskopffrakturen (mason iv; 5 fälle, gruppe 2) und monteggia-verletzungen (4 fälle, gruppe 3). in 11 fällen erfolgte der prothetische ersatz primär, in 2 fällen nach vorangegangener osteosynthese. bei 11 patienten wurde eine radiologische und klinische nachuntersuchung nach durchschnittlich 6 jahren (4-10 jahre) durchgeführt. das funktionelle ergebnis wurde anhand des scores von geel und palmer (corr 1992) erhoben. ergebnisse. radiologisch zeigte sich in keinem fall ein hinweis auf eine veränderung der prothese bzw. deren position. im bereich des humeroradialgelenkes fanden sich nur in einzelnen fällen angedeutete zeichen einer arthrose, das capitulum radiale humeri wies in wenigen fällen eine zentrale abflachung auf. das proximale radioulnargelenk war in allen fällen radiologisch unauffällig. geringgradige periartikuläre verkalkungen fanden sich hauptsächlich im bereich der ventralen gelenkskapsel. unter anwendung des o.a. klinischen scores, der sich aus den kriterien bewegungsumfang, gelenksstabilität, kraft und schmerzen zusammensetzt, fanden sich exzellente resultate bei allen patienten der gruppen 1 und 2. bei keinem dieser patienten bestand eine gelenksinstabilität. die patienten der gruppe 3 (monteggia-verletzungen) schnitten etwas schlechter ab (gutes resultat). hauptverantwortlich dafü r waren einschränkungen in der streckung und den umwendbewegungen. subjektiv waren alle patienten mit dem ergebnis zufrieden und konnten ihre vorherigen beruflichen und freizeitaktivitäten ohne wesentliche einschränkung wieder ausü ben. schlussfolgerungen. obwohl die implantation einer radiuskopfprothese eine sehr selten durchgeführte operation ist, beweisen die guten resultate die sicherheit der methode. die ergebnisse scheinen eher durch die schädigung des ellbogengelenkes infolge des initialen traumas als durch die prothese selbst beeinflusst zu werden. die radiuskopfprothese sollte daher bei entsprechender indikation im sinne einer primären definitivversorgung eingesetzt werden und ihren festen platz im implantatlager jeder größeren unfallabteilung finden. background. gastric bypass after vbg often is a technically difficult and demanding procedure. postoperative morbidity and mortality is significantly higher compared to primary bypass. massive adhesions and scar formation at the gastro-esophageal junction are responsible for the difficulties in this procedure. scopinaro's procedure (a distal gastrectomy with gastro-ileostomy) offers the great advantage of sparing the gastro-esophageal junction and avoiding staple lines through scary tissues. this operation may represent a safe alternative to gastric bypass after vbg. a video of scorpinaro's procedure after vbg will be presented. trotzdem kann durch eine operation nicht in allen fällen ein rezidiv verhindert werden. diese beobachtung und das streben nach noch geringerer invasivität führten zur entwicklung endovenöser therapien. allen gemein ist, dass sie ultraschallgesteuert durchgeführt werden. es kommt zur induktion einer thermischen oder chemischen phlebitis, die in weiterer folge zu einer obliteration der vene führt. der vorteil dieser neuen therapieoptionen ist, dass sie in lokaler oder tumeszenzanästhesie ambulant durchgeführt werden können. die kurz-und mittelfristigen ergebnisse nach laser-und radiofrequenzablation sind in prospektiven und retrospektiven untersuchungen mit den ergebnissen nach einer ,,klassischen varizenoperation'' vergleichbar. langzeitbeobachtungen über 5 jahre liegen nur nach solchen 4-schritt-varizenoperationen vor. die schaumsklerosierung ist eine wenig invasive und billige therapieoption, hat aber eine hohe rezidivrate. somit stellt die klassische varizenoperation aufgrund der guten kurz-, mittel-und langfristigen ergebnisse immer noch den ,,goldstandard'' in der therapie eines varizenleidens dar. die 4-schritt-varizenoperation wird heute gering invasiv, kosmetisch orientiert, mit endovaskulären gewebsschonenden stripping-operationstechniken und sicherer präoperativer therapie durchgeführt. sd 3, 8) schmerzen in verlauf der behandelten vene und nahmen im mittel 2,3 schmerztabletten (sd 4,2) ein. im mittel konnte nach 1,6 tage (0-5 tage; sd 1,1) die täglichen aktivitäten normal wieder aufgenommen werden. bei keinem der 50 behandelten fällen trat eine schwerwiegende komplikation (z. b. tiefe beinvenenthrombose) auf. in 6 % bestanden im bereich der behandelten stammvenen nach 6 monaten parästhesien. in der bare-fiber gruppe bestand eine tendenz zu mehr schmerzhaftigkeit, bei ebenfalls 100 % iger verschlussrate und ansonsten vergleichbarem outcome. schlussfolgerungen. zusammenfassend lässt sich anhand der hier vorliegenden studie zeigen, dass die therapie von vsm mittels elt mit 1470-nm-diodenlaser und radialfaser eine sowohl minimalinvasive als auch sichere und effiziente therapieoption darstellt und eine hohe frühzeitige erfolgsrate bei niedrigem schmerzniveau aufweist.in weiteren studien muss geprueft werden, ob aehnlich gute resultate auch bei weiterer absenkung des energienivaus zu erreichen sind. ergebnisse. es gab keine signifikanten unterschiede bezüglich geschlecht, alter, ceap stadium, bmi oder venendurchmesser in den beiden gruppen. in beiden gruppen wurden vergleichbare mengen an tla verwendet. in gruppe a lag die mittlere efe (endovenous fluence equivalent) bei 31 j/cm 2 und in der gruppe b bei 40 j/cm 2 . in beiden gruppen lag die verschlussrate bei 100 %. die durchmesserreduktion der vsm 3 cm distal der sapheno-femoralen crosse lag bei 1.1 auf 0.6 cm nach 1 monat und 0,3 cm nach 5 monaten. das c der ceap klassifikation verbesserte sich signifikant in beiden gruppen. gruppe a verwendete signifikant weniger schmerztabletten, an weniger tagen. in gruppe a gab es außerdem einen trend zu weniger postinterventionellen schmerzen. ecchymosen waren in beiden gruppen selten (17 % in gruppe a, 33 % in gruppe b). schlussfolgerungen. die laserpower beeinflusste nicht die verschlussrate bei der verwendeten hohen efe in beiden gruppen. in beiden gruppen waren ecchymosen und schmerzen seltener als in studien mit 810-980 nm. 10 w laserpower reduzierte signifikant die schmerzmitteleinnahme. in beiden gruppen fanden sich gute ergebnisse, es fand sich nur ein geringer, kurzfristiger vorteil für die lasertherapie (kleinere hämatomfläche) bei im weiteren verlauf nahezu gleichem patientenkomfort. die hohen kosten der lasertherapie können somit nur schwer gerechtfertigt werden. eine kombination von crossektomie und laserablation ist eher nicht sinnvoll. die laserablation kann als minimal invasive alternative zum standardverfahren stripping nach umfassender und objektiver patienteninformation (fehlende langzeitergebnisse, mögliches leistenrezidiv durch weglassen der crossektomie) angeboten werden. endovasculäre verfahren in der behandlung der rezidivvarikositas a. j. flor grundlagen. das leistenrezidiv nach crossektomie ist ein häufig zu beobachtendes phänomen und mittels farbcodiertem ultraschall gut nachzuweisen. als ursache sieht man eine neovaskularisation von gefäßstümpfen ausgehend, welche in der literatur mit einer häufigkeit bis zu 70 % angegeben wird. in vielen fällen zeigen sich im ultraschall reanschlüsse an intrafaszial gelegene stammgefäße. methodik. es erfolgt eine eingehende evaluierung mittels farbultraschall. finden sich insuffiziente intrafaszial gelegene stammgefäße, erfolgt die entscheidung, solch ein gefäß mittels elves-verfahren (1470 nm diodenlaser, in selektierten fällen mit radialsonde) oder mittels farbduplexgezielter schaumverödung zu behandeln. ergebnisse. die endolaser-obliteration mittels elves-verfahren fü hrt in mehr als 95 % zu einem primären komplettverschluss des insuffizienten stammgefäßes. in der ultraschallkontrolle zeigt sich das kontrahierte gefäß, welches sich in weiterer folge zu einem fibrotischen strang umwandelt, um schlussendlich komplett zu verschwinden. die farbduplexgezielte schaumverödung zeigt in vielen fällen rekanalisationen, zum teil mit reflux. in vielen fällen muss die farbduplexgezielte schaumverödung mehrfach wiederholt werden. auffallend ist, dass sich der venendurchmesser im zuge der behandlung mittels schaum deutlich weniger reduziert als beim endolaserverfahren. schlussfolgerungen. endolaser und farbduplexgezielte schaumverödung eignen sich gut zur behandlung insuffizienter stammgefäße bei der behandlung der rezidivvarikositas. sie können in vielen fällen recrossektomien und andere chirurgische zugänge ersparen und sollten somit gerade bei der behandlung der rezidivvarikositas nicht als 'lifestylephänomen' abgetan werden. insbesondere die endolaserbehandlung kann intrafaszial gelegene neovarizen suffizient in einer sitzung schnittfrei verschließen. ergebnisse. auf einer skala von 1-5 (1-sehr gut, 5-nicht genügend) ergaben sich durchnschnittliche werte von 1.2 (trokarplatzierung), 1,2 (nadelplatzierung), 1 (führungsdrahteinlage), 1 (faszienverschluss), 1.2 (lernkurve). schlussfolgerungen. der neue tic -faszienverschlusstrokar ist als leicht erlernbares, verlässlisches system zum verschluss von trokarinzisionen über 10 mm geeignet. langzeiterfahrungen bleiben abzuwarten, jedoch erscheint insbesondere die anwendung bei adipösen patienten und im rahmen von bariatrischen eingriffen sinnvoll. biological mesh in complex abdominal wall repairlong term results of use of permacol tm (porcine dermal collagen) in a single institution torbay hospital, torquay, uk background. abdominal wall repair (awr) if poor tissues, contamination, intestinal fistula, anastomosis, stoma and mesh impingement on bowel represent formidable surgical challenges. synthetic mesh or suture repair is inappropriate. biological meshes are biocompatible, offer resistance to contamination, minimal adhesion or fistula formation but retain strength. we use permacol tm -crosslinked porcine dermal collagen -in these cases and present data with long follow up. methods. retrospective review of patients treated with permacol tm for: 1. recurrent incisional hernia ae mesh; 2. post laparostomy; 3. enterocutaneous fistula; 4. contamination by anastomosis; 5. parastomal hernia. results. twenty-nine patients were identified. 19 with acute or chronic abdominal defects; 10 with parastomal hernia. defects sizes from 80 to 200 cm 2 . median age 56 (range 28-84) years and follow up 51 (36-67) months. eleven cases awr -4 with anastomosis, 1 paracolostomy hernia. eight enterocutaneous fistula with deficient abdominal wall; 3 with fistula associated with mesh, all with anastomosis. 4 recurrent of 10 parastomal hernias. repairs by onlay, inlay and sublay. sixteen cases had no complications. major complications in 6 patients -2 early deaths (myocardial infarct and multiorgan failure); 2 recurrent hernia, 1 colonic ischaemia requiring relaparotomy and 1 intra abdominal abscess requiring percutaneous drainage. 7 minor complications comprised 4 wound infections, 1 sinus and 2 seroma. there were no mesh rejections and no further complications. conclusions. in difficult anterior abdominal wall repair permacol tm is effective, biocompatible, resistant to infection, contamination and can sit in contact with bowel. the new flexible conductive bipolar loop-electrode for continuous neuromonitoring of the recurrent laryngeal nerve by vagus nerve stimulation -first experience with the 3rd and 4th generation background. ascites leaks (al) in patients with end stage liver disease (esld) are commonly associated with recent interventions or ruptured hernias and are associated with significant morbidity and mortality regardless if they are medically or surgically managed. methods. in a pilot study, 14 esld patients with a median meld score of 23 (range 8-33) underwent treatment of als with topic fibrin glue injection around the leak after failing conservative therapy. results. mean age of the ten men and four women was 50 (range 26-67) years. underlying eslds were chronic hepatitis c (n ¼ 5), alcoholic ld (n ¼ 2), cryptogenic cirrhosis (n ¼ 2) miscellaneous (n ¼ 5). there were six leaking incisions post emergent hernia repair (one inguinal, two umbilical, one ventral), two leaking/ruptured umbilical hernias, four leaking paracentesis sites, one leaking jp drain canal and one leaking laparoscopy trocar site. average ascites leak volume per day was 1000 ml (range 400 ml-2000 ml). all leaks were immediately resolved with a 3-5cc fibrin glue injection. five recurred requireding re-injection (4 within 24 h). following injection, albumin levels, mental status and meld-scores improved in the majority of patients within one week. five patients underwent (liver transplantation) lt median 15 (range 4-270) days post-injection. three patients died (two from sepsis one from metastatic cancer), the remaining patients were not accepted as lt candidates. conclusions. fibrin glue injection is a cost effective, simple and safe bedside procedure that resolves als for several months and allows for recovery in anticipation of lt and definitive repair. background. laparoscopic live donor nephrectomy requires meticulous dissection. therefore we have tested the endosite 3di digital vision system (viking systems + , biomedica, vienna) for applicability, ergonomic aspects and improved spectral depth perception in live laparoscopic donor nephrectomy. methods. the 3-dimensional visualisation system combined with high definition head displays (viking + , biomedica, vienna) was used for 2 live donor uretero-nephrectomies in 2 patients. side of nephrectomy was chosen according to selective renal function and vascular anatomy (right side, n ¼ 1 and left side, n ¼ 1). standard laparoscopic access was gained through 4 trokars. for the left side, vessels were clipped and transsected laparoscopically. in order to gain length of the renal vein on the right side the graft was retrieved in a ''semi-open'' fashion as described previously by our group. results. mean age of the 2 female patients was 41 ae 6 years. mean operation time, warm ischemia time and length of hospital stay were 242 ae 3 min., 3 ae 1 min. and 7.5 ae 0.5 days. upon discharge, creatinine levels, urea and c-reactive protein levels were 0.98 ae 0.03 mg/dl, 26.1 ae 3.5 mg/dl and 2.37 ae 0.63 mg/dl, respectively. there was no major complication or any procedure related morbidity such as infections or postoperative lymphatic leaks. conclusions. the 3-d laparoscopic system offers ergonomic advantages and improved spectral depth perception particularly in complex laparoscopic procedures like live donor nephrectomy. this system couples 3-d visualisation with traditional laparoscopy thus offering ergonomic advantages for less than one-tenth the cost of the da vinci system which may be of significant importance for the broad spectrum of minimally invasive surgery. background. obesity and vascular anomalies have been considered relative contraindications for living donor kidney transplantation. however, successful transplantation of laparoscopically retrieved kidneys with accessory renal vessels incidentially found upon operation, increasing body mass index (bmi) and donor age rise the question for the limits of live donation. methods conclusions. although a significant proportion of patients in our series qualifiy as ''marginal donors'' lldn is feasable and safe. however, adapted surgical technique and careful monitoring of postoperative renal function is mandatory in these patients. clinical feasibility of a new colonic access device (megachannel tm ) for interventional procedures at colonoscopy: a prospective, multicenter trial background. megachannel tm is a new colonic access system that was originally developed for colonoscopic appendectomy. once in place, the channel protects the colon from perforation risks during rapid, multiple passes of the colonoscope to the right colon. the 20 mm working channel allows rapid and safe delivery of bulky instruments, as the removal of large specimens. methods. the device (22 outer diameter, 100 cm in length) was constructed of a wire reinforced polyvinylchloride plastisol tube with a thermoplastic distal tip and a proximal hub with integrated scope-seal. a rounded introducer-plug was fitted onto the distal tip and formed a smooth solid surface between the overtube and colonoscope to prevent tissue entrapment. results. the megachannel tm was applied in 40 patients undergoing colonoscopy. the cecum was reached in 34/40 patients within 16 min, with 73 cm (60 to 90 cm) of the overtube being inserted into the colon. mild tissue bruises were observed in 9 patients, mild to moderate pain in 5 patients. in 7 patients the megachannel assisted the removal of multiple polyps. in one patient a eus scope was delivered for evaluation of tumor wall infiltration before submucosal resection, in another patient a suction cap was successfully delivered to the right flexure for removal of an incomplete-lifting polyp. conclusions. this new colonic access system (megachannel tm ) can be safely applied into the right colon and is useful for a variety of colonic interventions that require multiple insertion of the scope or delivery of bulky instruments. this instrument might support notes procedures and removal of colonic stents. fast track surgery in acute ileus -first results background. fast track rehabilitation (ftr) is well established in elective surgery, but there is little experience with this concept in emergency colorectal surgery. we present our data of application of ftr in patients with acute ileus. methods. 644 patient were included prospectively, 64 (9.6%) with ileus. all patients received a resection (colon 50/ 64, rectum 14/64) by laparatomy with primary anastomosis in 44 (68.8%) patients. the median age was 73 y (28-93). the level of chronic comorbidity was high: ! asa iii 55/64 (85.9%). results. the essential modules of ftr could be applied successfully intra-and postoperatively: -thoracic epidural catheter: 39 (60.9 %) -nasogastric tube removed at the end of operation: 46 (74.2%) -necessity of replacement of nasogastric tube: 7 (10.9%) -bowel stimulation: 14 (21.3%) -normal food intake at 1st day: 45 (70.3%) -normal bowel movement at postoperative day (m): 2 (1-7) -days of stay in the icu (m): 2 (1-11) the rates of major complications were: -insufficiency of anastomosis: 1 (2.3%) -wound infection: 5 (7.8%) -pneumonia: 5 (7.8%) -overall mortality: 11 (17.2%) conclusions. -the high mortality was due to the elderly population and concomitant diseases. -no deaths were seen from surgical complications. -based on good acceptance, low rates of major complications and excellent results in gi recovery ftr is suitable for emergency colorectal surgery and can be recommended for therapy of acute ileus. mit der accent ii studie hat die anti-tnf-alpha-therapie einen zentralen stellenwert insbesonders beim fistulierenden m. crohn etabliert [1] . in weiterer folge stellte sich die frage, inwieweit die notwendige operative therapie des fistulierenden anorektalen m. crohn durch die anti-tnf-alpha-anwendung positiv oder negativ beeinflusst werden könnte [2, 3] . als weiteren schritt sehen wir die anwendung dieser therapie mit infliximab, beim schweren anorektalen m. crohn, um voraussetzungen zu schaffen, den operativen eingriff zu minimieren oder weiterreichende auch rekonstruktive eingriffe in dieser region zu ermöglichen. unsere erfahrungen beziehen sich auf insgesamt 80 patienten mit schwerem anorektalem m. crohn, von denen 14 einer anti-tnf-alpha-therapie zugeführt wurden. insgesamt wurden an diesen patienten 22 abszessdrainagen, 23 fistelspaltungen, 15 fistelexzisionen, sowie 10 exzisionen mit mucosa-flap durchgeführt. bei 13 patienten musste wegen schwerer abszedierung oder destruktion eine hartmann-deviation angelegt werden. 6 patienten konnten einer intestinalen rekonstruktion, 5 patienten einer sphinkterrekonstruktion zugeführt werden. bei 7 patienten konnte, bei bestehender fistel, eine größere operation, durch minimierung der symptomatischen belastung der lebensqualität, vermieden werden. wir sehen heute die anti-tnf-alpha therapie als zusätzliche option einerseits weiterreichende operative eingriffe zu vermeiden, oder aber andererseits rekonstruktiv zu ermöglichen. methodik. unter 56 laparoskopisch-assistiert operierten patienten waren 28 (10 weiblich), die entweder ein crohnrezidiv (13) nach offener oder laparoskopischer voroperation oder komplikationen durch vorbestehende entero-enterale, entero-vesicale oder entero-vaginale fisteln (6), abszesse (7), gedeckte perforation (8) oder entzündliche konglomerattumoren (6) background. hyperthermic intraperitoneal chemotherapy (hipec) combined with cytoreductive surgery (crs) is an important treatment option for patients with peritoneal surface malignancies. for close to ten years the kantonsspital st. gallen has been offering this therapy. methods. since 2000, 80 patients with peritoneal surface malignancies were treated with crs and hipec as described by sugarbaker. hipec was performed using the open coliseum technique with mitomycin (25 mg/m 2 ) or cisplatin (50 mg/m 2 ) at 42 c for 90 min. results. indications for crs/hipec were pseudomyxoma peritonei (32 patients), colorectal cancer (12), ovarian cancer (26), mesothelioma (4) and other rare tumors (6) . median age of the patients was 57 years, with 31% males and 69% females. the mean and median surgical time was 510 min and median postoperative hospitalization 24 days. in-hospital mortality was 3.8%. 18% of the pmp patients had a second crs/hipec treatment 18 months (median) after the primary treatment. major complications requiring re-surgery occurred in 23%. over-all survival for pseudomyxoma peritonei patients after primary surgery was 91% after 1 year and 52% after 5 years, for patients with ovarian cancer 88% and 59%, respectively. conclusions. crs combined with hipec is a valuable addition to oncological surgery. due to the high morbidity, patients have to be carefully selected and surgeons have to learn which patients can profit from the treatment. the list of indications is still expanding and the outcome continues to improve, particularly at high volume centers specializing in this treatment. die praeoperative kombinierte radio/chemotherapie beim rektumkarzinom ab dem stadium t3 bzw. nþ gilt heute als standardisiertes neoadjuvantes therapiekonzept. voraussetzung ist ein exaktes praeoperatives staging um ein overtreatment zu vermeiden. in den letzten jahren werden vor allem unter chirurgen vermehrt stimmen laut um durch eine exaktere aussage der infiltrationstiefe in hinblick auf die mesorektale schicht und eine hohe chirurgische qualität die anzahl der erforderlichen bestrahlungen zu vermindern. wir berichten anhand der prospektiven colorektalen datenerfassung der patienten an der universitätsklinik für chirurgie der pmu salzburg aus den jahren 2003-2008 über unsere onkologischen ergebnisse, operationsverfahren, kontinenzerhaltungsraten, morbiditäts-und mortalitätsstatistik und tumorremissionsraten auf das strikt eingehaltene interdisziplinäre neoadjuvante therapiekonzept. anhand unserer erhobenen daten mit international vergleichbaren onkologischen resultaten, akzeptabler morbidität und zufriedenstellenden funktionellen ergebnissen wollen wir die sinnhaftigkeit dieses behandlungsalgorythmus unterstreichen. stellenwert der radiotherapie im onkologischen therapiemanagement die radiotherapie nimmt einen fixen stellenwert in der onkologischen gesamtbehandlung ein. der einsatz der strahlentherapie wird nach interdisziplinärer entscheidung -abhängig von der tumorentität, der tumorklassifikation, der tumorlokalisation, der geplanten behandlungsregime und der patientenbefindlichkeit -zeitlich koordiniert. die postoperative strahlentherapie wird generell am häufigsten eingesetzt. bei gastrointestinalen tumoren, hier vor allem beim rektumkarzinom, hat die neoadjuvante radiotherapie die nebenwirkungsreichere postoperative bestrahlung weitgehend abgelöst. durch das neoadjuvante therapiemanagement ist ein deutlich höheres tumoransprechen durch die bessere tumoroxygenierung bei deutlich geringeren spätfolgen, vor allem im dünndarmbereich, bestätigt. die entscheidung über den einsatz einer kurzzeitvorbestrahlung (5 â 5 gy in 5 tagen) oder einer langzeitbestrahlung (28 â 1,8 gy in 5 wochen) ist abhängig von der tumorgröße, tumorlokalisation und notwendigkeit einer konkomitanten chemotherapie. steht die organ-und funktionserhaltung, vor allem beim analkarzinom, im vordergrund, kommt die definitive radiotherapie mit oder ohne chemotherapie zum einsatz. die chirurgische intervention dient bei dieser indikation als salvage-methode. der intraoperative einsatz der strahlentherapie kann abhängig von der entität und den gerätetechnischen möglichkeiten eine behandlungsoption darstellen. durch die moderne gerätetechnik gelangen zunehmend hochpräzisionsbestrahlungen (intensitätsmodulierte radiotherapie, dynamische arc-radiotherapie), unter anwendung moderner bilddarstellungen am linearbeschleuniger (image-guided-radiation therapy), zum einsatz. background. postoperative morbidity remains a significant clinical problem and may alter´long term outcome particularly after neoadjuvant chemoradiation in patients with locally advanced low rectal cancer. the aim of the present study was to identify a potential long-term effect of postoperative morbidity. methods. analysis of prospectively collected data of ninety consecutive patients who underwent neoadjuvant chemoradiation and curative mesorectal excision for locally advanced (ct3/4, nx, m0/1) adenocarcinoma of the mid and low third of the rectum during a seven-year period (1996) (1997) (1998) (1999) (2000) (2001) (2002) . results. major postoperative complications occurred in 17,8% and minor complications in 26.6% of patients. hospital mortality and 30-day mortality was 0%. infectious complications were seen in 34.5%. the leading causes of infectious complications were anastomotic leakage and perineal wound infection. postoperative morbidity was statistically significantly associated with gender (p < 0.05), pre-therapeutic haemoglobin level (p < 0.05), asa score (p < 0.05), hospitalisation (p < 0.001), and clinical long-time course (p < 0.01). moreover, early postoperative morbidity was proven as an independent prognostic factor concerning disease free (p < 0.05) and overall survival (p < 0.05). conclusions. early postoperative morbidity in patients with preoperative chemoradiation due to locally advanced low rectal cancer is demonstrated as an independent prognosticator. gender, pretherapeutic haemoglobin level, and asa score indicate patients at risk for early postoperative complications and may therefore serve as predictive features. ergebnisse. bei 4 patienten mit primären ct2cn0-und ct3cn1-tumoren wurde bei klinischer kompletter tumorremission nach neoadjuvanter radiochemotherapie ganz auf die operation verzichtet. nach einer medianen nachbeobachtungszeit von 22 monaten (9-38) ergaben sich lediglich in einem fall fernmetastasen der leber und nebenniere. bei zwei patienten mit lokalrezidiven jeweils 2 jahre nach radikaler operation kam es zu kompletter remission nach radiochemotherapie. ein patient blieb ohne reoperation über 44 monate tumorfrei, im zweiten fall mit bekannten lebermetastasen bildeten sich zusätzlich lungen-und knochenmetastasen, jedoch kein lokalrezidiv mehr. nach transanaler vollwandexzision fand sich bei einem patienten nach 3 jahren ein lokalrezidiv mit lebermetastasen. nach radiochemotherapie und kompletter lokaler remission kam es zu zusätzlichen lungenfiliae, jedoch keinem lokalrezidiv. zwei weitere patienten blieben trotz r1-resektion des primärtumors nach neoadjuvanter radiochemotherapie ohne nachresektion tumorfrei. schlussfolgerungen. in selektiven fällen von rektumkarzinomen und rezidivtumoren ist durch radiochemotherapie eine vollremission zu erzielen, die langfristig anhält und ein abwartendes verhalten unter engmaschiger kontrolle rechtfertigt. neoadjuvante und adjuvante therapie des rektumkarzinoms im klinischen alltageine aktuelle analyse des im tumorzentrum erfassten patientengutes k. dommisch, j. sauer, k. sobolewski neoadjuvante und adjuvante therapieverfahren beim rektumkarzinom sollen zur verbesserung der lokalen tumorkontrolle und zur hemmung dissiminierter tumorzellen beitragen. diese aussage gilt als allgemein akzeptiert und wird in form der therapieempfehlungen vertreten. die deutsche studie konnte in einer phase-3-studie eindeutig zeigen, dass der präoperativen strahlentherapie im vergleich zur postoperativen strahlentherapie der vorzug gegeben werden muss, da sowohl kurzzeit-als auch langzeittoxidität postoperativ signifikant höher waren. die analyse des im tumorzentrum schwerin erfassten patientengutes (636 patienten) zeigt, dass nur zwischen 15-33 % der betroffenen patienten im durchschnitt in derartige multimodale therapiekonzepte gelangen. das eigene patientengut der letzten 2 jahre umfasste 87 patienten. davon hatten 38 patienten ein rektumkarzinom im unteren und mittleren drittel im uicc-stadium ii und iii. letztlich erhielten 17 patienten ein komplettes neoadjuvantes the-rapieschema ( ¼ 47%). für eine adjuvante therapie kamen 33 patienten in frage (16 mit falsch negativem staying, 6 notfallpatienten und 11 mit einem karzinom im oberen drittel), eine adjuvante therapie konnten aber nur 20 patienten in anspruch nehmen. mit den ursachen und hintergründen dieses doch ernüchternden ergebnisses setzt sich der vorliegende beitrag auseinander. die entwicklungsdynamik in der anwendung dieser therapiekonzepte innnerhalb des letzten jahrzehntes wird differenziert in bezug auf die eigene klinik und die im tumorzentrum erfassten kliniken von unterschiedlichen versorgungsebenen dargestellt. auch werden die patientenseitig vorhandenen gegebenheiten hinsichtlich der durchführbarkeit der diskutierten therapieverfahren angesprochen. background. tetrahydrobiopterin (bh4) is an essential cofactor for nitric oxide synthases (nos) and thus a critical determinant of no production. bh4 depletion during cold ischemia leads to uncoupling of nos and contributes to reperfusion injury (iri) due to increased superoxide formation. the role of bh4 during warm ischemia is still largely unknown. methods. ischemic renal injury was induced by clamping the left renal artery for 45 min in male lewis rats immediately after right-side nephrectomy. reperfusion was studied at r0 (no reperfusion), 15 min(r1), 2 h(r2) and 7days(r3). animals received either bh4 (20 mg/kg/bw) prior to reperfusion (groupi) or saline(groupii). sham operated animals served as controls(groupiii). renal function was determined by plasma creatinine/urea. bh4 tissue levels were assessed by hplc. morphologic changes were quantified by h&e histology. peroxynitrite formation was assessed by nitrotyrosine-immunostaining, kidney microcirculation was analyzed by means of functional capillary density and capillary diameters uing intravital microscopy. results. bh4 tissue levels significantly decreased after 45 min of warm ischemia (p < 0.05) up to two days(r1,r2) when compared to non-ischemic controls. additional bh4 treatment prior to ischemia significantly improved renal function at all time points studied following reperfusion (all p < 0.001). furthermore, bh4 reduced ischemia induced histologic damage (increased inflammation, interstitial edema, hemorrhage, tubular atrophy and focal areas of necrosis) and diminished peroxynitrite formation and hence nitrotyrosine staining(r1-r3).subsequently, microcirculatory changes correlated with kidney peroxynitrite generation, and improved considerably through bh4 treatment. conclusions. bh4 treatment significantly improves post-ischemic renal function as well as histologic and microcirculatory function and might be a promising novel therapeutic strategy in attenuating iri. grundlagen. bei der behandlung einer peripheren traumatischen nervendurchtrennung konnte bisher trotz anwendung modernster techniken keine zufriedenstellende funktionelle regeneration erzielt werden. die verzögerte nervenregeneration und die daraus folgende verlangsamte signalüberleitung stellen eine erhebliche einschränkung der muskelfunktion am endversorgungsgebiet der betroffenen nerven dar. ziel der studie ist es, ein neues nervenkoaptationssystem unter verwendung einer neuartigen künstlichen prothese mit der im klinischen alltag verwendeten klassischen nahtkoaptation zu vergleichen. neben der zeit und grad der nervenregeneration wird auch der einfluss der elektrostimulation getestet. methodik. es wurde an 14 weibliche göttinger minipigs mit einem durchschnittsgewicht von ca. 35-40 kg der nervus ischiadicus durchtrennt. während die tiere in der gruppe i mittels mikrochirurgischer koaptationsnaht versorgt wurden, wurden die tiere der gruppe ii mit der neuartigen nervenprothese behandelt. die hälfte der tiere in jeder gruppe wurde eine postoperativen nervenstimulation zugefü hrt. das postoperative kontroll-und stimulationsschema beträgt 9 monate, in denen die aussprossung der axone in monatlichen abständen evaluiert wird. ergebnisse. nach den vorliegenden ersten daten konnten wir feststellen, dass mit der nervenprothese ähnlich gute ergebnisse erzielbar sind, ohne dabei sich einer relativ aufwendigen mikrochirurgischen nahttechnik bedienen zu müssen, und in zukunft dadurch auch kein spezielles zentrum für mikrochirurgische operationen aufgesucht werden muss, sonder in jedem chirurgisch tätigem krankenhaus diese prothese eingesetzt werden kann. schlussfolgerungen. falls die ergebnisse der studie die vorläufigen resultate bestätigen sollten, wäre die implantation dieser nervenprothese eine neue und von jederfrau/mann bedienbare therapeutische option zur versorgung peripherer nervenverletzungen. prevention of oxidative stress induced organ damage in a porcine brain dead donor model background. the ''autonomic storm'' initiated after brain death is known to induce a cascade of chemokine and cytokine release which induces oxidative stress and consecutively causes cell damage and diminished organ quality. methods. brain death was induced in 16 pigs by trepanation of the skull and increasing intracranial pressure until brain stem herniation occurred. 10 h after brain death diagnosis, the pigs were randomized in two groups (n ¼ 8). group 1 was infused 500 ml of a solution containing alpha-ketoglutaric acid and 5-mmf over 4 h whereas group 2 received 500 ml nacl. blood samples were taken at defined time points, 24 h after brain death multiorgan donation was performed and tissue samples were taken immediately after organ retrieval and after cold ischemia time (cit). histology and immunohistochemistry were performed to quantify occurrence of apoptosis and of oxidative stress induced cell damage. results. analysis of the blood samples allowed us to describe exactly the chemokine and cytokine cascades initiated during the ''autonomic storm'' in this pig brain dead donor model. histology and immunohistochemistry revealed significantly lower apoptotic cells as well as lower anti-nitrotyrosine positive cells in group 1 when compared to group 2 immediately after explanation and after cit. conclusions. we could diminish oxidative stress induced cell damage and prevent the detrimental effects of the ''autonomic storm'' by applying a solution containing alpha-ketoglutaric acid and therefore achieved better organ quality after multiorgan donation in a pig brain death model. establishing a brain death donor model in pigs background. several factors influencing organ quality and recipient survival after multiorgan donation and transplantation are still unknown and difficult to investigate in humans. therefore the need for an animal model that imitates human conditions might be useful not only to be able to monitor pathomechanisms of brain death and biochemical cascades in the organisms after brain death but also to be able to investigate novel strategies to ameliorate organ quality and functionality after multiorgan donation. methods. in 16 pigs brain death was induced by inserting a catheter into the intracranial space after trepanation of the skull and augmenting intracranial pressure until brain stem herniation occurred. intracranial pressure was monitored continuously and after 60 min brain death diagnostics was performed by a neurologist including eeg examination and clinical examination. donor care was performed according to standard guidelines for 24 h. results. 60 min after brain death induction neurological examination and eeg examination confirmed brain death. all 16 animals showed typical signs of brain death. all symptoms could be treated using standard medication. after 24 h of brain death successful multiorgan donation was performed. after organ retrieval, abdominal and thoracic organs could be analysed for tissue damage and organ quality. conclusions. using this method, a suitable brain death donor model could be establish that will enable us not only to investigate in detail effects and pathophysiology after occurrence of brain death but also to evaluate new strategies to ameliorate organ quality and even to enlarge the donor pool for multiorgan donation. behandlung von gastrojejunalen anastomosenleaks nach roux-n-y magenbypass mit einem oder zwei überlappenden beschichteten metallstents im schweinemodell methodik. in 8 hausschweine wurde eine roux-n-y magenbypass hergestellt. in vier tieren wurde die gj mit einem 1 cm leak an der pouchhinterwand (retrogastrisch) hergestellt. in zwei tieren wurde ein stent platziert, die anderen beiden tiere wurden ohne stent belassen. in vier tieren wurde eine gj mit leak an der pouchvorderwand (anterogastrisch) angelegt, in zwei dieser tiere wurde ein stent und in zwei tieren jeweils 2 überlappende stents platziert. nach 2 wochen erfolgte die euthanasie und obduktion. ergebnisse. die stentplatzierung war in allen tieren erfolgreich. in der retrogastrischen gruppe überlebten beide tiere ohne stents ohne komplikationen mit abheilung der leaks, während die tiere mit stents am 4. und 5. postoperativen tag aufgrund von kinking mit obstruktion und drucknekrosen des roux-schenkels verstarben. in der anterogastrischen gruppe überlebte ein tier mit abheilung des leaks, jedoch mit stentmigration nach distal. die übrigen 3 tiere verstarben zwischen dem 4. und 6. postoperativen tag. in allen fanden sich durch das distale stentende bedingte drucknekrosen. in einem tier mit einem stent fand sich peritonitis bei persistierendem leakage. in tieren mit zwei stents fand sich einem ein leck der fußpunktanastomose und in dem anderen eine obstruktion durch kinking des roux-schenkels. grundlagen. während lokale verschiebelappen die besten ergebnisse bezüglich der hauttextur ergeben, ist bei ausgedehnten defekten mit lokalen verziehungen und formgebungsproblemen zu rechnen. mikrovaskuläre ferntransplantate zeigen im gegensatz dazu häufig eine andere spenderregion-abhängige hauttextur. der submentale insellappen bietet im gegensatz dazu eine alternative zu den genannten verfahren. in diesem vortrag wird dieser insellappen zur deckung von kinndefekten vorgestellt und über vor-und nachteile gegenüber anderen rekonstruktionsverfahren diskutiert. methodik. bei 8 patienten mit defekten des untergesichts nach ablativer tumorchirurgie erfolgte die defektdeckung mit einem ,,sub-mental-artery-perforator-island-flap''. sechs patienten zeigten primär ein ausgedehntes basaliom der kinnregion. nach doppler-sonographischer identifikation von ein bis zwei submentalen perforator-gefäßen erfolgte die submentale inzision und präparation der perforatoren im bereich der durchtrittsregion des musculus digastricus. der gefäßstiel wurde bis zum gefäßursprung aus der arteria facialis präpariert und das transplantat dimensionsgerecht gehoben. nach transposition in den defektbereich wurde der haut-fett-lappen eingenäht und die entnahmeregion nach lokaler subkutaner unterminierung direkt verschlossen. die klinischen und radiologischen nachkontrollen erfolgten 14 tage, ein, drei, sechs und zwölf monate postoperativ. ergebnisse. alle insellappen konnten komplikationsfrei gehoben werden. der postoperative heilungsverlauf war ebenfalls unauffällig. alle patienten waren im beobachtungszeitraum rezidivfrei. das ästhetische und funktionelle ergebnis war durchwegs zufriedenstellen. schlussfolgerungen. der ,,sub-mental-artery-perforator-island-flap'' ist für die weichteilrekonstruktion im kinnbereich nach basaliomentfernung gut geeignet. die lokalen gewebequalitäten paaren sich mit einer weitgehend freien transpositionierbarkeit des transplantierten gewebes. fallbericht. bei einem 20-jährigen patienten bestand ein ausgedehnter defekt der frontobasis und des os frontale betont linksseitig nach schussverletzung. im rahmen der primärversorgung erfolgte eine verplattung der orbitaringe, teilentfernung des frontalhirns, eines großen anteils der frontalen calvaria und ein duradefekt-deckungsversuch mit allogenen materialien. in der folgezeit kam es zu einer persistierenden rhinoliquorhoe und einer osteomyeltis der refixierten freien calvariaanteile. in kooperation mit der neurochirurgie erfolgte dann die revision der frontobasis. zur wiederherstellung der frontobasis und des os frontale wurde ein mikrovaskuläres osteoperiostales transplantat vom distalen femur unter einbeziehung proximaler tibiaanteile verwendet. nach der angleichung an die defektsituation wurde das transplantierte periost zur basalen duranarbe und zu einem lokalen calvaria.perioslappen vernäht und mit miniplatten zur übrigen calvaria fixiert. danach wurde der transplantatstiel mit der zur arteria und vena temporalis superficialis anastomosiert und der wundschluss durchgeführt. in einem nachbeobachtungszeitraum von 8 monaten kam es zu keiner erneuten liquoroe oder infektion dieser region. es konnte eine wesentliche verbesserung der schädelform erzielt werden. schlussfolgerungen. das mikrovaskuläre osteoperiostale femurtransplantat kann unter besonderen bedingungen durch die miteinbeziehung distaler tibiaanteile extendiert werden. die gefäßversorgung über das rete articularis gewährleistet eine gute perfusion des medialen proximalen tibiaperiosts. das transplantat ist somit für die deckung ausgedehnter calvariadefekte geeignet. grundlagen. die therapie von patienten mit lippen-kiefer-gaumenspalten birgt fü r chirurgen und kieferorthopäden große herausforderungen. einerseits zeigt sich häufig operationsnarben bedingt ein eingeschränktes sagittales wie transversales oberkieferwachstum, andererseits erschweren zahnnichtanlagen, sowie das fehlen von knochen im kieferspaltenbereich das therapeutische vorgehen. segmentosteotomien sind eine erprobte methode in der behandlung von dysgnathien, sowie zahnfehlstellungen können aber nur eingeschränkt beim wachsenden kind zum einsatz kommen. segmentdistraktion erlaubt eine entsprechende therapie auch beim wachsenden kind. methodik. 5 kinder mit kompletten lippen-kiefer-gaumenspalten wurden untersucht. alle kinder zeigten sehr breite kieferspalten mit zum teil multiplen zahnnichtanlagen. zum schluss der kieferspalten wurden die spaltfernen segmente osteotomiert und mittels individuell angefertigter distraktoren mesialisiert. am fünften postoperativen tag wurde mit der distraktion von 1 mm pro tag begonnen. ergebnisse. bis dato ist die kieferchirurgisch/kieferorthopädische therpie bei zwei patienten abgeschlossen. bei drei patienten ist die distraktionsphase abgeschlossen, nicht aber die kieferorthopädie. schlussfolgerungen. segmentdistraktionen sind ein probates mittel zum lückenschluss bei spaltpatienten mit ausgedehnten kieferspalten, sowie nichtanlagen. der vorteil der distraktion ist, dass die therapie während des wachstums durchgeführt werden kann. die ersten ergebnisse der durchgeführten segmentdistraktionen bei patienten mit kompletten lippen-kiefer-gaumenspalten sollen präsentiert werden. is a sarme possible without detachement of nasal septum? abteilung mund-, kiefer und gesichtschirurgie, graz, austria objectives. die chirurgische gaumennahterweiterung ist ein bewährter eingriff zur lösung der sutura palatina mediana bei einer transversalen größendiskrepanz der kiefer. ziel der untersuchung war die evaluierung einer möglichen bewegung des nasenseptums im rahmen einer chirurgischen gaumennahterweiterung. study design. der chirurgische eingriff wurde als laterale osteotomie und mediane osteotomie ohne lösung des septum nasi durchgeführt. anhand von gewählten radiologischen referenzpunkten wurde die position des nasenseptums im prä-und postoperative ct vermessen und mögliche abweichungen erfasst. conclusions. bei einer durchschnittlichen erweiterung von 4 mm wurde einer winkeldifferenz von 3,3 zwischen sagittaler und axialer ebenen gemessen. die sagittalen ebenen erfahren eine abweichung von 1 . die nasalen atemwege zeigen eine zunahme an volumen, ohne eine signifikante ä nderung der anatomischen gegebenheiten, so erweist sich die chirurgische gaumennahterweiterung als suffizienter eingriff. using bisphosphonates in the treatment and management of systematic illnesses e.g. plasmocytom and metastasizing illnesses is undisputed. however one of the most feared side effects of this systemic therapy is osteonecrosis of the jaw. estimates of the cumulative incidence of bronj range from 0.8-12%. with increased recognition, duration of exposure, and follow-up, it is likely that the incidence will rise. pathogenisis seems to be multifactorial. besides prophylaxis the spectrum of therapy of bronj reaches from conservative meassures to radical-surgical rehabilitation by plastic reconstruction with local and microvascular flaps. furthermore experiences of our own patients were compared to relevant literature. summary. concerning our patients (12 cases)the biggest percentage of relapse-free patients could be reached through radical surgical rehabilitation, where the obtained defect is to be reconstructed plastically. the results after reconstruction with microvascular iliac crest flap proved to be most effective. the same results could be seen in relevant literature. in case of surgical decortication plastic reconstruction proved to be less difficult but long-term results were not satisfying. concluding there is to say that the present staging system should be changed into a more comprehensive staging system, which would enable us to make even more accurate judgements about risk, prognosis, treatment selection, and outcome for patients with bronj. therefore more prospective clinical studies are required in the future. das calcitonin-nasenspray therapieresistente reparative riesenzellgranulom -ein fallbericht klinische abteilung für mund-, kiefer-und gesichtschirurgie, graz, austria grundlagen. das reparative riesenzellgranulom wurde wegen seinem aggressiven wachstum und seiner progredienz, zwar als nicht neo-plastische veränderung beschrieben, jedoch seine morphologische ä hnlichkeit mit einem riesenzelltumor rechtfertigte letztendlich eine radikale chirurgische therapie. eine chirurgische entfernung zeigte trotz einer additiv angesetzten calcitonin-nasenspraytherapie ein rezidiv. beim reparativen riesenzellgranulom handelte es sich um eine seltene intraossäre läsion, welche vor dem 30. lebensjahr auftrat und eine rasche indolente auftreibung des kieferknochens zeigte. methodik. bei einer 17 jährigen patientin war im november 2007 ein langsam wachsender schmerzloser tumor im kieferwinkel links diagnostiziert worden. im februar 2008 wurde eine exstirpation des tumors durchgeführt und die zähne 36, 37 wurden extrahiert. die patientin erhielt postoperativ additiv einen calcitonin-nasalspray mit 100 i.e täglich. bei regelmäßigen kontrollen zeigte sich trotz regelmäßiger einnahme des medikamentes nach 5 monaten ein doppelt so großes rezidiv im unterkiefer links. ergebnisse. das rezidiv wurde teilreseziert und operativ mit einem mikrochirurgisch anastomisierten beckenkammknochen im unterkiefer links rekonstruiert. die calcitonin-nasenspraytherapie wurde postoperativ sofort abgesetzt. diskussion. die radikale chirurgische entfernung der läsion unter erhaltung der funktion war eine effiziente therapie, zeigte jedoch bei der entstehung eines rezidivs in diesem fall keinen weiteren anhalt für die fortsetzung des calcitonin-nasensprays additiv. schlussfolgerungen. es wurde anhand eines fallberichtes bei einer 17-jährigen patientin die therapie einer exstirpation des tumors mit additiver therapie eines calcitonin-nasensprays, dem einer radikalen chirurgischen behandlung, bei einem reparativen riesenzellgranulom, gegenübergestellt und diskutiert. ein rezidiv bei dieser patientin erforderte eine radikale chirurgische teilresektion und rekonstruktion des unterkiefers, wobei eine additive calcitonin-nasenspraytherapie keine vermeidung eines rezidivs bewirkte. die funktion des kieferknochens kann durch neoadjuvante, adjuvante und auch alleinige radiotherapieoptionen ausgelöst verloren gehen, pathologische frakturen und osteoradionekrosen sind als folgen dieser behandlung von patienten mit kopf-halstumoren bekannt. bestrahlungsdosierungen beruhen dabei vor allem auf empirischen konzepten -erfahrungen bei der therapie früherer patienten. in der literatur ist wenig darüber bekannt inwieweit bestrahlter knochen auf stimulierende reize noch reagieren kann, ob die für die knochenhomöostase essentiellen mesenchymalen stammzellen (mscs) die bestrahlung tolerieren und ihr differenzierungspotential darunter leidet. im rahmen der bestrahlung werden neben dem eigentlichen zielvolumen ,,entartete krebszellen'' auch alle gesunden zellen samt den im knochen eingebetteten mscs getroffen. in dieser studie wurden deshalb einerseits humane mscs und andererseits porcine mscs vom unterkiefer des sus scrofa domestica auf ihre bestrahlungssensitivität in vitro und im gewebeverband in drei stufen analysiert. zunächst wurden humane und porcine mscs isoliert und in vitro bestrahlt. einerseits zeigte sich, wie erwartet, eine kohärente abnahme der proliferationskapazität mit zunehmenden dosen, aber andererseits blieb die osteo-und adipogene differenzierungsfähigkeit erhalten, annähernd ähnlich den unbestrahlten kontrollproben. anschliessend wurden die unterkiefer von sus scrofa domestica mit einer dosis von 2 â 9 gy im wochenabstand bestrahlt. zu verschiedenen zeitpunkten (nach 5, 6, 8 und 12 wochen) wurden die mscs aus knochenbiopsien gewonnen. interessanterweise bestanden keine signifikanten unterschiede zwischen bestrahlten und unbestrahlten mscs hinsichtlich proliferations-als auch osteogenem differenzierungsverhalten. deshalb wurden in einer weiteren analyse unterkiefer mit 9 und 18 gy bestrahlt und am gleichen tag mscs aus dem bestrahlten knochen entnommen. es zeigte sich kein signifikanter unterschied zwischen 0 gy-proben (unbestrahlt) und 9 gy-proben bezüglich proliferationsverhalten und osteogener differenzierung. aber bei den 18 gy-proben nahm die osteogene differenzierungsfähigkeit signifikant ab. innerhalb von 2 wochen nahm auch die proliferationsfähigkeit bei den 18 gy-proben deutlich ab. danach zeigten sie ein proliferationsverhalten wie die anderen proben. die ergebnisse dieser aufwändigen interdisziplinären kooperation von mkg-chirurgie, anästhesie, strahlentherapie und grundlagenforschung überraschen, da die mscs im knochen bis zu einer bestimmten dosis der bestrahlung widerstehen, jedenfalls besser als ursprünglich erwartet. weitere untersuchungen sind erforderlich, um auszuleuchten, ob mscs durch das umgebende gewebe oder ihre nische etwa geschützt sind oder ob doch periphere mscs neu einwandern und damit die knochenfunktion aufrecht erhalten werden kann. funding: oenb-jubiläumsfondsprojekt nr. 12246. background. gastroesophageal reflux causes dysfunction of the lower esophageal sphincter (les) and columnar lined esophagus (cle) resulting in gastric appearance: this is the dilated end stage esophagus (dese ¼ cle within endoscopically visible gastric folds interposed between squamous epithelium and oxyntic mucosa of the proximal stomach). we report intermediate follow-up data of patients who underwent modified laparoscopic nissen fundoplication (lnf) for gastro-esophageal reflux disease (gerd) with fundic wrap placement around the dese. methods. twenty-nine gerd patients [age 52.9 (27.6-73.6), 18 female)] underwent assessment of quality of life, endoscopy with multilevel biopsies from the esophagogastric junction (for assessment of dese length), esophageal manometry and (impedance-) ph-monitoring before and 9 (4-19) months after lnf ( þ intraoperative endoscopy). the distal limit of the fundic wrap was placed at the level of the peritoneal reflection ( ¼ anatomic esophagogastric junction) and extended proximally over a length of 1.5 cm. results. intraoperative endoscopy revealed adequate wrap placement in all patients. follow-up data. background. laparoscopic antireflux surgery is a well established treatment of gastroesophageal reflux disease (gerd). persistent or recurrent reflux, gas-bloat syndrome or dysphagia may result in repeated surgical treatment which are at higher risk of perioperative morbidity and mortality. methods. from march 1999 until april 2008, in 135 patients antireflux procedures were performed because of gastroesophageal reflux disease and hiatal hernia. in 19 patients (14%) of which 7 patients were male (37%) repeated antireflux surgery was necessary. retrospective data collection was analysed for postoperative course, perioperative morbidity and mortality after redo-fundoplication. results. redo-fundoplications were made on the ground of recurrent reflux (n ¼ 7), herniation of the wrap (n ¼ 9) or scarred adhesions and dysphagia (n ¼ 3). all procedures were completed laparoscopically. the mean operation time was 140 min (90-285 min). in 15 patients 360 nissen and in 4 patients 270 toupet fundoplication were performed. intraoperatively there occured in 3 patients lesions of the wrap and in one patient a lesion of the pleura. in one patient laparoscopic revisions with suture was necessary. there were no postoperative in-hospital deaths. the median length of hospital stay was 7 days (3-20 days). at discharge no patient had relevant symptoms of gastroesophageal reflux. conclusions. reoperative surgery after fundoplication is known to be very technical challenging because of scarred tissue. so it is associated with higher morbidity and mortality. in our case study laparoscopic redo-fundoplication was feasible and with low incidence of perioperative morbidity and no mortality. background. giant leiomyomas of the esophagus bear the risk of malignancy. treatment is a function of size, small tumors might be removed endoscopically with the ever present risk of hemorrhage. large tumors require surgery, the approach depending on the tumor site and size. methods. we report on a symptomatic male patient (45a) suffering from a giant leiomyoma (12 â 4 cm) in the esophagus. preoperative testing comprising contrast swallow, endoscopy, endoscopic ultrasound, ct, and true-cut biopsy confirmed the diagnosis. patient was found eligible for thoraco-laparoscopic esophageal resection. results. the minimal invasive procedure was carried out with the patient in the left-lateral position. thoracoscopic resection utilized four trocars. the azygos vein was divided with an endo-gia. after transection of the esophagus at the level of the thoracic apex the table was tilted to the right to perform laparoscopic preparation of the gastric conduit. thereafter the stomach was pulled up into the thorax. enlargement of trocar sites was necessary for specimen retrieval. intra-thoracic circular stapled anastomosis was done transorally (orvil + , covidien). procedural time lasted in total seven hours. blood loss yielded insignificant and no intraoperative complication was observed. histology yielded no malignancy. patient started with oral diet on postoperative day 2 and was discharged on day 18. follow-up after three months was uneventful. conclusions. giant leiomyoma of the esophagus require surgical resection. we present our technique for thoraco-laparoscopic esophageal resection. background. robot assisted laparoscopic surgery is an increasing field. laparoscopic microsurgery, difficult maneuvers like intracorporeal hand sewn anastomoses or a narrow operating field are ideal indications for the operation robot. methods. tertiary referral center with large expertise in robotic surgery. five patients with achalasia, (4 m/1 f), mean age 44 (34-50), underwent a robot assisted laparoscopic cardiomyotomy (rac) with a partial posterior (toupet) fundoplication. detailed description of the operation technique and review of the literature. results. the rac was feasible without any particular problem and the postoperative course of all five patients was uneventful. the mean operation time was 257 min and 47 min setup-time of the robot. on follow-up six months postoperatively, all patients were free of significant dysphagia and free of reflux symptoms and had a significant weight gain. there are several reports, series and trials about rac available in literature. the general conclusion is that this operation is easy to perform in experienced hands with a significantly lower rate of mucosal perforations, but at higher overall costs. a longer operation time has to be taken into account during the learning curve. discussion. the avoidance of mucosal lacerations and its possible consequences has to be weighted against higher overall costs. conclusions. the rac is the first ''standard laparoscopic'' operation where a clear advantage for the application of an operation robot has been proven. where available, the operation robot should be used for laparoscopic cardiomyotomies. methodik. bei 1515 schockraumadmissionen im beobachtungszeitraum mit 882 polytraumata finden sich 265 stumpfe und penetrierende verletzungen des abdomens und/oder des thorax. nach klinischer diagnostik mit obligater sonographie und -bei hämodynamischer stabilität, sowie fehlendem peritonismus oder eviszeration -ct-traumaspirale lässt sich das procedere festlegen: observanz und konservative therapie (n ¼ 170), laparo-/ thorakotomie (n ¼ 89) oder laparo-/thorakoskopie (n ¼ 6). ergebnisse. schussverletzungen wurden regelhaft offen versorgt. alle diaphragmalen läsionen wurden im ct oder per laparotomiam erkannt und therapiert. in lediglich 6 fällen kam eine laparoskopische bzw. thorakoskopische versorgung sicher und sinnvoll -selbst bei mehrfachverletzungen -zur anwendung: es handelte sich um 3 atypische pulmonale segmentresektionen bei stichverletzungen, je eine milzklebung, eine colonübernähung, einen umstieg auf offene milzerhaltende prozedur, eine perikardfensterung und eine rein diagnostische laparoskopie, wobei keine verfahrensabhängigen komplikationen beobachtet werden mussten. schlussfolgerungen. penetrierende verletzungen der brustund/oder leibeshöhle stellen für die chirurgische versorgung eine herausforderung dar: einerseits darf der diagnostik keine läsion entgehen, andererseits muß eine ü berversorgung mit dem eigenrisiko einer negativen explorationslaparotomie vermieden werden. klinische, sonographische und computertomographischeggf. wiederholte untersuchungen -lassen nur in hochselektiven situationen eine endoskopische annäherung sinnvoll erscheinen, zumal den therapeutischen endoskopischen verfahren technische grenzen gesetzt sind. unbestreitbar ist allerdings ihr wert bezüglich einer harten forensischen dokumentation. bmi 26, 9 (16, 1) kg/m 2 ) mit einer itp laparoskopisch splenektomiert. in einer univariaten analyse wurde der einfluss von alter, bmi, asa-score, krankheitsdauer, medikamentöser therapie, op-dauer, konversion, komplikation, milzgewicht, präoperativen thrombozytenzahlen, thrombozytenanstieg und blutproduktsubstitution auf das langzeitergebnis ausgewertet (anova mit bonferroni post hoc test, kruskal-wallis-test). ergebnisse. die erkrankungsdauer lag bei 1,5 (0,25-25) jahren. das milzgewicht betrug 150 (70-350) g. die operationsdauer betrug 123 (28-297) minuten. konversionen erfolgten in 8 %. die thrombozytenzahl stieg um 793 % (präoperativ 67 (3-318) tsd/ml, bei entlassung 247 (31-835) tsd/ml). die morbidität war 11,4 %, die letalität 0 %. die liegezeit betrug 6 (3-17) tage. das mediane follow-up betrug 12 monate (0,25-5,7 jahre). dauerhaft normwertige thrombozytenzahlen konnten bei 70,5 % der patienten erzielt werden. 4 patienten zeigten keinen thrombozytenanstieg nach splenektomie, während 13 patienten nach 5 (1-68) monaten eine rezidiv-thrombopenie entwickelten. patienten mit einer primären postoperativen thrombozytopenie < 60.000/ml waren therapieversager (3/3), postoperative thrombozytenwerte zwischen 60.000/ml und 150.000/ml resultierten in partieller (4/11) und kompletter (7/11) remission, während thrombozyten > 150.000/ml überwiegend zu einer kompletten remission (35/42) führten. schlussfolgerungen. die laparoskopische splenektomie ist ein sicheres verfahren bei selektionierten patienten und gilt als chirurgisches standardverfahren bei der therapierefraktären itp. die ansprechrate liegt bei 70 %. die postoperativen thrombozytenwerte sind ein prediktor für den langzeitverlauf, während periopereative komplikationen keinen einfluss auf die rezidivrate haben. grundlagen. die verwendung von sogenannten perforator-lappen in der plastischen chirurgie konnte in der rezenten vergangenheit zum einen zu einer massiven reduktion der hebedefektmorbidität und zum anderen zu einer größeren flexibilität im lappendesign beitragen. vorallem im bereich der mammarekonstruktion ist der deep-inferior-epigastric-artery-perforator-falp (dieap-flap) mittlerweile zu einem operativen standard geworden. in der vorliegenden untersuchung soll die bedeutung der präoperativen darstellung der perforatorgefäße mittels ct-angiographie untersucht werden. methodik. insgesamt wurden an unserer abteilung bei 61 von 345 patientinnen seit mai 2000 mammarekonstruktionen mittels dieap-flaps durchgeführt. bei 15 von 61 patientinnen wurde präoperativ eine ct-angiographie zur darstellung der perforatorgefäße vorgenommen. anhand von beispielen sollen sowohl die praktikabilität als auch die vorteile der untersuchung verdeutlicht werden. ergebnisse. in keinem der fälle mit präoperativer ct-angiographie kam es zu einem lappenverlust. die operationsdauer der lappenhebung konnte verkürzt werden, sowie das lappendesign anhand der untersuchungsergebnisse individuell angepasst werden. schlussfolgerungen. die präoperative ct-angiographie der perforatorgefäße zur hebung eines dieap-flap trägt zu einer reduktion der operationsdauer bei und hat einen positiven einfluss auf die realibilität der lappendurchblutung. roughly 2% of pediatric tumors are present at birth. with the increased use of prenatal imaging these tumors are detected at earlier stages of fetal development and pose a diagnostic and therapeutic challenge as of how to proceed in a situation of potential malignant grow. methods. if on routine prenatal ultrasound a tumor was suspected, axial, coronal and sagittal t1-w and t2-w sequences were obtained using a 1.5 tesla mri. the mri's were performed between the 22nd-39th gw (median 29 gw). no sedation or contrast enhancement was used for this study. results. between 2001 and 08, 10 tumors were diagnosed after exclusion of hemangiomas, lymphangiomas, ovarian cysts and ccam. 6 were teratomas localized to the face (1), neck (2), mediastinum(1) sacrococcyx(2). the remaining tumors were a hepatoblastoma, a cystic neuroblastoma, a adrenal cyst and a malignant glioma/pnet. three cases posed a special therapeutic dilemma. the facial teratoma that due to rapid tumor growth had to be delivered by c-section at 30 gw so that chemotherapy could be initiated. one of the cervical immature teratomas had rapid extension and should have been delivered earlier. the fetus with hepatoblastoma had rapid tumor progression and required a hemihepatectomy in the first week of life. conclusions. prenatally detected tumors pose a diagnostic and therapeutic challenge. location, size, extension and vascularity of the tumor will determine the viability of the fetus and therapeutic options including time and mode of delivery. consensus has to be taken by an interdisciplinary team (obstetrician, neonatologist, oncologist, surgeon) and the parents. background. burns are very common in pediatric patients. most children are very young ( < 3 years of age). a variety of none degradable products are available for closed wound management. suprathel tm is a degradable alternative. it is composed of polylactic acid in combination with other biocompatible polymers. it can be used for 2nd and partial 3rd degree burns, split skin donor sites and large-area abrasions. methods. between november 2006 and november 2008, we treated 123 children between 2 months and 16 years of age, most of them with 2a and 2b burns. suprathel tm was used in 74 cases (60%). debridement was performed without undue delay. three days later we applied suprathel tm and two layers of fat gauze to prevent adhesions. in 2 to 5 days intervals the superficial dressing was changed, leaving suprathel tm and the deeper gauze in place. results. changing of the superficial dressing was easy and painless. inspection of the healing progress was possible as suprathel tm becomes translucent. time spent in hospital was reduced, wound healing speeded up, no wound infection was recorded and the cosmetic results were excellent. suprathel tm came off naturally within 10 to 12 days after application. discoloration of the overlying fat gauze was observed and was never caused by infection. occasionally suprathel tm did not adhere initially. conclusions. suprathel tm handling is very simple. the most important benefits are no pain and less change of dressing with good cosmetic results. it is a considerable improvement of the management of 2nd and partial 3rd degree burns in children. erfahrungen in der kinderwundambulanz der kinderchirurgischen abteilung der lfkk linz grundlagen. eine der potentiellen anwendungen des monitorings von angiogeneseparametern ist die verwendung als tumormarker. ziel dieser studie ist, etablierte tumormarker wie ca 19-9 den angiogeneseparametern unter neoadjuvanter therapie mit bevacizumab gegenüberzustellen. untersucht wurden der pro-angiogene faktor vegf (vascular endothelial growth factor), der durch bevacizumab inaktiviert wird, sowie der angiogeneseinhibitor tsp-1 (thrombospondin-1). methodik. 19 patienten mit lokal fortgeschrittenem pankreaskarzinom wurden mit 4 zyklen (q 4 wochen) gemcitabin sowie 2-wöchentlich mit bevacizumab behandelt. blutproben wurden alle 2 wochen jeweils direkt vor der bevacizumab-applikation abgenommen. die angiogenesefaktoren wurden im plasma bestimmt. ergebnisse. im verlauf der therapie kam es zu einem kontinuierlichem abfall von ca 19-9 (p ¼ 0,025). die vegf-spiegel korrelierten positiv mit der bevacizumab-therapie und stiegen bereits mit der ersten behandlung signifikant an (p ¼ 0,004 background. endoscopic thoracic sympathetic block (etsb) provides excellent outcome for palmo-axillary hyperhidrosis (hh). the aim of the study was to investigate the long term effects of etsb4. methods. between 2002 and 2009 184 patients (mean age 30 ae 10 years) underwent 367 etsb4 procedures in a prospective study. satisfaction rates and two validated quality of life (qol) questionnaires were assessing postoperative outcome (keller: 0-10 and milanez de campos: 1-5; 0: no symptoms; 5 or 10: maximal symptoms), respectively. mean follow up was 48.3 ae 25.2 months. results. one hundred and sixty-two patients (88.0%) had palmar and 137 patients (74.5%) axillary hh. all patients with palmar hh were completely or almost dry postoperatively whereas 1 patient (0.5%) developed recurrence of the primary disease at follow up. among patients with axillary hh, recurrences appeared in 3.5% within six weeks and rose up to 6.3% at follow up. compensatory sweating (cs) and gustatory sweating were observed in 16. 8% background. at the time when notes techniques struggle on diverse problems a novel single incision laparoscopic method is developed utilizing the umbilicus as embryonic natural orifice. three intra-umbilical trocars allow a minimal invasive procedure which results in a non-visible postoperative scar. methods. twenty-four patients (age: 24-86a) underwent single incision laparoscopic cholecystectomy (10/08-01/09) for gallbladder stones and/or cholecystitis. the entire operation was carried out transumbilically following the standardized principles of the laparoscopic technique. one or two (in the initial 5 patients) intraperitoneal suspension sutures helped to expose the anatomical structures. results. in all but two patients single incision transumbilical surgery could be completed. in both cases placement of one and two additional trocars, respectively, was necessary due to severe adhesions from previous surgery. the operative time was in median 60 (range 37-130) min. no intraoperative adverse events were noticed. estimated blood loss yielded minimal in all cases. cholangiography was successfully carried out in two patients. all returned to oral diet after six hours. they were discharged in median on postoperative day 3 in accordance with local custom. an optimal postoperative and cosmetic result without apparent scar was documented at follow-up. conclusions. this initial series presents for the first time a novel laparoscopic technique for e-notes cholecystectomy utilizing a single ''scar-less'' intraumbilical approach which minimizes the surgical trauma. background. during the past decades anecdotic reports on single incision laparoscopic appendectomy were published. the scientific interest in notes procedures led to a renaissance of this technique in the surge for a minimal invasive approach. we developed a novel laparoscopic transumbilical method utilizing three instruments exclusively through the embryonic ''non-visible'' scar. methods. two patients (both 28a) underwent single incision laparoscopic appendectomy (11/08-12/08). the entire operation was carried out transumbilically following the standardized principles of the minimal invasive appendectomy technique. results. both patients underwent surgery for acute appendicitis with perifocal peritonitis. after dissection of the appendicular artery the appendix was transected by use of a loop and a stapler, respectively. the operative time was 77 min and 67 min. no additional trocar had to be placed. no intraoperative adverse events or significant perioperative complication was noticed. estimated blood loss yielded minimal in both cases. one patient suffered from infectious enteritis and mild wound infection postoperatively. oral diet was resumed immediately after the operation. at follow-up patients presented with an outstanding cosmetic result without apparent scarring. conclusions. for the first time instrumental developments allow a novel laparoscopic technique for appendectomy utilizing flexible instruments through a single intraumbilical approach resulting in a non-visible scar. methods. twenty-three patients (4 female/19 male; age: 36-75a) underwent single incision laparoscopic inguinal hernia repair (10/08-01/09). the entire operation was carried out transumbilically following the standardized principles of the tapp technique. results. sixteen patients underwent single site surgery (15 primary/1 recurrence procedures), whereas bilateral hernia repair was necessary in seven patients. the operative time was 39-125 min and 48-205 min for single and bilateral repair, respectively. one additional trocar had to be placed for dissection or suturing in four patients. no intraoperative adverse events or significant perioperative complication was noticed. estimated blood loss yielded minimal in all cases. in one patient redolaparoscopy was carried out after 23 days for undefined lower abdominal pain. oral diet was resumed immediately after the operation. patients were discharged on postoperative day 2 to 4 in accordance with local custom. at follow-up patients presented with an optimal postoperative and cosmetic result without apparent scarring. conclusions. this feasibility study presents for the first time presents a novel laparoscopic technique for tapp groin hernia repair utilizing a single ''scar-less'' intraumbilical approach which allows further reduction of the surgical trauma. background. on the way to ''no-scar'' techniques we developed a novel method for colorectal resection utilizing three intraumbilical trocars which results in a non-visible postoperative scar. methods. four patients (3 female/1 male; 42-65a) underwent laparoscopic colorectal resection for diverticulitis and infiltrating endometriosis of the rectosigmoid colon, respectively. the entire operation was carried out transumbilically following the standardized principles of colorectal resection. results. the operative time ranged in total from 85 min to 180 min and for dissection only 75-155 min, respectively. no intraoperative adverse events or significant perioperative complications were noticed. specimen retrieval was carried out through the umbilicus. segments measured in length 18 cm to 22 cm. circular stapled anastomosis was performed transanally. estimated blood loss yielded minimal in all cases. oral diet was resumed on postoperative day 1. patients were discharged on postoperative day 6 to 8. at follow-up patients presented with an optimal cosmetic result without apparent scarring. conclusions. for the first time a novel laparoscopic technique for sigmoid colon resection utilizing a single intraumbilical approach is presented. this new method is restricted to a limited number of patients but allows further reduction of the surgical trauma and to obviate any visible scar. background. besides the considerable advantages of laparoscopic ventral hernia repair one of the most severe complication is the incisional hernia of the trocar site. one of the key benefits of notes-procedures is to avoid surface incisions leading to a decrease of postoperative pain, infection and port site hernia. the aim of this experimental study was to assess the feasibility of the ipom repair in ventral hernia by transgastric access in a pig model. methods. under laparoscopic control a transgastric approach was utilized to create 4 abdominal wall defects in 5 female, domestic nonsurvival and 3 survival pigs respectively. titanized polypropylene meshes (tisure + ) armed by polypropylene sutures in the four corners were transferred via the umbilical trocar. after suture fixation of each mesh additional endoscopic transporous fibrin sealant fixation (tissucol + ) using a single lumen catheter was performed. the closure of the gastric access was achieved by applying endoclips in nonsurvival and by laparoscopic suturing in case of survival pigs respectively. results. the 3 survival pigs were euthanized at day 4, 11 and 22 postoperatively. the macroscopical evaluation revealed excellent integration of the meshes without signs of shrinkage or increased inflammation. only in 2 cases out of a total of 12 meshes minimal adhesions in the region of suture fixation were observed. histology confirmed the macroscopical findings. conclusions. the initial results of our experimental study demonstrate the feasibility of a notes repair of abdominal wall hernias. anticipating technical advances of notes-devices this new technique could be auspicious for the future. medical university, lviv, ukraine; 2 childrens hospital, lviv, ukraine recent advances in medicine brought to noticeable growth of premature newborns' survival value. but this fact brought to growth of necrotic enterocolitis morbidity of newborns that often occurs on the background of congenital bowels pathology. from 2007 to 2009 we treated 18 children with necrotic enterocolitis. the average gestational age of patients was 32.7 þ 2.4 weeks, average body weight -1736 þ 248 g. seven patients were operated with 3a stage of necrotic enterocolitis. large intestine hypoplasia was intraoperatively revealed in 5 cases; and after its biopsy congenital agangliosis was diagnosed. the signs of partial bowel obstruction kept after reduction of necrotic enterocolitis effects in 4 from 11 non-operated patients with 1b-2a stages of necrotic enterocolitis; large intestine biopsy of those patients revealed intestinal neuronal displasia type a in one case, intestine neuronal displasia type b in two cases, congenital agangliosis in one case. conclusions. different forms of disgangliosis can be one of the trigger mechanisms for the development of newborns' necrotic enterocolitis. at the same moment necrotic enterocolitis can be one of the first manifestations of congenital disgangliosis. that's why the visual large intestine hypoplasia or keeping of partial bowel obstruction signs after the reduction of necrotic enterocolitis effects of newborns must be the reason for the large intestine biopsy and histochemical investigation of biopsy material for this group of patients. zur angeborenen dilatation von intestinalsegmentenein beitrag zu einem seltenen krankheitsbild accidental ingestion of foreign bodies is a common problem in infants and childhood, but ingestion of magnetic construction toys is very rare. when multiple parts of these magnetic construction toys are ingested, they may attract each other through the intestinal walls, causing pressure necrosis, perforation, fistula formation or intestinal obstruction. a 20-month old boy presented with a three day history of abdominal pain and bilious vomiting. physical examination revealed a slighted distended abdomen. the white blood cell count was normal, but the c-reactive protein was elevated. ultrasound and x-ray of the abdomen showed a distended bowel loop in the right upper, a moderate amount of free intraperitoneal liquid and four foreign bodies. emergency laparotomy was performed and two perforations in the ileum could be detected. the perforation was caused by a magnetic construction toy and two iron globes. the fourth foreign body was a glass marble. the foreign bodies were removed, both perforations were primary sutured. the child was discharged on postoperative day 10 after an uneventful recovery. parents should be warned against the potential dangers of children's constructions toys that contain these kinds of magnets. interdisziplinärer zusammenarbeit bei kindern mit anorektalen malformationen -erfahrungen des colorektalen teams in linz landes-, frauen-und kinderklinik, linz, austria bei kindern mit anorektalen malformationen besteht eine sehr hohe wahrscheinlichkeit, auch an anderen stellen fehlbildungen aufzuweisen. dies erfordert nicht nur bei der abklärung sondern auch bei der behandlung und nachbetreuung eine enge zusammenarbeit mit anderen fachabteilungen und der pflege. an unserer kinderchirurgischen abteilung in der landes-, frauen-und kinderklinik hat sich ein colorektales team aus ä rzten und pflegepersonen gebildet, das zum einen die anorektalen malformationen der kinder operiert und nachbetreut, zum anderen als interdisziplinäre drehscheibe zu anderen abteilungen fungiert. mehr bereits bei der abklärung der patienten mittels endoskopie spielt der kinderchirurg eine wesentliche rolle. bewährt hat sich die anwesenheit des gastroenterologen während der endoskopie. sind die indikationen zur operativen intervention beim mb. crohn klar, ist bei der colitis ulcerosa nur die behandlung des toxischen megacolons eindeutig. im allgemeinen wird der chirurg erst am ende der konservativen therapie beigezogen, wenn sich der patient bereits in schlechtem allgemeinzustand befindet oder komplikationen von seiten der nicht ganz harmlosen medikation eingetreten sind. anhand eines 13-jährigen mädchens mit ausgeschöpfter therapie (sandimun, imurek und prednisolon) möchte ich unser vorgehen darstellen. trotz maximaler konservativer therapie konnten die blutungen nicht gestoppt werden. wegen grundlagen. die pilonidalsinus-erkrankung ist eine in der rima ani lokalisierte granulomätöse erkrankung, verifizierbar mittels ,,blickdiagnose''. trotz ihres häufigen vorkommens gibt es für die 3 erkrankungsstadien der affektion keine allgemein gültigen therapieempfehlungen. methodik. während der letzten 12 jahre wurden 49 kinder/ jugendliche (10 mädchen, 39 männliche kinder/jugendliche (alter zwischen 12 und 18 jahren)) wegen einer pilonidalsinus-erkrankung behandelt. 3 waren asymptomatisch, der prozess wurde exzidiert und der defekt linear verschlossen. 8 hatten ein chronisch-entzündliches geschehen: nach exzision des herdes wurde bei einem eine limberg-lappendeckung, bei 3 eine offene wundbehandlung und bei 4 eine karydakis-defektdeckung durchgeführt. die ,,restlichen'' 38 patienten mit abszedierendem pilonidalsinus wurden nach abszessinzision/exkochleation offen wundbehandelt; bei 2 wurde 8 tage später eine karydakis-operation angeschlossen. ergebnisse. bei 7 der 10 patienten mit den defektverschlüssen verheilten die wunden innerhalb von 2 wochen, bei den restlichen 3 (nach karydakis-operation) innerhalb von 4 wochen. die 39 offenen wundbehandlungen führten nach einer behandlungsdauer zwischen 8 1 / 2 und 12 wochen zu einem adäquaten wundverschluss, 4 davon entwickelten ein sinus-pilonidalis-rezidiv, das exzidiert und neuerlich offen behandelt wurde. diskussion background. as the elderly population is growing, the incidence of patients being diagnosed with pancreatic cancer at the age of 70 and above is rising. even overall morbidity and mortality rates for pancreatic resection decreased the last decades, the indication of major pancreatic surgery in elderly patients is still discussed controversial. methods. during the last ten years 81 patients at the age above 70a underwent pancreatic resection for adenocarcinoma of the pancreas at the surgical department of the muw. perioperative outcome, histopathological findings and overall survival was investigated and compared to 145 younger patients. results. between 1998 and 2008 64 patients (31 female and 33male) at the age of 70-79 and 17 patients (12 female and 5 male) 80a and older, had pancreatic resection with curative intent. the pancreatic head was the predominant location within both groups. 84% of the elderly patients had duodenopancreatectomy almost equal to 80% of the patients younger than 70a. there was no significant difference in perioperative morbidity (29.6% old vs. 34.2% young) and mortality (6.2% old vs. 6.9% young). mortality and morbidity were 0% and 17.6% in the group of patients 80a and older. the median postoperative stay in hospital was 13 days (old) and 14 days (young) respectively. there was no observed difference in the mean survival for both groups (20 months old vs. 22 months young). conclusions. an aggressive surgical approach for pancreatic cancer is justified in elderly patients, as they can benefit from resection similarly to younger patients. is preoperative tissue diagnosis mandatory for suspect lesions of the pancreas? background. it is still controversial if pretherapeutic cytohistological diagnosis is mandatory for patients with suspect leasions of the pancreas. even transgastric endosonographic biopsy is a save technique, with a sensitivity of 70-80%, a negative result does not rule out malignancy. methods. medical records of 255 patients who underwent surgery at our department, between 1994 and 2008, for suspected or biopsy proven pancreatic adenocarcinoma were analysed and literature on preoperative biopsy of suspect pancreatic tumors was reviewed. results. 108 of 186 patients with ductal adenocarcinoma had a biopsy prior to surgical resection. of these 65% (n ¼ 70) were histological diagnosed as adenocarcinoma. 38 patients underwent surgery even after negative cyto-histological workup. 40 patients had partitial pancreatic resection without preoperative biopsy. of 29 patients receiving neoadjuvant chemotherapy 90% (n ¼ 26) had histological diagnosis prior to therapy. on the other hand 69 patients with suspect pancreatic lesions showed pancreatitis and no malignancy after resection. 46% of them had biopsy with negative result but underwent operation due to preoperative radiological findings and or ca 19-9 level. conclusions. preoperative biopsy of potentially respectable suspect pancreatic masses is not mandatory as malignancy cannot be ruled out with adequate reliability. only in patients undergoing neoadjuvant therapy extended effort in receiving positive biopsy cyto-histological result is indicated. wie schlecht sind ,,low volume hospitals''? eine kritische analyse der ergebnisqualität von pankreaskopfresektionen an einer peripherieabteilung dynamic graciloplasty in patients with severe anal sphincter lesiona method still up-to-date? background. until recently the dynamic graciloplasty (dgp) was one of the most effective techniques to create a neo-sphincter despite its complexity. nowadays it has been replaced by less invasive methods in order to treat the fecal incontinence. however dgp still plays an important role and this prospective study shows the results of reconstructive surgery. methods. from january until december 2008 seven female patients (average age of 43.5 years, range 31-61 years) were enrolled in the study. inclusion criteria were severe faecal incontince after failed conservative treatment diagnosis was confirmed by rectoscopy, endo ultrasonography and anal manometry in preoperative form according to the study protocol and the fecal incontinence was recorded using the wexner-score. postoperative complications were classified in four levels according to dindo et al. results. five patients suffered a postpartum sphincter lesion ( > 180 in circumference) and two a congenital atresia of the sphincter muscle. postoperatively, one patient suffered level iii (reoperation) and three others level i complications (hypaesthesia distal to extraction area of the m. gracilis, extended aches due to sores in the neurostimulator and electrode area). after completion of the muscle conditioning (eight weeks postoperative) the median wexner-score was reduced from preoperatively 18 (range 16-20) to 8 (6-10). conclusions. all that exists today for the dgp is a modified indication list. in young patients with irreparable sphincter lesion or congenital atresia of the sphincter muscle the dgp remains an effective method in therapy with moderate morbidity. grundlagen. die versorgung von narbenhernien mittels offener oder laparoskopischer technik kann in wundkomplikationen und hernienrezidiven resultieren. mittels notes techniken könnten diese komplikationen verhindert werden. methodik. in 6 hausschweinen erfolgte die herstellung einer ventralen bauchhernie durch resektion eines runden 5 cm im dm haltenden muskulären defektes. nach 4 wochen erfolgte der transgastrische verschluß der resultierenden hernie mittels eines über einen overtube eingebrachtem biologischen netzes mit 5 cm allseitiger ü berlappung und fixation mit transfascialen nähten. nach zwei wochen erfolgte eine explorative laparoskopie und nach weiteren 2 wochen wurden die tiere euthanasiert und obduziert. ergebnisse. die größe der hernien lag zwischen 36 und 90 cm 2 . in allen 6 tieren konnte ein hernienverschluss mit einer mittleren operationszeit von 204 ae 123 minuten durchgefü hrt werden. die größe der implantierten netze lag zwischen 16 â 16 und 20 â 19 cm. ein tier verstarb unmittelbar postoperativ an hypoxie. bei der laparoskopischen exploration nach 2 wochen fanden sich in allen tiere massive adhäsionen, ein tier wurde aufgrund einer netzinfektion euthanasiert. die ü brigen tieren ü berlebten die vierwöchige beobachtungszeit. in allen tieren fand sich bei der obduktion ein erfolgreicher hernienverschluss. alle tiere hatten netzinfektionen. schlussfolgerungen. der transgastrische verschluss von großen ventralen bauchwandhernien ist technisch machbar. das sterile transgastrische einbringen des netzes und die verhinderung von netzinfektionen stellen derzeit die größten hürden dar die überwunden werden müssen, bevor dieser eingriff bei menschen in erwägung gezogen werden kann. background. transgastric notes procedures remain difficult due to the lake of innovative flexible endoscopic technology. in particular, independent movement of the instruments from the visual axis has been described as an essential part of complex notes procedures. methods. we present our experience using the endo-samurai tm (olympus) newly designed prototype platform for advanced endoscopic surgery, which is 15 mm in od and which allows 5 of freedom at the instrument tips with a variety of instrument configurations, in an animal model to perform transgastric cholecystectomy. results. a porcine model was used to perform transgastric cholecystectomy with the new device. gastric exit was easily performed using an overtube and needle knife in 22 min. the gallbladder was easily identified and dissected in a manner similar to laparoscopic procedures using graspers and hook cautery instruments with 5 of freedom. good user ergonomics were recorded and the gb was removed without spillage in 55 min. gastric closure was attempted with intracorporeal suturing but was still difficult due to grasping strength of the needle holders and visualization due to loss of pneumo-gastrium. conclusions. the new endosamurai tm device offers substantial advantage to the performance of transgastric notes procedures and may represent the configuration of operating flexible endoscopes of the future. background. laparoscopic cholecystectomy has become standard procedure. natural orifice transluminal endoscopic surgery (notes) will further decrease the operative trauma to the abdominal wall and reduce postoperative pain, wound infection, risk of hernia and hospital stay. we report the first results of transvaginal hybrid-notes cholecystectomy in switzerland. methods. from july 2008 to december 2008, 5 women were treated by transvaginal hybrid-notes cholecystectomy. pneumoperitoneum was created through a 5 mm incision in the umbilicus. two rigid trocars (12 mm and 5 mm) were inserted in the posterior fornix of the vagina. patient data, operative time, complications and postoperative course were recorded prospectively in each patient. results. the average age of the 5 patients was 34.6 years (19-44 years) and the mean body mass index was 24.8 kg/m 2 . all operations were performed without intraoperative complications. the mean operative time was 79 min (65-88 min). the mean hospital stay was 2.6 days (2-3 days). non steroidal antiinflammatory drugs and paracetamol or metamizol were administered for analgesia. the postoperative course was uneventful. no complications were recorded during the further postoperative follow-up after 4 weeks. conclusions. the transvaginal hybrid-notes cholecystectomy is a feasible and probably safe procedure. operative time was despite of any expected learning courve effects not significantly longer than in laparoscopic cholecystectomy. the posterior colpotomy is a simple approach to the abdominal cavity and wound healing is very rapid. using rigid instruments and techniques wellknown for laparoscopic techniques transvaginal cholecystectomy seems feasible with low operative risk. background. the latency time to develop colonic carcinoma in patients with uretersigmoidostomy (ursig) is usually more than ten years. we present a case of carcinoma in-situ of the colon in which a ursig was present less than six months. method. retrospective chart review. case report. an eighteen-year-old male born with bladder exstrophy underwent a ursig at age of 4 months after a failed bladder closure. four months later the ursig was converted to an incontinent uretero-ileostomy. at eighteen years of age during an operation to construct a continent reservoir carcinoma in-situ of the rectosigmoid was incidentally discovered. the involved bowel was resected and a continent reservoir with the ileal segment and descending colon was created. the patient remains disease free for the next 8 years. conclusions. colonic carcinoma can develop even after very short time with a ursig. when ursig is taken down, the involved colonic segment should be removed. adrenal tumors in children a. pereyaslov 1 , a. dvorakevich 1 , l. burda 2 1 medical university, lviv, ukraine; 2 regional children hospital, lviv, ukraine adrenal tumors are the rare cause of arterial hypertension in children. prolonged period of diagnosis determines inadequate treatment of arterial hypertension with the development of lifetreating complications. in this study summarized results of treatment 39 children with adrenal tumors during 20-years period. there were 34 (87.2%) children with benign adrenal tumors, including 30 children with hormonally active (cushing's syndrome -13, virilizing tumor -3, feminizing tumor -2, pheochromocytoma -9, conn syndrome -1) and 4 -with non-functioning tumors. five (12.8%) patients had malignant adrenal tumors: 3 patients had adrenocortical cancer, one -malignant corticochromoblastoma, and one -chromoandroblastoma. adrenalectomy was performed in 37 (84.9%) patients. conventional lumbotomy was applied in 30 (81.8%) patients and in 7 (18.2%) -laparoscopic adrenalectomy. laparoscopic removing of adrenal tumors was performed in 3 children with pheochromocytoma, in 3 -with adrenal cyst and in 1 -with myelolipoma. the retroperitoneal approach was applied in 5 patients and transperitoneal -in 2 patients. there was no conversion during laparoscopic adrenalectomy. two (5.1%) children with corticochromoblastoma and chromoandroblastoma did not operated due to the disseminated metastasis at the time of admission and they died at the follow-up. all patients who underwent adrenalectomy were discharged with normal blood pressure and no patient required adjuvant therapy. surgery remains the method of choice in the management of children with adrenal tumors and laparoscopic adrenalectomy may applied in patients independently of tumors' functional activity. damage to the ureter by an iatrogenic injury is a devastating occurrence. congenital ureteral anomalies present an increased risk of injury. case report. we report a 3-month-old baby that underwent right nephrectomy for a multicystic kidney. the left ureter had been damaged as an interlaced left and right ureter had not been recognized. repair of the damaged ureter had failed and the left kidney had to be drained by a j-stent through the retroperitoneal space into the bladder. the child was transferred to our institution at 6 months. results. we interposed the appendix from the left renal pelvis to the bladder. a double j stent was inserted for four weeks. two years afterwards this child is thriving normally without urinary tract infections and normal renal function. discussion. ureteral trauma if not timely recognized can lead to urosepsis and renal failure. several techniques have been described for the replacement of long ureteral segments: the use of urinary tract tissue, the psoas-hitch technique, pedicled intestinal segments and the yang-monti technique. the appendix is similar in size and length to the ureter and can be easily implantated with an antireflux technique. electrolyte absorption and mucous production by the appendix are negligible. conclusions. only a few case reports exist in which the appendix is used as a replacement of the left ureter. this case adds to those reports and suggests that ureteral reconstruction using the appendix vermiformis seems a viable technique even when used as a replacement of the left ureter. hypospadia is one of the most common deformities of the uro-genital system. a great diversity of procedures for correction of hypospadias is suggested. at our department we use for correction of the so called ''distal'' hypospadia mainly one method: the y-v glanuloplasty modified mathieu technique after hadidi. we investigated the outcome of 84 patients with distal penile hypospadia regarding to complications, voiding function and cosmetic satisfaction. the mean age is located in between the international recommended correction time of 12-18 month. the mean observation time is 35 months. beside a good cosmetic appearance with an erectly shape and a wide meatus, we found an adequate voiding function. fistulas occurred after failure of wound-healing in two cases. the use of an additional layer of connective tissue between neo-urethra and skin seemed to be beneficial against occurrence of fistulas. in contrast to other urethroplasties, we do not use any stent or catheter in the y-v glanuloplasty modified mathieu technique and the patients void immediately after the surgical procedure through the neo-urethra. the crucial element is, in our opinion, an adequate pain relief during the first two days so that the patient won't get a voiding problem. the mean hospital stay was 3-5 days. all over, we think that the patients benefit from the y-v glanuloplasty modified mathieu technique as for this method we do not use urethral stenting nor any kind of dressing. background. during laparoscopic cholecystectomy (lc) for symptomatic gallstone disease injury of the gallbladder with spillage of stones occurs frequently. subphrenic abscess after lc is a rare complication of this condition and may cause diagnostic dilemmas and delayed treatment. methods. we present a case report of a patient with subprenic abscess formation due to a lost gallstone and a review of the current literature. case. after a stay in india a 49 year old female patient presented with a subprenic abscess formation mimicking a liver abscess and pleural effusion. her medical history implied a hysterectomy for cervical cancer and a lc. the diagnostic and therapeutic management is exactly processed. results. spillage of stones at lc occurs in 0,1-20%. in a systematic review the complication rate of lost gallstones is stated to be 3-12%. a large variety of complications, some with serious morbidity, has been described. only 18 cases of subphrenic abscess have been reported previously. conclusions. every effort should be made to extract lost gallstones at lc laparoscopically. no conversion to an open procedure is necessary because of a low incidence of complication rate. composition of gallstones and bacteriological culture of bile is beneficial for prognosis of possible complications and their treatment. lost stones should be noticed in the operation report and the patient should be informed that in the case of complications the diagnostic and therapeutic way can be easier and performed in a shorter time. conservative treatment has a high failure rate. outcome of laparoscopic incisional hernia repair in immunocompromised patients following liver transplantation background. incisional hernias occur in up to 12% of patients following liver transplantation (ltx). laparoscopic incisional hernia repair (lihr) is well established in immunocompetent patients, and has been increasingly used in transplant patients. we report on our experience with lihr after ltx. methods. in a 48-month period, all patients undergoing lihr after ltx were included in this retrospective study. results are reported as mean ae sd or total number (%). results. fifteen patients (6.7% female; age 59.4 8.01 years) were included. mean time from ltx to lihr was 29.4 28.5 months. hernia location was midline in 9 (60.0%), laterally in 3 (20%) and both in 3 patients (20%). immunosuppression was calcineurin-inhibitor based (tacrolimus 40% / cyclosporine 60%) with a tapered steroid regimen in all patients. hernia repair was technically successful in all cases using a polyester mesh (436.5 148.8 square centimetres) anchored by transmuscular corner sutures and multiple spiral staples. perioperative antibiotic prophylaxis was routinely administered. no complications occurred in the early postoperative course, aside from one subfascial hematoma (6.7%). mean length of stay was 8.1 ae 1.8 days. highest c-reactive protein levels during hospitalization were 7.4 ae 8.4 mg/dl. after a mean follow-up of 19.8 ae 7.7 months, 4 (26.7%) patients developed recurrent hernias, which were repaired in 3 cases (1 open, 2 lihr). conclusions. with the use of perioperative antibiotic prophylaxis, lihr is safe in patients following ltx. no infectious complications occurred, however 27% of our patients developed a recurrent hernia after a mean follow-up of 20 months. added benefit of diagnostic laparoscopy in patients with suspected acute appendicitis methods. we defined a clinical pathway for diagnosis and treatment in patients with suspected acute appendicitis. in this pathway diagnostic laparoscopy is an early step whereas ultrasonography is not part of the diagnostic steps. the aim of this study was to know the positive predictive value for acute appendicitis and experience the outcome of these patients concerning the diagnostic value of a laparoscopy. results. between 1 apr. 2000 and 31 dec. 2008, 897 patients were prospectively recorded. the correct diagnosis was found in 756 (84%) patients. in 141 (16%) patients either the cause of the abdominal pain remained unclear (27 patients; 3%) or a different diagnosis was found (114 patients; 13%). in these 114 patients a list of 16 different diagnoses was found. in ten patients (1.3%) even a malignoma was found. conclusions. our defined pathway for diagnosis and treatment in patients with suspected acute appendicitis allows finding the cause of the abdominal complaints in 97% and in 84% acute appendicitis was confirmed. due to consequent diagnostic laparoscopy a broad list of differential diagnosis was found including malignant tumours in 1.3%. therefore, diagnostic laparoscopy should be an early diagnostic step in patients with suspected acute appendicitis. ergebnisse. der spitalaufenthalt betrug zwischen 2 und 4 tagen (mittelwert: 2,9 tage). in 30,4 % der fälle war kein schmerzmittel notwendig, 45,7 % benötigten schmerzmittel bis zu 5 tage, 23,9 % länger (mittelwert: 3,9 tage). die hauptbeschwerden reduzierten sich bei blutungen von 70,65 % (präoperativ) auf 9,84 % (6 monate postoperativ), bei durch prolaps hervorgerufener verschmutzter unterwäsche von 52,17 % auf 3,28 %. von den bis jetzt nachuntersuchten patientinnen gaben nach 6 monaten 91,8 % eine hohe zufriedenheit und beschwerdefreiheit an. bis jetzt erfolgte eine rezidivoperation, vier weitere wegen erneuten prolaps folgen. mit ausnahme von zwei postoperativ aufgetretenen abszessen mit fistelbildung gab es bislang keine nennenswerten komplikationen. schlussfolgerungen. obwohl langzeitergebnisse noch ausstehen, ist diese methode der hämorridenoperationen als komplikationsarm, sphinkterschonend und somit sehr empfehlenswert zu bewerten. sie zeichnet sich zudem aus durch eine hohe patientinnenzufriedenheit, einen kurzen krankenhausaufenthalt, einen geringen schmerzmittelbedarf und eine rasche reintegration in den alltags-und arbeitsprozess. observational study on grade-dependent treatment for hemorrhoidal diseasea single center experience background. hemorrhoidal disease is one of the most common health disorders in western civilization. the aim of this study was to retrospectively analyze the outcome of grade-dependent treatment of hemorrhoidal disease (i-iv) in a single center. methods. all patients suffering from hemorrhoidal disease referred to our unit between july 2001 and december 2005 were included in this analysis. the patients' medical records were studied in detail. a standardized telephone interview was conducted in all patients who had open hemorrhoidectomy or stapled hemorrhoidopexy. results. a total of 668 patients (284 female, 384 male; mean age 52.2, range 17-94 years) were assessed. conservative treatment was applied in 281 (42.1%) cases, while surgery was performed in 387 patients (57.9%) following a grade-dependent strategy. most common comorbidities were skin tags and simultaneous mucosal prolapse. postoperative complications comprised pain (8.1%), bleeding (9.1%) and fecal incontinence (3.4%). patients undergoing stapled hemorrhoidopexy showed significantly higher recurrence rates than after open hemorrhoidectomy (10% vs. 0%, p ¼ 0.048). urgency was more common in the stapled hemorrhoidopexy group (34.5% vs. 22.2%) and the incidence of anal stricture lower than in the open hemorrhoidectomy group (5.5% vs. 25%). conclusions. grade-dependent treatment of hemorrhoidal disease with respect to the clinical appearance and the extent of prolapse should be standard today. stapled hemorrhoidopexy appears to be an intervention with less postoperative pain and faster recovery than open hemorrhoidectomy, but long-term results include a higher recurrence rate and a higher incidence of fecal urgency and fecal incontinence. background. anal sepsis of cryptoglandular origin might be challenging for patients and surgeons due to recurrences and postoperative fecal incontinence. methods. patients with anal sepsis operated on between january 1st 1994 and december 31st 2000 at the department of general surgery, medical university vienna were retrospectively analyzed in terms of recurrence and postoperative fecal incontinence by chart review and by telephone interview using the vaizey incontinence score. results. operative treatment was given to 222 male and 78 female individuals (74% vs. 26%) with a median age of 40 years (20-83). 173 patients were availabe for follow-up investigation. after a median of 121 months, 55 patients (32%) had no recurrence after a single surgical procedure. a median of 3 operations (2-19) was performed in 118 patients with multiple procedures. in 264 patients (88%), a fistula-in-ano was detected. vaizey score was 0 in patients with single i þ d procedure. in patients with single i þ d plus fistulotomy, mild incontinence was seen in 9% and severe incontinence in 4%. in patients with muliple procedures, mild fecal disturbances were assessed in 19% and severe disturbances in 4%. conclusions. treatment of anal sepsis and fistula-in-ano is associated with a high recurrence rate and a substantial risk of fecal incontinence in this analysis. data suggest that a search for a fistula-in-ano should be performed already at the primary operation. in a case of recurrence, high transsphincteric, suprasphincteric or complex fistula-in-ano a specialized coloproctologist should be involved to avoid damage to the anal sphincter muscle. die hohe und rezidivierende analfistel background. studies have reported excellent healing rates for the treatment of cps with different skin flaps. the cosmetic outcome is less investigated. the aim was to enlighten the body image changes and patients satisfaction after limberg flap. methods. from august 2006 to december 2007 72 consecutive patients, mean age of 26.5 years (ae8.6) with cps underwent excision and closure with limberg flap. at 30 days morbidity and time off work were accessed. late infection, recurrence rate, selfesteem (worst 1, best 10), cosmesis (3, 24) , body image (5, 20), and patients satisfaction (0, 10) at one year were analyzed prospectively. results. no major complications such as flap necrosis occurred. minor complications occurred in 19%, including superficial infection and partial suture dehiscence. mean time off work was 24.1 days (ae18.8). in 5 patients (7%) occurred a late local infection in the first 12 months. the recurrence rate was 2.8% after one year. self-esteem before and after the operation remained almost unchanged (before 8.0, after 7.6) (p ¼ 0.27). mean cosmesis and body image were acceptable, 16.5 (ae4.0) and 18.0 (ae2.6) respectively. 92% estimated their change of body image as acceptable (>14). 76% of the patients were highly satisfied with the procedure (>6) and mean patients satisfaction was 7.5 (ae2.5). conclusions. morbidity and recurrence rate after treatment with limberg flap is low and compares favorably to other treatments. change of body image and cosmesis are acceptable in most patients, but are a problem in some and should be addressed preoperatively. background. there are more than a hundred different techniques to operate on a rectal prolapse. for old and frail patients the perineal approach is preferred. the rehn-delorme procedure and the altemeier rectosigmoidektomy are currently the most popular perineal procedures. both are demanding and time consuming. the aim was to develop a procedure, which is easy and fast to perform and has a good outcome. methods. internal rectal redundancy has recently been successfully treated with transanal resection using the contour + transtar tm stapler. this technique has been modified to the perineal stapled prolapse resection (psp). the prolapse is completely pulled out and then axially cut open at three o'clock in lithotomy position with a straight stapler. thereafter the prolapse is stepwise resected with the curved contour + transtar tm stapler. at the end of the circular resection the beginning of it is reached again at three o'clock. the staple line falls spontaneously into place and is oversewed with 8 absorbable monofil sutures to strengthen it and ensure hemostasis. results. in a feasibility study has been shown, that the psp procedure is easy to perform, safe and doesn't need a lot of time [1] . we present the correct operation technique. important steps are emphasized and pitfalls explained. conclusions. the video shows the psp procedure and how it's done. clinical investigations proved the feasibility of the transtar procedure. it is a safe and effective treatment for patients with ods. the aim of the presented study is to access the functional outcome after the procedure and its impact on quality of life. methods. female patients presenting with ods were enrolled prospectively for the transtar procedure. intussuseption and/or anterior rectocele were confirmed by clinical investigation and by mrdefecography. functional outcome was measured by ods-score, severity of symptoms score (sss) and wexner score at 3 months postoperatively. quality of life was accessed by the cleveland clinical obstipation score (ccos), the gastrointestinal quality of life index (glqi), the american society of colorectal surgeons score (ascrs) and the sf-36 6 months postoperatively. results. between january 2007 and november 2008 45 consecutive patients, median age 64 years (range 20-87) were included. eleven patients complained preoperatively fecal incontinence. functional scores improved significantly: ods decreased from a median of 14 (4-18) to 5 (2-10) after 6 weeks (p < 0.0001) and 4 (2-10) after 3 months. sss decreased form 14 (6-21) to 3 (0-19) after 6 weeks (p < 0.0001) and 3 (0-7) after 3 months. median wexner score was 0 pre-and postoperatively (range 0-10 and 0-8). at 6 weeks 10 patients presented fecal incontinence and 12 patients complained of fecal urgency. at 3 months 4 patients were still incontinent, two received a succesfully sacral neuromodulation. fecal urgency persisted in 4 patients. quality of life improved significantly: ccos (p < 0.00006), glqi (p < 0.003) and sf-36 (p < 0.008). in ascrs self-esteem improved (p < 0.003), the other aspects didn't change significantly. conclusions. the transtar procedure is an effective treatment for patients with severe ods and improves quality of life significantly. however, some patients suffer of incontinence and fecal urgency in the first weeks after the operation. in most of these the symptoms dissolve without further operative treatment. background. in gastric cancer, peritoneal carcinomatosis is a frequent finding and associated with a poor prognosis. the enhanced expression of phosphoglycerate-kinase-1 (pgk1) and its signalling targets chemokine-receptor-4 (cxcr4) and its ligand cxcl12 seem to play a crucial role in enabling diffuse primary gastric tumours to develop peritoneal dissemination. methods. comparative microarray analysis was conducted investigating human specimens from consecutive gastric cancer patients with peritoneal carcinomatosis versus gastric cancer samples without peritoneal carcinomatosis. subsequently selected target genes were evaluated using quantitative real-time polymerase chain reaction (qrt-pcr). further ,,genesilencing'' (sirna-knock-down) concerning cxcr4 and pgk1 and transfection (overexoression) of pgk1 was performed. the obtained results were further confirmed using western-blot, facs-analysis and invasion assays. results. the microarray analysis revealed a significant overexpression of pgk1, cxcr4 and its ligand cxcl12 in specimens from gastric cancer patients with peritoneal carcinomatosis. further ,,genesilencing'' of pgk1 and cxcr4 showed a significant co-regulation on expression and protein level in vitro. the transfection (overexoression) of pgk1 also revealed a significant upregulation of its signalling targets cxcr4 and its ligand cxcl12 on expression and protein level. in addition the transfected cells showed a 50-fold distinctive property in the invasion assay compared to cancer cells without pgk1 overexpression. conclusions. overexpression of pgk1 and its signalling targets cxcr4 and cxcl12 in peritoneal disseminated primary gastric carcinomas sustainable indicate a promising regulationpathway promoting peritoneal dissemination. this data may provide new prognostic markers and/or potential therapeutic targets to prevent migration of gastric carcinoma cells into the peritoneum generating peritoneal carcinomatosis. here, we investigated the expression of dkk-3 protein in gastric cancer and its potential value as a prognostic marker. methods. dkk-3 expression was analyzed by immunohistochemistry in 136 tumour samples and was correlated with microvessel density (mvd), tumor stage and grading, as well as the clinical outcome of the patients. results. dkk-3 expression was detected in endothelial cells of the tumour vessels but not in normal vessels in 129/136 (94.9%) and in tumor cells in 85/136 (62.5%) respectively. mvd was high and low in 57 (42.9%) and 76 (57.1%) specimens. in tumor cells, overexpression of dkk-3 was found in 41 (30.1%) and was correlated significantly to pt-stage (p < 0.05) and uicc stage (p < 0.05). survival analysis regarding dkk-3 expression in tumor endothelial cells showed that dkk-3 is an independent predictor of disease-free survival (p < 0.05) conclusions. dkk-3 expression in tumor vessels of patients with gastric cancer identifies a population of patients with relatively favorable prognosis. methodik. bei nach den international anerkannten kriterien (igclc -international gastric cancer linkage konsortium) gegebenen verdacht auf ein hereditäres diffuses magenkarzinomsyndrom wurde eine e-cadherin-mutationsbestimmung (cdh1) erstgradiger familienmitglieder durchgeführt. acht von neun untersuchten familienmitgliedern waren positiv für die cdh1 keimbahnmutation. in allen fällen konnte präoperativ das vorliegen eines karzinoms durch eine ausgiebige endoskopie ausgeschlossen werden. fünf träger der mutation entschlossen sich nach einer ausführlichen, chirurgischen beratung zur prophylaktischen operation. in einem fall wurde präoperativ eine mukosektomie einer ektopen magenschleimhaut im oesophagus durchgeführt. ergebnisse. aufgrund der indikationsstellung mit verzicht auf eine lymphadenektomie entlang der gefäße des trunkus coeliacus wurde die gastrektomie mit lk-dissektion d-1 in laparoskopische technik durchgefü hrt. in systemischer aufarbeitung des ganzen magens konnte in allen fällen ein intramukosales monozellulär verschleimendes magenkarzinom nachgewiesen werden. eine lymphknoten-oder gefäßinvasion konnte nicht nachgewiesen werden. es konnten zwischen 14 bis 28 lymphknoten untersucht werden (im durchschnitt 22 untersuchte lk). schlussfolgerungen. die gastrektomie in laparoskopischer technik ist ein onkologisch korrektes, sicheres und für diese indikation gutes verfahren. wir sahen bis auf eine wundheilungsstörung an einer trockareinstichstelle keine chirurgischen probleme. alle vorteile der laparoskopischen technik konnten umgesetzt werden. background. incisional trauma is major factor contributing to perioperative morbidity and mortality. cosmesis and body awareness also play an increasing role in patients' acceptance of cardiac surgery. during the last years it was our effort to increase the percentage of minimally invasive operations. methods. cardiac surgical operations of the last 3 years were evaluated regarding conventional (median sternotomy) approach and minithoracotomy or total endoscopic surgery. indications for either procedure were identified. results indications were extended to complex valvular, bivalvular and other combined procedures. major contraindications are severe calcifications and aortic dilatation. tecab could be performed for single and double vessel revascularisation as well as hybrid procedures including pci. conclusions. an increasing percentage of cardiac surgical operations can be performed minimally invasive. however this evolution has still to be more widespread especially in the era of interventional valve procedures. the heartport access for increased patient mobility and satisfaction t. fleck, w. wisser median sternotomy is the gold standard in cardiac surgery, as it enables superior exposure for nearly all surgical procedures. however, there are disadvantages, namely the risk of sternal dehiscence with or without infection with an incidence of 3-5% and the immobility of the patient for the healing process of the bone. since 2005 a total of 50 patients (mean age 56 years) underwent cardiac surgery through a mini right thoracotomy in the 4 icr without rib spreading. the underlying pathology was mvd n ¼ 38, tvd n ¼ 11, asd n ¼ 5, myxoma n ¼ 1 (mean es 5.3). cpb was established through a 2.5 cm incision in the right groin. the aorta was occluded with an endoballon. exposure was satisfactory in all patients. especially in redo procedures (n ¼ 6) the necessity of dissection of the entire heart was avoided and this reduced the amount of bleeding and the known risks of redo sternotomy. the indented surgical procedures could be preformed in all patients: mvr n ¼ 38, asd closure n ¼ 5, myxoma resection n ¼ 1, tvr n ¼ 11. complication and mortality rate was 4.3%. mean icu stay was 2 days, hospital stay 5 days. with the avoidance of a median sternotomy, the mobility of the patient postoperatively is increased. furthermore the patients appreciated the cosmetic aspect and the possibility to return to daily activity, sports and job in a shorter time. from a surgical point of view, the same technical standard of surgical performance can be maintained through this approach after the surgeon becomes accustomed to the instruments and exposure. background. atrial septal defects (asd) apply for 5-10% of congenital heart disease. the standard surgical approach used to be median sternotomy. we reviewed our experience on the development of a minimally invasive surgical technique and its introduction into clinical routine. methods. we reviewed all patients who underwent surgical asd-closure at our institution from 01/2001-12/2008. analysis was performed concerning asd-pathology, patient characteristics and operative variables. results. from 01/2001 through 12/2008, 171 patients underwent isolated asd-closure. in that period, 27 operations were performed in a minimally invasive technique through a right-sided minithoracotomy and remote-access perfusion through the right groin. in 2001, the development of the technique started using the heartport-perfusion system (5 pts). thereafter we started to use chitwood-clamp. 16 defects were closed by direct suture, 10 by patch closure. during the last three years, the number of patients undergoing minimally invasive surgery, is rising steadily (2006: 4 pts, 2007: 6 pts, 2008: 6 pts) . in 2007, the first sinus venosus defect was successfully treated in that fashion. furthermore, the technique is also applicable for treatment of dislocated interventional occluding devices (2 pts). the mean age of the patients was 40.7 years (11-71 yrs), mean weight was 70.2 kg (55-98 kg). mean aortic crossclamp time was 53.7 min. there was no operative death and no patient had to be converted to median sternotomy. conclusions. minimally invasive asd-closure via a right-sided minithoracotomy has successfully been introduced into clinical routine at our institution. with growing experience even sinus venosus defects and dislocated occluding devices can be operated on safely and with good results. background. the levitronix centrimag device is a centrifugal pump designed for short term support in cardiogenic shock. it is implantable both in adults and also in pediatric pts. we report our experiences using the centrimag device in all forms of cardiogenic shock (postoperative lcos, myocarditis, pre-htx, right heart failure post htx, acute myocardial infarction) in the adult population. methods. we have implanted in a four-year period the centrimag device in 227 adult pts (mean age 59.5 years). the cumulative experience was 6 years. the device was implanted in 158 cases as femoro-femoral bypass, in the 66 cases intraoperatively by cannulating the left atrium and the ascending aorta and in the remaining three cases by cannulating the right atrium and the pulmonary artery (right heart failure after htx). the mean support time was 9.8 days (1-183 days) . results. fifty-eight patients (26%) could be successfully weaned from device. in 43 cases (19%) the centrimag was used as a bridge to a more sophisticated device (cardiowest 16, dura-heart 3, ventrassist 2, thoratec 16, heartmate ii 3, incor 1 and novacor 2). at least 117 pts. (51.5%) died on device, mainly caused by multiorgan failure. three pts underwent htx, 5 pts are on support at this moment. conclusions. the levitronix centrimag seems to be safe and effective in the treatment of nearly all kinds of cardiogenic shock achieving rapid and sufficient circulatory support and ventricular unloading. bridge-to-recovery, bridge-to-bridge or bridge-totransplant are possible. grundlagen. das ziel dieser prospektiven studie war es, perioperative klinische parameter zwischen der minimal extrakorporalen zirkulation (mecc) und der konventionellen extrakorporalen zirkulation zu vergleichen. methodik. unter verwendung des mecc-systems wurde eine koronare revaskularisation bei 144 randomisierten patienten (mittleres alter 69,5 jahre (43-86 jahre), (gruppe i) durchgeführt. in der vergleichs-gruppe ii (n ¼ 144, mittleres alter 69,10 jahre (45-86 jahre) wurden die patienten mit einer konventionellen extrakorporalen zirkulation perfundiert. die einstammerkrankungen, sowie die notfalleingriffe wurden exkludiert. ergebnisse. in den beiden gruppen zeigte sich kein signifikanter unterschied der mittleren aortenklemmzeit (65 ae 19,2 min vs 70 ae 11,5 min), der mittleren extrakorporalen perfusionszeit (111 ae 28,1 min vs 115 ae 27,4 min), der mittleren anzahl der distalen anastomosen sowie in der anzahl der verwendeten erythrozythenkonzentrate. es kam zu keiner 30 tage mortalität. ebenso zeigten die nach 6, 24 und 48 stunden postoperativ gemessenen laborparameter (troponin t, kreatinin, ck, ck-mb, thrombozyten, leukozyten, hämoglobin, hämatokrit) keinen statistisch signifikanten unterschied. die gemessene laktatwerte zeigten im gegensatz dazu (intraoperativ 0,84 vs 1,39, 6 stunden postoperativ 1,12 vs 1,61, 24 stunden postoperativ 1,41 vs 1,61) statistisch signifikante vorteile für das mecc-system. die aufenthaltsdauer auf der intensivstation war in der gruppe i signifikant kürzer als in der gruppe ii (2,21 tage vs 2,60 tage). schlussfolgerungen. zusätzlich zu der aus der literatur bekannten reduktion von entzündungsmediatoren finden sich signifikante hinweise einer optimierten perfusion. der mecc-patient ist postoperativ aktiver, leider fehlt dazu ein objektiver parameter. training surgeons to establish a robotically assisted totally endoscopic coronary surgery program background. since ist introduction totally endoscopic coronary surgery (tecab) was standardized during the past decade. additionally younger surgeons needed training in robotically assisted cardiac surgery. methods. in 44 out of 239 robotically assisted (da vinci tm telemanipulator, intuitive inc., sunnyvale, ca) coronary operations parts of the procedure were performed by 2 surgeons trained in endoscopic cardiac surgery. the distinct parts of the tecab procedure were: lima/rima preparation, lipectomy, pericardiotomy, ima to lad anastomotic suturing. conclusions. we conclude that the tecab procedure can well be trained in a stepwise approach. the establishment of a robotically assisted coronary surgery program is feasible after adequate training. obesity has no effect on operative times and perioperative outcome of patients -undergoing totally endoscopic coronary artery bypass surgery background. more and more patients undergoing coronary artery bypass grafting (cabg) are overweight. even though in these patients there is no clear evidence of increased perioperative mortality, it has been shown that they suffer from superficial-and deep wound healing problems more often than normal-weight patients. therefore, avoiding sternotomy in obese patients by using an endoscopic technique could be a promising approach. robotic technology enables totally endoscopic coronary artery bypass grafting (tecab) procedures. we investigated whether the intraoperative times or perioperative outcome after tecab-procedure are negatively affected by obesity. methods. patients (n ¼ 127, 101 male, 26 female, median age 59 (31-77) years), undergoing arrested-heart tecab procedure were enrolled. the median bmi in this patient cohort was 26(19-38). in detail, 27 patients were normalweight(bmi 25 kg/m 2 ), 67 patients were overweight(bmi:25.1-30 kg/m 2 ), 29 patients were obese (bmi 30.1-33.9 kg/m 2 ) and 4 patients were morbidly obese (bmi ! 34 kg/m 2 ). the heartport/cardiovations tm (n ¼ 44) or the estech-rap tm system (n ¼ 83) were used for arrested heart tecab procedure with remote access perfusion and aortic-endoocclusion. results. there was no correlation between bmi (1) left internal-mammary-artery-takedown-time(r ¼ 0.2; p ¼ n.s.), (2) lipectomy and pericardiotomy-time (r ¼ 0.042, p ¼ n.s.) (3) total operative-time (r ¼ à 0.83: p ¼ n.s.), (4) cardiopulmonary-bypass-time (r ¼ à 0.12; p ¼ n.s.), (5) aortic-endoocclusiontime (r ¼ à 0.55; p ¼ n.s.), (6) mechanical-ventilation-time (r ¼ 0.001, p ¼ n.s.) (7) length of icustay (r¼ 0.4; p ¼ n.s.), (8) length of hospital-stay (r ¼ 0.103; p ¼ n.s.). or (9) occurrence of intraand/ or postoperative adverse events. conclusions. in overweight, obese but also morbidly obese patients the tecab procedure did not increase operative times or the rate of intra-or postoperative complications. this patient groups, therefore, benefits from this less traumatic version of coronary surgery. background. selective decontamination of the digestive tract is still not widely accepted, although it reduces the incidence of nosocomial infections. in a previous retrospective study we have shown a clear reduction of nosocomial infections in patients with esophageal anastomoses receiving selective decontamination. we thus started to apply selective decontamination routinely for esophageal anastomoses. here we report the outcome of a case series of 107 patients receiving this treatment and compared them to historic controls. methods. from 2002, patients with esophageal anastomosis were prospectively registered. patients received polymyxin, tobramyxin, vancomycin (ptv) and mycostatine four times a day orally on average for 8 days starting on the day before surgery. outcome was compared to a historic control treated before 2002 without selective decontamination (n ¼ 69), which did not differ significantly in age, gender, bmi and asa score. results. a total of 107 patients received selective decontamination. the average age was 62.4 years and asa score was 2. the pulmonary infection rate was 6.5% (95% ci: 3.2-12.9%) clearly lower than in the historic control (24.6%, 95% ci: 16.0-35.0%, p ¼ 0.0012). anastomotic leakage rate was 6.5% (95% ci: 3.2-12.9%) compared to 13.0% (95% ci: 7.0-23.0%, p ¼ 0.18) without selective decontamination. the perioperative mortality was only 1.9% (95% ci:0.5-6.6%) compared to 12% (6.0-21.3%, p ¼ 0.015) previously. conclusions. selective decontamination of the digestive tract significantly reduces perioperative morbidity and mortality in patients with esophageal anastomosis. anastomotic leakage rate could be reduced resulting in a much lower mortality. we suggest that selective decontamination to be used routinely in patients having an esophageal anastomosis. marienhospital, ruhr-universität bochum, herne, germany die therapie des ö sophaguskarzinoms ist inzwischen zu ca. 80 % multimodal ausgerichtet. jedoch ist immer noch unklar welche modalität zur welcher zeit und in welcher reihenfolge angewandt werden soll. beim lokal fortgeschrittenen plattenephithelkarzinom des ö sophagus wird generell die neoadjuvante radio-chemotherapie als standard angesehen, teilweise wird diese nach einer so-genannten induktionstherapie durchgeführt. dieses vorgehen ist bis heute jedoch in keiner randomisierten abschließend studie bewiesen, auch wenn eine kürzlich publizierte meta-analyse einen marginalen vorteil der multimodalen therapie beschreibt. nach kürzlich publizierten daten (bedenne et al., asco, 2008 , stahl et al. jco 2009 ) scheint der vorteil der resektion sich vor allem auf die patienten zu beschränken, die auf die multimodale therapie nicht oder nur unzureichend ansprechen. anders verhält es sich bei den adenokarzinomen des distalen ö sophagus. nach drei randomisierten studien, die mehrheitlich barrett karzinome einschlossen, ist die neoadjuvante chemotherapie bei lokal fortgeschrittenen adenokarzinomen als internationaler standard angesehen. neuere studien untersuchen derzeit den einfluss der präoperativen radio-chemotherapie auch bei adenokarzinomen des distalen ö sophagus sowohl auf das rezidiv-freie als auch auf das langzeitüberleben nach resektion. nach ersten daten schient die resektion nicht mit einer erhöhten morbidität oder letalität einherzugehen. im vortrag werden die aktuellen studien und der derzeitige therapiestandard der multimodalen therapie bei karzinomen des ö sophagus dargestellt. prognose bedeutend verbessert und in zunehmender häufigkeit ist auch eine kurative therapie möglich. besondere fortschritte gab es in der medizinisch onkologischen therapie, wodurch mittlerweile mediane ü berlebensraten von über 2 jahren erreicht werden können. die chirurgische therapie ist bedeutend sicherer geworden, erlaubt große resektionen auch bei chemotherapeutisch vorbehandelten patienten mit geringer morbidität und schließlich wurde das therapeutische armamentarium durch interventionelle radiologische, nuklearmedizinische und strahlentherapeutische möglichkeiten erweitert. deshalb background. lipocalin-2 (lcn-2, ngal) was recently shown to be highly expressed in various human cancers and increased protein levels were associated with worse survival of patients with breast, gastric or oesophageal cancer. the main focus of this work was to analyze the possible implication of lcn-2 upregulation in colon cancer development. methods. expression of lcn-2 was analyzed in various colorectal carcinoma cell lines, paired colorectal carcinoma tissues and normal mucosas by western blot. lcn-2 immunostaining was performed in 213 colorectal carcinoma resection specimens (intensity score 0-3) and correlated with clinical parameters. colorectal carcinoma cell lines were treated with various concentrations of recombinant lcn-2 protein and monitored for growth and survival. results. western blot analysis of colorectal carcinoma cell lines and tissues clearly demonstrated lcn-2 overexpression in carcinomas compared with normal mucosas in all colorectal carcinoma tissue pairs analysed. immunostaining revealed lcn-2 overexpression in 199 (93.4%) of colorectal carcinoma tissues. intense immunoreactivity was significantly correlated with tumor grading (p < 0.041). cancer samples of the right hemicolon showed significantly higher lcn-2 expression decreasing in the left hemicolon and the rectum (p < 0.001). addition of various concentrations of recombinant human lcn-2 protein to colorectal carcinoma cell lines did not have any influence on cell growth and survival in vitro. conclusions. our data provide evidence that lcn-2 expression is upregulated with tumor progression. the correlation of lcn-2 expression with localisation in the colon gives molecular biological evidence for distinguishing subsites of colorectal cancer. targeting lcn-2 might be a new therapeutic strategy in colorectal carcinoma. qualitätskontrolle der primären rektumkarzinom -chirurgie in einem nicht selektionierten, konsekutiven patientengut an unserer klinik wurden in zehn jahren 153 patienten neoadjuvant radiochemotherapiert (5 wochen) und anschließend mittles tme radikal operiert. die 10-j-ü r betrug 60%. von 10 synchron metastasierten patienten, welche nach therapie des primums metastasektomiert wurden, entwickelten 80 % ein tumorrezidiv, allerdings wesentlich früher als die primär nichtmetastasierten patienten. die hälfte der synchron metastasierten patienten mit tumorrezidiv konnten kurativ re-operiert werden, nur ein patient blieb tumorfrei. aufgrund der schlechten prognose wird in den letzten jahren -analog zum kolonkarzinom -beim synchron metastasierten rektumkarzinom zunehmend eine ä nderung der behandlungsstrategie diskutiert. die vorstellung, dass eine systemische erkrankung eine systemische behandlung benötigt, wird dadurch bekräftigt, dass eine sekundäre resektabilität von marginal operablen/inoperablen lebermetastasen in bis zu 40 % gegeben ist und auch patienten mit operablen metastasen durch die neoadjuvante chemotherapie einen ü berlebensvorteil aufweisen. zudem haben wir erfahrungen mit patienten, welche ,,liver first'' therapiert wurden und im falle eines ,,response'' auch das primum eine regression zeigte. sollte somit beim metastasierten rektumkarzinom auf die scheinbar ,,optimale'' neoadjuvante lokaltherapie zugunsten einer systemischen chemotherapie und einer ,,liver first'' taktik verzichtet werden? ist im falle eines ,,response'' auch die chemotherapie in der lage, eine ausreichende lokalkontrolle zu gewährleisten? können wir patienten selektionieren, welche unter systemischer therapie progredient sind, und diesen die neoadjuvante lokaltherapie und operation ersparen? bis dato bleibt die behandlungsstrategie beim synchron metastasierten rektumkarzinom kontrovers. ergebnisse. insgesamt entwickelten 33 % der patienten ein tumorrezidiv, während 67 % rezidivfrei blieben (10-jahres-krankheitsfreie-ü berlebensrate: 63 %). die in der nachsorge diagnostizierten asymptomatischen rezidive traten bis 8 jahre nach primärbehandlung auf; nahezu die hälfte (22/48; 46 %) dieser patienten konnte in kurativer absicht re-operiert werden. davon blieben 41 % (9/22) innerhalb der nachbeobachtung rezidivfrei. in einer multivariaten analyse zeigten das uicc-stadium (p ¼ 0.000) und das grading (p < 0.05) eine signifikante korrelation zum rezidivauftreten. die 5-und 10-jahres-ü berlebensraten dieses kollektivs waren 74 % bzw. 60 %. in bezug auf das ü berleben war in der multivariaten analyse nur das ypt-stadium (p < 0.01) ein signifikanter parameter. schlussfolgerungen. bei patienten mit lokal fortgeschrittenem rektumkarzinom können gute onkologische langzeitergebnisse erzielt werden. dazu ist neben der multimodalen therapie auch ein intensives nachsorgeprogramm notwendig, welches asymptomatische rezidive frühzeitig erkennen lässt und kurative re-operationen ermöglicht. background. transcatheter based aortic valve replacement (avr) is a promising procedure to reduce operative risk especially in old patients with significant comorbidities. we report the initial series of transapical and transfemoral-avr including 3 years follow up. methods. access was either antegrade through a anterolateral thoracotomy with direct puncture of the apex or retrograde through the femoral artery. after initial balloon-valvuloplasty the balloon-mounted crimped bioprosthesis was introduced and positioned under fluoroscopic and echo control. since march 2006 fifty-nine patients underwent transapical-avr and 34 patients underwent transfemoral-avr. mean age was 82 ae 5.5 years, the logistic euroscore predicted risk for mortality was 26.3 ae 15.7%. results. implantation was performed on beating heart with a period of rapid pacing for deployment of the valve. cardiopulmonary bypass was used only in the initial 7 patients. in the transapical group 4 patients had to be converted to conventional avr because of malpositioning. thirty days mortality for transapical was 13%, in the transfemoral group 5%. echocardiography showed excellent gradients (pmax 19.3 ae 12 mmhg) at discharge and 3 years after implantation. small paravalvular leaks without hemodynamic importance were observed in 27 patients (45%) in the transapical group and in all transfemoral patients. conclusions. transcatheter avr with the sapien-edwards bioprosthesis can be performed in high risk patients successfully. complications may be attributed to the high risk profile of the elderly patients and the learning curve of this new procedure. the valve exhibits excellent hemodynamics up to 3 years. however, longer-term valve performance and durability needs to be monitored. drei herzchirurgische notfälle nach 50 percutanen aortenklappenimplantationen background. in symptomatic patients with severe aortic stenosis (as), operative aortic valve replacement is the treatment of choice. however, not only symptomatic as becomes more prevalent in elderly patients but also comorbidities that increase the risk for operative valve replacement. therefore, percutaneous aortic valve replacement (pavr) might be an alternative therapy for high-risk patients. methods. in our institution, 53 patients (19 male, 34 female; mean age 80 ae 6 years) with symptomatic severe as and a logistic euroscore > 20% underwent pavr between may 2007 and january 2009. the procedure was performed in the catheterization laboratory via a bifemoral percutaneous approach under local anesthesia and analgesic sedation without surgical cut-down and hemodynamic support. after balloon valvuloplasty, the self-expanding corevalve prosthesis (diameter 26 mm, n ¼ 31; 29 mm, n ¼ 21) was implanted using the current 18 french delivery catheter system. results. acute procedural success rate was 98%. device implantation resulted in a significant increase of calculated aortic valve area (0.5 ae 0.1 vs. 1.4 ae 0.2 cm 2 , p < 0.0001). postprocedural aortic regurgitation was trivial or mild in 46 patients and moderate in seven patients. permanent pacemaker implantation was necessary in four patients due to complete atrioventricular block. major complications were myocardial infarction (n ¼ 1), stroke (n ¼ 2) and pericardial tamponade (n ¼ 2). actually, allcause mortality rate is 11.3% at 30 days and 22.6% after one-year follow-up. conclusions. pavr with the self-expanding corevalve bioprosthesis is an emerging alternative treatment for high-risk patients with symptomatic severe as. complication rate is acceptable and mortality rate lower than predicted by risk calculation. results. median length of stay was 12 days in conventional open repair encomprising 5 days on the intensive care unit. median length of stay in stent-graft placement was 5 days. the day rate on the normal ward is estimated at 1.180.00d and the day rate on the intensive care unit is estimated at 3.014.00d . median number of stent-grafts used was 1.7. despite substantial higher procedural costs of stent-graft placement (32.320.98d versus 19.534.12d ), total cost performance was lower (38.220.98d versus 50.764.12d ) resulting in a cost difference of 12.543.14d . as a consequence, the cost advantage of stent-graft placement turned out to be 24.7%. conclusions. despite substantially higher procedural costs as compared to conventional open repair of descending thoracic aortic aneurysms, endovascular stent-graft placement is cost efficient mainly due to the preventable intensive care stay and the shorter in-hospital stay. background. supra-aortic transpositions followed by endovascular stent graft placement are now an established tool in the treatment of aortic arch pathologies. results remain to be determined. methods. from 1996 through 2008, 73 patients (median age, 71 years) presented with aortic arch pathology (aneurysms, n ¼ 42; type b dissections, n ¼ 9; penetrating ulcers, n ¼ 17; traumatic lesions, n ¼ 2; aneurysms based on prior surgery for aortic coarctation, n ¼ 3). strategy for distal arch disease was subclavian-to-carotid transposition (n ¼ 24) or autologous double-vessel transposition through upper hemisternotomy (n ¼ 36). for entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n ¼ 13). endovascular stent graft placement was performed metachronously. results. in-hospital mortality was 6.8% (n ¼ 5). persistent early type i and iii endoleak rate was 9.6%. persistent late type i and iii endoleak rate was 5.5%. overall actuarial survival was 90%, 86%, and 72% at 1, 3, and 5 years. mean follow-up is 37 months (range, 1 to 120). early and late endoleak formation was independently predicted by the number of prostheses. survival was independently predicted by higher logistic euroscore levels. conclusions. results after supra-aortic transpositions followed by stent graft placement for the treatment of aortic arch pathologies are promising. endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. each type of arch rerouting has turned out to be effective. extended application of these combined treatment strategies substantially augments the therapeutic options. grundlagen. im rahmen einer aortendissektion typ a wird bei herkömmlichen operationsmethoden die aorta aszendens und teile des aortenbogens ersetzt, die absteigende aorta bleibt jedoch unbehandelt. das falsche lumen der thorakalen aorta bleibt in bis zu 70% der fälle perfundiert. wir berichten über ein kombiniertes chirurgisches und endovaskuläres verfahren für die behandlung komplexer typ a dissektionen unter verwendung einer hybridprothese. methodik. zwischen 08/05 und 12/08 wurde 6 patienten (44,5 ae 15,5 jahre; 5 männlich, 1 weiblich) mit aortendissektion typ a (3 akut, 3 chronisch) die e-vita open endoluminal stentgraftprothese im kreislaufstillstand in moderater hypothermie mit selektiver antegrader hirnperfusion implantiert. der gestentete teil der prothese wird über den eröffneten aortenbogen in die aorta deszendens vorgeschoben, anschließend wird mit der dacron hälfte der prothese der aortenbogen und die distale aorta aszendens ersetzt. ergebnisse. alle patienten überlebten den eingriff ohne neurologischem defizit. eine computertomographie der thorakalen aorta wurde innerhalb der ersten zwei wochen nach der operation durchgeführt, dann im abstand von 3, 6 und 12 monaten. nach 3 monaten zeigte sich bei 5 von 6 patienten (83,3 %) eine komplette thrombosierung des falschen lumens bis auf höhe des stentgrafts. ein patient mit chronischer typ a dissektion erhielt 5 monate nach dem ersteingriff einen thorakoabdominellen aortenersatz. der durchmesser der aorta deszendens war in der kontrolle nach 12 monaten bei 5 patienten rückläufig. schlussfolgerungen. bei noch geringer fallzahl zeigen die positiven ergebnisse, dass der simultane chirurgische und endovaskuläre zugang für die erweiterte therapie der typ a dissektion eine gute behandlungsmöglichkeit darstellt, ohne das perioperative risiko zu erhöhen. from trunk to trunkstent-graft coverage of the entire thoracic aorta background. aim of this study was to determine safety and practicability of stent-graft placement in patients requiring coverage of the entire descending aorta. methods. from 2005 through 2008, 15 patients (male ¼ 8, mean age 69a) underwent stent-graft placement from brachiocephalic to celiac trunk. all patients underwent rerouting of the supraaortic branches to gain sufficient proximal landing zone. indications for stent-graft placement were aneurysms (n ¼ 9) and penetrating ulcers (n ¼ 6). csf drainage was initiated only in case of neurologic symptoms. in all patients mean blood pressure was kept above 80 mmhg for 96 hours after stent-graft placement. results. arch rerouting and stent-graft placement were performed successfully in all patients. one early type iii endoleak was observed and treated by overstenting. no late endoleaks occured. symptoms of spinal cord malperfusion were observed in 2 patients (13.3%). in one patient paraplegia was seen, resolving after csf drainage (6.7%). another patient developed signs of chronic spinal cord ischemia (6.7%). this patient had undergone replacement of the abdominal aorta 6 years prior to stent-graft placement. in all other patients no signs of spinal cord malperfusion could be detected. conclusions. this study outlines the safety and practicability of the complete coverage of the descending aorta from trunk to trunk. the low number neurologic complications could be explained by aggressive rerouting procedures resulting in sufficient collateral flow from the left subclavian artery and the intended elevation of postoperative blood pressure. csf drainage is not required on a regular basis in these patients. endovascular stent-graft placement in atherosclerotic aneurysms involving the descending aortalong-term results background. to determine long-term durability and need for reinterventions after endovascular stent-graft placement in atherosclerotic aneurysms involving the descending aorta. methods. we performed a prospective follow-up analysis of a consecutive series of patients (n ¼ 100) undergoing endovascular stent-graft placement due to atherosclerotic aneurysms involving the descending aorta between 1996 and 2007. outcome variables included death, occurrence of early and late type i and ii endoleak formation, the rate of reintervention due to early and late endoleak formation and the survival of the patients. median follow-up was 50 (1-120) months. results. in-hospital mortality was 9%, whereas two third of these patients underwent stent-graft placement in the acute setting. assisted primary endoleak rate was 11%. assisted secondary primary rate was 13%. actuarial survival rates at 1, 3 and 5 years were 96%, 86% and 69% respectively. a short proximal landing zone and a high number of implanted stent-grafts were identified as independent predictors of the occurrence of early and late endoleak formation. the occurrence of late endoleak formation appeared to be an independent predictor with regard to survival. conclusions. long-term durability of endovascular stentgraft placement in atherosclerotic aneurysms involving the descending aorta is satisfying and the need for reintervention is acceptably low. an extensive landing zone and a low number of stent-grafts are mandatory for early and late success. background. swedish adjustable gastric banding (sagb) is an effective treatment for morbid obesity. the aim of this study was to assess the efficacy and safety of sagb in older patients aged ! 50 years. methods. between 01/1996 and 01/2006, 134 patients were aged ! 50 years. two groups of patients were analyzed: group 50 (n ¼ 107) patients aged 50-59 years and group 60 (n ¼ 27) patients aged 60-69 years. results. one hundred and thirty-four patients (17.1%) out of 785 entered the study. mean % ewl was 37.5 at 1 year and 48.8 at 7 years, bmi fell from 43.3 to 33.1 at 7 years. in the 134 patients, there were 65 patients with 121 complications (48.5%) and 69 patients with no complication (51.5%). the most common complications were esophagitis, esophageal dilation, port problems and pouch dilation. in group 50, mean % ewl was 38.4 at 1 year and 54.9 at 7 years. bmi fell from 42.9 to 33.1 at 7 years. in the 107 patients, there were 55 patients with 99 complications (51%) and a reoperation rate of 35.5%. in group 60, mean % ewl was 32.8 at 1 year and 41.2 at 7 years. bmi fell from 44.3 to 34 at 7 years. in the 27 patients, there were ten patients with 22 complications (37%) and a reoperation rate of 29.6%. there was no mortality. conclusions. at 7-year follow-up, for older patients, sagb is an effective bariatric procedure for achieving weight loss. nevertheless, based on the high complication and reoperation rate, a gastric band-specific patient selection will be necessary. background. study aim was to retrospectively assess whether patients were able to maintain their weight after gastric band removal or deflation and how they felt about gastric banding. methods. total 41 patients (93% female, mean age 34.1 (sd 10.5) years) were included in this study: patients who had their band removed/deflated without further surgical intervention (group 1, n ¼ 26), those who later underwent a second bariatric operation (group 2, n ¼ 15). we evaluated weight gain after band removal/during the time between band removal and second bariatric operation. results. of our patients 31 (76%) suffered a complication (18 late pouch dilatations, six band infections, five band migrations, two band leaks) requiring band removal. ten patients wanted their band removed (six) or emptied (four). mean time after band removal, when patients had neither a band nor a second bariatric operation, was 2.84 (sd 2.3) years. five (12.2%) patients maintained their weight, four of whom experienced a learning effect, all others gained weight. mean bmi for both groups after the period without a band was 36.7 (sd 8.0) kg/m 2 (vs. 29.4 (sd 7.0) at removal) and excess weight loss (ewl) was 33.2 (sd 39.2) % (vs. 69.8 (sd 32.9) % at removal). of our patients 73% stated they would not agree to gastric banding again. according to baros, long-term outcome of patients following band removal was a ''failure'' in 66% of patients. conclusions. long-term outcome following band removal is unsatisfactory in many patients. nevertheless, a minority of patients was able to maintain its weight loss. background. in bariatric surgery studies show that a better quality of life is correlated to increased weight loss. the question remained which type of surgery is superior in quality of life independently from weight loss. methods. in our study we recruited 250 bariatric patients, operated between 2003 and 2005 (196 women/54 men) at the mean age of 39.85 years (sd ¼ 11.65) and with a mean bmi of 44.78 kg/m 2 (sd ¼ 7.04). patients eligible for investigation were 78 patients with laparoscopic gastric bypass and 172 patients with adjustable gastric banding (agb). the patients were reviewed in the interval of 3, 6, 12, 24, 36, 48 and 63 months after operation. the bariatric analysis and reporting outcome system (baros) was used for the quality of life investigation which has been international established for obesity surgery outcomes. results. with a minimum of 3 years follow-up our patients showed a mean bmi of 28.8 kg/m 2 (sd ¼ 6.65). the statistical analysis (linear regression) showed a positive correlation between quality of life and weight loss, depending on operation method. additionally we used a partial correlation to rule out the influence of weight loss and remarked a significant result (r ¼ 0.234, p ¼ 0.000). with a t-test it could be demonstrated, that patients with a laparoscopic gastric bypass observed a significant different quality of life, than patients with an agb independent from weight loss (t (123) ¼ 3.477, p ¼ 0.001). conclusions. independently of the amount of weight loss, quality of life is different between surgical procedures. wir haben versucht, mit einem standardisierten modifizierten v.a.c. + -system und einer physikalisch-technischen analyse die anwendungstechnik zu optimieren und die suffizienzrate zu erhöhen. methodik. im rahmen einer versuchsanordnung wurden die physikalischen grundlagen untersucht background. the application of the abdominal vacuum assisted closure (v.a.c.) system has become a promising treatment strategy in critical ill patients with abdominal sepsis requiring surgical therapy and open abdomen. however, fascial retraction and high rates of incomplete fascial closure up to 70 % with subsequent high incidence of incisional hernia have been reported in literature. the aim of this study was to analyse the application of the abdominal v.a.c. therapy in patients with abdominal sepsis regarding rate of fascial closure and v.a.c. associated morbidity. methods. the study retrospectively includes all patients with abdominal sepsis requring emergency laparotomy with application of abdominal v.a.c. therapy between november 2006 and november 2008 at our department (80 patients, 51 male/29 female; median age 65, range 35 to 87). results. the lenght of v.a.c. therapy ranged from 1 to 13 days (median 4 days) with 0 to 5 v.a.c. changes (median 1). complete fascial closure of the abdomen was feasible in 60 patients (75%), partial closure with mesh graft implantation (vicryl, goretex) in 7 patients (8,75%), no closure in 3 patients (3.75%), and 10 patients died with the v.a.c. system in situ (12.5%). 13 incisional site infections and 8 intraabdominal abscesses were observed postoperatively, v.a.c. associated morbidity was 7.5% with 4 enterocutaneous fistulas and 2 bleeding complications. conclusions. the study confirms the feasibility of abdominal v.a.c. therapy in patients with severe abdominal sepsis guaranteeing a high rate of fascial closure and low morbidity. methods. retrospectively reviewed patient records between august 2003 and december 2008 12 patients with moderate or high volume output gi fistulae, where conventional treatment had failed to prevent skin excoriaton, had been included. they underwent the fistula-v.a.c. + procedure using the v.a.c. system sized from standard sponge supplies, topical negative pressure (at most 75 mmhg) and ostomy appliances. the v.a.c. + dressing was changed every two days. results. the v.a.c. system was found to be highly effective in controlling the fistula effluent and in promoting healing of excoriated skin. complete healing of fistula was achieved in five patients, intestinal reanastomosis in five patients, palliative care using fistula ostomy appliance in two of twelve patients. conclusions. the modified fistula v.a.c. + system can be an effective and economically viable method of containing fistula effluent and protecting the skin of patients with enterocutaneous fistulae. the v.a.c. + system may also actually promote spontaneous healing. background. surgical site infection (ssi) rates for colorectal surgery range between 5 and 30%. we performed a surveillance to determine our rate and to identify risk factors. methods. in 2008 cases with colon surgery according to the nnis·colo definition or a rectal resection were collected prospectively. ssi was diagnosed following cdc guidelines. followup lasted for 30 days, discharged patients were contacted by phone. results. one hundred and twenty-nine colon and 75 rectal surgeries were surveyed. ssi rate for colon surgery was 17.8% 8%) . ssi rate after properly timed antibiotic prophylaxis (30-60 min pre·op) was 9.5% (5.1-17.0%). otherwise the rate was significantly increased: > 60 min pre·op ¼ 27.9% (18.6-45.1%), < 30 min pre·op ¼ 16.0% (8.3-28.5%) or no prophylaxis ¼ 43. 8% (23.1-66.8%) (mainly due to antibiotic treatment before surgery). higher bmi or body surface were linked with a higher infection rate (bmi < 24 ¼ 7.3%, ! 24 ¼ 21.5%, p ¼ 0.02, body surface < 1.7 m 2 ¼ 7.2%, ! 1.7 m 2 21.6%, p ¼ 0.01). conclusions. our colo ssi rate is higher than reported by nnis (5.4%), but similar to rates obtained under study conditions. since data contribution to nnis is voluntary, a strong bias cannot be excluded. incorrect timing of antibiotic prophylaxis was the key risk factor for wound infections. bolus administration of antibiotics could explain the influence of body size on the ssi rate. patients with a big body size have a lower plasma concentration resulting in higher infection rates. in summary strict adherence to proper timing of antibiotic administration can drastically reduce colorectal ssi rates. first experience about treatment of chronic leg ulcers using ducest (dual cell stimulation) therapy t. payrits, s. viragos, a. ernst, g. klein, f. längle background. ulcus cruris describes a complex medical condition which affects the quality of life of patients considerably. this report refers first results about the treatment of 7 patients with chronic leg ulcers with varied underlying causes. aim. the aim of this study is to achieve granulation tissue by using endogenous growth factors and improving wound perfusion, where other methods failed. the ducest therapy associates the application of prf (platelet rich fibrin) with targeted stimulation of the vagal nerv to encourage peripheral blood flow by use of p-stim. methods. prf combines autologous fibrin sealant and platelets. this biomatrix protects endogenous growth factors against proteolytic degradation and thereby preserves their biological activity. we draw 120 ml blood from the patient to gain 6 ml prf solution. we apply the prf-biomatrix with a spraypen provided by vivostat. for patients with ulcus cruris who have an impaired blood flow in the wound, we use p-stim to improve circulation in the limbs. the p-stim is a miniaturized device designed to administer auriculo point stimulation treatment over several days. the mobility of the patient is a main benefit of this therapy. results. so far we treated 7 patients with refractory ulceras. 6 patients achieved wound healing or a clear improvement of their wound situation. in one patient we could stop the worsening of the ulcer. the lack of woundhealing in that case was due to the non compliance of the patient. conclusions. based on these favorable findings we will evaluate the ducest therapy in a prospective study. background. endo-vacuum assisted treatment (endo-vac) represents a novel approach to treat patients with anastomotic dehiscence following anterior resection for rectal surgery. yet, limited data are available to predict success, compatibility with radio-and/or chemotherapy as well as acceptance by the patients. methods. between september 2007 and june 2008 9 patients suffering from anastomotic leakage after anterior rectal resection (n ¼ 6) or suffering from leakage of rectal stump following hartmann's procedure (n ¼ 3) were treated by endo-vac. we recorded clinical outcome and patient's comfort using a ten point visual analogue scale (vas). results. median time of endo-vac treatment was 3 weeks (range, 2-8). there were no minor or major complications. in 6 (66.6 percent) patients the anastomotic leakage healed successfully. three patients showed no response and needed further surgical intervention. the lack of success was due to complexity of leakages, which comprised either more than 270 degree of the circumference or consisted of 2 distant fistulas. formation of granulation tissue was unaffected by chemotherapy. for the question ''alteration in daily life activity'' a median score of 5 (range, 1-9) was found. measuring ''pain sensation'' during end-vac treatment patients scored a median of 3 (range, 0-6). conclusions. endo-vac treatment can be recommended as an alternative approach to treat pelvic sepsis following anastomotic dehiscence or rectal stump insufficiency. extended leakages should be treated by different approaches having little probability of successful healing but can lead to discomfort for the patient. radiochemotherapy does not cause a problem for application of the endo-vac. background. carcinoid tumors of the vermiform appendix are reported to be a rare occasion and to contribute to classical ''carcinoid syndrome'' only in the case of distant spread. however, these tumors may present clinical signs even in absence of metastases. methods. one hundred thirthy one appendix carcinoids were identified out of more than 500,000 histological specimen, i.e. in 0.5% of all appendectomies. six (4.6%) were found at colonic resection for caecal carcinoma and angiodysplastic syndrome. all patients were operated for the the clinical signs of acute or chronic appendicitis. all carcinoid tumors were revised retrospectively for their medical history. results. 52/131 (39.6%) cases were found in combination with acute inflammation of the appendix, but 79/131 (60.4%) did not show pathological findings except the endocrine tumor. almost all had hormones of the midgut group as serotonin, nse and chromogranin a in immunochemistry, only one case expressed acth most tumors were located in the tip (76.8%), only 10% infiltrated the mesenteriolum or penetrated the serosa. when the endocrine parameters (serotonin. chrom ogranin a) were determined preoperatively in a group of 127 cases, we failed to establish elevated serum levels in the presence of an carcinoid tumor. conclusions. only fourty per cent of appendix carcinoids present in combination with acute inflammation and are ''incidental findings'' in appendectomy. sixty per cent present with typical signs of appendicits but without any histological proof of inflammation. so the endocrine tumor causes clinical symptomes per se besides carcinoid syndrome. background. net of the appendix makes a part of 17% of all gastrointestinal net. they mostly appear in younger people and major part is benign, because of little diameter and leak of hormon production. if diameter is about 2 centimetres or above, patients are running a significant risk to produce distant metastasis, generally without a carcinoid syndrome. the recently discussed entity is the goblet cell carcinoid (gcc), whose existence is to accentuate, because of the necessity to treat them like an adenocarcinoma. methods. from 1988 to 2008 we have done 4936 appendectomies. 0.3 percent or 16 patients had a net of the appendix. mean age was 41 years, 10 men in proportion to 6 women. most part (n ¼ 9) had surgery because of acute appendicitis. only five patients described a long period of pain with cramps and diarrhoe. most part (n ¼ 12) of net was located at the tip of the appendix with a diameter range from 2 to 18 mm. results. net was never diagnosed intraoperatively, although 50% of appendectomies have been done by specialists in surgery. in two cases right hemicolectomy was done primary because of an ileus, in four cases it was done secondary, belonging to tumor size, patients age and gcc. only one patient showed metastatic disease, when having done a second look. all net's immunehistochemically showed an expression of chromogranin a and synaptophysin. conclusions. although diagnose of net was not known when doing appendectomy, prognosis of patients outcome was not influenced in a negative way. why have neuroendocrine tumors (net) of the gut such a bad prognosis? nets in the gut mostly present multifocal disease with predominance of terminal ileum and coecum. diameter of the net mostly is above 2 centimetres, and tumor tissue already infiltrates muscularis mucosae, with or without lymph node metastasis. belonging to the desmoplastic reaction, obstruction of intestine is not rather seen. 30-40% of all net's of the gut are diagnosed by doing surgery because of an ileus. 15-20% have liver metastasis with carcinoid syndrome. in a period from 1988 till 2008 we operated 20 patients because of guts net. half of them were operated electively within a few days; the others had an acute operation within a few hours in case of ileus. median age was similar with about 68 years. all operations have been done by specialists. in none of the cases diagnose was felt preoperatively. histological results of planned operations all showed well differentiated carcinomas with rate of distant metastasis of 50%, lymph node metastasis of 70%, contrary to acute operations, which showed bad differentiated carcinomas in 50% with rate of distant metastasis and lymph node metastasis of 80%. according to the enet 2006 classification mean part of tumors belonged to stage iiib and iv. median survival in the first group was 59.5 ae 15.88, in the acute group 30 ae 34.67 months. because of an a priori more radical surgery in planned operations, survival is considerably better. perhaps this point might be the solution in order to improve prognosis of guts net. gastrointestinale frühkarzinome des oberen gi-trakts: eine viszeralmedizinische herausforderung innere medizin 2, hsk-kliniken, wiesbaden, germany die endoskopische therapie von prämalignen und malignen läsionen im oberen gastrointestinaltrakt hat in den letzten jahren zunehmend an bedeutung gewonnen. dabei war und ist die technische weiterentwicklung im bereich der diagnostik (einsatz einer hochauflösenden videoendoskopie unter einbeziehung einer virtuellen oder realen chromoendoskopie) die integrale voraussetzung, um eine detektion von frü hen neoplastischen veränderungen zu ermöglichen. ebenso stehen dem endoskopiker therapeutisch diverse neue verfahren zur verfügung (resektionsmesser, neue ablationstechniken z.b. halo-ablation), die eine invasive und sichere endoskopische therapie ermöglichen. in einem kürzlich von unserer arbeitsgruppe veröffentlichten 5-jahres-follow-up von 349 patienten mit einer hochgradigen neoplasie im barrettösophagus bzw. einem barrettfrühkarzinom konnten wir eine erfolgreiche therapie in über 96 % der patienten dokumentieren. bezüglich des plattenepithelfrühkarzinoms des ö sophagus wurden 2007 aus 3 arbeitsgruppen 5-jahres-ü berlebensdaten publiziert; hier zeigte sich ein 5-jahresüberleben von 58 % in der lyoner gruppe vs. 77 % der wiesbadener patienten vs. 79 % in einem japanischen kollektiv. eine weitere arbeit aus japan, in der das technische vorgehen der endoskopische therapie (esd vs. er) evaluiert wurde, konnte in 99 % der patienten ein 3-jahres-ü berleben dokumentieren. die in den letzten 3 jahren publizierten langzeitdaten von patienten mit t1-tumoren der speiseröhre und des magens beweisen, dass eine endoskopische therapie in kurativer intention bei einhaltung definierter histologischer kriterien die therapie der wahl ist. zusätzlich können die arbeiten belegen, dass es sich hierbei um ein sicheres und komplikationsarmes therapieverfahren handelt, dass entsprechend mit einer niedrigen morbidität und mortalität verknüpft ist. while the use of breast conserving surgery increased during the last century due to strong scientific data regarding oncologic safety, only little has been done to improve the real goal of breast conservation, cosmetic outcome. oncoplastic surgery is the next important development to fulfill the goal of breast conservation. however, only few scientific outstanding original manuscripts are available. this talk gives you an overview about scientific data, future perspectives and possible borders. cariatide study: evaluation of the effect of an educational approach on compliance and adherence to adjuvant aromatase inhibitor therapy for postmenopausal women with hormone sensitive breast cancer the efficacy of ai on reducing breast cancer recurrence, but also aspects of health economy, is bound to the adherence of regular and long-term intake of the medication. aim. the cariatide study evaluates the influence of supporting educational material on compliance and retention time under ai therapy in hormone receptor positive breast cancer patients. furthermore, the study will try to explore which patients -and for what reason -fail to be compliant, and how long it takes until they quit ai therapy. study design. cariatide is an international, randomized, multicentre observational study that will include approx. 2600 patients from more than 200 centers in 18 countries. patients will be randomized to either standard adjuvant ai therapy or to standard ai therapy plus additional educational material, which will provide information about attributes of breast cancer, the risks and benefits of endocrine therapy, the risk of relapse and management of long-term endocrine treatment and its side effects. the material includes questionnaires to objectify patient's conception of the disease and its treatment. conclusions. randomization is ongoing and will be finalized by march 2009; so far, 68 patients have been included in austria. the study will help to identify patients susceptible to compliance failure, to understand the personal reasons of compliance or non-adherence and offering possibilities to improve communication and the design of information material. grundlagen. das 70-genexpressionsprofil (mammaprint ?? ) ist als unabhängiger prognostischer marker beim lymphknotennegativen und -positiven mammakarzinom etabliert. der prädiktive wert für das ansprechen auf zusätzliche chemotherapie gegenüber hormonaler therapie alleine wird sowohl im adjuvanten als auch im neoadjuvanten setting präsentiert. methodik. 1637 tumoren aus 7 studien mit bekannten tumorcharakteristika und therapiedaten wurden unterteilt in niedriges oder hohes risiko entsprechend dem mammaprint profil. die mediane nachbeobachtungszeit war 7,1 jahre. der zusatznutzen adjuvanter chemotherapie (cmf oder anthrazykline ae taxan-basiert) wurde mittels gepoolter analyse für metastasenfreies (ddfs) und krankheitsspezifisches ü berleben (bcss) berechnet. zusätlich wurde die pathologische komplett-remissionsrate (pcr) bei 167 patientinnen nach neoadjuvanter chemotherapie analysiert. ergebnisse. in der adjuvanten analyse wurden mittels genexpressionsprofil 47 % der patientinnen in niedrigrisiko und 53 % in hochrisiko unterteilt. 349 frauen wurden mit hormontherapie alleine behandelt und 226 zusätzlich mit chemotherapie. in der hochrisiko-gruppe zeigte sich ein beträchtlicher zusatznutzen durch chemotherapie: ddfs hazard ratio (hr) 0,28 (0,14-0,56), p < 0,01 und bcss hr 0,17 (0,06-0,47), p < 0,01. bei multivariater analyse mit bekannten klinisch-pathologischen prognostischen faktoren waren die ergebnisse konstant. demgegenüber zeigte die niedrigrisiko-gruppe keinen signifikanten vorteil zusätzlicher chemotherapie gegenüber hormontherapie alleine: ddfs p ¼ 0,962 und bcss p ¼ 0,472. im neoadjuvanten setting zeigte sich eine pcr-rate von 20 % (29/144) für die hochrisiko-gruppe, während bei niedrigrisiko-patientinnen keine pcr (0/23) beobachtet wurde. schlussfolgerungen. das 70-genexpressionsprofil mamma-print ist nicht nur ein unabhängiger prognostischer marker; zusätzlich zeigt sich auch der prädiktive wert zusätzlicher chemotherapie sowohl im adjuvanten als auch im neoadjuvanten setting. während die hochrisiko-gruppe signifikant von einer chemotherapie zu profitieren scheint, kann ein niedrigrisiko-profil patientinnen selektieren, die mit hormonaler therapie ausreichend behandelt erscheinen. grundlagen. angiosarkome sind mit nur 1-2 % aller weichteilsarkome sehr seltene maligne tumore. ein zunehmendes problem stellen die sekundären angiosarkome nach brusterhaltender therapie eines mammakarzinoms und postoperativer bestrahlung dar. der erfolg einer chemotherapie ist zum heutigen zeitpunkt noch nicht abzuschätzen, nur eine frühzeitige mastektomie erscheint die prognose zu beeinflussen. wir berichten über zwei patientinnen, welche nach brusterhaltender therapie eines mammakarzinoms ein sekundäres angiosarkom der brust entwickelten. kasuistik. im ersten fall wurde eine 74 jährige frau zur beurteilung von neu aufgetretenen vaskulären läsionen an der brust nach quadrantenresektion und wächterlymphknotenbiopsie eines mammakarzinoms im stadium i und postoperativer radiatio zugewiesen. die stanzbiopsie der läsion ergab ein gering differenziertes angiosarkom. im präoperativen staging konnten keine fernmetastasen festgestellt werden. die patientin wurde mastektomiert und erhält adjuvant eine anthrazyklin-monotherapie. bei einer weiteren 77 jährigen patientin wurde im rahmen der onkologischen nachsorge nach brusterhaltender therapie und adjuvanter radiatio eines mammakarzinoms im stadium i ein weit fortgeschrittenes angiosarkom diagnostiziert. der tumor wuchs teilweise invasiv in die tiefe bis zum perikard und bis zur pleura. diese patientin erhielt noch 2 zyklen eines liposomalen doxorubicins, verstarb aber einen monat später. schlussfolgerungen. das sekundäre angiosarkom der brust nach brusterhaltender therapie wird immer häufiger beobachtet, da heute mammakarzinome zunehmend brusterhaltend operiert werden. diese ehemals seltene erkrankung sollte nicht unterschätzt werden. früherkennung ist die einzige möglichkeit, die ü berlebensraten dieser erkrankung zu verbessern. zur anwendung der intraoperativen sonographie bei der chirurgischen behandlung des mammakarzinoms grundlagen. mammakarzinome werden in den letzten jahren zunehmend in einem frühen stadium mit nicht oder unsicher tastbaren tumoren entdeckt. im ultraschall sind bis zu 95 % aller mammakarzinome gut sichtbar und abgrenzbar. mit hilfe der intraoperativen anwendung des ultraschalls durch den chirurgen selbst können der patienten die unangenehme präoperative nadelmarkierung erspart werden, zudem bietet sie neben vielen organisatorischen vorteilen auch eine wertvolle orientierung bei der tumorektomie. methodik. zwischen juli 2001 und dezember 2008 wurden am landeskrankenhaus feldkirch 861 mammakarzinome operativ behandelt. in 617 fällen (72 %) erfolgte primär eine tumorektomie, intraoperativ kam der ultraschall bei 434 oder 70 % aller dieser eingriffe zur anwendung. in 192 fällen (44 %) war der tumor nicht tastbar, bei den restlichen unsicher. intraoperativ erfolgte die begutachtung der schnittränder allein makroskopisch durch den pathologen, nicht jedoch histologisch. ergebnisse. nicht oder unsicher tastbare tumore konnten in allen bis auf 2 fälle sicher aufgefunden werden. metachrone nachresektionen waren 68 mal (16 %) erforderlich. davon fanden sich in 31 fällen (46 %) im nachresektat keine hinweise mehr für malignes gewebe, in 17 fällen (25 %) in-situ-formationen, 20 mal (29 %) in-situ-zusammen mit invasiven karzinomstrukturen. bei den nicht auffindbaren tumoren handelte es sich um t1a und t1b-tumore, die bereits durch die stanzbiopsie schon großteils entfernt waren. schlussfolgerungen. der intraoperative ultraschall in der hand des chirurgen hat sich zum auffinden von nicht tastbaren tumoren und zur orientierung bei der tumorektomie bewährt. die ausdehnung des tumorgeschehens wird jedoch relativ häufig unterschätzt, insbesondere was die in-situ-anteile betrifft. da das brusterhaltende konzept im mittelpunkt der chirurgischen versorgung des mammakarzinoms steht, stellt die postoperative bestrahlung einen goldstandard dar. strahlungsinduzierte tumore als folge dieser therapie sind eine absolute rarität. wir möchten 2 patientinnen präsentieren. beim ersten fall handelt es sich um eine 59 jährige patientin, die vor 15 jahren wegen eines invasiv duktalen mammacarzinoms nach einer brusterhaltenden operation einer bestrahlung zugeführt wurde. vor 4 monaten wurde eine derbe struktur im bereich der op narbe entfernt. die histologie ergibt ein angiosarkom. nach abklärung wurde diese patientin umgehend einer chirurgischen therapie zugeführt. es erfolgte eine ablatio der betroffenen brust. etwas aufwendiger gestaltet sich der 2. fall. auch hier wurde eine 67 jährige patientin vor 15 jahren wegen eines invasiv duktalen mammacarzinom einer brusterhaltenden operation mit anschließender radiatio unterzogen. vor 10 monaten kam es zum auftreten eines knotens in der axilla der operierten brust. man dachte primär an ein lokalrezidiv und entfernte dies. die histologie ergab ein malignes fibröses histiozytom. die resektion erfolgte damals nicht im gesunden. innerhalb weniger monate kam es zu einem neuerlichen rezidiv. dieses nahm nun die axilla, den gesamten m. pectoralis sowie die thoraxwand im bereich der 2. und 3. rippe ein. nun wurde eine resektion unter mitnahme der thoraxwand durchgeführt sowie einer deckung mittel myokutanen lappens. auch wenn diese fälle selten sind, so zeigen sie doch die aggressivität dieser tumorentitäten. daher muss unsere sensibilität dafür feinfühliger werden, um früher zu diagnostizieren und rasch radikal chirurgisch versorgen zu können. darin ist die größte chance zum ü berleben zu sehen. background. after aortic valve replacement using a tissue valve,patients are treated with coumadin for 3 months. if sinus rhythm is evident, therapy is changed to 100 mg of aspirin a day. these are sts, acc/aha and esc guidelines. clopridigel is well known in cardiology after coronary stenting and also in peripheral vascular surgery. methods. in our 2-year retrospective analysis 130 patients were treated with clopridogel after biological valve replacement (bavr). the therapy started on the fifth day after surgery and ended after 3 months. in our group we had also patients with combined surgery like valve replacement plus cabg or carotid surgery. all patients underwent echocardiography before dismission and after 3 months. results. in our study group we could not detect any signs of thrombembolic complications or neurological disorders. we found regular function of the valve prosthesis in all cases. one patient had to be re-operated cause of endocarditis of the prosthesis and died after prolonged ventilation problems. in the control group (230 patients) we found to cases of intracerebral haemorrhagia,which caused to death. both of them were older then 80 years. conclusions. in the last years the clinical use of tissue valves has increased because of longer durability. many post-operative regimes have been described. clopridogel 75 mg a day is an excellent alternative therapy after bilogical valve replacement. we all know the compliance of elder patients after cardiac surgery. so we have an easy treatment for this group of patients. grundlagen. die zunahme des perkutanen aortenklappenersatzes, berechtigt die notwendigkeit zur evaluation der ü berlebensrate nach operativem biologischen aortenklappenersatz mit und ohne zusätzlichen aortokoronaren bypass bei patienten !80 jahren. in dieser studie wurden risikofaktoren, die die 1-jahres mortalität beeinflussen, untersucht. methodik. retrospektiv wurden im zeitraum von jänner 2005 bis dezember 2007 einhundertvierundfü nfzig patienten (102 w, 52 m) mit einem medianen alter von 82,9 ae 2,5 jahren (80-92 jahre), einen biologischen aortenklappenersatz mit (n ¼ 80) oder ohne (n ¼ 74) aortokoronaren bypass unterzogen. mittels chi-square test und mann-whitney test wurden die einflussfaktoren auf die ü berlebensrate untersucht. ergebnisse. das 1-jahres follow-up zeigte eine ü berlebensrate von 81,8 %. nach isoliertem aortenklappenersatz sind 12 patienten (7,8 %) und nach einem kombinationseingriff mit koronarem bypass 16 patienten (10,4 %) verstorben. die präoperativen risikofaktoren in bezug auf die mortalität, wie renale insuffizienz (38,1 % vs. 39,3 %, p ¼ 0,44), copd (49,2 % vs. 60,7 %, p ¼ 0,45), diabetes mellitus ii (27,8 % vs. 32,1 %, p ¼ 0,82), cavk (15,9 % vs. 14,3 %, p ¼ 0,94), pavk (7,9 % vs. 21,4 %, p ¼ 0,07), logistischer euro score (median 12,3 vs. 13,0, p ¼ 0,64) und kombinationseingriff (50,8 % vs. 57,1 %, p ¼ 0,69) wurden evaluiert. die einzelnen risikofaktoren zeigten keinen signifikanten einfluss auf die mortalitätsrate bei patienten ! 80 jahren. schlussfolgerungen. die vorliegenden daten zeigen gute ergebnisse der ü berlebensraten nach operativem aortenklappenersatz bei patienten über 80 jahren in einem beobachtungszeitraum von einem jahr. results. mean baseline hematocrit serum levels were 35.8 ae 6.3%. the mean decrease of hematocrit serum levels was 20.0 ae 21.1% after surgery. the mean decrease of hematocrit serum levels in patients undergoing cabg without cpb was 12.5 ae 5.4% and 12.0 ae 20.0% in patients after isolated valve replacement. one patient died during the operation. four patients died in the postoperative period due to anemia. during followup, being 33 ae 34 months to date, no cardiovascular related adverse event has been observed. conclusions. the decrease of hematocrit serum levels is significantly characterizing the postoperative period of open heart surgery in jehovah's witnesses. in patients undergoing cabg without cpb and in patients undergoing isolated valve replacement, decrease of hematocrit serum levels was lowest. therefore, these techniques should be considered for first choice when appropriate. furthermore, highly normal preoperative hematocrit serum levels and a meticulous surgical technique remain the mainstay of therapy in these patients. grundlagen. routinemäßige intraoperative flussmessung von bypassgrafts dient der qualitätssicherung koronarer revaskularisation. ziel unserer studie war die evaluierung der flussmessung als indikator für langzeitmortalität. methodik. wir messen routinemäßig intraoperativ die flussgeschwindigkeit in bypassgrafts mit dem doppler-flowmeter (cardiomed + ) und speichern die daten in der archimed datenbank. fü r diese studie analysierten wir retrospektiv flussmessungen von 1596 cabg patienten, euroscore, lvef, alter, geschlecht fü r den beobachtungszeitraum 1998-2006. flussmessungen <10 ml/min >125 ml/min wurden exkludiert. wir unterteilten die patienten in 3 gruppen: cabg i (gruppe a), cabg ii (gruppe ii), cabg iii (gruppe iii). mittlerer beobachtunszeitraum war 8,8 jahre. die datenerfassung war vollständig und mit dem ö sterreichischen sterberegister abgeglichen. ergebnisse. gruppe a: mittlerer es 5 (3-10) und mittlere lvef 64 (33-67) hatte eine mittlere flussgeschwindigkeit von 46 ml/ min (20-56), mit arteria mammaria interna (ima) 39 ml/min (28-56), ohne ima 45.5 ml/min (20-55). altersdurchschnitt 72.3 jahre (71.8-74.9). m/w ¼ 58%/42%. langzeitmortalität von gruppe a war 8%. gruppe b: mittlerer es 3 (2-11) und mittlere lvef 61 (43.5-64) hatte eine mittlere flussgeschwindigkeit von 66 ml/min (36-104). altersdurchschnitt 66.4 jahre (65-71.7). m/ w ¼ 83%/17 %. langzeitmortalität von gruppe b war 10.3%. gruppe c: mittlerer es 3 (3-8) und mittlere lvef 62 (52-71.5) hatte eine mittlere flussgeschwindigkeit von 47 ml/min (32-53). altersdurchschnitt 68.4 jahre (68-71.4). m/w ¼ 75%/25%. langzeitmortalität von gruppe c war 4.5%. gesamtlangzeitmortalität war 10.2%. schlussfolgerungen. zwischen den 3 gruppen zeigte sich kein signifikanter unterschied bezü glich es, lvef oder flussgeschwindigkeit und keine signifikante korrelation derer zur mortalität. flussgeschwindigkeit ist kein indikator fü r langzeitmortalität. the radial artery as arterial bypass graft in coronary surgeryreport of an angiographic evaluation with 64-or 320multi-slice computed tomography k. mészáros, a. yates, f. dobaja klinische abteilung für herzchirurgie, graz, austria background. since 2001, the radial artery, additionally to lita and rita, was used as arterial bypass graft material in 160 cabg pts at our institution. the aim of this study is the evaluation of radial artery patency and stenosis with ctangiography. methods. before scanning, all patients were clinically examined and had to fill in a questionnaire concerning their current nyha-and ccs-state, their medication and risk factors. all patients were examined for presence of restrictions resulting from radial artery harvesting in the concerned arm (fine motor skills, sensibility, perfusion etc.). after that, the recent creatinine-level was analyzed in all patients. ct was performed in one group with a new 320-slice ct-scanner and in the other group with a 64-slice scanner, depending on the availability of the scanner. graft patency and stenosis was analyzed in cooperation of cardiac surgeons and radiologists in several reconstruction techniques. results. preliminary data of 18 pts showed 4 radial artery occlusions, in all other cases (77%), radial artery was widely patent after a mean follow up of 50 ae 8 months. conclusions. at present, the examination is still under proceeding. first results showed quite satisfying results in radial artery patency, data from all pts will show statistical significant factors impairing radial artery patency. these data will help us to improve long term patency rate of radial bypass conduits. surgical therapy options in ebstein's anomaly in adults n. reiss, u. schütt, r. körfer, j. gummert background. ebstein's anomaly is a rare congenital malformation of the heart, the basic feature of which is dislocation of the tricuspid valve into the right ventricular cavity. the onset of the symptoms and the diagnosis depend on the severity of the valve dysfunction and the right ventricular function and size. the age at diagnosis ranges from birth to adulthood. we report our experience with surgical treatment of ebstein's anomaly in adults. methods. twenty-three pts (11 male, 12 female, mean age 48 years, 21 to 75 years) underwent surgical treatment in ebstein's anomaly (tricuspid valve repair in various techniques ¼ 11, tricuspid valve replacement ¼ 9 (8 st. jude medical, 1 hancock), and heart transplantation ¼ 3). all pts with mechanical tricuspid valve replacement were introduced in inr-self-management. only four of the 23 patients had previous cardiac surgery. results. twenty pts recovered well after surgery. three pts developed cardiac low-output-syndrome, which was treated by implantation of mechanical circulatory support systems (2 thoratec, 1 cardiowest). one pt could be weaned, one pt was successfully bridged to htx and one pt died on device because of multiorgan failure. after a mean time of 5.5 years 78% of pts were in nyha class i or ii. conclusions. surgical therapy of ebstein's anomaly can be performed with good results in the adult population. when valve repair is not feasible we prefer implantation of mechanical valves with consecutive inr-self management. reduction of sternum instability after cardiac surgery with a newly designed thorax support vest methodik. in einer prospektiv randomisierten studie wurden 455 patienten untersucht, die einem herzchirurgischen eingriff unterzogen wurden. die patienten wurden in zwei gruppen stratifiziert: gruppe a wurde unmittelbar nach der herzoperation mit der posthorax + herzweste (fa. epple, wien) zur stabilisierung des sternums behandelt. gruppe b wurde wie bisher mit einer elastischen bandage versorgt. alle patienten wurden durch einen präoperativen risikoscore evaluiert. zahlreiche operative, laborchemische und klinische daten wurden anlaysiert. ergebnisse. die beiden randomisierten gruppen waren bis auf das vorliegen von diabetes, der in der gruppe a häufiger zu beobachten war, seitens der demographischen, laborchemischen und operativen variablen vergleichbar. 15 (5,4 %) patienten der kontrollgruppe ohne weste entwickelten komplikationen im bereich der sternumwunde, die eine reoperation erforderte. in der gruppe a musste ein patient wegen einer oberflächlichen infektion der sternumwunde reoperiert werden (0,4 %). dies bedeutet einen signifikanten unterschied zwischen den beiden gruppen bezü glich des auftretens von sternumproblemen (exact fisher's test: 0,0069). interessanterweise traten 25 % der komplikationen nach dem spitalsaufenthalt innerhalb von 90 tagen auf. schlussfolgerungen. der gebrauch der posthorax + herzweste zeigt in dieser prospektiv randomisierten studie eine deutliche senkung der komplikationen im bereich des sternum nach herzchirurgischen eingriffen. background. sine the quantity of icd implantations is steadily increasing the numbers of complications is rising too. one of the issues is how to deal with damaged or infected leads. we report our experience with icd and pm lead extraction, possibility and complications. methods. in a retrospective analysis percentage of lead extraction in icd patients, duration of operation and complications were evaluated. complications were defined as death of patient, surgery repair of vessel, sternotomy, blood transfusion, pericard effusion, infection, pneumothorax, embolic event and bleeding with surgical revision. extraction was done either by manual traction or by extraction tool. results background. to evaluate histopathological findings of intraoperatively gained aortic specimens. methods. between january 2003 and october 2008, aortic specimens were evaluated in 142 patients including 76 (54%) thoracic aortic aneurysms, 63 (44%) thoracic aortic dissections as well as 18 (13%) abdominal aortic aneurysms. mean age was 57 ae 18 years. 73 (51%) patients were over 60 years of age and 19 (13%) patients were over 75 years of age. results. medial degeneration was diagnosed in 94 (66%) patients. of these 46 (61%) had thoracic aortic aneurysms, 37 (59%) thoracic aortic dissections and 11 (61%) abdominal aortic aneurysms. severe medial degeneration was found in 24 (17%) patients including 8 (11%) thoracic aortic aneurysms, 9 (14%) thoracic aortic dissections and 7 (39%) abdominal aortic aneurysms (22% of diagnoses in patients <60 years of age vs. 36% of diagnoses in patient over 75 years of age). extensive arteriitis was diagnosed in 28 (20%) patients including 10 (13%) thoracic aortic aneurysms, 8 (13%) thoracic aortic dissections and 10 (56%) abdominal aortic aneurysms. marfan's syndrome was diagnosed in 4 (3%) cases (3 thoracic aortic aneurysms, 1 thoracic aortic dissection). giant cell arteriitis was found in one thoracoabdominal aortic aneurysm. conclusions. medial degeneration was the most frequently observed histopathological diagnosis irrespective of location and clinical presentation. aging is associated with a higher degree of medial degeneration as well as with a higher percentage of inflammatory disease of the aortic wall. österreichische gesellschaft für adipositaschirurgie: chirurgie der adipositas und metabolischer erkrankungen teil 2 448 intermediate weight loss after sleeve gastrectomy s. ali-abdullah, m. schermann, a. landsiedl, s. kriwanek background. the long term effects of sleeve gastrectomy have not been described to the present date. case series report significant reoperation rates due to inadequate weight loss, weight regain, or gastro-esophageal reflux disorder. the aim of our study was to analyze intermediate results 3 to 5 years after sleeve gastrectomy methods and results. twenty-nine patients (24 women, 5 men) were operated between 2003 or 2006. a standardized procedure was applied. calibration of the sleeve was achieved with a 33 f bougie. one complication (staple line leak) occurred and was treated by a reoperation. at follow up the average excess weight loss was 65 percent. six patients (20%) were converted to a gastric bypass in 3 cases due to weight regain and in 2 patients because of reflux problems (2). one patient was reoperated after a first step sleeve gastrectomy. conclusions. in our experience sleeve gastrectomy seems to be an effective weight loss operation but reoperation rates are significantly higher compard to roux y gastric bypass. background. the positive long term effects of bariatric surgery on obesity -associated comorbidities and survival depend on minimal postoperative morbidity and mortality. patient safety has therefore, gained a high level of attention in bariatric surgery in the last years. methods and results. patient safety is increased by a variety of steps including correct selection and preparation of patients, implementation of clinical pathways, application of a universal protocol concerning verification of patients and procedures during a ''time out'' at the beginning of every operation, structured intra-und postoperative communication (briefing, debriefing), high awareness of possible complications, guidelines for the diagnosis and treatment of complications, standardized follow-up, and systematic training of safety agenda during education. conclusions. a systematic approach to ensure optimal patient safety is mandatory to enable late benefits of overweight surgery. grundlagen. in der literatur wird die wahrscheinlichkeit einer bandmigration nach ,,gastric banding'' mit ca. 5% beschrieben. praktisch immer liegt eine bandinfektion zugrunde. fall. wir präsentieren eine 40 jährige patientin mit einem zu 60% in den magen migrierten magenband. die indikation zur endoskopischen entfernung mittels schneidedraht wurde gestellt. hierbei wurde der port entfernt, der schlauch in der freien bauchhöhle versenkt und anschließend das band endoskopisch mittels schneidedraht (ami) durchtrennt. während der versuche, das impaktierte band endoskopisch herauszuziehen, bemerkten wir eine massive auftreibung des abdomens. aufgrund massiv freier luft (perforationsverdacht) wurde die indikation zur laparoskopie gestellt. nach einbringen des optik -trokars imponierten 40 mm hg druck intraabdominell. laparoskopisch kein hinweis auf hohlorganperforation. somit kann man davon ausgehen, dass die luft während der gastroskopie über das zuvor durchtrennte schlauchsystem in den bauchraum gelangte. die dauer der intraabdominellen druckerhöhung betrug 1 stunde. postoperativ kam es zu einem akuten leberversagen mit massivem transaminasenanstieg (got > 11000, gpt > 13000, ldh > 7000) und abnahme der lebersyntheseleistung (inr bis 4,5), wohl infolge der druckbedingten portalen minderperfusion, jedoch ohne enzephalopathie. sonographisch konnte eine adäquate leberperfusion nachgewiesen werden. nach peak am 2. postoperativen tag waren die laborparameter rückläufig bis zur völligen normalisierung. im rahmen einer exakten leberdiagnostik konnte schließlich eine nash diagnostiziert werden. schlussfolgerungen. eine kurzzeitige portale minderperfusion der leber kann bei bereits vorgeschädigtem organ ausreichen, um zu einem funktionsausfall/akuten leberversagen zu führen. um so eine situation in zukunft zu vermeiden, haben wir be-schlossen, das schlauchsystem einzuknoten, bevor es in die freie bauchhöhle versenkt wird. background. due to the rising numbers of obese patients treated by roux-en-y bypass the problem of choledocholithiasis is of increasing importance. for anatomical reasons endoscopic access to the bile tract may prove difficult or impossible. methods and results. four patients who presented symptoms of choldeocholithiasis after roux-en-y bypass were successfully treated by laparoscopy-assisted transgastric ercp. in 2 cases this procedure was combined with a laparoscopic cholecystectomy. there were no complications related to the procedures. conclusions. in our opinion ''reversed-notes'' is a safe and effective way of treating choledocholithiasis in patients after roux-en-y gastric bypass. korrekturoperationen nach erfolgloser adipositaschirurgie p. beckerhinn, s. schöppl, f. hoffer grundlagen. das laparoskopisch implantierte verstellbare magenband (agb) ist der häufigste bariatrische eingriff in europa. langzeit-komplikationen wie band-slippage, pouch-oder ö sophagus-dilatationen und mangelnder gewichtsverlust erfordern neuerliche operationen. die offene vertikale band-verstärkte gastroplastik (vbg) war eine der beliebtesten adipositas-operationen der 1980er und 1990er jahre. klammernahtrupturen führten wegen neuerlicher gewichtszunahme zu reinterventionen. der magenbypass (rygbp) ist der häufigste eingriff nach erfolglosen bariatrischen operationen. wir untersuchten die ergebnisse nach korrektur-operationen. methodik. die daten aller patienten wurden prospektiv erfasst. die postoperativen veränderungen bezü glich gewicht, begleiterkrankungen und lebensqualität wurden untersucht. ergebnisse. zwischen 2004 und 2008 wurden 75 operationen an 64 frauen und 10 männern nach erfolgloser bariatrischer erst-operation durchgefü hrt. das durchschnittsalter betrug zum zeitpunkt der operation 41 jahre, der durchschnittliche bmi 43 kg/m 2 . die erstoperationen waren in 59 fällen ein agb, 9 mal ein vbg, 5 sleeve-gastrektomien und ein magenschrittmacher. dreimal war das band bereits vor der korrekturoperation entfernt worden. 55 revisionseingriffe wurden laparoskopisch begonnen, zweimal musste konvertiert werden. 45 mal wurde nach entfernung des magenbandes in der selben sitzung ein rygbp angelegt. 8 laparoskopische sleeve-gastrektomien wurden durchgefü hrt, dreimal wurde ein neues sagb eingebracht, drei bänder konnten repositioniert werden. revisionspflichtige komplikationen beobachteten wir bei 9 patienten (13 %) (2 blutungen, 2 trokarhernien, 2 innere hernien, 3 andere). keine leckagen oder todesfälle traten in dieser serie auf. schlussfolgerungen. korrektureingriffe nach erfolgloser adipositas-operation haben eine höhere komplikationsrate als erstoperationen. die guten erfolge in bezug auf die gewichtsreduktion, die verbesserung der assoziierten erkrankungen und die lebensqualität rechtfertigen das etwas erhöhte risiko. grundlagen. rund 80.000 ö sterreicherinnen leiden unter einer adipositas permagna (grad iii) mit einem bmi > 40 bei steigender tendenz. entsprechend nimmt die anzahl der bariatrischen operationen und in weiterer folge die notwendigkeit von konturverbessernden operationen zu. das untere bzw. das obere bodylift bieten die möglichkeit einer straffung von abdomen, oberschenkel, hü fte, gesäß und rü cken bzw. von oberem rumpf, der brü ste und der oberarme in einer sitzung. methodik. anhand von fallbeispielen werden das perioperative management und die einzelnen operationsschritte eines unteren bodylifts in der modifizierten technik nach ted lockwood bzw. eines oberen bodylifts in der technik nach al aly vorgestellt. ergebnisse. bei allen patienten konnte eine deutliche verbesserung der körperkontur erreicht werden. schwerwiegende komplikationen (thrombose, pulmonalembolie) traten nicht auf. schlussfolgerungen. das bodylift ermöglicht das gleichzeitige straffen von mehreren körperarealen mit fließenden konturübergängen in einer sitzung. dies führt nicht nur zu einem besseren ästhetischen behandlungsergebnis, als es die isolierten straffungen der einzelnen körperareale könnten. sondern es trägt auch zu einer reduzierung der sozioökonomischen kosten durch verkürzte spitalsaufenthalte und krankenstände im vergleich zu einzelstraffungen bei. durch das standardisierte behandlungskonzept lässt sich eine hohe patientensicherheit und -zufriedenheit erreichen. integriert in ein interdisziplinäres team aus bariatrischen chirurgen, plastischen chirurgen, internisten, psychologen, ernährungsberatern und sportmedizinern steht eine solche operation am schluss einer langen behandlungsreihe und erleichtert dem patient die rückkehr in ein normales leben. background. thyroid autonomy shows functional and/or autonomous nodular growth. should surgical therapy remove affected tissue radically or selectively, with risk of hypothyroidism or risk of functional/nodular recurrence. methods. a prospective study was conducted from 1982 to 1985. pts were stratified in 4 groups. first results in outcome were at 12 months, and after 15 years. late results are available 25 years postoperatively. results. in standard bilateral radical resection, a 100% need for t4-medication is overt, after 15 and 25 years in less than 60%, with a 2% risk of recurrence. in selective nodule removement a lower rate of hypothyroidism with a 10% risk of recurrence is noted. conclusions. aftt should be treated by adequate bilateral resection, selective nodular removement has a high risk of functional and nodular persistance or recurrence. evaluation of parathyroid hormone screening before thyreoidectomy methodik. eine perioperative pth-bestimmung wurde bei 316 konsekutiven normocalcämischen patientinnen durchgeführt. ergebnisse. 31 von 316 patientinnen (9,8 %) wiesen erhöhte pth-spiegel auf (gruppe a), durchschnittlich 84,25 pg/ml (normalbereich 11-67 pg/ml, range 67,5-134), bei 285 patientinnen mit normalem pth (gruppe b) lag der wert bei 36,90 (range 12, 7) . die ca-werte waren in beiden gruppen gleich (gruppe a 2,28 mmol/l, range 2,06-2,54, gruppe b 2,26 mmol/l, range 1,98-2,47). bei den 31 patien-tinnen der gruppe a wurden 53 schilddrü senlappen operiert. 69 (von 106) nebenschilddrü sen konnten exploriert werden, 68 ohne pathologischen befund, einmal wurde ein nebenschilddrü senadenom als ausdruck eines primären hpt gefunden. postoperativ wies die gruppe a einen durchschnittlichen pth-wert von 38,41 pg/ml bei einem durchschnittlichem ca-wert von 2,07 (range 1,77-2,30) auf, gruppe b einen durchschnittlichen pth-wert von 23,06 bei einem durchschnittlichem ca von 2,09 (range 1,73 bis 2,37). schlussfolgerungen. präoperativ erhöhte pth-spiegel bei normocalcämie sind bei jedem zehnten patienten zu finden; dabei liegt nur selten ein normocalcämischer primärer hyperparathyreoidismus vor, sondern ü berwiegend eine reaktive hyperparathyrinämie. ein generelles pth screening kann daher nicht empfohlen werden, es ist aber sinnvoll, wenn das präoperativ obligate calcium im oberen normbereich liegt. eine exploration der nebenschilddrü sen ist im rahmen der geplanten schilddrü senoperation angezeigt, eine ausweitung des eingriffs zur 4-drü senexploration, ,,en principe'' allerdings nicht. reoperation in recurrent goiter is associated with an elevated morbidity predominantly related to recurrent laryngeal nerve palsy between 2 and 20%. a benefit of intraoperative neuromonitoring (ionm) in reoperative surgery focusing on the recurrent laryngeal nerve palsy rate has not been demonstrated clearly. in a retrospective analysis (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) of 430 nerves at risk (nar) in reoperative thyroid surgery at our institution by using neuromonitoring (223 nar) or visual nerve identification (207 nar) transient recurrent laryngeal nerve palsy rate was comparable between both groups (11.6 and 12.1%). however a clear reduction in permanent recurrent laryngeal nerve palsy by using neuromonitoring from 11.2 to 4.4% was evident. after standardizing ionm in our clinic, we started a prospective study to confirm this finding and to define the influence of ionm on transient recurrent laryngeal nerve palsy rate. all reoperations in thyroid diseases by using neuromonitoring (63 nar) from january 2006 were included in this analysis with respect to the transient and permanent recurrent laryngeal nerve paralysis rate. the prospective evaluation of 63 nar in reoperative thyroid surgery shows a decreased transient (6.7%) and permanent (1.7%) recurrent laryngeal nerve palsy rate by using ionm. ionm decreases the transient and permanent recurrent laryngeal nerve palsy rate in reoperative thyroid surgery and should therefore be mandatory. das intraoperative neuromonitoring (ionm) wird bereits in zahlreichen kliniken zur identifikation des n. laryngeus recurrens (nlr) eingesetzt. während der der präparation ist die funktionsüberprüfung des nerven nur punktuell möglich. methodik. eine neu entwickelte vagussonde (v3; fa. inomed. teningen, deutschland) wird vor der präparation der grenzlamelle in der gefäßnervenscheide zwischen der a. carotis und der v. jugularis in engem kontakt zum n. vagus platziert. die schwellenwerte bis zur maximalen signalstärke der ableitungen über die tubuselektrode werden zu beginn und am ende der operation ermittelt. die stimulation erfolgt mit einer frequenz von 3 hz und einer stromstärke unterhalb der maximalen signalantwort. die ergebnisse einer konsekutiven serie von 30 beidseitigen resektionen (n ¼ 60 nerves at risk) werden dargestellt. ergebnisse. der schwellenwert zur supramaximalen stimulation lag zwischen 2,5 und 4 ma. diese werte unterschieden am beginn und am ender der operation um maximal 0,5 ma. passagere recurrensparesen wurden in 2 fällen beobachtet. in beiden fällen fiel während der präparation das signal des kontinuierlichen ionm aus, die schädigungsstelle konnte bei erhaltener kontinuität des nerven exakt lokalisiert werden. in beiden fällen zeigte sich ein stimmbandstillstand unmittelbar postoperativ, eine vollständige wiederherstellung der beweglichkeit nach 2 tagen und 2 wochen. die stimulationsdauer des einzelnen nerven lag intraoperativ zwischen 9 und 23 minuten. schlussfolgerungen. das kontinuierliche ionm scheint störungen der leitfähigkeit des nlr sehr empfindlich anzuzeigen. konsequenzen für die operationstaktik müssen in weiteren anwendungen evaluiert werden. aspekte der sicherheit für den motorischen nerven durch eine elektrische dauerstimulation werden diskutiert. grundlagen. diagnostik und therapie der choledocholithiasis werden in der ä ra der laparoskopischen cholecystektomie unterschiedlich gehandhabt. an unserer abteilung sind indikation und zeitpunkt der ercp/ept abhängig von anamnese, labor, sonographie und routinemäßiger intraoperativer cholangiographie. methodik. zwischen 1. 1.2003 und 31.12.2008 wurden an unserer abteilung 1015 laparoskopische cholecystektomien (83,1 % aller galleneingriffe) durchgeführt. bei 178 dieser patienten (17,5 %) wurde auch eine choledochuspathologie (papillenstenose, choledocholithiasis) diagnostiziert und prae-, intra-oder postoperativ mittels ercp/ept behandelt. schlussfolgerungen. in unserem krankengut hat sich die prae-, intra-und postoperative ercp/ept im rahmen der laparoskopischen cholecystektomie bei cholecysto-und choledocholithiasis sehr bewährt. die routinemäßige intraoperative cholangiographie führte bei 4,4 % der patienten zur diagnose und therapie unerwarteter choledochuskonkremente! randomized controlled trial to assess feasibility and efficacy of co 2 insufflation during colonoscopy in moderate and deep sedated patients background. air insufflation during colonoscopy is the considered standard method in most endoscopic centers. notably, several studies reported reduced abdominal pain during and after colonoscopy by using co 2 insufflation in unsedated as well as light sedated patients. the study was designed to assess the feasibility and efficacy of co 2 during and after colonoscopy in moderate and deep sedated patients. the secondary endpoint was to evaluate whether co 2 is able to enhance patient's compliance to undergo colonic cancer screening. methods. three-hundred consecutive patients allocated for colonoscopy were randomly assigned to either co 2 or air insufflation. patients were titrated to a level of deep sedation by propofol alone or to moderate sedation when combined with midazolam. postinterventional pain and satisfaction were registered by a visual analogue scale (vas). colonic cancer screening compliance was questioned separately. results. co 2 insufflation was used in 157 patients, whereas in 143 patients conventional air was applied during colonoscopy. both groups were comparable in regard to age, sex and bmi. neither major nor minor complications were observed. painsensation was significantly lower in the co 2 group 15 min, 30 min as well as 6 h after colonoscopy (p < 0.01). twelve hours after endoscopy no difference was observed. in contrast, satisfaction level did not show any significant difference. voluntary colonic cancer screening seemed not to be influenced by the type of insufflation gas. conclusions. co 2 insufflation in deep and moderated sedated patients during colonoscopy significantly reduced postinterventional abdominal pain. interestingly, patient's satisfaction was equal in both groups. review: optimal biopsy protocol in gerd patients background. endoscopy in patients with gastroesophageal reflux disease (gerd) aims to assess presence or absence of reflux and cancer risk. remains to be questioned which biopsy protocol adequately meets these requirements. methods. review on a novel histopathology based biopsy protocol. results. in keeping with recent endoscopy and biopsy studies coming from others and our group, gerd causes a specific morphology within the distal esophagus: columnar lined esophagus (cle). cle is interposed between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. the assessment of cle proofs the presence of reflux and includes oxyntocardiac, cardiac mucosa ae intestinal metaplasia (barrett's esophagus). over a sequence involving low-and high-grade dysplasia (intraepithelial neoplasia) intestinal metaplasia may progress towards esophageal adenocarcinoma (0.5 % annual risk). accordingly barrett's esophagus is recognized as having a cancer risk justifying endoscopic surveillance. based on the zonation of the mucosal types within cle (cardiac mucosa ae intestinal metaplasia and oxyntocardiac mucosa favor the proximal and distal segment of cle, respectively), biopsies obtained from the squa-mocolumnar junction have the highest yield for assessment of intestinal metaplasia (proofing reflux and cancer risk). thus the biopsy protocol should include at least 4 quadrant biopsies from the squamocolumnar junction and biopsies obtained at 0.5 cm increments from endoscopically visible tongues or segments of cle. conclusions. four quadrant biopsies obtained from the squamocolumnar junction have the highest yield for the assessment of reflux and cancer risk and should be included into the routine biopsy protocol in gerd patients. variceal bleeding. a danish expirience with the ella-danis stent gastroenheden, hvidovre hospital, hvidovre, denmark background. despite effective treatment modalities such as vasoactive drugs, banding therapy and sclerotherapy, a fraction of the esophageal varices continue to bleed. until recently, the sengstaken-blakemore tube has been the method of choice for those patients. there are, however, numerous disadvantages with the tube. methods. the first seven patients treated with the ella-danis stent (e-ds) in our institution are presented. in all patients other methods to achieve bleeding control had failed. all patients had alcoholic liver cirrhosis. results. in all patients the placement of the e-ds was uncomplicated and variceal bleeding stopped immediately. the e-ds was in place from 5 to 14 days. the removal of the stent was done under endoscopic control by means of an overtube and a biopsy -or rotating forceps. no complications were encountered. conclusions. the e-ds is excellent as rescue therapy in patients with bleeding esophageal varices in cases where other treatments have failed. internet platform for novel gerd management: www.igerd.com background. currently a mixture of symptoms, data obtained from endoscopy, histopathology, function tests and radiology define gastroesophageal reflux disease (gerd). recently an histopathology based concept for gerd diagnosis and management has been introduced (paull-chandrasoma classification). we aimed to create a platform for these novel developments. methods. design of an interactive, easy to use internet-based platform on gerd management for physicians and patients. results. igerd for physicians compares the currently used concept with the novel, histopathology based concept for gerd diagnosis and management. the information is presented using text, images, slide shows and video pod casts (topics: endoscopy videos, biopsy protocol, histopathology, manometry, ph monitoring, impedance technology, treatment algorithms). igerd news summarizes recently published papers on gerd. in addition, igerd provides patient informations. the content is monthly updated by members of the scientific board. igerd can be followed within the internet (www.igerd.com) or the content can be downloaded on a personal computer (pc, mac) and transferred to ipod and iphone, using itunes. with these tools videos and slide shows can be followed using the interactive stop and go function. thus igerd meets the requirements of the present time: actuality, mobility and flexibility. conclusions. igerd represents an interactive internet-based information and e-learning platform for gerd management designed for physicians and patients. temporary placement of self-expanding oesophageal stents as bridging for neoadjuvant therapy background. placement of self-expanding stents is the most commonly applied palliation for dysphagia in non-resectable esophageal or proximal gastric cancer (aeg ii, aeg iii). the aim of this analysis was to assess the efficacy of temporary stent placement for dysphagia relief enabling neo-adjuvant treatment strategies for locally advanced disease. methods. thirty-eight patients scheduled for neo-adjuvant chemo(radio)therapy for locally advanced esophageal cancer (n 29), cardia cancer (aeg ii; n ¼ 8) or subcardial gastric cancer (aeg iii; n ¼ 1) underwent stent placement due to severe dysphagia and weight loss using self expanding plastic stents (n ¼ 13) or covered metal stents (n ¼ 25). results. stent placement led to an instant dysphagia relief in 37 (97%) of the 38 patients. dysphagia scores were reduced from median 3.0 ae 0.5 before stent placement to 0.5 ae 0.8 thereafter. among those 38 patients, 20 (52%) underwent resection of the tumor after completion of the neo-adjuvant therapy, 6 patients (16%) underwent primary resection without receiving chemotherapy and 12 patients (32%) had only chemo(radio)therapy but no surgery. all of them were exclusively nourished orally at least until restaging or surgery. stent related complications were observed as perforation at stent placement (n ¼ 1), mediastinitis (n ¼ 1), tracheo-esophageal fistula (n ¼ 2), bleeding (n ¼ 1) and jejunal perforation caused by a migrated stent (n ¼ 1). four patients underwent placement of a second stent and 1 patient had bouginage due to stent migration (n ¼ 5). conclusions. placement of self-expanding stents is highly effective for instant dysphagia relief enabling adequate oral nutrition during neo-adjuvant therapy, but is limited by a high re-intervention rate. background. anastomotic leak is a potentially life-threatening complication after upper gastrointestinal resektions and bariatric surgery requiring long, cost-intensive and frequently failed treatment. this study has been undertaken to evaluate, whether endoscopic sealing with autologous fibrin glue is an effective treatment for persistent postoperative fistula. methods. between september 2007 and january 2009 16 patients who developed non-healing upper gastrointestinal leaks after oncologic (n ¼ 4) and non-oncologic oesophageal (n ¼ 3), gastric (n ¼ 1) or bariatric (n ¼ 8) surgery were treated by endoscopic vivostat + autologous fibrin sealing. fibrin sealant was applied in patients without systemic or advanced local sings of infection with a sufficient external drainage of leakage site. location was cervical (n ¼ 1), intrathoracic (n ¼ 4) and abdominal (n ¼ 11). previous leak treatment included surgery, external drainage or/and endoscopic stenting. endoscopic sealing occured after a median interval of 31 days (range 1-414) after primary surgery. results. fourteen of sixteen patients had complete healing of the anastomotic leak or fistula after one (7 patients), two (4 patients), tree (2 patients) or five (1 patient) sealing procedures. in six procedures sealing was completed by simultaneous implantation of a stent. in two patients treatment failed and the healing of the abdominal fistula was achieved by following insertion of a stent on the leakage site. conclusions. autologous fibrin sealing could be successfully used for management of persistent upper gastrointestinal fistula and promotes healing. results after different treatment modalities for achalasia background. achalasia is an esophageal functional disorder with esophageal body amotility and impaired lower esophageal sphincter (les) relaxation causing dysphagia, heartburn and regurgitation. methods. retrospective analysis of 105 patients with manometrically proven achalasia (50 females; 48 ae 19 years) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) . management included primary dilatation (stark dilator; n ¼ 41), primary laparoscopic myotomy and anterior fundoplication (n ¼ 11), secondary myotomy following dilatation (n ¼ 8), a mix of botox administration and dilatation (n ¼ 9) and is unknown in 36 patients. results. follow up manometry was available in 12/41, 7/11 and 4/7 patients after dilatation, primary and secondary myotomy, respectively. after dilatation les resting pressure decreased from 27.09 (22.96; 31.22; 95% ci) to 18.95 (15.13; 22.7 conclusions. primary dilatation is recommended for achalasia, primary myotomy may be considered in younger patients. grundlagen. osteosarkome sind die häufigsten primär malignen, nicht hämatopoetischen tumoren des knochens. ihre inzidenz beträgt 0,3-0,5 pro 100.000 einwohner pro jahr. während die ä tiologie primärer osteosarkome unklar ist, können prädisponierende faktoren wie vorangegangene bestrahlung oder paget's disease sekundäre osteosarkome (mit-)verursachen. das ziel der vorliegenden studie waren die berechnung der inzidenz für ö sterreich sowie eine analyse möglicher trends während der letzten 20 jahre. methodik. die autoren führten eine retrospektive populationsbasierende analyse der inzidenz von osteosarkomen in ö sterreich während der letzten 21 jahre grundlagen. präoperatives serum-crp konnte bereits für viele neoplasien als signifikanter prognosefaktor nachgewiesen werden. für das osteosarkom konnte bislang kein serologischer parameter als eindeutiger prädiktor identifiziert werden. ziel dieser studie war es, die prognostische bedeutung des präoperativen serum-crp bei patienten mit osteosarkom zu untersuchen. methodik. aus dem prospektiven wiener geschwulstregister konnten 87 an einem osteosarkom erkrankte patienten (43 frauen und 44 männer mit einem durchschnittsalter von 20,4 jahren) mit vollständiger dokumentation der prä-und postoperativen crp-werte und nach ausschluß einer begleitenden infektion hinsichtlich ihres gesamtüberlebens und ihrer infektionsrate im rahmen einer retrospektiven datenbankanalysenachuntersucht werden. ergebnisse. der präoperative crp-wert betrug durchschnittlich 0,73 mg/dl (0,0 bis 8,5) und korrelierte signifikant mit gesamtüberleben, operationsalter und histologischem subtyp, nicht jedoch mit geschlecht, tumor-grading, ansprechrate auf chemotherapie nach salzer-kuntschik, metastasierungsrate und postoperativer infektionsrate. patienten mit parostalem osteosarkom zeigten signifikant höhere crp-werte als in fällen von klassischen osteosarkomen. in der multivariaten analyse hatten sowohl alter als auch der präoperative crp-wert einen signifikanten einfluß auf das gesamtü berleben. patienten mit präoperativen crp-werten < 1 mg/dl zeigten ein 5-jahresgesamtü berleben von 70 % gegenü ber 43 % fü r patienten mit crp-werten > 1 mg/dl. präoperatives serum-crp war sowohl ohne als auch mit landmark-analyse kein prognosefaktor fü r protheseninfektion bei 60 patienten, die mit tumorporthesen versorgt waren. schlussfolgerungen. präoperatives serum-crp ist ein unabhängiger prädiktor für das gesamtüberleben bei patienten mit osteosarkom. inwiefern es in diesem zusammenhang auch einen prädiktor für das chemotherapieansprechen darstellt und welche prognostische rolle dem protheseninfekt zukommt, erfordert aufgrund der geringen inzidenz größere datenbankanalysen im rahmen von multicenter-studien. methodik. alle gemeldeten fälle von weichteilsarkomen (entsprechend der standard intnernational classification of diseases for oncology, icd-o-3) aus dem krebsregister der statistik austria wurden in unseren datensatz aufgenommen und die altersstandardisierte inzidenz, alters-und geschlechtsverteilung sowie geographische unterschiede analysiert. ergebnisse. insgesamt wurden 5333 fälle registriert, mit einem verhältnis männer/frauen von 0,8. die häufigsten entitäten waren: sarkom (nos) (36 %), leiomyosarkom (24 %), liposarkom (12 %), malignes fibröses histiozytom (mfh, 9 %) und fibrosarkom (5 %). die durchschnittliche altersstandardisierte inzidenzrate lag bei 2,4/100.000/jahr. die analyse der jährlichen sowie über drei jahre gemittelten inzidenzen ergab keinen anstieg der inzidenzraten (jährlicher gradient: à0,0025). im bundesländervergleich zeigten sich regionale unterschiede, mit der höchsten inzidenzrate in tirol (3,2/100.000/jahr). schlussfolgerungen musculoskeletal tumours are rare with an incidence of 3-4 patients/year/1 million. before any imaging procedure clinical assessment has to be carried out. the first pitfall is a delayed diagnosis. bone tumours are often accompanied with early pain and swelling and these symptoms lead the patient and the physician to perform further investigation. for soft tissue sarcomas, especially for the retroperitoneal localisation, first symptoms lack or are noticed after the tumour has achieved an important extension. another important pitfall is the diagnosis ''haematoma''. every tumour has to be considered as malign until malignancy is excluded in further imaging investigation. there is a number of frequently encountered and management pitfalls in the diagnosis of musculoskeletal tumours and limits in the diagnostic possibilities even for an experienced physicians. interpretation of an mri of a suspected neoplasm can be extremely difficult. this reveals how important an interdisciplinary approach, for the example the tumour board, in the diagnosis is. the final diagnostic skill is the adequate biopsy. biopsy is the key step in the diagnosis of musculoskeletal tumours. possible pitfalls are: the suspected lesion missed, the biopsy is done of the reactive zone of the tumour is and the sampling error. inadequate approach and surgical technique of the biopsy can complicate the tumour resection or even make a limb spearing procedure impossible and necessitate amputation to obtain adequate resection margins. this workout reviews various errors in the diagnosis of bone tumours, soft tissue sarcomas and metastasis and points out how important biopsy is. grundlagen. das ö sophaguskarzinom wird häufig in einem stadium festgestellt, in dem lediglich palliation möglich ist. hier liegt der hauptfokus an der wiederherstellung der schluckfunktion, manchmal ist auch die abdichtung einer ösophagotrachealen und/oder -bronchialen fistel notwendig. ziel des eingeladenen vortrages ist es, einen ü berblick über die endoskopischen palliationsmöglichkeiten zu geben. methodik. zusammenfassung publizierter erfahrungen und eigener daten bezüglich der endoskopischen palliation beim inoperablen ö sophaguskarzinom (ablative und lumenerweiternde techniken, ö sophagusstents, peg). ergebnisse. in ausarbeitung (eingeladener vortrag). schlussfolgerungen. bei der mehrzahl der patienten sollte eine weitgehend unabhängige schluckpalliation zu erreichen sein. probleme ergeben sich vor allem bei hohem tumorsitz und bei bestehender ösophagotrachealer oder -bronchialer fistel. implikation gefäßmedizin -gastroenterologie und chirurgie österreichische gesellschaft für gefäßchirurgie, wien, austria die zunehmende spezialisierung und zum teil freiwillige isolation der fachgebiete der medizin, führt dazu, dass die auswirkungen der entwicklungen eines fachgebietes von den übrigen fächern nicht mehr wahrgenommen werden, sodass folgen einer therapie oder prophylaxe nicht richtig erkannt und damit auch nicht richtig behandelt werden. bedauerlicherweise führt die isolierung der fächer auch dazu, therapieempfehlungen ohne rücksichtnahme auf, nicht unmittelbar zugehörende organsysteme, zu erlassen. ö konomische interessen des medizinalhandels fördern mitunter diese entwicklung. in dem referat wird versucht, einerseits auf die komplikationen, die sich in konsequenz moderner interventioneller endovaskulärer techniken oder sogenannter hybridtechniken ergeben können, hinzuweisen. mit diesen komplikationen sind gewöhnlich primär gastroenterologen und viszeralchirurgen konfrontiert. eine verzögerte richtige reaktion auf die ersten symptome verschlechtert die prognose der betroffenen patienten drastisch, daher ist es essenziell, die möglichen unerwünschten folgen endovaskulärer gefäßprothesen oder stents zu kennen. andererseits führen gelegentlich auch gastroenterologische und viszeralchirurgische interventionelle verfahren zu nachhaltigen gefäßchirurgischen problemen. ein gemeinsamer kongress ist die beste gelegenheit fachübergreifend konsensuell diese probleme zu diskutieren. im zweiten teil des referates wird die prophylaktische cardio-vasculäre gerinnungshemmende medikation kritisch betrachtet. der ü berbordenden zahl der publikationen, die sich mit den vorteilen der gerinnungshemmenden medikation befassen, steht nur eine verschwindend kleine zahl jener publikationen gegenü ber, die auf die adverse events, letalen blutungen und gefahren hinweisen, mit denen vor allem die gastroenterologen, chirurgen und gefäßchirurgen konfrontiert sind. kaum eine gastroenterolgische, oder chirurgische abteilung hat jedoch so eine große fallzahl prophylaktischmedikamentös bedingter blutungen, dass eine wissenschaftlich gewichtige arbeit entstehen kann. nach schätzungen gibt es jährlich weltweit 50.000 tote als folge der immer einschneidender in das gerinnungssystem eingreifenden prophylaktischen maßnahmen. wie gehen gastroenterologen und chirurgen mit patienten um, die einer dringenden intervention bedü rfen und wegen eines drug-eluting stents eine kombination dreier gerinnungshemmender medikamente einnehmen mü ssen, da es beim absetzen dieser therapie im ersten jahr nach stentimplantation mit großer wahrscheinlichkeit zu einem sofortverschluss und damit zu einem infarkt background. in 2007, a survey answered by 667 members of the austrian society of surgery revealed severe problems in the working conditions and a serious concern on trainee shortage in surgical disciplines. methods. our results are compared to those of a recent survey in the united states (mailed to all surgeons certified by the american board of surgery in 1988 surgery in , 1992 surgery in , 1996 surgery in , 2000 surgery in and 2004 895 respondents; presented at the american college of surgeons 94th annual clinical congress by kathrin m. troppmann). results. both surveys comprised more than twenty questions each; only selected examples can be given in this abstract. in the u.s. survey, the leading areas requiring improvement in surgeons' quality of life were reimbursement (93%), litigation (92%) and emergency calls (76%). in our survey, a clear majority worked 60-80 h per week or more, in the u.s. the average respondent worked a median of 64 h a week, but regarded 50 h per week as ideal. in our survey, only 18% were satisfied with payment, in the u.s. 26% were content with their reimbursement with respect to the total number of hours worked, but only 16% were satisfied in view of their unpredictable schedule and 14% when considering their responsibility for patients' health and lives. conclusions. although circumstances vary, the results of these two surveys show that many pressing questions are the same and must be tackled in order to overcome the prevailing problems in working conditions and the threat of trainee shortage/resident attrition in surgical disciplines. working models in surgery grundlagen. in den letzten jahren gelang es deutliche fortschritte in der personalisierten krebstherapie zu erzielen. praediktive marker wurden entdeckt die bei manchen patienten ein ansprechen auf eine bestimmte therapie erwarten lassen bzw. anderen patienten eine sinnlose, teure und belastende therapie ersparen. aber auch mit bildgebenden verfahren ist eine beurteilung des therapiansprechens möglich geworden. die auswirkungen dieser entwicklungen auf die onkologische chirurgie werden diskutiert. methodik. die wissenschaftliche literatur und ergebnisse entsprechender studien werden evaluiert und im kontext der eigenen erfahrungen beurteilt ergebnisse. es gibt zahlreiche ansätze um das therapieansprechen für den einzelnen patienten vorherzusagen. dies gilt für vor allem für systemische (neoadjuvante, adjuvante oder palliative) therapien aber auch für die strahlentherapie. die bedeutung für den rein chirurgischen teil des multidisziplinären managements dieser patienten ist allerdings limitiert. dabei sind unterschiedliche entscheidungen zu treffen, für patienten die mit primär unresektablen tumoren behandelt werden und resektabel werden, für patienten die unter einer neoadjuvanten therapie progredient sind und patienten mit bereits primär resektablen tumor die einen guten respose auf eine neoadjuvante therapie zeigen. schlussfolgerungen. die individualisierte onkologische therapie ist von eminenter bedeutung für die behandlung unserer patienten hinsichtlich vermeidung unnotwendiger nebenwirkungen und sinnloser und teurer therapien bzw. für das gesamte onkologischem management. für die chirurgie ergeben sich außer im rahmen der multidisziplinären planung derzeit noch wenig konsequenzen. anforderungen an die chirurgie durch individualisierung der therapie mittels genexpressionsanalyse beim mammakarzinom die chirurgie im zentralen case management bei der behandlung des mammakarzinoms steht neuen und wachsenden anforderungen gegenüber. die individualisierte therapie hat mit bestimmung von hormonrezeptoren und her2/neu-status erst begonnen -in den letzten jahren haben techniken wie genexpressionsanalysen die erstellung einer individuellen und besseren prognose als mit klassischen klinisch-pathologischen parametern ermöglicht. genexpressionsanalysen werden in vielen institutionen bereits routinemäßig durchgefü hrt und wurden zum teil bereits in therapierichtlinien integriert (nccn þ asco-guidelines). die indikationen fü r diese tests werden jetzt zunehmend erweitert: während einerseits auch diejenigen kleinen tumoren, welche metastasieren können, z.b. durch das 70-genexpressionsprofil mammaprint identifiziert und einer notwendigen adjuvanten therapie zugefü hrt werden können, gibt es andererseits auch in hochrisikogruppen wie her2-positiven karzinomen einen teil mit guter prognose, der vielleicht kei-ner chemotherapie bedarf. diese multigenassays erweisen sind nicht nur als prognostisch, sondern zunehmend auch als prädiktiv fü r das ansprechen auf (neo)adjuvante chemotherapie und wir wissen immer mehr, wer von welcher therapie profitiert, was essentiell sein wird fü r die notwendige kosteneindämmung und vermeidung von unnötigen nebenwirkungen. in der chirurgie verändert sich die logistik von diagnostik und therapie grundlegend. die schaffung strukturierter tumorbanken wird notwendig, wobei präoperative planung und operation die ersten wichtigen schritte darstellen. in hochrisikosituationen laut genexpressionsanalyse ist eine optimierte lokalbehandlung essentiell und bei hoher wahrscheinlichkeit auf pathologische komplettremission eine präzise prätherapeutische markierung des tumors. die resultate dieser genexpressionsanalysen bringen eine individualisierte adjuvante chemo-und/oder hormontherapie mit sich. jede(r) chirurgin muss sich mit möglichkeiten und grenzen dieser revolutionären techniken befassen, um weiterhin integrativ im tumorboard die besten entscheidungen fü r unsere patientinnen treffen zu können. background. peritoneal carcinomatosis defines tumor dissemination onto the peritoneal surface. hyperthermic intraperitoneal chemotherapy (hipec) after cytoreductive surgery seems becoming the standard treatment in peritoneal carcinomatosis avoiding the risk of tumor cell inoculation after surgery. subsequent adhesion of free tumor cells to human peritoneal mesothelial cells (hmcs) -the first line defense within the abdominal cavity -might lead to the formation of intraabdominal metastases. we investigated within an invitro-model the blockage of tumor cell adhesion by simvastatin (sim), an inhibitor of the 3-hydroxy-3-methylglutaryl (hmg) coenzyme a reductase. methods. hmcs were isolated by enzymatic disaggregation from human omentum majus and expanded in vitro. confluent hmc-monolayers were incubated with fluorescent labelled tumor cells in the presence or absence of sim. in time course experiments, adhesion of skov-3 (ovarian tumor) and ht-29 (colorectal tumor) cells to hmcs were determined either by fluorescence microscopy or reader. results. simvastatin reduced the number of adherent skov-3 and ht29 cells to hmcs significantly. at concentrations ranging from 2.5 to 10 mm, simvastatin reduced the adherence of tumor cells to hmcs up to 60%. conclusions. our findings suggest that simvastatin might be a novel therapeutic approach in order to reduce the risk of peritoneal metastasis due to tumor cell dissemination during cytoreductive surgery. further investigations also have to include the mechanism on the molecular level. einleitung her-2/neu (c-erbb2) ü berexpression ist assoziiert mit einem höheren angiogenetischen potential und einer erhöhten expression des vaskulären wachstumsfaktors vegf beim mammakarzinom. vorklinische studien haben gezeigt, dass her-2/neu eventuell eine zusätzliche rolle bei der regulierung der expression des lymphatischen wachstumsfaktors (vegf-c) und damit bei der lymphatischen metastasierung spielt. sinn dieser studie, war es diesen zusammenhang zwischen der her-2/neu expression, der expression des lymphatischen wachstumsfaktors vegf-c, dem ausmaß des lymphangiogenetischen potentials (lmvd) sowie der spezifischen lymphogenen invasion (lvi) in einem kollektiv von 150 lymphknoten-positiven mammakarzinomen zu ü berprü fen. methodik immunhistochemie und insitu-hybridisierung fü r vegf-c, den lymphatischen endothelzellmarker podoplanin sowie fü r her-2/neu wurden durchgefü hrt. weiters wurde eine her-2/neu fish analyse bei allen 150 karzinompräparaten angewendet. ergebnisse lmvd korrelierte signifikant mit lvi (p 0.005) und der vegf-c expression (p ¼ 0.014). weiters konnte eine positive, statistisch signifikante korrelation zwischen der her-2/neu-und vegf-c proteinexpression gefunden werden (p ¼ 0.015). patienten, deren tumore eine höhere her-2/neu expression aufwiesen, exprimierten auch signifikant mehr vegf-c und wiesen ein höheres lymphangiogenetisches potential (lmvd) auf. diskussion unsere daten geben den ersten hinweis auf einen klinisch relevanten zusammenhang zwischen vegf-c und her-2/neu beim lymphknotenpositiven brustkrebs und damit einen direkten zusammenhang zwischen dem ausmaß einer her-2/neu expression und dem lymphatischen metastasierungspotentials beim mammakarzinom ab. diese daten unterstü tzen die bedeutung des her-2/neus als konduktor eines aggressiven phenotyps beim mammakarzinom und liefern mögliche hinweise auf die wirkungsweise assoziierter therapien wie dem trastuzumab (herceptin). background. gerd affects up to 40% of the population in the western world. despite morphological changes in the esophagus, gerd causes significant impairment of the quality of life (qol). we aimed to identify the qol in patients with gerd and to assess the midterm effect of treatment on the qol-scores. in addition we aimed to compare data obtained by esophageal function tests (eft) between the two groups and with pre-interventional qol-scores. methods. ninty-seven patients with gerd symptoms underwent esophageal manometry and 24 h ph-monitoring or combined ph-multichannel-intraluminal-impedance. the patients received either medical or surgical treatment. qol was assessed using the german version of the sf 36. results. significantly lower pre-interventional sf 36 scores were found for 3 of the 8 dimensions compared with the published normative data for the general us population. conservative treatment could not improve patients qol whereas surgery significantly improved the score for bodily pain. after 1 year significantly better scores for 5 dimensions were found in the surgical group. for 2 of the 3 chosen eft-categories the surgical group showed significantly worse values. when comparing sf 36 scores with data obtained by eft no significant differences in the qol between patients with normal values and those with abnormal findings were found. conclusions. qol represents a reliable tool for assessment of severity of disease and outcome following therapy in persons with gerd. regarding patients qol surgical treatment seems superior to conservative treatment. der hiatus ösophageuswie groß ist er wirklich? ergebnisse. es wurden 24 männer und 26 frauen obduziert. mittleres alter: 74 j (range 40-90 j). gewicht: 71 kg (range 40-120 kg), größe 1, 68 m (range 1, 83 m), bmi 25, 2 (range 13, 1) . thoraxumfang 1, 01 m (range 0, 78 m) . die mittlere hsa betrug 5,84 cm 2 (range 3,62-9,56 cm 2 ). bei allen leichen war die z-linie intraabdominal, der abstand zum his winkel betrug im mittel 3 cm (range 1,2-4,8 cm) . der linke und rechte zwerchfellschenkel war bei allen exakt gleich lang, im mittel 3,6 cm (range 2,7-4,6 cm), der querdurchmesser (segment der ö ffnung) im mittel 2,4 cm (range 1,7-4,0 cm). schlussfolgerungen. der durchschnittliche hiatusflächeninhalt beträgt 5,84 cm 2 . er ist direkt proportional dem thoraxumfang und unabhängig von größe, gewicht, bmi und geschlecht. background. in patients with gastroesophageal reflux disease (gerd) esophageal acid exposure is assessed with a ph probe placed 5 cm above the manometric lower esophageal sphincter (les). we compared acid exposure within and 5 cm above the les. methods. between 11/2006 and 12/2008, 178 patients with gerd symptoms (45.2% females; age 47.4 ae 15 years) underwent multilevel ph monitoring (10 days off antisecretory therapy) with a catheter including ph probes 5 cm above (level þ5), at (level 0) and 1.2 cm distal (level à1.2) to the proximal les-limit; % time ph < 4.0 (5 cm above les) <4.2% was considered normal. les length was >2 cm in all patients. results. 5 cm above the les, 119 (66.9%) and 59 (33.1%) patients (no age difference, p ¼ 0.104) had normal and abnormal acid exposure, respectively. more women had normal acid exposure (75% vs. 56.4%; p ¼ 0.009). in those with normal acid exposure, time ph conclusions. acid exposure is maximal within the les and may explain why reflux is missed by probe placement 5 cm above the les. normative values or multilevel ph monitoring from asymptomatic persons are required. stellenwert der ösophagealen kombinierten 24 h-impedanz-ph-metrie zur refluxdetektion bei ph-metrie negativen patienten grundlagen. die ösophageale 24-stunden-ph-metrie gilt als gold-standard zur abklärung der gastro-ösophagealen refluxkrankheit (gerd). sie vermag allerdings nur saure refluxe zu detektieren (ph < 4). neuerdings wird die diagnostik zunehmend um die ösophageale kombinierte 24 h-impedanz-ph-metrie erweitert, mit der auch schwach saure oder nicht saure refluxe registrierbar sind. wieviele refluxpatienten bisher mit der alleinigen 24-stunden-ph-metrie unentdeckt blieben, ist unklar und soll durch die vorliegende studie berechnet werden. methodik. retrospektive analyse aller patienten, bei welchen zur gerd-abklärung u.a. eine ösophageale kombinierte 24 stunden impedanz-ph-metrie durchgeführt wurde. verwendet wurde ein comfortec + mii/ph katheter (fa. sandhill scientific,inc; nr. zan-bs-01) mit einem ph-sensor bei 0 cm, sowie 5 ringelektroden bei drei, sieben, neun, fünfzehn und siebzehn zentimetern von der sondenspitze. vor platzierung der impedanzsonde wurde eine ö sophagusmanometrie durchgeführt, u.a. zur längen-und lagebestimmeng des les. die platzierung des ph-sensors erfolgte dann 5 cm über dem oberrand des les. die auswertung erfolgte computerunterstützt (,,bioview + '', version z00-0145; sandhill scientific, inc.) die messdauer betrug jeweils 23 stunden. ergebnisse. es wurden 159 kombinierte 24 stunden impedanz-ph-metrien durchgeführt. bei 107 patienten (67,3 %) lag der demeester-score im normbereich (<14,7). dreizehn dieser patienten mit physiologischem demeester-score zeigten eine pathologische anzahl von >73 refluxen in 24 stunden (12,1 %; das entspricht 8,2 % der gesamten patientenpopulation). d.h., bei 8,2 % der patienten wurde eine pathologische refluxaktivität durch eine alleinige 24 h-ph-metrie nicht erfasst. schlussfolgerungen. bei vorliegen einer unauffälligen ösophagealen 24 h-ph metrie sollte, wenn verfü gbar, noch eine ösophageale 24 h-impedanzmessung angeschlossen werden, um weitere 8,2 % der patienten vor einer möglichen fehldiagnose zu bewahren. reflux characteristics and symptoms off and on proton pump inhibitor medication: an impedance-ph-study in 50 patients with gastroesopheal reflux disease background. the influence of proton pump inhibitor (ppi) medication on results of multichannel intraluminal impedance and ph monitoring (mii-ph) is controversial. aim of this study was to investigate the effect of esomeprazole 40 mg bid on mii-ph results. methods. fifty patients (24 f, 46.7a, range 20-66a) with heartburn or regurgitation underwent 24 h mii-ph off (ppi paused for 10 days) and on ppi (esomeprazole 40 mg bid for 14 days). patients recorded symptoms, meals and recumbent periods. tracings were automatically analyzed and manually reviewed. variables for comparison were number of acid and nonacid refluxes, heartburn and regurgitation episodes and symptom to reflux correlation by symptom index (si). results. see tables 1 and 2 . conclusions. esomeprazole 40 mg bid resulted in significantly lower numbers of acid but not total number of refluxes. peristant regurgitation on medication was more frequent than persistant heartburn. on ppi reflux monitoring has a lower diag-nostic yield, but contains more clinically useful information in patients with symptoms persisting on ppi medication. the incidence of gastroesophageal reflux after transthoracic esophagocardiomyotomy without fundoplication: a long term follow-up background. evaluation of the long term results of heller's myotomy performed over a lateral thoracotomy without additional fundoplication. methods. fourty patients (17 males, 23 females; mean age 43.2 years; range: 14-63 years) were operated between 1985 and 2000. preoperative evaluation included clinical scoring of symptoms, esophagogram, endoscopy, manometry and 24-hours ph-metry. at the follow-up investigation, the preoperative evaluation was repeated in all patients, adding a histological workup of the distal esophageal mucosa. the mean duration of follow-up after surgery was 10.3 years, ranging from 3 to 16 years. results. the clinical scores improved significantly: excellent relief from dysphagia was present in 86%, little or no regurgitation was found in 79%, little or no retrosternal spasms were reported by 72% of the patients. esophagogram showed an overall esophageal dilatation in all patients but no significant obstruction at the esophagogastric junction. endoscopically, 2.5% had candida-esophagitis, 5% showed signs of a gerd i, 92.5% had a macroscopically insuspect esophageal mucosa. histologically, 53% showed a mild chronic inflammation. manometry demonstrated distinct hypomotility of the esophagus in all cases, yet no elevated pressure of the lower sphincter; ph-metry showed moderate reflux in 46%. conclusions. transthoracic cardiomyotomy is a valid method for the treatment of achalasia, but it will not improve the esophageal motility, which slowly deterioriates in these cases. the patient's subjective assessment of the postoperative result was positive in the majority of cases. although fundoplication was not done in any of these patients, none of them showed signs of clinically relevant reflux. methods. review on the dilated end stage esophagus. results. anatomy and biopsy studies in gerd patients revealed the presence of cle within the proximal portion of the endoscopically visible gastric type folds over a length ranging from <0.5 to 2.8 cm, where cle (cardiac mucosa ae intestinal metaplasia, oxyntocardiac mucosa) transitioned towards the oxyntic mucosa of the proximal stomach, irrespective of the presence or absence of endoscopically visible cle within the tubular esophagus. fusion of histopathology and function test data indicated that this condition results from a mechanism involving gastric distention induced damage of the lower esophageal sphincter causing reflux, damage and columnar metaplasia with proximal dislocation of the squamocolumnar junction. loss of sphincter function causes gastric type folding of the cle thus giving it a gastric type appearance during endoscopy. this is the dilated end stage esophagus, which is frequently taken for hiatal hernia during endoscopy and may cause the formation of the adenocarcinoma of the cardia (siewert type ii). conclusions. in gerd patients, endoscopy without biopsy sampling of the proximal portion of the endoscopically visible gastric type folds misses the dilated end stage esophagus. differentiation of the dilated end stage esophagus from proximal stomach (hernia) requires the histopathology of biopsies. background. differences in the prevalence of the morphologic manifestations of gastroesophageal reflux disease (gerd), columnar lined esophagus (cle) and barrett's esophagus (be; 0.5% annual cancer risk) in those with and without gerd symptoms is not known. methods. esophagogastroduodenoscopy (egd) with multi level biopsies from the esophagogastric junction (1.0 cm, 0.5 cm above, at and 0.5 cm, 1.0 cm distal to the level of the rise of the gastric folds) was prospectively conducted in asymptomatic patients (controls; n ¼ 81; 25.5%) and gerd patients (n ¼ 237; 74.5%); aged between 17-84 years (50 ae 14.6) and 55.6% females. columnar lining above the level of the rise of the gastric folds was categorized as endoscopically visible cle (clev). histopathology of cle included cardiac mucosa ae intestinal metaplasia (¼be) and oxntocardiac mucosa; squamous epithelium and oxyntic mucosa (om) were considered as normal lining of the esophagus and the proximal stomach. prevalence of clev and histopathology proven cle was compared between controls and gerd patients. results. there were no significant age-, gender-differences between the groups (p > 0.05). prevalence of clev (p ¼ 0.083), histopathology proven cle (p > 0.999), cle length (p ¼ 0.321) and intestinal metaplasia (controls: 13.6%; gerd: 20.7%; p ¼ 0.159) was indifferent between controls and gerd patients. dysplasia and cancer have not been assessed. conclusions. the prevalence of cle and barrett's esophagus was comparable in patients with and without gerd symptoms. our findings may justify to consider screening endoscopy for barrett's esophagus. the aim was to evaluate long-term results of revascularization in significant coronary artery disease (cav). the group contained 55 patients (89% male). the mean htx age was 47 ae 10 yrs (range from 20 to 65 yrs). the mean donor age was 33 ae 11 years. the mean follow-up time after revascularization was 72 ae 36 months. the cumulative incidence of significant focal cav was 5%. the mean time to development of significant focal cav was 92 ae 36 months (range from 2 months to 16 years). a total of 164 lesions were treated. balloon angioplasty was performed 45 times (27.4%). a total of 46 (28.0%) bare metal stents (bms) and 73 (44.5%) drug eluting stents (des) were implanted. five patients underwent coronary bypass graft surgery. forty four percent of restenosis manifested in the first 6 months after intervention. restenosis was diagnosed during the long-term follow-up time in 26.26% lad, 22.89% in cx and 12.99% in rca stents. within the first 6 months after intervention the mean restenosis rate in bare metal stents counted 9% and in des 7%. after 36 months 72.2% of stented lesions remained patent (63.2% bms vs. 78.1% des). diabetes mellitus turned out to be the only independent predictor for early restenosis. the cumulative incidence of cav is low. lad is affected by the highest rate of restenosis. intervention of focal lesions in cav patients is feasible and effective as it is in non-transplant coronary artery disease. a trend towards improved patency with des could be observed. background. this study was designed to determine the posttransplant outcome of elective, lvad and urgent patients undergoing cardiac transplantation. methods. the post-transplant outcome of 485 elective, 64 lvad (debakey, duraheart, heartware lvad) and 43 urgent patients (hu) undergoing cardiac transplantation between 1998 and 2008 was retrospectively analyzed. survival, incidence of rejection, severe infections, cmv-disease and graft vasculopathy (cav) were compared. all patients received immunosuppressive therapy consisting of thymoglobuline, tac/cyclo þ mmf/evl and low dose steroids. kaplan-meier analysis was performed to test differences between the groups. results. patients in the three groups were comparable with regard to primary disease. urgent patients were younger (42 ae 16yrs) than elective (52 ae 13yrs) and lvad (50 ae 11yrs) patients (p < 0.001). actuarial survival of elective (80%, 75%, 72%), lvad (84%, 77%, 71%) and hu (81%, 78%, 71%) patients was comparable 1, 3 and 5 years post-transplant (log-rank 0.671). furthermore, freedom from rejection episodes (elective: 91%, 90%, 90%, lvad: 90%, 90%, 90%, hu: 93%, 93%, 93%; log-rank 0.991), severe infections (elective: 73%, 68%, 67%, lvad: 84%, 82%, 82, hu: 73%, 73%, 70%; log-rank 0.118), cmv disease (elective: 91%, 90%, 90%, lvad:92%, 92%, 92%, hu: 86%, 86%, 86%; log-rank 0.415) and cav (elective: 97%, 92%, 85%, lvad: 96%, 89%, 83%, hu: 94%, 82%, 82%; log-rank 0.317) was comparable between elective, lvad and hu patients 1, 3, and 5 years posttransplant. conclusions. despite the increased risk of lvad and urgent patients post-transplant outcome is excellent and compares to elective patients. the low incidence of rejections and cav underlines the importance of induction therapy and individualized immunosuppression. background. pgd is a major cause of morbidity and death early after cardiac transplantation. extracorporeal membrane oxygenation (ecmo) is a mechanical support system to support hemodynamics in case of acute heart failure. the aim of this study was to evaluate ecmo as support system for pgd. methods. between 2000 and 2008 59 out of 425 (14%) patients, who underwent cardiac transplantation, experienced pgd and received ecmo support. survival, rate of recovery and complications were analysed. results. overall survival was 41% after 100 weeks follow up. 44 patients (74.6%) could be weaned from ecmo and in-hospital survival of these patients was 55%. duration of ecmo support was 4 days. early experience (2000) (2001) (2002) (2003) with ecmo was significantly worse (survival: 20% vs. 50%; p ¼ 0.001) than later experience (2004-08). overall complication rate was 68%. most frequent complications were bleeding (n ¼ 16, 27%; cannulation area (n ¼ 9) and hematothorax (n ¼ 7)) and infections (n ¼ 11, 18%), (others: schreib eventuell alle in klammer nach 'others' auf und die gesamtzahl und % dazu, oder ganz weglassen) time of ecmo implantation had no impact on patient survival (problems during weaning off bypass: 66%; inability to wean off bypass: 40%, sudden pgd in icu: 30%; p ¼ 0.101) conclusions. ecmo is a valuable tool to overcome pgd after cardiac transplantation. bigger experience improves results significantly. however, complications can occur and proper management is of uttermost importance. the aim of the study was to evaluate the pattern of brain natriuretic peptide (bnp) concentration in heart transplant (htx) recipients and its relation to the degree of significant transplant coronary artery disease (cav background. minimally invasive follicular thyroid carcinoma (miftc) is defined to be an encapsulated tumor demonstrating limited unequivocal vascular and/or capsular invasion. considering the indolent behavior of these tumors the necessity of a radical treatment with routine lymph node dissection is questionable. methods. we evaluated our data in 2 periods of time focusing on the necessity of lymph node dissection in miftc: in the first period from 1985 to 1998 our pathologists reviewed all fol-licular thyroid carcinomas (ftc) and identified those tumors appropriate to the criteria used for diagnoses of miftc. the patients were followed for 11.6 years on average. in the second period from 1999 to 2008 we observed all ftcs demonstrating lymph node involvement. results. in the first group of 43 patients affected with miftc no lymph node metastases could be detected neither at time of diagnosis nor during follow-up time. no distant metastases or recurrent diseases were observed. the few tumors of the second period inducing lymph node metastases were all of widely invasive pattern of growth, none of them was minimally invasive. conclusions. lymph node involvement is generally rare in ftc. the absence of lymph node metastases in our series suggests no need for lymphadenectomy in miftc. we present an unusual case of a metastatic thyroid tumor, of which the primary cancer was an infiltrative high grade transitional cell carcinoma of the urinary bladder. the time from the diagnosis of primary tumor to metastasis was 13 months. the appearance of the thyroid metastasis was like a primary thyroid disease. diagnosis of thyroid metastasis as a consequence of urinary bladder carcinoma was confirmed by intraoperative biopsy, histopathological and immunohistochemical findings. the treatment consisted of radical thyroidectomy in addition to systemic adjuvant chemotherapy. report after 1-year follow up. diagnosis of hashimoto's thyroiditis: discrepancy between preoperative antitpo-autoantibodies and histological grading in thyroid tissue methodik. bei 320 konsekutiven weiblichen patienten wurden vor der schilddrüsenoperation prospektiv präoperative anti-tpo-bestimmungen durchgeführt und bei der histologischen aufarbeitung speziell auf die bewertung der lymphozytären infiltration und der graduierung (grad 1-4) geachtet. ergebnisse. 55 von 320 (17,2 %) patienten wiesen präoperativ erhöhte antitpo-spiegel auf, 130 von 320 (40,6 %) histologische zeichen einer thyreoiditis. bei den antitpo-positiven patienten wiesen 10 grad 1, 26 grad 2, 4 grad 3 und 10 grad 4 auf, 5 zeigten keine lymphozytäre infiltration. bei jenen 80 patienten mit his-tologischen entzündungszeichen ohne pathologischem antitpo-spiegel wurde grad 1 in 62, grad 2 in 17 und grad 3 in 1 fällen gefunden, kein patient wies grad 4 auf. der schweregrad der thyreoiditis zeigte eine signifikante positive korrelation (p < 0,01; r ¼ 0,579) mit der höhe der antitpo-spiegel. schlussfolgerungen. nur 40 % der histologisch verifizierten thyreoiditis-patienten konnten präoperativ durch serologische antitpo-bestimmung erkannt werden. die daten zeigen, dass speziell die milden verlaufsformen der thyreoiditis hashimoto serologisch nicht verlässlich zu diagnostizieren sind. late onset paralysis of the recurrent laryngeal nerve after thyroidectomya rare phenomenon grundlagen. nach postoperativ regulärer stimmbandfunktion kann es in seltenen fällen auch erst im spätpostoperativen verlauf zum auftreten einer recurrensparese kommen. da dieses phänomen in der literatur nur kasuistisch beschrieben ist, wird hier über eine patientenserie berichtet. methodik. vor und nach schilddrüsenoperation wird standardisiert eine laryngologische untersuchung an der eigenen hno-ambulanz durchgeführt. jene patientin, die unsere abteilung -nach unauffälligem postoperativen hno-befund-wegen spätpostoperativ einsetzender stimmstörung aufsuchen, wurden analysiert. ergebnisse background. objective cosmetic analyses are important to reproducibly evaluate the cosmetic outcome after breast surgery and radiotherapy. so far, only subjective irreproducible scores have been used such as the harris scale. we have developed an objective tool to reproducible analyse digital pictures, the ''breast analysing tool'' (bat). the aim of this study was to compare subjective with objective breast cosmesis scores. methods. digital pictures (frontal view) from 129 breast cancer patients (60 from porto and 69 from vienna) after breast conserving therapy and radiotherapy were analyzed with the above described software. all calculations were transferred to a breast symmetry index (bsi) ranging between 0 (excellent cosm-esis) and 11 (bad cosmesis). the same pictures were analyzed by 10 experts (surgeons) and 8 non-experts (students) using the harris scale (subjective score from 1 to 4; excellent, good, fair and poor cosmesis). these subjective scores were correlated with the objective scores from the bat software using the pearson correlation test. results. all subjective scores significantly (p < 0.05) correlated with the bat score with a pearson correlation coefficient of 0.716 (non-experts), 0.697 (experts) and 0.719 (overall). conclusion: the technical modifications of the bat-software have lead to the achievement of accurate and reliable results. this qualifies the use of bat in prospective and retrospective trials on breast cosmesis. offen-chirurgische intervention mit hohem komplikationspotential und langem krankenhausaufenthalt zu vermeiden. local hyperthermia combined with external radiation therapy as anti cancertreatment in recurrent breast cancer hyperthermia combined with radiation therapy has been confirmed in several randomised studies to be more effective than radiation therapy alone in various cancers. we evaluated the potential synergistic effect of local hyperthermia and conventional external beam radiation. we used a wave-guide applicator (bsd) with a typical emitting diameter of 15 cm and a frequency of 150-430 mhz with a therapeutic depth of 3 cm. hyperthermia was performed for 60 min for at total of six sessions, twice weekly, the temperature was exactly calibrated between 40 and 43 c. immediately after hyperthermia external radiation with 60 gy was applied in a daily fraction of 1.5 gy. no major side effects were observed during hyperthermia. 12 patients were treated and followed for during 2-12 months. ten of the tumours responded to the treatment (3 cr, 7pr), two patients died of distant metastases within one year. local hyperthermia combined with conventional radiation therapy may be useful tool to promote tumor regression and the local recurrence-free survival in cases of recurrance breast cancer. we conclude that hyperthermia and radiation therapy is effective in treatment breast cancer treatment and should be used in selected cancer patients. sentinel-node biopsy und lymphatic mapping von malignen tumoren mittels eines fluoreszenz-tracers (icg) the potential of plasma proteomics in predicting response to neoadjuvant chemotherapy in breast cancer patients using 2d-dige resistance to chemotherapy is still a major problem in oncology. especially for hormone receptor negative tumours there are no biomarkers available which identify patients who will not profit from treatment. such a selection would allow for a switch to another more effective chemotherapeutic regimen for these patients. chemotherapy not only leads to the destruction of tumour cells, but also affects actively proliferating healthy tissues as well as the immune system. as shown in another abstract of our group, neoadjuvant chemotherapy of breast cancer patients with epirubicin and docetaxel leads to expression changes of distinct plasma proteins within 2 days. based on these results, we investigated whether such changes can be correlated with the final response to chemotherapeutic treatment assessed 12 weeks later. therefore, plasma was prepared from 23 breast cancer patients before and 2-4 days after receiving the first course of neoadjuvant chemotherapy. after the removal of 12 major abundant plasma proteins by affinity chromatography, proteomic analysis was performed using 2d-dige. eight out of 577 protein spots showed a higher chemotherapy-induced increase in expression (p < 0.05) in responders (n ¼ 16) compared to non-responders (n ¼ 7), whereas one protein behaved vice versa. these proteins might be useful in future for an early identification of those patients who will not benefit from this kind of treatment. for further investigation these protein spots will be identified by mass spectrometry and for verification of the 2d-dige results quantitative 1d western blots are planned. background. demeester's composite score (cs) is a convenient parameter to assess gastroesophageal reflux activity by 24 h ph-monitoring. ingestion of acidic foods has been reported to compromise the reliability of this parameter. aim of this study was to evaluate the impact of meals on cs. methods. in a 100 consecutive ph-studies exclusion of meals resulted in cs values 3.3 higher to 3.7 lower than including meals. the range of differences (cs 11.0-18.0) was used as a reference for selection of risk group to cross the cut-off value when analyzed without meals. results. 79 of 515 patients with clinical signs of gerd who underwent ph monitoring during one year, had a cs 11.0-18.0 and their studies were reanalyzed. median cs was 14.7 (12.5-16.5) including and 14.5 (12.4-16.6) excluding meals. in eleven patients the cut-off was crossed depending on analysis type. multivariate logistic regression including gender, oesophageal motility, recumbent periods, meals' duration and number of acidic foods/beverages were performed to identify risk factors for changing cs interpretation. prolonged meal duration significantly contributed to changing from normal to abnormal score (or 3.64; 95% ci 1.09-12.2, p ¼ 0.037). the number of acidic foods consumed significantly raised the probability to change from abnormal to normal score when meal periods were excluded (or 1.37; 95% ci 1.01-1.86, p ¼ 0.04). conclusions. the exclusion of meal periods from 24 h phmonitoring rarely resulted in a different interpretation of cs. ingestion of acidic foods/beverages and long meal periods were identified as counteracting independent risk factors for crossing the cut-off value. colokutane fistel nach peg-anlage mittels introducer-technik mit gastropexie background. with a part of 1 percent of all malignant gastrointestinal lesions and an incidence of 1-2 new diseases referring to 100 000 persons, gastrointestinal stromal tumors (gist) are rather rare. nevertheless the number of cases is increasing, belonging to better endoscopic and radiological methods, but also because of the better knowledgement in histopathologic and moleculargenetic examinations. methods. in 2008 a group of two surgeons and two oncologists, started to discuss about a national registration of patients suffering from gist in austria. criterions for registration were discussed and fixed up in a sheet. also an informed consent for the patients registration was conceived. our concept, aims and visions were presented at the commission of ethics in lower austria, and a positive votum was given at the end of 2008. so we started our official work at the first of january 2009. results. as well the oncologist team as the surgeon group contacted as much centres as possible by phone call or by letter, inviting them to support the registry by bringing in their data. in a short time about 30 centres and also the contact persons were registered. in a second announcement we want to enlarge this number in order to get better results. conclusions. gist registry was started to find out incidence of disease, but also the way of diagnosis and therapy in patients in austria. do we have similar strategies in the (neo-) adjuvant setting and in treating metastatic ore advanced disease or not? colonic retrosternal esophagoplasty in young children with pure esophageal atresia r. kovalskyy 1 , a. kuzyk 2 , o. leniv 1 , i. avramenko 1 1 lviv regional children hospital ''ohmatdyt'', department of pediatric surgery, lviv, ukraine; 2 department of pediatric surgery, lviv national medical university, lviv, ukraine background. pure esophageal atresia is observed in 8-12% of the newborn with the mentioned pathology. there is still a search for the optimal problem solving of the esophagus patency correction in such patients. this concerns both the choice of methods and the age of the children. methods. since 1989 till 2007 11 colonic retrosternal esophagoplasty have been done. the newborns weight was 2400-2850 g. 7 children-born prematurely. 9 newborns had pneumonia. diastases between the esophagus segments equaled 6-7 cm. at the moment of operation the children were of 4-16 weeks old. body weight was 3100-4500 g. during the first three weeks the newborns had the distal esophagostomy in the necks and gastrostomy. when the weight was stably increasing, the patients had a laparotomy, the segment of colon was chosen for transplantation. usually it was a colon transversum and a part of colon descendens with a. colica sinistra. transplant was put behind the stomach and located retrosternally in anterior mediastinum. proximal transplant ending was sewed in the anterior wall of stomach, distal-was delivered to the neck next to esophagostoma, in 2-3 weeks-the anastomosis with esophagus. results. four patients had an anastomotic breakdown in the neck. two of them had the repeated cervical anastomosis, the others had fistula, which closed by itself. the children had a good passage in the transplant. conclusions. to treat the children with pure esophageal atresia without fistula it is possible to use successfully colonic retrosternal esophagoplasty in the early age. background. gastroesophageal reflux disease is associated with columnar lined esophagus (cle). we aim to summarize the novel developments regarding our understanding of cle. methods. review of the recent literature (2006-2009) on cle. results. gastroesophageal reflux causes damage and columnar metaplasia of the squamous mucosa of the esophagus resulting in the formation of columnar lined esophagus (cle). recent evidence indicates that cle results from refluxinduced genetic changes within the stem cells of the esophageal epithelium inducing the switch from squamous to cardiac mucosa (cm) mediated via bone morphogenetic protein 4. cm may progress towards oxyntocardiac mucosa (ocm) by inclusion of parietal cells (mediated via sonic hedge hog, ssh, promoting parietal cell maturation) or to intestinal metaplasia (im ¼ barrett's esophagus) by inclusion of goblet cells (mediated via cdx2). shh and cdx2 pathway is stimulated by acidic and alkaline ph, respectively. thus the proximal location of intestinal metaplasia within a given cle segment is considered to reflect the ph gradient with acidic and alkaline ph in the distal and proximal cle segment, respectively. while shh mediated ocm does not progress towards intestinal metaplasia and cancer, the cdx2 pathway favors progression of intestinal metaplasia towards dysplasia and cancer. expression of cdx2 within cle is reduced to control values following elimination of reflux after an effective anti reflux surgery. conclusions. cle results from milieu-dependent esophageal epithelial stem cell changes activated during gastroesophageal reflux. these findings are suggested to explain why antireflux surgery favors regression of barrett's esophagus. successful interdisciplinary management of 2 simultaneous mesenchymal tumor manifestations with synchronous resectionrare and challenging combination of a gastric ''high-risk'' gist and retroperitoneal liposarcoma methodik. anhand eines außergewöhnlichen exemplarischen fallberichtes wird eine 47-jährige patientin mit einem gist an der kleinen magenkurvatur und einem monströsen retroperitonealem liposarkom links-abdominal mit infiltration der linken niere dargestellt. der gist wurde durch eine tangentiale magenwandteilresektion und das liposarkom in toto zusammen mit der linken niere aufgrund der tumorinfiltration entfernt. im anschluss folgte eine kombinierte radiochemotherapie für das liposarkom. ergebnisse. beide tumoren wurden weitestgehend komplett entfernt. der technisch schwierige eingriff sowie der postoperative verlauf gestalteten sich komplikationslos. histologisch wurde beim magenwandtumor die r0-resektion bestätigt und dieser aufgrund seiner größe(6,5 cm durchmesser) und einer mitotischen aktivität(6 mitosen/50 hpf) als ,,high-risk''-gist eingeordnet. die neoplasie des linken retroperitoneums wurde als myofibroblastisch-dedifferenziertes liposarkom (grad 2 nach coindre) mit dem tumorstadium pt2b g2 r1 im sinne eines unabhängigen mesenchymalen zweitmalignoms klassifiziert und damit ein metastasierungsgeschehen ausschloss. bei histologisch gesicherter r1-resektion des liposarkoms erfolgten postoperativ eine additive radiochemotherapie nach vaia-protokoll (adriamycin, ifosfamid, vincristin) und eine bestrahlung des retroperitonealen tumorbettes von 46,6 gy gesamtdosis. in der radioonkologischen verlaufskontrolle nach 6 jahren zeigte sich kein anhalt für ein tumorrezidiv. schlussfolgerungen. die komplette tumorresektion stellt die therapie der wahl bei mesenchymalen tumoren dar (ziel: r0). je nach histologischer tumorklassifikation und -sensitivität bzw. resektionsstatus ist eine nachfolgende radiatio und oder chemotherapie erforderlich, was im vorliegenden fall trotz r1-resektion des liposarkoms und ,,high risk''-gist eine bisher 6jährige tumorfreie ü berlebenszeit ermöglichte. schlüsselwörter. gist, liposarkom, radiatio, vaia-protokoll. surgical aspects of pneumatosis cystoides intestinalis: report of two cases e. schröpfer, l. scheele, c. wichelmann, c. t. germer, t. meyer univ.-klinik würzburg, würzburg, germany pneumatosis cystoides intestinalis (pci) is a rare disease usually caused by an underlying condition. it is defined as air filled cysts within the wall of the gastrointestinal tract. the true incidence is unknown, pci is often an incidental finding on radiographs. we report on two different cases of pneumatosis cystoides intestinalis. both patients underwent surgical treatment in our department. the first patient, a 17 year old white european girl, with down syndrome and leucopenia due to chemotherapy for acute lymphatic leukemia was admitted to our surgical department with acute septic conditions and air filled cysts in the intestine wall. explorative laparotomy revealed acute ischemia of the right colon and resection of the affected intestine was performed. after a short interval in the intensive care unit the patient was referred to the pediatric department. the second patient, a 79-year old, white european man with urothelial carcinoma of the bladder and carcinoma of the prostate underwent radical cysto-prostatectomy in the department of urology. after several operations due to obstruction of the right common iliac artery the patient presented an acute abdomen and computer tomography revealed pneumatosis intestinalis and ileus of the colon. only adhesiolysis was performed and the patient was discharged into rehabilitation a few weeks after. patients with the radiographic diagnosis of pci should receive a thorough history and physical examination. we discuss the surgical management of pci according to literature and developed an algorithm. gastrointestinale stromatumore (gist): modifizierte therapeutische strategien durch pet/ct background. the liver is a frequent site for metastases of colorectal cancer. due to new chemotherapy agents, strategies and targeted agents response rates and respectability rates have improved. moreover, some patients with neoadjuvant chemotherapy have complete response of the liver tumors and the lesions are no longer visible by preoperative ct-scan or intraoperatively. methods. we report a case of a 50 years old female who underwent right hemicolectomy for caecal cancer in an outside hospital. owing to synchronous liver metastasis in segment iv b neoadjuvant chemotherapy was administered. follow-up ctscan revealed complete response and no tumor was visible in the liver. patient was then referred to our center for further investigations. results. ct-scan and mri showed no visible tumor. with the aid of the ct-scan before neoadjuvant chemotherapy the tumor was measured out and preoperatively a ct-guided hook-wire was placed at the position of the presumptive lesion. afterwards the patient was brought into the operating room and an atypical liver segment resection around the pike of the wire was performed. the operative and postoperative course was uneventful. the histologic specimen was tumor-free also presenting complete pathologic response. after close follow-up of 9 months the patient is free of tumor. conclusions. our approach with the ct-guided wire marking could potentially be a way to remove colorectal liver metastases with complete response to neoadjuvant chemotherapy. to leave lesions in place which are not visible could not be the goal, only a curative resection which removes all metastases should be the aim. rechtsseitiger oberbauchschmerz -ein klarer fall? background. breast cancer metastases to the liver are associated with a poor prognosis. in contrast to colorectal metastases, there are as yet no established guidelines for liver surgery for breast cancer secondaries. methods. our retrospective study compared 14 patients with an average age of 55.4 years (range 35-81 years) who underwent hepatic resection. both solitary and multiple liver metastases that seemed to be resectable by r0 were treated. six patients underwent chemotherapy before and 8 patients after the liver resection. nine women received hormone treatment, 3 before and 6 after liver surgery. results. we performed 6 major (hemihepatectomy or more than 3 segments of the liver) and 8 minor (less than 3 segments) resections. the median interval between primary operation and liver resection was 1.8 years (range 4 months to 9 years). fifty percent of the women had a solitary metastasis with a median size of 3 cm. there were liver secondaries in both lobes in 6 patients and in one lobe in 8. no patient died after liver resection. five of the women had a liver recurrence. the 3-and 5-year survival rates were calculated as 50% and 20%, respectively. conclusions. for selected patients with liver secondaries from breast cancer, surgical resection in combination with chemotherapy can be a safe option with low morbidity and mortality. ergebnisse. innerhalb der neoadjuvanten avastin therapie stiegen tems und cecs signifikant an (p ¼ 0,036 bzw. p ¼ 0,025). ebenso beobachteten wir im vegf verlauf einen rapiden anstieg (p ¼ 0,012), der einem deutlichen cea abfall gegenüberstand. in der adjuvanten therapie war wiederum ein vergleichbarer vegf anstieg (p ¼ 0,043) zu beobachten, wohingegen sich sowohl cecs und tems als auch cea kaum veränderten. schlussfolgerungen. der vegf anstieg unter neoadjuvanter und adjuvanter therapie scheint den einfluss von avastin auf die systemische angiogenesebalance widerzuspiegeln. dies steht dem ausschließlich in der neoadjuvanten therapie auftretenden anstieg der cecs und tems gegenüber, welcher nach tumorresektion nicht mehr zu beobachten ist. die vorliegenden daten deuten darauf hin, dass die angiogenese assoziierten zellpopulationen mit der tumormasse in zusammenhang stehen, sich unter therapie signifikant verändern und daher ein potenzial im monitoring der kombinierten avastin-chemotherapie besitzen. rescue approach for unexpected portal vein thrombosis during orthotopic liver transplantation d. kniepeiss, h. müller, d. wagner, e. jakoby, s. schaffellner, f. iberer, k. tscheliessnigg thanks to innovative surgical techniques, portal venous thrombosis no longer is a contraindication for liver transplantation. in case of extensive portal and mesenteric venous thrombosis, cavoportal hemitransposition has been described as a salvage technique but experience is still limited and there is a high risk of serious complications. we present an alternative management of portal vein thrombosis during liver transplantation. a 61-year-old man with liver cirrhosis underwent liver transplantation. although preoperative doppler ultrasound showed portal perfusion, severe portal vein thrombosis was found during transplantation. obviously, the flow of one variceal vein located cranial to the hepatic artery was interpreted as portal vein flow in the pretransplant ultrasound examination. as a salvage measure, the variceal collateral vein was used for portal end-to-end anastomosis. postoperatively, primary graft function was acceptable and improved day by day. moderate renal failure as defined by the k/doqi-guidelines improved gradually and dialysis was never indicated. persistent ascites required repeated paracentesis during the first month after liver transplantation but medical treatment sufficed thereafter. six months after transplantation the patient has normal liver function and adequate renal function. colour doppler ultrasound shows normal flow in all vessels. there are no ultrasonographic signs of ascites and diuretics are not required. we conclude that when there is portal vein thrombosis, a collateral vein of sufficient calibre in the hilum can be used if present for portal vein anastomosis. in our case the surgical procedure was uneventful; postoperative complications were not serious and were controllable with medical therapy. an in-vitro role of mtor proteins in the protection of hcv infected cells from apoptosis has been proven. the aim of this cohort study was to evaluate the effect of sirolimus as mtor inhibitor on hepatitis c recurrence in liver recipients. hepatitis c virus positive patients were followed up prospectively regarding transaminases, immunosuppressive target levels, hcv rna and influence of donor and recipient factors on viral recurrence and survival. viral recurrence was defined as elevated liver enzymes combined with active hepatitis defined as increasing viral load and/or biopsy proven hcv relapse in the transplanted organ. 67 hcv-positive patients were included 39 received a sirolimus including regimen, 18 patients stayed on calcineurininhibitors. sirolimus patients showed a significant decrease in the hcv pcr levels (p < 0,05). survival of the sirolimus patients was significantly higher (p < 0,03) as compared to the other patient cohort. sirolimus has shown to be a potent immunosuppressive agent for patients after liver transplantation. nothing is known about its effect on hcv. this analysis suggests a potential of sirolimus to be evaluated as immunosuppressant for hcv positive liver transplant candidates to suppress viral recurrence. langerhans' cell sarcoma of the spleensurprising diagnosis of a very rare tumor entity during the septic course of a patient background. ccc is a rare tumor disease in western europe with a poor prognosis. these tumors develop from cells of the bile duct epithelia and can appear in several locations along the biliary tract. methods. between 1998 and 2008 a total of 215 patients were reported at our surgical department because of malign bile duct tumor. 116 patients with histologically confirmed cholangiocarcinoma were included in this study. gall bladder and papillary cancer were excluded. patients were classified into 3 groupsintrahepatic, perihilar and distal-based on the tumor classification established by the john hopkins hospital. data was obtained retrospectively from the surgical, histopathological and clinical records of the patients. results. out of the 116 patients 31 suffered from an intrahepatic (27%), 33 a perihilar (28%) and 52 a distal ccc (45%). the overall resectability rate was 53% (51% intrahepatic, 27% perihilar and 78% distal). the overall perioperative mortality rate was 17% (11%, 21% and 15% respectively). the 1-, 3-and 5-year survival rates in all groups after curative resection were 73%, 71% and 60%; 20%, 35% and 15%; and finally 13%, 14% and 10%. the overall recurrence rate was 61%. conclusions. cholangiocarcinoma is a malign tumor disease with poor prognosis. tumor location has a decisive influence on the resectability rate and determines therefore the prognosis of the patient. however, when resectability is provided in all groups, location has no effect on the prognosis. das j123-ganzkörperszintigramm (gk) ergab multiple speicherungen in der sd-loge und der oberen thoraxapertur, einem rezidiv entsprechend. weiters wurden im abdomen mehrere speicherherde erkannt, die sich im spect/ct in der leber lokalisieren ließen. die sonographie bestätigte den verdacht auf lebermetastasen und auf einen weiteren, paracaval liegenden herd (lymphknoten). aufgrund des massiv erhöhten tg-wertes und der deutlichen speicherung im 123j-gk-scan wurde eine weitere hochdosierte rjt (7800 mbq) unter exogener tsh-stimulation veranlasst. posttherapeutisch fanden sich analog zum diagnostischen jod-scan deutliche anreicherungen im hals-und abdomen im sinne von jod-aviden speicherherden. schlussfolgerungen. dieser fallbericht demonstriert, dass bei der nachsorge eines ftc an sehr selten vorkommende tumorlokalisationen wie lebermetastasen gedacht werden sollte. zum anderen zeigt dieser fall auch, dass anatomische besonderheiten im rahmen medizinischer interventionen (z.b. tracheostoma, peg-sonden, div. katheter, etc.), pathologische speicherungen maskieren können. hier stellt die anatomisch/metabolische bildgebung mittels spect/ct ein probates mittel für die differentialdiagnose dar. chemotherapeutic treatment of cancer patients is aimed at eradication of the tumor. in the recent years it became clear that also the immune system contributes substantially the removal of tumor cells. tumor infiltrating leukocytes, however, are commonly suppressed by the tumor in their function which reduces the success of a chemotherapeutic treatment. in a recently published study we demonstrated that replication defective influenza a vaccine virus mutant delns1 is able to boost the cytotoxic response of peripheral blood mononuclear cells (pbmc's) to tumor cells ''in vitro''. here we investigated whether such a treatment could be used to overcome an immunosuppressive state of pbmc's. pbmc's from 3 healthy volunteers were treated with lps for 24 h. this is known to promote formation of unreactive m2-macrophages. then those pbmc's where added to mcf-7 and panc1 tumor cells in presence or absence of chemotherapeutic drugs (gemcitabine and cisplatin). lps-treated pbmc's showed a significant lower cytotoxic effect on tumor cells in comparison to untreated cells. this effect was detectable with and without chemotherapy. pre-incubation with delns1 boosted the cytotoxic capacity of pbmc's and abolished the effect of lps-pretreatment. these data indicate that pretreatment of patients leukocytes with delns1 might be useful to increase the effect of chemotherapy. background. pancreatic necrosis is a serious complication of acute pancreatitis. the identification of laboratory tests to detect subjects at risk of pancreatic necrosis may direct management and improve outcome. soluble thrombomodulin (stm) has been identified as a marker of poor prognosis in the critically ill. circulating (cell-free) dna in serum or plasma has been investigated as a non-invasive diagnostic tool in a variety of clinical conditions. methods. we studied 44 patients with acute pancreatitis (18 -mild, 26 -severe). a thrombomodulin level was determined by elisa. serum creatinine was analyzed on biochemical analyzer. dna was calculated by real time pcr. the degree of pancreatic necrosis was classified by ct balthazar criterion. results. the levels tm, free dna and creatinine of the severe acute pancreatitis group were significantly higher. free serum dna was in correlation with the extent of pancreatic necrosis. increase in creatinine within the first 48 h is strongly associated with the development of pancreatic necroses. pearson correlation coefficient between the degree of necrosis and tm values and between the apache ii score and tm values was statistic significant. conclusions. the plasma tm, free dna may use for identify pancreatic necrosis. high level of creatinine within the first 48 h indicates a high risk of pancreatic necrosis in patients with acute pancreatitis. need an aggressive surgical approach fpr management of giant cystic pancreas neoplasm? resection or palliation? s. dubecz, h. heuberger, m. prager, h. hudler, p. hoffmann, k. vetter the histologically unproven giant cystic pancreas malignancy is a common problem for the diagnostic team and the surgery also. his histological confirmation at the asymptomatic neoplasm are more important the differentiation between of benign or malignant desaeses. in a rare situations, like the presented case, an extremely rare malignant tumors (acinar cell carcinoma) can be resected without any preoperative confirmation. a 73 year old man presented with loss of appetit, history with icterus and changes in bowel habits and negative value with tumour markers. the praeop. investigations were the follows (ct: 8 cm large inhomogen pancreashead tumour, with well anhancing wall, without liver and ln metastases, ercp: cysticmucinous giant tumour in the papilla region, with double duct occlusion, bileduct stanting was not available, histology:any praeop. biopsy was notmalignant). at the exploration we found a large cystic tumour in the pancreashead without propagation to the great wessels: the frozen histology was also negative. instead of originally planed palliation we performed a whipple operation. the early and postoperative period was also complicationsfree (6 month follow-up). we demonstrating in details the macro-, and microscopic path investigations (pancreastumor with central haemorrhage and necrosis, solid tubulo-cribriform tissue, cells with hyperchromatic nuclei and granular, with pas pos cytoplasm, with few cells are reactive with chromogranine and synaptophysine). also demonstrating the literature of the this very rare pancreas malignancy. it seems to be possible to achieve a curative result with an aggressive surgical approach at older patient also with a giant benign or semimalignant pancreas neoplasm. minimally invasive methods and surgery at the management of pancreatic pseudocyst methods. two hundred and forty-seven patients were undergo to percutaneous puncture of ppc under ultrasonographic guidance resulted in drainage in 63 patients. transpapillary and transmural approaches for endoscopic internal drainage were used in 12 and 62 patients, respectively. sixty-eight patients were undergo to opened surgery: internal (39) or external (18) drainage of ppc, distal pancreatectomy with cystectomy (9), enucleation of the cyst (2). results. ppc have been disappeared after percutaneous procedures in 22.6% patients with mature and in 68.2% patients with immature ppc. total success rate of endoscopic drainage of ppc was 93,5%. four patients after surgery have died (6.0%) because of bleeding, abscess and retroperitoneal phlegmon. obtained results and experience let us to propose the algorithm for the management of ppc. conclusions. both percutaneous and endoscopic methods are good minimally invasive alternatives for surgery in selected patients, but percutaneous procedures result in higher morbidity and longer hospital stay. the number of successful laparoscopic common bile duct exploration in patients with acute cholecystitis range from 34% to 98% because of changes of hepatoduodenal ligament anatomy. background. the purpose of study was to prognosticate possible difficulties and problems for laparoscopic choledochoscopy and bile duct clearance in patients with acute cholecystitis. methods. 1460 patients underwent to laparoscopic cholecystectomy because of acute calculous cholecystitis. by usage of blood tests, ultrasonography, x-ray examination of the gastrointestinal tract, ct, mri, endoscopy in 264 (18.1%) patients choledocholithiasis, stenosis of vater's papilla or peripapillary diverticulum were revealed and they underwent pre-or intraoperative common bile duct (cbd) exploration. results. prognostic factors for difficult and/or failed laparoscopic cbd exploration were hard masses in the hepatoduodenal ligament (ultrasonographical echopositive paravesicular masses close to the gall bladder neck and/or hyperechogenic strips, that usually occurs in 7-10 days after onset of acute cholecystitis), paravesical abscesses, thick (1.5 mm and more) wall of cbd, multiple stones in the cbd, large stones that completely filling up the cbd, peripapillary diverticulum, sludge with microcholelithiasis. 14 (5.3%) patients had conversion because of problems with cbd exploration. conclusions. laparoscopic cholecystectomy with cbd exploration and stone extraction is the method of choice in the treatment of patients with acute cholecystitis complicated with choledocholithiasis. in patients with predicted difficult laparoscopic cbd exploration the preoperative endoscopic retrograde resolution of intracholedocheal problems is favourable. operative treatment of pancreatic cancer: our experience y. i. havrysh 1 , y. i. shavarow 1 , m. p. pavlovskyy 2 , a. t. chykaylo 1 1 lviv regional hospital, lviv, ukraine; 2 lviv medical university, lviv, ukraine in our surgical department from 1997 to 2008 we treatment 252 patients with cancer of pancreas. we executed : 52 whiplle procedure,16 left pancreatectomies, 126 palliative operations, 58 patients were not operated. we diagnosed invasion of pancreatic tumors into colon in 3 patients, into stomach -3, into v. portal -2, into hepatic artery -1. from 52 patients for which one was executed whiplle procedure: male-39, female-13. age was from 28 to 74 years. we observed mechanical icterus in 34 patients. we used bilio-enteric anastomosis as first stage of the operation in 8 patients and conduction of stent implants in 16 patients. we performed pancreatectomy whiplle in two stages: 1 -resectional stage, 2 -reconstructional stage. conduct a reconstruction on the isolated loops for roux-en-y. we made drainage outside of common bile duck and pancreatic duck. we imposed anastomosis by single-row knotty suture: bilioenteric, gastro-enteric, pancreato-enteric, entero-enteric. post operative complications: bleeding in 8 patients, acute pancreatitis in 7 patients, peritonitis in 6 patients. we observed incapability of stitches of pancreato-enteric anastomosis in a 4 patients. we performed relaparotomy in 12 patients. died -6 patients: 2 patients died in result of postoperative bleeding, 2 patients -from acute pancreatitis, 2 patients -after peritonitis. life duration of our patients after operation: died till 1 year 6 persons, died till 3 years 14 persons, lived more than 5 years 8 persons, lived more than 10 years 3 patients. endoscopic papillectomy is feasible and safe in suspicious lesions of the papilla of vater (case series of 54 patients) diabetic gastroparesis (dgp) represents a chronic gastrointestinal disorder defined by delayed gastric emptying in the absence of mechanical obstruction. following successful pancreas transplantation dgp remains a major concern in one third of these patients. here we report on the application of intrapyloric injection of botulinum toxin a (botox) in six pancreas recipients. all six patients (four males) with stable graft function suffered from severe and persistent gastroparesis. symptoms of gastroparesis were quantified by the patient-assessment-of-gastrointestinal-symptom (pagi-sym#) severity-index before injection and during follow-up. likewise quality-of-life was assessed (pagi-qol#). total score varies from 0 to 5. to exclude other possible underlying causes gastric emptying was determined by x-ray and scintigraphic examination prior to treatment. botoxtherapy consisted of 100u injected equally distributed over the four quadrants of the pylorus. control x-ray was performed 24 h later. clear effects were evident within two weeks following botox-injection in all patients. while the mean symptom score before botox-application was 3.5 (range 2.9-4.5) early after treatment it decreased to 0.7 (0.3-2). similarly mean pagi-qol#-index decreased from 2.5 (1.6-3.2) to 1.1 (0-2.8). two patients required a second injection due to recurrent symptoms. no adverse events were observed. after a follow-up of 457.7 days (65-694) five of six patients experience substantial improvements in dgp symptoms and four report considerable amelioration of their quality-of-life. intrapyloric botox-injection should be considered in pancreas transplant recipients suffering from severe dgf if they are refractory to prokinetic and anti-emetic medication. #2002 johnson&johnson pharmaceutical services, llc. abscess in abdominal wall containing calculus -cholecystocutaneous fistula secondary to perforation of gall bladder: a case report background. complications of calculus cholecystitis include abscess up to perforation of gallbladder, which has been classified into acute (free perforation: type 1), subacute (abscess walled off by adhesions: type 2) and chronic (fistuleous communication in other viscus: type 3) perforation refering to modified niemeiers classification. primary manifestation of chronic perforated gallbladder could be presented as cholecystocutaneous abscess/fistula extremely infrequent, whereas fistula in general occurs in less than 1% of patients with biliary calculus (most likely cholecystoduodenal > 50%). methods. we encountered a 84 years old patient presenting with swelling at right upper abdomen with slightly elevated wbc and normal liver function test, sonography and ct-scan confirmed abscess and gallbladder adherent to abdominal wall. after cutaneous drainage with spilling of calculus and conditioning with antibiotics preoperatively secondary laparoscopic cholecystectomie and fistulectomie were performed. conclusions. in contrary to frequent cholecystocutaneous fistulas in former times, abscess in abdominal wall as a result of perforation in calculus cholecystitis is a rare entity nowadays due to the advent of sonography, antibiotics and early surgical treatment of biliary tract disease. diagnosis of cholecystocutaneous abscess or fistula might be difficult due to the lack of clinical specifity. anyway it should be considered and kept in mind as important differential diagnosis, therefore be affirmed aided by fistulogram, accurate ultrasonographic and ct-scanfindings and clinched with findings of bilious fluid on drainage. increased preoperative awareness for diagnosis of this condition as well as percutaneous drainage prior to subsequent surgical intervention will diminish rate of morbidity and mortality of the disease. background. acute sigmoid diverticulitis is a very frequent disease in western and industrialized countries. immunosuppressed patients show an increased incidence of complicated diverticulitis and a high risk of colonic perforation. the clinical presentation can range from non-specific signs of abdominal discomfort with delayed diagnosis of perforation to life-threatening abdominal sepsis. the standard surgical management mainly consists of hartmann procedure or primary anastomosis, but is still very controversial due to high morbidity and mortality in both cases. we present four case reports from our department with a short review of literature. methods. between 2000 and 2008 four patients after organ transplantation (lung â 2, kidney, liver) were admitted to the department of surgery for acute sigmoid divertculitis with free perforation (4 male patients; median age 65, range 35-87). two patients underwent a hartmann procedure, two patients had a primary anastomosis. results. the time interval between transplantation and perforation ranged between 7 months and 12 years with two patients having a history of diverticulitis. a dehiscence after laparotomy and an anastomotic leakage required revisional surgery in two patients. postoperative morbidity included acute rejection, pneumonia and acute renal failure. two patients died with mods following pneumonia and acute rejection (bilateral lung transplantation). conclusions. sigmoid perforation in transplant recipients is a rare, but life-threatening event with a high mortality. elective surgical interventions should be considered in patients with high risk of perforation (history of diverticulitis, steroid immunosuppression and heart/lung transplantation). außergewöhnlicher kasus der ausbildung von kolorektalen karzinomen an 4 lokalisationen bei pancolitis ulcerosa eines jungen patienten es ist hinreichend bekannt, dass die colitis ulcerosa als präkanzerose für die generation eines colonkarzinoms gilt. bei einem 36-jährigen patienten wurde im rahmen einer koloskopie wegen persistierender abdominalbeschwerden eine pancolitis ulcerosa diagnostiziert, die außerdem intraepitheliale neoplasien nachwies. erkrankungsassoziierte incompliance mit temporärer therapieablehnung für 1 jahr führte zu einer beträchtlichen verzögerung der indizierten proktokolektomie, die letztlich ein inzidentelles, simultanes kolorektales karzinom an 4 lokalisationen ergab [4 â pt3c pn1 (2/104) m0]. eine adjuvante radiochemotherapie konnte aufgrund von wundheilungsstörungen und nebenwirkungen nur verzögert und nicht zeitgerecht durchgeführt werden. der patient war 9 monate postoperativ rezidivfrei, erlag jedoch im verlauf nach einer notoperation bei bridenileus einer sepsis. trotz bekannter prädisposition bei colitis ulcerosa ist die ausbildung eines kolorektalen karzinoms noch immer ein relevantes pathogenetisches geschehen im krankheitsverlauf. insbesondere können diagnoseverzögerung und incompliance das risiko der manifestation maligner läsionen, wie im vorliegenden fall mit multiplen karzinomen, deutlich erhöhen und zu vermeidbar schweren ausmaßen mit sekundären krankheitsbildern führen. mit diesem aussergewöhnlichen fallbericht wird herausgehoben, dass aufgrund multilokulären, lokal fortgeschrittenen (nþ) tumorstadiums trotz erfolgreicher operation und stadiengerechter adjuvanter therapie eine engmaschige onkochirurgische verlaufsbeobachtung und frühe inrervention bei erhöhtem rezidivrisiko dringend verfolgt werden muss. das primäre amelanotische melanom des rektums background. a new surgical technique, the perineal stapled prolapse resection (psp), for external rectal prolapse was introduced by a feasibility study in 2008. this study now presents the first results of a larger patients number with functional outcome in a midterm follow-up. methods. from july 2007 to december 2008 the psp was performed on 28 patients with external rectal prolapse. the prolapse was completely pulled out and then axially cut open at three o'clock in lithotomy position with a straight stapler. finally the prolapse was stepwise resected with the curved contour + transtar tm stapler at prolapses' uptake. perioperative morbidity and functional outcome was prospectively documented by different scores. results. in all 28 patients, median age 82 years (range 26-93), psp was performed with no intraoperative complications. 14% postoperative complications occurred, two patients had a first degree complication (¼ no specific treatment necessary), one patient a second degree (¼ need special medication) and one a third degree (¼ interventional treatment necessary). no mortality. the median operation time was 31 min , the median hospital stay 6 days (2-29). in two patients a reccurence of the prolapse was observed (7%) and treated with a second psp procedure. functional result of 25 of 28 (89%) of the patients were available after a median time of 9 months (1-17) the median reduction of the wexner score was from 17 (8-20) before surgery to 0.5 (0-14) postoperatively, p < 0.0001. conclusions. the psp is an elegant, fast and safe procedure, with good functional results. colorectal adenocarcinoma in heart transplant recipients background. conflicting data exist whether patients undergoing heart transplantation (htx) are at increased risk for developing colorectal adenocarcinoma (crc). specifically, data on the age matched incidence are rare. methods. the vienna heart transplant database was queried to configure a list of eligible patients. exclusion criteria included: age less than 35 years at the time of transplant, diagnosis of colorectal cancer or patient death less than 12 month posttransplant, and pretransplant history of colorectal cancer. results. a total of 959 patients with htx were eligible for analysis from 03/1984 through 12/2007. the mean follow-up was 7.2 years. we identified 11 cases of crc. nine of those patients were between 55 and 64 years of age at diagnosis of crc. thus, the incidence of crc in htx recipients in this age groups is 1.67/ 1000, which is 9-fold higher than the incidence in the general austrian population for crc in this age group. the latter is 0.19/ 1000, derived from statistic austria. there was no difference in the incidence of crc in other age groups between the austrian population and htx recipients. median time from transplant to cancer diagnosis was 7.3 years. the median survival postcancer diagnosis was 3.9 years. conclusions. with the limitation of small numbers of htx recipients and crc available in our study, the incidence of colorectal adenocarcinoma in heart transplant recipients from 55 to 65 years appears to be markedly increased than the general population. our data warrant an intensified crc screening program for htx recipients in this age group. there is growing evidence that chemotherapeutics induce an inflammatory response during the very first course of treatment. we investigated the diagnostic history of patient with either breast or colon cancer. due to their underlying disease they receive different regimes of chemotherapeutic treatment. our standard neoadjuvant treatment of breast cancer is epirubicin and docetaxel whereas patients suffering from colon cancer receive oxaliplatin, irinotecan and 5-fluoruracil. we hypothesize that chemotherapeutic treatment should be mirrored within the blood plasma proteome. for this reason, blood was taken from both groups on the day before and 2-4 days after receiving the first course of chemotherapy. plasma proteomic analysis using 2d-differential in gel electrophoresis (dige) was performed. differentially expressed proteins were identified by mass spectrometry. using investigations of plasma proteome analysis we validated our findings using western blot. twenty-six out of 577 protein spots showed a more than 1.4 fold (p < 0.05) change within 4 days of chemotherapy, including complement factors c1, c3 and c4, alpha2hs glycoprotein and alpha 1-anti chymotrypsin in the breast cancer collective. in contrast, in colon cancer patients the expression level of only 5 out of 471 proteins was affected by the treatment. future investigations will show whether this difference in the treatment induced protein expression changes were related on different chemotherapeutic treatment or different patient collective. lösliches cytokeratin 18-m65-hat potential als postoperativer surrogate marker für den nachweis einer systemischen erkrankung beim kolorektalen karzinom bei einem 81 jahre alten männlichen patienten trat nach einer notwendigen parenteralen infusionstherapie am handrücken eine phlegmone auf, die primär unbehandelt blieb. es kam jedoch zu einem fortschreiten der infektion. schließlich musste eine incision durchgeführt werden, trotz der incision kam es jedoch zu einem handtellergroßen hautdefekt am handrücken rechts mit konsekutivem abriss sämtlicher strecksehnen. der patient war in stark reduziertem allgemeinzustand (zustand nach beckenfraktur, postantibiotische enterocollitis, demenz). trotz des schlechten allgemeinzustandes musste eine rekonstruktion der sehnen und deckung des hautdefektes durchgeführt werden, da sonst der patient in weiterer folge sich selbständig nicht mehr versorgen hätte können. es erfolgte in vitaler indikation die rekonstruktion sämtlicher strecksehnen durch strecksehnenplastik und die deckung des hautdefektes durch einen gestillten hautlappen. gleichzeitig musste eine antibiotische therapie mit metronidacol durchgeführt werden. es erfolgte anschließend eine ruhigstellung und durch diese therapie konnte eine völlige wiederherstellung der handfunktion erzielt werden. zusätzlich kam es zu einer besserung des allgemeinzustandes und der patient kann sich nun selbst versorgen. es wird auf die therapie und auf die ergebnisse eingegangen. neuropathien der oberen extremität präsentieren klinisch oft mit sehr ähnlichen symptomen, obwohl oft sehr unterschiedliche ä tiologien zu einem eng gefassten klinischen zustandsbild gefü hrt haben können. dies kann entweder zu einer glatten fehldiagnose und entsprechender fehlbehandlung fü hren oder den behandelnden arzt in ein diagnostisches dilemma bringen. bei einer klaren anamnese, welche eine mechanische ursache, wie trauma oder chronische kompression nahe legt, ist natürlich die therapie klar vorgegeben. bei patienten mit unklarer ä tiologie und klinischer präsentation sollte auch an den seltenen fall einer isolierten neuritis gedacht werden. diese spontan auftretenden lähmungen können auf unterschiedlicher höhe des armnervengeflechtes und den entsprechenden armnerven auftreten und dem unerfahrenen als typische nervenkompressionskasuistik imponieren. bei genauer begutachtung zeigt sich jedoch eine spontan aufgetretene rein motorische lähmung mit entsprechender anamnese und typischen prodroma. die elektroneurographie zeigt eine deutlich erniedrigte spa mit denervationspotentialen als reflexion der rein axonalen schädigung des motorischen systems. in diesem bericht werden wir die typische klinik der häufigsten neuritiden der oberen extremität und deren therapie anhand von fallbeispielen präsentieren und einen diagnostischen und therapeutischen algorithmus vorstellen. die zweizeitige beugesehnenrekonstruktion c. pazourek, u. mildner-deutschmann, p. aspalter, a. pachucki lk mostviertel amstetten, amstetten, austria wir zeigen an mehreren fallbeispielen einen algorithmus zur rekonstruktion von beugesehnen der hand sowie deren sehnenscheiden und ringbänder im rahmen eines zweizeitigen verfahrens unter intermittiernder verwendung eines silastikstabes. wir gehen auf einzelne indikationen ein und entwickeln in der folge ein schema zum zeitlichen ablauf. die op-technik wird beschrieben, ebenso wie zu gewährtigende komplikationen. visceral heme oxygenase-1 expression is determined by hip to waist ratio and linked to insulin sensitivity grundlagen. das diffuse intravaskuläre b-zell-lymphom (ivl) ist eine seltene, maligne erkrankung, charakterisiert durch eine intravaskuläre proliferation von lymphomzellen mit konsekutiven thrombosen der kapillaren und kleinen gefässe mit nachgeschalteten nachgeschalteten organischämien. jedes organsystem kann davon betroffen sein, die diagnosestellung erfolgt ausschließlich histologisch. eine 49 jährige patientin zeigte seit drei monaten b-symptomatik mit fieberschüben bis zu 40 c, reizhusten und müdigkeit. zusätzlich lagen eine hepatosplenomegalie mit hypoperfusion der milz, erhöhte entzündungsparameter mit anämie, sowie eine hsv-infektion und ein pulmonaler hypertonus vor. methodik. im thorax-ct wurden konfluierende infiltrate in beiden oberlappen und in den apikalen unterlappenanteilen verifiziert, im pet-scan fand sich kein pathologischer fdg-uptake. aufgrund von candida albicans im tracheobronchialsekret bestand der verdacht einer pulmonalen mykose. zur histologischen diagnostik erfolgte eine thorakoskopische keilresektion im segment 1 rechts. ergebnisse. histologisch zeigte sich ein diffuses intravaskuläres großzelliges b-zell-lymphom mit lambda-positivität, positiver immunhistochemischer reaktion auf vegfr2 und vegfr3, sowie cd 5-koexpression. typischerweise wiesen die arteriolen, venolen und kleinen peripheren gefässe eine vollständige thrombosierung durch tumorzellen auf. die patientin entwickelte peri-operativ ein sirs-artiges bild mit nicht beherrschbarer sepsis, welche den sofortigen beginn einer chemotherapie nicht zuließ. sie verstarb am 9. postoperativen tag an den folgen des multiorganversagens. in der obduktion fanden sich als ursache des mov tumorzellembolien in allen parenchymatösen organen. schlussfolgerungen. das diffuse intravaskuläre b-zell lymphom zeigt im vergleich zur kutanen manifestationsform eine extrem ungünstige prognose. das ü berleben ist wesentlich von der frühzeitigen diagnose und dem sofortigen therapiebeginn abhängig. bei ischämischen organläsionen in verbindung mit fieber sollte daher immer an das vorliegen eines intravaskulären lymphoms gedacht werden. die auswirkung von präoperativem aufwärmen auf die performance von unerfahrenen und erfahrenen chirurgen bei der laparoskopischen cholezystektomie das aufwärmen vor der eigentlichen tätigkeit gehört in vielen bereichen, etwa dem spitzensport oder der fliegerei, zur täglichen routine. wir haben die auswirkung von präoperativem aufwärmen an einem laparoskopie -simulator auf die operationsergebnisse bei einer laparoskopischen cholezystektomie, sowohl fü r junge als auch erfahrene chirurgen, untersucht. 6 chirurgen (3 mit über 10 jähriger dienstzeit, 3 am beginn ihrer ausbildung) führten jeweils 2 cholezystektomien an einem tübinger boxtrainer, mit beziehungsweise ohne 15 minütigen präoperativem aufwärmen an einem laparoskopie -simulator (lapsim, surgical science), durch. in das ergebnis flossen die operationszeit, die anzahl der instrumentenwechsel, die der leberschäden und jene der gallelecks ein. es zeigte sich, dass die jungen chirurgen bei allen parametern, bis auf die anzahl der instrumentenwechsel von präoperativem aufwärmen profitierten. bei den erfahrenen chirurgen hingegen zeigte sich ein anderes bild: sie benötigten zwar in beiden gruppen gleich lang, wechselten die instrumente gleich oft und es kam zu gleich vielen leberschäden, allerdings kam es in der gruppe mit präoperativem aufwärmen zu mehr gallelecks. präoperatives aufwärmen scheint einen positiven einfluss auf die operationsperfomance von jungen chirurgen zu haben. sie profitieren in hinblick auf die operationszeit, die anzahl von gallelecks und leberschäden. erfahrene chirurgen hingegen scheinen von präoperativem aufwärmen nicht zu profitieren. quality of life after sympathetic block at t3 for facial hyperhidrosis: results of a disease-specific evaluation background. endoscopic thoracic sympathectomy at the 2nd thoracic ganglion (t2) is the treatment of choice for patients with erythrophobia according to the lin telaranta classification. unfortunately, the incidence of compensatory sweating (cs) was reported to be higher in case of t2 sympathectomy. therefore, clip application (endoscopic sympathetic block, esb) has been introduced as it provides potential reversibility. the aim of the study was to analyze the outcome of patients treated by esb at t2 with special emphasis on the severity of cs. methods. between 2002 and 2009 47 patients (mean age 37 ae 11 years) prospectively underwent 94 procedures. satisfaction rates and visual analogue scales (vas) from 0 (no symptoms) to 10 (maximal symptoms) have been evaluated. mean follow up was 62.7 ae 12.7 months obtainable from all patients. results. the preoperative vas scores ameliorated from 8.9 ae 1.5 to 1.7 ae 0.4 six weeks after operation and remained stable during follow up (p < 0.01). 37 patients (78.7%) were free of symptoms, 8 (17.0%) improved, whereas unchanged blushing was found in 2 patients (4.3%). cs was observed in 20 patients (42.6%) with a mean vas score of 7.1 ae 2.0 at follow up. twelve patients (25.5%) rated cs as severe and another 2 patients (4.3%) as unbearable. two patients underwent clip removal with improvement of cs. overall, 93.6% would recommend this surgical procedure. conclusions. esb at the 2nd ganglion presents satisfying postoperative results for the vast majority of erythrophobic patients. furthermore, clip removal offers reversibility of unbearable side effects as cs mainly embarrasses patients' quality of life and satisfaction. experiences of using v.a.c. in the treatment of a complicated, recurring fistula on the small intestine after severe peritonitis p. metzger, m. bergmann, p. herbst, h. rola, f. messenbäck schlussfolgerungen. da es kaum möglich ist unterschiedliche wunden miteinander zu vergleichen konnte kein signifikanter unterschied zwischen den einzelnen systemen gefunden werden. auch bei gleichartigen wunden, bei demselben patienten konnte kein wesentlicher vorteil eines spezifischen systems herausgearbeitet werden. die unterschiede beschränken sich somit auf bedienerfreundlichkeit, schmerzmanagement, patientenkomfort und auf die kostenfrage. background. around one percent of people in industrialised countries will suffer from a leg ulcer at some time. the majority of these leg ulcers are due to venous problems and are so called venous ulcers. the main treatment has been a firm compression and classical wound dressings. additional methods like vacuum assisted closure (v.a.c.) are established in the management of acute and chronic wounds. we report on a case where v.a.c. was used in a 66-years old female patient with severe sepsis. methods. the patient was transferred to our hospital with a haemorrhagic shock due to a bleeding of a giant septic venous leg ulcer. we performed haemostasis and initial necrectomy under high dose antibiotic therapy followed by two weeks v.a.c. therapy. in two consequent operations we performed mesh grafting of the defect. results. grafts showed complete take-rate. after a total stay of two months the patient was discharged from hospital in good condition and with totally healed ulcer. conclusions. v.a.c. therapy was rapidly efficacious in cleaning the wound, promoting angiogenesis and the formation of healthy tissue. negative-pressure wound treatment may accelerate closure of large leg wounds even in septic ulcers. a close monitoring in these patients is mandatory. in such situations v.a.c. can be seen as a salvage procedure to avoid amputation of the lower extremity and to maintain patients' quality of life. further reports in large series are necessary to confirm our results. schwerste arm-und brustbandphlegmone nach insektenstich: behandlungskonzept offene wundbehandlung nach eröffnung sämtlicher nervenengstellen und debridement der nekrotischen gewebe a. obiltschnig bei einem immunsupprimierten patienten kam es nach einem insektenstich am ellbogen zu einer massivsten rasch auftretenden phlegmone des gesamten arms und der brustwand. der patient wurde zur therapie ins zentralkrankenhaus eingeliefert. es hätte primär nur eine exarticulation im bereich des rechten schultergelenkes durchgeführt werden können. hier wäre die hautdeckung jedoch immens schwierig gewesen. aus diesem grund wurde primär eine ausgedehnte nekrektomie im bereich des gesamten armes durchgeführt. zusätzlich die eröffnung sämtlicher nervenengstellen in der höhe des handgelenkes, des ellbogengelenkes und in der axilla. postoperativ wurden die vitalparameter in der intensivstation überwacht und eine gezielte antibiose durchgeführt. mit unterstützenden hilfsmaßnahmen (niere, lunge) konnte eine normalisierung der entzündlichen parameter erreicht werden. die nachbehandlung der hand erfolgte offen. es erfolgten keine hauttransplantationen, sondern nur die offene wundbehandlung. mit dieser behandlung (waschung -lokalmaßnahmen) konnte ein völliger verschluss der wunde erreicht werden und es wurde auch die funktion der hand wiederhergestellt. anhand dieses fallbeispieles sollte eben die offene wundbehandlung bei infektionen auch mit eröffnung der nervenengstellen diskutiert werden. methods. a retrospective review was performed on 1601 patients, who suffered a bite injury during january 1992 to december 2008. there were 881 males and 720 females, average age of 7.2 years (range 0-18 years). the most frequent site of injury were the face and the upper extremities, more than half of the victims were bitten by their pets. bite injuries ranged from relatively minor wounds to major injuries, that included open fractures, nerve and tendon laceration or loss of tissue. the incidence of dog-bites is higher in young children, involving the head, face or neck. in two-thirds of cat bites the upper extremities were effected, usually the hands and fingers. 10-50% of human bite wounds, concerning the middle hand, resulted in an infection. details of their injury treatment and outcome were recorded. results. there were 43 cases of primary infection within 12 h after the bite injury and 103 cases of delayed infection (12-72 h after bite injury). thirty-two patients required surgery like debridement of devitalized tissue to minimize the wound infection after thorough disinfection and intravenous antibiotic therapy. conclusions. the aim of immediate surgical repair is to obtain a satisfactory cosmetic result with a minimal risk of wound infection. antibiotic prophylaxis makes sense in immunsuprimized patients, children up to two years, bite injuries of the head, face, hands and fingers, and feet. background. we report on three diabetic foot patients suffering from verrucous skin lesions. all patients were suffering from neuropathy and other complications. in two patients partial forefoot amputation had been performed before, followed by split thickness skin grafting. one patient developed atypical malum perforans with verrucous surface with a pea-sized ulcer embedded in macerated horny material over the first metatarsal head. methods. in all three patients verrucous carcinoma of the skin was suspected. clinical findings showed slowly developing cauliflower-like warty tumours with deep sinuses and foul smelling thick greasy material. punch biopsies, respectively histological examination of derided tissue were performed. in all patients histological findings showed verrucous carcinoma. results. two patients were simultaneously suffering from deep neuropathic ulcers and underlying osteomyelitis requiring surgical intervention. transmetatarsal amputation was performed to heal osteomyelitis and to obtain a stable weightbearing foot stump. in one patient deep ulcer debridement was performed followed by offloading. healing was achieved in all patients. final histological findings showed pseudoepitheliomatous hyperplasia with focal papillomatosis according to papillomatosis cutis carcinoides, in case of diabetic neuropathy called vsldn (verrucous skin like lesions in diabetic neuropathy). conclusions. vsldn and diabetic foot ulcers are closely related in their aetiology and pathogenesis, whereas therapeutic strategy has not yet been established. in case of accompanying osteomyelitis required surgical procedure enables histological exclusion of verrucous carcinoma. in case of lacking surgical indication, offloading, professional foot care and compression to avoid friction is the main strategy for therapy and prevention of vsldn. survived suicide shooting through the cavities of pleura, pericard and peritoneum auch wenn die retrograde kontrastfüllung im ct nicht diagnostisch ist! die laparoskopie bietet sich sowohl diagnostisch wie therapeutisch an und ist möglicherweise dem offenen verfahren vorzuziehen. außergewöhnlicher fall eines dermatofibrosarcoma protuberans -ein fallbeispiel mit literaturübersicht grundlagen. das dermatofibrosarcoma protuberans (dfsp) ist ein mesenchymaler maligner tumor, der nur selten metastasiert und durch eine oftmals späte diagnosestellung und langsam infiltrativem wachstum gekennzeichnet ist. die resektion mit einem ungenü genden sicherheitsabstand resultiert in einem lokalrezidiv. berichte ü ber dfsp sind selten aufgrund der geringen inzidenz von weniger als 0.1 % aller malignome. in der vorliegenden arbeit wird die bedeutung eines ausreichenden sicherheitsabstands zur vermeidung eines lokalrezidivs aufgezeigt. methodik. ein 36-jähriger patient stellte sich mit einem an grösse zunehmenden knoten medial des linken schulterblattes vor. klinisch zeigte sich ein 6 â 8 cm großer, derber, subkutan liegender knoten, der gut verschieblich, leicht überwärmt und hämangiom-artig imponierte. ergebnisse. die klinischen befunde ergaben den verdacht auf ein atherom. daraufhin erfolgte eine spindelförmige exzision. intraoperativ präsentierte sich ein kugelig-glattes, prall-elastisches, gräuliches und hämorrhagisches gebilde. auf grund der für ein atherom untypischen befunde wurde eine histologische untersuchung veranlasst. diese zeigte ein unvollständig exzidiertes dfsp. es erfolgte die empfohlene nachresektion mit einem sicherheitsabstand von 2 cm mit der histologischen dokumentation der radikalen exzision. im bisherigen verlauf keine hinweise auf ein lokalrezidiv. schlussfolgerungen. hinter der verdachtsdiagnose eines atheroms kann sich seltenerweise ein dfsp verstecken. die histologische untersuchung eines resektates mit ,,auffälligem'' aspekt ist ein chirurgischer grundsatz. nur so kann ein rezidivfreies ü berleben erreicht werden und exzessive resektionen mit plastisch-chirurgischer deckung vermieden werden. hydrogen sulphide is a colourless, highly toxic, flammable and mucosal irritating gas which mainly originates during breakdown of organic matter in the absence of oxygen. after inhalation hydrogen sulphide binds to the mitochondrial respiratory enzyme preventing oxydative phosphorylation, thereby causing reversible inhibition of aerobic metabolism and cellular anoxia. the therapeutic use of hyperbaric oxygen for hydrogen sulphide intoxication is not standardised and its use is still controversial. 21 victims of occupational hydrogen sulphide intoxication were referred to our centre between 3/2006 and 9/ 2007. before admission, 100% oxygen had been was given by mask (n ¼ 15) or by endo-tracheal tube (n ¼ 6). two patients had been resuscitated at the site of the accident, in the six severe cases 4-dimethylaminophenol was administered as antidotal therapy. hyperbaric oxygenation was done immediately after admission in all 21 patients by using the schedule otherwise applied in carbon monoxide-intoxication. 2 out of 21 patients (9.5%) died of irreversible cerebral ischemia or pulmonary edema, respectively. the remaining 19 patients recovered without any neurological sequelae and were discharged for outpatient care after a median of 2.8 days (range 1-12 days). no antidote-related adverse effects were observed. in hydrogen sulphide intoxication hyperbaric oxygenation ensures quick re-oxygenation and counteracts the decrement in oxygen carriage caused by methemoglobinemia due to antidoteadministration. in our experience, hyperbaric oxygenation alone or in combination with 4-dimethylaminophenol therapy proved a safe tool in the management of mild or severe hydrogen sulphide intoxication, respectively. influence of a new self-fixing hernia mesh on the ductus deferens in the rat model inferior vena cava-associated tumor lesionschallenging vascularsurgical management in a representative case series of 14 patients methodik. anhand einer außergewöhnlichen kasuistik wird die seltene konstellation eines abdominalen fibromyxoiden sarkoms mit nicht vorbeschriebener manifestation im greisen lebensalter, wesentliche aspekte des perioperativen diagnostischen und therapeutischen managements dargestellt und ins verhältnis zu verfügbaren literaturangaben gesetzt. ergebnisse. eine 88-jährige multimorbide patientin fiel durch erhebliche obstipationneigung mit subileus auf (nebenerkrankungen: z.n. lungenembolie, diabetes, khk, hypertonie, beginnend dekompensierende chronische niereninsuffizienz). anamnestisch z.n. punktion unklarer lebertumorläsion 6 jahre zuvor (histologie: sklerosiertes hämangiom)-klinisch monströse resistenz im mittelbauch. sonographie und ct: monströse teils zystisch, teils mit liquiden anteilen bzw. solide imponierende tumorläsion zwischen leber und magen ohne organzugehörigkeit; angiographisch keine pathologischen tumorgefäße (venöse abflussbehinderung). die transcutane fnp erbrachte keine diagnosesicherung. therapeutisch wurde eine tumorexstirpation in toto mit resektion des omentum majus und atypischer leberresektion im segment 3 ausgeführt. nach histomorphologischem aspekt von leberkapsel ausgegangenes, niedrig malignes sarkom (durchmesser: 25 cm; gewicht: 2,350 g). keine leberinfiltration, ü berwiegend myxoider background, spindelzellige, teils pleomorphe tumorzellen mit hyperchromasie, faseriges stroma (immunhistochemisch: glattmuskuläres aktin: þ; desmin/s100/ö strogen-und progesteronrezeptor/cd31/cd34/cd117: negativ). lymphknoten tumorfrei. 14 monate nach tumorresektion war kein tumorrezidiv zu verzeichnen. schlussfolgerungen. der bisher älteste berichtete patient ist 78 jahre alt. der vorliegende fall steht also, insbesondere im hinblick auf das fortgeschrittene alter der patientin und die lokalisation eine ausgesprochene rarität dar. grundlagen. die elektrische impedanz-tomographie (eit) stellt eine nicht invasive methode zur darstellung der lokalen lungenventilation sowie der lungenwasserverteilung dar. intrapulmonale flüssigkeitsverschiebungen können beobachtet werden bei lageveränderungen des körpers oder als pathologische veränderungen wie sie zum beispiel im rahmen eines lungenödems auftreten. interessanterweise kann auch ein direkter einfuß der regionalen lungenventilation zur lage des körpers im raum dargestellt werden. weiters zeigten mehrere studien das lungenteile die unter einem höheren mechanischen stress stehen besser ventiliert werden als die restlichen lungenregionen. methodik. die messungen wurden an 6 gesunden männlichen probanden durchgeführt mithilfe des ,,multichannel impedance spectroscope mxs1 (osypka medical gmbh). für die dauer der messung wurden die probanden in ein rotierendes bett (rotorest -kci austria gmbh)platziert mit einer kontinuierlichen rotationsgeschwindigkeit von annähernd 30 pro minute. die messungen beinhalteten die waagrechte position sowie einen 62 schwenk jeweils nach links und rechts und endeten wieder in der waagrechten für 5 minuten. mittels image -rekonstruktion konnte der zeitpunkt der ventilation verschiedener areale dann bildlich dargestellt werden. ergebnisse. bei allen 6 probanden konnte bewiesen werden das immer der mechanisch am stärksten belastete lungenabschnitt (linksrotation -linke lunge, rechtsrotation-rechte lunge, waagrechte -posteriore lungenabschnitte) bevorzugt ventiliert werden. schlussfolgerungen. die ergebnisse dieser studie zeigen das eit zukünftig als ausgezeichnete nicht invasive untersuchungsmethode zur beurteilung der lungenventilation dient. mögliche einsatzorte wären zum beispiel intensivstationen, wo auf relativ einfache weise der erfolg von kinetischen therapien verifiziert werden kann. background. lichtenstein hernioplasty is a very common technique for repairing an inguinal hernia and foreign body reaction after mesh implantation is a very rare complication. case report. a 68-year-old patient with an inguinal hernia came to our department. we did a lichtenstein hernia repair with a paritex polyester mesh (14.9 cm). five months later the patient came again because of right inguinal pain and swelling. ultrasonography and a ct-scan were done. it showed three liquid formations in the right inguinal region. blood test showed signs of a moderate inflamation, no feaver. we described antibiotics and nsar. a few days later we did a punction which showed pus. a reoperation was performed. an abscess formation subcutaneously was laid open. the smear culture was steril. during the first month post operation the patient felt well, but there was still serous secretion from a fistulous tract. two and a half months post operation an mri scan was performed which showed a abscess formation involving the inguinal canal. at re-operation we found serous fluid, an intact mesh surrounded by inflamated tissue. we removed the mesh, a bassini's procedure was performed and the patient got antibiotics. in the smear culture we couldn't find any microorganismus. histologically a chronic granulomatous foreign body reaction was found. the finding was a proof for a foreign body reaction. in the following controlls the patient didn't have any further problems. methods. we report on two patients, who developed massive postoperative pe and received sildenafil as an adjuct to thrombolytic therapy. results. the first patient underwent gastric wedge resection for a large perforated gastric ulcer after initiation of interferon/stroid therapy for multiple sclerosis. on the evening after discharge, she was admitted to the emergency room with acute dyspnea and cardiac failure and diagnosed with massive pe. she underwent mechanic-pharmacological clot fragmentation (angio-jet device in conjunction with tpa using the power pulse technique). on the intensive care unit, oral sildenafil was started (50 mg twice daily), which resulted in significant improvement of right heart failure. the patient suffered renal and hepatic failure, however, ultimately recovered with restored organ function. she is well and alive after more than one year. the second patient developed acute pe four days after liver transplantation for primary biliary cirrhosis. she was treated with systemic thrombolysis. application of sildenafil resulted in significant improvement in cardiac output and right heart failure which caused congestion of the liver allograft. she later developed takotsubo cardiomyopathy and renal failure, however, recovered from these complications and is alive with good graft function after 10 months. conclusions. although the two cases suggest that sildenafil may be a useful pharmacologic intervention in acute massive postoperative pe, a controlled trial is necssary to confirm our findings. chirurgische therapie des katamenialen pneumothorax w. kolb, r. kuster, w. nagel klinik für chirurgie, st. gallen, switzerland grundlagen. der katameniale pneumothorax ist eine seltene ursache eines spontanpneumothorax, der durch eine abdominale bzw. thorakale endometriose verursacht wird. methodik. wir berichten ü ber drei patientinnen, die aufgrund eines rezidivierenden mensassoziierten rechtsseitigen spontanpneumothorax an unserer klinik behandelt wurden. in der vergangenheit waren zwei patientinnen bereits thorakoskopisch mittels einer lungenspitzenwedgeresektion behandelt worden. aktuell erfolgte bei allen drei patientinnen zunächst eine diagnostische thorakoskopie zur diagnosesicherung. in allen fällen erfolgte bei ausgedehntem befall des zwerchfelles eine zwerchfellteilresektion ü ber eine rechtsseitige thorakotomie, in einem fall erfolgte die implantation eines kunststoffnetzes zur defektdeckung. die operationen verliefen durchwegs komplikationslos. histologisch konnte bei allen patientinnen anhand des operationspräparates die präoperativ gestellte diagnose eines katamenialen pneumothorax bestätigt werden. postoperativ wurde eine konservative therapie mit ovulationshemmern begonnen bzw. fortgesetzt. ergebnisse. im rahmen der nachbeobachtungszeit von nunmehr 24 monaten ist bei einer patientin nach pausieren des ovulationshemmers ein neuerliches rezidiv eines spontanpneumothorax aufgetreten, welches durch einlage einer thoraxdrainage behandelt werden musste. die beiden anderen patientinnen sind beschwerde-und rezidivfrei. grundlagen. benigne fibröse tumore der pleura sind in der literatur kaum beschrieben. zu 70 % gehen diese von der viszeralen pleura aus. methodik. an der abteilung für herz-thorax-und gefäßchirugie im lkh klagenfurt wurde 2008 ein 64 jähriger männlicher patient aufgrund rezidivierender pleuraergüsse rechts bei bekanntem zwerchfellhochstand rechts vorgestellt. klinisch präsentierte sich der patient mit geringer dyspnoe (nyha ii) nach bereits erfolgten mehrmaligen pleurapunktionen, welche in der zytolgischen diagnostik keine besonderheiten zeigten. ein durchgeführtes pet ct ergab keinen keinen pathologischen fdg uptake, allerdings eine raumforderung beziehungsweise ein fragliches hämatom im bereich des rechten lungenunterlappens sowie den bekannten erguss. ergebnisse. zur weiteren abklärung führten wir eine videoassistierte thorakoskopie (vat) durch. nach endoskopischer absaugung der flüssigkeit konnte ein solitärer tumor, ausgehend vom rechten lungenunterlappen identifiziert werden. die resektion gestaltete sich technisch einfach. der pathologische befund zeigte einen fibrösen pleuratumor ohne malignität ausgehend von der pleura viszeralis mit einer größenausdehnung von 10,5:8,5:5,5 cm. schlussfolgerungen. benigne fibröse tumoren der pleura sind selten. eine chirurgische resektion sollte angestrebt werden, rezidive werden kaum beschrieben. indikation zur onkologischen resektion und lymphknotendissektion bei acthsezernierendem net der lunge grundlagen. nach histologischem nachweis eines acthexprimierenden malignen neuroendokrinen tumors mittels thorakoskopischer lungen-wedgeresektion wird die indikation zur onkologischen lungenresektion mit mediastinaler lymphadenektomie anhand eines fallberichtes diskutiert. ergebnisse. ein 29 jähriger patient mit dem klassischen bild eines zentralen morbus cushing wies bei unauffälliger craniocerebraler magnetresonanztomographie in der thora-duced by pulmonary vascular endothelial cells, playing a role in the pathophysiology of pulmonary edema. whether pretransplant pulmonary tissue et-1 mrna could predict pgd in ltx is unknown. et-1 mrna expression was examined by real time rt-pcr in lung tissue biopsies of 50 donors (mean age 39 ae 13 years) and recipients (mean age 48 ae 13 years) obtained shortly before ltx. the mean ischemic time of the graft was 295 ae 59 minutes. the underlying disease in recipients was chronic obstructive pulmonary disease (n ¼ 28), cystic fibrosis (n ¼ 9), emphysema (n ¼ 9), primary pulmonary hypertension (n ¼ 1) and retransplantation (n ¼ 3). in 28% of patients, pgd was diagnosed and scored by oxygenation and radiological characteristics according to ishlt guidelines. expression levels of et-1 mrna were significantly increased in both donor (p < 0.01) and recipient (p < 0.03) tissue in the patient group developing pgd. moreover, donor and recipient et-1 gene expression correlated with the grading of pgd severity (r s ¼ 0.56; p < 0.01). neither pgd grade nor et-1 expression correlated to patient age or ischemia time of the graft. this study indicates for the first time that pre-transplant et-1 mrna overexpression in both donor and recipient mediates pgd development due to alteration of pulmonary vascular resistance and permeability. assessment of et-1 tissue gene expression is thus a sensitive and specific predictor of pgd in ltx and might be beneficial in donor selection and in the prophylactic treatment of recipients by using targeted et-1 antagonists. surgical closure of the asd was possible with near-normalized paps after ten months of ''conditioning'' medication with bosentan (250 mg/day). the patient could be discharged from the hospital on post-operative day 28 under ongoing bosentan treatment. eight months thereafter the patient was in good clinical condition with residual mild pulmonary hypertension. the traditional rule of inoperability of an asd with severe pulmonary hypertension was recently challenged by case reports where asd could be closed after long-time conditioning therapy with prostacycline. we now present a similar case treated with bosentan (an endothelin antagonist), which has several advantages compared to epoprostenol. because it is an oral drug, there are no complications related to an intravenous delivery system which are common under long-time prostaglandin therapy. we conclude that a pre-operative bosentan treatment of a patient with asd ii and severe pah is feasible and may allow surgical correction. lung compression and cardiac displacement resulting from the caved-in chest. in the second case, a 40-year-old woman that received chemotherapy for an aggressive undifferentiated tumor of the sarcoma group, infiltrating clavicle, humeroclavicular and acromial joints, was chosen for forequarter amputation with resection of thoracic wall. reconstruction also involved a myocutaneous armflap. in the third case, a 58-year-old woman with a chondrosarcoma of the sternum underwent a subtotal resection of the sternum. reconstruction was performed with an additional dualmesh. the fourth case is about a 67-year-old woman with a giant tumor of the thoracic wall (fibrosarcoma) treated with radiacal resection (5th to 8th rib) and a dualmesh patch. the use of the stratos tm system represents a safe and practical approach for the correction of chest wall deformities and the reconstruction of the chest wall after tumor removal. artery disease. the underlying mechanism remains largely unknown. methods. endothelial cells and fibroblasts were established from rat hearts. additionally h9c2-cardiomyocytes were used. a water bath was designed to avoid distracting physical effects. adherent cells in cell culture flasks filled with culture medium were dunked into the bath. sw (0.15 mj/mm 2 ) were applied. analysis were performed over a period of 7 days. results. sw stimulate every cardiac cell type to a different extent. each cell type reacts at another timepoint. the distance between applicator and cells, as well as the energy flux density have an influence on the cells' behaviour. between days 4 and 5 the duplication time of treated cells was significantly higher compared to controls. significant differences in the gene expression of mmps, timps and collagen were shown. treated cells do alter their cytoskeleton (vimentin, tubulin, beta-actin), show significantly more proliferation (ki-67) and changes in the expression of adhesion molecules (cd31) as well as connexins 40, 43, 45. no apoptosis was found in the treatment group. conclusions. sw activate proliferation of cardiac cells. moreover cells alter the assembly of microfilaments, thus seem to ameliorate cell migration. changes of the mmp and timp levels and the expression of adhesion molecules seem to be strongly involved in the sw tissue regenerative effect on ischemic myocardium. idiopathic dilated cardiomyopathy (dcm) is characterized by ventricular wall remodeling and an increased incidence of apoptosis. apollon is a member of the inhibitor of apoptosis protein (iap) family that promotes cell survival by ubiquitination facilitating the degradation of pro-apoptotic molecules. traf2 belongs to the tnf-receptor-associated family ubiquitinated by other iaps after pro-apoptotic stimuli. whether the apollon/ traf2 system may mediate programmed cell death in dcm is unknown. apollon and traf2 protein expression was examined in left ventricular biopsies of explanted failing hearts using western blotting in 36 dcm patients and 10 controls. human cardiac cells were transfected with a plasmid containing the human apollon cdna or control vector and were subsequently stressed by hypoxia. apollon and traf2 mrna expression was then measured in cell lysates by real time rt-pcr and tunel assays were used to determine the apoptotic index. in dcm myocardial tissue, apollon expression was downregulated and traf2 was upregulated compared to control hearts (p < 0.01). cell stress resulted in increased apoptosis in cardiac cells in vitro with downregulation of apollon and upregulation of traf2 mrna expression compared to control cells (p < 0.001). transfection with apollon increased apollon and decreased traf2 mrna expression in cell lysates (p < 0.001) and completely abolished hypoxia-induced apoptosis. these results suggest for the first time that apollon regulates the level of traf2 and that both apollon and traf2 are involved in the programmed cell death associated with dcm. upregulation of apollon with subsequent traf2 suppression might therefore constitute a novel strategy in dcm treatment. monalvenen durchgeführt. zur kontrolle des operationserfolges wurde zusätzlich ein permanenter loop-recorder medtronic reveal tm xt implantiert. ergebnisse. es konnten 4 ganglien isoliert und selektiv abliert werden. postoperativ trat normofrequenter sinusrhythmus ein, ein postoperatives 24-stunden holter zeigte durchgehenden sinusrhythmus mit einer frequenz von 54-84/min. bei den kontrollen nach 3 und 6 monaten ergab die abfrage des loop recorders einen stabilen permanenten sinusrhythmus ohne aufgezeichnete vorhofflimmerepisoden. schlussfolgerungen. die selektive isolation und ablation der autonomen ganglien im rahmen der vorhofablation bei vorhofflimmern kann zu einer verbesserung der operationserfolges führen, wobei bei unserem patienten die normale sinusknotenfunktion erhalten blieb. perioperative antibiotikaprohyplaxe bei herzchirurgischen eingriffendas erfolgreiche regime der grazer herzchirurgie grundlagen. weichteilinfektionen sind in der herzchirurgie eine bekannte komplikation. in der literatur kommt es in 7 % zu oberflächlichen infektionen, in 1,6 % zu tiefen steruminfekten, in 1-2 % der fälle wird von postoperativer mediastinitis mit einer sternumdehiszenz berichtet. die mortalität bei den mediastinalen infektionen ist mit 9-14 % hoch, die kosten für patienten mit sternalen wundinfekten sind 2,8 mal so hoch wie für patienten mit unkompliziertem postoperativem verlauf. methodik. an der herzchirurgie graz wird seit 1996 folgendes antibiotisches regime angewendet: eine stunde präoperativ wird cefuroxim iv gegeben, unmittelbar vor hautschnitt teicoplanin, die zweite dosisgabe der beiden antibiotika erfolgt noch an der hlm. das cephalosporin wird für 24 h postoperativ bei cabg verabreicht, bei klappenoperationen bis zum 3. postoperativen tag. die daten beziehen sich bis zur entlassung ins rehabilitationszentrum. bei langliegern werden antibiotika nur nach vorliegendem antibiogramm verabreicht. alle patienten werden präoperativ auf mrsa mittels nasenabstrich (positiv bei n ¼ 27) gescreent. ergebnisse. 2008 kam es weder zu postoperativer mediastinitis noch zu chirurgisch behandlungsbedürftigen oberflächlichen sternalen wundinfekten, an der beinwunde war die inzidenz für weichteilinfekte 0,51 % (n ¼ 5), bei diesen patienten wurden mit einem v.a.c.-system behandelt, in einem fall musste der defekt mit einer spalthaut gedeckt werden. in sechs fällen (0,62 %) wurde eine sterile sternumdehiszenz noch am tag der wundrevision recercliert. bei keinem patienten wissen wir von chronisch offenen wunden. die mortalität aufgrund von wundinfekten war 0 %. schlussfolgerungen. nach 5 jahren kam es nicht zu resistenzen. die rate an wundinfektionen ist erfreulich gering. unverständlicherweise kommt dieses grazer antiobiotische regime kaum zur anwendung. grundlagen. morbus castelman (angiofollikuläre lymphknotenhyperplasie) ist eine seltene erkrankung vornehmlich der cervikalen und mediastinalen lymphknoten. klinisch imponieren lymphknotenschwellung mit b-symptomatik, splenomegalie und hepatomegalie. die diagnosesicherung erfolgt durch biopsie. wir berichten über eine 24 jährige patientin, welche nach vorangegangenem respiratorischen infekt akute hämoptysen und dyspnoe zeigte. bronchoskopisch fanden sich zeichen einer stattgehabten blutung. im labor waren leukozytose und crp erhöhung auffällig. methodik. im thorax ct fand sich eine ausgedehnte diffuse, tumoröse infiltration des oberen und mittleren mediastinums und beider hili mit umscheidung der supraaortalen ä ste, der aorta ascendens, vena cava superior sowie der beiden vorhöfe. infolge völliger einmauerung des rechten pulmonalarterienhauptstammes bestand rechts keine perfusion. keine dieser strukturen zeigte eine speicherung im pet, nur an der mesenterialwurzel fand sich ein hypermetaboler herd. der versuch einer mediastinoskopie zur diagnosesicherung scheiterte an der fehlenden darstellbarkeit der strukturen im extrem derb-fibrotischen gewerbe. ü ber thoracotomie gelang es aus einzelnen, in die fibrösen massen eingelagerten hilären lymphknoten eine diagnose zu stellen. ergebnisse. es fand sich die seltene, plasmazellreiche variante des mb. castleman mit ausgeprägter hyalinisierung und fibrosierung. diese form ist multifokal und zeigt verstärkte il 6 expression und in deren folge unspezifische entzündungszeichen. eine koinfektion mit hhv 8 bzw. mit hiv (in ca. 50 % zu beobachten) konnte ausgeschlossen werden. schlussfolgerungen. durch die einleitung einer therapie mit einem monoklonalen chimären antikörper (rituximab; mabthera + ) wurden eine signifikante besserung der klinischen symptomatik sowie eine deutliche befundregredienz erreicht. germany ziel der untersuchung war es, machbarkeit, therapieergebnisse & ,outcome'' der endoskopischen papillektomie zu untersuchen. methodik. ü ber einen definierten behandlungszeitraum wurden alle konsekutiven patienten mit tumor-ähnlichen papillenläsionen mit möglicher endoskopischer papillektomie in diese systematische klinische ,bicenter''-beobachtungsstudie einbezogen & in 4 gruppen entsprechend des endoskopischen & eus-befundes sowie der pathohistologischen diagnose eingeteilt. machbarkeit & behandlungsergebnisse wurden durch r0-resektionsrate, morbidität (z.b. rate/spektrum von komplikationen) & mortalität charakterisiert; outcome wurde durch rezidivrate & tumor-freies ü berleben eingeschätzt jahre) eingeschlossen. vor der papillektomie wurde die eus in 4/5 (79,6 %; n ¼ 43) der patienten durchgeführt gr.2 (karzinom/neuroendokriner tumor, n ¼ 18): 55,6 % (n ¼ 10) mit r0-resektion gr.3 (adenomyomatosis, n ¼ 4). gr.4 (nicht einführbarer katheter in die papille bei hochrisikopatienten mit papillenkarzinom jedoch ohne hinweise auf ein tief infiltrierendes tumorwachstum kann sie als sinnvolle therapieoption mit niedrigem risiko & einer ca. 80 % -wahrscheinlichkeit hinsichtlich rezidivfreiheit angesehen werden, wenn r0 erreicht wird die toxizität des antikörpers (ak) unterscheidet sich von der traditionellen chemotherapie. eine zwar seltene aber schwerwiegende ak-spezifische komplikation ist die gastrointestinale (gi) perforation, die mit hoher morbidität/letalität einhergeht. das ziel bestand darin, an hand eigener exemplarischer und publizierter erfahrungen befund-bezogene besonderheiten dieser außergewöhnlichen pathogenese einer perforationsbedingten peritonitis nach ak-therapie einschließlich therapeutischem ,outcome'' darzustellen. methodik. es wurden patienten mit einer bevacizumab-induzierten perforationsbedingten peritonitis seit klinischer einführung (i) aus dem eigenen patientenklientel recherchiert (design: prospektive fallserie), (ii) literaturangaben gegenübergestellt (historische[retrospektive] vergleichsgruppe) und (iii) hinsichtlich der ergebnisse des chirurgischen managements frauen: n ¼ 2; geschlechtsverhältnis: m:w ¼ 1:1). die durchschnittliche behandlungsdauer bis zum auftreten der komplikation betrug durchschnittlich 70d patienten verstarben ohne operative versorgung an den peritonitisfolgen. die perioperative gesamtmorbidität betrug 73,3 % (n ¼ 11/15) in allen fällen mit primärer anastomose (n ¼ 4) trat im verlauf eine anastomoseninsuffizienz auf (100 %). die rate der wundheilungsstörungen betrug die peritonitis nach gi-perforation infolge einer bevacizumab-therapie stellt eine seltene akassoziierte, aber ernstzunehmende, da lebensbedrohliche komplikation dar. die im zusammenhang mit der neoangiogeneseinhibition gestörte wundheilung bedingt abweichungen im management gi-perforationsereignisse im vergleich zur etablierten chirurgischen standardversorgung klinik für viszeral-, transplantations-und thoraxchirurgie das amelanotische melanom des rektums (amr) ist eine seltene erkrankung, dessen chirurgische therapie derzeit kontrovers diskutiert ist. die transrektale ultraschalldiagnostik (eus) besitzt in der diagnostik und nachsorge eine entscheidende bedeutung der literatur wurden innerhalb von 30 jahren anhand von 2 repräsentativen fallberichten für amr im rahmen einer klinischen bicenterbeobachtungsstudie zur qualitätssicherung in der rektumchirurgie wird über das therapeutische spektrum dieser seltenen befunde und maßnahmen in abhängigkeit vom individuellen verlauf berichtet die patientin verstarb jedoch 36 monate nach der erstdiagnose. schlussfolgerungen. die prognose des amr ist unabhängig von der chirurgischen therapie schlecht. die lokale tumorresektion mit einem sicherheitsabstand von 1 cm ist das primäre verfahren der wahl, die apr hingegen sollte den verbleibenden fällen vorbehalten bleiben severe facial hyperhidosis (fh) bothers patients' every day life and leads to human withdrawal and social phobia. the aim of the study was to assess pre-and postoperative quality of life (qol) using a disease-specific qol questionnaire after limited endoscopic thoracic sympathetic block at t3 (esb3) for fh. methods. fifty patients underwent 100 esb3 procedures in a prospective study between 2002 and 2009 at a mean follow up of 57.8 ae 22.0 months. a validated disease-specific qol questionnaire by milanez de campos (1-5) and a visual analogue scale (vas; 1-10) concerning the extent of fh were evaluated by annual telephone calls (1: no symptoms; 5 or 10: maximal symptoms). results. vas scores decreased from 9.1 ae 1.5 preoperatively to 1.9 ae 0.6 postoperatively and to 2.1 ae 0.4 at long term follow up (p < 0.001). 46 patients (92%) were completely or almost dry postoperatively. side effects, such as compensatory sweating (cs) and gustatory sweating were each ae 14.1 at a 5 year follow up (p < 0.01) endoscopic sympathetic block at t3 reduces fh efficiently and improves qol. cs impairs qol substantially emphasizing the importance of clip removal induce clip removal as final retreat strategy -cava-inferior(vci)-assoziierte tumorläsionen stellen eine außerordentliche herausforderung im interdisziplinären behandlungskonzept von viszeral gefäßwandinfiltration und (iii) intraluminalen tumorzapfen mit alteration des blutstroms im gefäßchirurgischen patientenklientel eines chirurgischen zentrums prospektiv erfasst und retrospektiv ausgewertet. ergebnisse. es wurden insgesamt 14 patienten operativ behandelt: 6 leiomyosarkome der vci (42,8 %), 2 retroperitoneale tumore (seminommetastase, paraganglion; 14,3 %) als auch von außen infiltrierende tumore und 1 cholangiozelluläres karzinom mit vci-adhäsion (7,2 %) und 5 tumorzapfen (35,7 %; 4 nierenzell-/1 nebennierenrindenkarzinom). die tumorresektionsrate betrug 100 %. op-technisch wurde die vci entweder ü ber die tumorbefallene strecke komplett durch eine gefäßprothese ersetzt, eine partielle wandresektion mit anschließender patchplastik, die tangentielle resektion mit primärer naht oder die ausschälung des cavathrombus nach cavotomie vorgenommen. die tumorzapfen wurden mit/ohne vci-resektion erfolgreich reseziert eine operation vci-assoziierter tumore ist nur bei aussichtsreicher r0-resektion sinnvoll 316 patients underwent 19-or 21-mm mechanical aortic valve replacement, receiving either a carbomedics top hat valve (n ¼ 56; mean age, 66 ae 14 years) or a standard carbomedics one (n ¼ 260; mean age, 60 ae 13 years) at our institution. median follow-up time was 83.5 months. we performed echocardiographic follow-up austria neben dem angeborenen av-block haben zunehmende fortschritte der herzchirurgie mit tendenz und notwendigkeit, immer komplexere operationen zu immer frü heren zeitpunkt auszufü hren, zwangsläufig zu einem gelegentlichen bedarf postoperativer schrittmacherimplantation im säuglingsalter gefü hrt angeborene herzfehler bestanden bei 19 säuglingen und erforderten herzoperationen mit folgender, meist iatrogener rhythmusstörung bei allen säuglingen wurde der generator zunächst in einer submuskulären tasche des rechten mittel-oder unterbauches eingebracht, die elektroden entweder epikardial platziert oder über die rechte a. subclavia (5) bzw. die a. jugularis (4) eingebracht, in einem fall transatrial. im kollektiv mit angeborenem av-block gab es keine perioperativen todesfälle, bei angeborenem herzfehler sind 2 patienten (10,5 %) verstorben: ein neugeborener mit 1500 g körpergewicht und komplexem syndrom nach verschluss eines ductus botalli und im insgesamt wurden bei diesen 19 patienten bislang 49 folgeeingriffe vorgenommen (1,9/patient): vorrangig wachstumsbedingte anpassungen des systems sowie aufrüstung im betriebsmodus. die moderne schrittmacherchirurgie gewährleistet auch im neugeborenen-und säuglingsalter eine uneingeschränkte entwicklung mit hervorragender lebensqualität, nur durchbrochen von hauptsächlich wachstumsbedingt erforderlichen folgeeingriffen acknowledgments. this study was supported by mammamia. we also thank all experts and non-experts for their time-consuming subjective evaluation. methodik. der 49-jährige bechterew -patient wurde aufgrund einer perforierten sigmadivertikulitis mit stercoraler peritonitis notfalllaparotomiert, wobei eine stomasituation nach hartmann angelegt werden musste, sowie eine dünndarmteilresektion mit einem endständigen ileostoma erfolgte. es entwickelte sich eine stercorale peritonitis, welche mit einem ,,kci-v.a.c.-abdominaldressing'' im sinne eines laparostomas behandelt wurde. weiter entwickelte sich eine dünndarmfistel. nach frustranen reoperationsversuchen entschied man sich, die gegebene fistelsituation seitens des therapieansatzes als zweites stoma zu behandeln und arbeitete daher auf einen entsprechenden bauchdeckenverschluss hin.um eine schnellere abheilung zu erreichen, entschied man sich schließlich nach der v.a.c.-versorgung für eine defektdeckung mittels mesh-craft-transplantat. dieses konnte mittels v.a.c.-verband zum anheilen gebracht werden.nach klinischer stabilisierung erfolgte eine dünndarm-reanastomosierung. allerdings entwickelte sich in der folge erneut eine anastomoseninsuffizienz mit ausbildung einer dünndarmfistel. eine konservative verbandstechnik gestaltete sich in dieser situation als schlichtweg unmöglich. da aufgrund der vorgeschichte eine erneute spalthautdeckung der wieder klaffenden bauchwunde nicht möglich erschien, kam wieder eine versorgung mit einem v.a.c.-system zum einsatz.ergebnisse. die wundfläche konnte damit in wenigen wochen auf fast die hälfte reduziert und mittels stomaplatte versorgt werden. die verbandstechnik erlaubte es, dass durch eingeschultes pflegepersonal eine verbandsüberwachung und sogar neuanlage möglich wurde.schlussfolgerungen. die erreichten ergebnisse bei diesem primär lebensbedrohlichen krankheitsbild und der rezidivierenden entwicklung von dünndarmfisteln wären ohne innovative chirurgisch-pflegerische betreuung und der wochenlang durchgeführten v.a.c.-therapie wohl kaum zu erzielen gewesen, das verfahren konnte klar überzeugen. unterdrucktherapiebesteht ein qualitativer unterschied zwischen den verschiedenen systemen? tumor-induced bleeding by affection of the axillar artery due to recurrent tumor growth of breast carcinoma with successful endovascular treatment grundlagen. die tumor-induzierte blutung aus einem stammgefäß ist ein seltenes ereignis, kann jedoch lebensbedrohlich in erscheinung treten.methodik. es wird die suffiziente alternative option der blutstillung bei einem außergewöhnlichen casus mit fortgeschrittenem tumorleiden und infiltrationsbedingter blutung demonstriert, die kaum konventionell angehbar erschien.fallschilderung und therapieergebnis. eine 70-jährige patientin wurde mit hämorrhagischem schock intubiert und beatmet ü ber die rettungsstelle eingeliefert und reanimiert. in der anamnese war ein z.n. operativer spaltung eines schweißdrü senabszesses links-axillär vor 1 jahr mit chronischer wundheilungsstörung (mikrobiologischer abstrich: gram-negative stäbchen, candida) bei inflammatorischem mamma-karzinom links (histologisch durch tumor-pe gesichert) und erfolgter palliativer strahlenchemotherapie bekannt. die sofortige notfallangiographie via a. femoralis sinistra erbrachte eine blutung aus dem proximalen segment der a. axillaris sinistra. in gleicher sitzung wurde interventionell-radiologisch ein selbstexpandierender endoluminaler stent (5 â 40 mm viabahn + , gore, flagstaff, usa) ü ber die arterienläsion hinweg platziert, die eine umgehende suffiziente blutstillung erbrachte. die abschließende kontrollangiographie zeigte die korrekte stentlage mit sicherer peripherer perfusion im brachialen abstromgebiet ohne weiteren blutungsnachweis. am 7. postinterventionellen tag wurde die patientin nach zwischenzeitlicher antiseptischer wundpflege links-axillar entlassen.schlussfolgerungen. die endovaskuläre versorgung umgrenzter arterieller läsionen ist eine geeignete option, in schwierig zugänglichen arteriensegmenten aufgrund der anatomischen lokalisation, begleiterkrankungen und therapiekonsequenzen eine suffiziente blutstillung herbeizuführen und eine aufwändige, grundlagen. ,,omphalozele'' und ,,ö sophagusatresie'' sind als einzelfehlbildungen häufig mit zusätzlichen malformationen vergesellschaftet. ä ußerst selten ist das gleichzeitige vorkommen von omphalozele und ö sophagusatresie, in der internationalen literatur sind nur einige wenige fallberichte zu finden.methodik. bei einem feten wurde sonographisch in der 14. ssw eine omphalozele diagnostiziert. die chromosomenanalyse (normaler weiblicher karyotyp) war unauffällig. das organscreening und die verlaufskontrollen ergaben keinen hinweis auf assoziierte fehlbildungen. bei der postpartalen untersuchung des neugeborenen war, abgesehen von der omphalozele und einem präaurikuläranhang rechts, klinisch und bildgebend keine zusätzliche malformation festzustellen. während der bauchwanddefektkorrektur kam es plötzlich zu beatmungsproblemen, zurückzuführen auf eine ö sophagusatresie typ iii b nach vogt. nach anlage einer ,,schusterplastik'' wurde die tracheoösophageale fistel durchtrennt und, da das kind stabil blieb, eine endzu-end-ö sophago-ö sophagostomie angeschlossen.ergebnisse. der postoperative verlauf gestaltete sich, abgesehen von einer sich spontan schließenden leckage der ö sophagusanastomose, komplikationslos. drei zusätzlich diagnostizierte kleine ventrikelseptumdefekte blieben asymptomatisch. das kind entwickelte sich in der folge aufgrund einer schweren schluckstörung allerdings nur bescheiden.diskussion. die intrauterine realisierung von mehrfachfehlbildungen ist schwierig. aber auch postpartal gelingt der nachweis einer fehlbildungskombination nicht immer. im seltenen fall kann eine gravierende fehlbildung gleichzeitig mit einer zweiten korrekturbedü rftigen, u.u. erst intraoperativ verifizierbaren anomalie vorkommen. die kombination von omphalozele und ö sophagusatresie, einhergehend mit ventrikelseptumdefekten und einem präaurikuläranhang, ist ungewöhnlich und konnte keiner/m der in frage kommenden fehlbildungsassoziationen/-syndrome (vacterl-assoziation, charge-syndrom, schisis-assoziation) zugeordnet werden.schlussfolgerungen. wenn bei einem neugeborenen eine komplexe fehlbildungskombination zu keiner/m assoziation/ syndrom ,,paßt'', ist die prognoseeinschätzung in hinblick auf outcome und zukünftige entwicklung des betroffenen kindes schwierig. background. the prognosis of colorectal cancer is primarily determined by anatomic extend of disease and by amenability to radical resection. results of treatment in patients who underwent resection for colon and rectal cancer in two time periods were compared, before and after introduction of multidisciplinary tumor board in the second period. methods. in order to improve the results of colorectal cancer, a multidisciplinary tumor board was set up and beside the strict adoption of tme principles, an oncological treatment has been systematically included in the management. 1478 patients with colorectal cancer underwent a potentially curative resection between 1991 and 2000. results were analyzed for two groups of patients given different diagnostic approach and treatment regimens during two consecutive 5year periods.results. the 5-year survival rate of r0 resected patients with colon cancer stage i and iii in the period 1996-2000 was significantly higher than of patients operated on between 1991 and 1995 (stage i: 86% vs. 70%; stage iii: 58% vs. 40%). similarly, the 5-year survival rate for r0 resected patients with stage iii rectal cancer between 1996 and 2000 was significantly better than that for patients operated on during the early period (58% vs. 31%).conclusions. patients who underwent r0 resection for colon and rectal cancer during the period 1995-2000 showed a significantly improved 5-year survival rate compared to those operated on between 1991 and 1995. improved survival in these patients is to a great extent attributable to improvements in clinical practice combining surgery with other modalities of treatment. schlussfolgerungen. trotz der oft schwerwiegenden grunderkrankung der patienten und dem aggressiven infektionsmuster der zygomycosen und der daraus resultierenden schlechten prognose kann eine solche infektion bei chirurgischen handeln gepaart mit einer optimalen antimykotischen und intensivmedizinischen therapie überlebt werden. context. adipose tissue (at) macrophages are key suspects to cause obesity-associated insulin resistance. besides inflammatory mediators promoting insulin resistance, at macrophages express the hemoglobin scavenger receptor cd163 and the downstream enzyme heme oxygenase-1 (ho-1) that protect from free hemoglobin-induced oxidative stress and metabolize hemoglobin to anti-inflammatory mediators, respectively. background. aim of this study was to evaluate the association of cd163 and ho-1 expression in visceral and subcutaneous at with obesity, metabolic parameters, body fat distribution, and at inflammation.methods. morbidly obese patients (bmi > 40 kg/m 2 ) who underwent laparoscopic surgery for gastric banding (n ¼ 20) were matched for age and sex to lean control subjects (bmi < 30 kg/m; n ¼ 20).main outcome measures. cd163 and ho-1 as well as the macrophage marker cd68 mrna expression was analyzed in visceral (omental) and subcutaneous at. moreover, serum concentration of soluble cd163 was determined by elisa.results. cd163 expression was highly upregulated in human at and soluble cd163 serum concentration was elevated in obesity. also ho-1 was upregulated in at and expressed exclusively in macrophages. while cd163 expression strictly correlated with macrophage abundance as assessed by cd68 expression, ho-1 upregulation by obesity exceeded the increase of cd68, indicating a regulation within macrophages. strikingly, waist to hip ratio negatively correlated with relative visceral expression of ho-1 (p ¼ 0.009) and visceral ho-1 expression negatively correlated with homa-ir (p ¼ 0.024).conclusions. visceral ho-1 expression is determined by body fat distribution and attenuates obesity-induced insulin resistance. do we need to substitute vitamin b12 parenterally after gastric sleeve resection? background. daily oral multivitamin supplementation is recommended for patients after restrictive bariatric surgery, whereas after malabsorptive procedures or major gastric resections, parenteral substitution of vitamin b12 (vitb12) is mandatory.sleeve gastrectomy (sg), a mainly restrictive procedure, has been established in many bariatric surgical centers in the last few years, either as a definitive measure or as a first step before major malabsorptive procedures. the resected stomach volume has been reported between 700 and 1000 ml. sg therefore amounts to a subtotal (80-90%) gastrectomy.we analyzed serum values of vitb12 in order to assess the need for parenteral vitb12 supplementation in sg patients.methods. between jan. 2002 and aug. 2008, 54 patients (30 females, 24 males) underwent sg at our department. postoperatively, all patients were advised to take a multivitamin supplement daily. serum values of vitb12 were obtained after a median follow-up of 20 months (range, 2.6 to 65 months).results. fifty-two of 54 patients displayed serum values of vitb12 within the normal range (118-716 pmol/l according to our laboratory). the median serum level of vitb12 was 277 pmol/l (range, 61 to 876 pmol/l). neurological symptoms of vitb12 deficiency or macrocytosis were not observed.conclusions. vitb12 deficiency after sg is rare. on the other hand, the median serum level in our sg patients was far below the median laboratory value (416 pmol/l), and eight values were within the so-called ''gray area'' (118-200 pmol/ l). this perhaps indicates incipient vitb12 deficiency and warrants further observation of rbc indices and serum vitb12 values in sg patients. grundlagen. die perforation der neoblase, nach zystektomie, ist selten. in der literatur sind solche spontanrupturen als einzelne case reports beschrieben. als ursache sind ischämien der neoblase oder mal-compliance des patienten bei der ,,blasenent-leerung'' zu nennen. in der vorliegenden arbeit wird erstmalig die laparoskopische neoblasen-ü bernähung beschrieben. methodik. ein 58-jähriger patient, mit status nach zystektomie mit orthotoper anlage einer ,,ileumblase'' wegen rezidivierendem blasenkarzinom (t1 g3), präsentierte sich mit zunehmender dysurie, und fehlender vollständiger blasenentleerung. es zeigte sich bei der notfallaufnahme ein akutes abdomen, mit generalisierter peritonitis. in der computertomographie des abdomens fand sich freie flüssigkeit, jedoch keine freie luft und eine prall gefüllte ersatzblase. die katheterisierung der blase brachte keine beschwerdeverbesserung, auch war die retrograde füllung mit kontrastmittel nicht diagnostisch. laborchemisch bestand eine leukozytose von 10,300 g/l bei einem crp von 1 mg/l.ergebnisse. in der notfallmäßig angeordneten diagnostischen laparoskopie zeigte sich im bereich des unterbauches freie flüssigkeit und fibrinauflagerungen im bereich der ersatzblase. nach füllen der neoblase mit ca. 500 ml methylenblau konnte eine 0,5 â 0,5 cm messende perforationsstelle, welche laparoskopisch übernäht werden konnte. der postoperative verlauf war unauffällig, entlassung des patienten mit klarer instruktion zur regelmässigen blasenentleerung nach 10 tagen.schlussfolgerungen. das auftreten einer spontanruptur der neoblase ist selten. daran denken und die diagnose erzwingen background. posters are used widely at surgical meetings to present news of clinical and scientific research. posters are presented in special areas preferably at meeting points and provide a relaxed environment for exchanging ideas. especially for young scientists and surgeons poster presentations often are the first scientific contacts to the surgical community. many societies award ''best poster prices'' however mostly without uniformly agreed assessment methods. we generated poster assessment guidelines in a checklist to evaluate posters at surgical meetings.methods. according to well published guidelines for the designing and presentation of posters we constructed an evaluation checklist consisting of three main parts: presentation, design of the poster, background and purpose of the poster (scientific impact).results. the table shows our recommendation for the checklist in three parts.conclusions. awarding poster prices are stimuli especially for young scientists to participate at surgical conferences and meetings. however it can be very disappointing if great efforts have been applied to prepare posters and presentations and it is not possible to see through the evaluation process.therefore the evaluation process has to be objective as well as open and above board. the posters should be evaluated by independent scientist of different institutions. our assessment guidelines and checklist meet these mentioned requirements.an examination of the quality will show if this tool is applicable or not. background. complications after extensive thoracic surgery can be complex and life threatening, and diagnostic pathways are potentially difficult. we present the case of a 66 years old patient who postoperatively developed an acute displacement of mediastinal structures by abdominal viscera after extrapleural pneumonectomy. methods. the patient was treated with extrapleural pneumonectomy in a curative intention. diaphragm was reconstructed with an artificial mesh implant after a major part of the diaphragm had to be resected. the mesh was fixed with interrupted non-absorbable sutures.results. due to failure of the diaphragmatic reconstruction and subsequent displacement of abdominal strucutes, acute displacement of the mediastinal structures occurred. initial x-ray led to the false diagnosis of suspected tension pneumothorax with a classical picture of mediastinal shift. the correct diagnosis was diagnosed by ct scan only. the treatment of choice therefore was operative revision and not the placement of a chest tube for decompression.conclusions. this rare but very dangeours complication after extensive cytoreductive surgery for malignant pleural mesothelioma is important to know for every general surgeon. interestingly the displaced stomach was massively bloated due to ''air trapment'', which led to the false diagnosis. only retrospectively, a very thin line in conventional x-ray was found being the stomach wall. in situations of postoperative impairment of a patient's condition after extensive thoracic surgery, we recommend to perform further diagnostic measures with early ct scan. in this situation placement of a chest tube would have been potentially harmful to the patient who recovered without further complication. erfolgreiche konservative therapie des postoperativen chylothoraxein klinischer algorithmus grundlagen. der chylothorax nach thorakalen chirurgischen eingriffen ist eine seltene aber wegen seiner metabolischen und nutritiven konsequenzen gefürchtete komplikation. die optimale therapie -konservativ versus operativ -wird kontrovers diskutiert. chirurgische reinterventionen sind häufig, neben dem nochmaligen operativen trauma und einer potentiellen versagensrate, mit einer erhöhten morbidität und mortalität assoziiert.methodik. alle konsekutiven patienten, die in unserer einrichtung während eines 2-jahreszeitraumes eine abdomino-thorakale ö sophagusresektion wegen eines ö sophaguskarzinoms erhielten, wurden in dieser studie prospektiv erfasst und im rahmen des internen qualitätsmanagements auf ihr komplikationsspektrum untersucht. bei diagnose eines postoperativen chylothorax' erfolgte primär die konservative therapie entsprechend eines an unserer einrichtung inaugurierten und etablierten therapiealgorithmus'.ergebnisse. von dezember 2006 bis november 2008 unterzogen sich 56 patienten einer subtotalen ö sophagusresektion wegen eines ö sophaguskarzinoms. insgesamt drei patienten entwickelten einen postoperativen chylothorax, jeweils rechtsthorakal. dieser konnte nach klinischer und laborchemischer diagnosebestätigung (detektion von chylomikronen, triglyceridlevel >110 mg/dl) in allen fällen erfolgreich mittels (1) totaler parenteraler ernährung, (2) nahrungskarenz, (3) pleuraler drainage sowie, (4) subkutaner octreotidgabe, gefolgt von einer, (5) speziellen oralen diät (mct-fette) therapiert werden. die mittlere behandlungsdauer dieser konservativen therapie betrug 16 tage.schlussfolgerungen. beim vorliegen eines postoperativen chylothorax' sollte zunächst konservativen therapiemaßnahmen im stufenschema der unbedingte vorzug gegeben und diese ausgeschöpft werden. das chirurgische vorgehen hingegen ist frühzeitig bei versagen konservativer therapien sowie beim auftreten von komplikationen zu favorisieren. operability of advanced central lung tumors usually is limited and the prognosis is dismal. however, combination of chemoradio induction therapy owns the potential for significant downs taging of the tumor and can bring the patient back to operability, even in advanced tumor situations.we present the case of a 54 years old patient with nsclc (t4, n2, m0; stage iiib) of the right upper lobe and infiltration of the carina. induction therapy with 4 cycles of gemzar and cisplatin combined with 30 gy local mediastinal radiation resulted in a major clinical response (yt3, yn0, m0; stage iib). this was followed by surgical resection (upper bi-lobectomy, resection of the carina, end to end anastomosis of the left main bronchus into the trachea, re-implantation of the right lower lobe into the left main bronchus; all performed under temporary ecmo support). pathological investigation revealed a complete response with no vital tumor cells left.this report demonstrates the potentials of modern combination therapy of extended lung tumors, emphasizing the value of aggressive induction therapy, followed by a technically demanding operation, in case of good clinical response. response to induction therapy, together with completeness of surgical resection, remains the most significant prognostic parameters for outcome.keywords. nsclc, carinal resection, ecmo, neoadjuvant chemo-radiotherapy, complete response. pulmonary benign metastasizing leiomyomatosis (bml) is a rare smooth muscle cell disorder of the lung. the prevailing treatment option is a primary excision of the nodules or if unresectable a long-time hormone therapy. herein, we present a case of bml in which a wait-and-see strategy after diagnosis has been decided.a 56-year-old female was admitted to the medical university of vienna presenting with multiple, bilateral suspect pulmonary tumor masses in 1993. subsequent diagnostic workup revealed a bml. the patient refused a surgical intervention and hormone treatment was abandoned because of the patient's heavy menopausal disorders. as malign transformation of bml is uncommon a wait-and-see strategy was agreed upon. however, the patient was lost to follow-up, until in 2007, 14 years later, she developed expiratory rhonchus. a thoracic-ct revealed eleven intrapulmonary circumscribed circular foci. in addition the left lower-third was filled up with tumor mass and a giant cyst (diameter 18 cm) extended into the thoracic cave. the nodules and the tumor mass were excised and the patient fully recovered without any evidence of a remaining disease. pulmonary bml nodules have been shown to stay constant for a long time. if resectable, a surgical excision is recommended as first line therapy. our case report indicates that a wait-and-see strategy is feasible but could lead to severe complications. we therefore conclude that a primary excision of bml tumor masses is preferable in order to avoid complications leading to more extended surgical interventions. background. pulmonary re-transplantation (prt) remains the only therapeutic option in some cases of severe primary graft dysfunction (pgd), advanced bronchiolitis obliterans sydrome (bos), and in some cases of severe airway problems (awp), mainly cicatriceal stenosis. however, its value has been questioned due to the overall scarcity of donor organs and reports indicating unsatisfactory outcome. we analyzed our institutional experience with prt to evaluate its value for different indications.methods. we retrospectively analyzed all 46 patients undergoing prt in our department from august 1995 to august 2006. we stratified patients according to indication for prt and analyzed the outcome.results. forty-six patients (mean age 41 ae 16 years, 18 male and 28 female) underwent prt (14 bilateral lung-transplantations, 32 single-lung-transplantations) for pgd (n ¼ 23), bos (n ¼ 19) and awp (n ¼ 4). mean time to re-transplantation was 26 ae 27 days for pgd, 1,069 ae 57 days for bos and 220 ae 321 days for awp. thirty-days, 1-year and 5-years survival rates after prt were 52.2, 34.8 and 29.0% for pgd; 89.2, 72.5 and 61.3% for bos. all 4 patients with awp are presently alive (bos vs. pgd: p ¼ 0.02; bos vs. awp: p ¼ 0.27; pgd vs. awp: p ¼ 0.06). long-term survival rates for prt due to pgd are significantly lower, warranting restrictive use in this setting. in our experience prt for awp has shown excellent results.prt for chronic problems is a plausible approach, provided that patients are carefully selected. prt for pgd should be avoided.herzchirurgie /chirurgie der thorakalen aorta grundlagen. hämodynamisch wirksame stenosen der aorta, insbesondere am thorakoabdominellen ü bergang sind eine seltene entität. ü bliche behandlungsstrategie ist die konventionelle, chirurgische versorgung, neben der weiteren option einer axillo-bifemoralen bypassoperation. die endovaskuläre stent-graft insertion dient als behandlungmethode erster wahl für zahlreiche thorakale und abdominelle aortenpathologien. insbesondere bei älteren und multimorbiden patienten zeigt sie ihre vorteile.methodik. wir berichten von zwei patienten, die aufgrund von angina abdominalis, sowie claudicatio intermittens an unser zentrum transferiert wurden. in der computertomographie zeigte sich jeweils eine symptomatische stenose der aorta am thorakoabdominellen ü bergang (,,coral-reef aorta''). aufgrund des hohen operationsrisikos, das sich insbesondere in den euroscores (numerisch 16 bzw. 13) zeigte, wurden beide patienten mittels transfemoraler, endovaskulärer stent-graft insertion versorgt.ergebnisse. beide patienten konnten wenige tage nach dem eingriff entlassen werden. die abschließenden kontrollen mittels computertomographie zeigten jeweils den stent-graft in korrekter position und voller entfaltung, sowie distal davon vollständig wiederhergestellte, antegrade perfusion. die patienten waren zu diesem zeitpunkt beschwerdefrei und zeigten auch in einer ct-kontrolle nach 6 monaten keine veränderung dieser situation.schlussfolgerungen. gleich anderen aortenpathologien, wie perforierende ulcera, ist diese sogenannte korallenriffaorta das fortgeschrittene stadium eines obliterativen, atherosklerotischen chronisch-systemischen prozesses. gerade deshalb ist der allgemeinzustand dieser patienten meist sehr schlecht, weshalb minimal invasive therapieoptionen vorteilhaft erscheinen. obgleich wenig erfahrung mit der endovaskulären versorgung der aortenstenose am thorakoabdominellen ü bergang existiert, könnte diese option zur behandlungsstrategie erster wahl werden, indem sie minimale invasivität mit maximaler effektivität vereint.paraplegia after thoracic surgery has been reported in the literature. the paraplegia rate after intrathoracic operations ranges between 0.08 and 12% overall. after vascular surgery for ruptured aneurysm of the thoracic aorta paraplegia has been reported up to 12%. however; this specific complication is greatly reduced for planned surgery (0.4%). the thoracoabdominal approach for oesophageal resection is associated with a risk of 0.2%. it is unclear, whether thoracotomy alone, regardless the extent of other surgical procedures bears a risk for paraplegia. the blood supply of the spinal cord in adult is highly variable. we report on a case of paraplegia after an uneventful thoracotomy in a 47 year-old man. indication for surgery was an epiphrenic diverticulum of the oesophagus. paraplegia after thoracotomy is a rare but typical complication and should be mandatory included in informed consent. background. total supra-aortic rerouting as well as double vessel transposition followed by endovascular stent graft placement are now an established tool for the treatment of various aortic arch pathologies. however, details about the motion of the aortic arch after this procedure remain unknown. moreover, no perfectly fitting risk stratification score exists for outcome prediction of this specific patients.methods. we applied a fully automated method to quantify the deformation patterns of the aortic arch in a gated ct sequence. the aorta is detected and segmented by an active surface approach, that accurately identifies the vessel wall in all frames. the correspondences of landmarks on the vessel wall are established by tracking the deformation during the cardiac cycle, resulting in a dynamic deformation model of the structure.results. with help of this model, global and local deformation properties like stretching and bending were measured. after registering the models acquired pre-treatment, post-transposition, and post-stent-graft-placement we compared these local properties and were able to quantify the change caused to the aortic arch motion.conclusions. this new method of automated computational motion analysis of the aortic arch may establish a risk stratification score for outcome prediction after supra-aortic rerouting followed by endovascular stent-graft placement. background. simultaneous surgical repair and endovascular treatment are now a common approach for various aortic pathologies. for minimizing the risk of an untreated descending aorta after surgical repair of ascending aorta in acute stanford type a dissections a new type of bare-metal stents was established.methods. from august 2006 to january 2007 we performed combined surgical and endovascular treatment with the djumbodis dissection system in 8 patients (mean age 59) suffering from acute type a dissections.results. early results after treatment obtained by gated ct scans were satisfactory. nevertheless, thrombosis of the false lumen was not enhanced in most patients. combined surgical and endovascular approaches need stent devices with a self expanding capability, since the djumbodis stent seems to be not that attached to the aortic wall during systolic excursion.conclusions. additional implantation of the non-covered, non-self-expanding djumbodis device in the distal arch and the proximal descending aorta does in most cases not enhance thrombosis of the false lumen in patients undergoing surgery for acute type a dissections. the most limiting factor seems to be the non self-expanding capability of the device. the purpose of this study was to evaluate outcome in patients with a small aortic root receiving either a standard carbomedics or a top hat mechanical aortic valve. cox regression analysis revealed age, previous cardiac surgery, additional procedures at the time of valve replacement, nyha iv and severely impaired lvef to be independent predictors of survival.mechanical aortic valve replacement in the small aortic root is associated with substantial perioperative mortality. nevertheless, long-term outcome is satisfying. because the type of prosthesis does not predict outcome in the multivariate cox model, we conclude that use of the top hat prosthesis can be recommended for the challenging cohort of patients with a small aortic root. klinische abteilung für herz-thoraxchirurgie, wien, austria stumpfe thoraxtraumen können unabhängig vom unfallmechanismus und schweregrad des traumas zu mitralklappeninsuffizienz führen. die unterscheidung zwischen vorbestehender schädigung und traumatischer genese ist unter begutachtungsmedizinischen aspekten von großer bedeutung.kasuistik: ein 35 jähriger gendarm wurde im rahmen einer ü bung in knie-ellenbogen-position mit auf dem rü cken stehendem kollegen von einer mauer aus einer höhe von 2 meter herab fallenden sandsäcken getroffen und erlitt ein hws-und bws-trauma. erst 16 monate später wurde erstmalig ein herzultraschall durchgefü hrt und ein sehnenfadenabriss mit höhergradiger mitralinsuffizienz diagnostiziert und drei jahre nach dem trauma ein mechanischer herzklappenersatz vorgenommen.als häufigste ursache fü r eine posttraumatische insuffizienz der mitralklappe besteht ein papillarmuskel-abriss, seltener ein ausschließliches trauma der sehnenfäden. die literatur der jahre 1964 bis 2005 enthält 14 berichtete fälle von isoliertem abriss von sehnenfäden mit höhergradiger mitralinsuffizienz, zwei davon als autoptische diagnose. das alter der in 86% männlichen betroffenen lag zwischen 7 und 64 jahren, im mittel 40,5 jahre. als unfallursache dominierten verkehrsunfälle unterschiedlicher art (n ¼ 10; 71 %) und in einzelfällen sturz aus 2 meter höhe, gegen ein boot oder vom pferd sowie ein pferdetritt. das intervall zwischen ereignis und operativer versorgung durch rekonstruktion oder prothetischen ersatz lag zwischen 4 tagen und 24 jahren, in 67% (8 von 12) jedoch unter einem monat.die frage der ursächlichkeit ist meist retrospektiv zu beantworten. häufig sind fokussierte untersuchungsbefunde nicht verfügbar und bleibt die genese letztlich spekulativ. daher sollten nach jedem thoraxtrauma eine echokardiographie und anlässlich jeder herzoperation nach anamnestischem ereignis eine detaillierte makroskopische und histologische befundung durchgeführt werden. simultaneous mitral valve and lung surgery for complicated endocarditis and abscessing pneumonia over a thoracotomy approach a 48-year-old man developed severe sepsis after a blunt chest trauma. the patient suffered from presternal and cervical abscesses, mediastinitis, septic arthritis of the right shoulder, abscesses in the right and severe infective endocarditis of the mitral valve. after subcutaneous and mediastinal abscess drainage, hemodynamic stabilisation,and control of sepsis, biological mitral valve replacement and concomitant resection of the right lower pulmonary lobe were performed over a muscle sparing 15 cm right anterior-lateral thoracotomy. restoration of the shoulder could be performed 22 days later. the patient was discharged after 4 weeks and is well one year after surgery. asd repair after a 10-month treatment with bosentan in a patient with severe pulmonary arterial hypertension large congenital type ii atrial septal defect (asd ii) can lead to precapillary pulmonary hypertension (pah) if not repaired in early childhood. once severe pulmonary hypertension or eisenmenger's syndrome have developed, asd closure is problematic due the increased risk of right ventricular failure and pulmonary hypertensive crisis. however, single case reports have demonstrated that a surgical correction of an asd is feasible, but requires long-time pre-and post-operative prostacycline treatment.we report the case of a patient with asd ii (15 â 36 mm) and severe pulmonary hypertension (mpap 54 mmhg). successful background. sternal wire fixation was first used in 1897 and since then was the preferred method for sternal closure, as it is inexpensive, fast and effective.however, as cardiac surgery patients get older and more debilitated, the risks of wire closure, namely breaking or cutting through porous bone often resulting in sternal nonunion and wound infection. therefore, alternatives are needed to ensure a reliable sternal closure.methods. during january to december 2008 a total of 13 patients with am mean es of 9 (mean age 67.6 years) underwent closure with the sternal talon. indication was copd and adipositas in 6 patients each, delayed sternal closure in 2, parasternal sternotomy in 3 and secondary closure after sternal wound infection and v.a.c. therapy in 2 patients.results. all patients had combined procedures (cabgx 3 and ake or mkr or both) with a mean operating time of 300 min. the sternal talon was easy and convenient to use, with a mean implantation time of 10 min. none of the patients developed a sternal nonunion or wound infection during follow up.conclusions. the sternal talon offers the advantage of a rigid sternal fixation without injuring the bone as it pulls the two sternum halves together, without cutting or screwing through the bone, thus preserving the bone integrity. full sternal closure is achieved in a minimum of time in contrast to other rigid fixation devices. through the non touch technique, patients experience less pain and can be mobilized in a shorter time. we want to share our experiences with the application of the stratos tm system (strasbourg thoracic osteosyntheses system) for the correction of chest wall deformities and reconstructive surgery of the chest wall after tumor removal.this system uses a titanium implant consisting of two adaptable rib clips and a length connecting bar.we will discuss one case of a benign condition and three cases of reconstructive surgery of the chest wall after radical resection of malignant tumors that were treated with the above described system. ergebnisse. im schnitt wurden 2,11 venensegmente bevorzugt vom oberschenkel entnommen.bei gleichzeitiger präparation der linken arterie mammaria tritt durch die endoskopische venenentnahme kein zeitverlust auf.in 2 (2,3 %) fällen kam es zu einer verletzung der vsm. bei 2 (2,3 %) patienten war eine konversion aufgrund einer starken blutung notwendig und bei 5 eingriffen (6 %) zusätzliche inzisionen.postoperativ beobachteten wir lediglich eine wundinfektion (1,1 %), welche mittels v.a.c. + system und anschließendem sekundärem wundverschluss behandelt wurde.schlussfolgerungen. die endoskopische entnahme der vsm ist eine sichere und mit weniger postoperativen komplikationen verbundene methode im vergleich zur konventionellen präparation.dies sollte einen routinemäßigen einsatz weiter fördern. prophylactic low-energy shock wave therapy improves wound healing after vein harvesting for coronary artery bypass graft surgery background. wound healing disorders after vein harvesting for cabg surgery increase morbidity and lower patient satisfaction. low-energy shock wave therapy (swt) reportedly improves healing of diabetic and vascular ulcers by overexpression of vascular endothelial growth fractor and downregulation of necrosis factor kappab. in this study, we investigate whether prophylactic low-energy swt improves wound healing after vein harvesting for coronary artery bypass graft surgery.methods. one hundred consecutive patients undergoing cabg surgery were randomly assigned to either prophylactic low-energy swt (n ¼ 50) or control (n ¼ 50). low-energy swt was applied to the site of vein harvesting after wound closure under sterile conditions using a commercially available swt system (dermagold; tissue regeneration technologies, woodstock, ga). a total of 25 impulses (0.1 mj/mm(2); 5 hz) were applied per centimeter wound length. wound healing was evaluated and quantified using the asepsis score.results. patient characteristics and operative data including wound length (swt 39 ae 13 cm versus control 37 ae 11 cm, p ¼ 0.342) were comparable between the two groups. we observed lower asepsis scores indicating improved wound healing in the swt group (4.4 ae 5.3) compared with the control group (11.6 ae 8.3, p ¼ 0.0001). interestingly, we observed a higher incidence of wound healing disorders necessitating antibiotic treatment in the control group (22%) as compared with the swt group (4%, p ¼ 0.015).conclusions. as shown in this prospective randomized study, prophylactic application of low-energy swt improves wound healing after vein harvesting for coronary artery bypass graft surgery. myocardial regeneration by shock wave therapyan in-vitro examination background. inflammation and thrombogenicity are important issues in cardiovascular tissue engineering. this in-vitro study was designed to investigate the influence of platelet alpha granule release on polymorphonuclear leukocytes (pmn) adhesion and activation on the decellularized porcine matrix.methods. cryostat sections of decellularized porcine heart valves were sequentially incubated with platelet-rich plasma (prp) and isolated, autologous pmn. to block -granule release platelets were pre-incubated with either cytochalasin d (cytd) or iso-butyl-methyl-xanthine (ibmx). to investigate the involvement of the complement system, specimens were exposed to prp that had been pre-incubated with 10 mm edta. at the end of the incubations, specimens were fluorescently stained for cd 41, thrombospondin-1 (tsp-1), cd45, cd11b, and the complement factor ic3b.results. laser scanning microscopy revealed the binding of multiple platelet aggregates to the decellularized porcine tissue surface. platelet adhesion was associated with up regulated expression of tsp-1. pre-treatment of tissue specimens with prp induced a strongly enhanced binding and activation of subsequently added pmn. inhibition of platelet -granule release by either cytd or ibmx markedly reduced the secretion of tsp-1 correlating with a decreased pmn adhesion and cd11b expression. although inhibition of complement activation by addition of edta to prp inhibited ic3b deposition, it failed to prevent pmn binding.conclusions. the decellularized porcine heart valve matrix represents a high thrombogenic surface. activated platelets induce subsequently pmn adhesion and activation. the platelet/pmn interaction seems therefore to play a key role in the early, non-specific inflammatory response towards the decellularized xenogenic matrix independent from complement activation. acute cellular allograft rejection (acr) remains a significant problem in cardiac transplantation. calreticulin (crt) is a ca 2þ binding chaperone suppressing activity of the sarcoplasmic/endoplasmic reticulum ca 2þ -atpase (serca2a) responsible for ca 2þ homeostasis in cardiac muscle. acr is associated with apoptosis and crt induces apoptosis in mature cardiomyocytes. whether myocardial crt expression plays a role in ca 2þ -dependent apoptosis in acr is unknown.crt and serca2a mrna expression was quantified by real time rt-pcr in routine endomyocardial biopsies (embs) of transplanted patients (n ¼ 170) at 1, 2, 3, 4, 7, 12, 24 and 52 weeks post-transplant and when clinically indicated. the apoptotsis was assessed in embs with tunel assays. graft rejection was histologically diagnosed and scored according to ishlt guidelines.myocardial mrna expression of crt was significantly increased (p < 0.04) while serca2a mrna levels were decreased (p < 0.05) in acr grades 1r-3r compared to embs with grade 0 at all post-transplant weeks. moreover, crt mrna expression were significantly elevated in acr grades 2r-3r compared to grade 1r (p < 0.05). in addition, significant positive correlation between increased crt expression (r s ¼ 0.8915; p < 0.0001) and negative correlation between decreased serca2a (r s ¼ à0.7900; p ¼ 0.0005) and the degree of emb apoptosis was observed.these results suggest that crt is involved in disruption of intracellular calcium regulation and mediates ca 2þ -dependent cellular apoptosis in cardiac grafts with acr. moreover, assessment of crt levels could be an accurate and quantitative method to diagnose and score acr. further studies are necessary to establish the benefit of targeting crt in the cardiac acr treatment. methodik. im tierexperiment wurde bei 18 schafen am kardiopulmonalen bypass die aorta ascendens geklemmt und kristalloide kardioplegielösung infundiert. nach 30 min wurde nachkardioplegiert. in der gruppe i (n ¼ 9) wurde nadh zur kardioplegielösung beigegeben. in der kontrollgruppe (gruppe ii, n ¼ 9) wurde kardioplegie ohne nadh zusatz verwendet. nach 60 min wurde die aortenklemme geöffnet und das herz reperfundiert. nach einer reperfusionsphase von 60 min und stabilisierung der hämodynamischen und elektrophysiologischen parameter wurde der kardiopulmonale bypass beendet. nach weiteren 60 min wurden myokardstücke aus dem linken ventrikel entnommen und mit patch-clamp technik untersucht. weitere stücke wurden mit der gefrierzange entnommen und in flüssigem stickstoff bis zur weiteren analyse gelagert.ergebnisse. in gruppe i kam es zu einem signifikanten atp anstieg (p < 0,05) im vergleich zur kontrollgruppe. der unterschied an atp werten spiegelt eine verbesserung des metabolischen zustandes in der nadh gruppe wider. weiters wurde der ladungszustand der zellen, der den energiestatus repräsentiert, verbessert.schlussfolgerungen. nadh zusatz könnte durch seine positiven effekte auf den metabolismus in herzmuskelzellen ein potenter pharmakologischer und therapeutischer ansatz sein. isolation und selektive ablation von autonomen ganglienplexus bei linksatrialer vorhofablationcase report grundlagen. autonome ganglien-plexus haben als trigger einen einfluss auf die entstehung von vorhofflimmern. durch selektive ablation dieser ganglien im rahmen der pulmonalvenenisolation konnte gezeigt werden, dass der erfolg der ablation von 70 % auf 90 % zunimmt.methodik. bei einem 58-jährigen patienten wurde im rahmen der mitralklappenrekonstruktion wegen permanentem vorhofflimmern eine linksatriale vorhofablation mit medtronic cardioblate + maps durchgeführt. intraoperativ wurden die autonomen ganglien am rechten und linken atrium durch hochfrequenzstimulation am schlagenden herzen epikardial isoliert. als positive antwort wurde eine verlängerung der rr-intervalle um mindestens 50 % gewertet. diese stelle wurde mit dem cardioblate + maps pen selektiv abliert. anschließend wurde am offenen herzen die endokardiale ablation mit isolation der pulkey: cord-005816-i54q5gsu authors: nan title: 10(th) european congress of trauma and emergency surgery: may 13–17, 2009 antalya, turkey date: 2009-08-06 journal: eur j trauma emerg surg doi: 10.1007/s00068-009-8001-z sha: doc_id: 5816 cord_uid: i54q5gsu nan introduction and aims: although liver is well protected by the thoracic cage, it is a frequently injured organ especially by penetrating traumas and also rarely by blunt traumas. retroperitoneally located pancreas and duodenum injury with or without liver injury occur rarely but they are seriously life threatening injuries. for these reasons we aimed to investigate the traumatic liver, duodenum and pancreas injuries as a whole. materials and methods: 55 cases of blunt and penetrating traumas occured in our district are included in this study. in these patients parameters of sex, age, etiology, admission time, stability and physical status on admission, concurrent organ injury, operation type, gradings of injuries, were investigated. results: 51cases (92,7%) suffered from liver injury, while 4 cases (7,3%) suffered from hepaticopancreaticoduodenal injury. 31 cases (56%) were caused by penetrating injuries. 31 cases of liver injury group had isolated liver injury whereas 15 cases of the group has additional thoracic injury, 3 cases had great vessel injury, 1 case had orthopedic injury and lastly 1 case had head injury in addition to the liver injury. in the combined hepatic injury group mortality rate was 7,3%. conclusions 1. in hepatoduodenopancreatic injury group blunt and penetrating injury rates are equal. 2. duodenum-pancreas injuries occur rarely. liver,with injury rates of 51 cases in this study, is the most frequently injured organ. 3. mortality rate is higher in the subgroups of patients who admitted to hospital late, and who had concurrent thoracic, orthopedic, and head trauma. background: the incidence of blunt bowel and mesenteric injury (bbmi) has increased recently in blunt abdominal trauma and this is possibly due to an increasing number of high speed motor accidents and the use of seat belts. objective: in this study we sought to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with bbmi. this was achieved by reviewing our experience as a major victorian trauma service in the management of bowel and mesenteric injuries and how this compares to current literature. methods: a retrospective study reviewing 278 consecutive patients who presented to the alfred trauma centre with blunt bowel and mesenteric injuries over 6 years. results: of the 278 patients with bbmi 66% were male, 34% were female. 80% of the patients underwent a laparotomy, 17% of patients were treated conservatively and 3% were diagnosed post-mortem. the times from admission to laparotomy were: 0-4 h 67%, 4-8 h 9%, 8-12 h 3%, 12-24 h 10%, 24-48 h 4%, more than 48 h 7%, respectively. fast (focused abdominal sonography for trauma) was done in 86 and 51% of this group had a positive fast. while 44% of patients had a negative fast and 4% of patients had an equivocal fast. 13% overall group did not have a fast. computerised tomography (ct) scans were undertaken preoperatively in 68% of the patients and showed: free gas (22%), bowel wall thickening (31%), fat and mesenteric stranding or hematoma (38%) and free fluid with no solid organ injury (43%). conclusion: the timing of surgical intervention is mostly determined by the clinical examination and the helical ct scan findings in bbmi. fast lacks in sensitivity and specificity in identifying bowel and mesenteric trauma. delayed diagnosis of more than 48 h has significantly higher bowel related morbidity but not mortality. 6 predictors for the selection of patients for abdominal ct after blunt trauma: a proposal for a diagnostic algorithm introduction and objectives: gastrointestinal and mesenteric injuries (gimi) are not common in trauma, and their diagnosis is frequently delayed. our aims were to determine the reliability of ct scan and to assess the clinical significance of a delayed diagnosis. methods: retrospective analysis of cases confirmed at laparotomy. patients were identified at the severe trauma registry of our hospital, between 1993 and 2006. results: we found 105 (16,6%) gimi out of 632 patients with abdominal trauma, in a registry with 1.495 severe trauma cases included. the mean iss and niss were of 20 and 25, respectively. mortality was of 9 (8,5%) patients, 4 of them unexpected. a ct scan was performed in 56 (53%) cases, and only in 37 were there signs suggestive of a gimi. surgery was delayed for more than 8 h in 21 (20%) patients, the most common reason being a false negative result in the ct scan. there was no significant increase of morbidity or mortality in the delayed diagnosis group. conclusion: the overall incidence of gimi was high in our registry (31% in penetrating and 10.7% in blunt trauma). several factors such as the initial lack of symptoms, a low diagnostic sensitivity of the ct (34% false negatives), and the nonoperative management of solid organ injuries, have contributed to a delayed diagnosis in one of every five patients in our series, but this has not led to a significant increase in septic complications in this group. author to editor: ct scan diagnosis of gastrointestinal injuries continues to be a matter of concern. there is controversy on the clinical significance of a delayed diagnosis of small bowel injuries 10 management of rectal injury: reappraisal of old techniques introduction and objectives: due to immunological functions, conservation of injured spleen following abdominal trauma is very important. for this reason nonoperative management (nom) in the last 25 years has been accepted as the ideal treatment in those patents who are hemodynamically stable and do not require a laparotomy; however in case of multiple abdominal solid organ injuries (soi) nom is controversial. methods: we report on a case of a 27-years-old patient with spleen and renal injury subsequent to blunt abdominal trauma. ct scan revealed a ois iv injury (third degree in graz classification) and an ois iv renal injury. since chances for successful spleen angioembolization were judged poor by radiologist, a laparotomy and partial spleen resection with preservation of one-third of the spleen was performed. immediately after surgery, angioembolization of the renal injury was successfully performed. results: a contrast enhanced ultrasound (ceus) performed on day 7 and day 30 after trauma revealed a hypertrophy of the residual spleen with diffuse distribution of contrast agent in the spleen parenchyma, confirming functional activity of the organ. morphological and functional evolution of left kidney was normal. conclusions: sequential treatment (surgical preservation of the most injured organ followed by immediate angiographic embolization) could be a valid option in case of multiple abdominal soi; furthermore, ceus is an interesting new tool to determine functional activity of residual spleen. introduction: precise timing of cholecystectomy procedure after biliary pancreatitis is still controversial. the major drawback of interval cholecystectomy is the recurrence of pancreatitis within the interval of 6-8 weeks. early cholecystectomy (performed prior to discharge), however, have the disadvantages of increased technical difficulty and conversion rates. methods: we reviewed 47 patients with recurrent biliary pancreatitis among a total number of 277 cases of biliary pancreatitis in-between january 2007 and january 2009. results: the mean age was 64.5 (range 29-85), and male-to-female ratio was 0.4 (13:34). seventeen patients (%36) had a history of previous cholecystectomy. of these 17 patients, 8 (%17) have had early cholecystectomy, and 9 (%19) have had interval cholecystectomy. the rest of the patients (%64, n = 30) consists of those who have been scheduled for interval cholecystectomy but have had a recurrent episode during the 8-week interval (%6, n = 3) or after the 8-week interval (%57, n = 27). conclusion: the majority of patients with biliary pancreatitis do not have any recurrent episodes even if they do not have a surgical or an endoscopic treatment. according to our data, however, an influenced percentage of recurrent pancreatitis develops in patients who do not have early cholecystectomy. therefore, we prefer early cholecystectomy in means of reducing the risk of recurrent pancreatitis during or after the 8-week interval. introduction and aim: nonoperative management (nom) of splenic injury is currently the most common management strategy in hemodynamically stable trauma patients. aim of this study was to asses if the success rates of 80-97% described, mainly in the north-american literature could be confirmed. methods: we conducted a retrospective study of all patients older than 17 year with blunt splenic injury who were admitted to a level i trauma center. a total of 120 patients were identified with blunt splenic injury during the 10-year study period (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) . results: the majority were young men; mean age was 34 years. thirty-three (27%) patients underwent immediate surgical management. sixty-seven (56%) patients were treated with planned nom and 20 (17%) patients underwent angiography and embolization (a&e). we did not encounter early complications following a&e. fourteen patients failed observation due to ongoing bleeding. of these, 10 were treated with splenectomy and three with a&e. the splenic salvage rate after observation was 84%. the splenic salvage rate after a&e was 80%. four of the five patients with a rebleeding after initially a&e underwent splenectomy and one patient was treated with reembolization. the overall mortality rate was 7.5%. none of the patients died as a result of splenic injury treatment failure. conclusion: nonoperative management in blunt splenic injuries in our trauma center is a well-tolerated treatment with a success rate of 84%. the splenic salvage and mortality rate is comparable with the literature which is mainly based on north-american studies. mannheim peritonitis index (mpi) is a scoring system with prognostic significance. we applied mpi to patients with perforative peritonitis (on patients in sri ramachandra medical college) to validate the scoring method. it is a specific score with accuracy and allows prediction of prognosis. aim of the study (1) to study the incidence and aetiology of perforative peritonitis. (2) to study the demographics of the study population. (3) to analyse if mannheim peritonitis index (mpi) is a valid scoring method. p-possum (p < 0.01) scores in the index surgery. malignancy was the most frequent initial diagnosis in patients with spp and benign diseases in tp. there were no differences on the interval between operations (11 ± 14 days tp vs. 10.8 ± 8 days spp; p = 0.9) neither in the number of previous laparotomies (p = 0.2). tp was associated to emergency index surgery (p = 0.01) and icu hospitalization (p < 0.001), mechanical ventilation (p = 0.0001) and vasoactive drugs (p = 0.002). there were no differences in any of the clinical and biochemical parameters analyzed, neither in sirs (p = 0.08) or p-possum scores after relaparotomy (p = 0.13). we found no differences regarding mean hospital stay (48 days tp vs. 45 days spp; p = 0.7) and mortality rate (30% in spp vs. 21% in tp; p = 0.43). conclusions: although certain differences exist, the clinical course of postoperative peritonitis seems to depend more on factors other than their secondary or tertiary origin. background and aim: patients with primary acs will often develop a secondary acute respiratory distress syndrome (ards). mechanic pressure is mainly responsibe in pulmonary findings in acs. we aimed the role of aspiration of gastric contents into lower airways in pulmonary complications of acs. methods: the 50 rats were initially divided into five groups (group i-v), and then these groups were divided again into two groups if they are unfed (group ia-va) or fed (group ib-vb). in animals in group i-v intraperitoneal pressure (iap) was applied as follows: 15, 20, and 30 cm h 2 o by instillation of isotonic saline solution. results: total scores of lung histopathologic findings were concordant with the degree of iab. when the total scores of histopathologic findings in lungs were compared for each applied iab with control group, the scores were higher in fed animals than unfed animals. histopathologic findings in lungs were observed when increased-iap to 15 mmhg (20 cmh 2 o) which was accepted as cut-off value. the comparison of the scores of histopathologic findings in two groups in which the applied iab was lower then the cut-off value were not significantly different from the control group. however comparison of the scores of histopathologic findings equal to or above 18 mmhg were significantly higher then the control group. conclusion: our results show that that pulmonary aspiration related with passive regurgitation in acs has a substantial influence on histopathologic findings seen in this disorder. editor to self: secilmiş bildiri 50 emergency surgery and delayed abdominal closure: results in 16 cases carlos mesquita, marco serô dio, francisco castro-sousa 1 1 emergency and general surgery departments, coimbra university hospital, coimbra, portugal delayed abdominal closure (dac), in emergency surgery, must be economical, fast to execute and easy to maintain, allowing second look and definitive closure, with minimal prejudices to the abdominal wall. as an alternative to the vacuum closure systems, the aa have been utilising the rotondo and schwab technique (iatsic-dstc course), by the interposition of a plastic towel between abdominal contents and wall. dac has been utilised in 16 patients (8 male, 8 female, 2005-2008) , median age of 51 (32-90). in five, after abdominopelvic packing for hypovolemic shock conditions. in 11, after mediastinal and peritoneal decontamination procedures and lavage for septic situations with actual or potential compartment syndrome: three from acute necrotizing pancreatitis, six from dehiscent digestive sutures and two from strangulated hernias. four patients died in the open abdomen situation, one from pancreatitis and three from dehiscent sutures. primary abdominal closure has been possible in 11: in the 5 cases of packing and in 6 of the 7 of the cases of sepsis. in one case of pancreatitis it has been possible a secondary closure. dac is now accepted like a safe procedure in damage control and compartment syndrome conditions which contributes to ameliorate the results in life threatening situations. than 40%. this report describes our experience with vacuum assisted closure (vac-)therapy in the management of efs in an oa. materials and methods: nine patients with seventeen high output efs in an oa were treated with vac-therapy from january 2006 till january 2009. the abdominal wound was covered with fatty gauzes. small efs were covered with a patch of hydrophilic polyvinylalcohol foam. the entire abdominal wound was covered with polyurethane foam which promotes granulation and seals of the oa preventing further spillage of enteric contents. continuous negative pressure at -125 mm hg was applied. for large fistulas with protruding mucosa a hole was cut within the polyurethane foam and an ostomy bag was placed over the fistula mouth. surgery with enterectomy was planned 6-10 weeks later. results: the vac-dressing was changed every 4 days. three efs closed spontaneously. time between onset of fistulisation and surgery was 52 days (median 51 days). no additional fistulas occured. one patient died postoperatively. conclusions: although previously considered a contraindication to vac-therapy, the oa with efs can be managed with vac-therapy. a taylored application of the foam and a reduced negative pressure seem to allow a safe and reliable way to manage efs. partial enterectomy and abdominall closure is possible after several weeks. introduction: it was the aim of the study to analyze the potential value of microdialysis in the rectus abdominis muscle (ram) compared with conventional monitoring parameters currently in clinical use for the detection of the abdominal compartment syndrome (acs). methods: 30 pigs were anaesthesized, mechanically ventilated and continuously monitored. microdialysis was performed in different abdominal organs, the ram and cervical muscle (distant reference) for glucose, lactate, lactate-pyruvate ratio (lpr) and glycerol. iah was maintained for 6 h. three groups were analysed: control (a), iah 20 mmhg (b) and 30 mmhg (c).cardiopulmonary parameters, urinary output, blood gas analysis and venous lactate were recorded. results: mean arterial pressure and abdominal perfusion pressure remained above clinically defined thresholds during the experiments for groups a and b. in contrast, group c demonstrated a persistent decrease below these thresholds. significant reduction of urinary output was only seen in group c. lactate levels also remained within physiological range in all groups. in contrast, microdialysis revealed a significant increase of lpr in all monitored organs in groups b and c, indicating ischemia and energy failure. of interest, lpr in the ram showed a significant increase already after 2 h of iah in group b. conclusion: microdialysis of the ram detected local metabolic derangements in animals with iah of 20 mmhg while clinically established monitoring tools failed to show organ dysfunction/tissue ischemia. our data suggest that continuous microdialysis in the ram may represent a promising tool for early detecting iah-induced metabolic derangements before manifestation of clinically apparent acs. introduction: to avoid morbidity associated with open abdomen, subcutaneous linea alba fasciotomy (slaf) was introduced for management of abdominal compartment syndrome (acp) in severe acute pancreatitis (sap). we analyzed the efficacy and safety of slaf as a surgical decompressive technique. methods: a retrospective study of a 3-year period identified 10 patients with sap and acs undergoing slaf. mean age was 46 (range 33-61) years, 9 were male and 9 had alcohol-induced sap. slaf was performed 1-17 days post-admission, in 6/10 cases within 48 h. results: the mean (range) preoperative intra-abdominal pressure (iap) was 31 (23-45) mmhg and immediate postoperative iap 20 (10-33) mmhg. the mean decrease was 10 (2-17) mmhg and the decompressive effect was considered sufficient in 7/10 cases. two of these developed recurrent acs and required completion laparotomy, as did the 3 with insufficient effect (0-3 days post-slaf). the mean preoperative sofa score was 12 (4-17) and 11 (1-20) 1-5 days postoperatively, the decrease was > 5 in 3 patients with successful slaf. eventually four patients underwent necrosectomy, two following sufficient slaf. the overall mortality and morbidity rates were 4/10 and 3/10, no complications were attributed to slaf itself. mean hospital stay was 35 (11-70) days. of the survivors, fascial closure was achieved in two, and planned hernia in four (two with split-thickness skin graft and two with post-slaf hernia). conclusion: slaf is a safe decompressive technique in sap-related acs. it is effective in about 50-70% of cases, but some require completion laparotomy and/or necrosectomy later on. methods: between march 2007 and december 2008, 44 patients were managed with vac technique (kci, san antonio). the mean age was 54.8 (28-87) , and m/f sex ratio was 1/4. indications were severe abdominal sepsis in 12 patients, mechanical obstruction due to colorectal cancer in 10 patients, pancreatitis in 4 patients, posttraumatic abdominal compartment syndrome 8 patients, evisseration in 4 patients, enterocutaneous fistule in 6 patients. results: as morbidity there were 2 fistulaes and 2 intraabdominal abscess in all 44 patients. four of the patients were died with concomitant disease. there was no mortality related using vac system. thirty five patients (80%) was underwent a delayed primary closure, five underwent secondary healing by granulation, and four underwent split thickness skin grafting. surgical outcomes of severe hepatic injury were retrospectively reviewed. (methods) among 567 patients with hepatic injury treated between 1975 and 2005, 247 patients who underwent surgery were included. the study period was divided into early (1975) (1976) (1977) (1978) (1979) (1980) (1981) (1982) (1983) (1984) (1985) (1986) (1987) (1988) (1989) (1990) (1991) (1992) , middle (1993) (1994) (1995) (1996) (1997) (1998) (1999) (2000) and late (2001) (2002) (2003) (2004) (2005) phases, and type of injury, surgical procedure performed and patients' outcome were retrospectively reviewed. (results) (1) percentage of patients undergoing surgery: 70% (161/274) underwent surgery in the early phase, 37% (66/192) in middle and 25% (25/101) in late phase. (2) timing of surgery: the numbers of patients underwent laparotomy in er, urgent laparotomy in or, and delayed laparotomy (after 24 h) were 42 (28%), 111 (67%) and 8 (5%) in early phase; 27 (41%), 33 (50%) and 6 (9%) in middle; and 11 (44%), 14 (56%) and 0 in late phase, respectively. (3) surgical procedures performed: for type iiib (jast grading) cases, hepatectomy was performed in 88% and hepatorrhaphy was performed in 10%, giving a mortality rate of 25% in early phase, 23.5% in middle and 0% in the late phase. for iiib + ivc/hv cases, hepatectomy was performed in all patients, giving a mortality rate of 60% in early phase, 40% in middle and 33.3% in late phase. (discussion) with the increase in nonsurgical management, surgical treatment for hepatic injury is performed preferably in patients requiring immediate response, such as laparotomy in er. the surgical outcome of hepatic injury has been improving, with a survival rate of approximately 90% for type iiib cases and 60% for iiib + ivc/hv cases. rifat tokyay, tolga taymaz 1 1 amerikan hastanesi, istanbul, turkey objective: the aim of this study was to assess the unexpected returns (ur) within 1 month of the adult patients and the pediatric trauma patients initially seen in the _ istanbul american hospital emergency department. design: all urs between 01.01.2005-01.01.2009 were recorded. initial diagnosis, final diagnosis, initial treatment, final treatment, reason for readmission, and last medical condition were noted. results: eighty eight urs were recorded. final diagnosis of 46 of these 88 patients were surgical. forty one of these surgical patients had ur due to error in diagnosis and five due to error in treatment. fifty two of these 88 patients returned on the same day or the next day, 13 between 2nd and 3rd days, 15 between 4th and 7th days and 7 between 7th and 30th days. male to female ratio was 1 to 1. three of the patients were pediatric trauma patients, 71 were between 15-65 years, and 14 were over 65. missed final diagnosis were: acute cholecystitis (10), acute appendicitis (10), missed fractures (8), pneumothorax (2) liver mass (2), urethral stone (2), ectopic pregnancy (1), diverticulitis (1), subarachnoid bleeding (1), others (9). conclusions: acute cholecystitis, acute appendicitis, and missed fractures were the most frequent surgical causes of urs after emergency department discharges. liberal utilization of abdominal sonography and abdominal ct scan may reduce missed acute abdomen in abdominal pain patients and appropriate radiological imaging and meticulous evaluation of the x-rays may reduce unnoticed spinal, pelvic and facial fractures in trauma patients. editor to self: seçilmiş bildiri olabilir introduction and aim: bacteremia sepsis and septic shock might develop rapidly for the patients with infection in bile path. early diagnosis, surgical treatment and antibiotherapy decrease mortality. in this study, the relation between choledocholithiasis, cholangitis and pancreatitis and treatment methods have been evaluated. method: the demographic features, the treatments, the intensity of the illness and mortality rate of the 155 patients in afyon kocatepe university general surgery clinic between the years 2006 background: enterocutaneous fistula continues to be a serious surgical problem. they are related with major electrolyte imbalances, malnutrition and delayed tissue healing. our recent experience with enterocutaneous fistulas is reviewed hereby. methods: we analyzed the charts of all patients with enterocutaneous fistula from january 2006 to december 2008. fistulas were assessed for localization, type, output, etiology, use of somatostatin analog and fibrin glue, nutritional support, type of surgical intervention, wound vac, and endoscopic findings. results: we identified 20 patients. fistulas were localized as gastroduodenal in five patients, jejuno-ileal in seven, and colonic in eight. there were 11 enterocutaneous and 9 entero-atmospheric fistulas. endoscopy was performed in 12 patients. output was low (< 400 ml) in 14, whereas high (> 400) in 6 patients. seventeen patients developed fistulas due to iatrogenic reasons, six patients had an underlying malignancy, and three patients developed fistulas after pancreatitis. somatostatin analogs were used in 12 patients. conservative treatment was performed in 10 patients, primary surgical intervention in 3 patients, and secondary surgical intervention in 7 patients. fibrin glue was used in 9 patients and was of benefit to 3. healing was achieved in 18 patients (90%) after mean 19.3 days (range 14-75). two (10%) patients were died. conclusion: there appears to be no strict rule for treatment of enterocutaneous fistulas. liberal use of endoscopy, fibrin glue as well as restorative surgical intervention all play a major role, and should be employed selectively on an individual basis in the management of enterocutaneous fistulas. aim: in this study we aimed to evaluate the patients whose admitted to neurosurgery and anesthesiology intensive care unit (naicu) between 2004 and 2009. matherial and methods: the patients whose admitted to naicu between 2004 january 1 and 2009 january 1 evaluated retrospectively. diagnosis, age, gender, mortality rate, staying day in icu of the all patients were determined. head traumas were obtained in trauma and multitrauma patients. results: total number of the patients those are admitted to naicu were 1,768 and 716 of them because of head trauma (40.5%). 438 of the 716 cases were pure head traumas (61.2%) or politraumas accompanied with head traumas (ht).the rate of ht was 24.8% of all traumas.there were 351 men, 365 women. mean age of men were 44.32 and women were 45.17. staying icu were obtained as 7.48 days. the mortality rate was found as 43.72% (313 cases). operated cases were 350 (48.88%) and the cases followed without any operation were 366 (51.12%). mortality rate between operated cases were 49.14% (172) and nonoperated cases were 55. 46% (203) . ht cases were evaluated by glascow coma scale (gcs) as severe (gcs £ 6),intermediate ,moderate (gcs ‡ 11).the cases which had gcs £ 6 were 39(8.9%). operated cases were 24 (61.54%) and 19 of them dead (79.17%). the mortality rate of operated cases (37 cases) which had gcs = 7-10 were 45.96% (17cases). the number of cases were 315 which had gcs ‡ 11 and the mortality rate of operated cases (87cases) were 18.39% (16cases) at this group. the mortality rate of nonoperated cases (228 cases) were 11.40% (26 cases). conclusion: the higher rate was ht cases when the trauma patients evaluated and mortality rate of nonoperated trauma patients were higher then operated trauma cases. author to editor: this study send for giving knowledge about traumas which admitted to kocatepe university school fo medicine at a period of 51 months. introduction and aim: this study has been carried out to compare conservative and surgical treatment for the acute pancreatic. method: the treatment processes and radiologic outlook of the patients with acute pancreatitis in afyon kocatepe university general surgery clinic between the years 2006 and 2009 have been observed retrospectively. results: the average age of the 52 patients with acute pancreatic is 54 and 67.3% of them were women. while conservative treatment was applied on 29 patients, surgical treatment was applied on 23 patients. while the etiologic reason was based on a known source for the 55.7% of the patients, no reason was found for the 44.3% of the patients. ercp was applied for six patients within the scope of conservative treatment. necrotizing pancreatitis existed in five patients. surgical debritment and abdominal washing were applied for four of the patients. acute pancreatitis were diagnosed for the 51.9% of the patients after tomography. one of the patients which had surgical treatment died (0.23%). there was no mortality for the patients having conservative treatment. there was not a substantial distinction between the two treatment methods in terms of mortality. ten of the patients had laparoscopic cholecystectomy, ten of the patients had open cholecystectomy (one of the patients with abdominal washing), one of the patients had choledochal exploration with t tube drainage and open abdomen. conclusion: the conservative treatment should be prefered though the treatment ways of acute pancreatitis under discussion. there is not a distinction between the tow methohds in terms of mortality. mü nevver moran, emre gundogdu, ismail bilgiç, hayrettin dizen, mehmet mahir ö zmen 1 1 department of surgery, ankara numune teaching and research hospital, ankara, turkey our aim was to compare to efficiancy of different scoring systems as a prognostic indicator in acute pancreatitis. medical records of 234 patients (125 female) with mean (range) age of 55 (19-92) years who are diagnosed as acute pancreatitis during 5 years were evaluated according to age, sex, etiologic factors, sirs, apache ii, balthazar scores and ranson scores at admission and at 48 h in order to evaluate the correlation with mortality. the commonest cause was gallstone seen in 157 (67%) cases followed by idiopathic in 48 (20%), alcohol in 24 (10%) and other in 4 (1%). there were 11 (4,7%) cases with mortality and 99 (42%) patients underwent operation. in 223 survivors mean (sd) age was 62 (21) years, sirs score was 0.78 (1) , ranson scores at admission was 1.4 (1.2) , ranson scores at 48 h was 1.1 (0.8), apache ii score was 6.2 (4.1), balthazar scores was 2.6 (1.3). in the nonsurvivors group of 11 (4,7%) cases, the mean age (sd) was 55 (16). admission sirs score was 3.4 (0.54), apache ii score was 13 (3.6), ranson score was1.2 (0.8), ranson scores at 48 h was 3.3 (0.5). when both groups were compared sirs score, apache ii score at the admission and ranson score at 48 h were found to be statistically significant (p < 0.001, p = 0.001, and p = 0.001, respectively), and no differences observed in reference to balthazarscore, hospital stay and icu stay (p > 0.05). although admission sirs score, apache-score and 48 h ranson score were all found to be important prognostic indicators, sirs seems better and most promising indicator as it is easy to use and not requires sophisticated tests. normal in 52 patients (5%). the appendix was divided by endo-loop in 96%, intracorporeal suturing in 3% and endo gia in 1% of the patients. the meso-appendix division was performed by endoclip (43%), ligasure (54%) and bipolar cautery (3%) . conversion to open procedure rate was (7%). mean operating time was 42 min (20-150). mean hospital stay was 1.9 days . major complications were as follows: right iliac artery injury (n = 1), bladder injury (n = 1), post operative bleeding (n = 3), intraabdominal abscess (n = 9), appendiceal stump leakage (n = 4). minor complications were trocar site infection (n = 32) and mechanical bowel obstruction (n = 3).there was no mortality. conclusion: la is associated with considerably decreased morbidity and might be considered as the treatment of choice in aa. hakan yanar, cemalettin ertekin, korhan taviloglu, ali fuat kaan gö k, emre sivrikö z, gü lay sarıçam, recep gü loglu 1 1 trauma and emergency surgery service, istanbul university, istanbul faculty of mediine, istanbul, turkey background: gastrointestinal stenting is increasingly employed to relieve passage. it provides a palliation in inoperable cases or anastomotic strictures. in left-sided colonic and rectal obstruction, it allows decompression for a definitive surgery to be performed. methods: between may 2006 and december 2008, 30 patients with acute mechanical intestinal obstruction were treated with endoscopic stenting. localization of malignancy, stenting complications, and surgical interventions were assessed. results: there were a total of 30 patients undergoing gastrointestinal stenting. sixteen patients received gastroscopic stents, four patients with esophageal, eight patients with gastric, four patients with duodenal tumors. stenting failed in five patients (31%), and surgery was required in four patients. nine patients were referred to adjuvant oncologic treatment. fourteen patients received colonoscopic stents; in one patient with a left-colon, in nine patients with sigmoid colon, and in four patients with rectal tumors. stenting failed in seven patients (50%), and six patients were operated emergently with a need for stoma in two patients. ten patients were referred to adjuvant oncologic treatment. no patient was died related with procedure. conclusion: gastrointestinal stenting is a useful adjunct in the treatment of patients presenting with acute mechanical intestinal obstruction for palliation as well as for decompression before definitive surgical therapy. introduction and objectives: internal hernia (ih) is a rare entity which occurs due to the protrusion of an intraabdominal viscus through a normal or abnormal mesenteric or peritoneal aperture. ih can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. intestinal obstruction due to ih is very dangerous and lethal because it may be silent, and delay in diagnosis may cause severe abdominal conditions. in this report, we aimed to present 17 patients with ih. methods: seventeen patients who were admitted to our clinic with the diagnosis of ih between january 1990 and january 2009 were included. patients' demographic data, type of the hernias, type of surgical procedures, length of hospital stay, and prognosis of the patients are evaluated retrospectively. results: there were nine male, eight female patients. mean age of the patients was 51. 1 years (15-83) . postsurgical ih were seen in eight, paraduodenal in four, transomental in one, sigmoid mesocolon hernia in one patient, and the remaining three hernias were not classified. laparotomy was performed in 15 patients, laparoscopy in 1 and conversion to open surgery in 1 patient. small bowel perforation was found in three patients. seven patients underwent intestinal resection and anastomosis. mean length of postoperative hospital stay was 10.4 days (4-20). there was no mortality. conclusion: ih is a rare cause of small bowel obstruction in adults and often present with complications. a high index of suspicion may lead to early surgical intervention and reduce morbidity and mortality. introduction: esophageal perforation is a serious surgical condition in which delay for surgery results in high mortality. application of covered stents is an alternative for emergency surgery. the aim of this study is to analyze the results of esophageal stent application retrospectively. the clinical data and outcome of 6 patients diagnosed and treated for esophageal perforation by endoscopic stent application between february 2006 and december 2008 were evaluated. results: the mean age of these 6 patients was 34 (18-62) and male to female ratio was 3/3. causes of perforation was mediastinal abscess (n ¼ 1), metal stent application (n ¼ 1), and balloon dilatation (n ¼ 4). stents were applied immediately after perforation in three patients. remained three patients were referred from other institutions and the mean time of delay was 4 h (2-8). perforations were at proximal (n ¼ 1) middle (n ¼ 1) and distal esophagus (n ¼ 4). self expanding covered metal stents were applied in an appropriate position to bridge perforation area in a fashion to cover minimally 2 cm distal and proximal normal esophageal mucosa to all patients under fluoroscopic control. no contrast leak was observed immediately after application and 48 h later. patients were interned and observed under intravenous fluid and antibiotic therapy. except one patient developing transient subcutaneous emphysema no complication was observed. all perforations were closed and the stents were removed at the end of fourth week. conclusion: at the early phase of esophageal perforations covered esophageal stent application can be a better alternative to surgery. introduction: upper gi bleedings are serious conditions which may be life threatening. in seriously bleeding cases the failure of the endoscopic interventions makes surgical intervention necessary. the aim of this study is to present the success rate of endoscopic interventions for upper gi bleeding performed by surgeons. methods: clinical data and the outcome of endoscopic interventions made to 359 of 1,943 upper gi bleeding patients admitted to a large community hospitals single surgical endoscopy center between january 2002 and september 2008 were analyzed retrospectively. results: hemostasis with endoscopic interventions was achieved in 336 (95.7%) at initial (n ¼ 231) or at second endoscopy (n ¼ 105). 23 patients underwent emerging surgery. there was no mortality at the patients treated by endoscopic interventions where as seven patients died after surgery (30.4%). conclusion: the outcome of surgery is poor in upper gi bleeding. thus maximum effort should be given to achieve homeostasis by endoscopy. the success rate of endoscopic interventions in this study performed by surgeons is extremely high and satisfying. naomi beks, mariëlle van gameren, sander ten raa, armand van kanten, gert roukema 1 1 emergency department, maasstad ziekenhuis, rotterdam, the netherlands analgesia use at the emergency department, how evidence-based do we work when dealing with patient with acute abdominal pain? based on a pilot at our emergency department we concluded that it is still common practice to withheld a patient with acute abdominal pain from analgesia till examined by a surgeon or resident. this in contrary to evidence presented in literature which show no negative effect of analgesia use on accuracy of diagnosis in patients with acute abdominal pain. a total of 280 inquiries were send to nurses, physicians and surgeons working at the emergency department of teaching hospitals in the netherlands. we questioned their standard policy on analgesia use in acute abdominal pain. a total of 108 completed inquiries were retrieved, resulting in a response rate of 39%. there is a difference between the response of nurses and doctors, 70 versus 30%, respectively. compared to nurses, doctors are more optimistic about the moment analgesia is given. remarkable is the result that 46% of patients do not receive any analgesia even after examination by a surgical resident and 25% of the patients have to wait till they are examined by a surgeon is outshining. patients are still withheld from analgesia till a resident or surgeon examines them even though this is not evidence-based medicine. there is no consensus in the netherlands on analgesia use in patients with acute abdominal pain in the emergency department setting. a national guideline for patients with acute abdominal pain is recommended. introduction and objectives: the benefits of laparoscopic appendectomy remain debated in literature. methods: this is a monocentric, retrospective study to evaluate the differences between open and laparoscopic appendectomy for length of hospital stay, wound infection, major complications. retrospective surgical site infection rate evaluation has been possible only for in hospital stay, no further clinical data has been collected regarding outpatient follow-up. results: from january 2007 to october 2008 we reviewed 150 patients undergoing surgery for acute appendicitis. 67 patients underwent laparoscopic appendectomy (44.7%) (group a), 83 patients open appendectomy (55.3%) (group b). two different surgical teams, one for laparoscopy and one for laparotomy, performed the procedures. complicated (perforated or gangrenous) appendicitis were 16 in group a (23.9%) and 28 in group b (33.7%). mean hospital stay group a was 5.4 days, 4.9 (p = n.s.) group b. mean hospital stay in complicated appendicitis group (a + b) was 6.2 days, in uncomplicated (a + b) was 4.7 days (p < 0.05). laparoscopic appendectomy was associated with lower wound infection rate (group a 4.5% vs. group b 14.5%) (p < 0.05). infection rate in complicated appendicitis (a + b) was 18.2%, in uncomplicated cases (a + b) was 6.6% (p < 0.05). no mortality in both groups has been observed. one conversion in laparoscopic group was reported. no cases of deep surgical site infection have been observed. conclusions: laparoscopic appendectomy seems to be associated to a lower rate of wound infection. length of hospital stay and rate of major complication seems to be related to gangrenous or perforated appendicitis and not to the surgical technique. significantly lower on postoperative third and seventh day, respectively. conclusions: in this model of general peritonitis, mb significantly reduced adhesion formation. mb is blocking the tnf alpha early postoperative days. early blocking of the activity of tnf-alpha after peritonitis resulted in lower rates of adhesion formation macroscopically. the tnf-alpha can be an important factor for postoperative adhesion formation. results: laparoscopic surgery was performed in 105 patients due to peptic ulcer perforation. seventy-five patients (71%) underwent laparoscopic repair alone or laparoscopic repair with omentoplasty. in the remaining 30 patients (29%), the procedure was converted to laparotomy. amongst 75 (59 men /16 women) patients who were included into the study, the mean age was 38.8 (15-88) . in 19 patients (25%, 19/75) preoperative diagnosis was unclear and the patients were taken to operating theater due to acute abdomen. in all patients, but one, the duodenal defect was repaired by primary suturing; in one patient, simply intra-abdominal lavage and drainage were performed because the omentum was found to seal the defect. omentoplasty was performed in 39 (52%) patients. one and two abdominal drains were used in 51 (68%) and 24 (32%), respectively. mean hospital stay was 6.3 (3-20) days. morbidity was 7% (n = 5). early morbidity included bile leakage in three patients, postoperative intra-abdominal bleeding in one. one patient had trocar site hernia. one patient (88-year-old female) died on postoperative day 2 due to sepsis in the intensive care unit. conclusion: laparoscopic primary repair is a safe and efficient method in peptic ulcer perforation. akın tarım, sedat yıldırım, cem aydogan, gö khan moray, mehmet haberal 1 1 department of general surgery, baş kent university, ankara, turkey introduction: approximately 5% of multiple trauma patients sustain concomitant burns. complicated management issues arise in these patients as burn and trauma care often conflict. the purpose of this study was to describe the different types of burn injuries seen in burn patients with additional forms of trauma, and to report the survival rate for this patient group. methods: in this retrospective study, 67 patients were admitted to our center with concomitant burns and trauma from 2000-2008. this study retrospectively analyzed the types of burn injury, extent of burns, types of other trauma associated with the burns, and outcomes. results: of this study group, 65 were male. average age was 30.5 ± 13.0. mechanisms included 8 motor vehicle collisions, 18 electrocutions with subsequent falls, one plane crashes, 23 lpg or oxygen tube explosions and 17 other type of explosions. average burn size was 24.4 ± 21.7%. the most common traumatic injury was fracture and head injury (44). management of fractures in burn patients and resuscitation in head injured burn patient represented the most common conflicts in patient care. there were 22 deaths in this series. conclusion: burns are a rare but significant complication in the trauma patient. outcomes are dependent on rapid trauma evaluation as well as effective resuscitation and wound management. given the complexities of their problems, these patients necessitate a balanced multidisciplinary approach to maximize their potential for full recovery. thoughtful compromise between trauma and burn priorities is frequently necessary. introduction: fournier's gangrene (fg) is a rapidly progressive, polymicrobial, synergistic necrotizing fasciitis. in this study we aimed to determine the risk factors effective on the prognosis of the disease. methods: the files of 18 consecutive patients operated for fg during 2003-2007 were investigated retrospectively. the surviving and mortal groups of patients were compared for demographic data, etiological factors and treatment modality besides length of hospital stay and treatment cost. results: the mean age of the patients was 54.5 years and female/ male ratio was 6/12. mortality was seen in 6 (33.3) patients and significantly high in female (66.6%) (p = 0.035). the most frequent comorbid disease was diabetes (39.2%), etiological factor was perianal abscess (55.6%) and etiological source was anorectal region (61.1%); and they did not affect the mortality. the most frequent cultivated microorganism e.coli (66.6%) was significantly high in the mortal group (p = 0.012). imipenem was the antibiotic used in all of the patients. the mean number of debridements was 4,67 and intestinal diversion was utilized for 22.2% of the patients. fecal decontamination (38.8%) of the patients was performed by surgical (4) and nonsurgical (3) methods. the length of hospital stay in surviving group (34.17 days) was higher than the mortal group (10.50 days) (p = 0.002). there was no difference between two groups of patients for the length of hospital stay (p > 0.05). conclusion: female gender, duration of complaint prior to treatment, fournier gangrene severity point and cultivated microorganism (e.coli) were the factors affecting the mortality. aim: post-traumatic coronary aneurysms (ptca) are extremely rare. we report an asymptomatic ptca in a young patient. case: 26-year-old male, with no significant previous history. admitted intubated and ventilated after a car runover. he had cerebral, thoracic, abdominal, pelvic and lower extremity trauma. initial assessment disclosed eight left fractured ribs with associated pneumothorax; fast was negative, head ct normal. thoracic ct reveled small bilateral hemothoraces and pulmonary contusion, with no evidence of vascular lesions. he also had a fibular, clavicle, and pelvis fracture. control angio-ct at day 40 showed pleural and pericardial effusions and raised the suspicion of left descending ptca, subsequently confirmed with mri. the patient remained asymptomatic with normal ekg and cardiac enzymes throughout this period. a coronariogram confirmed the ptca, that had undergone spontaneous thrombosis, with no further treatment required. discussion: coronary aneurysms (true or false) may occur after blunt thoracic trauma. ptca normally result from controlled rupture post myocardial infarction or cardiac contusion, with gradual wall rupture. although in this patient the diagnosis was made without any clinical manifestation, suspicion is the main key for diagnosis. aneurysms must be considered as a differential diagnosis in patients with thoracic trauma history associated with arterial emboli, congestive heart failure, arrhythmia, chest pain or dyspnea. conclusion: every trauma victim must be exhaustively evaluated. in any case a careful follow-up must be made in thoracic and abdominal trauma victims to decrease the possibility of missing injuries. aim: acute mesenteric ischemia (aim) continues to be highly morbid cause of emergency. early diagnosis and treatment may reduce severity of the disease. the aim of this study is to investigate causes for morbidity and mortality in ami patients. materials and methods: this retrospective study has 76 patients of ami. the patients were classified according to their age, sex, clinical and laboratory findings, comorbidity, etiology, operative procedures, complications. and effect of these causes on mortality and survival was investigated. the results were statistically evaluated. results: of 76 patients 45 were male and 31 were female. mean age was 64.3 for females and 62.1 for males. the most common symptom was abdominal pain. only one third of patients had diagnosed correctly before operation. amylase was high in 73% of patients. plain abdominal graphy showed air-fluid levels in all patients. mortality rate was high in patients aging over 60 years (p < 0.001). there were no relationship between mortality and gender. the patients those who had massive small bowel and colon resection developed high mortality rates (66%). resection of ileocaecal valve also increased the mortality. five patients all of whom developed perforation died. majority of survivors had surgical intervention during first 24 h of ischemic attack. the patients those died due to perforation had delayed surgical intervention. • there is no benefit of routine laboratory findings in early diagnosis of ami. • massive intestinal resection, absence of ileocaecal valve and stomal procedure increased mortality rate. • delay in diagnosis and treatment also caused high mortality. cem aydogan 1 , yahya ekici 1 , ebru sakallıoglu 2 , sedat belli 1 , mahir kırnap 1 , emin tü rk 1 , mehmet haberal 1 1 department of generel surgery, baş kent university, ankra, turkey 2 institute of burn, fire and natural disaster, baş kent university, ankara, turkey introduction: more than 95% of all burn patients can be managed on an ambulatory basis. appropriate management of minor burns minimizes further damage. methods: the epidemiology, demographics, and outcomes of 611 ambulatory acute burn patients were reviewed at our center between 2003 and 2008. patients who were in aba referral criteria were excluded from the study. results: the patients' mean age was 30.25 ± 1.13 years (range, 1-85 years) . the percentage of patients whose first admission was to our center was 42.9%; the percentage of those referred from another center was 57.1%. scald burns were the most frequently reported cause of burns (64.4%). the house was the most frequently reported place at which the burns occurred (88.3%). the percentage of stoverelated burns was 10.7%. the upper extremities (59%) and lower extremities (20%) were the most frequently reported places on which the burns occurred. mean tbsa affected and superficial partial thickness burned area were 3.1 ± 0.09% and 2.07 ± 0.06%. the mean follow-up and the mean number of dressings applied to the burns were 7.54 ± 0.11 days (range 3-16 days) and 4.05 ± 0.05 (range 2-9). four patients (0.65%) needed skin grafting, and two patients (0.32%) were hospitalized for debridement without grafting. conclusions: close follow-up is important in minor burns to minimize further damage. burn centers must play an active role in the care of all burns. the devastating effects of burns can be prevented and decreased by educational programs. stove-related burns remain a problem in turkey. results: mean age was 26.25 ± 1.05 years. the percentage of the male patients was 89.5%. the mean tbsa affected was 27.85 ± 1.44%. the percentages of high voltage electricity injury, lightning injury, and lowvoltage current injury were 63.7, 25.8, and 10.5%, respectively. place of employments (47.3%) and outdoors (33.9%) were the most frequently reported places at which the burns occurred. the burns mostly occurred in urban areas (70.4%).upper and lower extremities were the most frequently affected regions. the percentages of the patients who underwent debridement, grafting, amputation and fasciotomy were 61.6, 54.2, 18.4, and 10,1%, respectively. the percentage of patients who had additional trauma other than electric burn injury was 10.5%. mean hospital stay of patients was 29.31 ± 1.72 days. the mortality rate was 11.1%. majority of the patients died from septic complications (50.1%) conclusion: aggressive multidisciplinary treatment modalities and early debridment, grafting and/or flaps are very important. special considerations are required for public education about electricity and its hazardous effects. governmental supports are needed both in prevention and in therapy. ahmet erkilic, harun analay, sabri mehmet barazi, halil ç eliksö z, bayram rü zgar 1 1 burn center, av.cengiz gö kçek general hospital, gaziantep, turkey early staged excision and autogenous skin grafting or temporarily wound coverage with biologic dressing or allograft until autogenous donor sites are available is now conventional treatment for fullthickness burns. typically, tangential excision is performed with a handheld knife thus it may be difficult to control bleeding from the wound bed and difficult to assess the suitability of underlying for accepting a graft. a hydrosurgery system -versajet ò is available that can be used for tangential burn wound excision. this device offers an easy and more precise way of excising eschar and is particularly useful excising nonviable tissue from the concave surfaces of hands and feet, as well as the eyelids and ears. totally, 134 hydrosurgical tangential excision (hte) were performed for 107 patients with burn, in our burn center in one and half year. several times performing were needed 27.1% of patients (n = 29). wounds of patients with 10-15% total burned body surface were covered autogenous skin grafts subsequent to hte. more extensive wounds were covered with biologic dressings temporarily and wounds as soon as suitable autogenous skin grafting was performed. at this interval, burn wounds were shrunk average 20-30% and donor skin poverty was increased. frequently, delaying to excision and coverage of burn wounds may be awful. early excision and early coverage of the burn wounds must be a golden standard for the current treatment of the burns. also hte is becoming a candidate to golden standard at burn treatment. introduction: in our previous study, we examined the treatment results of burn patients older than 45 years, and found a significant increase in mortality with increasing age groups. the aim of the present study was to reevaluate this patient group and also compare these results with the previous study period of 1979 to 1998. patients and methods: one-hundred and fifteen patients older than 45 years were admitted to our burn unit during the last 10 years. these patients were divided to three groups with respect to their ages (group a: 45-60 years, group b: 61-59 years, and group c: older than 70 years). demographic properties of patients, etiology, and extend of burn injury, co-morbidity, length of hospital stay, and mortality rates were recorded. results: during the last 10 years, demographic properties and etiology of burn injury did not changed significantly. however overall survival rate increased from 51.3 to 82% and ld 50 values for burn injury are significantly increased in all age groups. length of hospital stay is significantly decreased in all age groups, especially in group b (from 60.7 to 26.5 days). co-morbidities did not change over time and sepsis is the leading cause of death in 16 patients (80%). conclusion: in our burn unit, treatment results in patients older than 45 years showed a significant improvement during the last 10 years. introduction and objectives: patients who has weakness of mental and motor functions are under more risk than normal burned injured population. we would like to focus on burn injured cases that have co-exiting morbidities. methods: comorbid 15 patients who applied to burn unit due to burn between january 2008 and july 2008 were taken into evaluation. comorbid etiologies were seizures (7 case), mental retardation (5 case) and down syndrome (3 case), respectively. results: during follow-up period, one of the cases had aggrevated petit mal convulsion due to devastating effect of burn injury. in one case there was grade 1 pressure sore and urethral infection who was paraplegic patient. weight loss was observed on a geriatric case that had seizure due to insufficient nutrition. conclusion: burn injured cases that have comorbidity, special care, and additional measures should be taken. psychological, neurological or geriatric causes are the factors that affect the recovery of burn defects and success of operation. detailed evaluation of coexisting disorder and additional care are the key points of the comorbid burn patient. aim: the present study was aimed to evaluate the gender differences of burned children in clinical course and outcome. methods: children (aged 0-15) admitted to our burn center between august 2008 and january 2009 were retrospectively evaluated. total burn surface area (tbsa), levels of some acute phase markers, grafting need, and hospitalization time were analyzed. results: sixty three patients [45 (71.4%) males, 18 (28.6%) females] were included in this study. the mean age was respectively 2.41 ± 1.52 years and 3.06 ± 1.29 years in males and females (p = 0.117). the mean tbsa burned respectively 14.31 ± 7.32% and 16.11 ± 2.32% in males and females (p = 0.312). the mean wbc count in admission was significantly higher in males than females (17.6 ± 8.9 x 10 -9 /l vs. 12.6 ± 1.59 x 10 -9 /l, p < 0.05), but there was not any significant difference between females and males in crp count. (p = 0.76). skin graft operation was performed in 14 (31.1%) of males and in 7 (38.9%) of females (p = 0.554) and also, we did not find any significant difference between males and females in hospitalization time (11.5 ± 9.8 days vs. 12.6 ± 7.7 days, p = 0.689). conclusion: although many studies have showed that critically ill females have a better outcome than critically ill males, any significant difference was not observed between burned male children and burned female children in most of the clinical parameters, except white blood cell counts. introduction and objectives: the goal of our study was to evaluate the preparedness of hospital physicians, emergency physicians and paramedics in the eu and the usa for a mass casualty incident. methods: an online survey which contained 16 questions was sent to the head of the department of trauma-surgery, emergency medicine and to paramedics by e-mail. among other things we questioned: existence of a hospital emergency-and disaster plan and the yearly exercise of the plan. coordination with the local rescue service as well as existence of decontamination facilities were asked for. replies were analysed statistically with the one-way analysis of variance (anova) test and the turkey-kramer multiple comparisons test. results: altogether, 238 assistant and emergency doctors as well as paramedics answered. 30% were not conscious of the details of the disaster plan of her hospital while 14% did not know the plan at all. 35% of the interviewed doctors did not know her area of responsibility in the case of an internal emergency. 85% of the interviewed know what to do in case of an mci. 30% of the interviewed doctors and 55% of the paramedics did not know her area of responsibility at the treatment of patients contaminated chemically, nuclearly or biologically. conclusions: the preparedness for doctors and paramedics in hospitals and in the preclinical rescue service in the eu and the usa on a mci (mass casualty incident) are insufficient. the emergency medical education of doctors and paramedics should be adapted to the terrorist threats disaster 84 preparedness of chief physicians and hospitals in germany, the eu and the usa for a mass casualty incident introduction and objectives: the goal of our study was to evaluate the preparedness of hospitals in the eu and the usa for a mass casualty incident. methods: an online survey which contained 16 questions was sent to the chief physician of hospitals by e-mail. things we questioned: existence of a hospital disaster plan and the yearly exercise. coordination with the local rescue service as well as existence of decontamination facilities. replies were analysed statistically. results: altogether, 117 senior consultants, of this 72 senior consultants from germany as well as 45 senior consultants from the usa and the eu, answered. all people claimed to have a hospital disaster plan. 65% of the german hospitals made an exercise of the plan with tabletop exercises. however, 92% of chief physicians in the usa and the eu made an exercise of the plan regularly with table top exercises. 84% of the hospitals in the brd did not have any decontamination possibility of nbc (nuclear, biological, chemical) contaminated patients, while 70% of the hospitals had this possibility on the spot in the eu and the usa. conclusions: the exercise of the hospital disaster plan in germany is insufficient, compared with the hospitals in the eu and the usa. furthermore the german hospitals are badly equipped in the worldwide comparison to decontaminate patients on the spot. we demand for an increase of the ''exercises'' of the hospital disaster plan (also by tabletop exercises) as well as an improved equipment for the decontamination of the injured. in the two big earthquakes that occurred in the north-west of turkey in 1999 in short intervals within less than 3 months there were approximately 20,000 cases of death and around 100,000 were injured. there were several other deadly earthquakes in the whole world the same year. main survival factors in the post-disaster period are prevention from injuries as well as detecting the location of the survivors and the rescued. the reality of the situation of persons who lost their lives in such traps, the severely injured, and the ones who survived must be analyzed. rational prevention methods against possible crush injuries due to collapsing buildings have been con-sidered in the light of the field and simulation experience we gained and suggestions have been presented to reduce mortality and morbidity. our work has been conducted with the aid of medicine based on proof, appropriate observation as well as sampling and experimental methods. a global approach concerning worst case scenario led by earthquakes has been proposed taking into consideration the different models of behavior in different countries and societies to increase the chance of survival to a maximum and to reduce injuries to a minimum level. due to unlimited possibilities of travelling nowadays, it is not possible to estimate the place, the country or the circumstances under which a person could experience a disaster. carlos alberto godinho cordeiro mesquita 1 1 ordem dos mé dicos, colé gio de competê ncia em emergê ncia mé dica, lisbon, portugal in portugal there are three official ways to differentiate: specialty (vertical), subspecialty (vertical) and competence (transversal). doctors may access to a subspecialty or a competence as a second step, after a specialty. portuguese medical association (ordem dos mé dicos, om) is the official entity that regulates all the medical and surgical activities in portugal, being his duty to protect the public interest. doctors must be registered with to practise medicine or surgery. om also sets the standards and outcomes for basic medical education. after graduating from medical school and completing their foundation training, doctors usually complete a third and even a fourth stage of postgraduate training, whose standards are set by the colleges. these are responsible for promoting the development of postgraduate medical education and training for all, establishing standards and requirements and making sure they are met across the country. emergency medicine exists as a competence since 2002 and goes behind the prehospital acute care. this college is strongly interested in the development of an autonomous college of competence on emergency surgery (trauma surgery included) and it exists, since 2007, an official national working group on emergency surgery education (grupo de trabalho para a formaçã o específica em cirurgia de emergê ncia), with 13 representatives of general surgery (7), neurosurgery (1), orthopaedics (1), thoracic (1), vascular (1) , urological (1) and paediatric surgery (1) . the general surgeons, iatsic members and dstc instructors, also integrate and lead the national steering committee for dstc, after a recently signed memorandum of understanding. author to editor: the point of the situation, from an organisational point of view, about trauma and emergency surgery education in portugal and the importance for the relationship with portuguese speaking doctors around the world introduction and objectives: practical training in emergency medicine should be an important part of undergraduate education, as every physician should be able to handle medical emergencies. however, adequate practical training is time and personal consuming. this work seeks to determine whether medical students (peer to peer education) can be trained as course instructors in emergency medicine training and if there are differences in the training outcome. methods: the undergraduate training consists of both basic life support (bls) and advanced cardiac life support (acls) courses. after both courses, students have to pass a multiple choice test and have to complete a course evaluation. during the instructor training, all candidates, students and physicians were trained together with theoretical and practical training and were furthermore supervised during their first courses. results: until now, 210 bls and 185 acls trainings were conducted of which 71% (bls) and 52% (acls) were run by medical students. there were no significant differences in the written examinations nor in the course evaluations (1 = very good to 6 = unsatisfactory) between courses by staff (1.38 for bls and 1.10 for acls) or medical students as trainers (1.34 for bls and 1.17 for acls, respectively). conclusions: peer to peer education can be a useful tool in the manpower consuming practical training in emergency medicine without influencing the learning outcomes or the evaluation. background: non-invasive pelvic ring stabilization (pelvic binding, pb) in shocked patients is recommended by state and institutional guidelines regardless the fracture pattern. the purpose of this study was to determine the adherence to the guidelines, radiological efficacy of the technique, and identification of potential adverse effects associated. methods: analysis of the prospective database of a level 1 trauma center on high-energy unstable pelvic fractures. collected data included patient demographics, physiology, fracture classification, application, and timing of pb, associated injuries and outcomes. pre and post-pb radiographs were compared to evaluate the changes in fracture position. the potential effects of pb on soft tissue complications were assessed by independent experts. results: during the 41-month study period a total of 43 pb was performed on 115 patients with high-energy unstable pelvic ring injuries. stable patients were less likely to get pb (32%) than shocked patients (50%). the adherence to guidelines was 50%. analyzing fracture types (ao/ota classification) of shocked patients the adherence was: b1 80%, b2 20%, b3 20%, c1 66%, c2 86%, c3 33%. better radiological appearance was detected in b1 100%, c1 80%, c2 83%, c3 100% types. one femoral artery, four bladder and three rectum injuries were identified in patients with pb applied. there were no association between the complications and the pb. introduction and objectives: in our country, the vast majority of circumsicion is stil not done by physicians. in this study, we evaluated the patients who treated for circumsicion complications in our clinic. methods: a total of 27 children who treated for cicumsicion complication in our clinic between 2005 and 2007 were evaluated. results: mean age during circumsicion was 19.5 months (5-7 years). 26 out of 27 had not been circumsiced by physicians. complication was bleeding in 16 patients, burred penis in 7, complete glanular amputation in 3, and urethral fistula in 1 patient. one suture was enough to control bleeding for the majority of patients with this complications, while general anesthesia required for treating other complications. conclusions: significant number of children still undergo circumsicion between 2 and 7 years old (fallic period) in our country. the vast majority of complications occur when circumsicion is not done by physicians; significant number of these complications require revision under general anesthesia. as a result, circumsicion is still a challenging both public and social problem in our country, and results in high morbidity because the majority is not done by experienced hand. arda demirkan 1 , salih ekinci 1 , onur polat 1 , serdar gü rler 1 , mü ge gü nalp 1 , semih baskan 2 1 department of emergency, ankara university, ankara, turkey 2 department of general surgery, ankara university, ankara, turkey objective: multiple trauma involves at least two systems of body which abdomen, extremities, chest and head-neck. the aim of this study is to show relationship between the severity of injury and electrolyte changes in multiple trauma patients. method: this is a prospective study which 45 adult multiple trauma patients (30 male and 15 female) were studied. the median age was 41.68 (range 16-87) . in all cases, serum sodium, potassium and calcium levels and injury severity score (iss) were obtained on admission to emergency department after trauma. severity of injury was estimated with iss. degree of association between variables was evaluated by spearman's correlation coefficient test. results: the mean sodium levels was 139.02 mmol/l, the mean potassium levels was 4.61 mmol/l, the mean calcium levels was 9 mg/ dl. there was a negative correlation between calcium and iss, and this is statistically significant (p = 0.006). while other serum electrolytes (sodium and potassium) did not change according to iss. conclusion: electrolyte abnormalities often occurs in critical ill patients, this imbalance has a prognostic importance particularly in multiple trauma patients. electrolyte changes determinated in early period and appropriate resuscitation is indispensable. we suggest that low calcium levels can be considered for the severe injury. this condition may be related to interrupted calcium mechanism in critical trauma patients. introduction and objectives: preparation is essential to meet the challenge of optimal care for a sudden unexpected surge of casualties due to a major incident. by definition, requirements exceed standard care facilities in qualitative and or quantitative respect and interfere with regular patient care. to meet the growing demand for disasterpreparedness a permanent facility to provide structured, prepared relief in such situations was developed. we describe this facility. objectives: the aim of this study is to find out the effects of melatonin on the erythrocyte and kidney malodyaldehyde (mda) and superoxide dismutase (sod) levels in radiocontrast nephropathy. methods: in this study, 24 new zealand type rabbits were included. the test subjects were divided into four groups six rabbits in each (control, sham, hydration and melatonin groups). blood samples of all subjects were taken in beginning of study. renal tissue was obtained in the control group. the rest received 10 ml diatrizoat sodium intravenously. hydration group was given 10 ml/kg/day iv bolus 0.09% nacl. melatonin group was given 10 mg/kg iv melatonin four times with the same dose isotonic. it was blood and renal tissue samples were taken at the 48th and 72nd hours. mda levels were determined with ohkawa method, sod enzyme activity was studied with ransod (randox,uk) superoxide dismutase assay kit. results: the mean renal sod value of the melatonin group (1786.9 ± 188.1 nmol/g) was significantly higher than in the sham (1211.3 ± 163.7 nmol/g), control (1420.7 ± 373.2 nmol/g) and hydration groups (1492.1 ± 166.1 nmol/g) (respectively p = 0.012, 0.031, 0.029). the mean renal mda value of melatonin group (43.1 ± 7.8 nmol/g) was significantly lower than sham (67.2 ± 6.9 nmol/g) and hydration groups (59.5 ± 8.4 nmol/g) (p = 0.012, 0.048 respectively). conclusion: melatonin has a curative effect on the lipid peroxidation caused by the contrast substance in the kidney. in preventing nephropathy resulting from contrast substance, giving melatonin together with hydration can be more effective than giving hydration alone in the clinic. in addition, all datasets entered with voice recognition were complete and available in the system as soon as the patient left the trauma bay. compared to the retrospective cohort 37% of the patients had incomplete data concerning the vital parameters. conclusion: the introduction of voice recognition technology real time produces more accurate data more quickly. we are convinced that high tech technology will increasingly assist the trauma surgeon and if we are correct it looks like the prediction of don trunkey will come true viz: ''the current possibilities for using digital resources within medical care are merely limited by our own imagination'' introduction and aims: despite the improvements in the diagnosis and treatment, mortality rates are still high following urgent operation for perforated peptic ulcer (ppu). in this study, we analyzed the factors affecting the survival of the patients operated for ppu. materials and methods: the records of the 147 patients operated due to ppu between january 1997 and january 2007 were analyzed. age, sex, american society of anesthesiology (asa) score, alcohol consumption, smoking, nonsteroidal antiinflammatory drug (nsaid) usage, the time passed from the onset of symptoms to operation, history of previous peptic ulcer disease, diameter and localisation of the ulcer, surgical technique, length of stay, postoperative complications and mortality rates were determined. results: the mean age was 51 and asa score was 2. primary suture and omentoplasty was the selected procedure in 80 patients while gastrostomy was added to primary suture to another 31 patients. twenty nine patients received primary suture, truncal vagotomy and gastroenterostomy and seven underwent resection. the mean length of stay was 7 days. three patients suffered from atelectasis and pneumonia, one from empyema, eight from surgical site infection and four from leakage. twenty three of the patients experienced respiratory failure and 10 died of multi organ deficiency (6.8%). age and asa score were found as factors significantly affecting survival. abdominal cocoon (idiopatic sclerosing encapsulating peritonitis) is a rare disease of the peritoneum which refers to a condition where there is a total or partial encasement of the small bowel by a dense fibrous membrane. the abdominal cocoon is probably a developmental abnormality, largely asymptomatic, and is found incidentally at laparotomy or autopsy. it is an unusual cause of intestinal obstruction. pre-operative diagnosis cannot be often made correctly. complete recovery is expected after removal of the membrane surgically. a 39-year-old man presented with abdominal pain, swelling and vomiting of two day's duration. there was no history of peritonitis, abdominal surgery or tuberculosis. physical examination of the abdomen revealed a distended abdomen, hypoactive bowel sounds, tenderness and rigidity in the whole abdomen. a tender lump was palpated in the right lower quadrant. routine laboratory workup revealed a total leukocyte count of 17030 cells/ml, and normal serum chemistry. pa x-ray of the chest normal. plain abdominal x-ray showed few air-fluid levels. contrast-enhanced abdomen-pelvis computed tomography showed a dilatation up to 4.5 cm in small intestine. emergency laparotomy was performed through a right paramedian incision. in exploration, small bowel was observed to be dilated, its mesentery was edematous and the whole small and large bowel was covered by a dense whitish and approximately 2 mm thick membrane. the membrane was partially removed, and adhesiolisis of the intestinal loops was performed without bowel resection. after surgery, the patient was tolerated diet without any complication and was discharged, on hospital day 7. methods: the data of al-ain hospital trauma registry were prospectively collected over a period of 3 years (2003) (2004) (2005) (2006) . all trauma patients who were admitted to intensive care unit (icu) were included in the study. univariate analysis was used to compare gender, age, nationality, mechanism of injury, systolic blood pressure and gcs on arrival, the need for ventilation, presence of head or chest injuries, ais for both the chest and head injuries and the iss. significant factors were then entered into a direct logistic regression. results: there were 202 patients (181 males). mean (range) age was 30 year. 22.8% were uae nationals. the two most common mechanisms of injury were road traffic collisions (62.9%) followed by fall from height (14.4%). the median (range) iss was 17 . the mean (sd) icu stay was 5.7 (6.7) days while the mean (sd) hospital stay was 17.7 (22). the overall mortality was 13.4%. significant factors that have affected mortality included gcs (p < 0.0001), mechanism of injury (p = 0.004), age (p = 0.004) and iss (p = 0.02). the best gcs that predicted mortality was 5.5 while the best iss that predicted mortality was 13.5 conclusions: rta is the most common cause of serious trauma in uae followed by falls. gcs is the most significant factor that predicted mortality in icu trauma patients. introduction: glutamine is an antioxidant which enhance glutathione levels. in this study our goal is to assess the safety and efficacy of parenteral glutamine on antioxidant capacity and organ dysfunction in septic patients. methods: prospective, randomized study of the septic patients admitted to the surgical intensive care unit (icu). patients were randomized to receive either glutamine (group glu, n = 12) or glutamine + n-acetylcysteine (group nac, n = 11) or a control supplement-placebo (group pla, n = 10) parenterally up to 10 days. organ dysfunction and clinical outcomes were assessed by daily total sequential organ failure assessment (sofa) score over the 10-day study period. serum total antioxidant capacity (tac) was measured by cuprac method. also we evaluated procalcitonin (prc) and c-reactive protein (crp) levels as infection markers on days 0, 3, 6, and 10. results: there was no significant differences between the patients' ages, apache ii, sofa scores and infection markers on the day of admission. group glu and nac showed a significant decline of daily total sofa score (glu: p < 0.05, nac: p < 0.001, pla: p = 0.05) and crp levels (glu: p < 0.05, nac: p < 0.001, pla: p < 0.05). but prc levels decreased significantly over time just in group glu (glu: p < 0.001, nac: p = 0.2, pla: p = 0.05). on the other hand, serum tac measurements were not significant. the mean icu length of stay were glu: 29 ± 19.2, nac: 12.4 ± 6.7, pla: 12.5 ± 8.7 (glu/nac: p < 0.05, glu/pla: p < 0.05), but in group glu the overall mortality was significantly lower than nac and pla groups (glu: 25%, nac: 45%, pla: 40%). conclusion: in septic patients, parenteral supplementation with glutamine results in significantly better recovery of organ function compared with nac and pla. we coud not find any significant relationship between tac levels and clinical outcomes. background: acute renal failure (arf) requiring renal replacement therapy in icu setting is related to high mortality. the purpose of the study is to assess any indicators of improved survival. materıal and methods: retrospective study of 64 trauma patients, who underwent haemodialysis over a period of 5 years (patients with penetrating, blunt trauma and burns). information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily icu records were collected. the majority of patients were initially dialysed with cvvhd and later on with sled. results: of the 64 patients, 47 died and overall mortality was 73.4%. this was highest in the group of burn patients (84%). survival in all patients irrespective of mechanism of injury was unrelated to rts, iss, apache ii and triss. the duration of haemodialysis be-tween the three different trauma mechanism groups was not significantly different. age is not a significant predictor of survival. patients with polyuria at time of initiation of haemodialysis had not a better outcome than those who were oliguric/anuric/normouric. conclusions: arf in trauma patients has a low survival rate. controversial conclusions have been presented in the literature. in our study, none of the parameters reported in previous publications to affect survival was proven as correct, although our number of patients was comparable to that of other studies. as we are still at an early stage of understanding the predictors and the behaviour of renal failure in the trauma patients there is a need for the planning multicentric prospective studies. weaning from mechanical ventilation constitutes a dynamic process, and represents one of the most challenging decisions in the management of critically ill patients. success of weaning depends on multiple factors, and wrong decisions result either in prolonged mechanical ventilation, or reintubation and nosocomial pneumonia. many mathematical indexes have been described and used for decision making with varying successes. we have developed a multiparameter fuzzy-logic decision support system for prediction of success of weaning from mechanical ventilator. after fuzzifying relevant numerical variables, this system evaluates the appropriateness of perfusion, arterial blood gases, mechanical properties, and gas exchange, and converts these to a weaning probability. system has been designed using jfuzzylogic package and uses mamdani center of gravity algorithm for defuzzification. after optimization system has been tested over a software that creates random clinical scenarios within a range that can represent challenging patients. for each scenario jabour' weaning index, rapid shallow breathing index (rsbi) and pressure time index have also been calculated and compared with fuzzy-logic system. results indicate that currently used indexes and especially rsbi, disregard many important parameters and shown a potential to fail in many critical scenarios (in 52% of simulations). additionally we would like to discuss the potential of fuzzy-logic in clinical decision support, and design and optimization issues. trauma scoring systems used for uniform reporting and evaluation of trauma outcomes include physiologic, anatomic and combined systems. these systems have already been evaluated and shown to have accurate performance. we proposed a possible effect of response to resuscitation on the performance of trauma scoring. data necessary for calculation of iss, rts, triss and ascot systems have been retrospectively collected from the records of last 150 consecutive trauma patients admitted to our surgical critical care unit. score and mortality prediction calculations have been performed over a software developed in our department, at three time points, at admission to er, after 1 h of resuscitation, and at icu admission. additionally a fuzzy-logic inference system which uses physiologic variables as input has been designed for trauma related mortality prediction and applied to the same dataset. performances of scoring systems and fuzzy-logic inference system have been evaluated. results indicated that all systems have good discrimination, but variable calibration characteristics. for all systems evaluated response to resuscitation has effected system performance and scores and predicted mortality values calculated after resuscitation have shown better discrimination. fuzzy-logic inference system designed has shown discrimination characteristics comparable but not better then the other systems, which indicate the importance of inclusion of specific organ injuries in trauma scoring and mortality prediction. daily monitoring of immune/inflammatory status is a fundamental procedure in the icu. in small animal disease models such a surveillance is challenging given the limited blood volume available. to validate a new method for daily immuno-inflammatory monitoring in critically ill (septic) mice, we followed their short/longterm survival, organ function and inflammatory status. furthermore, the reliability of complete blood count (cbc) differential was tested in re-suspended blood cell pellet. female of-1 and cd-1 mice were subjected to cecal ligation and puncture (clp). 20 ll blood samples were collected (facial vein puncture) from half of each strain daily for 5 days or on day 5 only. additionally, 35 ll (diluted 1:10) volume was collected (of-1 only) and divided to compare cbcs in whole versus resuspended blood. there were no differences in 5/28-day clp mortality. for both strains, changes in circulating interleukin-6 and chemical parameters (alt, ldh, bun, glucose) were comparable between sampled subgroups. 20 ll sampling in of-1 mice caused a decrease of 10% in rbc and 11% in hb (both p < 0.05). in cd-1 animals, both rbc and hb showed a similar decrease of 13% (p > 0.05). platelet and wbc counts were unaffected. cbc comparison displayed a high correlation for all cell types (r > 0.9, slope > 0.9) except lymphocytes (r > 0.5,slope > 0.6). this was reproduced in non-clp mice. the results indicate the minimal biological effect of daily sampling upon septic mice. cbc differential from resuspended pellet is highly reliable. this newly validated facial vein punture sampling protocol allows multi-directional monitoring in mouse models of critical illness such as acute peritonitis. introduction: a comparison of the amount of procalcitonin (pct) with that of c-reactive protein (crp) during various types of and severities of multiple trauma., and their relation to trauma-related complications, was performed. the aim of this study was to describe the amount of and the time course of pct and crp induction in patients with various types of and severities of high-velocity trauma. background: to provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (gsw) based on three clinical parameters. methods: all patients admitted to baragwanath hospital, johannesburg, south africa, between october 2000 and may 2005 for an isolated single craniocerebral gsw were retrospectively evaluated for the documentation of (a) blood pressure on admission, (b) inspection of the bullet entry and exit site, and (c) initial consciousness (n = 214). results: conscious gsw victims had an early mortality risk of 8.3%, unconscious patients a more than fourfold higher risk (39.2%). patients with a systolic blood pressure between 100 and 199 mmhg had a 18.2% risk of mortality. hypotension (< 100 mmhg) doubled this risk (37.7%) and severe hypertension ( 3 200 mmhg) was associated with an even higher mortality rate of 57.1%. patients without brain spilling out of the wound (''non-oozer'') exhibited a mortality of 19.7%, whereas it was twice as high (43.3%) in patients with brain spill (''oozer''). by logistic regression a prognostic index (pi) for each variant of the evaluated parameters could be established: non-oozer: 0, oozer: 1, conscious: 0, unconscious: 2, 100£rrsys < 200 mmhg: 0, rrsys < 100 mmhg: 1, rrsys 3 200 mmhg: 2. this resulted in a score (0-5), by which the individual risk of early mortality after gsw can be anticipated. conclusions: three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral gsw was established. gunshot wounds to the head are associated with poor outcome. we reviewed data to identify prognostic factors. we performed a retrospective study of all patients admitted to a level 1 trauma center with isolated gunshot injury to the head during six and half years. data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial ct scan characteristics. the primary outcome measure was the glasgow outcome scale (gos). seventy-two patients with isolated gunshot wounds to the head were admitted. overall mortality was 58%. the mortality for patients with an initial gcs of < 8 was 81 versus 14% for those with initial gcs > 8 (p < 0.0001). fifty percent had pupillary abnormalities on arrival at the emergency department. mortality in this group was 78 versus 53% in those with normal pupillary reflexes (p = 0.06). elevated plasma lactate was associated with nonsurvival. thirteen percent of survivors were assessed as able to live independently after their injury. civilian gunshot injury to the head is related to high mortality. indicators of outcome are the admission gcs score, pupillary abnormality, metabolic acidosis, and ct pattern of severe injury. introduction and objectives: the aim of this study is to compare the effects of the mannitol and melatonin on the levels of blood and brain malondialdehyde (mda). methods: in the study, 24 new zealand type rabbits were used. the test subjects were divided into four groups; sham (n = 6), control (n = 6), mannitol (n = 6) and melatonin (n = 6) groups. blood cerebrum tissue samples were taken to research for mda in the control group. head trauma was applied with feeney method to the rabbits in the other groups. venose blood samples were taken before and after trauma to observe mda. 100 mg/kg melatonin was given to the melatonin group, and 2 g/kg mannitol was given to mannitol (12%), between 9 and 12 in 33 (5.6%), and between 13 and 15 in 474 patients (81.3%). mortality rate was 6% (n = 35). patients who died had significantly higher iss (p < 0.0001), lower gcs, (p < 0.0001), and higher head ais (p < 0.0001). conclusions: road traffic collision is the leading cause of head injury in our setting. in this study population, head injury was severe, more than one fifth of the cases were admitted to the icu, and gcs was below 8 in 12%. patients who died had significantly higher iss, lower gcs, and higher head ais. backgrounds and objectives: benefits of emergency burr-hole craniotomy (or evacuation) for patients with critical head trauma remained unclear. our study objective is to compare the effectiveness of burr-hole craniotomy to decompressive craniotomy using data from a large-scaled, multicenter and nationwide registry of hospitalized trauma patients in japan. materials and methods: among a total of 20257 records registered in japan trauma data bank, we selected patients with critical head trauma which were scored as ais 5 (critical injury on the abbreviated injury scale) on head and underwent either of burr-hole craniotomy or decompressive craniotomy. parameters of the trauma injury severity score (triss) were used to adjust the baseline trauma severity. univariate analysis and multivariate logistic regression analysis estimated the relative risk of inhospital death. results: a total of 180 zygomatic and/or orbital fractures were identified with 74 subtarsal (41%), 56 subciliary (31%), 45 transconjunctival (25%) incisions, and 5 laceration (3%). the risk of ectropion was highest in subciliary incisions (13.2%, p = 0.018), however, only one case required operative management. entropion was found in two cases after transconjunctival incisions (p = 0.108); both required operative management. lid edema was present in 1.4% of subtarsal and 8.9% of subciliary incisions (p = 0.016). one hypertrophic scar was seen with the subtarsal and two cases with the subciliary approach (p = 0.545). conclusions: lower eyelid malposition occurs after any lower eyelid incisions for facial fracture repair. ectropion is most commonly seen in subciliary incisions, while entropion is rare. a subtarsal incision has a low risk of malposition, however is associated with hypertrophic scars. although choice of incision can be based on surgeon preference, a thorough patient discussion must include potential complications with each approach. in traumatology things happen quickly, data are often incomplete and therefore misleading and there is also pressure for quick decision. in dealing with the matter we distinct among wrong decisions based on insufficient data and errors due to systemic faults or individual incompetence or negligence. possible systemic faults are at every level of treatment: taking history, clinical examination, diagnostics, decision making, treatment procedures and even rehabilitation. most analysed errors occured when patient was handed over to another team or another level of treatment. haste and insufficient or inadequate report leads to wrong assumptions and -if that is not discovered in time -to wrong treatment. on personal level usual mistake was being satisfied when one injury was found and others were missed to insufficient exam or diagnostics. dealing with unfamiliar drugs lead to overdosage and sometimes death of the patient. to avoid such disasters extra training was added to medical school and medical students systematically approach the subject. at the emergency department adherence to protocols is encouraged, especially in cases of unresponsive patients. on hospital level enough time should be provided for attending physicians to make thorough rounds. this should provide much needed redundancy in the age of maximum efficiency. unfortunately we feel it is still not possible to implement measures of self-reporting as known by the airline industry due to inadequate law regulation! author to editor: measures for preventing medical errors in trauma department is showed. background and aim: missed injuries adversely affect patient outcome and damage physician, as well as institutional, credibility. autopsies are useful in uncovering missed injuries or undiagnosed conditions that contribute to death after injury. the aim of this paper is to analyze and compare medical documentation and autopsies findings in searching for missing injuries in trauma fatalities treated in our hospital. patients and methods: we analyzed data for patients died after trauma in 4 years period (january 1st, 2004 -december 31st, 2007 introduction: immune suppression is a compensatory mechanism in acute inflammation e.g. following trauma. multiple mechanisms underlying this phenomenon include decreased cytokine production, shifts in cytokine balance and unresponsive adaptive immunity. we show in a model of acute inflammation that neutrophils, apart from their established pro-inflammatory characteristics, possess multiple mechanisms mediating immune suppression. methods: healthy male volunteers were given 2 ng/kg e. coli lipopolysaccharides intravenously. blood was taken at various time points. neutrophils were stained with antibodies and isolated by facs. neutrophil receptor-expression, phagocytosis and oxidase were measured. lymphocytes were cultured in the presence of neutrophil subsets and cd3/cd28 or pha. proliferation was measured by incorporation of 3h. results: distinct neutrophil subsets were identified. 3-6 h after administration of lps 40% of neutrophils displayed a two to threefold decreased expression in innate immune receptors, decreased phagocytosis and oxidase production. another neutrophil subset (25%) inhibited lymphocyte proliferation by 50% (in the presence of cd3/cd28 or pha) in a 1:1 ratio independent of il-10, tgfb, arginase or indoleamine 2-3. instead direct delivery of h 2 o 2 appeared to be the mechanism of immune suppression. conclusion: in acute inflammation neutrophils utilize multiple mechanisms mediating immune suppression. firstly refractory neutrophils appear in the circulation. secondly another population of circulating neutrophils effectively suppresses adaptive immunity. these observations dictate an important role for neutrophil-mediated immune suppression following conditions such as trauma, contributing to the susceptibility to infections seen in these patients. sham-group) received a single intraperitoneal injection of either zinc protoporphyrin (znpp), an ho inhibitor, hemin, an ho-1 inducer, or vehicle. 6 h later, rats were anesthetized and subjected to hts, including bleeding, laparatomy, and reperfusion (inadequate and adequate phase) and were sacrificed 16 h later. ho-1 mrna was determined by real-time pcr and ho activity was determined in liver homogenate. free iron was measured by electron paramagnetic resonance spectroscopy in nonhomogenized liver tissue. ho-1 mrna was elevated only in the hts-group pretreated with znpp versus the sham-group. ho activity was increased in all hts groups compared to sham groups, with the most distinctive increase seen in the hemin pretreated groups. plasma bilirubin values showed a similar increase in the groups pretreated with hemin. no significant difference was found in free iron concentration among all groups. our data show that changes of ho activity prior to hts are not associated with elevated free iron, late after reperfusion, suggesting that free iron released from ho is efficiently deactivated. introduction: cells of the innate immune system are essential in the development of inflammatory complications. the activation status of this system can be determined by analyzing expression activation markers on neutrophils in peripheral blood. our research group previously showed that a combination of these receptors, the 'priming score', reflected the inflammatory status of individual patients. hypothesis: systemic activation of the innate immune system attracts functional neutrophils into damaged tissues. dysfunctional neutrophils stay behind in the circulation, causing a paralyzed innate immune system and increased susceptibility to late onset sepsis (>5 days objectives: our study objective is to stratify risk factors of the second (within hours) and third peak (within days) of trauma death independently. materials and methods: 20,257 records from japan trauma data bank were retrospectively analyzed. as outcomes for the analysis, we defined the early and delayed death as deaths within 2 days and those after 3 days, respectively. based on the framework of trauma injury severity score (triss), coded glasgow coma scale (cgcs), coded systolic blood pressure (csbp), coded respiratory rate (crr), injury severity score (iss) and coded age (cage) were used as independent variables to determine the outcomes using proportional hazard analysis. conclusions: in our observation, statistically-significant risk factors of early and delayed trauma death differed. physiological severity largely affected the second peak. in contrast, the third peak mainly correlated to anatomical severity and elderly in age compared to risk for the second peak. especially, an initial hypotension might no longer affect the third peak of trauma death independently. regression analysis including all the parameters of rts as explanatory variables showed the odds ratios of categorical sbp variables predicting the inhospital death. results: a total of 12,077 records matched the inclusion criteria. score-0, 1, 2, 3, 4a and 4b in sbp subcategory consisted of 1, 043, 161, 298, 382, 9, 233 and 960 patients, respectively. inhospital mortality of score-0, 1, 2, 3, 4a and 4b were 98, 66, 38, 21, 6 and 16%, respectively. after adjustment for rts, the odds ratios for the inhospital death of score-0, 1, 2, 3, 4a and 4b were 26.7, 10.0, 4.9, 2.5, 1.0 (reference) and 2.2, respectively. isolated head trauma were more frequent in score-4b compared to score-4a (46 vs. 29%, p < 0.0001). conclusion: a trauma patient with systolic hypertension ‡ 180 mmhg is scored 4 points in sbp category under rts rule, however, exposed to higher mortality rate similar to patients with 3 points in sbp subcategory and maybe related to isolated head trauma. author to editor: to whom it may concern: we have received a e-mail replied from abstractagent.com which alert the exceed in limitations of abstract submission. the e-mail noticed us, the presenting author of this abstract (akira endo) posted 3 or more abstract as a presenting author, however, the authors of ''increased mortality in trauma patients with systolic hypertension'' believed that akira endo in department of accdm, tmdu, japan surely posted this abstract only. the name ''akira endo'' is common in japan. we suppose that ''akira endo'' of the other institutes were doublecounted. editor to self: seçilmiş bildiri background: the united arab emirates (uae) is developing rapidly, with many foreign construction, farm, and industrial workers at risk of injury. aims: to assess external causes, risk factors, severity, and anatomical region of work-related injuries using a trauma registry. methods: surgical admissions 03/2003 to 04/2005 were recorded in the registry at the main trauma hospital in al-ain region, population 348,000. prevention-related variables were analyzed using spss and severity quantified by injury severity scores (iss). results: there were 614 work-related injury hospitalisations, equating to an incidence of about 136/100,000 workers/year. males accounted for 98%, ages 25-44 years 69%, and nonnationals 96%, with 70% of workers from the indian sub-continent. external causes included falls 51%, falling objects 15%, powered machines 11%, animals 7%, burns 6%, and other 10%. at least 39% of falls were from relatively high levels. median iss was 4 for all six main external causes. extremities were most frequently injured. mean hospitalisation was 9.4 days. 4% (n = 22) were admitted to the intensive care unit and 1% (n = 5) died after admission. conclusions: main external causes were proportionately much more frequent than in industrialised countries, and admissions prolonged. priorities include effective countermeasures for falls from height and falling objects, and for machinery injuries. improved work injury data, access to occupational health services, specific regulations and frequent inspections at all construction sites, workshops, and farms, together with appropriate penalties for safety violations, are essential to reduce incidence and severity of occupational injury among vulnerable migrant workers in the uae. introduction and objectives: immobilization of the spine in trauma patients at risk of spinal damage is performed using a rigid long spineboard or vacuum mattress both during pre-hospital and inhospital care. however, disadvantages of these immobilization devices in terms of discomfort and tissue-interface pressures have guided the development of a new soft-layered long spineboard. we compared tissue-interface pressure and degree of comfort during immobilization on a rigid spineboard, a vacuum mattress and a newly developed soft-layered long spineboard. methods: in this randomized cross-over trial, 30 volunteers were immobilized sequentially on all three devices for 15 min per device. tissue-interface pressures were measured using an xsensor pressure mapping device, including the peak pressure and the peak pressure index (ppi). comfort was rated on a visual analogue scale (vas) after 1 min and after 15 min of immobilization. results: tissue-interface pressures were significantly higher on the standard long spineboard and the vacuum mattress than on the softlayered long spineboard. ppi for the sacrum on the soft-layered long spineboard was significantly lower than on both other devices, with an average ppi close to normal diastolic blood pressures. the participants reported significantly more comfort on the soft-layered long spineboard compared to the rigid long spineboard, both after 1 and 15 min (p < 0.0001). conclusion: using the soft-layered long spineboard, which imposes less pressure on the tissue and provides better comfort than the standard long spineboard and the vacuum mattress, means buying time to optimize the patient's treatment while minimizing tissue damage. background: trauma and emergency surgery models differ all across europe. no definitive model was accepted and work and surgical emergency load are different in each region. we performed a cohort study to analyze the impact of emergency (including trauma) surgery in the general surgical practice at a portuguese university hospital. methods: data on emergency surgical cases and admissions to the surgical service over a 3-month period were collected and analyzed; this included patient demographics, referral sources, diagnosis, operation, and length of stay (los conclusion: emergency workload represents a significant part of the work for the general surgeons. the emergency surgical cases and admissions had a significant impact in the mortality rates of the general surgery admissions. resource planning and training should be based on more comprehensive, prospective data such as these. background: the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance remain uncertain. the aim of this study was to investigate the cost-effectiveness of hems assistance versus emergency medical services (ems). methods: a prospective cohort study was performed at a level i trauma centre. quality of life measurements were obtained at 2 year after trauma, using the euroqol-5d as generic measure. health outcomes and costs were combined into costs per quality-adjusted life year (qaly). results: the study population receiving hems assistance was more severely injured than that receiving ems assistance only. the incremental costs for intramural care were e4,700 for hems treated patients compared with patients treated by ems only, which was mainly determined by the costs of the intensive care stay and the used diagnostics. finally, the costs for hems assistance instead of ems assistance were e28,537 per qaly. the sensitivity analysis showed a cost-effectiveness ratio between e16,000 and e62,000. conclusion: the costs per qaly for helicopter emergency medical services in the netherlands remain below the acceptance threshold. therefore, hems should be considered as cost-effective. author to editor: this study describes the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance. it investigates the cost-effectiveness of hems assistance versus emergency medical services (ems), and may serve as a reference for future quality of life and cost-effectiveness studies on the subject of hems and severely injured patients introduction: in usual multi-trauma care (utc) each partner has its own ''autonomous'' treatment perspective. clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('supported fast-track multi-trauma rehabilitation service': sftrs), featuring earlier transfer to a specialised trauma rehabilitation unit; earlier start of 'non-weight-bearing' training and multidisciplinary treatment; early individual goal-setting; co-ordination of treatment between trauma-surgeon and physiatrist, may be more (cost-)effective. the feasibility of a multi-centre trial examining the (cost-)effectiveness of sftrs was assessed. methods: data from 1892 multi-trauma patients (iss ‡ 16, complex multiple extremity injuries or complex pelvic fractures) were inventoried. patient characteristics, trauma severity, quality of life, health status, anxiety and depression, and cognitive functioning were assessed in two dutch trauma centres providing utc or sftrs. results: no differences in patient characteristics', trauma severity or discharge destination were found between sftrs and utc. discharge destination was 'home' (49.4%), 'rehabilitation clinic' (20.3%), 'nursing home' (5.2%), 'other hospital' (5.8%), 'unknown' (6.4%). 12.8% of patients died. however, hospital length-of-stay differed: 10.4(sd: 10.4) days (sftrs) and 13.9(sd: 13.5) days (utc). conclusion: adequate patient numbers may be recruited, baseline patient characteristics did not differ between collaborating centres, hospital length-of-stay was reduced in sftrs and adequate patient follow-up is possible. based hereupon, a nonrandomised multi-centre clinical trial started. (isrctn68246661). the trauma-region of north-west netherlands has consensus criteria for mobile medical team (mmt) scene dispatch. the mmt can be dispatched by the ems-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. although much attention has been paid to improve the dispatch criteria, the mmt is often cancelled after being dispatched. the aim of this study was to assess the cancellation rate and the noncompliant dispatches of our mmt, and to identify factors associated with this form of primary overtriage. methods: we conducted a retrospective case review of 605 consecutive mmt-dispatches during a 6 months period. by means of chart review, data pertinent to prehospital triage, patient's condition onscene and hospital course were collected and analyzed. all dispatches were evaluated by using the mmt-dispatch and mission appropriateness criteria results: median age was 35.9 years and 65.3% of the patients was male. of these, 430 patients were trauma victims (86.7% blunt trauma). after being dispatched, the mmt was cancelled 203 times (43.5%). statistically significant differences between assists and cancellations were found for overall mortality, mean rts, gcs, and iss, mean hospitalization and amount of icu admissions (p < 0.001). almost 26% of all dispatches were neither appropriate, nor met the dispatch criteria. fourteen (3%) missions were appropriate, but did not meet the dispatch criteria. conclusions: nearly a half of mmt-dispatches were cancelled and almost 29% did not meet the dispatch criteria. dispatch criteria for the mobile medical team in our trauma-region need further refinement and compliance. the ''traumax ò '' hip screw plate is a new device that allows the treatment the fractures both of the neck and the trochanteric area of the femur, expected subtrochanteric area. this plate conserves the characteristics of a dynamic hip screw (compression of the fracture site, good positioning of the pieces of bone, integrity of gluteus muscles) more specific characteristics: this device is modular, allows to choose the length of the barrel adapted to the length of the head screw, the diaphysal screws are locked by a tech nut according to the patented ''surfix'' system. the locked screw gives a good stability even if the bone has a poor density and allows to use a short plate that preserves the piercing lateral vessels of the femur. this short modular screw plate can be implanted by a 3 cm minimal invasive approach using a particular instrumental pipe. during the presentation we will report the results of a prospective study colligating 250 cases of ten french hospitals. a preliminary study of 60 consecutives cases gives prominence to a few blooding with an average of 180 ml, a operative time of an average of 32 mn, a xr exposing time of an average of 16 s. healing bone has been obtained in all cases. the head screw has been placed at the center or just below in 97%. no complication dues to the plate has been reported; in all cases only one approach has been used. aim: to assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint. methods: the 32 patients (37 feet) that had silastic implants inserted were reviewed at an average of 2 years and 4 months (ranging 7 months to 5 years and 4 months). the mean patient age was 63 years. these patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative aofas score was calculated for each. results: the questionnaire revealed that every patient described that their pain had decreased after surgery and 17 feet (46%) were completely pain free. there was a significant improvement in patients' subjective pain scores after surgery (t value £ 0.0001). preoperatively, the mean pain score for all 37 feet was 8.14, whereas post-operative the mean pain score was 1.32. the mean aofas score before surgery was 39.97. this increased to a mean score of 87.40 after surgery (p £ 0.0001). this again is a significant improvement. no patient was dissatisfied with the outcome with their surgery. conclusion: these moderate term results are encouraging, with good subjective and objective results. however, long-term follow-up will be required to assess the longevity of this implant • theatre staff should be trained for proper application and cleaning of the exsanguinators • alcohol wipes are good alternative to current practice and should be used for decontamination • we must wash our hands before and after its use • we should use plastic bag over the limb first before using the exsanguinators it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator developed by the author. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanically. in clinical use it has been applied to 1,050 patients in treatment of femoral fractures. the age of patients was from 14 to 87 years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. received clinical results are promising, as it has been shown early callus formation and radiological union within the 3-4 months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with 3d configuration resulted in unexpectedly quick fracture healing. follow up was 19 months (6-60). according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site. it can be used as primary method or soon after external fixation if damaging control concept used. (2000) (2001) (2002) (2003) (2004) and followed-up for a minimum of 2 years formed the study population. a retrospective review of data from electronic patient record (epr), clinical coding, clinic and gp letters was made. age, residential placement, garden's classification of fracture, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. an indepth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions was critically analysed. results: the mean age of patients was 68 years (range 18-96 years). the incidence of non-union was 8% and avascular necrosis at 1 year was 19%. revision surgery was performed in 87 (27%) cases. complications were more principally in patients who had end-stage renal failure (76%), diabetes mellitus (60%), osteoporosis (43%), and steroid use (67%). conclusion: the complications and revision surgery rate was high in patients with particular co-morbidities despite being undisplaced. comorbidities and patient's age were also strong predictors of healing in addition to fracture configuration. outcome of hip fractures is influenced by complex interplay of multiple factors and not only by radiographic appearance. methods: this is a 6-year of retrospective study. we had included 14 patients to our study (12 females and 2 males) with the average age of 56.6. we used bryan and morrey classification system and included type i and type iii fractures. results: there were 11 type i and three type iii fractures. associated injuries were two dislocations with one mcl injury and two radial nerve symptoms. all the patients had orif with screw and two patients had supplementation of fixation with wires. most patients were mobilized early in 2 weeks time. nine of them treated with miniacutrak screw fixation, four with herbert screws and one lag screw (ao miniscrew). the approach was mainly postero-lateral but for five patients, it was antero-lateral. all patients were clinically and radiologically assessed. average time for radiological union was 7 weeks. on the other hand, one patient had revision fixation because of failure of metalwork. additionally, one patient had capsular release for contraction and another one had removal of screw for prominence of metalwork. average follow-up was 33.7 months (8-72 months). mayo elbow score was excellent for seven patients, good for three patients, and fair for three patients. one patient could not be fully scored due to learning difficulties. we recommend open reduction and internal fixation for all type 1 and type 3 fractures so that function can be regained early. objectives: to report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. methods: a prospective study of the patients with intra-articular calcaneum fractures in the foot&ankle unit of a busy trauma hospital. all the patients were followed up with the calcaneal fracture score. we compared the outcome of surgical management sanders type 2 (group a) and type 3 (group b) fractures with conservative treatment (group c) at 2 years and assessed the medium term outcomes of groups a and b. group c were a consecutive series of patients recruited to the study later than a and b, hence the smaller number in that group. results: 126 patients were included in our study. there were 70 in group a, 38 in group b, and 18 in group c. mean follow-ups for the groups were a = 6 years, b = 5.5 years, and c = 2.34 years. mean 2-year scores for the groups were a = 68.13, b = 63.78, and c = 51.36, with statistically significant differences between groups a and c (p = 0.0006), and between groups b and c (p = 0.04), but no significant difference between groups a and b. at medium-term follow-up (> 5 years), the scores for group a and b were 77.06 and 63.66, respectively. there were 7 deep, 5 superficial infections and 32 metalwork removals in total. conclusion: on comparing the medium term outcome to the 2-year one, group a showed some improvement and group b stayed the same. in this series, contrary to published articles, there was a better outcome at 2 years with surgical treatment than conservative treatment. author to editor: all the authors have agreed with content of the abstract. there was not any conflict of interest for this study. objective: to assess the effectiveness of mobile angiography with a digital subtraction angiography (dsa) technology directly into the emergency room (er) for blunt trauma patients with pelvic injury. materials-methods: this is a retrospective review of a cohort of blunt trauma patients with pelvic injury treated after the direct availability of mobile angiography by trained trauma surgeons into the er for resuscitation. data was collected including demographics, hemodynamic variables, resuscitation intervals form admission through completion of hemostasis, metabolic factors (ph and body core temperature), mortality and transcatheter arterial embolization (tae) related complications. results: twenty-nine patients underwent tae in the er. mean age, shock index, and injury severity score were 40 ± 17 years old, 1.1 ± 0.6, and 30 ± 14, respectively. the interval from the decision to perform tae through initiation of tae and the interval from the decision to perform tae through completion of tae were 31 ± 12 min and 110 ± 32 min, respectively. the mean dbody core temperature (bt) from admission through completion of tae was -0.2 ± 1.5°c. and the mean dph from admission through completion of tae was 0.02 ± 0.13. there were clinically significant correlations between dbt and resuscitation interval, and between dph and resuscitation interval. tae was successfully performed in all cases and mortality was 17%. no tae-related complications were observed. conclusion: immediate availability of mobile angiography into the er by trained trauma surgeons was effective to shorten the time required to restore normal physiology of trauma patients with pelvic injury without leaving the er for resuscitation. introduction: tgf-b1 is a regulatory protein, involved in fracture healing. the purpose of this study was to investigate the role of tgf-b1 in human fracture healing, and to verify whether tgf-b1 is a reliable marker of nonunion. methods: serum samples of 114 patients with long bone fractures were collected over a period of 6 months. patients were assigned to 2 groups: first group contained 103 patients with physiological fracture healing. eleven patients with nonunions formed the second group. 33 healthy volunteers served as controls. results: in patients with physiological healing serum concentrations were initially high. serum concentrations then decreased rapidly after 2 weeks and reached a plateau between weeks 6 and 8. thereafter, another continuous slight increase of the concentrations was observed between weeks 12 and 24. in patients with impaired fracture healing tgf-b1 serum concentrations were initially similar to those with normal healing. a significant increase of the concentration was observed between weeks 4 and 6, followed by a continuous decline of the serum levels for the remainder of the observation period. significant differences between the concentrations in both groups were observed at weeks 6 and 8. tgf-b1 as marker would have detected patients with nonunions at 6 weeks after fracture with a sensitivity of 100% and a specificity of 49%. distal metaphyseal radial fractures are extremely common fractures in children (%20,2). high rates of displacement occurs during conservative treatment. the aim of this study was to determine the effect of kirschner wire application after closed reduction of radial metaphyseal fractures with high risk of redisplacement. in this retrospective study 40 cases were studied in two groups. in group 1 (n = 20), k-wire applied after closed reduction. in group 2 (n = 20), only cast was applied following closed reduction. the mean follow-up was 20 months. the compared clinical and radiological parameters were; pain, limb deformity, range of motion of the wrist, angulation of the fracture site, radial distal epiphyseal angle and severity of translation. redisplacement rate was 10% in group 1 and 50% in group 2. this shows, kirschner wire fixation had a positive effect in continuity of the initial reduction (p = 0.014). age (p = 0.289), gender (p = 0.264), reduction quality (p = 0.970) had no effect on redisplacement. concerning the severity of translation, the risk of redisplacement increases in stage 3 (50-100%) and stage 4 (> 100%) fractures (p = 0.003). concomitant complete ulnar fracture had also redisplacement risk (p = 0.016). redisplacement risk increases when the distance of fracture line to epiphyseal line was between 11 and 20 mm (p = 0.073). there was no significant difference between two groups after last evaluation based on radiological parameters and clinical results (p > 0.05). as a conclusion; this study shows that kirschner wire fixation prevents redisplacement in early follow-up of first 3 weeks but there is no superiority after 20 months follow-up in distal metaphyseal fractures of children. patients in group c showed the best functional results, the greatest ankle range of motion, the fastest full bearing, the fastest walking on toes and heels, and the shortest duration of physical limitations (walking on uneven ground and sports activities) (p < 0.001 for all). in group b, there were two reruptures, in group c one, and in group a there were no reruptures. good functional results and a relatively small number of postsurgical complications advocate the usage of surgical techniques. the best and fastest functional recovery was attained in the group treated with the original technique of percutaneous fixation with two embracing and crossed loops. open surgical reconstruction is indicated only in the case of rerupture after percutaneous suturing. introduction: there are different techniques for arthrodesis of endstage arthrosis of the ankle-joint. internal fixation is the favoured method in many institutions. we retrospectively examined the technique and clinical results of external fixation in a triangular frame. patients/methods: from 1994 to 2001 a consecutive series of 95 patients with end-stage arthritis of the ankle joint was treated. mean age at the index-procedure was 45.4 years, 67 patients were male (70.5%). via a bilateral approach the malleoli and the joint-surfaces were resected. an ao-fixator was applied with steinmann-nails. follow-up examination at mean 4.4 years included a standardised questionnaire and a clinical examination including the criteria of the aofas-score and radiographs. results: in two cases, due to contracture a pes equinus position had to be accepted. in two cases a further bone transplant was performed at 6 and 9 weeks for unsatisfactory bony union. after mean 12.3 weeks, radiographs confirmed satisfactory union and the fixator was removed. in four patients a nonunion of the anklearthrodesis developed (4.5%). the mean aofas score improved from 20.8 to 69.3 points. statistical analysis of the insurance status showed that patients insured under a workers injury compensation scheme had a mean score of 63.6 compared to 75.1 for the remaining (p = 0.027). discussion: nonunion rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods in literature comparison. the complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations. implants with multidirectional locked screws have theoretical advantages in the treatment of periprosthetic fractures. in osteoporotic bone they provide a high stability. we concluded a retrospective study of a consecutive series of the outcome of vancouver b1 and c femoral injuries using two specific locked-implants. from 1996 to 2004 we treated 58 patients with a periprosthetic fracture of the femur with a locked plate. the mean age at the index procedure was 72.4 years, 40 patients were female (69%). in 32 cases (55.2%) we saw a hip endoprosthesis, in 21 cases (36.2%) a knee endoprosthesis and in 5 cases both (8.6%). outcome measures were intra-and postoperative complications, bony union, degree of mobility and social status, barthel-mobility-index and ''stand-up&go'' test. union occurred in 56 cases (96.5%) after the index procedure. twice the implant failed, we saw four general complications. the mean duration until full weight bearing status in these patients was 8.6 weeks. at follow-up 46 patients (78%) had maintained the same social status as before the fracture. regarding the mobility status 52 patients (89%) had regained their previous level, 4 patients walking without aid before now required a cane and 2 patients a walking frame. the mean barthel-index was 85 points of 100. the mean stand-up&go time was measured as 22 seconds. conclusion: overall failure rates of osteosynthesis after periprosthetic fractures of up to 35% are reported (20). with 3.5% implant related failures and 7% general complications, the presented methods achieve bony union and mobility in a high percentage of cases. 184 arthroscopic-assisted percutaneous figure introduction: we describe a new arthroscopic-assisted reduction and percutaneous tension band wiring technique for patella fractures that combines the advantages of minimally invasive surgery and stable internal fixation. surgical technique: we reduce the fracture percutaneously by towel clips with the patient in the supine position. we insert two 3.0 mm kirschner (k) wires in a caudocranial direction under arthroscopic control. we do four stab incisions to assign the inferolateral (il) and inferomedial (im), superolateral (sl) and superomedial (sm) portals besides the k wire tips. we insert a trocar with its cannula from sl portal to sm portal under the k wires. we take the trocar out and leave the cannula inside. we run 18-gauge cerclage wire through the cannula in sl to sm direction. we take out the cannula. we perform exactly the same steps directed from sm portal to il portal, from il portal to im portal, and from im portal to sl portal, respectively. finally near the sl portal, wires are secured with a single knot. we check the fixation by c scope. results: radiographic consolidation was achieved in all five patients at an average of 2 months. all patients returned to the activity level previous to fracture. conclusion: this technique presents advantages over open techniques. it is minimally invasive and cosmetically pleasing, permits visualization of reduction and stability, allows concomitant intraarticular pathology to be exposed, and facilitates early rehabilitation. although we did not attempted yet, we believe that even comminuted fractures can be fixed with this technique. (1) timing of the procedure, (2) accurate technique, (3) stable implants for early mobilisation. in this study we present our experience in the treatment of ftp with locking plates trying to define the role of a medial plate. materials and methods: from 2005 to 2008 we treated 20 patients with a ao c3 ftp by orif with locking plates. indications for a medial plate were: involvement of the medial joint surface, coronal fracture of the medial plateau and irreducible dislocated medial condyle. all the patients have been followed up clinically with the lysholm and rasmussen scores and radiographically until consolidation. results: all fractures united. one patient underwent knee amputation for septic complication. the mean lysholm score was ''fair'' while the rasmussen score was ''good'', that means that the subjective result was worse than the objective one. patients treated by double plating had a worse clinical result that was not dependent on the quality of reduction. we had three cases of malalignment, one rsd, two superficial infections, two transient nerve palsy. conclusion: complications in our series were frequent and the clinical results not particularly good. the right timing and an accurate surgical technique are essential for a good reduction, newer implants control effectively the fragments but the high energy of the trauma remains the major determinant of the bad outcome of these fractures. introduction: the high percentage of failure of fixation systems in periprosthetic fractures depends on the technical difficulty of the procedure, the presence of the cement mantle and the poor quality of the remaining bone. the lcp system offers an enhanced stability that reduce the implant mobilization, and preserves the bone vascularity, fastening the healing time. we present our results in the treatment of periprosthetic fractures with lcp. materials and methods: 27 consecutive patients with vancouver b1 fractures were operated on using 4.5 lcp. a standard open reduction of the fracture through a lateral approach was used. patients were evaluated clinically and radiologically for a mean follow up time of 17.8 months. results: all the fractures united except two where a narrow 4.5 plate and too many cerclage wires around the fracture were used. all the patients showed at fu an hhs over 90 points. the anatomical reduction of the fracture led to a faster healing. conclusions: the effect of the position of screws and cerclages in relation to the plate and fracture are discussed. the authors conclude that lcp system, has to be considered the golden standard in the osteosynthesis of vancouver type b1 periprosthetic hip fractures, permitting early weight bearing and healing in physiological time. it is better to avoid narrow 4.5 plates and cerclages at the fracture site. suggestions on the plate length and screw and cerclages position are given depending on the fracture type and length. 187 the role of the anatomical prosthesis in the treatment of proximal humeral fractures ló ránt bardó cz, jános csotye 1 1 pá ndy ká lmá n county hospital, gyula, hungary, traumatology introduction and objectives: we would like to present the results of the treatment of proximal humeral fractures with endoprosthesis. methods: between 1997 and 2007 we operated 74 patients with endoprosthesis for proximal humeral fractures. 11 were delta prosthesis, the results of these operations are the subject of an other presentation. 63 patients were treated with anatomical shoulder prosthesis. the results of these were controlled by personal examination (constant score, x-ray) and by the base of the clinical documentation. 61 was hemi-and 2 total endoprosthesis. in 50 cases the operation was acute and in 13 cases for chronic cases. the average follow up time was 76.9 month. we categorized our patients in different groups, based on the fracture type and the time of the surgery. results: we compared the cs of the operated shoulder with the contralateral one in each patient group. we have to accentuate the importance of patient cathegorization, because the results can be analyzed properly only on base of these. on the x-rays the prosthesis were in good place, we found no evidence of losening. conclusions: when the indication is good, the prosthetic procedure is the choice for acute or chronic fractures of the proximal hunerus, and the results are good. we confirmed the statistically significancy of the efficacy of the treatment methods between the same analyzed groups. aim: to discover if how often lateral x-ray change the management of fracture neck of femur fractures as an adjunct to the standard ap film. method: 6 orthopaedic consultants and 6 registrar grade orthopaedic surgeons were asked to decide the management of 30 neck of femur fracture solely from an ap film. at a second sitting the same films were shown in a different order in conjunction with the associated lateral hip x-ray. the surgeons were asked to comment on the adequacy of the lateral x-ray and their choice of management using the both films to make a decision. results: less than half of the lateral hip x-ray were adequate when reviewed on the monitors and very few operative decisions were changed with the addition of the lateral x-ray. conclusion: a standard ap film is usually sufficient to plan management in a fractured neck of femur fracture and the additional time, money, and discomfort of obtaining lateral films does not seem justified in these circumstances. an sermon, stefaan nijs, barbara bosch, paul broos 1 1 department of traumatology, university hospitals gasthuisberg, leuven, belgium introduction: humeral head fractures extending into the shaft often are a challenge to the surgeon. although they are a rather rare entity, they often occur in osteoporotic bone and are difficult to stabilize. however, because of their intra-articular extension, a perfect reduction and stable osteosynthesis is needed. methods: between august 2005 and august 2008, 16 patients with a combined shaft and humeral head fracture were operated in our department. a long philos plate was used in all cases through an extended deltopectoral approach. postoperatively, immediate mobilization was allowed. mean follow-up time was 11 months. results: there were three preoperatively existing radial nerve palsies of which two completely and one partially recuperated postoperatively. there occurred no radial nerve palsies which did not exist preoperatively. revision surgery was necessary in two patients because of hardware failure and secondary fracture displacement within the first week after surgery. in both cases, again a long philos plate was used. all fractures were radiographically healed within 6 months; there were no cases of avascular necrosis of the humeral head. most of the patients were subjectively satisfied with the functional result although mobilization of the shoulder was only moderate in nearly half of the cases. conclusion: in conclusion we can say the use of long philos-plates for the treatment of combined shaft and humeral head fractures gives good results when carried out by experienced hands. osteosynthesis with the use of locked nails is an efficacious method for the treatment of long bone fractures and nonunions of extremities. however, it is contraindicated in case of infection. one way to obviate this problem is to coat implants with antibiotic-loaded bone cement. the objective of this work was to evaluate the efficiency of antibiotic cement-coated interlocking nails for osteosynthesis of long bones in case of infection (infected nonunions) or at high risk of its development (severe open fractures). in 2007-2008, nails with antibacterial cement coating were used to treat 29 patients including 15 ones with severe open long bone fractures (gustilo-anderson type iiia-iiib). these fixators were employed both at admittance of the patients (with an isolated injury) and within 5-6 days after it (in case of polytrauma). 7 patients of this group underwent one-step surgery combining osteosynthesis and the closure of soft-tissue defects with local muscular flaps. in 14 patients with infected nonunions of long bones, osteosynthesis was performed after seeding fistula discharge for microflora. none of the patients in the group with severe bone fractures suffered deep suppuration and all achieved consolidation of fractures. one case of recurrent infection associated with extensive necrosis of bone was documented in the group of patients with infected nonunions. the remaining patients had resolution of signs of infectious process, and their nonunions consolidated. the use of antibiotic cementcoated interlocking nails is a promising method for osteosynthesis of long bones in case of infection and at high risk of its development. author to editor: severe open fractures and infected nonunions are one of the most difficult problems in trauma orthopedic surgery. we had only one treatment option for this pathology down to resent times. it was an external fixator, but it has many disadvantages. in 2007 we start using antibiotic cement-coated interlocking nail, and we have promising first results. this results we would like to present in eurotrauma 2009. hawar akrawi, david gordon hargreaves 1 1 department of trauma and orthopaedics, southampton university hospitals nhs trust, southampton, the united kingdom introduction: we describe our clinical experience with a new posterior approach for reconstruction of distal intercondylar fractures of humerus. the maserati approach comprises of a midline proximal triceps split in conjunction with elevation of medial and lateral edges of triceps from the condylar ridges. this approach gives adequate access for accurate reduction and internal fixation of distal and intraarticular humeral fractures. methods: a single consultant series of 13 patients with distal humerus fractures (ao grade 13-a to 13-c) were treated using the maserati approach and distal humeral locking plates over 4-year period at level 2 trauma centre. all cases were reviewed. there were 7 female and 6 male patients with age range from 17 to 79 year. average follow-up was 12 months. these patients were assessed for: 1. accuracy of reduction of fracture fragments. 2. complications i.e. infection, triceps weakness, triceps lag and fracture union. 3. elbow function as per the mayo elbow performance score (meps). results: nine patients had anatomical reduction. no cases of infection or nonunion. one case of delayed union. none of the patients exhibited triceps lag or weakness. the meps was 70-100 (mean 91). discussion: the maserati approach is a safe approach that provides good access to the articular surface of elbow without compromising the triceps muscle. triceps continuity is preserved, allowing early rehabilitation without the possible co-morbidities associated with other posterior elbow approaches (non-union of olecranon, triceps weakness or triceps lag). author to editor: dear sir/madam, i will be very grateful if you could offer me the opportunity to give a podium presentation about this innovative approach. patients with distal humeral fractures are difficult to manage and with oral presentation, i will be able to demonstrate clearly, with media presentation, the full advantage of this new approach. results: improvement of the neurological deficit was observed in 13 cases. ct control at least of 3 years follow up shows good bone integration of the iliac crest bone in majority of the cases. two patients experienced temporary neurological symptoms, which showed complete remission. the endoscopic procedure for reconstruction of the anterior load-bearing spinal column developed to a standard concept in trauma management. the minimal morbidity of the operative approach, good visualisation of the operative field and angle stable implant make it possible to restore the anterior column on a safe technique. full weight bearing (painless) ranged (un)14-32(ø20) and (rn) 10-36(ø20) weeks. x-ray healing ranged (un) 10-32 (ø16) and (rn) 8-24 (ø14) weeks. there was one patient with delay union(32 weeks) in un group. there were any infection; loss of reduction; re-operation and nonunion in both groups. discussion: we started this study because many studies before preferred reamed nailing but we have long term experience with undreamed nail with the comparable results (retrospective analyze). our hypothesis is that the biological advantages of undreamed nail should display if the perfect technical performance is done. conclusion: there are no significant differences between un and rn groups in our study in this time. we expect recruiting more than 100 patients by the year end and during next 2 years we will be able evidence the data completely. this work was supported by the research project moofvz 0000503 198 septic arthritis following acl reconstruction péter frö hlich 1 1 zentralinstitution for sportsmedicine, budapest, hungary infection after arthroscopic anterior cruciate ligament reconstruction is an uncommon complication, which could be a danger not only for joint function, but also for the joint integrity. we have to differentiate by the clinical recognition of this complication from swelling caused by other conditions (for example suffusion). there is no standardized opinion and method in the field of arthroscopic or open procedure, or necessity of aggressive graft removing. from a consecutive case series of 1,663 patients, who underwent anterior cruciate ligament reconstruction between 2004 and 2006. we report on 16 patients with postoperative septic complication. 4 of these were extraarticular, and 12 intraarticular manifestation. our protocol is based on infection severity classification modified by gä chter. reliability and significance level of diagnostic criteria (clinical evaluation, laboratory tests, synovial fluid analysis, and bacterial culture) were analyzed. the outcome was determined by early recognition and consequent treatment. there is only one patient, whose acl tendon graft has to be removed. the ikdc score shows the following result: a: 4, b: 5, c: 2, d: 1, it proved to be similar to the multicenter studies. in the last 2 years we have no more postoperative infection following acl reconstruction by the application our protocol. we will review this protocol. introduction: early fixation of long bone fractures in the multiple injured patient has been recognized as beneficial in minimizing secondary lung and remote organ failure. although early fracture fixation is expedient in px with multiple injury etc may be associated with post-traumatic systemic complication. in this study all pz from a consecutive series of 690 trauma patients with truama team activation admitted between 01/04 and 01/06 to department of emergency of niguarda hospital in milan were included when they fulfilled all of the following criteria: directly admitted, iss of more than 15, and survival of more than 24 h. patients with fracture of long bones and/or pelvis with a clear indication for operative treatment and the necessity of immediate fracture stabilization where treat according with dco. all other patients fulfilling the inclusion criteria with minor fracture or thus not requiring immediate fixation formed the control group. iss, rts and ps was calculated at the admission and reevaluated later by the trauma leader. all injury was classified with ao and gustilo classification conclusion: the goals of dco include stopping ongoing injury including local soft-tissue injury and remote organ injury secondary to local release of inflammatory mediators further thought to prevent pulmonary complications by allowing patients to avoid the enforced supine position. this study was conducted retrospectively to evacuate the effectiveness of the trauma team organization and to evaluate the concept of dco by immediate external fracture fixation and consecutive conversion osteosynthesis with regards to time saving, effectiveness and safety. introduction: injury of the soft tissue results in a release of numerous cytokines, which activate fibroblasts of the surrounding tissue to proliferate and to undergo a phenotypic transdifferentiation into contractile myofibroblasts (mfs). in this study we analyzed the hypothesis, that human joint capsule mfs are specifically regulated by the cytokine ifn-c via the modulation of alpha-smooth muscle actin (a-sma) which is responsible for the contractile phenotype. methods: joint capsules were obtained from patients undergoing orthopaedic surgeries. to investigate the functional effect of ifn-c, we cultured mfs in a three-dimensional (3d)-collagen gel contraction model. an alamarblue assay in combination with the collagen gels was established to analyze the viability and the proliferative capacity of mfs upon ifn-c treatment. the effect of ifn-c stimulation on the gene expression levels of the specific mf markers a-sma and collagen i is going to be determined by real-time pcr (rt-pcr). this part of the study is in progress. results: mfs cultured in the presence of ifn-c show a reduced proliferative capacity. moreover, the addition of ifn-c reveals a dose-dependent decrease of collagen gel contraction. these effects were specifically blocked by a neutralizing ifn-c antibody. first results of rt-pcr analysis show an inhibition of a-sma and collagen i gene expression by ifn-c. conclusions: ifn-c reduces mf viability and contractility in a dosedependent way, presumably by down-regulating mf specific genes. this study suggests that ifn-c might be effective in attenuating the contraction of soft tissue in fibrocontractive disorders. with an average age of 31.2 years old were included and a retrospective database study was performed. the outcome parameters we analysed were the radiological outcome, the functional outcome and the prevalence of complications. results: the fracture healed in an accurate anatomical position in all patients treated with esin (100%). seven patients (26,9%) suffered from irritation around the entrance opening and in four patients (15.4%) the pen migrated medially. in eight cases (30,8%), this resulted in a reoperation, consisting of remodelling, reposition or removal of the pen. in two cases we saw a refracture after removing the pen. the overall complication rate was 38.5%. dash scores showed an average functional outcome of 6.9 points (range: 0-100) at 14.5 months follow-up. conclusion: operative treatment with esin in dislocated midclavicular fractures offers good mid-term radiological results and a good dash score. the overall prevalence of complications was 38.5% and in 34.6% a re-operation was required. the results found in the available literature showed a re-intervention rate of 50%. prospective randomised research is required in order to determine the right surgical indications and to find out what the long-term results of this relatively new method of fixation are. aim: our main aim was to find out whether there is a place for nonoperative treatment as a definitive primary option in patients with significant medical co-morbidity. methods: we did this audit in 2007 collating information on 1,010 hip fracture patients across 14 nhs hospitals in england. 50 out of 1,010 (4.95%) patients were treated conservatively. results: there were 17 males and 33 females patients managed conservatively in our study. during hospitalisation, 4 became bedridden and 30 died. among these 50 patients, 8 were deemed physically unfit for surgery by anaesthetists and 2 by medical consultants. the decision was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. five patients refused surgery and five patients were palliative due to terminal illnesses. patients who did not proceed to surgery had significantly higher mortality rates (overall mortality rate 60%) suggesting that they were physiologically much worse group of patients. conclusion: as the average life span of our population increases, some hip fractures are now treated nonoperatively because of the possibility of severe or fatal complications due to surgery. often, refusal of surgery by the patient or the patients' family obligates the need for nonoperative treatment. it might be acceptable not to opt for the surgery if the patients are medically very high risk because of these reasons (e.g. acute cardiac event, severe aortic stenosis, multiorgan failure etc). the burden of patients with pubic rami fractures seems to be increasing. more patients with pubic rami fractures are admitted to hospital due to the absolute increase in the number of elderly people. although pubic ramus fractures are generally considered a benign fracture for its inherent stability experience indicated that this fracture is accompanied with a high morbidity and mortality. in a case-control study patients aged over 60 years old with an isolated single fracture of the pubic rami admitted to the hospital were compared for morbidity and mortality to age-and gender matched hospitalized patients without fractures. data was acquired by the patient files. during 14 years 99 patients, with a median age of 80.1 (range: 60-98) years, were admitted with a median length of stay of 10 days (range: 2-57). the mortality rates of patients with isolated pubic rami fractures at 1, 5, and 10 years were significantly higher in the patient group compared to our control group, being: 24.7, 64.4 and 93.8%, respectively (p < 0.05). one third of the mortality is explained by cardiovascular events. during hospital admission a complication rate of 20.2% was found, which was mainly caused by infectious diseases, including urinary tract infection and pneumonia. thirty-three percent of the patients (temporarily) went to a nursing home, because of the incapability to mobilise independently. in conclusion, patients admitted to the hospital for an isolated pubic ramus fracture have significant morbidity and mortality both during hospital admission and during 10-year follow-up. purpose: comminute fractures of the radial head are challenging to treat with open reduction and internal fixation. radial head arthroplasty is an alternative treatment. the purpose of this study was evaluating our results of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with modular pyrocarbon/metallic prosthesis. methods: from may 2003 to september 2007, 24 patients were operated for traumatic injuries in elbow. there were 12 female and 12 male with mean age 49 (34-70 years). the follow-up was a mean of 31 months (12-54 months). fractures of the radial head have been classified by mason with a subsequent modification by johnston. the indication for a radial head replacement are comminuted type iii fractures in 16 cases, type iv in 5 cases, and monteggia variant with olecranon and radial head fractures in 3 cases. results: by using the mayo elbow score, 18 patients had good/ excellent results, with 5 fair and 1 poor outcomes. patients showed an average arc of motion from -10º to 135º. complications were three implant dislocations, needed to remove the implant. asymptomatic radiographic heterotopic ossification in elbow was showed in one case and bone lucencies were found in seven cases. we had not seen persistent instability, infection, synostosis, loosening, severe degenerative changes or impingement. conclusion: the treatment of unreconstructible comminute radial head fracture with noncemented pyrocarbon radial head implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated injuries. methods: this retrospective clinical study is a follow-up examination of bony avulsion fractures of the intercondyloid eminence in adults and adolescents treated in our hospital in the last 7 years. after the medical history was recorded, the course of the accident and type of injury was documented (classification according to meyers and mckeever) . also the type of treatment (conservative, arthroscopic surgery or open surgery) and accompanying injuries were analysed. the clinical follow-up examination took place after more than 12 months after the trauma. during the face-to-face interview, physical and radiological examination, the knee function, and especially the stability of the knee-joint were assessed. furthermore the clinical outcome was determined using the lachmann-test and the lysholm-knee-score. results: the patient group consisted of 19 male and 9 female patients aged 11-74 years. the patients showed subjective and functionally predominant good to very good results. despite subjective stability and absence of pain, in some patients remained a mild hyperlaxity of the anterior cruciate ligament. conclusion: fractures of the intercondyloid eminence are a rare but serious injury of the knee. the correct diagnosis, classification, and curative treatment of the fracture is indispensable for the flawless function and stability. an individual approach is necessary in every patient. distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. the angle stable plate, often also multidirectional is today the most common stabilisation device. because of the introduction of bulky and bended implants as the micronail or targon dr we decided to test the xs radius nail witch is a 4,5 mm or 3,5 mm straight nail and witch is introduced after guide wire placement and over drilling with a cannulated drill of the same diameter. it is locked parallel to the joint in 3 different directions with angular stability with threaded wires. methods: 16 radius sawbones were osteotomised corresponding to a a3 fracture and stabilised with a angle stable plate (8) and xs nail (8). 1,000 alternating load cycles from 20-200 n were performed and the deformation was registered. also a fe analysis with the msc patran/marc software were performed. both types of osteosynthesis showed good stability. the deformation of the xs group however was 20% lower. also the calculated deformation in the fe study was 20% lower. also deformation amplitude was lower with 0.31 mm compared to 0.42 mm in the plate group. the differences however were not significant. both devices show good biomechanical results. the xs nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. styloideus radii and over drilling with a cannulated drill of the same size. the exposure of the n rad.superf. must be performed. first clinical evaluation is presented. 212 angioembolization in severe pelvic fractures: experience of a tertiary centre in united arab emirates results: twelve patients (all males) having a median (range) age of 25 (16-37) years were studied. five were vehicle drivers, four passengers, two pedestrians, and one fall from height. seven had abdominal tenderness while four had abdominal guarding. median (range) systolic blood pressure before angioembolization was 87 (60-132) mmhg and 106 (0-123) mmhg after embolization. nine patients had unilateral internal iliac artery embolization, one had embolization of the pubic bone artery, one had pudendal artery embolization, and one had bilateral iliac embolization and liver embolization. six patients had external fixation of the pelvis after the angioembolization. three patients had a laparotomy, the first had intraperitoneal urinary bladder rupture which was repaired, the second had pelvic packing and diverting colostomy for a severe perineal wound, the third had a liver injury and died on the table. one patient had a thoracotomy with interposition aortic thoracic graft. eleven were admitted to the icu having a median (range) icu stay of 10 (1-18) days. the overall median (range) hospital stay was 33 (14-117) days. only one patient died (8.3%). conclusions: angioembolization of severe pelvic fractures with haemorrhage was successful in 93% of cases and played an important role in the initial management of severe pelvic fractures with haemorrhage. there were nine female and eight male patients passed with a mean age of 27.7 years. the knees were assessed at regular intervals and the mean follow-up period was 11.2 months (range 6-16). after initial assessment to confirm absence of trochlear dysplasia, the technique involves plication of the medial retinaculum with a nonabsorbable suture passed percutaneously using a long curved needle under arthroscopic vision and a small incision to bury the knot from the plication. post operative rehabilitation was done with flexion restricted to 30°for the first 2 weeks followed by a gradual return to normal range of movements with vastus medialis obliquus strengthening exercises. results: 16 patients reported good outcomes with no further episodes of dislocations. one patient who had persistent patellar instability requiring further distal bony-realignment procedure to achieve stability. none of the patients had major complications. conclusion: we report good results with this relatively simple technique of medial retinacular plication and would advocate it as an effectiveless invasive surgical option for patients with recurrent patellar instability in the absence of major trochlear abnormality or significant mal alignment. in a lateral (group a) and 9 in a prone position (group b) with no significant difference in age (39.9/42.1 years) as well as pre-and insurgery parameters; no patients were excluded. the complication rate was analyzed by medical records, the radiographic outcome by plain x-rays and ct scans after an average of 9 months postoperatively. comparison of the two patient groups utilized t-tests or chisquare testing of pearson as determined by number of data points for each variable assessed. results: the adequacy of fracture reduction had significantly poorer findings according to matta in a (p = 0.032), resulting in a significantly higher post-traumatic arthrosis rate (p = 0.049) defined as helfet iii or iv. no revision surgery was needed; no infection was detected in any group whereas 2 iatrogenic nerve damages (1 temporary, 1 persistent) were found only in a. there was no significant difference concerning extensive blood loss, femoral head necrosis, epstein grades, heterotopic ossification classified by brooker and secondary surgery needed. conclusions: due to gravity the femoral head in the lateral position may constrain reduction leading to an inferior radiographic outcome. purpose: the incidence of fracture neck of femur (nof) has been increasing worldwide, due to an aging population. the commonest forms of analgesia are opioids and in some units regional blockade. but regional block is skill dependent and opiates are known to have many side effects. paracetamol is an analgesia that is safe and has an excellent side-effect profile within standard doses. intravenous paracetamol has a far higher predictable bio-availability than oral, within standard dosage. this study is to assess the suitability of using intravenous paracetamol as an alternative. method: prospective study: a change in protocol resulted in all nof's admitted under the care of the senior author being prescribed regular intra-venous paracetamol within standard dosage. prn opioids were available for breakthrough pain. nof's admitted under the care of other consultants remained on the established protocol. opioid usage and pain scores (0-10) were measured. results: results of 72 patients were collected, 44 in intravenous paracetamol group and 28 in the original protocol group. there is a 65% reduction in opiate usage in the intravenous paracetamol group (p value = 0.015). there is only a 0.5 difference in average pain score between groups (p value = 0.173). conclusion: the use of regular intra-venous paracetamol results in a significant reduction in the need for opioid analgesia. the pain relief within this group was comparable to that in the control group. a simple change in analgesia protocol to a safer, more predictive agent can result in an improved pre/postoperative period. author to editor: funding: the study received no funding from any source. external fixation has already became on the end of last century as routine temporarily method of fracture bone fixation, especially in the light of damage control. but out of damage control, external fixation has been accepted in many developed countries as routine temporarily method in treatment of complex articular fractures (knee, ankle, elbow). the main reason was absence (night time, weekend) of experienced surgeon who can treat these complex particular fractures, as during the night. sometimes, the skin problem can prolong such fixation for three or more weeks. however, external fixation of tibia and distal radius can be method of choose for definitive treatment not only in open but in closed fractures as well. it becomes justified when high mobile and relatively simple external fixation devices have been developed allowing addition correction of reduction. in this paper, we want to present possibility of using already applied, external fixation device as temporarily method. about 1 week after external fixation done (on femur or tibia) we developed technique existing external fixator to be used as a reduction device. once, desirable fracture reduction achieved, internal fixation is very easy and we do not need fluoroscopy control for reduction, just for internal device fixation by minimally invasive method. using this method, we already treated 10 patients with femur fractures and 12 with tibia fractures. from results obtained it can be concluded that external fixator developed by mitkovic is suitable to function as accurate fracture reduction device providing condition for simple minimally invasive internal fixation. results: with the antegrade nailing technique the mean postoperative constant score was 62.6 (flexion 122.9°m abduction 125.7°, pain 14.6). the elbow extension was free in 77.8%. a correct axial alignment was found in 88%, in 12% we found a varus deviation of 10°-20°. in 17% the nail perforated. in complications there was one prolonged bone healing, one pseudarthrosis and one infection. two thirds of the patients were very satisfied with the outcome. in the retrograde nailing technique the mean postoperative constant score was 75.4 (flexion 152.2°, abduction 148.8°, pain 13.9). the elbow extension was free in 81.1%. only 6% of the patients showed a mild discomfort at the operative approach at the elbow. a correct axial alignment was found in 88%, in 12% we found a varus deviation of 5°-15°. in 4% patients showed a postoperatively detected fracture in the supracondyle region. 71.4% of the patients were very satisfied with their outcome. conclusion: the retrograde nailing technique is a save and sufficient method for treating humeral shaft fractures, especially because the rotator cuff is not disturbed. introduction and objectives: the bony bankart lesion is an avulsion fracture of the glenoid that usually occurs after anterior shoulder dislocation. this injury is frequently missed and often creates shoulder instability. therefore, open reduction and internal fixation (orif) of the fragment is recommended. in this study we looked at shoulder function, instability and pain after this operation. postoperative x-rays were reviewed on anatomical reduction. patients and methods: between 2000 and 2008, 19 bankart fractures were operated. they were classified according to ideberg. sixteen patients had an ideberg type 1b fracture and three a type 2. these patients received questionnaires with a number of validated scoring systems. we used the ases, rowe shoulder score and the dash questionnaire. results: the response was 73%. all respondents did get a stable shoulder after surgery. two patients regularly experience mild pain. the average rowe score was 90.8 (range 0-100). the average ases score for adl was 24 (maximum score 30, adl unlimited). the median dash score on the quality of life was 5.6 (where 0 means no loss of quality of life). there was a clear positive relationship between the radiological postoperative congruency of the joint, the shoulder function and quality of life. introduction: traumatic dislocation is the most severe form of ligament injury of knee.the purpose of this study is to report our cases in past 10 years. methods: between 1998 and 2008, 26 knees in 21 men and 4 women; 25 patients were treated for traumatic knee dislocation in our trauma center. the mean age was 32 (16-80) years at the time of injury. the mechanism of injury were motor vehicle accident in 19, fall from high in 4 and industrial accidents in 2 patients. 11 patients had additional extremity trauma. vascular injury detected in 4 knees who required immediate reconstruction by vascular surgeons. the orthopaedic stabilization of the initial injury was bridging external fixation in 13 knees included all vascular injuries. 5 patients had fibular nerve palsy. in 14 knees medial collateral ligament, in 13 knees lateral collateral ligament, in 26 knees anterior cruciate ligament, in 24 knees posterior cruciate ligament and in 5 knees posterol ateral corner lesions were diagnosed. one had tuberositas tibia avulsion. multiligament reconstruction was performed on a delayed basis in 13 patients for a minimum of 1 (1-12) month after the injury all patients had functional rehabilitation for a mean 18 (12-28) weeks. results: at an average follow-up of 6.3 (1-10) years they were examined for stability and range of motion. all knees having multiligament reconstruction and 8 of the 12 patients in whom nonsurgical treatment was undertaken were stable. patients having multiligament reconstruction had slightly lower knee range of motion hypothesis: computed tomography (ct) is more accurate than bone scintigraphy for diagnosis of a radiographically occult scaphoid fracture. methods: in a study period of 1 year, 70 consecutive patients with a suspected scaphoid fracture but no fracture on scaphoid radiographs were evaluated with ct within 24 h of injury and bone scintigraphy between 3 and 5 days after injury. the reference standard for a true (radiographic occult) scaphoid fracture was either (1) diagnosis of fracture on both ct and bone scintigraphy, or (2) in case of discrepancy, clinical and/or radiographic evidence of a fracture. results: ct showed 6 scaphoid and 13 other fractures. bone scintigraphy showed 17 scaphoid and 21 other fractures. according to the reference standard there were nine scaphoid fractures. the prevalence of true scaphoid fractures among suspected fractures was therefore 13%. ct had a sensitivity of 67%, specificity of 100%, accuracy of 96%, a positive predictive value (ppv) of 100% and a negative predictive value (npv) of 95%. the prevalence corrected ppv was 100% and the prevalence corrected npv was 95%. bone scintigraphy had a sensitivity of 100%, specificity of 90%, accuracy of 89%, a positive predictive value of 53% and a negative predictive value of 100%. the prevalence corrected ppv was 53% and the prevalence corrected npv was 100%. summary: this study could not confirm that early ct imaging is superior to bone scintigraphy for suspected scaphoid fractures. bone scintigraphy remains a highly sensitive and reasonably specific study for the diagnosis of an occult scaphoid fracture introduction: the therapeutic management of scaphoid fractures is still surrounded by controversy. immobilisation for non-or minimal displaced scaphoid fractures results in a union rate of more than 90%. functional outcome is often measured using clinical examination and radiological consolidation. however, the indication of how successful the treatment has been is the functional outcome of the patient. functional outcome of upper-extremity fractures can be measured reliably using the dash (disabilities of the arm shoulder and hand) outcome measure. materials-methods: 39 consecutive patients with 40 non-or minimally displaced scaphoid fractures, treated conservatively, were included. the trauma mechanism, treatment modality, diagnostic modalities, duration of cast immobilization and complications were analysed for all patients. functional outcome was measured using the dash outcome measure. results: 30 patients showed good clinical and radiologic outcome after 6 weeks of cast immobilization with a mean dash of 4.6. six patients consolidated within 12 weeks with a mean dash of 11.8. three patients with four fractures took more than 12 weeks to achieve clinical and radiologic consolidation and had a mean dash of 38.5. the dash questionnaires showed statistically significant differences between patient age, fracture location and duration of cast immobilization. conclusion: conservative treatment of non-or minimally displaced scaphoid fractures results in good functional outcome after 6 weeks of cast immobilization, particularly in young patients with distal or waist scaphoid fractures. objective: pedicle screw instrumentation is the most common procedure in stabilizing fractures of the throracolumbar spine, but yields an immanent potential for iatrogenic damage due to malpositioned pedicle screws. methods-materials: 99 patients undergoing posterior instrumentations were included. preoparative ct scans were used to determine fracture level and classification. postoperative ct scan were evaluated for screw positions of all pedicle screws. cobb angles were compared to calculate the degree of reduction. the position of all pedicle screws was determined according to the classification proposed by zdichavsky. results: 426 pedicle screws were assessed. 305 pedicle screws were classified as optimal (ia, 72%), 39 ib, 23 iia, 48 iib, 11 iiia and 8 iiib. malpositions were more often the more cranial pedicle instrumentation was performed (11% increase per level, p < 0.01). malpositions (ib-iiib) occurred more often on the right side of the patient (p < 0.05). the mean reduction was 10°. discussion: this study confirms the hitherto felt but unproven suspicion that malpositioning occurs more often in the upper thoracic spine. even more remarkably is the side-dependency in malpositioning. we attribute the higher rate of malpositioned screws on the right side of the patient to the circumstance that the surgeon usually stands on the left side of the patient and visual control of the direction of the pedicle screw during insertion is probably more difficult on the opponent side. we recommend envisioning this fact and -if navigation is not used -changing the position during the procedure. background: u-shaped sacral fractures are rare and highly unstable pelvic ring injuries. surgical stabilization may facilitate early mobilization and reduce mortality. however, limited evidence has prevented the development of a standard treatment algorithm. furthermore, little is known about the quality of life in these patients. purpose: to assess the injury characteristics, choice of treatment and quality of life of patients with u-shaped sacral fractures. methods: eight patients with u-shaped sacral fractures were identified over a 6-year period. neurological outcome was classified by gibbons' criteria. quality of life was evaluated using the euroqol-6d questionnaire. results: there were five women and three men; the median age was 29 years. the injury severity score ranged from 17 to 45. definitive internal fixation was established after 2 to 22 days. percutaneous iliosacral screws were used in two patients with relatively stable fractures. transsacral plate osteosynthesis was used in one patient with minor displacement. triangular osteosynthesis with transsacral plating was used in four patients with multilevel sacral fractures, highly unstable fractures or traumatic spondylolysis l5-s1. one patient with an associated l2 fracture received a triangular osteosynthesis without transsacral plating. early partial weight bearing was encouraged whenever possible. follow-up ranged from 5 to 65 months (median 36 months). four patients kept severe bowel and/ or bladder dysfunction. in the euroqol-6d, pain, mood disorders and mobility problems prevailed. conclusion: u-shaped sacral fractures are rare and complex injuries. operative stabilization is tailor-made on the individual fracture characteristics. outcome is dominated by neurological deficits, pain, mood disorders and mobility problems. background: traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. in this study, we aimed to present traumatic amputated patients needed more psychiatric support than the other trauma patients during the hospitalization period in the orthopaedics and traumatology clinic and in the later periods more post-traumatic stress disorder could be observed in this patient group. patients and methods: twenty-two traumatic amputated patients who have been treated in our clinic were evaluated retrospectively. during the early post-traumatic period, between the 2nd and 20th day, it was observed whether they needed any psychiatric support treatment. after the 6th month of the trauma, the patients were referred to the psychiatry department, and it was evaluated whether they needed any psychiatric support treatment by measuring the 'post-traumatic stress disorder scale' (tssb-ö ). results: twenty-one (%95.5) of twenty-two patients were male, one (%4.5) of them was female. introduction: intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. to date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures. materials and methods: 18 fresh-frozen cadaver lower extremities were used to simulate an ao/ota 41-a3 fracture. six nails (expert tibial nailing system, synthes, salzburg, austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. after nail insertion, alignment in the coronal plane was recorded. results: mean varus malalignment was dependent on the entry point at the lateral tibia plateau. mean varus malalignment was 16°if nails were inserted at the lateral third, 10°at the middle third and 4°after nail insertion at the medial third. if nails were inserted from the medial third, valgus malalignment was recorded in two specimens. discussion: the effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. primary valgus deformation up to 20°can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion. introduction: treatment of patients with distal radial fractures is primarily based on radiologic parameters. however, correlation between these parameters and functional outcome is questionable. objective: determine the value of radiological parameters for the appropriate treatment of patients with distal radial fractures. methods: a retrospective analysis was performed for a consecutive series of patients with conservatively treated distal radial fractures. axial radial shortening, radial displacement, radial angle, dorsal angle, and dorsal displacement were measured on the postero-anterior and lateral x-rays. functional outcome was measured using the quick dash-score (qds). minimal follow up was 24 months. the radiological findings of patients who met the criteria for conservative treatment were compared to those of patients that met the current criteria for operative treatment (dorsal angulation > 10°, radial angle > 10°, radial displacement > 2 mm, radial shortening > 5 mm and step off > 2 mm) but who had been treated conservatively instead. results: in a 2-year period 396 patients were treated conservatively for a distal radial fracture. the qds was performed in 256 (65%) patients. male female ratio was 1:3, the average age was 60 years (range 18-94). the mean qds was 12 (sd ± 18; range 11-84). age and female sex associated negatively with the qds. none of the radiologic findings was associated with the qds. half of the patients met the current criteria for operative treatment. the qds of this group corresponded however with that of the correctly conservatively treated patients. introduction: conservative treatment is generally preferred for simple elbow dislocations. in this study, the clinical and radiological results of conservative treatment are retrospectively evaluated. the patients were treated with closed reduction, plaster splint and brace. methods: dislocations of all 21 patients were towards posterior and the average length of immobilization was 20.2 days (7-30 days) after closed reduction. the patients were assessed clinically for range of motion, instability, and atrophy after 33.9 months of mean follow up. mayo elbow performance score (meps) was used to evaluate functional outcome. standard elbow x-rays were evaluated for degeneration, heterotopic ossification, and concentric reduction. results: the average age of the patients was 35.4 (12-81) years. none of the patients had muscular atrophy. four patients (19.1%) reported mild pain with heavy activity. six patients (28.6%) had neurological complaints related with ulnar nerve. the average flexion arc and average rotational arc were 131°and 172°, respectively. the differences between the contralateral elbow motions were 10.9°for flexion arc and 3.1°for rotational arc. four patients (19%) had minimal residual instability. three patients (14.3%) had mild radiographic signs of arthrosis and 14 patients (66.7%) showed minimal-mild degree of heterotopic ossification. an average score of 96.9 was obtained using meps. only four patients (19%) considered themselves fully recovered. conclusion: closed reduction and immobilization is a universal method for simple elbow dislocations. however, although functional scores were excellent, most of the patients did not consider themselves fully recovered. anterior odontoid screw fixation (aosf) is a valuable treatment after of, reported union rates in the elderly vary between 70 and 100% when assessed on plain radiographs. in this study union-rates in of treated with aosf in patients aged ‡ 60 years were revisited and risk factors for non-union analyzed. retrospective data review of a prospectively gathered c2-fracture patients treated with aosf for of and age ‡ 60 years were included for study. asides demographics and common injury characteristics, injury radiographs and ct-scans were assessed for fracture displacement, type, atlantodental osteoarthritis and particularly focussing on the square surface of of. follow-up ct-scans were assessed for technical failures, odontoid union, number of screws in aosf, square surface of screws used and the related healing surface. there were 13 male (72.2%) and 5 female (17.8%) patients with a mean age of 78.1 ± 7.6 years at injury (60-87y). mean follow-up with ct-scans was 75.7 ± 50.8 months (4.2-150.2mo). intervall injury to aosf was 4.1 ± 5.3 days (0-16 days). mean square surface of fractures was 127.1 ± 50.9 mm 2 (56.3-215.9 mm 2 ) and mean osseus healing surface was 84.0 ± 6.8% (67.6-91.1%). ct-based analysis revealed osseus union in nine (50%), while the remaining nine patients (50%) revealed non-union. in two patients, symptomatic non-union indicated posterior fusion of c1-2. union-rate significantly correlated with increased fracture surface (p = 0.02). observable was the trend that using two screws for aosf correlated with increased fusion-rate compared to one screw (p = 0.06). lifethreathening hemorrhage is often seen in pelvic ring fractures. efficient treatment of this hemorrhage is critical for survival in these patients. the purpose was to analyse the causes of death in hemodynamically unstable patients with a pelvic ring fracture and to determine if standardized treatment will reduce mortality. retrospectively, all data were reviewed of hemodynamically unstable patients with a pelvic ring fracture in the period 1/1/1999 till 1/9/2006. of all patients, the pathway of treatment was analysed and compared with the standardized treatment protocol in our clinic. all injuries were categorized in injuries in airway, breathing, circulation and disability according to atls ò principles. death was classified as directly related to the pelvic fracture if the patient required massive transfusions, died within 24 h after admission and had no other body area injury with ais ‡ 4 responsible for persistent hemorrhagic shock. we reviewed the data of 115 patients. 26/115 patients died (23%). these patients were significant older and had a significant higher iss and shock class than survivors. two patients died of pulmonary trauma (7%), 11 patients (43%) died of exsanguination(c) and 7 patients (28%) died due to major head trauma. in 6 patients (21%) there was a combination of injuries, which caused death. thus, overall hypovolemic shock contributed to mortality in 17 cases. only in three patients death could be directly related to hemorrhage from the pelvis. two nonsurviving patients (8%) were not treated according to our standardized treatment protocol. in the survivor group this was only one patient. there is no consensus on the treatment of the acute total achilles tendon rupture. treatment modality is chosen on the basis of patient characteristics or the preference of the attending surgeon. using ultrasound, the distance between the two tendon ends in equinus position can be measured. this could form the basis for decision making between conservative-and surgical treatment. this cohort study consists of 164 consecutive patients, between january 2000 and january 2007. using ultrasound, patients were assigned to a surgicalor conservative treatment group. a gap of more than 2 mm in maximal equines position was an indication for surgical treatment. seventy-two patients, 60 men and 12 women, received a conservative treatment. in 91 patients the achilles tendon was primarily sutured. in the surgical group the post operative treatment was identical to the conservative treatment. the male-female ratio did not differ significantly (p = 0.738). the average age was 41 years. sports caused 88% (n = 144) of all injuries. the surgical group showed six re-ruptures versus nine in the conservative group (p = 0.195). on average, a rerupture occurs after 55 days. no significant difference in major and minor complications (p = 0.500). outpatient treatment was needed 75 days for the surgical treatment group versus 85 days for the conservative treatment group (p = 0.357). ultrasound measured distance between the two ends of the achilles tendon in equinus in an acute total rupture can be used as a selection method in making a decision between surgical and conservative treatment. introduction: missile wounds induced by aviation bomb splinters pertain to grave injuries, due to large wound area and high risk of complications. material-methods: 11 patients with large defects, in 7 of casescombined with long bone fractures caused by missile injuries were treated by us in the period of august-november in 2008. every cases were subjected to radical primary debridement with complete drainage. after relevant preparation for soft tissue plastic repair (involving primary radical debridement, primary external fixation, complex drug therapy and repetitive regular debridement) the following repair procedures were undertaken: in four cases, soft tissue defects were covered via rotation of local flaps. in three cases, defects were covered through transplantation of free skin grafts. in four cases, large soft tissue defects were overlayed by vascularized thoraco-dorsal (ld flap). in two of these, bone defect repair was simultaneously performed applying avascular graft taken from hip bone crista. results: in seven cases, transplanted flaps adhered perfectly, without trophic or infective complications. in one case, rotated local flap necrotized due to interrupted perfusion, which was subsequently replaced by free skin transplant. in five cases, fracture consolidation was completed in 4-5 months. in remaining two cases (after bone defect repair), consolidation process still proceeds with satisfying rate. conclusion: transplantation of vascularized thoraco-dorsal flap is especially effective for covering large soft tissular defects. soft tissular plastic repair has the double advantage of defect reconstructive ability and prevention from secondary infections, with additional stimulation of bone tissue regeneration. introduction: shoulder arthroplasty remains a valuable treatment for complex fractures of the proximal humerus. however the success of anatomical arthroplasty is mainly dependent of anatomical healing of the tuberosities. even with specific prostheses and fixation techniques in 25-40% of cases anatomical healing is not achieved. using a nonfracture specific trauma prosthesis we achieved better elevation and abduction; however endorotation, exorotation, subjective shoulder rating and complication rate did score poorer than in anatomical arthroplasty. we assumed that the impossibility to refixate the lesser and greater tuberosity fragment, and subsequently the subscapularis and infraspinatus-teres minor tendons, are the main cause for this observation material-methods: we developed a fracture specific reversed shoulder prosthesis allowing for anatomical refixation of the tuberosities. we included 20 patients in the reversed fracture arthroplasty group. function is scored using the constant murley-score. radiographically we evaluate for evidence of scapular notching. complications are recorded. we compare our results to an historical series of delta iii prostheses. results: at 6 months the mean constant score is 51.5 points. there was no case of notching. there was one complication, an early infect. the mean constant score in the delta group was 42 points. there was notching present in 55% of cases. in the delta group there were five reoperations in three patients because of dislocation. conclusion: there is a strong trend to better functional outcome using the fracture specific design. there are less complications and less notching. the possibility to refixate the tuberosities leads to better results. introduction: as fractures of the femur are severe injuries and patients mostly suffer from extensive pain they quickly attract the physician's attention in the emergency room. the literature has shown that injuries to the ipsilateral knee can occur accompanying such injuries. in most cases, these injuries though were diagnosed on delay. excluding cases in which a knee injury was apparent already on admission, we sought to investigate the number and severity of initially undetected lesions to the knee accompanying a femoral shaft fracture and give an overview of the literature. methods: charts and x-rays of patients treated for a femoral shaft fracture from january 2000 until december 2007 were reviewed. patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. also patients, in whom an injury to the knee had been diagnosed on admission, were excluded. results: fifty-three patients with midshaft femoral fractures were available for analysis. an injury to the knee was diagnosed in 3 cases (5%). there was one partial tear of the posterior cruciate ligament and two grade 2 lesions of the medial meniscus. all lesions were conservatively treated. the shoulder is the most mobile joint of the human body. it has a great range of movement that takes place in all three cartesian planes. this is a complex phenomenon. there is considerable controversy over an ideal method for the functional assessment of shoulder joint complex. various methods have been used but they are often inaccurate and unreliable. thus, a better technique, that is reliable as well as repeatable, is required to measure the movements. the aim of this study is to assess the shoulder movement by fastrak ò and vicon ò systems and to compare their repeatability. methods-materials: the functional movement of the shoulder joint was assessed by fastrak ò and vicon ò systems. a difference between the two systems was determined and a comparison of repeatability was carried out. a population of healthy male volunteers were asked to perform six different tasks that covered all the movements occurring at the shoulder. these tasks were repeated twice on each side on two different days. the measurements were recorded and a custom-made programme, prepared for each system separately, calculated the angles. results: the recorded data was analysed using repeated measure analysis of variance. it was found that the coefficient of repeatability of fastrak ò was better than the vicon ò system for each task and there was no significant difference (p < 0.05) between the two sides. conclusion: the fastrak ò system is better than the vicon ò system for assessing shoulder movements. it can be used in clinical practice. (19-25). we applied sarmiento cast without any padding or little padding immediately. we encouraged the patients moving their arms. the treatment ends upon the presence of a bone callus and absence of pain at the fracture site. during the whole therapy the skin condition is monitored and emphasis is put on the prevention of reflex sympathetic dystrophy. we evaluate the result of the treatment with a focus on the any restriction of the range of motion of joints and the presenting any angulation of the humeral shaft. average follow up time was 6 months (4-48). all fractures were healed without any major problem and we did not face any nonunion and no major angulations axis of the humerus. average union time was 3 months (2-4). the results of nonsurgical treatment of the humerus mid and distal thirds shaft fractures are reported as a less complicated way and have a higher rate of union. this method is practical, efficient, cheap, and safe, if a good cooperation with patients is established and close observation is done. (2004). the aim of this study is to evaluate the surgical anatomical aspects of the minimally invasive hip surgery procedure in cadavers. methods: the mis approach was performed on four specially embalmed cadavers. all cadavers had a normal 'range of motion' of the hip joint. the difference in muscle length and work space were measured in all leg positions. additionally the difference in muscle tension in anterior and posterior luxation was compared with regard to the accessibility of the femoral shaft. results: the length of the medial-and minimal gluteal muscles is reduced in abduction. a difference of more than 1 cm was found between 20°to 30°abduction and full abduction. the working space (6.3 · 5 cm), is limited in the maximum (50°) abduction position. posterior luxation gives a better femoral shaft approach and less/ none muscle tension/damage compared to anterior luxation. the optimal approach to the femoral neck during mis of the hip is achieved during 20°-30°abduction of the ipsilateral leg combined with 10°retroflexion. the best femoral shaft approach for prosthesis insertion is the posterior luxation. no additional damage, excluding the skin and fascia incision, was seen during posterior luxation. posterior luxation and exorotation of the leg enables straight and direct access to the femoral shaft compared to the access obtained during anterior leg luxation. background: it has been stated that acromial morphology plays an important role in the etiology of rotator cuff pathology. the system most widely used to describe the morphology is the bigliani classification. recently nyfeller introduced the acromial index. we wanted to examine whether there is a correlation between these two parameters and the presence of a rotator cuff tear or an impingement syndrome. methods: we assessed both parameters in four groups of 100 patients each. the first group consisted of patients with operatively treated rotator cuff tears (average age 62.29 years) and the second group of patients known with impingement syndrome but documented intact rotator cuff (average age 52.37). for both groups, an age and gender matched control group was constructed. results: type three acromions were significantly more prevalent in the rotator cuff tear group than in the control group (p < 0.05). the average acromial index was 0.698 + 0.0766 in the rotator cuff tear group and 0.683 + 0.0733 in the rotator cuff control group, which is not statistically significant (p = 0.16). in the impingement group, the acromial index was 0.647 + 0.0784 and 0.680 + 0.0744 in the impingement control group. this difference was found to be statistically significant (p < 0.005). conclusions: patients with a rotator cuff tear appear to have more frequently bigliani type three acromion than age and gender matched, asymptomatic patients. there is no correlation between acromial index and acromial type or age. objective: extracorporeal membrane oxygenation (ecmo) is rarely used successfully in trauma. transfusion related acute lung injury (trali) is also rare in plasma containing blood product transfusion. methods: this is a case report of a trauma patient with life-threatening trali following trauma that was rescued successfully using ecmo. a 24 year old patient was struck by an automobile and suffered a grade ii splenic injury, grade iv-v right renal injury as well as multiple orthopedic injuries. an attempt at angiographic embolization failed as the patient required multiple transfusions and became progressively hypotensive. the patient underwent emergent nephrectomy but rapidly became hypoxic with the pao 2 becoming less than 20 mmhg for over an hour. despite aggressive attempts at ventilation and oxygenation, the endotracheal tube was filled with fluid and hypoxia pursued despite low right heart filling volumes. rescue ecmo was instituted with successful oxygenation. after 48 h the patient recovered from trali and was able to have ecmo discontinued. the patient was weaned off the ventilator within 12 days and the patient had full recovery. the patient did not suffer any hypoxic brain insult. conclusions: although it is often thought that ecmo is unsuccessful in trauma patients, this case demonstrates its potential use in trauma patients. author to editor: will also present as poster findings: a total number of 14 patients (all male; 22.9 ± 8.7) were found. injuries were resulting from gun shot fires (n = 5; 35.7%) or stab wounds (n = 9; 64.2%). injury sites within the heart were the right atrium (n = 2; 14.3%), the right ventricle (n = 4; 28.6%), the left atrium (n = 3; 21.4%), and the left ventricle (n = 7; 50.0%) (more than one site was observed in 2 patients). the accompanying injuries were observed in the spleen (n = 3; 21.4%), the lung (n = 2; 14.3%), the liver (n = 1; 7.1%), and the stomach (n = 1; 7.1%). in 10 (71.5%) patients emergent thoracotomy was clinically decided with suspicious findings of hypovolemic shock or cardiac injury including low blood pressure, jugular fullness, deeply heard heart sounds, filiform pulse, narrowing of pulse pressure. the rest patients (n = 4; 28.5%) were operated after major blood drainage from tube thoracostomy. all the injuries were repaired with sutures, and pericardial fenestration was done in all. mortality was observed in two cases (14.3%). patients with penetrating regional wounds should be suspected for penetrating cardiac injuries, since immediate surgical intervention may decrease the risk of mortality. introduction: the use of ''pan-ct'' is discouraged in settings of high imaging demand. this study compared clinical and plain chest film findings to determine need for, and results of, chest ct. methods: during recent 9 month period, 400 patients sustained blunt chest injury either isolated or in setting of multisystem trauma. data was tabulated by a combination of prospective and retrospective analysis. initial injury assessment followed atls protocol. supine chest film, followed by chest ct, were performed in all patients and compared with clinical findings. results: significant clinical findings were defined as tachypnea, decreased air entry, chest wall tenderness and initial oxygen saturation less than 95%. the presence of two or more of these clinical findings occurred in 138 patients (34%). ct findings in this group included multiple rib fractures ± flail chest, sternal fractures, pneumothoraces, hemthoraces, and pulmonary contusions. higher ais and need for interventions occurred in this group. the co-existence of tachypnea and desaturation correlated with the need for tube thoracostomy in 91/138 patients(65%) -15 pre-ct, 76 post ct. conclusions: in patients with blunt chest injury, the presence of two or more of the clinical signs -tachypnea, decreased air entry, chest wall tenderness, oxygen saturation < 95% -is associated with: (1) significant chest injury demonstrated on chest ct; (2) higher correlation with ct findings than plain films alone; and (3) introduction: complex regional pain syndrome (crps) sustained after trauma has a great negative impact on rehabilitation and activities of daily living. treatment is most often unrewarding. aim: to analyze prospectively the efficacy of endoscopic thoracic sympathectomy (ets) in reducing pain and disability associated with crps. patient and methods: over a 5-year period, 15 patients (7 females and 8 males; mean age 48.9 ± 2.2) with posttraumatic crps underwent unilateral ets. the median duration of crps symptoms before ets was 4.1 months (range: 1.2-194) . the sympathetic chain was resected from the second to fifth rib. mean postoperative follow-up was 18.7 ± 3.4 months (range: 1-40.9). pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (vas) from 0 to 10. results: one patient (6.7%) had a hydrothorax and three patients (20%) complained about contralateral compensatory hyperhydrosis. at 1 month (n = 12), 2 months (n = 8), 6 months (n = 11) and 1 year (n = 10) after ets, there was a significant decrease in passive and active vas (p < 0.05). ten out of 14 patients (71,4%) needed less analgesics after surgery, and seven (50%) did not need analgesics at all. the mean sleep duration improved significant from 2.7 ± 1.6 h preoperatively to 6.0 ± 1.1 h postoperatively (p < 0.05). overall, patient satisfaction was 85% (11 out of 13 patients). conclusion: ets is efficient for decreasing pain and improving quality of life, and therefore should be considered in the treatment of crps. author to editor: complex regional pain syndrome (also known as sudeck or reflex sympathetic dystrophy) is a complex disease that trauma surgeons frequently encounter in the post-traumatic period. endoscopic thoracic sympathectomy is not well known among trauma surgeon, although it is an good option in relieving the pain and improving the quality of life. monitoring is accomplished with chest x-ray (cxr), but ultrasound (us) is nowadays established as more sensitive than cxr in detection of ptx. patients and methods: from october 2005, thoracic views for detection of ptx are systematically included in the efast protocol during primary survey for every trauma patients (pts) admitted to our level i trauma center. among hospitalized pts, a selective usguided aspiration for small ptx was applied in three pts (two with a slow reabsorption time, one in a pt requiring hyperbaric oxygen therapy for a soft tissue infection of the leg). in supine position, delimitation of the area of anterior ptx was done with a linear probe, searching for lung points in adjacent intercostal spaces. under local anesthesia, a 8 fr catheter was inserted in the ptx and aspiration monitored in real time by us, until restoration of sliding lung. the day after, after confirmation of normal gliding lung, two pts were discharged and one deemed suitable for hyperbaric oxygen therapy. discussion: small traumatic ptx is generally monitored without treatment. in some pts, drainage is however required, but the procedure is blind if performed on the basis of cxr findings. us allows to precisely define the site and the limits of ptx, insert a small catheter in the right area, monitoring reexpansion of the lung and complete aspiration of ptx and shortening recovery. background and objectives: occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. we report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with penetrating thoracoabdominal injuries. methods: the patients who underwent thoracoscopic management of thoracoabdominal stab injuries between june 2001 and june 2008 were included into the study. the data were retrospectively analyzed. results: eighteen selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. the procedures were performed under general (n = 17) or local anesthesia (n = 1). diaphragmatic injuries were repaired by intracorporeal sutures in seven cases and bleeding was controlled in another two cases by electrocautery coagulation. the procedures were simply diagnostic in nine patients. the mean operating time and hospital stay were 36.4 min and 4.7 days, respectively. there was neither intraoperative or early postoperative complication, nor mortality. in a patient who had intra thoracic adhesions due to prior tuberculosis, unmentioned by the patient preoperatively, adequate exploration could not be achieved during thoracoscopy. the procedure was converted to laparoscopy and laparoscopic gastric and diaphragmatic repairs were performed. conclusion: thoracoscopy seems to be a safe, quick and efficient method in the diagnosis and treatment of diaphragmatic wounds, due to thoracoabdominal penetrating injuries. the nonoperative management is gradually more used in abdominal stab injuries and surgeons can resort to thoracoscopy and laparoscopy as a minimally invasive, diagnostic and therapeutic tool. trauma surgeons should be aware of the benefits of thoracoscopy and must have sufficient skills to carry out this technique. summary: generating acute lung injury by smoke inhalation and analyzing a method to pursuit standardized smoke. methods: a standardized glass, measures of 25 cm width, 25 cm length and 25 cm height used as a closed area. we established a valf system under the glass which allows air inside but does not let it outside. with a hole above the glass, we attached the system to pomp with a hose. and the pomp was attached to a 20 cm radial length balloon by another hose. we put a four ampere electricity owen in to glass and put 2 g cotton to the oven. we burned the cotton for 180 s in the closed area and we fullfilled the balloon with smoke by the pomp in 120 s. rabbits were entubated after being anestesized. we waited 180 seconds for the smoke to reduce down to room tempe rature to avoid thermal damage. after that, we seperated the balloon from the pomp and put it right through rabbits by ambulant air flow and inhalated in 5 min.this procedure repeated for each rabbit. after the procedure ended,the entubation tubes were pulled away and the rabbits were left to spontaneous respiration. rabbits were allowed to standart rabbit bait and water at the 12th hour. results: we think we used a standardized smoke inhalation model in this study. methods: ten wistar rats were anesthetized and heparinised before the femoral artery was pierced to initiate bleeding. rats were than randomized to control and study groups. mph was poured into the bleeding site and a mass was placed on it. after 30 s, the mass was removed and assessment of hemostasis was done. if bleeding ceased the test was scored as ''passed at 30 s''. if not, additional dose of mph and compression was reapplied for an additional 30 s. if bleeding has stopped after the second application, the test was scored as ''passed at 60 s''. if not, the same procedure was repeated for the last additional 30 s. if bleeding stopped now test was scored as passed at 90 s. similar sequence of trials was done in the control group but without mph. the difference between bleeding periods in two groups was observed. results: application of mph resulted in complete cessation of bleeding in four of five and one of five rats at 60 and 90 s, respectively. in the control group hemostasis could not be achieved in all five rats, even at 90 s. the statistical difference between the groups was significant (p < 0.05 (1.4-15.6 year) with supracondylar humeral fractures were treated operatively. according to gartland 12 (27%) were type-ii, 31 (73%) were type-iii. at the time of arrival at emergency department, four (9%) children sustained vascular impairment with pink pulseless extremity persisting after reduction. in three cases, a cubital approach was performed. two arteries showed a major lesion (one direct suture, one saphenus vein graft), and one artery showed an entrapment. all lesions showed a normal postoperative pulsation. another three (7%) children sustained a complete paralysis of the radial nerve. these cases were conservatively treated with complete neural restitution. conclusions: urgent anatomical reduction and fixation are crucial. in persisting vascular impairment after reduction, surgical exploration for the restoration of arterial patency should be performed, even in the presence of a pink hand. conversion to open surgical repair was needed in one case due to retroperitoneal bleeding from the iliac arteries. early postoperative mortality was observed in 2(20%) patients; due to massive coagulation disorder and hemodynamic instabiliy in postop 1st day and 11th day. mean follow-up was 12 months (range 1-41 months). late mortality was not observed. overall reintervention rate was 20% (n = 2); proksimal re-stenting was needed due to type 1 endoleak in one patient. embolectomy for crossfemoral bypass was needed in one other patient after stenting for aneurysmal abdominal aortic rupture, this patient underwent re-crossfemoral bypass surgery later on. introduction: dislocations of and fractures around the knee are accompanied by injuries of the regional vessels to a certain extent. in any case of suspicion at the scene of accident an immediate transport to an adequate trauma center is the precondition for successful limb salvage. methods: between 1994 and 2007, 20 patients with arterial injury after dislocation of or fractures around the knee have been treated. retrospective analysis was performed in order to acquire epidemiologic data. furthermore we investigated the sufficiency of preoperative management and diagnostics. we explored peri-and postoperative complications, such as compartment syndrome, secondary thrombosis, infection and number of revision surgeries and related the data to the final follow up after 12 and 24 months. results: arterial injury was found in four cases of knee dislocation, in seven cases of proximal tibial fracture, and in nine cases of distal femur fracture. seven patients underwent acute angiography, since the year 1998 all patients were assessed with cta. seventeen cases were treated with venous interposition, one with a venous patch, and two with direct suture. fasciotomy was performed in all cases. limb salvage was successful in 13 cases. in seven cases secondary amputation was necessary, six of these patients were polytraumatized. discussion: sufficient time management is crucial for the survival of vessel injured extremities, as the time of ischaemia must not exceed 6 h. perfect interdisciplinary coordination and the establishment of specific algorithms are needed in order to decrease the risk of complications and amputations of lower extremities. 289 the survey on the epidemiology of car-motor related accidents in children in kashan, iran iman ghaffarpasand, maneli dorudian tehrani 1 1 department of surgery, kashan medical university, kashan, iran introduction: the most common cause of death in children is accident and reinforced a lot of taxes on the society. kashan has the second position in trauma ranking of iran so we studied this important issue in the children. methods and material: in this descriptive study, data has been gathered by trained hospital nurses during 12 month in traumatic patients refered to 400-bed teaching hospital, kashan. the main method is questionnaire filling by direct interviewing. findings: among 98 cases of trauna 45(45.91%) of them was children below 19 years old that 32 cases (71.1%) were due to car accident, 9 cases (9.18%) were due to motor accident and rest of them (5.42%) were pedestrian accident. boys involved 3.5 times as girls the most injuries happened was head-injury (73.3%). conclusion: these finding suggest that we have to pay more attention to this age group specially 16-18 because of the high rate of their involvement. finally as you see the last but not the least, these findings emphasise on protective cap wearing for every persons. 290 managing blunt splenic injury in a level ii trauma center: the laparoscopic option background: the past 2 decades treatment modality of blunt splenic trauma was a point of discussion. where nowadays explorative laparotomy remains the standard of care for hemodynamic unstable patients, treatment of hemodynamic stable patients is less uniform. in this stable population maximum conservative approach seems preferable, though level 1 evidence is still absent. failure of the conservative pathway is backed up by percutanous angioembolisation or laparoscopic salvation. the evolution to minimal invasive access makes laparotomy as a primary care for hemodynamic stable isolated splenic injury superfluous. methods: this paper discusses the initiation of explorative laparoscopy and successive splenectomy in two patients scoring a grade iii posttraumatic splenic injury. grading was based on ct scan imaging using the spleen injury scale defined by the american association for the surgery of trauma (aast). conservative treatment was abandoned because of moderate hemoperitoneum and continuing need for transfusion. results: an uncomplicated laparoscopic splenectomy was performed in both patients. perioperative spleen preserving measures failed because of the extent of the parenchymal lesion. conclusion: performing laparoscopic splenectomy seems a good procedure when conservative treatment for splenic injury fails. this accounts for a rural level ii trauma center where the accommodation to perform safe angioembolisation is missing, knowing that laparoscopic splenectomy is not a straight forward procedure but is made easier because of the growing skills of our surgeons. hepatic portal venous gas (hpvg) is often associated with serious intra-abdominal pathology like ischaemic bowel disease and necrotizing enterocolitis, with reported mortality rates above 75%, with most requiring urgent operation. however, hpvg has been reported seen on ultrasound or computed tomography (ct) scans immediately after blunt trauma, followed by spontaneous resolution. gastric pneumatosis (gp) has rarely been reported as a trauma-related entity. the combination of hpvg and gp after blunt trauma has been described in very few patients. we report the case of a 16-year-old woman who presented with an edh requiring craniotomy and an initial abdominal ct scan showing only an ois grade 2 liver injury. a transient increase in serum amylase combined with abdominal distension led to a repeat abdominal ct scan 48 h post injury to rule out pancreatic and duodenal injuries, revealing gp and hpvg. endoscopy demonstrated mucosal erythema of the posterior gastric wall from the fundus to the pylorus. however, the clinical status of the patient was benign, and did not mandate surgical intervention. the patient was treated nonoperatively with nasogastric decompression and antibiotic coverage, and underwent a successful recovery with no abdominal complications. to our knowledge, only one other adult patient has been described with hpvg and gp occurring after an initial normal abdominal ct scan. a gastric resection was performed, and operative treatment was recommended for this combination of entities in trauma patients. our patient shows that treatment strategies in these cases probably should be guided by the clinical status of the patient. introduction and aims: while the number of colorectal injuries due to penetrating trauma are increasing, increased traffic accident rates also cause the number of blunt rectal injuries associated with trauma in traffic accidents to be increased. rectal injuries occur rarely. because of post operative septic complications, morbidity and mortality rates are high. early admission, stability, operation type all play important roles in the fate of the patient. we aimed to investigate these criteria in our patients who have colorectal injuries. material-method: 21 cases who had penetrating or blunt trauma in our district during last 10 years were included in this study. aim of this study is to present three cases with torsion of omentum, that often resemble acute cholecystitis or appendicitis, and the diagnosis is made at the time of exploratory laparotomy. case description: the first case, a 30-year-old men, presented with a 7-day history of right hypocondrial abdominal pain, fever and vomiting. the pain increasing in severity while the patient is standing and relieved in supine position. laboratory findings were normal, except for mild leucocytosis (12,500/cc). the patient underwent u/s examination, which showed an encysted mass in the right abdomen. a mass, originating from the omentum, was revealed after laparotomy. the mass was excised and an appendectomy was also performed. the second patient, a 43-year-old female, was admitted in our department with abdominal pain, associated with vomitus. a mild leucocytosis (13,700/cc) was observed. an u/s was carried out, which revealed a mass 5 · 6 cm lying besides a stone-free gallbladder. the patient underwent diagnostic laparoscopy and a cystic mass, which was twisted, was resected using bipolar forceps. sixteen of all laparotomies did not reveal any internal organ lesion. of these 16 laparotomies with negative findings, 13 had been operated for stabbing injury and 3 had been operated for gunshot injury. twenty-one cases had single organ injury; whereas, multiple organs were affected in 43 cases. frequencies of organ injuries were as follows: 18 small intestine, 12 colon, 12 stomach, 8 liver, 8 diaphragm, 6 spleen, 3 kidney, and 2 pancreas. the mean duration of hospitalization was 5.9 ± 2 days. after surgery, four cases needed intensive care unit; therefore, they were referred to a higher-level healthcare center. among cases whom the treatment was completed in our institution, 8 had complication. conclusion: penetrating abdominal injuries mostly occurred in young males and stabbing injuries were more common. most penetrating injuries can be treated at secondary care centers. however, they should be referred to a higher-level institution after the initial intervention, when necessary. background: both nonoperative management (nom) of blunt hepatic trauma and the damage control laparotomy are significant advances in the management of massively injured trauma victims. methods: this study is a retrospective evaluation of 29 patients admitted with liver trauma during 2008. 12 of them required early surgical procedures, 7 damage control surgery and 10 followed nom. patients were stratified by age, mechanism of injury, ais, initial blood pressure, heart rates, and blood transfusion volume. initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. readmission data including the number of admissions, surgical procedures, and hospital length of stay were then analyzed. the average age of the study group was 39, 58 years. almost all of these patients were males (75, 86%) and car crash was the main mechanism involved (51, 72%). liver injuries were frequently an element of multiple trauma and was associated with cranio-cerebral trauma (65, 51%) and spleen lesion (37,93%). the overall mortality during the first admission was 41, 13%, yet 17.24% attributable to the liver trauma and only 6.8% after damage control. conclusions: damage control surgery offers a simple effective alternative to the traditional surgical management of complex or multiple injuries. phase i can be done at a local hospital before transfer to a major trauma center for resuscitation and definitive repair. reasonable surgical procedures based on classification of liver injuries and damage control principles increase the survival rate of severe liver trauma. background: at our department, a simple scoring system based on three criteria (blood pressure below 90, be below -7.5 and body temperature below 35°c) has been used to determine the suitability of individual patients as candidates for dcs. objectives: the present study was undertaken to establish a valid strategy for the treatment of severe pancreatic injury and to test the validity of the scoring system used at our department for identifying suitable candidates for dcs. subjects and methods: the subjects of the study were 12 patients with the grater and equal of grade iii (organ injury scale (ois))pancreatic injury treated surgically (type iii in 3 cases and iv or v in 9 cases). results: resection of the pancreatic body and tail was performed in both the groups to treat type iii injury, and all of the cases with type iii injury had favorable outcomes. among the cases with type iv or v injury, all of those patients satisfying two or fewer than two of the criteria of the dcs scoring system survived dcs, while two patients satisfying all the three criteria of the dcs scoring system died after dcs. the two patients who underwent pancreatic duct-forming surgery needed prolonged hospitalization. discussion: our results suggest that dcs should be selected in cases where at least one of the three criteria of the dcs scoring system is satisfied. as a procedure for radical operation, resection of the distal pancreas may be recommended for type iii, and pancreatoduodenectomy for type iv or v. author to editor: our results suggest that dcs should be selected in cases where at least one of the three criteria (systolic pressure below 90, severe hypothermia with body temperature below 35°c, and acidosis with be below -7.5) of the dcs scoring system is satisfied. this dcs score is accords with the score of another abstract (abs ref 0087). we did not show the details of the score in another abstract (0087). please refer in our another abstract (ref 0087 iatrogenic and traumatic lesions involving common hepatic duct and duodenum can be treated with a primary and contemporary reconstruction, at the condition of hemodynamic stability. we propose a technique which include the following steps: cholecystectomy with intraoperative cholangiography; transection of the common bile duct above the tear, oversewing its distal part; kocherization of the duodenum; a 80 cm long roux-en-y jejunal loop is constructed and brought up retrocolically in the right sub-hepatic space, orientating its antimesenteric side towards the corresponding duodenal wall; termino-lateral hepatico-jejunostomy with a transanastomotic temporary stent in case of small biliary duct's size; a side-to-side jejuno-duodenostomy performed 40 cm distally; a feeding jejunostomy. we remark the following advantages of this procedure: (1) the rouxen-y biliary diversion reduces the risks of stenosis and cholangitis, frequent after a direct repair of the common bile duct; (2) an adequate distance between the biliary and duodenal anastomosis prevent entero-biliary reflux; (3) the duodeno-jejunal anastomosis appears more appropriate, considering the complications after direct repair of large duodenal tears. more aggressive options, such as duodeno-cephalo-pancreatectomy, pancreas-preserving-duodenectomy and segmental duodenal resection, must be considered more risk solutions. introduction: the liver is the most commonly affected organ in abdominal trauma. in our department, the majority of traumatic liver injuries are treated conservatively. this option involves the monitoring of possible complications, such as late rupture, hemobilia, arterio-venous fistula, pseudo-aneurysm, biloma and abscess formation. case: a 19 year-old patient was admitted after a 8 m fall. established diagnoses were: multiple facial fractures, right pneumothorax with pulmonary contusion, right renal artery thrombosis and grade 3 hepatic laceration. the patient was discharged on the 21st post-trauma day (ptd), after an uneventful course. on the 61st ptd, he was readmitted for abdominal pain. thoracoabdominal ct revealed an intra-hepatic arterio-venous fistula. angiographic superselective embolization was performed, and the patient was discharged following a control abdominal ct scan that showed resolution of the fistula. he was again readmitted on the 84th ptd, with abdominal pain, jaundice and gastrointestinal bleeding. an abdominal ultrasound raised the possibility of hemobilia, confirmed by upper endoscopy. a new angiography did not reveal any active bleeding, and an abdominal ct showed satisfactory evolution of the liver lesion. the patient was discharged on the 97th ptd, asymptomatic. at 6 month follow-up, the patient presents no complaints, other than a new-onset arterial hypertension of renovascular origin. conclusion: arteriovenous fistulae and hemobilia are relatively uncommon sequelae of abdominal trauma. however, these diagnoses should be actively sought in the presence of abdominal pain, especially when associated with jaundice and gastrointestinal bleeding. a multidisciplinary approach is essential for a successful treatment. diaphragmatic hernias constitute frequent complications after thoracic and abdominal trauma (0.8-5%), especially on the left side (90%) and the diagnosis is frequently delayed. clinical presentation is variable and may include respiratory distress and abdominal pain, frequently attributed to intestinal obstruction, pancreatitis, biliary colic or peptic disease. the authors present a case report of a right diaphragmatic hernia diagnosed 2 years after a thoracoabdominal blunt trauma. the male patient, 64 years old, was admitted in the emergency room with epigastric pain, bloating, slight abdominal distension with 6 months of evolution and recent worsening. he suffered a previous thoracoabdominal trauma 2 years ago, consecutive to a downfall of about eight meters high with lumbar vertebrae fracture (l1) and was submitted to conservative treatment in an orthopaedic ward; x-ray signs of diaphragmatic hernia were unrecognized. actual chest x-ray revealed an elevated right hemidiaphragm and presence of abdominal content in the right hemithorax. mr demonstrated a right hemidiaphragmatic rupture and the presence of abdominal content in the thoracic cavity. patient was operated by laparoscopic approach; a diaphragmatic hernia grade iii (a.a.s.t. classification) was observed and submitted to prosthetic repair. postoperative period was uneventful. patient remains asymptomatic with no signs of recurrence after 3 years. this case is paradigmatic of the difficulty of immediate diagnosis of diaphragmatic hernias, especially at the right hemidiaphragm. high index of clinical suspicion is needed for its early recognition in context of blunt trauma. laparoscopic treatment revealed to be safe and efficient, with the known advantages of minimally invasive procedures. results: their ages were between 5 and 69, 168 were male and 35 were female. the type of injury was penetrating in 122, blunt in 80 and blunt and penetrating in 1 patient. in 117 patients, the left kidney was injured, in 80 the injury was at right kidney and in 6 injuries was bilateral. the average transport time to hospital was 112 min (30 min-10 days). one hundred and seventeen out of 203 patients were explored immediately as they hemodynamically unstable position. remaining 86 patients were evaluated with ultrasonography, intravenous urography and computerised tomography. sixty four of these patients were followed conservatively. the injuries in patients followed conservatively were in 46 patient's grade 1, in 15 grade 2, in 3 grade 3. 145 renal units of 139 patients were operated. nephrectomy was done in 78, nephropathy was done in 54 and renal artery repairing was done in 1 patient. conclusion: nephrectomy and mortality were high because of the long transport time, frequent high grade and high rate of associated organ injuries. rojnoveanu gheorghe sigmoid volvulus is seen more frequently at elderly ages and early diagnosis and treatment decreases its mortality and morbidity rate. we reviewed sigmoid volvulus cases treated in our clinic. 24 patients hospitalized and treated due to diagnosis ofsigmoid colonic volvulus in dr. lü tfi kırdar kartal education and training hospital during 2004-2009 were analysed. treatment modalities, morbidity and mortality rates were analysed. 12 patients were male, 8 were female. mean age was 69 (52-87). sigmoid colon resection and end colostomy was done to 12 patients, sigmoid colon resection and end to end anastomosis was done to 8 patients and nonoperative colonoskopic decompression was applied to 4 patients with sistemic illness and they were prepared for elective sigmoid colon resection and end to end anastomosis. in one patient with anastomosis, anastomotic leakage was detected and end colostomy was applied. two emergently operated patients with sistemic illness died. mortality rate was%8. in conclusion, sigmoid volvulus patients with sistemic illness should be prepared to elective surgery with colonic decompression. we think that the best treatment for early diagnosed cases is sigmoid colonic resection and end to end anastomosis. introduction: onset of world war ii, the report concerning diverting colostomy declared reduced mortality rates for colon injury, compared to world war i. in spite that nearly 70 years has passed away, although all therapeutic options, this method -used for the management for colon injury -still include some controversial points. methods: ninety-five patient's characteristics were compared in two groups (patients with or without diverting stoma). clinical findings and patient's characteristics, injury mechanism, localisation of the wound, blood transfusion requirements, fecal contamination, colon injury score (cis), penetrating abdominal trauma index (pati score), evidence of shock, morbidity rate, mean hospital stay, main and additional surgical procedures of 95 patients who admitted to our clinic from 1996 to 2008 were reviewed retrospectively. results: we have no mortality in both groups, except the first postoperative 24 h. diversion colostomy was performed in 58 patients and primary repair in 37 patients. median hospital stay for primary repair and diversion groups were 8 and 13 days, respectively, (p < 0.05). respiratory system, septic complications, clinical anastamosis leakage and other complications were similar in both groups. conclusions: although all articles that prompt primary repair, this approach includes some inconvenient points. it is acceptable in military or war originated injuries. diversion mostly is necessary in wounds, related to highly potent and energic fragments. nevertheless, nearly all of the civilian colonic injuries can be treatment with primary repair without diversion since the mechanism of the wound is different than war injuries. dogan gö nü llü 1 , oguz ç atal 1 , nilü fer yazgan yıldırım 1 , tayfun yucel 2 , ferda nihat kö ksoy 2 1 taksim trainig and research hospital, _ istanbul, turkey background: the management of haemodynamic stable penetrating injuries of the flank has not been well defined; laparoscopic exploration, closed abdominal examination and triple contrast computed tomography (ct) are alternative modalities. our aims are to explain our experiences in these cases. methods: we reviewed the patients with isolated penetrating flank trauma admitted between 2003 and 2008. the flank was defined as area between the anterior and posterior axillary lines, inferior to the fifth intercostal space superior to the iliac crest. results: there were 79 haemodynamic stable patients (7 gunshot and 72 stab injuries). there were three patient groups: laparotomy (g1) (n = 9), laparoscopy (g2) (n = 14) and only closed clinical observation with triple contrast ct scan (g3) (n = 56). 7 patients in the g1 were gunshot injuries; the other two gunshot injuries were tangential and were included in the g2. in the g2 there were four left diaphragmatic injuries, all repaired laparoscopically. one patient with splenic laceration and another with small bowel injury were converted to an open exploration. there were eight negative laparoscopies (8/14).two patients of g3 (2/56) with negative tomography were submitted to laparotomy after 3 day of closed observation. the mean length of hospitalization in the groups was respectively 10.2, 3.0 and 3.5 days. introduction: intra and retro abdominal hemorrhage are common following blind and penetrating abdominal trauma. liver, spleen and kidneys are known to be prone to injury and to bleed after an abdominal trauma. hepatocellular carcinoma is a well known disease. however, a renal mass from a primary origin in the liver is rare. this paper presents a patient, who was treated with right nephrectomy for traumatic bleeding from a ruptured renal mass. end diagnosis was metastatic hepatocellular carcinoma. case: the patient was 50-years-old man. he had no positive medical and surgical history, and no complaint. he was referred to emergency service after traffic accident. during his initial assessment abdominal rigidity and tenderness were found, which were accompanied with tachycardia and hypotension even after fluid resuscitation. fast revealed that there was free fluid in his abdomen, so we decided to operate him. at laparotomy we observed a bleeding tumoral mass in the right kidney and in his liver. he was treated with right nephrectomy and irregular hepatectomy. pathologic examination demonstrated a metastatic hepatocellular carcinoma. conclusion: hepatocellular carcinoma is a well known disease with its common acute complications such as rupture and bleeding. in this case, we observed hcc metastasis to the right kidney although the patient had no medical and surgical history including hcc. bleeding was induced after a blind trauma, was treated with resection. gall bladder (gb) injuries either following penetrating or blunt abdominal trauma is a rare entity and usually misdiagnosed with a delay in diagnosis. the incidence of gb injury is reported to range between 0.5 and 8.5% among the surgically treated patients following abdominal trauma. cholecystectomy is the definitive treatment even in severe contusion of a nonperforated gb. simple suture repair or cholecystostomy are also advocated as alternative surgical interventions by some authors. gb is afforded significant anatomic protection from external trauma, since it is partially embedded in the relatively massive liver parenchyme, cushioned by the surrounding omentum and intestines, and shielded by ribcage. clinical symptoms may be minimal or nil initially but gradual clinical deterioration, related to spillage of bile into the peritoneal cavity, can follow. bilous fluid taken by paracentesis or diagnostic peritoneal lavage can only be helpful after a delay as abdominal computed tomography. an 18year-old male was admitted to our emergency department for the fifth time because of penetrating abdominal trauma of at the right upper quadrant by a knife in a 15-day-period. he was hospitalized in three of them and operated on at last, because of acute abdomen, since paracentesis revealed bile coloured free abdominal fluid in addition to abdominal guarding, leucocytosis(19,000/mm 3 ), and fever.the ultimate ultrasonography and computed tomography revealed large amount of free fluid (bile) and minimal intrahepatic hematoma. at laparotomy; full-cut hepatic and cholecystic perforation (both anterior and posterior surfaces) resulted in cholecystectomy. he was discharged on the fourth postoperative day. since almost all reports about the delayed rupture of gb are usually unrecognized gb perforations,a diagnostic delay can only be avoided by a high clinical index of suspicion. sixty-three patients were treated conservatively, whereas 22 patients had laparotomy and 2 patients underwent angiography. of 47 patients transported by ambulance or helicopter, 83% arrived at the emergency unit within 60 min after prehospital alert. in 57% the time on scene were longer than 10 min. in this group only 31% were diagnosed by ct within 60 min after arrival to the emergency unit. conclusion: low volume in trauma care results in substandard handling time. in hospitals with a low volume exposure to trauma, the prehospital response teams and surgeons achieves limited experience, especially in penetrating trauma. exchange programs must be emphasised. author to editor: this study describes the complete workload in primary handled trauma patients in a typical nothern european universtyhospital with very low incidence of penetrating trauma and low volume of blunt trauma. our trauma registry covers 100% of patients admitted to the hosptial. it is the only hospital in the area, and patients do not bypass the system and are treated elsewhere. the study will point out that prehosptial responsetime and inhosptial procedures are is acceptable, but emergencyroom handlingtime is to long, due to lack of practice. national or european exchange programs for surgical trauma care must be practiced. introduction: explosives create and energize particles that act as projectiles prone to further fragmentation in the body. these fragments may result in secondary injuries. this has been repeatedly described in the orthopedic and neurosurgical literature. in this paper we demonstrate that such a process is also possible for abdominal injuries during or after fascial penetration. material-method: in all abdominal wall injuries, despite negative physical examination of conscious and alert patients we used local wound exploration as a standard approach. finding a full thickness fascial defect, we assumed an intraperitoneal injury and performed laparotomy. result: using this method, we found hollow organ injuries in 7 of 8 (87.5%) patients. in 3 (37.5%) of these patients at laparotomy, we found multiple, projectile induced injuries in a sprayed distribution. these injuries were found far from the trajectory, in the absence of bone fragmentation. the mean number of peritoneal defects was 1.7, however, for each peritoneal defect, we found an average of 6.8 intraabdominal injuries when through and through injuries were excluded. conclusion: local wound exploration is an accurate indicator of possible intraabdominal injuries. although fragments of projectiles would be expected to be distributed along the trajectory, meticulous exploration of abdomen is mandatory because this is not always true. despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. introduction and objectives: nonoperative management of penetrating abdominal stab wounds has been established as standard care recently. it decreased negative laparotomy rate without any increase in morbidity and mortality. in this study we evaluated the outcome of patients managed due to penetrating abdominal stab wounds. intraabdominal injury due to blunt abdominal trauma usually presents acutely. in the absence of peritoneal irritation findings or shock the patients may be treated conservatively. delayed small bowel obstruction after blunt trauma is very rare clinical entity. it may be caused by subclinical bowel perforation, localized bowel ischemia or mesenteric vascular injury. we present a 34 years old man of blunt abdominal trauma that was treated nonoperatively. despite the success medical treatment, 2 months later, the patient presented with abdominal pain and vomiting. the radiologic studies suggested a mechanical intestinal obstruction. at the operation a conglomerated terminal ileal segment causing obstruction was found and the patient is treated by a resection and primary anastomosis. the operative findings may be explained by a subclinical perforation at the time of the trauma. this kind of complication should be suspected in patients with post traumatic patients which presents with signs of intestinal obstruction in weeks after the trauma. nevin kanan, ayfer ö zbaş 1 1 department of surgical nursing, istanbul university, florence nightingale school of nursing, ankara, turkey with traumatic injury, kidneys can be thrust against the lower ribs, resulting in contusion and rupture. up to 80% of patients with renal trauma have associated injuries of other internal organs. injuries may be blunt (automobile and motorcycle crashes, falls) or penetrating (gunshot wounds). approximately 80-90% of all renal trauma cases are blunt trauma injuries; penetrating renal trauma accounts for the remaining 10-20%. blunt renal trauma is classified into one of four groups which are contusion, minö r laceration, majö r laceration and vascular injury. • with a contusion of kidney, healing may take place with conservative measures (i.e. bed rest) • if minö r laceration is present, the patient is hospitalized and kept on bed rest until the hematuria clears. • depending on the patient's condition and the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery) • vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. the patient is often in shock and requires aggressive fluid resuscitation. for the management of patient with renal trauma, nursing diagnoses are: • inefective tissue perfusion (renal) related to interruption of arterial flow • anxiety related to physical injury • acute pain related to physical injury • impaired urinary elimination related to renal damage and shock background: penetrating abdominal buckshot wounds are believed to necessitate emergent laparotomy to rule out any hollow or solid organ injury. recently, nonoperative management has been suggested in selected patients. this paper aims to present two cases with penetrating abdominal buckshot wounds, treated nonoperatively. materials-methods: a chart review has been conducted for patients operated in our institution for abdominal buckshot wounds. demographics, evaluation tools and follow-up parameters has been analyzed and documented. results: a total number of two patients (both male; 23 and 16 years old) were found. both were shot on their left thoracolumbar regions. left and bilateral chest tubes were necessitated after initial examinations, but both denied any abdominal tenderness, although computed tomography showed multiple abdominally located pellets. gastroscopy (n = 1), echocardiography (n = 1), intravenous pyelography (n = 1) were necessitated for further evaluation, but showed no abnormality. the patients were followed up with routine abdominal examinations, vital signs and routine laboratory tests and discharged from the hospital on days 4 and 5 after uneventful recovery periods. discussion: patients with penetrating abdominal buckshot wounds may be followed with nonoperative management instead of routine laparotomy. objective: treatment procedures in cases who were operated due to colon injuries were investigated in this study. material-methods: thirty-two cases who were operated due to colon injuries in our clinic between 2002 and 2008 were investigated retrospectively. cases were investigated with regard to age, sex, type of trauma, hemodynamic condition, interval between injury and surgery, additional organ injury, transfusion volume, injury site and severity, faecal contamination, surgical procedures, postoperational complications and mortality and factors affecting morbidity and mortality were determined. colonic injury severity scale (ciss), abdominal trauma index (ati) and flint classification were used for evaluating severity of colon injury,severity of additional organ injury and faecal contamination, respectively. systolic blood pressure less than 80 mmhg on admission was referred to as ''shock''. results: males comprised 28 out of 32 cases and mean age was 35.7 (range:17-72) years. twenty-five cases were injured due to penetrating trauma and left colon injury was the most common (12 cases) type of injury. additional intraabdominal organ injury and extraabdominal injury were observed in 21 and 6 cases, respectively. mean interval between injury and surgery was 2.7 (range 0.5-8) h. fifteen cases received blood transfusion. five cases had shock on admission. seven cases received stoma surgery while all cases with flint grade more than iii or ati score higher than 25 received colostomy. only cases with high ciss score received resection and anastomosis surgery. complications were observed in 11 cases while mortality occurred in two cases due to hemorrhagic shock. conclusion: routine primary repair cannot always be performed in colon injuries since many factors affect the decision for type of surgery. primary repair may be performed safely in hemodynamicallystable cases with ati score less than 25 and flint grade i-ii. seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report a 48-years old male who was a front seat restrained passenger involved in a head-on collision. he has presented with lower abdominal and back pain. seat belt mark was seen transversely across the lower abdomen. initial trauma ct scan was normal except for burst fracture of l5 vertebra which was operated by internal fixation on the same day of admission. the patient continued to have abdominal pain and distention which became clear on the third day. repeated abdominal ct scan on the third day has shown free intraperitoneal air. exploratory laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. hartmann's procedure was performed with end colostomy. the abdomen was left open and temporarily closed using saline iv bags sandwiched between 2 layers of steri-drape. peritoneal toileting was performed four times under general anesthesia with gradual closure of the abdominal fascia over a period of 2 weeks. postoperatively, the patient had urinary retention due to a quada equina injury although he could walk. the presence of seat belt sign and a lumber fracture should rise to the possibility of a bowel injury. author to editor: seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report such a case. fuat ipekçi, muharrem karaoglan, hü seyin toptay, hasan ş ahin 1 1 department of general surgery, tepecik education hospital, izmir, turkey introduction and aims: meckel's diverticulum results from incomplete degeneration of omphalomesenteric duct. it is usually diagnosed incidentally during appendectomy; however, sometimes perforation or bleeding may lead the surgeon to the diagnosis. we aimed to investigate the frequency of meckel's diverticulum during emergency laparotomy performed for acute appendicitis and clinical and pathological characteristics of the patients with meckel's diverticulitis and appendicitis. material-method: the material consisted of 1,372 patients who admitted to our hospital and treated by appendectomy during a 10-year interval between the years 1998 and 2008. of these patients 824 (60,05%) were male and remaining 548 (39,95%) were female. all patients were investigated for meckel's diverticulum weather they have acute appendicitis or not. results: meckel's diverticulum was found during 20 out of 1,372 appendectomies (0.01%). of the cases, 16 were asymptomatic but four patients were symptomatic with inflamed diverticulitis. of these four patients two have normal appendix and other two have secondary appendicitis due to meckel's diverticulitis. all four symptomatic cases were treated by diverticulectomy and appendectomy. all 16 asymptomatic cases were treated by appendectomy alone. no mortality or major morbidity was detected. conclusions: despite of its rarity (0.01% in our appendectomy series), meckel's diverticulum must be searched weather the appendix is normal or inflamed. introduction: illegal drug smuggling is a widespread problem. drug packs carried inside body cavities may leak its contents and be dissolved inside the body and signs of toxicity (aka. body packer syndrome) become evident. this case was reported to represent the very first proven patient in turkey. case: a 36 year-old man were brought in the emergency department (ed) from the airport because of severe tremor, palpitation, restlessness associated with hypertension and tachycardia. the patient was cooperative and oriented. on examination, his blood pressure (bp) was 210/150 mmhg, pulse rate 124/bpm, whereas other systems were unremarkable. he was put on cardiac monitor and infusion of glycerol trinitrate was instituted (10 mcg/min). urinary toxicologic screen was positive for cocaine and benzodiazepine. after admission to the ed he complained of epigastric distension and abdominal pain and admitted that he had swallowed cocaine packs. his abdominal xrays showed gas-fluid levels and opaque round-shaped mass images. a nasogastric catheter was inserted and gastric contents (approximately 1,500 ml) were drained. he was consulted with surgery clinic with a diagnosis of an ileus due to swallowed packs. he was hospitalized in the surgical ward. after supportive treatment and repeated enema applications he excreted 104 cocaine packs in 2 days. he was discharged following clinical stabilization and abdominal x-rays were repeatedly normal. conclusion: toxicologic analysis must be employed in patients who are suspected to have intoxication, to identify life-threatening drugs and vasoactive substances. advanced imaging methods must be exercised to exclude bowel obstruction in these patients. background: pseudoaneurysm is a well recognized complication of pancreatitis. angioembolization is considered to be the first option of treatment. to our knowledge, the case we hereby report is the first one with successful re-angioembolization. case: a 41-year-old man, with aids, history of cns toxoplasmosis, chronic pancreatitis with pseudocyst secondary to alcohol abuse, was hospitalized for pneumonia. during his hospitalization, he developed abdominal pain and hypotension. after resuscitation, ct angiogram of the abdomen revealed active bleeding into a pseudo-aneurysm, near the head of the pancreas, measuring 2.7 x 1.8 cm and arising from superior and inferior pancreaticoduodenal arteries. this was confirmed by angiogram. angioembolization distal and proximal to the bleeding area was performed using coils. eight days later, the patient became hypotensive and dropped his hemoglobin again. he was taken for an emergency laparotomy which revealed a 5 cm pancreatic pseudocyst with hemorrhage. the pseudocyst was opened through the medial wall of the duodenum, ligation of the bleeding intracystic vessels, and cysto-doudenostomy were performed. his postoperative course was uneventful and he was discharged home on postoperative day 16. five days later he was readmitted with hematemsis and anemia. celiac angiogram revealed bleeding from the gastrodoudenal artery which was embolized. he died 5 months later due to hiv nephropathy without any evidence of re-bleeding. objectives: any sort of discomfort in the abdominal cavity that lasts less than 1 week is defined as acute abdominal pain. the purpose of the study was to evaluate the outcome of hospitalized patients with unspecified acute abdominal pain following initial clinical and laboratory evaluation. method: from january 2008 to december 2008, 114 patients with acute unspecified abdominal pain were admitted to surgery department. gender, age, definite diagnosis, time from hospitalization to surgery and hospital length of stay were retrospectively reviewed. results: fifty-six of the patients with acute unspecified abdominal pain were females (49%) and 58 were males (51%), median age was 34 years (range 16-82). while definite diagnosis was confirmed in 70 patients (62%), the initial diagnosis was not changed in 44 patients (38%). distribution of new diagnoses were appendicitis (n = 24), gastroenteritis (n = 7), genitourinary disorder (n = 17), familial mediterranean fever (n = 6), inflammatory bowel disease (n = 2), mesenteric adenitis (n = 2), peptic ulcus perforation (n = 1), constipation (n = 1), diverticular disease (n = 1), pneumatosis intestinalis (n = 1), hepatobilier disease (n = 7) and intra abdominal tumor (n = 1). depending on the cause of abdominal discomfort, 28 patients (25%) required surgical intervention. median time from hospitalization to surgery was 20 h (range 4-55 the use of temporary skin substitutes (tss) is a useful technique in the treatment of full-and partial thickness burn wounds affecting a large body surface area. early excision of the eschar is mandatory. but if we cannot find sufficient donor site, tss using seems to best choice. the ideal tss must be has some properties: adherence, control of water loss, safety, flexibility, stability on wound surfaces, bacterial barrier, and ease of application, ease storage and cost effectiveness. case report: a 2-year-old girl was admitted to our burn center with deep flame burns affecting face, thorax, upper and lower extremity (45%). she underwent an early burn excision on day 4 post-burn day. the whole area excised with hydrosurgically was covered with biobrane ò and compressive dressing. seven days after we removed biobrane from the upper and lower extremities and grafted the wound bed. face healed spontaneously under the tss and tss covering the thorax was rest intact. after 10 days thoracic tss was removed and grafted and we covered the thorax with biobrane ò over the grafts again. after 10 days a second grafting was needed. patient was discharged from the hospital 56th post-burn day. the use of biobrane ò as a tss after burn wound excision was satisfactory, because it enabled us to delay auto grafting until we were sure of good conditions in the wound bed. also it proved to be a good dressing over the meshed autografts. it reduces the healing time and improved the quality of grafts. introduction: endoscopic examination of the colon during the diagnostic or treatment purposes, perforation incidence is reported between 0.01 and 0.3%. determination of risk factors may decrease the incidence with early recognition of the serious complications of surgery may reduce interference. method: we have examined retrospectively the patients in whom colon perforation appeared due to endoscopic analysis of colon carried out at endoscopy unit between january 2007 and december 2008. results: total colonoscopy and rectosigmoidoscopy were applied to 7,881 patients. in 7 patients (0.088%) perforation was observed. the median age was 74.5 (66-85), m/f: 5/2. all colonoscopys were made for diagnosis; anemia in two, hemorrhodial disease in one, subileus in two, anal prolapsus in one, right colon tumor suspation in one patients. one sigmoid polypectomy was applied, diverticulosis disease of the colon in two patients, dolichocolon in one, one previous pelvic surgery were observed. perforation zone was observed in sigmoid colon in all patients. four patients were diagnosed in the process of colonoscopy (57.1%), 2 were diagnosed in 24-48 h (28.5%), 1 was diagnosed 5 days later. laparotomy was applied to all patients. perforation zones of 5 patients were fixed primarily and these 5 patients were discharged as cured. one patient who was applied to diversionary ostomy was reoperated due to abdomen collection. no mortality was observed. conclusion: colonoscopic perforation is a rare, serious complication. sigmoid colon is the location where the perforations are mostly observed. although primary fixation is generally efficient in cases of early diagnosis, morbidity increases seriously due to late diagnosis. with more than one stomas. eleven patients were discharged with planned ventral hernias. primary abdominal closure succeeded in four patients. fasciitis due to severe peritonitis and stomas prevented primary closure. eighteen of 34 patient died during treatment, 16 were discharged. sixteen of 21 patients with more than one bag were died, five survived (mortality 76.2%). conclusions: morbidity and mortality were higher in patients with more than one stoma than patients with single stoma. second stoma has a negative effect on primary fascial closure. fasciitis due to severe peritonitis also prevents fascial closure. 347 acute diaphragmatic hernia after minimally invasive esophagectomy the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was 0.72, and mean age was 72.3. main causes were biliary system disease (34.1%), intestinal obstruction (27.1%), peptic ulcer perforation (17%) and acute appendicitis (14.4%). median asa class was 2 and 73.6% of the patients had at least one preexisting disease. mortality ratio was 19.4%. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly effective on mortality. background: resveratrol is a strong antioxidant with antiinflammatory effects. we aimed to investigate the effects of resveratrol on oxidative injury, histopathology and bacterial translocation in induced i/r injury in rats. methods: 32 female wistar-albino rats were randomly allocated into four groups; sham-operated group(laparotomy without i/r injury), i/ r group (laparotomy plus 60 min of ischemia followed by 60 min of reperfusion), alcohol group (only 0.5% ethyl alcohole 0.3 ml/day intraperitoneally for both 5 days before surgery and 15 min before ischemia), resveratrol group (15 mg/kg resveratrol intraperitoneally both 5 days before surgery and 15 min before ischemia. intestinal tissue samples were obtained for investigation of tissue levels of malondialdehyde (mda), nitric oxide (no), superoxide dismutase (sod), myeloperoxidase (mpo) and histopathologic evaluation bacteriological translocation (bt) in mesenteric lymph node (mln), liver and spleen was also studied. results: resveratrol significantly decreased mda, no and mpo levels in i/r injury (p < 0.001). sod activity of resveratrol-treated group was significantly lower than sham group and significantly higher than i/r and i/r + alcohol groups (p < 0.05). histopathologically, the median intestinal injury score in i/r and i/r + alcohol groups was significantly higher than in sham and resveratrol-treatment groups (p < 0.001 and p < 0.05, respectively). the incidence of bt differred between the groups i/r and i/r + alcohol in mlm, spleen and liver (p < 0.001). nevertheless, the treatment with resveratrol reduced bt to mln, spleen and liver, compared to other i/ r groups (p < 0.01 gastrointestinal stromal tumors (gists) represent rare neoplasms of the gastrointestinal tract. here we describe a case with gist and thrombocytosis presenting as an acute abdomen. our knowledge, the co-existence of gist and thrombocytosis has not been reported so far. case: a 66-year old female was admitted to the emergency room with epigastric pain and vomiting over duration of 3 days. physical examination showed abdominal distension, rebound tenderness, and a palpable rlq mass. the laboratory findings were, wbc:16.740/l, plt 574 · 10 -9 /l and c-reactive protein 289.4 mg/l. a computed tomography scan of the abdomen showed conglomerate of small bowel. the abdominal exploration showed that a 6 · 6 · 6 cm mass was located on small intestine. the mass was completely resected and enteroenterostomy was performed. the histological examination demonstrated whirling sheets of spindle cells which were stained positively for cd 117 (c-kit) and cd34, mitotic index > 10/50 hpf, while smooth muscle actin and vimentin were focally positive, and keratine, desmin, s-100 protein were negative. this specific immunophenotype characterized gist. during the post operative follow up, platelets were above normal levels 400 · 10 -9 /l. therefore, bone marrow biopsy was performed. hiperplasia in megakaryocytes were found. the patient was negative for bcr-abl and philadelphia chromosome. discussion: here we describe a case with gist and thrombocytosis presenting as an acute abdomen. ten percent to 30% of these tumors are biologically aggressive; signs of malignant potential are metastases and invasion. the current treatment for localized disease is surgical resection. co-existence of thrombocytosis and gist has never been reported. laboratory tests showed no abnormality except white blood cell count of 11600/ll.plain abdominal x-ray and ct did not show any abnormal findings including free air (fig.1) . endoscopic examination of the stomach revealed an ingested toothpick protruding from the prepyloric antrum (fig.2) . the toothpick was deeply fixed into the antral wall. the whole toothpick 2.2 cm in length was removed using a loop without damage to the gastrointestinal wall, bleeding or any other complication. after endoscopic removal of the toothpick, her epigastralgia resolved. on the second hospital day, the patient was asymptomatic. medical therapy with proton pump inhibitor was stopped and she was discharged on the third hospital day. conclusion: accidental ingestion of foreign bodies is common and in general harmless. a perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than 1% of ingested bodies like toothpicks are involved in less than 0.1%. occasionally, the passage of the swallowed item may stop at one of the anatomic bottlenecks of the gastrointestinal tract, which may lead to perforations that may require operative or endoscopic interventions. results: we analyzed the number, causes and rates of emergency operations. the total number of emergency operations was 1,147 and 1,021, for the first and second groups, respectively. we observed an 11% decrease in number of emergency operations for the second group. we also observed that the cause of majority (70% for the first group, 71% for the second) of the emergency operations was acute abdomen and the rate between the groups did not change. lower extremity amputation and strangulation hernia operations decreased 51 and 22%, respectively. the number of operations which are caused by ileus and acute cholecystitis increased 25 and 74%, respectively. conclusions: difference in distribution of emergency operations between two groups was statistically insignificant. however, we observed both an increase and a decrease in small numbers of some subgroups. it is believed that this is related to the change in patient profile and technological improvements in surgery. aim: we hypothesized that one of the most widely used anesthetic agents, propofol, may reduce inflammatory processes, and organ injury induced with cecal and ligation puncture study design: bacterial peritonitis was induced in 18 rats by cecal ligation and puncture. the rats were randomly assigned to three groups. group 1 (n = 6) received propofol, group 2 (n = 6) received intralipid, group 3 (n = 6) was control, which did not receive any injection. all animals were killed 14 days later so we could assess the adhesion score. tissue antioxidant levels were measured in 1-g tissue samples taken from the abdominal wall. results: the adhesion score was significantly lower in the propofol group than in the control group (p < 0.05). the catalase levels were higher in the intralipid and control groups than the propofol groups. conclusions: intraperitoneal propofol reduced the formation of postoperative intra-abdominal adhesions without compromising wound healing in this bacterial peritonitis rat model. propofol also decreased the oxidative stress during peritonitis approximately, 20 min after the onset of the operation, a sudden decrease in end-tidal carbon dioxide from 32 to 11 mmhg was noticed. soon after, both systolic arterial pressure and heart rate decreased dramatically. arterial blood gas measurements showed that pco 2 was 41 mmhg at that moment. surgery and insufflation of gas was stopped, ephedrine 5 mg was given intravenously and ventilation with 100% o 2 was started. trendelenburg position was achieved immediately. a catheter was introduced through the right juguler vein to the right atrium rapidly and 3-4 ml gas bubble was withdrawn. soon, hemodynamic measures were recovered. since substantial amount of blood in the peritoneum was noticed, conversion to laparotomy with subcostal incision was performed. at exploration, through and through tear of 3 mm in inferior vena cava was detected. the defect was sutured with 6/0 polypropylene. anesthesiologist and surgeon must be aware of this dangerous complication. the emphasis is given to the prevention and prompt recognition of this event to the use of available tools in the management of cardiovascular complications. aim: obstructive jaundice, develops accompanied with high morbidity and mortality rates. the absence of bile in bowels leads to bacterial translocation and ultimately to endotoxemia and septice-mia. _ in our study, observing changes on bowel level during obstructive jaundice and examining its contribution to bacterial translocation have been aimed. material-methods: the study has been carried out at _ istanbul university _ istanbul faculty of medicine experimental medical research center (detam) with approval of _ istanbul university _ istanbul faculty of medicine ethical board for animals. two groups out of 20 male wistar albino rats have been formed. one hour after injecting d-xylose to first group the rats were put to sleep (anesthetized) and specimens of tissue (liver, spleen, mesenteric lymph nodes) and blood were taken for microbiological and biochemical examinations. in the second group an obstructive jaundice has been established by ligation of common bile ducts. the same specimens were obtained after 7 days. findings: in the first group no proliferation on tissue and blood cultures were detected. an obstructive jaundice has been shown in biochemical investigation of blood. d-xylose was found to be 102.7 ± 33.1 mg/dl. in the second group, proliferation, of mainly e. coli, were detected on cultures and d-xylose was found to be 151.0 ± 37.9 mg/dl. statistically significant increases were assigned between groups, between tissue and blood cultures (p < 0.001) and d-xylose values (p < 0.007). results: detecting statistically significant increases in d-xylose levels in the second group leads to the conclusion that increases in bowel permeability plays an important role in bacterial translocation. conclusions: while wound infections were higher in open appendectomy procedure group, surgical time was higher in laparoscopic procedure group. the achievement of optimal results will be based on increasing surgical laparoscopic experience. objectives: intraabdominal hypertension (iht) in intensive care units is a common problem. investigation of the effects of dexmedetomidine on respiratory system in rats with iht was aimed. patients and methods: 32 adult wistar-albino male rats were anaesthetized by rata ''ksalazin/ketamin'' combination. experimental model of iht(12-15 mmhg) was induced via pressure cuff. rats were left to spontaneous respiration for 2 h prior to randomly division into four groups. the first group underwent no process (control group). in sf group; 1 cc of 0.9% nacl,in the third group; 0.2 lg/kg dxmt and in the last, 0.7 lg/kg dxmt were intravenously administered. thereafter 30 min passed to observe the effects of dxmt. the rats were killed via cervical dislocation prior to surgery. lung tissues were fixed in 10% formalin and stained with he. whereas the other cross sections were stained with tunel method,the rest were stained with anti-caspase3,8,9 and anti-fas/fasl antibodies for immunohistochemical analysis. results: histological changes in group 3 were the less. there were no atalectatic changes in the same group. pnl infiltration and interalveolar thickness were higher in the 0.7 lg/kg dxmt group than others. in indirect immunohistochemical studies, in the 0.2 lg/kg dxmt group, immunoreactivity of caspase 8 and 3 were increased. however, the caspase-3 immunoreactivity was less than caspase-8. these results supported that 0.2 lg/kg dxmt administration led apoptosis, even though to be delayed, to start and showed that extrinsic pathways was used through apoptotic pathways. it was concluded that low dose of dxmt caused to delay in apoptosis in the lungs. results: a total of 93 microorganisms were responsible for the 81 cris, of which 22 (23.6%) were gram-positive bacteria, 63 (67,7%) were gram-negative bacteria and 8 (8.6%) were candida species. isolated from the 93 microorganisms were: klebsiella pneumoniae 12 (19%), acinetobacter 4 (6.3%), enterobacter 4 (6.3%), rroteas mirabilis 3(4.7%) pseudomonas aeroginosa 17 (27%), staphylococcus 14 (63.6%).12 patients (14.4%) developed crbsis and in 9 patients with positive blood cultures cris were negative. in our study, femoral venous access was associated with a significantly higher incidence of cri and crbsi than jugular and subclavian access; and jugular access was associated with a significantly higher incidence of cri and crbsi than subclavian access conclusion our results suggest that the order for punction, to minimize the cvc-related infection risk, should be subclavian (first order), jugular (second) and femoral vein (third). introduction and objectives: undescended testis is a risk factor for the testicular carcinoma, especially a seminoma. seminoma can be seen at any age, but it is considerably rare in elderly patients. we describe a patient who presented with acute abdomen secondary to an ileum perforation due to the involvement of seminoma. case: a 48 year-old man complaining with right lower abdominal pain and a palpabl mass with a 2-week history was evaluated. an abdominal computed tomography was showed a large, solid, welldefined intraabdominal mass, measured about 16 · 14 ·x 10 cm in right quadrant of lower abdomen. an exploratory laparotomy was adjudged to perform. whilst the preoperative investigations for surgery were continued, the patient admitted to the emergency service with acute abdomen symptoms, which was started suddenly. he had peritoneal irritation signs. he underwent an urgent laparotomy and a large mass located on terminal ileum mesenter through the retroperiton was detected. dilated ileum segments with omentum wrapped along the antimesenteric border of the distal ileum was found. on separating omentum from ileum, perforation along the antimesenteric border was noted. extended right hemicolectomy and an end ileostomy was performed. histopathologic examination revealed a classical seminoma with extensive tumor necrosis and showed evidence of vascular invasion. conclusions: undescended testes should be considered in men with an intraabdominal groin mass and should be aware of its potential complications. department with diagnosis of acute cholecystitis and on exploration giant gallbladder with giant stone and gallbladder adenocarcinoma. case: a 78 years old female was applied to emergency department with abdominal pain, nausea and vomiting. on physical examination, right upper quadrant tenderness and defence were detected. murphy sing was positive and gallbladder was palpable on subcostal space. in laboratory tests, white blood cell count was 16,000/mm 3 , glucose was 137 mg/dl and liver function tests were minimally elevated. in hepatobiliary ultrasonography, the gallbladder was hidropic (14 · 7 cm) and there was a stone (5 cm in diameter) and a mass (8 · 6 cm) in the gallbladder.cholecystectomy operation was performed. acute cholecystitis + cholelithiasis + adenocarcinoma were reported in the histopathological evaluation. conclusion: the carcinomas of the gallbladder were associated with gall stones in 80-90% of the patients. we concluded that the presence of the symptoms in our patient was delayed due to the magnitude of the gallstone and the excessive size of the gallbladder. 373 perforation of the gallbladder by trans-gastric migration of a sewing needle _ ingestion of foreign bodies is a common problem, especially in the elderly, pediatric, and psychiatric population, but fortunately, most of them pass spontaneously and uneventfully within 1 week.the perforation and migration of ingested foreign objects into the abdominal cavity is very rare and usually leads to a laparotomy. perforation of the stomach by sewing needle with migration to the gallbladder is extremely rare, and none cases have been reported in the literature. a 30-year-old woman was admitted because of abdominal pain and a history of a swallowed sewing needle 1 month ago. she had been followed-up at her local hospital and referred to our hospital because of the failure of progression of the foreign body. physical examination showed right upper quadrant tenderness, guarding, and a positive murphy's sign. blood analysis showed increased white blood count. she was submitted to abdominal plain x-rays, which revealed a radio-opaque objects in the liver area with the form of the sewing needles. the patient was clinically stable, and a semi-urgent laparotomy was planned. at laparotomy the needle was in the gallbladder and that the end of the needle could be palpated and the site of gastric perforation. removal of the intra gallbladder needle did not cause any problem. we was performed cholecystectomy and primary gastroraphy. the postoperative period was uneventful and the patient was discharged on seventh day of the operation. if there is a history of sewing needle ingestion and failure of progression and also signs of an acute abdomen, the surgeon must carefully evaluate gallbladder. introduction: sigmoid volvulus is an unusual intestinal obstruction form (1) . it is most common in the middle aged, elderly, institutionalized or neuropsychiatric patients (2). patients and methods: twenty-one sigmoid volvulus patients were reviewed retrospectively between 2004 and 2008.the recorded data were age,gender,admission symptoms,physical examination,radiological, and operative findings, surgical procedure, postoperative complications, mortality, and hospital stay.there were 10 male and 11 female patients. the mean ages of the patients was 66.5 years (34-84).the most common symptoms in acute abdomen patients were pain, and tenderness. abdominal distension were the most recorded sign in patient without peritonitis. the mean admission time was 3.9 days (2-7). five patients had a history of sigmoid volvulus (23%). leukocytosis and high fever were found in 12 (57%) patients. radiological evaluation of the patients revealed sign of intestinal obstruction (n = 7, 33%),frimann-dahl sign (n = 12, 57%) and bilateral free air under diaphragm due to perforation of the twisted sigmoid colon (n = 2, 9.5%). no patient underwent contrast enema examination of the colon. the mean hospital stay was 10.4 days (1-26 days) . two patients without signs of peritonitis were treated by sigmoidoscopy and operated on elective course.patients with signs of acute abdomen were operated urgently. the patients had several associated diseases such as atherosclerotic heart disease, diabetes mellitus, hypertansion, chronic obstructive pulmonary disease, cerebrovascular disease. eight patients (38%) died due to sepsis. morbidity rate was 33%. wound infection, evisseration pneumonia, and acute renal failure were found in 7 (33%) patients. the principal strategy in treatment of sigmoid volvulus is early nonoperative detorsion followed by elective surgery consist of colectomy and anastomosis on well-hydrated patient. urgent laparotomy is indicated in case of peritonitis. sigmoidopexy is an alternative option but it is usually ineffective and has high recurrence rate. results: ten men and four (six) female were enrolled in the study. mean age was 56 years (range 23-81). e.coli and acinetobacter were the common organisms cultured. all patients were treated with a common approach of resuscitation, broad spectrum antibiotics, and wide surgical excision. objectıves: acute appendicitis is one of the most common nonobstetric surgical pathology. clinical symptoms and findings are masked due to anatomical and physiological changes of peregnancy, so diagnose and treatment of acute appendicitis in pregnancy generally late. the curent study reported the cases which were diagnosed acute appendicitis in pregnancy and promptly operated in our general surgery clinic. material-methods: we evaluated sixteen cases' data between october 2006 and october 2008 who admitted to emergencey department with abdominal pain, vomiting, nausea and anorexia complaints and diagnosed as acute appendicitis in pregnancy and operated. results: the average of the cases were 29.3 (range 20-44) and thirteen of them were second, two of them were third and one of them was in the first trimester. the time interval between the onset of the complaints and operation was 1.5 (range 1-6) days. upon physical examination, there were rebound tenderness present in 13 cases, muscular rigitide in three cases, right lower quadrant pain in nine cases and widely irration of all abdominal guadrant in four cases. there were not any maternal mortality and morbity after operation, however in only one case fetal mortality was observed inevitable abortion due to vaginal bleeding. conclusion: in our cases acute appendicitis was diagnosed frequently in the second of the pregnancy with abdominal pain symptoms and rebound tenderness findings. recognition is important because early diagnose and prompt surgical intervention can reduce maternal and fetal mortality and morbity in acute appendicitis. introduction and objectives: conservative management of penetrating trauma has been mainly advocated in centres with a high incidence and large experience with those injuries. our aim was to assess the preventable death rate in our patient population, and the failure rate of conservative management. introduction and objectives: the data about role of amelogenin that is an extracellular matrix protein, during the healing process of the gastrointestinal anastomosis is lacking. in this study, the effects of amelogenin treatment on normal and ischemic colon anastomosis were evaluated. methods: adult male wistar albino rats weighing 200-250 g, were divided into four weight-matched groups: normal colon anastomosis group (n = 8); amelogenin treated normal colon anastomosis group (n = 8); ischemic colon anastomosis group (n = 8); amelogenin treated ischemic colon anstomosis group (n = 8). sufficient equal volume of amelogenin to entirely cover the anastomosis area had been applied. all animals were killed on postoperative day 4. bursting pressure levels were measured. peri anastomotic colon tissue hydroxyproline, catalase (cat), cu-zn superoxide dismutase (sod), glutathione (gsh), malondialdehyde (mda) and nitric oxide (no) levels were assessed to evaluate oxidative stress. results: bursting pressure levels of the ischemic colon anastomosis group is significantly lower than the normal colon anastomosis, the amelogenin treated normal colon anastomosis and the amelogenin treated ischemic colon anastomosis groups respectively (p = 0.003, p = 0.05, p = 0.011). hydroxyproline level of the amelogenin treated normal colon anastomosis group is significantly lower than the normal colon anastomosis and the ischemic colon anastomosis groups respectively (p = 0.026, p = 0.003). gsh level of the ischemic colon anastomosis significantly lower than the amelogenin treated normal colon anastomosis group and the amelogenin treated ischemic colon anstomosis group respectively (p = 0.019, p = 0.002). conclusions: amelogenin treatment could support the physical strength of ischemic colon anastomosis and effect oxidant/antioxidant response positively. introduction: meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, occuring in 2-3% of the population. in the majority of patients, meckel's diverticulum is asymptomatic. we report our experience with the management of complicated meckel's diverticulum in adults. methods: between april 2005 and january 2009, the data of seven patients (5 males and 2 females) aged 17-65 years who underwent surgery due to complications of mechel's diverticulum was retrospectively evaluated. results: of the seven patients, three presented with acute surgical abdomen, two had abdominal pain mimicking acute appendicitis, one had incarcerated incissional hernia, and one had intussusception. intraoperative diagnoses were as follows; littre's hernia in one, ileoileal intussusception due to meckel's diveticulum in one, diverticulitis in two, perforation of the diverticulum in three patients. while diverticulectomies were performed in five patients, two had small bowel resections. in addition to, appendectomy was performed in four patient. all the patient had an uneventful recovery except one, who experienced a postoperative wound infection. the hospital stay was 4-16 days. ectopic gastric mucosa was found in two cases. in one case, neuroendocrine tumor was detected in the appendix. conclusions: meckel's diverticulum is an uncommon cause of acute abdominal disease in adults. meckel's diverticulum presents distinctive challenges to a clinician, as it is prone to varied complications such as intestinal obstruction, diverticulitis, perforation. the diagnosis of meckel's diverticulum is difficult to establish preoperatively, and index of suspicion is necessary in patients with an acute abdominal illness. introduction: pneumatosis cystoides intestinalis is a pathologhy which is rarely incidentally seen and is characterised with submucosal or subserosal air cysts. there is no surgical indication in asymptomatic cases. surgical treatment is needed in the development of complication or the possibility of risk. a patient who is hospitalized with diagnosis of pyloric stenosis and is detected pneumatosis cystoides intestinalis incidentally at the operation is presented. case: 54 year old male was admitted our emergency department with vomiting weight loss complaints. pyloric stenosis was diagnosed by radiologic and endoscopic examination. he was hospitalized and acute abdominal signs developed. free air was detected in radiologic examination. surgery was performed. pyloric stenosis and pneumotosis cystoides intestinalis in jejenum were diagnosed. biopsy specimen was obtained from the cysts in jejunal serosa. subtotal gastrectomy, gastrojejunostomy and bilateral truncal vagotomy were performed for the pyloric stenosis. result and discussion: there is no surgical indication in asymptomatic cases. pneumotosis cystoides intestinalis commonly accompony pyloric stenosis and perforation of the cysts may bring out acute abdominal symptoms. knowing this pathology, we may avoid unnecessary emercent laparotomies. aim: in urgent surgical procedures for peptic ulcer perforation, there is considerable postoperative morbidity and mortality. this study aimed to describe and analyze the risk factors that determine beforehand morbidity and mortality in cases with perforated peptic ulcer. materıals-methods: age, sex, co-morbid diseases, symptom duration, abdominal air, amount of intra-abdominal liquid, location and diameter of perforation, operation, and the mannheim peritonitis index (mpi) score were prospectively analyzed in 128 cases. significant risk factors that cause morbidity and mortality were determined through a statistical study. results: the study sample consisted of a total of 128 cases (113 males and 15 females) with a mean age of 37 (range 20-84). duodenum and stomach perforations were detected in 93 and 5.5% of the cases. in 12 cases (9.4%), a total of 14 complications were detected. the mortality rate was 4.7%. statistical analyses revealed significant relationships between morbidity and > 50 age (p = 0.000), co-morbid disease (p = 0.006), perforation location (p = 0.010), type of operation (p = 0.011), and mpi score (p = 0.005). the factors significant for mortality included > 50 age (p = 0.002), co-morbid disease (p = 0.017), > 8 h of symptom duration (p = 0.07), > 500 cc intra-abdominal liquid (p = 0.047), a perforation diameter of > 0.5 cm (p = 0.001), omentopexy (p = 0.025), and a mpi score of > 21 (p = 0.000). conclusion: factors such as age, co-morbid disease, prolonged perforation duration, amount of intra-abdominal liquid, perforation diameter, type of surgical operation, and mpi score were significant for mortality. the present study found that primary suture is a safe procedure for cases with peptic ulcer perforation. introduction: the presence of foreign objects in the rectum is a rare encountered situation. these objects are usually inserted transanally or swallowed as foreign objects. this study was conducted to investigate the results of patients admitted to our clinic with a rectal foreign body. methods: data of 30 patients who admitted to our clinic between 1980 and 2008 were evaluated retrospectively results: mean age of the population was 51.3. the foreign object was taken out in the proctological position in 18 patients. in 4 patients these methods failed and laparatomy was performed and the objects were taken out transanally without colotomy. in three patients symptoms and signs of peritonitis were significant at admission and all of them were lost because of rectum perforation followed by septic shock. distribution of foreign objects was: six deodorant lids, five glass bottles, two aubergine, a glass, a salt cellar, a piece of plastic pipe, a vibrator, a plastic cover, a chocolate cover, a chicken bone, a fish bone, needles, a spiral, coins and key, a piece of thermometer, teeth prosthesis and soap. mortality was seen in three patients. the presence of foreign objects in the rectum is a rare encountered situation which should always be kept in mind for differential diagnosis. most of these objects can be taken out transanally. if this fails, all efforts must be shown to take it out without opening the colonic lumen. because of potential complications, the surgeon must be careful during intervention. median age of the alive was 54. median leukocyte number at the moment of appliance was 13.9, median debridement 2.6 and median inpatient stay were determined as 27 days. median age of the dead 63. median leukocyte number at the moment of appliance was 31.5, median debridement 2.5 and median inpatient stay were determined as 19 days. the most common reason of the aetiology was determined as perinal abscess. diversionary ostomy was applied to six patients. chronic kidney failure, and type 2 diabetes was exist in four patients of dead-group. in addition, in one patient type 2 diabetes and hypertension was observed. conclusion: chronic kidney failure related to hemodialysis and high level of lekucyte number at the moment of appliance are the important prognastic factors of deaths related to fg. computed tomography (ct) has become the mainstream of evaluating all hemodynamically stable patients with acute problems when the attending doctor, is urging for diagnosis. basing a diagnosis solely on radiological data sometimes ignoring medical history and physical examination may lead to unexpected errors. wrong interpretation of radiological images or images with equivocal findings which may delude the radiologist and technical errors (artifacts) are all potential sources of mistakes. the aim of this study is to draw attention to the danger of the modern imaging diagnostic modalities to misguide the treatment of patients who need emergency care. we present some cases we faced in our clinic where radiological images showed pathologic entities which in fact did not exist (false positive errors) but forced us to inappropriate treatment. two patients underwent negative laparatomies with imaging diagnosis of a ruptured gallbladder in one case and free air under the diaphragm in the other. a patient with a severe head injury and a ct scanning showing pneumocephalous was transferred to a tertiary centre to be proved on repeated images that initial diagnosis was mistaken due to a wrong calibration of the gantry. imaging findings do not necessarily represent reality. almost always surgeons rely on ct scans for treatment decisions. it is a hard task for a surgeon to question or ignore the pictures to treat a patient based on medical history and physical examination. experience of radiologist is essential and close cooperation with the attending surgeon is needed to avoid radiological misfindings in emergency cases. author to editor: to be presented as a poster. a full text is available on demand. intentional own insertion of rectal foreign bodies in a married, claimed to be straight male, using antidepressive medicaments because of sexual orientation disorder, resulted in resurgery with the same reason of mechanical intestinal obstruction after 7 years in the same surgery clinic by the same surgery team as an emergency intervention. failure of the nonoperative measures under local, spinal and general anesthesia led to the surgical treatment of the 54-year-old patient in 2002 and 2009, who is now 61 years old during the second event. large bottles were removed through laparotomies and colotomies followed by primary repair to reverse the ongoing ileus, which resolved on the 5th postoperative days in both events. a surgeon who is called to see a patient with retained foreign body should answer whether the patient had rectal perforation and whether the foreign body could be removed transanally without regional or general anesthesia with or without surgical intervention. in case of children; habitually self inserting objects in her vagina or sexually aggressive behaviour with others, e.g. for a boy ''humping'' toys in sexual positions can be a behavioural indicator of child sexual abuse or assault. hence message is: if in a patient perforation of sigmoid colon or rectum history after anal insertion of foreign body in an otherwise healthy adult becomes habitual,the patient should be send to psychiatric counselling. discussion of the nonoperative measures to remove rectally inserted objects is also an utmost important opportunity constituting the largest part of the report of the present case. necrotizing fasciitis is a highly morbid and mortal condition. as a result of aggressive debridement, wide tissue defects occur. wound cleaning from infective material, granulation process and grafting of wound requires a long time. recently, a vacuum assisted therapy system has begun to use for this kind of wounds. this study discuss the treatment result of vacuum assisted therapy (vac ò therapy tm ) in two patients with giant abdominal wall defect in view of current literature. case1: a 44 years old man had an operation because of an accident on railway. at the time of admission there was a wide defect with necrotizing fasciitis on the right lombar region and anterior abdominal wall. there was a full thickness defect about 40 · 30 cm after an aggressive debridement. it was successfully treated with vac and the patient has been discharged after tissue grafting on the postoperative day 85. case2: a 22 years old man had an operation because of an accident. he was admitted at postoperative day 4. he underwent an aggressive debridement because of necrotizing fasciitis. the skin, rectus abdominus, transversus abdominus, internal and external oblique muscles and some part of quadriceps femoris on the left side was excised. the sacroiliac joint was also broken and pubis was separated. vac abdomen has been applied on two different sites and the wound has become available for grafting after 65 days of therapy. as a conclusion, vacuum assisted therapy provides safe and accelerated wound healing, improves proper tissue granulation in patients with giant abdominal defect. introduction: bogota bag (bb) is a device used for the temporary closure of the abdominal wall (aw). despite its potential benefits, their use is not widespread and remains controversial in the present. aım: to describe our experience in its management for the temporary closure of the aw in emergency situations. methods: for a period of 4 years, bb has been used in 10 patients (pts), with an average age of 58.7 years. six had a secondary peritonitis, one tertiary peritonitis, two haemoperitoneum and one a compartment syndrome established. the technique consisted of the placement of a bag of sterile serum, stitched to the skin with nonabsorbable material. results: the average of bags placed by year was 2.2. no morbidity was associated with the placement and/or replacement of bb. the average time of hospitalization was 88.9 days and the average time of income in the icu was 26.2 days. in 5 pts, the bag was replacement one or more times. the average number of surgical interventions by patient during the income was 3.3. the average time of permanence of the patient with the bag was 22.4 days. sixty percent of patients are alive today. objectıves: the aim of the current study is to assess the role of ultrasonography in the management of acute appendicitis. methods: ultrasonography was performed to 318 patients with acute appendicitis suspicion between 2004 and 2008. appendectomy was performed to patients with acute appendicitis diagnosis according to clinical examination after ultrasonography. patients who had a diagnosis different from acute appendicitis with clinical examination were observed. the histopathological findings of patients with appendectomy were compared with their usg findings. results: 254 of 318 patients had acute appendicitis diagnosis by ultrasonography. hystopathological examination showed acute appendicitis in 242 of these patients. 12 patients did not have acute appendicitis. usg showed that 64 patients did not have acute appendicitis. ten of these patients showed gynecological pathology, and six of them showed urinary pathology, and they were all treated appropriately. in eight patients the appendicitis findings became evident in clinical observation; resulting in appendectomy, and histopathological examination showed acute appendicitis. forty patients showed improvement at follow up. no spesific treatment was needed. misdiagnosis rate was determined as 4.58%. the sensitivity, specificity, positive predictive value, negative predictive value and accuracy percentage of ultrasonography in the diagnosis of acute appendicitis was 96.8, 82.35, 95.27, 87.5 and 93.71%, respectively. conclusion: ultrasonography has a high degree of accuracy in the diagnosis of acute appendicitis. however, we also conclude that ultrasonography results should always be interpreted in combination with clinical findings. background: hydatid cyst disease is frequent in some regions of the world, including our country turkey, and is most commonly located in the liver and lungs. the hydatid cysts may rupture spontaneously or as a result of trauma. herein, we describe a rare case of retrovesical hydatid cyst which was resulted from rupture of spontaneous rupture of liver hydatic cyst intraperitoneally. case: fifty-four years old male was admitted to emergency department with complaints of frequent urination and abdominal pain lasting for 10 days. there was general abdominal tenderness on physical examination. there was no history of trauma or operation. in his abdominal ultrasonography and tomography there were primary cyst (11 · 6 cm), ruptured cyst (6 · 4 cm) and retrovesically located cyst (15 · 13 cm). indirect hemagglutination test was positive for echinococcus granulosus (1/4,096) . laparotomy was performed and all the cysts were excised by partial cystectomy. there was no postoperative complication. the patient was externalized on postoperative 5th day with albendazol treatment. conclusion: retrovesical localization of hydatic cyst is a very rare. these cysts mostly occur as a result of surgical inoculation caused by inadequate surgery or free intraperitoneal rupture of primary hydatic cyst. in endemic regions, possibility of hydatic cyst should be kept in mind in differential diagnosis of intrapelvic cysts and masses. background: wegener's granulomatosis (wg) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by involvement of the upper airways, lungs, kidneys and may rarely involve the gastrointestinal tract. intestinal involvement may be asymptomatic. we herein report a wg with massive lower gastrointestinal hemorrhage due to colonic involvement. case: the patient complained of dyspnea which started 2 months ago, fatigue, generalized arthralgia and myalgia together with loss of sensation on right upper extremity was applied to emergency and hospitalized by internal medicine department. physical examination revealed a very ill-looking patient, there were positive lung findings for wg and c-anca was positive. we consulted the patient because of hematochesia with abrupt drop of hemoglobin and platelet count. on colonoscopy whole mucosa was full with fresh blood from sigmoid to anal canal. on angiography multiple foci of bleeding were demonstrated on descending and sigmoid colon. embolectomy was not performed because of multiple foci. hemoglobin decrease continued and his clinical condition deteriorated; an explorative laparotomy and total left colectomy was performed. his melena persisted for 34 days but hemoglobin was maintained at 9 after 8 units transfusion after operation. conclusion: we herein report a case with clinical wg who developed a gastrointestinal hemorrhage and treated by surgery. the uremic state and cytotoxic agents given to patients may detoriated the gastrointestinal bleeding. immunosuppressive therapy might exacerbate gastrointestinal complications. the clinicians should be aware of this situation, therefore treatment of these must be performed in centers where angiography and endoscopy are available. background: the aim of this study is to determine the strength and proceeded efficiency of mda, sod, and catalase levels that are indicators of oxidative stress in generalized peritonitis. material-methods: this study was conducted as prospective and randomized with patients who applied at dicle university, department of general surgery between march-september 2008. patients were composed as group 1 (n = 50); generalized peritonitis, group 2 (n = 50); laparotomy under elective conditions and not present peritonitis; group 3 (n = 50) as control group. in order to measure limits of mda, sod, crp and catalase, blood samples were drawn from the patients in group 1 and group 2 on before operation day (bod), 1st and 3rd days. the mda values of group 1 on before operation day, 1st and 3rd days were compared to group 2 and 3, the difference were found statistically meaningful. statistical differences noticed between group 1 and 2 mda values on bod, 1st and 3rd days. statistical differences were noticed between catalase values measured bod and 3rd days when group 1 and 2 values compared to group 3. the sod values of group 1 and group 2 on 0 day were compared to group 3, meaningful statistical difference was found. statistically meaningful difference was found between the sod values group 2 and 3 on 1st day. conclusion: values of sod, mda and catalase were noticed usable parameters for the following and detection of severity of generalized peritonitis sinan cumhur karakoç, gü rkan yetkin, _ ismail ethem akgü n, mehmet uludag, bü lent ç itgez, hamdi ö zş ahin, cabbar kartal 1 1 general surgery departmet, ş iş li etfal training hospital, istanbul, turkey objectıve: we aimed to evaluate the effects of early cholecystectomy on morbidity and patient comfort in patients with acute biliary pancreatitis. methods: 58 patients who underwent cholecystectomy for acute biliary pancreatitis in our clinic between 2004 and 2009 were evaluated retrospectively. the patients were divided into three groups as early, late and elective cholecystectomy cases. fındıngs: 20 patients who had undergone cholecystectomy operation in the first 10 days until the administration to hospital were classified as the first group (early cholecystectomy). 12 patients who had undergone cholecystectomy between the 2nd and 10th weeks until the administration to hospital were classified as the second group (late cholecystectomy). 26 patients who had undergone cholecystectomy after 10 weeks were classified as the third group (elective cholecystectomy). in group 2, no patient had pancreatitis attacks; 8 of 26 patients in group 3 had recurrent pancreatitis attack in the preoperative period and treated in our clinic. in order of these data, age, height, weight, gender, sgot, sgpt, amylase, bilirubin and the time for waiting for the operation were compared and evaluated statistically. the time for waiting for the operation was found to be p > 0.001, and it was shown to be significant. results: there is a tendency to perform cholecystectomy in patients with acute biliary pancreatitis, after the acute attack is resolved. we believe that the early cholecystectomy prevents the patient from the additional morbidity in patients with acute biliary pancreatitis, by showing this with a statistically significant result in our study. traumatic right sided diaphragmatic hernia is clinically rare and may present with complications in a later period. on the right side presence of liver is thought to be a protective factor for both development of diaphragmatic injury itself and for its complications. we present a case of right sided diaphragmatic hernia due to blunt trauma, which was asymptomatic for 57 years and has been presented with intestinal obstruction. the patient, 76 years of male, has presented with intestinal obstruction and abdominal pain which has been relieved after nasogastric decompression. despite conservative treatment patient has not shown further improvement and has been operated on a semi-elective basis. significant part of small and large bowel, distal portion of stomach, and almost whole of liver had been herniated and reduced by right thoracoabdominal approach. 10 cm wide defect in diaphragm has been repaired with prolene mesh, laparotomy has not been closed and bogota bag has been applied. in the early postoperative period transaminase levels have increased 4,000 u, and ct-angiography has revealed patchy areas of low per-fusion in both lobes of liver. after therapeutic anticoagulation liver function has recovered completely, abdomen is closed and oral feeding commenced. at the 9th postoperative day respiratory insufficiency has occured after witnessed aspiration of gastric contents, followed by multiple organ failure. this case represents a quite late presentation of right sided traumatic diaphragmatic hernia, for which treatment was complicated. this case clearly shows the importance of detailed evaluation and timely treatment of all traumatic diaphragmatic hernias. cem ibis, dogan albayrak, fedayi calta, eren taskin, mehmet ali yagci, ahmet hatipoglu, irfan coskun 1 1 department of general surgery, medical faculty, trakya university edirne, turkey introduction: amyand hernia is first described by claduis amyand in london in an 11 year old male. it is a rare condition and described as appendix vermiformis in the hernia sac. we present a case of an incarcerated inguinal hernia with appendix vermiformis inside. case: sixty nine years old male with bulging and pain in the right inguinal region is evaluated. right inguinal hernia was detected. after opening the hernia sac, the appendix and ceacum were observed. lichtenstein procedure was performed. the patient was discharged in the second postoperative day. discussion: although the incidence of appendix vermiformis in the hernia sac is 0.5-1%, the incidence of acute appendicitis in the hernia sac is 0.13-0.62% in various reports. the treatment of amyand hernia is related to the appendix found inside. the application of appendectomy to normal appendix in routine hernia repair procedure is controversial due to infection risk. we do not routinely perform prophylactic appendectomy in such patients. we thought that a patient tailored approach is more acceptable. introduction and objectives: hydatid disease is typically asymptomatic. it can become symptomatic due to expansion, rupture or pyogenic infection. rupture of the cyst is the most common complication, followed by secondary infection, jaundice, and anaphylaxis. methods: in this study, we analyzed demographic and clinical characteristics of the cyst hydatic patients who admitted the emergency service due to complications of the cyst hydatic. the medical records of patients, with a final diagnosis of complicated cyst hydatic were reviewed for demographic information, admission symptoms, laboratory findings, evaluation techniques, and outcome. results: ten patients (7 men, 3 women) with final diagnosis of complicated ce (cystic echinococcosis) included the study. all of the patients had abdominal pain. while the pain was diffuse in the entire abdomen in seven patients, it was located in the right upper quadrant in three patients. patient's complaints were nausea, vomiting, jaundice, ileus and urticaria. the clinical signs and symptoms of hc rupture are not always severe, but hydatid fluid can irritate, which can cause peritonitis as occurred in our series of patients, all of whom had acute abdominal signs. in this study, 100% of the patients with ruptured ce had abdominal pain. thus, the clinical presentation of ce rupture is not always silent. the severe clinical presentation and infrequency of ce perforation has been held partially responsible for the misdiagnosis by the surgeon. conclusion: in conclusion; complicated hc may be admitted to emergency service with different clinical pictures especially in endemic regions and must be considered in differential diagnosis. background: to evalute the changes in the pattern of iatrogenıc bılıary injury and consequentıal effects on treatment strategy and outcome. methods: seventy-three patıents treated for iatrogenıc bılıary injury (ibi) between 2003 july and 2008 november at a tertıary care center in izmir, turkey were retrospectıvely analysed. results: underlyıng diseases were; missed tumor (n: 2, 2.7%), biliary surgery (n: 67, 92%) and hydatıc dısease (n:4, 5,3%). in recent years wıth a gradual increase in the avaılabılıty of endoscopıc and radiologial expertise the majorıty of patıents underwent extensıve preoperatıve diagnostic and therapeutıc procodures includıng endoscopıc retrograd panceratography for 26 cases(35.6%) and percutaneus transhepatıc cholangıography for 11 cases(16%). defınıtıve surgery was performed in all patıents except 9(12.3%) of them. roux-en-y hepatıco-jejunostomy was the primary reconstructıon technıque and performed for 35 cases (48%). there was only one (1.36%) hospıtal mortalıty. restenosıs developed in 2 (2.7%) cases and was reoperated. percutaneus baloon dilatation was faıled in three patıents as a fırst treatment optıon. none of patıents died of dısease related causes durıng the follow-up perıod. conclusion: increased experınece in laparoscopıc biliary surgery might be caused to attempt more challengıng cases and increased bılary tract injurıes. tolga kafadar, ercan gedik, sadullah girgin, bilsel baç, _ ibrahim halil taçyıldız 1 1 department of general surgery, dicle university, diyarbakir, turkey the aim our study was to determine the independent risk factors affecting patients with upper gastrointestinal hemorrhage who underwent surgery. materials and methods: the medical records of 62 patients with upper gastrointestinal hemorrhage who underwent operation were reviewed for variables including age, gender, shock, association with co-morbidity, pulse rate, hemoglobin levels, white blood cell count, serum urea, creatinine, sodium and potassium levels, time of opera-tion, number unit of blood transfusion, rockall risk score and length of hospital stay. in order to determine the independent risk factors mortality and morbidity, we carried out entered logistic regression analysis. results: morbidity and mortality rate were 35.4% (22 patients) and 29.1% (18 patients), respectively. the independent risk factors affecting morbidity were serum albumin level [odds ratio (or) = 1.442, 95% confidence interval (ci) = 1.060-1.962, p = 0.020] and rockall score ‡ 5 (or = 0.027, ci = 0.001-0.690, p = 0.029), and the independent risk factors affecting mortality were advanced age (or = 1.048, ci = 1.008-1.090, p = 0.0189), and high rockall score (or = 0.578, ci = 0.370-0.903, p = 0.016). conclusion: to decrease the postoperative morbidity and mortality rates in patients with ugih requiring surgery, patients preoperative risk factors should be demonstrated. we believe that establishment of interventional indication on time and evaluation of intraoperative surgical region and technique in combination with the patient-and disease-related factors in patients requiring surgery would help reduce morbidity and mortality rates. blunt thoracic trauma leads to various clinical conditions, such as hemothorax, pneumothorax, pulmonary contusion, and respiratory tract hemorrhage. especially, respiratory tract hemorrhage resulting from pulmonary contusion is so critical to require a clinical challenge. of our experienced survivors, 3 trauma victims (male 3/3, 19-23 years old) with blunt thoracic trauma associated with motorcycle accident were transferred to our emergency departments. they similarly suffered respiratory failure (average respiratory rate of 32) and hypotension (average shock index of 1.2) on arrival. immediate after the rapid-developing respiratory failure in relation to lung contusion and endobronchial bleeding, bronchial blockade device and extracorporeal membrane oxygenation (ecmo) were urgently introduced at an average of 32 and 104 min, respectively, and achieved rapid resolution of their respiratory crisis. all of them withdraw from ecmo within 5 days. pulmonary contusion sometimes follows fatal progress, and we consider that quick bronchus blockade and ecmo introduction is the key of survival. emergency departments (ed) in greece are incorporated to the departments of the hospital and are divided in two major areas: one for internal medicine and one for general surgery. every patient has free access to the (ed). the workload and the conditions treated in ed in greece are geographically and social -economically depended. the national health system is represented by one hospital for each prefecture. the general hospital of trikala, is categorized as an urban hospital, with 300 beds, and is covering a population of approximately 150,000 people, living in the town and in villages situated in the surrounding mountain area. the department of general surgery is stuffed by 8 general surgeon specialists and seven residences. during 2008, 15,833 patients were examined in the surgical ed. in this study we analyze the characteristics of the patients, the number and causes of admissions in the various departments of our hospital and also the transferals to a tertiary center. aim: pneumotosis cystoides intestinalis is a rare entity, and may be associated with pyloric stenosis. materıals-methods: data of a patient operated for pyloric stenosis and pneumotosis cystoides intestinalis in our institution are presented. results: patient was a 50 year-old addicted male, and his body mass index was 18.5 kg/m 2 . he had been suffering from nausea/vomiting, bloating and constipation for a few months. a gastroscopic examination revealed atonic gastric dilatation, duodenal ulcer and related pyloric stenosis, and positive serology for helicobacter pylori. an eradication treatment in conjunction with long term proton pomp inhibitors were given, however the patient readmitted to our department with worsening symptoms including vomiting, pain and weight loss after 2 months. repeated gastroscopies and gastric meal x-ray examination revealed pyloric stenosis and the patient decided to have an operation instead of repeated medical treatment. during laparotomy, subserosal foamy air bubbles were observed on the serosal wall of ileum. a partial resection of ileum was necessitated for the suspicion of perforation. vagotomy with finney pyloroplasty was performed in order to cure the pyloric stenosis. the postoperative period was uneventful and the patient was discharged from the hospital on day 8. the patient has not have a recurrence, gained weight and have no problem since 2 years postoperatively. conclusion: pneumocytosis cystoides intestinalis may be observed in the presence of a pyloric stenosis and necessitates resection if any doubt for perforation is present. granulosus. in this study, a rare appearance of the disease is presented as an abscess located in the retroperitoneal space. results: the patient was 75 years-old male with several comorbidities admitted to our emergency department with fever and left lumbar pain. he had had operated for hepatic hydatid disease 20 years before the admission. physical examination revealed local tenderness and slight hyperemia on his left lumbar region. his laboratory findings showed leucocytosis, and a computed tomography demonstrated a huge retroperitoneal abscess located between spleen and pelvic entrance and denied any pathological finding regarding to the left kidney or adrenal gland. since the general condition of the patient did not allow an operation under general anesthesia, the abscess was drained through a 7 cm long incision located on the hyperemic area under local anesthesia. after complete removal of the abscess and daughter cysts, a drain was left behind, and removed on day 7. the patient was discharged out of hospital on day 2, after an uneventful recovery period. discussion: to best to our knowledge, this is the first hydatid disease case presented as a retroperitoneal abscess in the literature. hydatid disease may be kept in mind as a differential diagnosis in the presence of a cystic retroperitoneal mass in endemic regions. ali uzunkö y 1 , zekeriya sayın 2 1 harran university school of medicine department of general surgery, sanliurfa, turkey 2 osm ortadogu hospital, sanliurfa, turkey introduction and objectives: giant true splenic artery aneurism is rare lesions. these aneurisms have risk of rupture and bleeding. we have performed a giant true splenic artery aneurism. case: the case is a 38 year old female patient. she applied to hospital with complaints of abdominal pain. at the physical examination, there were a moderate splenomegaly and a pulsatile mass in the left upper abdomen. it was shown a giant splenic aneurism at the abdominal computed tomography and colour doppler ultrasonography. colour-doppler abdominal ultrasonography showed about 50 mm splenic artery aneurism. computed abdominal tomography showed a hypo dense mass situated anterior and superior to the pancreas tall and corpus extending up to the splenic helium. the diagnosis was confirmed by ct angiography. the patient was performed with general anaesthesia and left subcostal incision. at the exploration, splenic arterial dilatation and aneurismal sac was shown and aneurysmectomy with splenectomy was performed. there was no complication intraoperatively and postoperatively. the patient was discharged at the postoperative fifth day. there was no complaint at the control examination at the fifteenth day after discharging. conclusions: although giant splenic artery aneurism is rare, but they have risk of rupture and bleeding. there are two options for treatment of these lesions. one of them is aneurysmectomy. it is frequently performed with splenectomy. other option is embolisation. in our opinion, surgery for giant splenic artery aneurism is performed successfully without important complication. author to editor: saved by lookus introduction: an association between the administration of paracetamol and relative hypotension in critically ill patients has been reported by the staff working in the surgical and trauma intensive care unit of istanbul faculty of medicine. methods: a prospective, observational study was undertaken to investigate the effect of paracetamol on systemic blood pressure in two groups of critically ill patients. a dose of 500 mg of paracetamol was administered intravenously to both groups in 15 min time. blood pressure, heart rate were recorded at baseline, at the end of infusion and then at 15, 30, 60 min after administration. the differences occured over the observation period was measured by friedman analyse. results: twenty-eight patients with sepsis, were enrolled to group-1 (anti-pyretic effect) and 20 postoperative patients were enrolled to group-2 (analgesic effect). analysis of data from all patients showed that systolic arterial pressure (sap) and mean arterial pressure (map) were reduced significantly over the observation period in both groups (sap:p < 0.001 for both, map:group-1 p < 0.05, group-2 p < 0.001). sap and map in group-1 and group-2 decreased by an average of approximately 7 and 10% respectively. however, no significant decrease in dap was noted in group-1. conclusions: utilization of the intravenous paracetamol for febrile and/or postoperative patients caused a significant decrease in systemic blood pressure after administration. this drug-induced hypotension was clinically relevant to control the required blood pressure. thus, clinicians should be aware of this potential effect, especially in critically ill patients. yazile sayın 1 1 faculty of health, surgical nursing division, cumhuriyet university, sivas, turkey background: pain is considered one of the most important symptoms which guide diagnosis, treatment and nursing care in the emergency departments. aım: to discuss pain evaluation by nurses in emergency departments and to attract attention towards nurses' responsibility for pain evaluation. methods: qualitative and quantitative data from 18 studies on pain evaluation by 520 nurses were evaluated. results: all studies reviewed showed that about three fourths of the nurses in the emergency departments did not make pain evaluation based on the standards (using pain rating scales, reporting the conditions likely to affect pain evaluation etc.). the nurses included in 10 studies assigned significantly lower scores for pain than the researchers(p < 0.05;p < 0.001). all studies revealed the following reasons why triage nurses did not play an effective role in pain evaluation: insufficient knowledge, the idea that doctors are responsible for pain evaluation, doctors not appreciating the value of pain data provided by nurses, insufficient cooperation among members of the health staff, work overload, time constraints, errors in reporting data on pain evaluation and conflicting attitudes and beliefs concerning pain evaluation. it has been reported that only 30-40% of the patients presenting with pain to emergency departments received effective pain management. the most important reason for this low rate has been shown to be deficiencies in pain evaluation due to insufficient multidisciplinary cooperation. conclusion: it can be concluded that nurses in emergency departments are not efficient enough to use interventions which help to evaluate pain for effective pain management. introduction: diverticulosis of the colon is a common condition. complications of diverticulitis often require surgery. perforated diverticulitis may rarely present with spreading superficial sepsis. case: male, 54 years, history of chronic depression. admitted in the emergency department after a 15-day history of abdominal pain in the left lower quadrant (llq), associated with asthenia, anorexia and weight loss, without diarrhea, constipation or fever. the patient examination showed edema and thickening of the abdominal wall with swelling and redness in the llq. blood chemistry revealed leukocytosis with neutrophilia and elevated c-reactive protein. a diabetic ketoacidosis was diagnosed. the abdominal ct confirmed abdominal necrotizing fasciitis with an abscess, without other intra-abdominal changes. the patient was then submitted to emergency surgery with debridement of the necrotising fasciitis and drainage of the abscess. he was admitted to the icu. further debridement was necessary 48 h later. at d6, fecal contamination of the wound was detected, leading to a subsequent laparotomy with identification of a sigmoid inflammatory mass attached to the site of the fistula's external orifice. a hartmannprocedure was performed (histology confirmed the diagnosis of perforated diverticulitis). the patient developed a sirs complicated with a right-side necrotizing pneumonia requiring multiple antibiotic treatment and pulmonary decortication. death occurred at the 54th hospitalization day. conclusion: necrotising fasciitis as a consequence of perforated diverticulitis is an uncommon but potentially lethal condition requiring prompt surgical intervention. when accessing an abdominal necrotising fasciitis without recognisable source, an elevated index of suspicion is necessary to link it to complicated diverticulitis. fatih baş ak, kü rş ad ö ztü rk 1 1 tc sb bozkir community hospital introduction: care of trauma patients may be difficult in small community hospitals. these hospitals are usually staffed by a small number of general practitioners and, perhaps, a general surgeon, and a significant number of trauma cases are brought to them. the records of minor and major trauma patients who admitted to bozkir community hospital between june 2007 and december 2008 were evaluated. mortality and transfer rate were recorded. general surgeon was not present in first 12 months. the rates of last 6 months when general surgeon has been present were calculated separately. results: 738 trauma patients were admitted in first 12 months 139 (18.83%) of these were transferred to larger centers. treatment of remaining 599 (81.16%) patients continued in our hospital. mortality rate of first 12 months was 0.6%. three patients requiring immediate surgery died because of absence of general surgeon. 898 patients were admitted in last 6 months. 147 (16.3%) of these were transferred to larger centers. mortality rate of last 6 months was 0.3%. three gunshot wound and one penetrating cardiac wound patients were saved with emergent surgery. conclusions: regardless of the sophisticated techniques for dealing with trauma that exist in larger centers, it is the staff of smaller hospitals that often shoulder the initial burden of trauma care. transfer rate is between 16 and 18% of all trauma cases. our hospital is 1.5 h away from larger centers. presence of general surgeon in last 6 months mainly affected the care of patients that requiring immediate surgical attention. metin kement, hakan acar, ilhami soykan barlas, uygar dü zci, cem gezen 1 1 burn center, kartal education and research hospital, istanbul, turkey aim: fecal contamination which may result in septicemia, graft loss and wound healing delay is the most serious problem for burns in perineal, gluteal and upper thigh regions. temporary fecal containment devices can be used for diverting feaces from burned area. the aim of this study was to evaluate early results of using of these devices in our burn center. methods: twelve patients, who were applied temporary fecal containment devices in our burn center, were retrospectively evaluated in this study. results: 7 (58.3%) of the patients were male.the mean age was 37.33 ± 17.34 year.the mean tbsa burned was 32.08 ± 14.05%. 6 (50%) of the patients had burn in all three regions (perine, gluteus and upper thigh). three (25%) of the patients had burn in upper thigh. and 3 (25%) of the patients had burn in gluteal region. the devices were placed intra-rectally on the first admission days of all patients.the mean application time was 14.25 ± 4.51 days. except minimal fecal leakage in 2 (16.7%) patients, any complication was not observed in our cases. local infection confirmed by tissue culture was observed in 4 (33.3%) patients including two patients with fecal leakage. besides, in one of these four patients, septicemia was developed and managed successfully with antibiotics and supportive treatment in intensive care unit of our center.one patient with 70% burn was died on 5 days of application due to multiple organ failure. conclusion: temporary fecal containment devices aim to protect patients' wounds from fecal contamination by diverting feaces. if the safety of these device is proved in further studies, they may reduce the necessities of diverting stoma operation in burn patient. metin kement, ilhami soykan barlas, uygar dü zci, hakan acar, cem fazlı gezen burn center, kartal education and research hospital, istanbul, turkey aım: reactive thrombocytosis which develops secondary to infection, trauma, malignancy or surgery is the most common ethiology of thrombocytosis. although thrombocytosis is a benign and self-limiting condition in most cases, it may result in some thrombotic and hemorrhagic complications. the aim of this study was to evaluate the reactive thorombocytosis in burn patients. material: thrombocyte counts was retrospectively evaluated in 158 consequent burn patients admitted to our burn center between august 2008 and january 2009. the correlations between thrombocyte counts and demographic data, total body surface area burned (tbsa), hospitalization time and levels of some acute phase markers also analysed. results: the mean thrombocyte counts were respectively 317.910 ± 150.380/mm 3 , 379.750 ± 174.430/mm 3 on admission day and second day (p < 0.05). the number of patients with thrombocytosis was 25 (14.6%) in admission, 21 (84%) of them were children. the rate of thrombocytosis was 21/63 (33.3%) in children,whereas the rate of thrombocytosis was only 4/95 (4.2%) in adults (p < 0.001). the mean thrombocyte counts in children and adults were respectively 400.520 ± 175.920/mm 3 , 250.330 ± 77.900/mm 3 in admission (p < 0.001). the mean wbc count was significantly higher in patients with thrombocytosis than patients with normal thrombocyte count (p < 0.05), but there was not any significant difference in crp count (p = 0.58). and also,we did not find any significant difference between patients with thrombocytosis and patients with normal thrombocyte count in tbsa and hospitalization time (p = 0.690 and 0.895, respectively) conclusion: reactive thrombocytosis is seen more frequently in burned children than burned adults and mostly unrelated to degree of burn. background: electrical injuries are related with multiple organ dysfunction as well as high morbidity and mortality. pulmonary compromise is rare, if compared to other organ dysfunctions related with electrical injuries. in this study, we presented a case with pulmonary hemorrhage associated with electrical injury. case: a 24-year-old previously health man was brought to our emergency department (ed), 1 h following the accident, with electrical injury. initial examination findings were blood pressure 80/ 40 mmhg, heart rate 79/min, respiratory rate 37 breath /min. glasgow coma score was 3. decreased breath sounds, bilateral rales and wheezing were determined. there were small necrotic wounds (typical contact injury) on the first finger of left hand and under the right foot of patient. there was no trauma in thoracic wall. blood gas analysis revealed respiratory and metabolic acidosis. the inr and platelet levels were normal. when chest radiograph and thoracic computed tomography were assessed, air bronchograms and symmetric consolidations were determined in the both lungs. patient was intubated and fresh blood was aspirated from endotracheal tube. mechanical ventilatory support was performed the patient due to lung hemorrhage and respiratory failure. patient died after 4 h of admission in the ed. conclusion: multiple organ dysfunction and necrotic skin lesions could be occurred in electrical injuries. electrical injuries on the chest may cause lung infarction because of the direct effect of the electrical current and vascular embolism. possibility of lung injury should be investigated after electrical injury especially in patients with respiratory failure. nebahat yıldız 1 , aysel gü rkan 2 , _ imren aş ar 1 , ayş e hale uysal 1 1 trauma and emergency surgery service,istanbul university, istanbul faculty of mediine, istanbul, turkey 2 health science of faculty marmara universty, istanbul, turkey introduction and objectıve: the outcome of burn treatment is measured not only by mortality and morbidity, but also by post-burn psychological factors. the purpose of this study was to investigate whether difference in length of hospitalization exist between burn patients with and without mental health problems and if so, why. methods: the descriptive study was retrospective review of 448 patient with burn injuries who had received care at one burn unit in the istanbul from october 2004 to december 2008. socio-demographic features of patients, burn criteria (kind, depth, size, location), duration of hospital stay, and psychological problems were tabulated. results: psychological impairment was found in 69 of 448 hospitalized burn patient. there were acute stress disorder in fifteen patient, anxiety in nine, adjustment disorder together with anxiety in eight, depression in seven, post-traumatic stress disorder in six patient. fortyone (59.4%) patient had burns which were between i and ii degree and 28 (40.6%) patient had burns which were between ii and iii degree. in 44 patient, burned area has been 21% or more. patients with psychologocal impairment were longer hospital stay and intensive care unit than patients without psychologocal impairment. sixty-four (92.7%) patients with psychologocal impairment had been discharge either getting better or recovering completely but unfortunately 5(7.2%) patients died. conclusion: the presence of psychological problems in burn patients have an impact on their burn care. psychological interventions can contribute towards successful outcomes. introduction and objectives: major burns can cause disseminated intravascular coagulation (dic) and is a serious clinical problem. we would like to present 2 dic cases whose burn rate is 40% according to total body surface area (tbsa) which developed after late postoperative period. methods: two cases over 40%, 2nd and 3rd degree burn injury admitted to our facility. first case who was 9 year old female developed s. aureus and second case was 18 years old female developed p. aeruginosa sepsis which was confirmed by blood culture. in first case dic developed at postburn 18 day and in second case at postburn 26 day. in both cases dic developed after postsurgery day 7. results: on patients, bleeding points, as leaking, were detected on all over burn areas. at the same period thrombocyte values decreased sharply (88.9 k/ul). increase in prothrombin time (pt) (38.2 second) and active partial thromboplastin time (aptt) (108 second) values, decrease in fibrinogen levels was observed. cases were discharged from hospital in 35th day, without any problem. patient was taken for 9 iu erythrocyte suspension and 6 iu platelet suspension in this time totally. conclusion: dic occurs in early period of burning; but it can be formed in later periods, even after defects were recovered by operation. rapid establishment of dic table just before the discharging term from hospital is an unusual and interesting situation. the patients in our study can be accepted as an example of the necessity of observing coagulation parameters in every periods of burn damage. methods: sphere project handbook reviewed by experts in the field of each section, the terms of our country's adaptation has been made. within the framework of the project dissemination, sphere workshops have been organized in various provinces. the ppt slides were adapted to turkey's needs. the project's outcomes have been observed through the pre-post tests and the workshop evaluation forms. results: expert review and the end of the first study, with a high risk of disaster in our country, the handbook was understood to be necessary and useful. in addition to this, the control lists in details but useful and also, the summary tables are useful to take a decision in emergencies. it is also understood that preliminary results from the project is compatible with literatur data. conclusions: developed in each country is adapting to the local experience of the sphere, significant experience with disasters in our country the right to contribute are welcome. indeed, the first application of the new approach by the sphere project's coordination center is monitored with interest. introduction: (1) initial assessment of trauma patients is a period with a high frequency of treatment protocol deviations and an elevated number of avoidable complications. (2) the majority of medical errors are diagnostic or cognitive, whereas operative technical complications accounted for less than 8%, and (3) general surgery residents (gsr) do not feel well-trained on the management of major trauma patients. aim: describe initial experience with one approach to foster quality improvement in trauma care modifying the method by which we train surgeons. methods: we integrated in the gsr program, simulation based training sessions with other educational tools as lectures and workshops. the scenario objectives were based on research data indicating major deficiencies in trauma care (tc). we incorporated team training and crisis resource management sessions. to review trauma life support diagnostic and therapeutic standardized protocols we run scenarios to train initial assessment, and head, thoracic and abdominal trauma. after every clinical case, residents participated in a video assisted debriefing session leaded by a specialized instructor. an evaluation interview was made after the course. results: all resident viewed the experience as a ''very good'' training modality. many of them felt their time was better spent in the simulator session than in the operating room, and wanted to do it more often or in a scheduled way. some of them complained about evaluating the mannequin and the equipment when compared to the one in their actual work setting. conclusions: integrating patient simulation with traditional surgical training may strength the approach to tc education. introduction: pulmonary embolism is a life-threatening condition and its diagnosis is generally based on clinical suspicion. case: a 34 years old male had been admitted to another hospital with acute dyspnea and syncope and after initial evaluation he had immediately been undergone an operation due to epidural hematoma. he was referred to our emergency department with early diagnosis of acute coronary syndrome after operation because intraoperative and postoperative tachycardia could not be controlled. in his physical examination gcs: 15, arterial blood pressure 120/ 80 mmhg, heart rate 180/min and breath rate 25/min. ecg, echocardiogram and thorax ct findings complied with pulmonary embolism. venous doppler ultrasonograpy findings complied with chronic deep venous thrombosis. thrombolytic or antiaggregant medication could not be started because of epidural hematoma operation. at postoperative 72 h low molecular weight heparin and at 96 h warfarin was administered. in follow-up period his symptoms regressed and there was no complication due to epidural hematoma surgery. he discharged from hospital at day 15. conclusion: in trauma patients, one of the important issues that have to be considered during clinical evaluation is the primary reason leading to trauma. in this case, the investigation for syncope etiology revealed the haemorrhage and thrombus diagnosis concomitantly. these two diagnoses have opposite treatment strategies and due to this condition we had difficulty in management of the patient. although there are intracranial haemorrhage cases due to pulmonary embolism treatment (thrombolytic or antiaggregant), a similar case report cannot be found in the available literature. introduction and objectives: different societies have different type of snake bites. _ in our actually series, two patient from u.k. and seven patients from south-eastern part of turkey presented with lıke compartment syndrome result of was bitten by a snake to their fingers. methods: four of nine patients applied to our clinic at the day of event, the other five were referred to us after the emergency treatments have been done. all bites were over or distally to the pip joint. after being bitten by snake, patients admitted to our accident and emergency department because they had like as compartment syndrome on the forearm. two of the patients were referred to us very late stage and one of them had partial necrosis and the other had total necrosis already. none of patients had signs of systemic envenoming. results: two patients with local swelling and no other symptoms were discharged. coverage of the defects were performed with full thickness skin grafting in two patients, cross-finger flap in one patient, reverse dorsal digital arter flap in one patient and dorsal interosseous metacarpal flap in two patients. one patient had amputation. none of patients had fasciotomy. conclusions: this study represents the clinical effects and current approaches for the treatment of snake bites to distal finger. all patients presented with compartment syndrome like symptoms on the hand or forearm. these patients should be followed-up very closely. final wounds should be closed either with skin grafts or local flaps. simultaneously, systemic envenoming should be considered. the aim was to evaluate the geriatric patient with abdominal pain in emergency department (ed). methods: the preliminary retrospective study included the period between january 1 and june 30, 2008, ankara. data were achieved from registration notebooks, manually. the patients separated within age to three groups as 65-74, 75-84, 85 and over. the finalization of management, hospitalization, operation rate, mortality were studied. results: there were 113 (0.63%, annually) patients. the mean age was 74.8 ± 7.0 (65-100), the mean hospitalization duration was 6 days (1-23). the sex and the age of patients can be seen in table 1 . 46.02% (n = 52) of them discharged from ed. abdominal ct and usg usage were 33.62% (n = 38), 38.06% (n = 43) in ed. 0.97% (n = 11) patients had both ct and usg. abdominal ct and usg results are showed in tables 2, 3. finalization of patient management was demonstrated in table 4 . the operation rate for all patients was 33.33% (n = 13). general surgery hospitalization and operation rate were 33.63 and 10.62% (n = 38, n = 12). the mortality rate was 7.69% (n = 3) in admission. there were not any significant difference between the groups of 65-74 and 75-84 according to sex, finalization, ct, usg utilization, operation rate (p = 0.866, p = 0.135, p = 0.786, p = 0.822, p = 0.3120) with spss 15 x 2 test, while the number of advanced geriatrics was unsuitable for statistics. conclusions: females and the 65-74 age group were common with a complaint of abdominal pain in ed. most of them had hospitalization indications and the primary yard was general surgery with brid ileus. mortality rate was lower than 10% introduction: nontraumatic epigastric and left upper caudran pain is a common complaint in emergency department. it can include lifethreatened various reasons as cardiac, respiratory, and serious gastrointestinal problems, rarely. case: a 47 year old man had an emesis with recurrent epigastric and left upper caudran pain admitted as second turn to ed in 24 h. physical examination except a slight epigastric sensitiveness, ekg, urine test and biochemical tests, complet abdominal ultrasonography, x-rays were nonspesific on the first day. wbc was 12.2 on cbc. his complaints relieved with semptomatic treatment with an 50 mg ranitidine, 10 mg metoclopramide, serum sale on his observation and discharged with suggestions. in second admission with nonspecific physical examination findings, computerized tomography (ct) revealed splenic unenhanced parenchymal areas consistent with splenic infarcts. computerized tomography angiography (cta) showed a small aneurysm of the celiac trunk, a characteristic pattern of caliber irregularities and arterial wall thickening of the splanchnic arteriesincluding splenic artery, common hepatic, right and left hepatic arteries-, suggesting splanchnic arterial mediolysis (figures 1 and 2 are presented with permission of patient's written consent). he was hospitalized to general surgery and started low molecular weight heparin. as clinical and radiologic findings were degrated, he was discharged without an operation. conclusions: splanchnic (segmental) arterial mediolysis is a rare noninflammatory vascular disease of the abdominal splanchnic arteries with slight symptoms. ct for vasculary and internal organs should be performed to diagnose in recurrent complaints beside observing the physical findings. introduction: it is well documented that healing of peptic ulcer perforation (pup) is possible with conservative therapy in selected cases. thus a spontaneously closed pup diagnosed at exploration may not require surgical repair. methods: study included three patients in which diagnostic laparoscopy suggested spontaneously closed pup between 2007 and 2008. suggestion criteria were; fibrin cloth on duodenum with or without subhepatic fluid collection, no visible perforation, otherwise normal exploratory findings. omentum minus was dissected and cautiously observed. the stomach was filled with 500 ml diluted methylene blue fluid via nasogastric tube, operation table was tilted to right and up, a gentle pressure on the stomach was made with the shaft of laparoscopic irrigator to fasciculate the passage while the descending section of duodenum was compressed with the shaft of a grasper. duodenum was cautiously observed for 10 min to detect dye leakage in all patients. if no leak was observed, operation was terminated after abdominal irrigation and inserting a catheter to the subhepatic area. therapy for pup was given postoperatively. results: all patients were male and the mean age was 32 (26-42), no leak of dye was observed at operation. nasogastric tube was removed and food intake was allowed at postoperative second day. all patients were discharged on third day. conclusion: although the perforation site is almost always identified at operation, to meet a spontaneously closed pup is also possible. irrigation and drainage alone may be sufficient for these cases after blue dye test as described in this study. the complicated appendix with/without abscess was delivered through the umbilical incision for an open technique safely. this gave our patients the maximum benefits of the minimally invasive surgery with better visualization, reducing equipment needs, less postoperative pain, rapid discharge, no postoperative infections, and excellent cosmetic results. all patients were quite satisfied during follow-up. conclusions: it is concluded that hybrid appendectomy seems to be feasible and reliable for children with complicated appendicitis not suitable for conventional laparoscopic technique. vata was successfully accomplished with obvious advantages, and avoided conversion to the open fashion. background: appendicectomy remains the most frequent emergency operation. the management of these patients varies between surgeons and hospitals. at our centre, it was a routine to review post operative children at 3 months. aims: is to evaluate the need for a routine follow up in children who had appendicectomy. methods: it is a retrospective observational study for 100 consecutive patients between 2006 and 2007. a parallel questionnaire was sent to the parents of all the children. results: the average age was 11.6 years. 14% of the patients were found to have normal appendices. 70% of the patients were discharged within 2 days. 37% of the patient had intravenous antibiotics for 1 day and 15% were discharged with oral antibiotics. 94% had a routine follow up appointment in 3 months time. in 88% of cases there was no change in the management. on the questionnaire 85% of the parents thought they were given enough information regarding the procedure. in terms of routine follow ups, 68% of the parents found it very useful while 19% found it a little or not useful. conclusion: this study shows that there is no change of the management or a clinical need for the routine follow up. however the patients and their families like to keep a follow up appointment. it is more convenient for the patients and their family to arrange other sorts of follow up like a phone call conversation or a general practitioner follow up. yavuz savaş koca, mustafa ugur, celal ç erçi, recep ç etin 1 1 department of general surgery, sü leyman demirel university, isparta,turkey the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was 0.72, and mean age was 72.3. main causes were biliary system disease (34.1%), intestinal obstruction (27.1%), peptic ulcer perforation (17%) and acute appendicitis (14.4%). median asa class was 2 and 73.6% of the patients had at least one preexisting disease. mortality ratio was 19.4%. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly efective on mortality. 438 reliability of ultrasonography for diagnosing acute appendicitis aylin hande gö kçe 1 , acar aren 1 , feridun suat gö kçe 2 , hakan ö zkan 1 , alper dursun ş agban 1 , _ ibrahim aydın 1 , gü rhan ç elik 1 , gü rol kö roglu 1 1 s.b. _ istanbul eg itim ve araş tırma hastanesi, istanbul, turkey 2 balıklı rum hastanesi, istanbul, turkey purpose: abdominal ultrasonography is the most commonly used diagnostic tool for diagnosing acute appendicitis,which is one of the most common causes of acute surgical abdomen. _ in this study, we examined the reliability of ultrasonography for diagnosing acute appendicitis. in this prospective study we performed abdominal ultrasonography on 235 patients admitted to our surgical emergency department and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings during 2007. these patients were surgically treated by appendectomy and the materials were pathologically examined. results: 235 patients were admitted to this study.193 of these patients (82.1%) were diagnosed as acute appendicitis, and 42 (17.9%) of them diagnosed differently. 133 (88.67%) of 150 patients diagnosed as acute appendicitis on ultrasonography examinations were reported as acute appendicitis on histopatological examination. 60 (70.58%) of 85 patients diagnosed differently on ultrasonography examination were reported as acute appendicitis on histopathological examination. conclusion: the sensivity of abdominal ultrasonography for diagnosing acute appendicitis is high (89%), but the specificity is low (p = 0.01). we calculated that the specificity is 0.29, positive predictive value is 0.69, negative predictive value 0.60, accuracy is 0.67. abdominal ultrasonography is a helpful diagnostic tool for diagnosing acute appendicitis.however, it should not be seen superior to anamnesis and physical examination findings. poisoning: a case report background: mushroom poisoning is an important clinical problem which may cause serious complications and death. acute pancreatitis is a rare complication of mushroom poisoning. in this study, we presented a case that developed liver damage and acute pancreatitis following wild mushroom ingestion. case: sixty-six years old women admitted to emergency department with complaints of nausea, vomiting and abdominal pain. it was learned that patient was ingested wild mushroom before 24 h of admittance and her complaints were started after 2-3 h of ingestion. in initial examination, general appearance and vital signs of patients were normal and there was epigastric discomfort. laboratory findings were leukocyte 5,300/ll (4.1-11.2), aspartate aminotransferase 235 u/l (8-46), alanine aminotransferase 193 u/l (7-46), amylase 529 u/l (28-100), lipase 1,090 u/l (13-60) on admission. liver and pancreas was determined as normal in abdomen ultrasonographic examination. computerized tomography of the abdomen showed minimal peripancreatic fluid. the patient was observed in emergency intensive care unit and symptomatic therapy was performed. hepatic transaminases and pancreatic enzymes were decreased progressively during the observation. the patient was discharged from the hospital after 5 days clinical course, without complication. conclusion: mushroom poisoning and acute pancreatitis have similar gastrointestinal symptoms and sings. therefore, possibility of acute pancreatitis as well as other organ dysfunctions should be investi-gated in patients with mushroom poisoning. early recognition and appropriate therapy for acute pancreatitis and mushroom poisoning may lead to an improved prognosis and complications. mehmet mustafa altıntaş 1,2 , ayhan ç evik 1,2 , yekin ö zcabı 1,2 , gü lay dalkılıç 1,2 , hü seyin ekinci 1,2 , nejdet bildik 1,2 1 dr. lü tfi kırdar kartal education and training hospital, istanbul, turkey 2 general surgery clinic, istanbul, turkey diagnostic emergency laparoscopy is very helpful in diagnosing acute abdomen and evaluating abdominal trauma. parallel to developments in laparoscopic techniques, its emergency applications are increasing. we reviewed our diagnostic emergency laparoscopy procedures applied to patients with acute abdomen and could not be diagnosed after 24 h of follow-up. we applied diagnostic emergency laparoscopy to 24 patients in dr. lü tfi kırdar kartal education and training hospital during 2007-2008. in 15 patients laparoscopy indication was undiagnosed acute abdomen. there were four acute appendicitis, two peptic ulcus perforation, two small bowel necrosis, one perforated hepatic hydatid cysts, one iatrogenic urinary bladder perforation, one postlaparoscopic cholecystectomy bile fistula and 4 non-surgical adnexial pathologies. diagnostic emergency laparoscopy was performed in five patients with penetrating abdominal injury. there were small bowel injury in two patients, colonic injury in two patients and no injury in one patient. diagnostic emergency laparoscopy was performed in four patients with blunt abdominal injury. there were grade 2 splenic laceration in two patients, grade 3 liver injury in one patients and intraabdominal bleeding in one patient. in conclusion, diagnostic emergency laparoscopy is a suitable technique in undiagnosed acute abdomen patients which could not be diagnosed after physical examination, laboratory, radiology and follow-up and helps surgeon to diagnose the disease. also diagnostic emergency laparoscopy performed by experienced surgeons prevents negative laparotomy especially in abdominal trauma patients. mehmet ali yagcı, atakan sezer, ahmet rahmi hatipoglu, irfan coskun, zeki hoscoskun, aydın altan 1 1 department of general surgery, trakya university school of medicine, edirne, turkey introduction: appendectomy is known as the most common nonobstetrical operative procedure in pregnant women with an estimated frequency of 1/1,500 of all pregnancies.pregnancy continues to obscure the accurate diagnosis of acute appendicitis due to gestational physiological changes.diagnostic delay increases the incidence of perforation, hence increasing maternal and fetal morbidity and mortality. patients and results: four patients of appendicitis during pregnancy were concluded in study between 2002 to may 2008 ( table 1 ). the mean age was 25 (range 21-36). three patients presented during three trimester and one in first trimester.the mean time interval of symptoms to the admission is 72 h (range 24-120).abdominal pain, vomiting, and nausea are the most common complaints.rebound was the main sign observed in all patients.fever was noted in two patients. mean value of wbc count was 18,000 per l (range 9,700-26,900). ultrasonographic examination was performed to all patients with the diagnosis of acute appendicitis.three patients were operated under general anesthesia and one under regional anesthesia. paramedian incision was applied to three patients and mcburney to the other one. the exploration findings were two perforated, one phlegmonous appendicitis and a normal appendix. no maternal or fetal mortality occured. cesarean section was performed on 37-week pregnancy during appendectomy due to early onset contractions. adhesiolysis was performed in same case because of postoperative ileus. conclusion: the accurate diagnosis of appendicitis during pregnancy requires a high level of suspicion and clinical skills. delay of operation correlates to more inflammatory changes in the appendix and to higher maternal and fetal complication rates. early laparotomy with appropriate preoperative diagnosis will reduce the fetal and maternal morbidity and mortality. introduction: paraesophageal hernias occur most commonly in elderly and account for 5% in all hiatal hernias [1] . although the fundus or corpus of the stomach are most commonly the contents of a paraesophageal hernia, we reported a case in which the gastric fundus and corpus incarcerated in the paraesophageal space, followed by perforation. case: 64-year-old woman admitted to state hospital following sudden onset of abdominal pain.previously she was diagnosed as esophageal hiatal hernia. on physical examination, abdominal distension with mild tenderness was recognized. pulse rate and blood pressure were 120 per min and 80/50 mmhg. the initial laboratory investigations revealed wbc 3,700 per ml, urea 230 mg/ dl, creatinine 6.3 mg/dl. chest graphy revealed unusual gas shadow in the left thorax (fig. 1) . ct demonstrated intraperitoneal free air, ascites, and the prolapsed stomach in the left thorax (fig. 2 ). an urgent laparotomy was performed revealing dirty ascites.the gastric fundus and corpus were incarcerated in paraesophageal space (fig. 3) . a perforation 15 mm in size was recognized in the fundus. the perforation was sutured primary and cruroraphy was performed. the patient required respiratory support and died on the 14th postoperative day due to multiple organ failure and septic shock. conclusion: the contents of paraesophageal hernia commonly include the gastric fundus or corpus. paraesophageal hernias can cause lethal complications, including gastric obstruction, strangulation, perforation, and hemorrhage. paraesophageal hernias can usually be repaired easily, even using the most recent laparoscopic technique (2). thus, because of the very serious potential complications inherent in cases such as ours that can result from an untreated paraesophageal hernia, we recommend that elective repair be carried out, even in asymptomatic patients. introduction and objectives: the solitary fibrous tumor (sft) of peritoneum, especially arising in lesser omentum is extremely rare. we report a case of lesser omentum soliter fibrous tumor, causing pain and abdominal fullness with its mass effect. case: a 56-year-old male was admitted to our hospital, due to an intraabdominal mass lesion, epigastric pain, abdominal fullness and vomiting episodes. on physical examination, a hard, non-tender mass was palpated in the epigastric region. computed tomography (ct) showed, an approximate 11.5 · 8.5 · 7.5 cm sized solid mass with fibrous capsula between left liver lobe and stomach. at laparotomy, a yellowish brown solid tumor with hard consistency was found on the lesser omentum. the tumor was not adhered to the adjacent structures and could be resected completely. postoperative course was uneventful and no recurrence was determined during follow up. results: histopathologic examination diagnosed the mass as a sft. the tumoral cells were spindle-shaped and did not present mitotic activity or atipies and showed very low proliferation index with ki 67 (<1%) and immunohistochemical positivity for cd 34 and negativity for c-kit (cd 117), actin, and s-100. conclusion: although sft are rare, especially in the abdomen of adults, are generally benign but malignant cases have been reported. in our case, the tumor has a benign character shows neither mitotic activity nor nuclear atypical. this is the third case of soliter fibrous tumor of the lesser omentum described in the english literature. introduction and aims: a single hamartomatous adenoma of stomach is rare. gastric hamartomatous polyps are usually multiple, familial and assosciated with other syndromes. they are also associated with chronic helicobacter pylori infection, acid hypersecretion and predisposition to gastric cancer. this is the first case of gastric hamartoma which is coexistent with duodenal ulcer perforation. case: a 59-year old male admitted to our hospital with complaints of stomach ache, nausea and vomitting. because there was free air under right subdiaphragmatic surface on chest x-ray, an emergency operation was performed. there was a perforated ulcer on the first part of duodenum and a large quantity of bile mixed with blood in the abdominal cavity. on further exploration a tumoral mass which was about 3 cm in diameter was found on the stomach corpus. because of possibility of malignancy, a subtotal gastrectomy including the perforation zone was performed. histologically the tumor was well circumscribed and it consisted of uniform, clear cells. at first, it was thought to be metastatic lesion from kidneys or other organs. in this context, all body was scanned however no pathology has been identified. later on, the tumor was approved to be hamartomatous adenoma and helicobacter pylori was positive. postoperative course was entirely uneventful. objectıve: the aim of this work is to determine the level of apoptosis, which is believed to hold an important role in septicemia process that affects mortality and morbidity in obstructive jaundice, in lingers of rats that were experimentally subjected to obstructive jaundice. materials and methods: the experimentals were separated into two goups of eight. choledoch was isolated in each group and while surgery was ended at this level in the control group, choledoch was tied with 4-0 silk from two different places and cut between ligatures full fold. experiment animals were operated for the second time in the postoperative seventh day for liver sampling and sacrificationaimed histological analysis through the old incision with anaesthesia provided. to exhibit the p53 expression immunohistochemically, anti-p53 clone do-7 was used as the primer antibody and hrp as the secondary antibody. samples taken for the determination of apoptosis were painted by the tunel method. fındıngs: in the evaluation of apoptotic cells in liver cells, apoptotic cells were observed to widely exist in the liver tissue and it was determined that they exhibited dense accumulation in some regions. in the immunohistochemical evaluation made for evaluation of p53 expression in hepatocytes, p53-positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the experiment group. result: consequently, in this study we determined that in the obstructive jaundice group, both apoptotic index and, as a result of the immunohistochemical studies, p53 expression increases in the liver. introduction: the risk of leakage from an anastomosis is higher in large intestine. in emergent colon operations primary anastomosis is avoided especially on the left colon, and multi-step procedures are preferred if there is a dirty abdomen. the aim of this experimental study was to compare different suture materials in left colonic anastomosis in presence of peritonitis. metods: this study was conducted on 21 wistar-albino rats by dividing them in 3 groups of equal numbers. after median laparotomy, the whole layer of left colon was cut 2 cm over the pelvic peritoneum and fecal contamination was performed. one day later, the abdomen was opened again under general anesthesia. the abdomen was washed with sf before starting colonic anastomosis. for colonic anastomosis; vicryl + silk was used in the 1st group rats, pds was used in the 2nd group rats, and coated vicryl plus antibacterial suture and silk was used in the 3rd group rats. results: tissue hydroksiproline, anastomosis bursting pressures and histopathologic findings on the anastomosis line were evaluated on the 10th postoperative day. the highest anastomosis bursting pressure was found in group iii (p < 0.05). the highest tissue hydroksiproline level was found in group iii (p < 0.005 group i-iii, group ii-iii). when histopathologic findings were evaluated by comparing three groups, the healing of the intestine tissue score was found to be highest in group iii (p < 0.005, groups i-iii). conclusion: consequently, it was observed that using antibacterial suture increased resection safety in the presence of peritonitis and anastomosis safety in primary anastomosis. introduction and objectives: the chance of finding the vermiform appendix within an inguinal hernia occurs in approximately one percent of the cases, and is known as amyand's hernia. appendicitis within an inguinal hernial sac is rare. materials and methods: we present two amyand's hernia cases: one with a vermiform appendix and one with a perforated appendicitis. case 1: an 86-years-old man presented with a 20 years history of bilateral inguinal mass. ultrasound examination described a hernia which contains mobile bowel segments inside, on the right side. the appendix was obsereved edematous and hyperemic in the hernial sac. an appendicectomy was done. further exploration of the bowels revealed a meckel diverticulitis which was managed by a wedge resection. case 2: a 57-years-old woman presented with one week history of an inguinal mass, pain and anorexia. abdominal computerized tomography demonstrated an incarcerated right-sided inguinal hernia.the hernia sac was filled with the perforated appendix. appendicectomy was carried out. results: postoperative recovery was uncomplicated, the patients were discharged without any complication. discussion: acute appendicitis or perforation of the appendix within the hernia sac simulates perforation of the intestine, and does not have specific symptoms or signs. preoperative clinical diagnosis is very difficult and the diagnosis is made intraoperatively. since the absence of any pathognomonic radiological features, the value of preoperative computed tomography is limited. treatment of hernial appendicitis is an appendicectomy with suture hernial repair. the management of a non-inflamed appendix is debatable. the usual practice covers reduction of the appendix, and mesh repair. in the immediate post-operative period the patient had a high output jejunostomy and was dependent on total parenteral nutritional support. a bishop-koop procedure was performed on day 11 and by day 37, the patient was completely independent of any adjuvant nutritional therapy. five months from primary surgery colostomy was closed. introduction and objectives: the management of pancreatic pseudocysts which occur after blunt abdominal trauma in children is still controversial. in this study, we present our experience therapeutic approach of pancreatic pseudocysts that occur after trauma. methods: we evaluated 9 patients with traumatic pancreatic pseudocysts who admitted to our clinic between 2003 and 2007. we performed ultrasonography, computerize tomography (ct) and blood amylase level for all patients. results: there were eight males and one female. the average age was 9.2 years (range 6-15 years). the mechanism of injury was bicycle handle bar injury in four, falls in three, assault in one and motor vehicle accident in one patient. abdominal pain was the most common symptom. the median size of cysts was 10.3 cm (range 5-17 cm). the time interval between trauma and pancreatic pseudocysts was 17 days (range 9-30 days). of the nine patients, four (44.4%) occurred in less than 2 weeks. all patients were initially followed up conservatively. three patients (33%) were successfully treated conservatively, while 6 patients (66%) required intervention either by percutaneous radiological drainage (4), cystogastrostomy (1) and external drainage with laparotomy (1). complication developed in two patients (septic shock, persistent hyperamylasemia). no patient died. conclusion: traumatic pancreatic pseudocysts may occur short after traumatic injury in children. all patients with traumatic pancreatic pseudocysts should be managed by conservative approach initially. however, if the cyst is cause of gastric outlet obstruction or the size of cyst is bigger than 6 cm, interventional management may be required. introduction: splenic abscess is a rare entity,with a frequency of 0.14-0.7% in autopsy series.mortality rate is still high, up to 47%, and can potentially reach 100% among patients who do not receive antibiotic treatment. case 1: 63 year-old woman presented with fever and left upper abdominal pain for 15 days. hepatomegaly and tender splenomegaly were present.ct of the abdomen revealed 5 · 8 cm hypoechoic lesion in the spleen (fig. 1) . initial laparoscopic approach was performed but failed due to inappropriate anatomy. conventional splenectomy was done and at exploration there was 6 · 8 cm abscess in spleen. the patient was dischared on the eighth day of operation. case 2: 43 yearold woman admitted with femoral artery thrombosis.thromboembolectomy and leg amputation was performed by cardiovascular surgeons.she was consultated with fever and left upper abdominal pain on the second day of operation. ct of the abdomen revealed a 14 · 8 cm mass with air fluid levels in the spleen (fig. 2) . splenectomy was performed and a 12 · 10 cm abscess was observed in spleen.the patient died on the second day of operation due to sepsis. a proximal stoma after resection of the perforated small bowel and colon, closure of the distal stump in case of severe generalized peritonitis without the possibility to perform a primary anastomosis. a loop ileostomy to prevent bacterial translocation in case of pancreatitis. retrospective analysis of clinical data of patients admitted between 2004 and 2008 for emergency operation requiring laparotomy and the construction of one or more small-bowel stomas. 32 patients had ileostomies created for temporary fecal diversion after emergency surgery including bowel obstruction was the most frequent cause of peritonitis (11 cases),followed by anastomotic leakage and peritonitis (7), acute mesenteric infarction (4 cases), intestinal perforation (3 cases), strangulated incisional hernia (3 cases), acute abdomen of crohn disease (2 cases), peritonitis carcinomatosa and frosen pelvis (2 cases), mean age was 57.5 years (range 23-87), being 16 males and 16 females. overall mortality was 62% (20 patients). 11 patients died on the first 7 days postoperatively. indications, morbidity, mortality and problems involving the ileostomies in emergency abdominal surgery urgency are herein discussed. in the majority of patients with acute abdomen doing ileostomies,lacking of vital capacity of bowel wall as well as insufficiency of previously laid sutures were revealed, which forced a surgeon to resort to resection; in such cases the method of choice for decompression should be the application of ileostomy. postoperative jaundice is often multifactorial. a precipitating or causative factor may be identified but seldom can a specific therapy be offered. the late complications were mainly presented by the biliary ducts cicatricial stricture, the jaundice and cholangitis recurrency. in this report, we described an extremely rare case of a 29-year-old woman presenting with pain in the right upper quadrant, jaundice, and weight loss in whom a whipple procedure was performed. usg and mr cholangiography showed that dilatation of intrahepatic and extrahepatic bile ducts and hepaticojejunostomy line. mrcp also showed that, there was a closed jejunal loop related with hepaticojejunostomy. obstruction by local tumor recurrence and infiltration of the efferent jejunal conduit between the proximal hepaticojejunostomy and the duodenojejunostomy led to closed loop syndrome and jaundice. frozen sections by direct incisional biopsy revealed a recurrent tumor invasion. a previously unreported late complication after whipple resection of the head of the pancreas was recognized as ''closed efferent loop syndrome'' mimicking obstructive jaundice. the case was accepted as inoperable because of tumor invasion to the jejunum, transverse colon, and surrounding tissue. roux-en y type jejunojejunostomy was performed. the patient had an uneventful postoperative course. introduction: the form of mechanical asphyxia where respiration is prevented by the external pressure on the body: a large weight compressing the chest or abdomen, wedging of the body within a narrow space death in large crowds is traumatic asphyxia. case: a 19-year-old man was found compressed by a motorboat in the garage while he was working for installation of the boat. the face, neck and upper part of the chest were congested and many petechiae were observed on the conjunctivae. ecchymotic bruises were observed on the right cervical, lower chest, upper abdominal regions and open fracture of the right humerus, ecchymotic abrasion on right anterior superior iliac spine line were detected. subcutaneous haemorrhages in the chest wall and bleeding without subcutaneous haemorrhage in the inferior part of the right sternocleidomastoid region were observed during the internal examination. fractures of the right third and fifth ribs which were accompanied by bleeding in the surrounding soft tissues and muscles, and ecchymoses over the right sixth rib without any fracture were also observed. macroscopic examination of the lungs revealed congestion, subpleural superficial bleeding areas and histopathological examination showed hemorrhagic alveolar oedema. all the internal organs and big vessels were intact. there was no hemorrhage in the thoracal and abdominal cavity. toxicological analysis was negative. conclusions: in the presented case, the impact cause of the chest compression was distinctly determined by the autopsy and criminal investigation. death was reported as asphyxia by the thorax compression without other lethal factors. purpose: the purpose of this prospective study was to evaluate safety of early surgical interventions in the repairment of animal bites with tissue injuries. materials and methods: tissue repairment and/or reconstruction were done, total in 34 patients. 20 of them were dogs', 14 of them were horses' or donkeys' biting between the years 2003-2007. wound sterilization and debridement were made before repairment. rabies and tetanus prophylaxis were done for all patients. tissue repairments after animal biting were made early and promptly. patients having animal injuries, apart from biting were not included in the study. results: 22 of the patients were male and 12 of them were female. the minimum age of the patient was 1.5 and the maximum was 84, and the average age was 39. in 24 cases head-neck, in eight cases extremities and in two cases body were biting areas. horses' or donkeys' bitings were seen particulary in ears. in these animals' biting tissue lose was emphased. we prefered primary saturation in 20 cases, skin greft in ten cases and repairment with flap in five cases. finger amputation was required in one of the patients. total ear reconstruction was done gradually in a patient. no infections observed in patients after the surgical interventions. conclusion: we concluded that, early tissue repairments may done after wound sterilization and debridement, safely. treatment plan. multidetector computed tomography (mdct) imaging is an improving and being a widely used method recently in many areas of medicine. it is possible to evaluate the peripheric vascular structures, anatomic variations or vascular pathologies with mdct angiography (mdcta). methods: the arcuate foramen is an anatomical variant of the atlas vertebra: anterior and posterior osseous bridges or ponticles can arch over the vertebral artery, to a greater or lesser degree, transforming the arterial groove into a canal. dissection of the vertebral artery leading to thrombotic occlusion or ischaemia from narrowing of the arterial lumen has been described in trauma. there are fistula between a dural branch of the spinal ramus of a radicular artery and an intradural medullary vein in spinal vascular malformations. mdct angiography is feasible and is an alternative technique in diagnosis spinal vaskü ler malformations. the craniovertebral junction (cvj) is a funnel-shaped structure comprised of the clivus and foramen magnum and the upper two cervical vertebrae. the most frequent neoplastic lesions of the craniovertebral junction are meningiomas, neurinomas, chordomas, paragangliomas, epidermoids, dermoids and chondrosarcomas. conclusion: in this presentation, pathologies seen in craniocervical junction (congenital variation, trauma, vascular malformation and tumor) were discussed with figures and compared with the literature. introduction and objectıves:small bowel obstruction (sbo) is very rare. although the diagnosis is straightforward, some patients with intermittant and low-degree symptoms could be misdiagnosed as psychiatric disease. we presented here a patient with intermittant symptoms of ileus treated as psychiatric disease case: a 44 year old male patient was referred from phsyiciatry clinic to our department with complaints of weight loss, nausea and malnutrition. his medical history revealed a laparoscopic appendectomy 6 months ago. he emphasized that his complaints started shortly after the operation and increasingly got worse. he was admitted to hospital 3 days after operation with symptoms of ileus and managed conservatively. the intermittant abdominal pain and nausea continued. since the pain was intensified after meals, patient refused eating. during the period of 6 months he lost 20 kg of weight. after numerous radiological and endoscopic investigations patient was referred to psychiatry due to persistent anorexia. after short psychiatric medication, he was referred to our surgical unit. multislice abdominal computerized tomography and and enteroclysis of small bowel clearly demonstrated an obstruction in the jejunal segment of the intestine. at laparotomy, small bowel obstruction was detected and segmental resection was performed. postoperative period was uneventful and patient was discharged from hospital on postoperative day 6. conclusions: the diagnosis of anorexia and nausea due to sbo is relatively difficult. the patients were sometimes misdiagndosed as having psychiatric disease. before starting psychiatric medication, they must be reevaluated for all putative causes of sbo. introduction: endoscopically placed biliary stents are a well-established procedure for the treatment of benign and malignant biliary disease. duodenal perforation may occur at the time of insertion of a biliary endoprosthesis or following endoscopic manipulation of such a stent. methods: we report a case of duodenal perforation complicating stenting for biliary fistula in surgery for hepatic hydatid cyst. case: a 74-year-old man was admitted to a local hospital following the sudden onset of abdominal pain,distension with nausea and vomiting. he developed a biliary fistula after surgery for hepatic hydatid cyst 2 months ago. endoscopically placed biliary stent was performed for the treatment of biliary fistula at the same hospital 2 months ago.on examination, marked abdominal distension with mild tenderness was recognized. his pulse rate and blood pressure were 120/min and 80/50 mmhg, respectively. abdominal x-ray showed two foreign body images and subdiaphragmatic free air. emergency laparotomy revealed dirty ascites and perforation of the third portion of the duodenum by the plastic stents. the second stent was found at pericecal area. after extraction the plastic stents and irrigation with isotonic sodium chloride solution, the site of perforation in the duodenum was primary reparing and triple tube placement performed. conclusion: endoscopic retrograde cholangiopancreatography (ercp) is considered to be the most difficult endoscopic procedure in gastrointestinal endoscopy, and is associated with potentially severe and sometimes life-threatening complications such as duodenal perforation. surgical statistics indicate the importance of early diagnosis and treatment for duodenal perforation. introduction and objectives: ticks play an important role in transmitting several infectious agents, such as viruses, bacteria, spirochetes, rickettsia, and parasites. in this study, we analysed the demographic and clinic characteristics of the patients who admitted to emergency service due to tick bite. methods: in this study, patients were selected from cases of tick bite admitted to the department of emergency medicine of ankara numune hospital during the 2007-2008 periods. detailed histories and some blood tests of patients were taken, and the body of the tick grasped gently avoiding to inject more salivary toxins. results: totally 301 patients admitted to hospital in this period. the most frequent symptoms at administration were malaise, myalgia, and fatigue. hemorrhagic manifestations were observed in 28 patients and bleeding was from multiple sites in 15 patients. other symptoms were watery diarrhoea, skin eruption, macular rash, and petechia-ecchymosis. in the comparison of the clinical features and laboratory results of the surviving and the patients who died, we found that the rates of fever during hospitalization, confusion, neck stiffness, bleeding from multiple sites and presence of petechia/ecchymosis were higher in the patients who died than in the surviving ones. additionally, the mean values of alt, ast, lhd, ck, ptt, international normalized ratio (inr), and urea were also higher and mean plt counts were lower in the patients who died. conclusion: the acute tick-bite reactions show special histologic features, which are unquestionably related to the particular morphology and physiology of the mouthparts of these arthropods. results: totally 46 patients (33 men and 13 women) were evaluated. the mean age was 55.7 (20-97) years and the mean follow up period was 38 (7-68) months. the localization of the hernias were as follows: 33 inguinal hernias, seven femoral hernias, two umblical hernias, two paraumblical hernias, one epigastric hernia and one inguinal + femoral hernia. all of these strangulated hernias were treated with prosthetic graft repairing. in addition to these hernia repairs, in the same operation sessions three hydrocele repairs, three omentum resections, two partial small intestine resection and anastomosis, one lymphadenectomy, one orchiectomy and one laparotomy were done when necessary. in the early post operative period four patients died because of other diseases not related with the surgical procedures or hernia itself. wound infections were observed in three patients and they were treated with antibiotics and anti inflammatory drugs. we report a rare case of ileal perforation caused by an ingested 15cm long fork. a 43-year-old man presented to the emergency department with exhaustion, weight loss and abdominal pain. he had been having pain in the abdomen, nausea and vomiting for the previous 2 days. the patient had received psychiatric treatment, and started to experience weight loss and exhaustion 3-4 months previously. no conclusions could be drawn from physical examination for abdominal tenderness and defence. direct x-ray showed an appearance conforming to a fork in the intestine and subdiaphragmatic free gas. the patient was sent for emergency surgery, with a diagnosis of ileal perforation and foreign-body ingestion. most of the ingested foreign bodies that reach the stomach pass through the alimentary tract without complication. perforation occurs in, 1% of all cases of foreign-body ingestion, usually in the oesophagus. other sites where perforation can occur are the pylorus, the duodenum, the duodenojejunal flexure, the ileocaecal region and any site of congenital anomalies. long, thin or sharp objects, as seen in our case causing ileal perforation. foreign-body ingestion is a possibility to be borne in mind at presentations to the emergency department, especially those with symptoms described in psychiatric cases. appendicectomy is a common emergency operation, its major complications are uncommon. most complications of appendicectomy occur in the early postoperative period and easy amenable to treatment with conservative medical therapy. appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. the latter occurs rarely after open appendicectomy but accounts for 10% of the morbidity rate. schloffer tumor (inflamatory granuloma or abscess in the abdominal wall at the operative scar) is rare complication that usually develop months to years postoperatively and late postoperative enterocutaneous fistula has been described in literature as a rare complication of acute appendicitis. we describe one such case where the patient presented with a tender mass under the incision site six months later after appendicectomy. findings of computed tomography were demonstrated thickening in the abdominal wall and abdominal wall abscess like schloffer tumor. abscess was drained. there were not produced any microorganisms in the wound culture. after conservative therapy healing was completed in a short period. one year later, the patient was admitted with complaints. on the examination, passage of undigested food particles through a sore in the appendicectomy incision site. computed tomography were demonstrated fistula tract extending from appendicectomy site to skin. enterocutanous fistula was occured at the appendicectomy incision 1 year later after operation and successfully treated with en-block fistulectomy and right hemicolectomy. postoperative course was uneventfull. patient discharged from hospital at seventh day after operation. objective: vascular insufficiency may lead to hypoxic injury in intestines. the lesions in the colon are called ischemic colitis. mesenteric ischemia is more prevalent in patients getting hemodialysis. in this study we report 3 hemodialysis patients admitted to the emergency department because of acute abdominal symptoms. case 1 39 year old woman was chronic hemodialysis patient admitted to the emergency room with acute onset abdominal pain.the initial diagnosis was acute appendicitis and she underwent laparotomy. peroperatively isolated cecum necrosis was seen. right hemicolectomy and ileotransversostomy was performed. she died 43 days after surgery because of sepsis. case 2 38 year old man was chronic hemodialsysis patient admitted to the er because of abdominal pain persisting for 24 h. with an initial diagnosis of acute abdomen a median incision was performed. peropertively widespread peritoneal adherences and isolated cecum necrosis were seen. cecum was resected and side to end ileocolostomy was performed.he died 12 days after his first operation. case 3 77 year old man was chronic hemodialysis patient admitted to the er with pain localizing to right inferior abdomen. with an initial diagnosis of acute appendicitis laporotomy through a mc burney incision was performed. there was 2 · 3 cm cecum necrosis. cecum resection and end colostomy and ileostomy was performed. the patient was discharged 9 days after the operation without any problem. discussion: ischemic necrosis of cecum is a rare variant of ischemic colitis. in hemodialysis patients requiring colon resection due to ischemic colitis, primary anastamosis should be avoided, diversion stomies should be preferred. agitation is a non-specific constellation of comparatively unrelated behaviours that possess a risk to the safety of the patient or caregiver, impedes the process of care giving or impairs a person's function. the management of agitated trauma patient contains hospital, prehospital, in emergency department and inside of the hospital transports. the reasons of the agitation hypoxia, hypoglycemia, hypovolemia, pain, traumatic brain injury, anxiety disorder, drug and alcohol abuse, psychiatric disorders. pain management has had a limited role in the management of trauma patients, primarily because of the concern that side effects (decreased ventilatory drive and vasodilatation) of narcotics may aggravate preexisting hypoxia and hypotension. health professionals should monitor pulse oxymetry and serial vital signs if any narcotics are administered to a trauma patient. small doses of benzodiazapine sedatives should be titrated cautiously because of the potential side effects of hypotension and ventilatory depression. to control agitated patients with traumatic brain injury include haloperidol, midazolam, and propofol. in the emergency setting, they are most often indicated to control agitated or psychotic behavior that constitutes an imminent danger to the patient or others. to control agitated patients should be a part of the trauma management. we present a protocol for trauma team. there were 294 males (82.8%) and 61 females (17.2). eighty percent of the patients were between 5 and 45 years of age. the overall mortality was 11.5% (41 patients). eighty percent of deaths occured in comatose patients (p < 0.000). comatose state, precence of focal motor signs, respiratory irregularities and hypertansion-bradycardia, pupillary changes were determined as the bad prognostic factors. a midline shift greater than 10 mm, hematoma volume greater than 150 ml, accompanying intracerebral and extracranial traumatic pathologies significantly increased the mortality rate. there was no significant statistical correlation between the outcome and the age, sex of the patient, trauma-to-operation interval, thickness, localization and origin of edh and aetiology. results: the primary factor on outcome is glasgow coma scale scores of the patients at the time of surgery. therefore early surgery is crucial in the management of edh which is a dynamic process. introduction: in this study, we have evaluated the incidence and clinical characteristics of the patients for traumatic brain injury (tbi)-associated coagulopathy after tbi retrospectively. methods: retrospective study of all patients admitted to the trauma and emergency surgery intensive care unit (icu) from january 2005 through december 2008 with tbi. criteria for tbi-coagulopathy (tbi-c) included a clinical condition consistent with coagulopathy in conjunction with a platelet count < 100,000 mm3 and/or international normalized ratio (inr) > 1.2 and/or activated partial thromboplastin time (aptt) > 29 s and/or prothrombin time (pt) > 14.5 s. the following potential risk factors were included to identify independent risk factors for tbi-c and its association with mortality, age, mechanism of injury (blunt (b) or penetrating (p)), glasgow coma scale (gcs), injury severity scale (iss), presence of polytrauma, icu length of stay (icu-los). results: a total of 82 patients met study criteria. tbi-c occured in 86.5% (n: 71) of all patients (b: 66.1%, p: 33.9%). in patients with tbi-c, mean age was 36.42 ± 17.03 years. the averages of gcs was 7.9 ± 2.74, iss was 33.14 ± 14.12, icu-los was 11.51 ± 6.77 days, polytrauma was considered 57.7% (n:41) and the overall mortality was 21.1%(n: 15) in patients with tbi-c. conclusions: in our study, tbi-c occured more frequently among patients sustaining blunt versus penetrating injuries. to our knowledge, tbi patients are at considerable risk of developing coagulopathy and anesthesiologists should be aware of this life-threatening syndrome, especially in tbi patients with blunt injuries. erythropoietin (epo), glycoprotein hormone, is a mainly produced by the kidney that stimulates proliferation, growth and differentiation of erythroid precursors in the bone marrow. recently, anti-inflammatory, neuroprotective, antiapopitotic, angiogenic and vasodilatator effects of epo have been also determinated. the purpose of this study was to investigate the effects of rhuepo in reducing the severity of experimental spinal cord injury (sci). ninety adult sprague-dowley rats weighted 200 g (± 15) were used for the study. through a dorsal incision, t6-9 laminectomies performed in prone position and clip compression had made for ischemic injury as tator method. the rats divided in three groups. systemic 200 l (1,000 u/kg) rhuepo had given 24 h before the trauma in the first group, 30 min. later after the injury in the second group and the third was the control group. the rats were killed with high dose intraperitoneal ketamin 24 h later after the injury. the histological examination of injured spinal cord specimens for the potential neuroprotective effects of rhuepo was done. further more the axial spine sections stained with ttc (triphenyl tetrazolium chloride). the ischemic areas were evaluated with a imaging calculation program. we use wet-dry method for determination of ischemic tissue edema. we concluded that administrating a single dose rhuepo (1,000 u/ kg) has potential neuroprotective effect on experimental spine injury by reducing severity of inflammation and tissue edema in the secondary ischemic area. it has known both early surgery and high dose steroid treatment prevents the neurological function and viability caused of the traumatic secondary spine injury. we present surgically treated a traumatic rotation-compression spinal cord injury caused by a motor vehicle accident. the patient referred to our clinic 45 h after the injury. at the time of admission, he had a localized pain at the thoracic 10-11 vertebrae level, loss motor and sensorial function under the level t10 classified as asia grade a. he was incontinent. in the radiological evaluation we found loss of height at the thoracic 10th and 11th vertebrae body, serious spinal column injury include t10-11 burst fracture, laminas and facet joints fractures with three colon damage (denis f). we detected the spinal instability criteria in . we did not see penetrating injury or primary spinal cord injury signs but spinal canal tightness for 30 percent in ct and mri scans. we took the patient to surgery in unusual classical surgery timing. first, decompressing surgery applied to the t10-11 laminas and posterior stabilization with transpedicular screw-rot system. one day after the first operation, t10 and t11 corpectomy applied for anterior stabilization with cage-screw system. mega dose steroid had given also before the first surgery. postoperatively early neurological evaluation, he had asia grade c, after second month asia grade d without incontinence. in our opinion the decompressing surgery that applied in 48 h in the patients without complete primary spine injury, has a positive neurological feedback. introduction: it is a rare occurrence with the rate of 1% in the subjects with spinal infestation cyst hydatic echinococcus granulosus. intradural hydatic cyst is relatively rare when compared with other spinal hydatic cysts. we are presenting here a 68-year-old female case who applied to emergency service with backache and paralysed legs and was diagnosed with spinal intradural extramedullary hydatic cyst. case: a 68-year-old female patient applied to emergency service with complaints of a backache started two days ago, paralyses in both legs and being unable to walk. in her neurological examination, a complete motor power loss in the lower extremities and bilateral sensation loss compatible with t11 dermatoma were detected. in the torako-lomber spinal magnetic resonance imaging (mri), multiple cystic characterized nodular lesions having peripheral contrast with regular contour including right neural foramen and paravertebral zone at the level of t11-t12 and l1 in the intradural distance were determined. the patient was diagnosed with common spinal intradural extramedullary hydatic cyst exhibiting bone involvement. as the lesion was very broad had paraplegia, we did not consider operation. conclusions: hydatic cyst infestation is a benign disease. if it is not diagnosed early and treated when it involves in some systems rarely as it did in this study, the results can be serious. diagnosis should be confirmed quickly with increasingly common advanced radiological diagnosis methods. the aim in these cases is to eradicate the cysts surgically, however, chemo-therapy and percutaneous drain methods have become more significant recently. introductıon: several guidelines advocate multiple chest radiographs during primary resuscitation of trauma patients. several local hospital protocols include a repeat radiograph before leaving the trauma resuscitation room (tr). the purpose of this study was to determine the value of routine repeat radiograph. methods: one year data of all radiological imaging in our tr were prospectively collected for all patients presented to the tr of the hospital. we counted and assessed the radiographs and classified our findings as either 'new injury detected', 'presence of intervention equipment', or 'deterioration of previously detected injury'. results: in total, 674 patients were included. more than 75% had two radiographs. eight (2.1%) new injuries without clinical relevance were found on the repeat radiograph after an initial normal radiograph. in total 61 patients (9%), had a repeat radiograph to verify the effect of an intervention or position of equipment. in 28 patients (22%) with two abnormal radiographs, newly diagnosed injuries (n = 9) or deterioration of known injuries (n = 19) were found. in 411 patients (81%) the results of the repeat radiograph had no clinical consequences. conclusıon: our study supports a strategy of omitting a routine repeat radiograph in trauma patients whose initial radiograph is normal. introduction and objective: the neck region is affected in only about 5-10% of all trauma cases, and isolated neck injuries, especially from a blunt mechanism, is even more rare. our objective was to assess the incidence, disability from spinal cord injuries, and preventable deaths in our patients with isolated neck trauma. material and methods: patients were identified at the severe trauma registry of our hospital, between 1993 and 2006. the triss method was used to assess preventable deaths. results: we found 117 (7.4%) patients with neck injuries out of 1.575 patients included in our registry, 70 (60%) from blunt (bnt) and 47 (40%) from penetrating trauma (pnt). only 9 (13%) bnt and 19 (40%) pnt were isolated. the mean iss of the bnt and pnt groups was of 25 ± 7 and 14 ± 9.5, respectively. in the bnt group, 6 (67%) patients had spinal fractures (with 2 spinal cord injuries with permanent disability), 3 had airway injuries and 1 a vascular injury. in the pnt group, 1 patient had a spinal fracture, 7 had vascular injuries and 4 airway injuries. overall mortality was of 4 (14%) patients, 2 in each group, and only one of them was deemed preventable. conclusions: isolated neck trauma is a rare cause of disability and preventable death in our area. most penetrating injuries have a lowto-moderate degree of anatomic severity (ais £ 3). for each group. however about applications increased gradually with a peak at 17 o'clock in all groups. patients treated at ed were mostly stricken (58.5%) and the busy period was between 12-24 h with two peaks at 17 and 22 o'clock. totally, 231 patients were hospitalized mostly in group iii (48.9%) regardless of cause (p < 0.01). patients referred to another hospital were frequently in group iii (39.9%) and also in group iv (32.3%). mortality was slightly high in group iii. however higher rate (1.1%) was seen among patients in group ii. conclusion: midnight hours seemed safe in terms of mortality and severity of trauma. whether the reason for a higher transportation rate at night hours is the severity of trauma or sedation of ed staff is not clear. introductıon: in this study we aimed to investigate and compare the features of child and adult injuries due to bicycle accidents admitted to our emergency department. patients and methods: the study was carried out retrospectively by searching the files of patients admitted to the emergency department due to bicycle accidents, in the emergency department and archive records between the dates of january 2005 and december 2008. the patients were divided into two groups as adults and children. age and sex of patients, season or month of injuries, place and mechanism of injury, injury site of the body, diagnosis and treatment modalities, discharge and hospitalization rates were evaluated. results: totally 150 patients were included in the study. 79% of the patients were in child age group, 21% were adults. it was determined that number of accidents increased especially in the summer months. 71.4% of accidents concerning children and all of adult accidents occurred in the streets. falling down from the bicycle was the most common injury mechanism in children (91%) and adults (90%). head and neck region was the most common body site subjected to the injury both in children (32%) and adults (40%). 78% of child patients and 84% of adult patients were discharged after emergency department follow up and treatment. there was a significant difference between two groups with respect to injury severity. conclusıon: as a conclusion most of the injuries due to bicycle accidents happen in children, in the streets, in summer months and school vacations. conclusıons: road traffic collision is a major cause of trauma and death in al-ain city. seatbelt compliance is alarmingly low and should be enforced. introduction and objectives: the controversy between the ''scoop and run'' versus the ''stay and play'' approach in severely injured trauma patients has been an ongoing issue for decades. the present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the netherlands, have improved outcome. methods: in this retrospective study, files were analysed for all patients admitted to one of six hospitals in the limburg region in the netherlands with a gcs < 8 on admittance over the period january 2006 -december 2008. all patients had proven traumatic brain damage on ct or mri. relevant prehospital and clinical data from a similar study conducted 20 years ago were compared to data from the present cohort. the main outcome was mortality. results: the two research groups had similar characteristics. in the historic cohort, basic life support (bls) and the 'scoop and run' method in patients with major traumatic brain injury (tbi) was common, with an average time on scene of 7.5 min. nowadays, prehospital care is performed mainly on the level of prehospital advanced life support (als), with average time on scene about four times as long as in the historic cohort. however, the overall mortality rate for the current cohort compared to 20 years ago has not decreased. conclusion: despite more on-site als in major tbi nowadays, there was no reduction in mortality. the team is provided to be ready all the time by making monthly and yearly national education exercises. these exercises are planned with two methods: (1) as demonstration during education (2) by creating extraordinary condition simulations aim: _ interpret the support of exercises plans on umke operational agility and to accomplish next plans through this way. material -method: 16 umke teams are divided into two parts after geting their basic educations. first group is planned to exercise in education room with demonstrations. the second is planned to exercise the extraordinary situation simulations in which people(not from the groups) made up and acted as injured and moulage is also used in this group. after the exercises, results are compared according to the criteria for assessment. in the first group's demonstrations it is worked by giving roles to team members in the education atmosphere with existing equipments (chair, table, ladder…). in the second group, worked with the moulaged volunteers and extraordinary situation simulations just like the real(wreck, avalanche, fire…) the results are considered statistically by t test. findings: according to the assessment criterias the first group's average point is 5.5 and the second is found as 8.38. (p < 0.0001). discussion and result: exercises in a form of extraordinary situations effected team's performance, operational success and involvement positively. planning the exercises with this data will increase the quality of the educations which planned in the future. nurhan babaoglu, tayfun cucioglu, gö khan akbulut 1 1 national medical rescue team, ministery of health, afyonkarahisar, turkey entry: umke designed as serving medical rescue in extraordinary circumstances. they carries their approaching skills to the top by managing regional and national exercises. the teams in different cities coordinate and share their knowledge and agility by this exercises. aim: after the workshop oriented educations, criteria are needed to improve and decide the affect of the exercises as numerical which supplies standardization of the teams. material-method: 17 teams are evaluated according to 10 criteria and graded from 1 to 10. after the exercises, results and the importance of criteria shared with teams. 1 month later same teams evaluated again in exercises. criteria: (1) equipment (2) team accordance and work discipline (3) security and to define work risks (4) approach to the injured (5) evaluate the injured people (6) convert the theory to practise (7) usage of materials correctly and in proper place (8) packaging (9) taking out the injured safely (10) cleanness of the materials and control of medical bag findings: after antalya umke basic education, 17 team's evaluated and average score was 7.82. this results shared with teams and in next exercises in isparta mean score founded as 9.00. (p < 0.0001) discussion and result: when the evaluation criteria and results shared with the teams, it is confirmed that the teams react better in ongoing situations. it is considered that it will also increase the quality and effectiveness of the education. the criteria for evaluation going to help standardization which can be used by all medical rescue teams will provide a common manner between the groups. hasan ç elik, gö khan akbulut, nurhan babaoglu, tayfun cucioglu 1 1 national medical rescue team, ministry of health, afyonkarahisar, turkey umke teams are established in 2004 in 81 cities in order to act in disasters and extraordinary circumstances as a medical rescue team. members are chosen among the volunteered medical crew. the team's mission is to support the search and rescue teams medically in extraordinary circumstances. team starts with the first intervention and maintain the stabilization of the injured person before the transport so that prevents the second insult. working principles was not obvious during the establishment phase and this caused chaos at the beginning. by designating the teams responsibilities work distribution reached to the standard. national medical rescue team is consisting of 5 medical personnel who are named as 1 leader, 1 logistic, 1 pigeon, 1 squirrel and 1 courier. the team leader who is chosen from doctors who has experienced in disaster medicine and have knowledge about leadership, provides a common manner and motivation among the team. also directs the intervention to the injured person and coordinates with search and rescue teams just after the fast arrive in extraordinary circumstances. squirrel communicates with injured at first and starts his intervention with the direction of the leader. logistic is responsible for all equipment (spin board, medical bags…). courier provides the equipment transportation between logistic and squirrel. pigeon is responsible for photographing, recording and communicating with the center. this organization type performed in regional and national practises from 2006 to 2008 and also in train accident in kü tahya. _ it helped maintaining standardization and acquired successful results. author to editor: bu yazıyı ulusal medikal kurtarma ekiplerini (umke) tanıtmak amacıyla hazırladık. eg er uygun gö rü rseniz, umke yi tanıtıcı bir stand açıp medikal çantamızı ve dig er kullandıg ımız malzemeleri tanıtabiliriz. ayrıca bu gü ne kadar katıldıg ımız (pakistan depremi, isparta uçak kazası, kü tahya tren kazası) afet, tatbikat ve eg itimlerimizi(ameliyathane konteynırımızı) power point olarak sunabiliriz. 508 helicopter use as a part of trauma care introductıon: rapid transport and persistence of prehospital care is crucial to decrease the mortalities and morbidities of combat related injuries. hence, helicopters are effectively used by the military although they are austere environments that offer limited space, equipment and resources for the crew and requires higher level of skills for prehospital trauma care. materıal-method: the data were collected from 60 consequent casualties, by the helicopter medical team (a surgeon, anesthesiology technician and a paramedic). during the flight, we triaged the casualties according to wound characteristics (severity, mechanism, location), physiological parameters, and provided basic life support stated by trauma resuscitation course (trk). we transmitted these findings to the military trauma center to provide hospital preparedness. result: injury mechanisms were 70% explosives and 30% highvelocity weapons. time to hospital admittance was < 50 min after the injury. most frequent sites of injury (ais 1-5) were extremities (75%) and thorax (38.3%); the frequency of ‡ 2 anatomical site injury was 35%. capillary refill rates were; < 2 seconds 74.3%, > 2 seconds 25.7%. mean sao2, gcs, hr, respiratory rate values were 97.2 ± 3.2, 14.1 ± 2.34, 87.6 ± 20.5, 17.5 ± 3.1, respectively. during uninterrupted care, 6 (10%) intubations were performed and 67% of casualties were operated upon admittance without any onboard mortalities. conclusion: the high energy and lethality of the wounding agents in combat render the helicopter evacuations indispensible. additionally, civilian major trauma patients may benefit from expeditious transport to the closest trauma centers or from rural inaccessible areas within the 'golden hour of trauma'. the most important steps for the treatment of the combat injury causalities are to stop or reduce bleeding and to start fluid resuscitation. peripheral intravenous (iv) line placement is one of the most important procedure in the battlefield conditions. most of the time, fluid resuscitation would be the only available medical treatment for the injured combatant because of the prolonged evacuation period in the battlefield. also, this procedure would be very difficult and time consuming especially under hostile gunfire. excessive blood loss and hypotension may cause the peripheral venous collapse and makes the procedure more difficult. here we described a simple method to make this procedure easier. we offer the forward medical team personal to perform the upper extremity peripheral venous mapping of the combatant before the operation. the medical providers (doctor or paramedic) who would perform the first medical intervention would examine the upper extremities of baddy just before the operation. the medical care provider should determine the suitable situations for the iv line placement. then he should remark the both site of the appropriate vein by camouflage paintings, leaving the probable angiocath insertion sites non-painted. we believe that this method would make the peripheral iv line placement easier and faster for the forward medical team personal in the war conditions. one probable disadvantages of this method is the negative psychological effect on the combatant that makes them to estimate the risk of wounded in a few hours. introduction and objectives: ambulance and emergency care technicians are the key personnel for pre-hospital care of trauma. this study reviews the work anxiety states of some of the students in ambulance and emergency care technicians department, vocational school of health services, marmara university by comparing it with those of the students in radiology department of the same school. methods: this study was developed as a sectional type of study and was conducted on 94 volunteer students from the above mentioned departments. the data were analyzed using the spss 16.00 software and employing the frequency distribution, t-test for individual groups, and unidirectional variance analysis methods. results: the study group of subjects was 81.9% female and 18.1% male. 57.4% of the subjects expressed anxiety over their employment in the future; 42.6% of them expressed no work anxiety. the work anxiety points of the subjects were compared in terms of their genders, academic years and departments, and said comparison did not reveal any statistically significant difference (p > 0.05). conclusions: the work anxiety state is one of the major factors having an impact on professional success, and is a negative state having an impact on one's performance, success and, in turn, psychological state. it would be proper to study the issue of work anxiety by obtaining psychological support, and to cooperate with the actors in this sector to develop solutions. it is concluded that further studies should be conducted on work anxiety and its reasons. in general, emergency patients should be transported to the closest appropriate hospital. if the emergency medical services have identified a specific hospital with better resources to treat seriously injured patients, the patient should be transported to that institution, bypassing closer hospitals. the cooperation is expected between the hospitals, and the development of formal transfer agreements, describing all of the legal, economic, and medical aspects of the relationship are encouraged. ideally, the entire trauma system in a city should be designed on the basis of need and existing resources, with all affected parties involved in the planning, development, and implementation. the goal of the system is to match the needs of an injured patient to the resources of the available facilities so that optimal and cost-effective care is achieved. we conduct six essential questions for the preparation of trauma. is there a legal authority to formally designate hospital's trauma response in your city? what sources were used as a basis for standards of the trauma response in your service area? were the number of hospitals identified for your service area limited based on the results of needs assessment? what type of transport practice occurs in your service area when a field assessment identifies a trauma patient with severe injuries that threaten loss of life or limb? is a trauma registry present in your service area? is there a designated trauma advisory committee that evaluates the performance of trauma care delivery within your service area? we evaluated the role of primary hip arthroplasty (consisting of both total hip replacements and hemiarthroplasty) in these comminuted, osteoporotic or neglected fractures. these patients at-risk were in need of a single definitive surgical plan for early ambulation and preventing complications. typically these patients were elderly with poor mobility and had multiple other medical condition to be able to withstand multiple surgeries. there was a need to obtain the best results with the single, rapid procedure for pain relief and early ambulation. excellent to very good results were obtained in about 77% of these patients. good results were obtained in about 19% of these patients and poor results in about 4%. most of the poor results were the outcomes of complicated medical conditions rather than the failure of the orthopaedic procedure itself. we advocate arthroplasty in neglected, osteoporotic or severely comminuted per-trochanteric fractures for immediate mobilization and optimising outcomes. the role of intra-articular steroids or hyaluronic acid injections in early arthritis may be warranted and perhaps safe. but for patients waiting for a knee replacement these can prove positively dangerous. a meta-analysis has revealed that intra-articular injections given in patients waiting for a knee replacement procedure is fraught with dangers. apart from a high risk of post-operative infection and failure of the procedure, several other side-effects or complications make this risky. there is a higher-than-average chance of quadriceps tendon rupture, delayed wound healing, superficial infections and slower rehabilitation. in comparison hyaluronic injections have been found efficacious in the short term and do not contribute to complications normally attributed to steroids. thus intra-articular injections should be used with caution, repeated injections are best avoided and are certainly contraindicated if a procedure is anticipated to be performed within six months. introduction: pediatric forearm fractures are common. the majority has satisfactory outcome. but poor results do occur and malunion can compromise rotation. we belief that the angulation of the fracture depends on the action of the body and that we can reduce the fracture by completing the action. this way we can perceive a stable anatomic reduction without internal fixation. methods: we undertook a prospective study of distal forearm fractures in children. we included 21 children with a non-displaced angulated metaphyseal distal forearm fracture. the angulation was between 15°and 42°.we all reduced them by completing the action of the body. this means a volar angulated fracture is reduced by pronation of the hand and a dorsal angulated fracture is reduced by supination. after the reduction they were casted in an upper-arm cast in pronation or supination depending of the reduction manoeuvre. afterwards the all received 3 weeks of upper-arm cast and 3 weeks of lower-arm cast. results: they all healed without loss of reduction and without further treatment. they all had full recovery of function. conclusıon: non-displaced angulated metaphyseal distal forearm fractures in children can be treated conservatively by closed reduction and plaster cast. background: vascular endothelial growth factor (vegf) plays an important role in the bone repair process as a potent mediator of angiogenesis and influences directly the osteoblast differentiation. inhibiting vegf suppresses angiogenesis and callus mineralization in animals. however, no data exist on systemic expression of vegf with regard to delayed or failed fracture healing in humans so far. methods: one hundred fourteen patients with long bone fractures were included into the study. serum samples were collected over a period of 6 months following a standardized time schedule. vegf serum concentrations were measured. patients were assigned to 2 groups according to their course of fracture healing. the first group contained 103 patients with physiological fracture healing. eleven patients with delayed-or non-unions formed the second group of the study. in addition, 33 healthy volunteers served as controls. results: an increase of vegf serum concentration within the first 2 weeks after fracture in both groups with a following decrease within 6 months after trauma was observed. serum vegf concentrations in patients with impaired fracture healing were higher compared to the patients with physiological healing during the entire observation period. however, statistically significant differences were not observed at any time point between both groups. vegf concentrations in both groups were significantly higher than those in controls. conclusıon: the present results show significantly elevated serum concentrations of vegf in patients after fracture of long bones especially at the initial healing phase indicating the importance of vegf in the process of fracture healing in humans. first, dsbls is applied to 2.5 cm proximal to most prominent point of medial malleol of tibia. the dsbls was inserted parallel to the joint surface in frontal and horizontal plane. after the dsbls is applied the selected nail is inserted. reamed imn is used for the tibias with narrow isthmus (6). the success of di is checked following the insertion of nail with set screw on the dslbs. the unsuccessful attempts are repeated after the reason is removed. the di of 36 tibias were successful and 4 were unsuccessful at the first attempt. in unsuccessful cases, the nails were at the posterior (2), anterior (1) and lateral (1) collum femoris fractures accounts 4.5-5% of all fractures. however it is very rare in children (1%). in this study we evaluated 12 pediatric patients who were operated due to collum femoris fracture in terms of avascular necrosis and functional outcome. age of the patients ranged from 3 to 14. there were seven girls and five boys. two of the patients were admitted to the emergency department due to a fall from height, therefore they had multi system trauma. the remaining ten patients had isolated collum femoris fracture. fractures was classified according to delbet classificaion; seven transcervical and five cervicothrochanteric. locking plate-screw fixation was applied to one patient, other fractures were fixed with two or three cannulated screws. open reduction was applied to four patients and closed reduction to eight. five of the cases were operated in the first 24 h of the fracture, however the remaining seven patients were operated after the first 24 h (2-10 days) due to late admission. range of motion of the hip joint was limited in only one patient who had polytrauma and operated after the first 24 h. there were three avascular necrosis as acomplication. all of them operated after the first 24 h and all the fracture types were cervicotrochanteric. open reduction was applied to two patients and closed reduction to one. pediatric collum femoris fractures are rarely seen in children but treatment is challenging and open to complications. fracture type, surgical methods, did not effect the outcome, but timing of surgery did. author to editor: in this study we discussed the outcome of pediatric collum femoris fractures, which is a very rare fracture in orthopaedic experience. surgical management of humerus shaft fractures is an increasing interest nowadays. we want to discuss the outcome of conservative, open reduction and internal plate fixation (or _ if) and intramedullary nailing (imn) methods in adults (22-80 years old). 10 patients had conservative treatment with modified custom made sarmiento brace and 9 of them had union with 5°-20°of malunion. none of the nine have complains and the avarage union duration is 10 weeks (8-12). one patients did not tolerate bracing and undergone surgery. 14 patients had or _ if and 2 had gone second operation for nonunion and 4 had elonged wound drainage. all the fractures healed eventually with in 10 weeks (6-16). no neurovascular complication was observed. 18 patients had imn treatment and 4 had delayed union up to 6 months, 2 had undergone reoperation with or _ if for non-union, 1 had intraoperative fracture of elbow and 6 had shoulder problems with impingement and rotatory cuff problems. avarage union duration was found 9 weeks (7-12). surgical treatment is getting more popular for long bones nowadays. early return of work and social life, anatomic reduction, using no sling or such devices and easy follow up protocols are the facts that popularising the surgical management. but in our series, we had seen multiple types complications that are as high as they are mentioned in literature. with the experience of those 42 patients that had been treated with in this year, conservative treatment methods have to be conserned firstly in suitable and tolerable patients for us. intoduction and objectives: correction of sagittal deformity is important in thoracolumbar burst fractures. the clinical maneuvers needed for reduction and the assessment of correction of the fractured vertebra is not well described. in this prospective series we used the length of the interspinous ligaments as reduction parameter. our aim was to evaluate the efficacy of this assessment technique in achieving good correction. methods: from 1999 to 2005 25 patients (m/f 14/11, mean age 34.7) with unstable thoracolumbar burst fractures were treated by posterior fusion with a standard construct by a single surgeon. all patients were treated with segmental posterior instrumentation with two levels above and two levels below the fracture level fixation by means of pre-contoured rods and distraction technique. with these maneuvers the length of the injured level was tried to be equalized to the mean of upper and lower levels. anterior column was assessed by radioscopy. preoperative and postoperative radiographs were analyzed and local kyphosis (lk), farcy's sagittal index (fsi) and compression percentage (cp) were measured. results: the preoperative lk decreased from 18.96°to 3.44°, fsi decreased from 18.2°to 3.8°and cp decreased from 28 to 46.8. after a minimum follow-up time of 2 years all patients continue to do well with no statistically significant decrease in these parameters. conclusions: assessment of thoracolumbar burst fracture reduction with pre-contoured rods and distraction technique can be made safely by intraoperative measurement of the length of the interspinous ligaments. case: an 85-year old lady was admitted in our emergency department with a neer 3-part fracture of the right proximal humerus caused by a fall. she was operated on and received a shoulder hemiarthroplasty. during cementation of the stem the patient became bradycard and acute respiratory arrest occurred. she was resuscitated, but eventually died 9 h postoperatively. postmortem examination revealed embolic bone marrow occluding the pulmonary capillaries. comment: pulmonary embolus after upper extremity surgery is a rare complication. fatal pulmonary embolus is even more rare. when reviewing literature there is no previous case of fatal pulmonary embolus caused by fat emboli described. fat embolism syndrome was first described by zenker in 1861, but its frequency today is still unclear. usually it presents as a multisystem disorder. the most often and most seriously affected organs are the lung, brain, cardiovascular system and skin. it is a self-limiting disease, therefore treatment should be mainly supportive. purpose: lack of knee flexion is a possible complication in severe femur fractures. two different techniques for the treatment of this problem were applied. materıals-methods: from 2006 to 2008, 3 patients with severely arthrofibrotic knees were managed with two different operative techniques. the mean age of the patients at the time of the operation was 45 years. we recorded the clinical outcome of 1 patient using judet quadricepsplasty with a follow-up of 28 months, and of two patients using extra-articular mini-invasive quadricepsplasty and intra-articular arthroscopic lysis of adhesions during the same anesthesia session with a mean follow-up of 14 months. all patients were evaluated according to the criteria of judet and the hospital for special surgery knee-rating system. results: the average maximum degree of flexion increased from 33°p reoperatively to 65°at the time of the most recent follow-up. according to the criteria of judet, the result was good for 2 knees, and fair for one. the average hospital for special surgery knee score improved from 48 points preoperatively to 58 points at the time of the most recent follow-up. a superficial wound infection occured in one patient. conclusions: if you select the appropriate cases, the judet procedure and mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome. purpose: floating knee and elbow injuries are complex injuries. the types of fractures, soft tissue and associated injuries make this a challenging problem to manage. we present the outcome of these injuries after surgical management. materials and methods: two patients with floating knee injuries(classified by blake and mcbryde) and one patient with floating elbow injuries were managed over an average of 22 months. both fractures of the floating knee injury and the three fractures of the elbow injury were surgically fixed using different modalities. the associated injuries were managed appropriately. assessment of the end result used the karlströ m criteria after bony union. results: mechanism of injury was road traffic accidents in two patients (floating knee) and falling from height for one patient (floating elbow). there were 2 associated injuries, patient 1 was tipiia, patient 2 was tipiib. both these patients had intramedullary nailing for femur fractures. patient 1 had ilizarov external fixation for segmenter tibia fractures, patient 2 had a proximal medial plate for proximal tibia fracture. patient 3 had plates afıxed to all fractures.complications were knee stiffness and delayed union of femur in a patient (second operation required). the bony union time average from 32 weeks for femur fractures, 18 weeks for tibia, 12 weeks for upper extremities. according to the karlstom criteria the end results was acceptable. the average elbow score was 85/100 (good). patients with tibial bio-screw fixation there is insufficient evidence from randomized trials to determine the optimal intervention in patients with displaced four-part fractures of the proximal humerus: head preserving surgery with problem to obtain and maintain reduction until bone healing, implant failure, avn of the head, ha with > 50% tuberosities related complications-resorption, displacement, rsa with high complication rate, moderate function due to restricted rotation and insufficient long-time follow-up. in our presentation we will discuss: • new rsa designs, which improve function and lessen complication rates • question of tuberosities fixation to rsa in proximal humeral fractures • literature overlook of rsa in proximal humeral fractures the goal of rsa is to minimize shoulder immobilization and to start functional rehabilitation immediately. indications are same as for ha + tuberosity osteoporosis and comminution + week or absent rc. decision for if, ha or rsa is often intraoperative. tuberosities fixation is debatable (prolonged immobilization, prosthesis dislocation). functional results are more consistent than in ha, but complication rate is higher (it may be lowered by new prosthesis designs). 536 frequent ct scanning due to incomplete 3-view x-ray imaging of the cervical spine background: conventional c-spine imaging is still widely used, despite increasing replacement by ct scanning. the aim of this study was to analyze the frequency of incomplete c-spine x-rays (3-view series) in blunt trauma patients. methods: during a 2-year period we analyzed the frequency and value of 3-view series of the c-spine. secondary we assessed the reasons for subsequent ct scanning after the 3-view series according to the following classification: inevaluability, incomplete 3-view series, evaluation of findings on 3-view series or for unexplained, persistent clinical symptoms. furthermore we evaluated predictors for incompleteness. results: 88 c-spine injuries were diagnosed in 1283 blunt trauma patients (6.9%). 159 patients (12%) had their c-spine cleared based on the nexus criteria. 717 patients were primarily evaluated with 3view series and 395 patients primarily with ct scanning. within the population with primarily 3-view series 249 (35%) were repeatedly incomplete and 16 (2%) were inevaluable. in the major part of the incomplete 3-view series no apparent reason could be determined. however, the presence of clavicular fractures (resulting in incomplete radiographs in 68 vs. 43% without a fracture; p < 0.001) and rib fractures (56 vs. 34%; p = 0.008) were associated with incomplete 3-view series. conclusion: in more than a third of the patients primarily assessed with 3-view series, the results are incomplete or inevaluable necessitating ct scanning. therefore, the diagnostic value of 3-view series is questionable. in patients with clavicular and rib fractures 3-view series can be omitted and primary ct scanning is advised. the treatment of open distal tibia fractures is still discussed controversially and they are a great challenge for surgeons. it is still not clear if there should be initial stabilization with an external fixator or primary osteosynthesis with an intramedullary nail or plate. we retrospectively examined 20 patients with ii°and iiia°open distal tibia fractures which were treated during the last 4 years in our level one trauma center. we treated 16 male and 4 female patients with an average age of 31 years. ten patients were treated with an external fixator and 10 patients were treated with an intramedullary nail or plate osteosynthesis in acute surgery. the patients, firstly treated with an external fixator, were stabilized with reamed intramedullary nailing in eight cases and with locked plating in two cases after wound closure. there was no difference in the duration until bony union in any groups. fewer unplaned revisions (n = 3) and no deep osseous infections were found in those patients treated with an external fixator in the acute phase of the injury. patients treated with a definitive osteosynthesis underwent unplaned revisions in six cases and developed deep osseous wound infections in four cases. we therefore recommend that initial treatment with an external fixator should be preferred and after consolidation of the soft tissue, the definitive stabilization should be done with a stabile osteosynthesis system. author to editor: this topic remains of a high interest among trauma surgeons, especially now, that angle stable intramedullary fixation systems run the market. fractures of the clavicle shaft are common and have been typically addressed to nonoperative treatment. but favorable results with the precontured anatomic plates are facilitating surgeons for primary surgical treatment. this study reports the surgical results of 10 adult clavicle shaft fractured patients (age range 18-76) that had been operated with in last 18 months. all fractures were displaced and none of them was open nor had neurovascular injury. avarege healing time was found 8 weeks (4-50 weeks). all patients had anatomic reduction postoperatively. 5 of the patients fracture site was grafted with dbm. 4 of 10 patients had sterile wound drainage which was lasted for 2 weeks postoperatively (all were grafted with dbm), 5 of them re-operated (3 of them for early implant failure and 2 early implant removal for plate disturbance) and one patient was operated for 5 times (2 of them was in another center) for early implant failure, nonunion,wound problems and neurovascular complications. 9 of 10 was healed eventually. 9 of 10 patients were satisfied with the treatment and had a full range of motion at final follow-up and were able to return to pre-injury occupational and activity levels. nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits. however, our study shows that surgical treatment also has high complication rates. there is currently considerable debate about the benefits of primary operative treatment of these injuries because it remains difficult to predict which patients will have these complications. platelet rich plasma (prp) is applied in orthopaedic, maxillofacial and plastic surgery with variable outcome. different growth factors and cytokines are stored in platelets, including platelet derived growth factor (pdgf), contributing to the potential positive effects of prp. the aim of our study was to investigate the properties of pdgf administered locally in a rat femoral non-union model. in our experiment a critical sized osteotomy was performed in the rat femur, which was filled with a spacer, inhibiting bone formation for a period of 4 weeks. in a second operation this spacer was removed and the test item was applied into the defect. we compared the pdgf group (d = 250 ng, c = 1 lg/ml of pdgf in fibrin matrix) with the fibrin alone and blank control groups. four weeks after the second operation, specimens were analysed by x-ray, lct imaging and histology. in group pdgf we found a lct confirmed union in 0 of 7 specimens and the lct evaluated bone volume was median 7.2 mm 2 (q1 = 6.1/ q3 = 10.8). in the control groups there was a bony bridge in 3 of 7 fibrin and in 2 of 8 blank specimens. the bone volumes were median 15.7 mm 3 (q1 = 8.0/q3 = 18.4) fibrin and median 9.1 mm 3 (q1 = 7.1/q3 = 22.7) blank, respectively. we did not find a strong tendency for new bone formation in the group treated with pdgf. in our model we observed even a tendency to inhibit bone regeneration for pdgf. introduction and objectıves: hand traumas are one of the most common encountered complex traumas. closing the defects on either dorsal or palmar side of the hand is sometime difficult because of limited local tissue and to provide a tissue the tendon glides underneath. in spite of high risk of donor side morbidity and sacrificing a major artery of the hand, radial forearm flap is the most frequent choice to close the defects at this region. method: in a year time, five patients with severe hand traumas who admitted to our clinic, treated with perforator based three radial artery and two ulnar artery adipose-fascial forearm flaps. the adipose-fascial island flap was raised on one or two of these perforators without sacrificing a major vessel.the flap was transposed to defect region and covered with stsg. in all five patients' donor side was closed primarily. results: the biggest flap size was 10 · 8 cm. there was no flap loss except one patient who had partial flap necrosis and it healed secondarily. the donor side was healed uneventfully in all the patients. there was no tendon adhesion. conclusıon: perforator based radial or ulnar artery adipose-fascial flap is a safe and reliable method for closing defects on the hand. it has both less donor side deformity and fascial component of the flap provides better tendon gliding and less tendon adhesion. however, it requires more experience to raise adipose-fascial flap. introduction and objectıves: one of the most common causes of the lower extremity defect in adult is a road traffic accident. the most challenging issues is to close the defect on the 1/3 of lower extremity because local tissue is very limited and mostly damaged due to high energy injury. we investigated the difficulties of how we close the defect on one third of the lower extremity particularly in children, in our unit. method: in a year time, 7 patients under 6 years old admitted to our unit. all patients had gustillo iiib injury and the biggest size of the defect was 20 · 13 cm. one patient had 2 different lesions on the heel the other was on the anterior aspect of tibia. after radical debridement, the wound closed with alt free flap with in first week of admission. 2 different defects on a lower extremity were closed with alt and vastus lateralis muscle free flap with a single pedicle. result: the biggest flap size was 22 · 13 cm. an average pedicule length was 6.3 cm and the diameter of the vessel was 1.2 cm the average operation time was 5 h 53 min. one flap had partial necrosis and healed secondarily. they had uneventful recovery and discharged on average 8 postoperative days. conclusıon: in children even less than 6 years age, one of the good and suitable options for closing the defect on the one third of the lower extremity is alt as a free flap. stable odontoid fractures can be treated with external immobilization using, e.g., a philadelphia collar (pc) or a halo thoracic vest (htv). it is important to delineate the capacity of both orthoses, halo and philly, for immobilization of the atlantoaxial complex (aac), e.g., for their use in odontoid fracture care. in this in-vivo biomechanical comparison 20 volunteers (mean age = 30.9 ± 4.2) were subjected to flexion-extension radiographs immobilized in a modified htv and a pc. radiographs were analyzed for the segmental rotation angle of c1-2 in sagittal plane (sra c1-2) and the absolute rotation angle of c2-7 (ara c2-7). separation angles (rsra c1-2 and rara c2-7) were calculated from flexion-extension views. concerning restriction of subaxial sagittal plane motion, the htv was more effective than the pc. the difference for the rara c2-7 between the pc (mean 20.7°) and htv (mean 9.2°) yielded significance (p = 0.01). but, concerning restriction of flexion-extension at the aac, there was no statistical significant difference for the rsra c1-2 between the pc and htv (p = 0.3). pc (mean 1.3°) was superior to the htv (mean 3.3°) in restricting sagittal motion at c1-2. in comparison to normals atlantoaxial motion was restricted by 88.5% (pc) and 70.8% (htv). the current study demonstrated that there was no significant difference in restriction of sagittal motion at c1-2 between the pc and htv. in light of the current biomechanical data and a selected review of literature it is concluded that the use of a pc is sufficient for the treatment of stable odontoid fractures. introductıon: although most ankle injuries are associated ligamentous structures, some types of fractures mimic to ligamentous sprain and misdiagnosed as well. most of the ankle sprains undergo radiographic examination and some of type fractures easily are missed even x-ray. the aim of this study is to evaluate the missed talar neck fractures and to emphasize the missed fractures. materıals-methods: misdiagnosed 8 cases were included in the study. average age at the time of trauma was 28 (20-40). all cases evaluated prospectively. if the patients had ankle sprain and their initial x-rays show no evident of fracture, they were involved in the study. the diagnosis of the fracture was figured out by control x-ray, ct scan and mri (except 1 case). all patients were evaluated by the scoring system of american orthopaedic foot and ankle society (aofas introductıon and objectıves: treatment of proximal humeral fractures remains controversial, because of complexity of this kind of fractures. the purpose of this study is to present our first experience using angular stable fixation in 3 and 4 part proximal humeral fractures method: in last 6 mounts we treated 19 patients with this method, 9 men and 10 women (mean age 62). anterior approach was performed in every case (mis technique in two cases), and every patients underwent to early rehabilitation. periodical clinical and radiographic control were performed. results: short term results are good with satisfaction of the patient, no pain and acceptable range of motion. we have 1 case of deep infection that need revision surgery and antibiotic treatment. preoperative diagnosis of appendiceal diverticulitis is rare. the incidence of appendiceal diverticulitis ranges from 0.004 to 2.1%. 60% of the diverticulitis of colon cases appear above 70 years of age, and they are mostly in the left colon. case: a 73 year-old male, who had a 1-year history of episodic right lower quadrant abdominal pain was admitted to the surgical emergency department for worsening of his complaints. the physical examination was only notable for right lower quadrant abdominal tenderness. laboratory findings was normal. on ultrasonography examination signs of acute appendicitis was noted. as the radiological findings did not match with the clinical status of the patient, he was followed up. later, acute abdominal symptoms appeared, and the patient was admitted to the operating theatre. two 1 cm long nodules were seen on the appendix preoperatively. appendectomy was done. the patient was discharged on the first postoperative day. the histopatological examination revealed acute appendicitis signs and two 10 mm long diverticula one of which is inflamed in the middle and the other in the distal part of the specimen were reported. conclusıon: the most common cause of acute appendicitis in adult population is fecaloid. lymphoid hyperplasia, carsinoid tumors, mucosel, parasites, fruit and vegetable seeds are other causes. although appendiceal diverticulitis is rare, clinicians should be aware of its occurrence and tendency for appendiceal perforation. introduction and objective: traumatic intracranial hematoma is the most common complication of the head injury requiring emergency intervention. as most of them are located supratentorially, they can be seen less frequently in the posterior fossa. this study aims to evaluates the clinical, radiological and surgical aspects of traumatic posterior fossa hematomas in patients who were treated at our center. methods: the records of 16 patients with of traumatic posterior fossa hematomas that had been treated at our center between 1998 and 2008 were reviewed. results: of the 16 cases, 10 had cerebellar hematomas and 6 had epidural hematomas. fall was the most common cause, followed by animal kick, assault and traffic accident. diagnosis and management decisions were determined by cranial computed tomography scans. surgical intervention was performed in 8 cases. the outcome was good in 13 patients. three patients died who had low gcs at admission and additional cranial lesion. conclusions: patients with occipital trauma should be evaluated immediately using cranial computed tomography scans. early diagnosis of traumatic hematomas and prompt surgical intervention in those having mass effect provide good results. introduction: transcranial stab wounds made with a knife mostly produce a classic slot skull fracture and underlying tract hematoma, and often cause severe neurological deficits. an unusual case with combined pareses of oculomotor and trochlear nerves due to penetrating stab wound to the brain is presented. methods: a 14-year-old boy was admitted to our clinic after an altercation that resulted in the patient sustaining stub wound to his head. results: he was conscious. neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, and infraduction, incomplete convergence and left sided ptosis with dilated pupil. an emergency computed tomographic scan of his brain was obtained, which revealed a left slot fracture at the squamous portion of the temporal bone of the anterior cranial fossa and a frontotemporal intracerebral stub tract hematoma. he underwent emergent surgery. fractured bone pieces and lacerated brain tissue were removed. neurological deficits remained unchanged at 12 months follow-up. conclusions: cranial nerve injury related to the knife wound to the brain is very rare. the penetration site, depth of penetration and trajectory of the object are important in occurring of this injury. prognosis seems to be poor in these cases. introductıon: large number of knee x-rays are done incidentally for patients presenting with knee trauma in accident and emergency. using only one lateral view knee x-ray as a screening tool would reduce the cost by 67% as per a. verma et al., an interesting proposition. method: we investigated the validity of lateral view knee x-rays alone as a screening tool for detecting fractures around the knee in acute knee trauma. 102 randomly picked x-rays were reviewed. the ap and lateral views were interpreted by a consultant radiologist and the findings used as gold standard for the study. the lateral views alone were independently interpreted on two different occasions by the (a) radiographer (b) emergency nurse practitioner accident & emergency (c) middle grade doctor accident and emergency (d) consultant orthopaedic surgeon. results: there was significant inter observer variation in sensitivity which ranged from 66 to 86% with the highest sensitivity being achieved by the radiographer. the specificity was generally high with a range from 84 to 97%. though there was a high validity in the case of the radiographer the sensitivity for the other observers was low. conclusıon: though there could be a significant saving in terms of resources and unnecessary radiation by doing lateral views alone as opposed to the routine ap & lateral views as first line x-rays, we do not recommend using the lateral views alone as a safe screening tool in knee trauma because of high inter observer variation in sensitivity. tk gullett, charalambous p. charalambous, ajay sahu, matt j. ravenscroft 1 1 stepping hill hospital, stockport, uk introductıon: in distal biceps tendon ruptures, re-attachment to the radial tuberosity should ensure an adequate tendon to bone surface contact to achieve a sound repair and fast tendon to bone healing. method and technique: we are describing a l-configuration reattachment of distal biceps tendon rupture, using a single anterior transverse incision at the cubital fossa crease. each pair of sutures from the most distal anchor is passed through the distal part of the tendon. one strand of each pair is passed in a zig zag fashion through the tendon whilst the other strand is simply passed straight through the tendon in a posterior to anterior direction. the four strands of the proximal anchor are passed so that they form two mattress sutures through the proximal part of the tendon. tightening is then performed in a specific sequence with initially pulling on strand a and b to bring the tendon down to bone and then tightening these to the corresponding suture strand of their pair. the two pairs of sutures are then tied to each other. this second anchor tightening ensures that the tendon is brought down onto the bone in an l configuration increasing the contact surface area between tendon and bone. results: we have used this technique in 26 patients till now with excellent results and no re-ruptures. discussion: our technique is simple to perform and provides a sound repair with a large surface area of contact between tendon and bone. results: out of a 66% (n = 494) response rate, 305 respondents (101 male, 204 female) were included in the study. we excluded people with previous hip, knee or back problems. in our study, the symptom scores that is lysholm, oxford and visual analogue scale for pain and function did not show any significant decline with age. on the other hand, the scores measuring activity levels that is tegner and ucla scales declined significantly with increasing age. our normal scores were far ahead of age-matched post operative scores following total knee replacement. there was no difference between males and females. the symptom scores declined with increase in medical problems. conclusıon: our age matched scores were superior to post operative total knee replacement (tkr) scores from the njr. this furthered our motive to create a set of reference knee scores in the normal population which could be used by other studies to compare their results and help improve postoperative outcomes. mesenchymal stem cells (mscs) are multipotent stromal cells that have extensive proliferative potential and the ability to undergo multilineage differentiation. traditionally, osteogenic differentiation of mesenchymal stem cells has been studied in cells isolated from bone marrow and iliac crest. however, these harvest techniques are associated with several problems, including donor morbidity, pain, and limited amount of cells. only a few years ago, adipose tissue has been identified as another source of mulitpotent mscs, which are referred to as adipose derived stem cells (adscs). the aim of our study was to provide a comparative analysis of primary osteoblasts from the iliac crest and osteogenic differentiated mscs from adipose tissue, using osteoblast-specific protein expression. in 21 patients the cells were differentiated into the osteoblast lineage using osteogenic medium (adobs). primary osteoblasts were isolated from iliac crest specimens in 30 patients undergoing osteosynthesis with spongioplasty (female: 16, male: 14, mean age 54 ± 14.7). phenotype marker expression of osteoblast-specific proteins osteocalcin, alkaline phosphase, type i collagen, and cbfa-1 (runx-2) was analyzed up to 21 days following incubation using rt-pcr, western blot, and immunocytochemistry. additionaly, the following surface proteins of adscs were analyzed: nucleostemin, cd34, cd105, cd 10, cd 13, cd 59, and cd 166. rt-pcr analysis revealed that the non-differentiated adscs contained different types of stromal cells with a large variety of cd marker expression. surface protein expression (cd) did not differ significantly in cells isolated from either fat tissue or bone. author to editor: saved by lookus. background: at our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. cases and methods: we examined 247 out of 289 hepatic injury patients, excluding cardiopulmonary arrest cases. the present study was undertaken to establish a valid strategy for the treatment of hepatic injury, and further improvement of the survival rate was evaluated based on the grater and equal of grade iv [organ injury scale (ois)] hepatic injury necessitating emergency room laparotomy. result: interventional radiology (ivr) treatment cases were all stable or responder patients and all survived with effective hemostasis. transient responder or non responder patients that needed hemostasis were treated by emergency laparotomy, and all the cases that eventually expired needed dcs. the mean injury severity score (iss) was 42.3 and the mean probability of survival (ps) was 0.413, and hemostasis treatment was started within a mean of 39.1 min, yielding a survival rate of 42.9% in the cases with grater and equal grade iv (ois) liver injury that needed emergency room laparotomy. conclusion: our criteria for deciding the therapeutic strategy based on the response to the initial fluid resuscitation seemed to be useful from the viewpoint of hemostasis for liver injury. the key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients to the center as rapidly as possible. author to editor: we show that our classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system is very effective for liver injury strategy. fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. the gamma-nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. a series of 70 fractures of the proximal femur in which this nail was used is reported. the average age of patients was 81.5 years (range 50-97 years). 72.2% (51 patients) of the cases were female. the average duration of the operation recorded was 42 min. in all cases closed reduction was achieved. the mean healing time was 8.5 weeks in 97.1% of the cases. there were two cases of delayed consolidation but no pseudarthroses. postoperative complications occurred in 12 cases (17.1%). one case of migration of the proximal screw was the most important complication. the most frequent complications (7 cases) were seromas and hematomas of the surgical wound, which resolved satisfactorily in all cases. superficial infections (4 cases) also evolved favorably, once the appropriate antibiotic treatment had been instituted. no breakages or failures due to implant fatigue were seen. the patient's recovery after suffering the fracture and the operation was evaluated and the 80% (56 patients) recovered their previous walking ability. the overall mortality was 8.6% (6 patients) with 2 of the deaths occurring while in hospital. in conclusion, this preliminary study has shown that gamma-nail can be safely used by the average surgeon in the average hospital to treat a common and sometimes difficult fracture. valerio ranieri, loris trenti, aldo rossi, antonio manenti 1 1 departement of general surgery, university of modena and reggio emilia, modena, italy a 27 years old nigerian woman, at the end of the 2nd pregnancy, was submitted to a caesarean section for uterine atony. post-operative thrombo-prophylaxis was given. from pod 3, fever, abdominal pain and increasing tenderness in the right lower quadrant with leucocytosis appeared. ultrasonography showed only small amount of fluid in the douglas pouch, while a contrast-enhanced ct and a rmn revealed a dishomogeneus cylindrical mass of 2.5 cm in diameter extending from the right parauterine space towards the duodenum, suggestive of thrombosis of the ovarian vein. laparotomy followed: uterus, ovaries, appendix and bowels were normal. after mobilizing the right colon the ovarian pedicle appeared enlarged and firm; it was dissected, starting from the vena cava, and completely excised preserving the adnexa. post-operative course was uneventful. histology confirmed a suppurative thrombophlebitis; the haematological study ruled out any coagulation abnormality. the patient completed a 6 months low-molecular-weight-heparin treatment. ovarian vein suppurative thrombophlebitis can seriously complicate a caesarean section, till to require a surgical treatment. the imaging is essential for a prompt diagnosis. purpose: to prospectively study the mechanism, distribution of injury, and outcome of patients hospitalized with camel bite injury. methodology: all patients admitted to al-ain hospital with a camel bite were prospectively studied over 6 years (october 2001 -october 2007 . mechanism of injury including behavior of the camel, distribution and severity of injury, patient's demography, and outcome were studied. results: all 33 patients were males having a median (range) age of 27 (10-58). almost half of them were pakistani. twenty-five were camel caregivers while five were camel riders. seven patients were raised up by the camel's mouth and thrown to the ground while the other patients were only bitten. majority of the injuries were in the upper limb (21) followed by the head and neck (8). 10/21 upper limb injuries had associated fractures. two patients who were bitten at the neck were admitted to the icu. one of them died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. the median hospital stay was 6 days. one patient died (3%). conclusıon: the behavior of the camel is occasionally unpredictable and the canine teeth of the camel, which are long, can cause severe penetrating trauma despite the small puncture on the skin. care should be taken when handling the camel. author to editor: dear colleague: this is the only prospective clinical study of camel bites in the literature that took us 6 years to collect. the data is very unique and is of great interest. fikri abu-zidan gastrointestinal cytomegalavirus infections occurs predominantly in immunocompromised patients.involvement of the gastrointestinal tract in acquired immunodeficiency syndrome (aids) patients is frequent. however the prevalence of cytomegalovirus appendicitis is exceedingly rare. case: a 44 year-old male infected with the human immunodeficiency virus, who had chronic abdominal pain with subsequent development of acute right lower quadrant tenderness was admitted to the surgical emergency department. his physical examination revealed no other finding than a mass in the right lower quadrant. his abdominal ultrasonography and abdominal ct revealed a plastron appendicitis. so he was hospitalized for medical treatment and discharged after 10 days of treatment. his control abdominal ultrasonography and ct at the second month showed that plastron appendicitis persisted, therefore the patient was rehospitalized. he was discharged after 10 days of medical treatment. after 3 months the patient experienced severe abdominal pain. appendectomy was performed and histopathogic examination revealed a cytomegalovirus infection. the problems related to diagnose cytomegalovirus appendicitis and therapeutic management of cytomegalovirus infections are discussed. conclusion: aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended. introduction: spontaneous intramural hematoma of intestine due to anticoagulan therapy is an unusual reason for acute abdomen. the first symptom is usually severe abdominal pain, nausea and vomiting. the most useful radiographic methods is computed tomography. the treatment approach is conservative and surgical. we present four patients treated our clinics due to intramural hematom. two patients are treated surgically and two patients are treated conservatively. material and method: we carried out four patients diagnosed and treated for intramural hematoma of small intestine between 2003 and 2008 years in haydarpasa numune training and research hospital second surgery department. we examine in this patients age, sex, etiologcy, hematologic parameters, the treatment approach (conservative and surgery), hospitalization times. results: the mean age of the patients was 60.2 years (range 38-78). all patients were male. the etiological factor was warfarin treatment due to aort valve replacement in three patient and ischemic cerebral disease in one patient. laboratuary parameters were elevated leukocyte counts in all patients. two patients was treated by surgical treatment due to intestinal obstriction and ishemia two patient was treated conservatively (nasogastric decompression and total parenteral nutrition). median hospitalization time was 8.7 day (8-11). discussion: when patients using anticoagulan therapy applied to emergency unit with abdominal pain, physicians must remember intramural hematoma as reason of acute abdomen. first choice is conservative treatment however cases of acute abdomen with intestinal obstriction and ischemia require surgical intervention. introductıon: motorcycle accidents continue to be a source of severe injury. the joy and exhilaration of riding motorcycles brings with it the risk of morbidity and mortality associated with these accidents. case: it concerns a 47-year-old man that in 21/10/07 entered the emergency room after suffering a motorcycle accident. at the admission he had pain, swelling and deformity of the left knee. radiographs showed tibial plateau fracture type vi of schatzker. he was submitted to surgical treatment with open reduction and ostheosynthesis with liss plate and was orientated to rehabilitation. six months after, the fracture was healed in correct alignment, had normal gait, normal knee range of motion and returned to work. eight months after surgery he suffered another motorcycle accident with left leg trauma, radiographs showed a supracondylar femoral fracture type 33.a3 ao-asif and diaphyseal tibial fracture below the plate. he underwent surgical treatment with open reduction and osteosynthesis of the supracondilyan femoral fracture with lcp plate, extraction of the liss plate and ostheosynthesis with diaphyseal lcp plate. eleven weeks postoperatively, he was able to walk without crutches. five months after had normal range of motion of the left limb and was working. conclusıon: tibial plateau fractures are serious injuries and stable fixation without compromising the soft-tissue envelope is often difficult but with the liss plate we can achieve fixation of an associated metaphyseal/diaphyseal fracture component with minimal approach. multiple consecutive fractures are an important source of limb deformity and impairment, which we could prevent in this case. introduction: the optimum management of non-united humeral diaphyseal fractures remains unclear. a number of implants are available utilising varying operative philosophies and balancing operative complication risks. we present two cases of humeral shaft non-union treated with an intramedullary compression nail, a technique which is previously unreported. cases: case 1: a 23 year old male with a closed fracture of the humeral diaphysis (12-a3). initial failed open reduction and internal fixation with an anterior placed 4.5 mm dynamic compression plate (dcp) was subsequently revised to a posterior 4.5 mm dcp plus bone graft 3 months later. one year post revision, the fracture had failed to unite and was referred to the senior author. he underwent a 2 stage reconstruction with the t2 humeral intramedullary nail in compression mode. at 6 month review the fracture had united and at 2 years postoperatively he had full range, pain free shoulder and elbow movement. case 2: a 90 year old female with a closed diaphyseal humerus fracture (12-a1) treated conservatively in a u slab and functional brace developed a mobile, painful non-union. she underwent the same procedure as above and at 6 months the fracture had united. she was pain free and had full range of elbow movement. shoulder movement was restricted due to co-existing glenohumeral osteoarthritis. conclusion: key tenets of fracture and non-union surgery include the ability to obtain stability and compression. this paper describes the first reported use of an intramedullary nail in compression mode for humeral diaphyseal non-union. fingertip amputations are the most common type of amputation injury in the upper extremity and they are important because of an often disproportionately long period of convalescence. different surgical procedures are available for reconstruction, but none is absolutely satisfactory. twenty-two cases (19 patients) of fingertip amputation have been treated by primary skin closure using the v-y plasty (tranquilli-leali). there were 14 men and 5 women. the average age was 38.7 years. the procedure was carried out under regional anaesthesia using a tourniquet. all devitalized tissue was excised and the bone was smoothed. a triangular flap with a distal base was developed. the width of the base should be the same as the amputated edge of the nail or the nailbed, and the length should be a little longer than the width. the flap was mobilized and sutured to the nail or the nailbed. finally the volar gap was closed. the average follow-up period was 18 months, ranging from 6 to 27 months. all of the flaps survived and achieved normal or adequate two-point discrimination. two patients had some loss of distal interphalangeal joint extension and five patients had cold hypersensitivity. rapid return to work was possible in most cases. the technique is simple and presents an excellent method for fingertip reconstruction in allen type i, ii and iii injuries. bilateral anterior shoulder dislocation is rare, and his aetiology is via various traumatic insults, atraumatic occurrences, and through extreme muscular contractions like epilepsy. in epileptic seizures is more common to occur posterior bilateral dislocation. the aim of this work is to describe a rare case of anterior bilateral shoulder dislocation after a convulsive crisis. it concerns a case of a 35-year-old male, with alcoholism history, who entered the emergency room in 25/05/08 with a generalized tonic-clonic seizure. after, he had bilateral shoulder deformity and swelling. radiographs demonstrated a bilateral anterior shoulder luxation and bilateral greater tuberosity fracture. the dislocation was reduced and both shoulders were immobilized. 1 month later, radiographs showed bilateral reduction maintenance and bilateral greater tuberosity fracture deviation. the patient had extremely restriction of active and passive ranges of motion in both shoulders: in the left had 5º of active external rotation and 60º of abduction; in the right 0º of active external rotation and 50º of abduction. at this moment surgical procedure was done with bilateral open reduction and osteosynthesis with ''phylus'' plate and was orientated to physical rehabilitation. at the 2 month follow up, he had significantly improved both shoulders range of motion, and returned to the normal daily activities and 2 months later returned to work. displaced fractures of the greater tuber-osities after shoulder dislocation may result in motion limitation and functional disability. open reduction and stable fixation allows for early passive motion of the joint and early return to activities of daily living. introduction and objectıves: direct inoculation, hematogenous spread or underlying medical illness which can predispose a patient easily for osteomyelitis are the causes of a vertebral infection. this case report represents a vertebral osteomyelitis of a patient seen after spine trauma. case: an 11 year-old girl was admitted to our out-patient clinic with a history of progressive back pain. her inflammatory markers were high, physical examination revealed only spinous tenderness to palpation and she had a spine trauma history when she was at nine. radiological evaluation demonstrated lumbar 1 and 2 mild anterior compression, an incomplete intervertebral fusion and endplate irregularities with an intact spinal cord. bilateral sequential transpedicular drainage from l1 vertebra was performed without any complication. she has a pain free course of 6 months with negative inflammatory markers. conclusions: the management of vertebral osteomyelitis is often challenging and in case of continuing pain and progressive kyphosis, surgical treatment is indicated. beside aggressive surgical procedures, minimally invasive techniques can be an option for the treatment of such cases. 1. instead of standard screws with diameter of 8 mm using screws with diameter of 9.5 mm 2. instead of 2,2 diameter cannulated tunnel using 3, 2 mm cannulated tunnel results: in use of this new modified method the time of surgery is shorter, the percutaneous surgical technique is simplified, the blooded lose is minimalizied, the surgery can be performed by two persons: the surgeon and the scrub nurse and few special instruments required. conclusion: based on our results we recommend this modified minimal invasive percutaneous osteosynthesis in case of garden iii femoral neck fractures, in garden iv one, especially immobile patients and patients with poor general conditions (asa score iv). introduction: pelvic fracture is one of the serious skeletal injuries, resulting in substantial mortality. the large amount of kinetic energy necessary to fracture the bony pelvis often leads to concomitant thoracoabdominal injury. pelvic fracture and combined injuries need effective initial resuscitation. however, it is hard to predict the mortality due to the complexity of multiple injuries. therefore, the introduction and objectıves: in this study, we aimed to investigate the distribution of the diagnosis in patients who underwent urgent surgical intervention in the operating room. methods: distribution of the diagnosis in patients who underwent an orthopaedic urgent intervention in the year 2008 are evaluated retrospectively from the medical records. results: 18 patients with orthopaedic complaints [17 male, 1 female; mean age 28.8 (3-56) years] were operated on urgently in the year 2008. 10 patients (7 shoulder, 2 hip and 1 lisfranc dislocations) had traumatic acute joint dislocation in which closed reduction was unsuccessful without general anestesia, one had supracondylar humeral fracture, one had distal femoral epiphyseal type ii fracture, one had isolated radial shaft fracture with neurovascular injury, one had t12 spinal fracture dislocation with paraplegia, one had type iii acromiaclavicular ligament rupture, one had quadriceps muscle laceration due to knife wound, one had tendo calcaneus rupture and one had patellar tendon rupture with medial meniscal injury due to knife injury. the mean time from admission to operation was found 4.5 h (range 1-6). conclusıon: it was concluded that the closed reduction of joint dislocations under general anestesia were the major group in orthopaedic urgent intervention. 589 why ankle should be reduced urgently? shahzad sadiq, tariq mahmood 1 1 worcester acute hospital, worcester, uk fracture dislocation of ankle is common orthopaedic emergency. it is paramount that to avoid soft tissue damage, the ankle is reduced as soon as possible. despite all efforts ankle dislocations could lead to significant blister formation. we reviewed a case series in which ankle joint was reduced with external fixator until skin healing methods: the cases who were admitted to our emergency department between august 2006 and2008 and were exposed to traumatic extremity amputation were studied. the medical records such as age, sex, education level, occupation, the way trauma occurred, the affected anatomic zones, performed interventions and hospitalization duration parameters were evaluated. results: the data of 309 subjects were evaluated in this study. mean age was 29, the rate of female/male was 1/4.5. there was a reverse correlation between the education level and occurrence prevalence. 48.12% of the cases were laborers, 30.45% various free self employed and 12.40% were farmers. according to their occurrences, industrial accidents 65.69%, pinching finger in the doorway 17.15% and home accidents 8.73% formed the first three rank. hand finger amputation was 93.85%, toe amputation 3.24% and others were 2.91%. while 209 cases were treated at the emergency service and discharged, 93 cases were referred to related clinics. five cases were referred to other centers and two subjects willingly left our clinic. the mean length of stay was 3.8 days. conclusıons: traumatic amputation concerns particularly the young and the people in active work life. since the majority of the cases have hand injuries, they are striking because they cause workforce lose in addition to cosmetic and functional defects. introduction: distal radius fractures are one of the most common injuries regardless of age group. due to their localization they pose a serious threat to the fine wrist movements. for most of the patients the perfect functional result is of a vital importance. open reduction and stable osteosynthesis may help to produces desired outcome. methods: we have compared 15 distal radius radius fractures treated with open reduction and stabilization with 3.5 mm synthes lcp and 15 treated with synthes 2,4 mm lcp. we have compared the functional results, neurological damage and patient comfort with questionare form. measurements from x-rays were also compared. we have included 30 patients of age between 24 and 68 years, with distal radius fracture. 18 of them with intraarticular fracture. results: intraarticular fractures of distal radius treated with synthes 2.4 mm lcp show better functional results compared to synthes 3.5 mm lcp. there is no relevant difference depending on used material in extraarticular fractures. conclusıons: we recommend the use of synthes 2.4 lcp for intraarticula distal radius fractures for its greater diversity and abillity to stabilize even a small fragments. introduction and objectives: surgical treatment of fractures by using resorbable implants is not too expanded alternative to classical steel or titanium implants. indication for using are intraarticular and periarticular fractures at first of all. the most advantage is no necessary of implants extraction. another one is propagation of load callus during the degradation of material. possibility of making profitable ct and nmr is indispensable.in this paper author presents experiences with using of resorbable screws. methods: at our department there are resorbable cortical screws 2.7, 3.5 and 4.5 mm bionx made from polyamide polymer with minimal stronghold for 20 weeks and total absorption after 4 years. this screws are determinated for cancellous bones in periarticular areas. we are using them in cases of fracture posterior wall of acetabulum, distal humeral intraarticular fractures, radial head. it can be used for treatment children¢s fractures too. the follow up is same like in ''classical'' osteosynthesis. results: there were no infection's complications, no malfunction screws in our group of patients. the postoperative and ambulatory treatment including physiotherapy was same like in group with classical osteosynthesis. the only one failure was during surgery -we have wraped screw four times because of insufficient pre-drilling and using too much power during insertion. we could recommend resorbable screws as suitable alternative in some type of surgical treatment intraarticular fractures at most. the indication have to be well look over and way of using has to be well understand as well as careful manipulation during surgery. the benefits are no metal material, no extraction in future and profitable ct and nmr. 598 heart valve lesions in blunt cardiac trauma -mechanism, diagnosis and treatment robert lipovec, granc gregorcic 1 1 department of cardiac surgery, university clinical center maribor, maribor, slovenia because of the variation in diagnostic criteria, cardiac involvement in blunt chest trauma is estimated at approximately 15%. in contrast to cardiac contusion which is often difficult to validate, traumatic valvular lesions are usually associated with some degree of hemodynamic impairment. patients with positive findings on clinical examination, ecg, cxr and troponine should be screened for valvular lesions by transthoracic echocardiography. blunt injury to cardiac valves can lead to progressive ventricular failure often requiring surgical management. patients with structural damage to the left sided heart valves usually require immediate surgical repair, while right sided valvular lesions can be managed in a delayed fashion. the management is based on type of structural injury and hemodynamic compromise. valvular reconstruction is usually attempted, if possible. the paper outlines historical perspective, mechanisms of injury as well as our experience with diagnosis and treatment of traumatic valvular lesions. two case reports are presented. one patient had a traumatic mitral chords rupture and the other had a tricuspid papillary muscle rupture. both cases were diagnosed immediately and surgically corrected. the ruptured mitral valve was urgently replaced. the tricuspid valve was repaired by delayed surgery. patients in al-ain city, united arab emirates 13.18%, respectively. only the difference between group iia and iib was found to be statistically significant. dıscussıon: rib fractures increase the pain and have a negative effect on breathing during postoperative course. ineffective breathing may cause athelectasis, fever and infection which is associated with increased morbidity. the incidence of rib fractures are higher in anatomical resections in whom the thoracic cavity should be opened widely. a longer incision and step to step opening of the thoracic cavity may decrease the incidence of this undesirable complication. objectıve: this case report describes a surgical method to treat multiple rib fractures by using arch bars. case: a 52 year old male patient was admitted to emergency unit with bilateral flail chest, bilateral multiple rib fractures, bilateral hemopneumothorax and pulmonary contusion. the patient was initially tachypneic and had a shallow breathing. because of the respiratory arrest he was intubated. physical examination revealed crepitation from subcutaneous and oseeous tissues especially on the left hemithorax. after left sided tube thoracostomy 1500 cc hemorrhagical drainage and massive air leak was observed. ct scan showed bilateral rib fractures extending from the first to the eleventh ribs, bilateral hemopneumothorax and bilateral pulmonary contusion (picture 1,2). therefore tube thoracostomy was also administered on the right hemithorax and 150 cc hemorrhagical drainage and air leak occured. because of the thoracic deformity, persistant hemorrhagical drainage and air leak from the left hemithorax, the patient underwent exploratris thoracotomy and damaged pulmonary parenchyma was repaired. multiple rib fractures which damaged the thoracic wall stability severely were fixed by using arch bars (picture 3). the patient required mechanical ventilation for 20 days postoperatively. the latest ct scans of pulmonary parenchyma and thoracic wall after arch bar application are seen in pictures 4 and 5. conclusıon: in this case the conventional rib fixation procedures with kirschner wires or plate plaques could not applied because of multiple small fractured segments. despite various materials suggested in literature, the use of arch bars to repair flail segments with multiple small pieces are not mentioned. tariq siddiqui, kimball maull 1 1 the trauma center at hamad, hamad general hospital, doha, qatar introductıon: intrathoracic fluid following blunt chest trauma is almost always blood, and derangement in the patient's cardiorespiratory status is directly related to the volume of blood accumulated in the pleural space and the associated compression of pulmaonary parenchyma. tension chylothorax in the setting of bilateral chylothoraces is a rare cause for such a condition. a 40 year old man fell from a height of three meters and presented with back pain. examination disclosed abrasion and tenderness over the right paraspinal area. he was discharged home. four days later, he returned in severe respiratory distress -hypertensive, with rapid pulse, tachypneic and with peripheral cyanosis. there were no breath sounds on the right side and decreased air entry on the left, and bedside ultrasound showed fluid in the right chest. chest x-ray confirmed complete opacification of the right hemithorax and loss of the costo-phrenic angle on the left side. a right tube thoracostomy yielded 2,500 ccs of pinkish-white fluid with immediate improvement in cardiorespiratory status. computed tomography disclosed bilateral 10th and 11th rib fractures, spinous process fracture of the 12th thoracic vertebra and bilateral effusions. a left chest tube brought back 600 ccs of additional similar fluid. diliatation of the cisterna chyli in the abdomen with collapse of the thoracic duct were confirmed by mri. conclusıons: post-traumatic tension chylothorax causing cardiorepiratory compromise is rare. in this report, the patient responded to chest tube decompression and dietary measures without complication. author to editor: this report is complimented by excellent illustrations, including ct and mri findings, showing the anatomy of the injury… conducive to poster display. introduction: blast lung injury (bli) is a unique injury rarely seen in the civilian population. our objective was to assess its severity, prognosis and associated injuries as compared to victims with chest wall trauma following explosions. material and methods: retrospective study of victims of the march 11 terrorist bombings in madrid who were treated at the closest hospital. we compared the group with pure bli (bilateral infiltrates in a butterfly pattern, and absence of chest wall fractures) (group i) with that of patients with peripheral infiltrates and chest wall fractures (group ii). results: of 58 patients included in the registry, 45 (78%) had thoracic injuries. 17 (40%) were included in group i, and 27 (60%) in group ii. the mean iss in groups i and ii was of 25.8 ± 7 and 20.6 ± 9.5, respectively. among the critical patient population in both groups (n = 27), those belonging to group ii were in need of a longer period of ventilatory support and had more ventilator-associated pneumonias. in group i, the most frequent associated injuries were tympanic perforation (94.4%), 2º-3º burns (83.3%) and abdominal trauma (33%). in group ii, 1º-2º burns (92%), followed by tympanic perforation (89%) and skeletal trauma (52%). one patient died in each group (5.6 vs. 3.7%). conclusions: pure bli patients had a greater degree of anatomic severity, had more severe burns and abdominal trauma than patients with lung infiltrates and thoracic wall fractures. overall prognosis was excellent in both groups. aım: aim of the study was to determine the rate of injuries detectable by ultrasonography in patients suffering from blunt thoracic trauma. materıals-methods: this study include the patients suffering from blunt thoracic trauma who have not any pathological findings in routine radiological diagnostic procedures. ultrasonography of the thorax was prospectively performed in patients with blunt chest trauma additionally to the routine radiological diagnostic procedures. ultrasound findings referring to the rate of detection of fractures, pneumothorax, pleural effusions, lung contusions, haematomas of the lung and chest wall was performed. results: we studied 50 consecutive patients suffering from blunt thoracic trauma who has any pathological findings in routine radiological diagnostic procedures. the findings detectable by ultrasonography were the following: pleural effusion 18%, haemopneumothorax 16%, haematoma of the chest wall 4%, contusion of the lung 2%. conclusıon: rib fractures and pleural effusions are commonly diagnosed by ultrasonography in patients with blunt thoracic trauma. this study showed that ultrasonography may have superiority to chest-x-ray in diagnosis of rib fractures, pneumothorax, haemothorax, haematomas of the chest wall and pulmonary contusions in blunt thoracic trauma patients. ş adiye emircan 1 , ö zlem kö ksal 1 , fatma ö zdemir 1 , halil ö zgü ç 2 1 department of emergency medicine, uludag university, bursa, turkey 2 department of general surgery, uludag university, bursa, turkey aım: the purpose of this study is to define the epidemiologic properties of patients that have been subject to thorax injuries and general body traumas, analyze their condition when they are brought to our emergency department, to determine the correlation of physiological and anatomical risk factors with the mortality rate, and to ensure early diagnosis of severe trauma. methods: 371 trauma cases that had been subject to general body trauma have been retrospectively examined in this study. epidemiological properties of the cases have been determined, their initial condition during initial admission to emergency department have been analyzed, and cases have been assessed in terms of mortality developments. survival probabilities and unexpected mortality rates have been computed using trauma revised score-injury severity score (triss) methodology. results: mortality rates was 22.6%. univariance analysis revealed that hypotension, age, pathologic respiration pattern, blunt injury, accompanying injury, abdominal trauma, high injury severity score (iss), low glascow coma scale (gcs), revised trauma score (rts), triss were the factors affecting mortality. in logistic regression analysis, presence of blunt injuries, triss < 85, iss > 22 and gcs < 13 have been found independent prognostic factors. strongest factor indicating mortality has found to be triss. in presence of factors affecting mortality, patients with thorax trauma should be evaluated as being of high risk group and therefore diagnosis and treatment strategies must be aggressive. case analysis based on triss model shall further reveal the mistakes that may be made in patient care and may improve patient care. introductıon: penetrating thoracal and cardiac wounds are asssociated with high mortality. we aimed to present our experience in such cases. materıals-method: twenty three patients with penetrating thoracal stab injury, between 2004 and 2008, were investigated retrospectively. gender, age, injured areas, extent of thoracal damage, accompanying organ damages and outcomes of these patients were evaluated. results: all patients, except one, were male with a mean age of 30.9 years (between 19 and 63 years). in 15 patients penetrating abdominal injury accompanied thorax trauma and one of these patients died peripoeratively. 10 patients out of 23 thoracal trauma had an additional cardiac stab wound and half of them were only pericardial injury. one of these cases went into emergency coronary artery bypass surgery due to lad injury. only four patients required intensive care postoperatively and four patients were lost perioperatively all of which had additional cardiac injury. conclusıon: the overall mortality rate was 18%, but mortality of patients with additional cardiac stab injury was higher, with a rate of 40%. suspect of cardiac injury should be considered in patients who are injured close around cardiac area and one should intervene quickly both in diagnosis and treatment. introduction: abdomen and thorax blunt and penetrating injuries, common cases of emergency surgery, cause less complication with proper analysis and surgical intervention. material and method: we retrospectively evaluated 31 patients operated due to thoraco-abdominal blunt and penetrating trauma in _ istanbul training and research hospital last year. results: median age was 33.1 (9-78) and all were male. patients were operated due to blunt abdomen in 8, penetrating abdomen injury in 18, abdomen and thorax penetrating injury in 5 by general surgeons. abdominal exploration in 5 (16.1%) were negative laparotomy. background: we described a patient with dysfunctions of all the nerves and ruptured brachial artery and vein due to closed injury caused by spontaneously reduced dislocation of the elbow. case: a 42-year-old man fallen down onto his left elbow with small skin erosion and a large area with ecchymosis on the elbow presented. left radial and ulnar pulses were nonpalpable but no sign of acute ischemia was noticed. he had drop hand and could minimally make flexion, opposition, abduction and adduction of fingers. strength of fingers, wrist flexion and thumb adduction were weak. radiography was normal. emergent surgical exploration was performed with prediagnosis of severe closed soft tissue injury and vascular damage. brachial artery and vein had complete disruption with rupture of brachial muscle and the anterior joint capsule. elbow joint could be posteriorly dislocated. artery and vein were repaired with saphenous vein graft. median and ulnar nerves had normal appearance. at postoperative 12th hour nerve injuries showed complete recovery. he could have normal range of motion in the wrist and hand. sensorial examination was normal. he had a well perfused arm. conclusıon: spontaneously reduced dislocations of the elbow can be sometimes missed. large hematoma and neurologic dysfunction in closed injury of the elbow indicate severe trauma of joint also in case of normal bone structure in radiography. immediate diagnosis and operative treatment of brachial artery injury is mandatory. closed elbow dislocation and multiple nerve injuries may have good results with conservative treatment. we present the case of a 53 y male, with his left lower limb severely damaged by a caterpillar vehicle. he was admitted in the er about 90 min after the accident. he presented with exposed fractures of the femur and leg bones, extensive soft tissue and muscle damage, class iii shock, and an umbilical clamp in the exteriorized femoral artery in the thigh, placed by a fireman in site. the mess (mangled extremity severity score) calculated for this patient was 9. after the initial assessment in the er the patient was transfered to the or. he had a complete transection of the femoral artery and vein with a severe ischemic foot. despite the mess score, a vascular and bone repairs have been considered. two temporary shunts were placed in both femoral vessels (artery and vein) followed by external fixation of the femur and leg fractures. the definitive vascular repair of the artery and vein was made with autologous saphenous vein after the bone fixation. some damaged skin and necrotic soft tissues were removed, and the reminder skin was only proximated. the limb was functionally and anatomically preserved, with no obvious neurologic deficit, despite subsequent debridements and skin grafts. the authors concluded that in similar cases: introductıon: trauma is responsible for 3.2 million of death, 80% of them in young people. vascular injuries of the upper extremity represent 50% of all peripheral vascular lesions, the majority of them at the braquial artery. objectıve: report a case of chemical injury of braquial artery. methods: 41-year-old man was admitted in the emergency room with third degree sulphuric acid burn in the middle third of arm (2% of total body surface area). the radial and ulnar artery pulses were palpable. at the 20th day after injury, haemorrhage was noted and disruption of braquial artery was clear. a braquial-radial reversed long saphenous vein interposition graft was performed. after surgery palpable radial and ulnar pulses were present, without evidence of nerve injury. results: the chemical burns severity depends on the concentration, properties of the agent and the duration of skin contact. sulphuric acid causes coagulation necroses, with thrombus formation in the microvasculature. its corrosive properties are accentuated by exothermic reaction with water. its burns are more serious than those compared with strong acids, and, as observed in this case, it causes frequently third-degree injuries. besides this, it has the ability to cause continuing tissue destruction, from 6th hour to 28th day after injury. this fact could explain why there was no artery lesion at the admission but at the 20th day. conclusıon: sulphuric acid burn is potential devastating and tend to be prolonged in time, obliging to a continuous monitoring and multidisciplinary approach. introduction and objectıves: the medicolegal studies show that the most frequent mechanisms of the lethal major vascular injuries were stab wounds followed by gunshot wounds and blunt trauma. during the blunt traumas, simple lethal major vascular injuries without any fracture are seen rarely. we experienced a case of common femoral artery and vein transection as a cause of death without any femoral fractures which were caused by blunt trauma. case: during the transportation of wood blocks, a wooden log fell from the truck over the forester, 34-year-old man. he sustained a crush injury and died in the emergency service on the same day of the trauma. it was learnt that no medical intervention was performed on the case. ecchymotic bruises on the left abdominal-pelvic, femoral, right inguinal, genital region, deformation under the right knee were observed during the autopsy. it was determined that there was a traumatic transection on the left common femoral artery and vein, which was accompanied by massive bleeding in surrounding soft tissues and muscles without any fracture of the left femur. all the internal organs were intact and showed paleness. death was due to internal hemorrhage caused by the transection of the femoral artery and vein. conclusıons: during the examination of the cases who were exposed to the blunt trauma, peripheral vascular injury must be investigated without any delay. if vascular injury was determined in the early times after the trauma, surgical and medical treatment could be performed successfully and the case could survive. introductıon: traumatic internal carotid artery dissection is a rare and grave cause of embolic strokes occurred especially in young age group. if it is not diagnosed early and required treatment is not given, thrombosis can be a serious trouble with permanent neurological deficit and high mortality rate up to 40%. case: we presented a delayed diagnosed traumatic carotid artery dissection in a 21 year-old female case. there were no ischemic infarct findings in the cerebral ct on admission, but there were cerebral infarct findings in the cerebral ct taken twice because of the left hemiplegia noticed 7 days later when the patient regained her consciousness. we made the diagnosis of the case, forwarded to our emergency service with acute cerebral infarct diagnosis, certain through arterial doppler ultrasonography, cerebral mri, diffusion mri and mr angiography. we did not consider invasive treatment since the neurological damage was permanent and dissection grade was iv according to angiography findings. we did not administrate anticoagulant treatment considering that the patient can turn her ischemic infarct into hemorrhagic infarct. the case was discharged within a week and advised physiotherapy. conclusıon: although the advances in diagnostic methods, diagnosis with traumatic carotid artery dissection is still missed out or delayed as in the case we presented. early diagnosis enables permanent neurological damage to be decreased or vanished. however, the vital factors for early diagnosis are the obtained anamnesis to direct to radiological examinations, detailed physical examination and high clinical doubts. introduction: acute arterial occlusion is a serious clinical condition resulting death of patient or related organs. these are usually older patients with a lot of comorbid conditions. method: _ in our clinic, we retrospectively examined the records of 73 patients who underwent surgical treatment for acute arterial occlusion between january 2005 and december 2008. mean age of patients was 66.8 years. 35 (48%) of these patients were female, and 38 (52%) were male. embolic occlusions were found in an upper extremity in 13 (18%) patients and in a lower extremity in 60 (82%). the most common source of these emboli was cardiac origin. atherosclerosis, trauma and arterial catheters were the other causes of emboli. 35 (48%) of patients were admitted less than 6 h preoperatively, 18 (25%) were admitted 6-24 h preoperatively, 20 (27%) were admitted after a delay of longer than 24 h preoperatively. 27 (37%) of patients were in sinus rythm, 46 (63%) were in atrial fibrillation preoperatively. motor dysfunction of extremity was found in 24 (33%) of patients preoperatively. diagnosis was based on the findings of physical examinations and emergent doppler ultrasonography. any other invasive evaluation was not performed to decrease acute occlusive ischemic period. surgical intervention had performed immediately results: the overall mortalıty rate was 12% (9). _ in 10 (13.6%) of patients, after setting of demarcation line, amputation was performed. conclusıon: early diagnosis, catheter embolectomy and use of anticoagulation are very important therapeutic modalities for limb salvage and reduction of morbidity and mortality. there was a comorbidity in all patients and cardiac disease and hypertension were the most common ones. the most common laboratory abnormalities were leukocytosis, hypoalbuminemia, hyperamylasemia. there was superiory vasculary necrosis in 16 patients, inferior vasculary necrosis in one patient.one patient had nonocclusive mesenteric ischemia. segmentery resection was performed to 13 patients. abdominoperineal resection was performed to the patient with inferior mesenter artery occlusion. we performed duodenotransversostomy on two patients and only laparotomy on two patients. reoperation was required in five patients. causes of death was multiorgan insufficiency in seven cases, cardiac death in two cases.one patient died due to short intestine syndrome. results: the patient was discharged on postoperative 16th hours without any complications. conclusıon: single incision laparoscopic appendectomy is a safe and effective technique that can be performed in well experienced centers success. jorge pereira, luis filipe pinheiro 1 1 surgery department, sã o teotó nio hospital, viseu, portugal trauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease. recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the teaching of this new method, albeit its good results, has not seen many changes over the years. however, in recent days, we have seen the introduction of new computer technologies in teaching. this methods use simulation, e-learning and even interaction as learning techniques. taking advantage of the mentioned techniques, the authors produced an animated video, using computer-animated drawings that allow demonstrations difficult to reproduce in real life. using simple software and computer video editing, the authors invite you to watch a trauma patient in the emergency room, since his arrival to the end of the primary survey, watching demonstrations of life saving techniques and the stabilization of the patient. the authors present a video of a young male, 28 years of age, ± 100 kg victim of a motorcycle crash, with a fall over cut branches of trees, 30 min before his admission in the e.r. he sustained an impalement with a stick in the fourth right anterior para-sternal space. at admission he was conscious, gcs = 15, bp = 140/80, hr = 90/m, sato 2 = 94%, hemodynamically normal. breath sounds slightly diminished in the left. a left anterolateral thoracotomy as been done, as well a left subcostal lararotomy, since the stick also had penetrated the left hemidiaphragm. the patient had no significant thoracic or abdominal injuries despite the violence of the trauma mechanism. the ''foreign body'' was successfully removed by combined abdominal and thoracic route, and a left chest tube was put in place. the patient recovered very well and was discharged in the eighth day. author to editor: ''english'' corrections are welcome, please! berker bü yü kgü ral, mehmet bekerecioglu al-marashda 1 , amgad elsherif 1 , hani o. eid 2 , fikri m univariate analysis was used to compare patients who died and those who survived. significant factors were then entered into a backward stepwise likelihood ratio logistic regression. results: out of 2,573 patients of the registry, 477 patients (18.5%) had chest trauma with a mean (sd) age of 35.2 (14.6) years. 428 (90%) were males 87. 304 (63.7%) got injured in the street or highway, 90 (18.9%) at work place, and 45 (9.4%) at home. the main mechanism of injury was road traffic collision in 315 (66%) fall from height in 80 (16.8%). 88 (18.4%) were admitted to icu. the median (range) iss was 5 (1-43). 175 (36.7) of patients got isolated chest injury, 130 (27.3%) had head injury, 119 (25%) lower limb injury, 118 (24.7%) upper limb injury iatrogenic rib fractures during thoracotomy: comparision of posterolateral and anterolateral thoracotomies operations for thoracic trauma, extended lung resections and re-thoracotomies were excluded. posterolateral thoracotomy incision was performed for group i (463 patients; 78.8%), and anterolateral thoracotomy incision for group ii (125 patients; 21.2%). groups were also divided into two groups for the type of resection the percentages for rib fractures for group ia, ib, iia, and iib were 53.34, 33.6, 41.17, and 1. damage control principles can a be used in all surgical fields 2. general surgeons must have experience in vascular repair skills 3. the reperfusion of the limb joão filipe coutinho vasconcelos 1 , sandrina braga 1 , pedro brandão 1 , daniel brandão 1 , miguel maia 1 , joana ferreira 1 , paulo barreto 1 , vítor martins 1 , a. guedes vaz 1 , leonor rios 2 vila nova de gaia, portugal 2 department of plastic surgery rectal prolapse describes the protruding of the entire rectum or some parts of the rectum from anus. it is caused by the weakening of the ligaments and muscles that hold the rectum in place.it is associated with advanced age, long term constipation or diarrhea, childbirth, previous surgery, and sphincter paralysis. trauma may cause sphincter paralysis and can be associated with rectal prolapse. it usually begins with prolapse of the rectum during defecation or val salva movement and usually progresses to a chronic stage. long term prolapse can cause ulcerations, bleeding and in some cases perforation if not reducted. a 51-year-old male presented with rectal prolapse, bleeding, abdominal pain. he stated that he could not replace the prolapsed segment for 2 days and has been suffering for 20 years since after he fell from a tree and he had massive bleeding during the last 8 h. physical examination revealed that a 15 cm segment of the rectum was prolapsed with the whole layers. there were ischemic and necrotic areas and active bleeding from the mucosa. reduction trial was not successfull. emergent laparotomy was performed. bimanual reduction failed.thus transanal intervention, with sigmoid resection was performed. end colostomy was preferred. no complications occurred the following 6 months and colorectal anastomosis was performed with a preventive ileostomy. although rectal prolapse is usually a benign condition it may cause fatal complications such as perforation, necrosis if not reduced for a long time and surgery should be performed promptly in these cases.ing to the age, diagnosis, treatment results, mortality rates between the years of 2006 and 2008. results: summarised in the table 1 .in conclusion, the most of our multitrauma cases caused by traffical accidents, were young. the mortality rate 34% for multitrauma cases, the percentage of multitrauma cases were 8.8% of all intensive care patients. preventing the accidents is as much important as treatment strategies for multitrauma cases. arif tü rkmen, ertan gü nal, mehmet bekerecioglu, berker bü yü kgü ral 1 1 department of plastic and reconstructive surgery, gaziantep university school of medicine, gaziantep, turkeyintroduction and objectıves: as personal problems dealing with health, jobs, financial status and the family problems increasing, more suicide attempt subjects are consulted in emergency rooms day-byday. although gunshots to the oro-facial region form 4-12% of the total victims, it is important that seconder deformities resulted with aesthetic, functional and psychological problems were usually encountered after primary surgery. this study reviews 11 cases of self-inflinct gunshot injuries of face and our experiences in early and late managements over a 5-year period.methods: this study is based on 11 subjects who attempted suicide resulting in extensive facial deformities, not in death between 2000 and 2008. demographic details, mechanism and direction of injury, early and late management and seconder deformities were recorded. results: after establishing the airway control and completing the primary survey, all patients underwent debridement and bleeding control. reconstruction of maxillofacial fractures were performed in 8 patients on the day of admission and the remaining 6 within 5 days of injury. following procedures as scar revisions, rhinoplasty, mandible reconstruction, ectropion operations or coverage of palatal defects etc. were performed after earliest 6 months from primary operation.conclusıons: after stabilization of life-threatening injuries, the goals of early management are regenerate of anatomic form and function to include dental occlusion and mouth opening to prevent scarring, contractures of mobile structures and ankylosis. seconder operations required for aesthetic and functional problems should be performed earliest after 6 month from primary operation that all the scar formations and wound healing's were completed. background: injuries of maxillofacial region in patients with polytrauma are frequent but are rarely treated primarily. in order to achieve satisfactory treatment results trauma treatment team must include a maxillofacial surgeon.materıal-methods: the study shows treatment results of 29 polytraumatized patients with maxillofacial injuries. dominant trauma was: maxillofacial in 17%, craniocerebral in 38%, locomotor in 17%, thoracic in 14% and abdominal in 14% of cases. treatment of maxillofacial trauma was in 28% of cases surgical and in 72% conservative. treatment of other traumas was operative in 17% and conservative in 83% of patients. results: early mortality rate was 21%. four exitus were recorded during the first 24 h, 1 exitus on the 4th day and 1 exitus on the 6th post-trauma day. dominant trauma was in 4 exitus craniocerebral, in 1 exitus thoracic and in 1 exitus severe locomotor. long-term treatment results in remaining 23 patients were: for maxillofacial regiongood in 16 patients (70%), satisfactory in 3 patients (13%) and poor in 4 patients (17%); for other regions -good in 20 patients (87%), satisfactory in 1 patient (4%) and poor in 2 patients (9%). conclusıon: existing maxillofacial trauma in polytraumatized patients usually directs treatment toward conservative methods.reasons for this are insufficient number of maxillofacial surgeons in trauma teams and delay of surgical treatment of other present traumas due to difficult anesthesia application. unfortunately, conservative treatment approach induces inadequate treatment results from both functional and esthetic point of view. however, as revealed by hospitalization, transportation, and mortality data, women were exposed to more severe trauma. in addition, poisoning and fall caused more death. the rate of mortality of women seems to be less when compared to literature. conclusıon: bicyclists in non-fatal frontal crashes with cars suffered the most serious injuries from the impact to bonnet and windshield, likely due to highest energy transformation. bicycle helmets, collision mitigation system that alerts the driver or automatically brakes the car, and external airbags protecting the bicyclists from hitting bonnet and windshield, may reduce injuries.author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus bicyclist. journals were completed with traffic notes from police at scene, patents own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. or street (11 ais2 +). third impact in 42 patients gave 29 injuries (16 head/neck) at windshield (9 ais 2 +) or street (4 ais 2 +). thirteen persons, who hit the street as the fourth impact point, sustained three injuries (zero ais 2 +) as contusions of the pelvis and lower back. conclusıon: pedestrians in non-fatal frontal crashes with a car suffered the most serious head injuries at second impact in bonnet, windshield or street. safer passageways for pedestrians might preclude the crash. mechanisms preventing the pedestrian of hitting the bonnet and windshield, may reduce the injuries. author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus pedestrian. journals were completed with traffic notes from police at scene, patients own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. one of the primary characteristics which professions possess is to make the members of a profession have autonomy in decision making and practice. nursing practice is evaluated in relation to professional practice standards and guidelines, rules, etc… application of professional standards requires that nurses use critical thinking for the good of individuals or groups. critical thinking also requires the use of scientifically based and practiced-based criteria for making clinical judgments. these criteria may be practice based on standards developed by clinical practice guidelines developed by individual clinical agencies. for example, intensive care units (icus) are designed to meet the special needs of acutely and critically ill patients. a patient is generally admitted to the icu for one of three reasons. the patient may be physiologically unstable, at risk for serious complications and require intensive and complicated nursing support. despite the emphasis on caring for the patient who can survive death is common in icu patients. it is reported that 10% of patients admitted to icus will die, and another 20% may leave the icu but will not survive to discharge. this suggests a need for caution and coordination of care when transferring patients from icus to general units. in this article, the practice guideline which titled ''patient appropriateness for adult icu admissions and discharge'' will be discussed. the terminology for pelvic fractures and its recent modifiers are confusion to the trainee to say the least. we surveyed 70 orthopaedic trainees in the latter part of their surgical rotations. the same set of radiographs were shown to all trainees and their classifications recorded. the same set of radiographs were shown to the trainees again after a period of 21 days. we found significant inter-observer variability (45%) and wide intra-observer variability (15%). though trainees were adept at identifying basic fractures patterns and identifying individual column or lip/wall fractures the complex fracture patterns seems to generate different answers from the same observer at different times. the ct scan was the most effective tool identified for accuracy of the fractured fragments but the more complex assignments resulted in the trainees grouping them differently. results: twenty-one fractures (87.5%) healed without complication including five fractures where external fixation was converted into internal one. the mean time to union was 6.5 (4-9) months. there were two pin-track infections, two deep infections, and only one nonunion. the femur length was equal to the healthy side in 19 cases, and was shorter by 1-2 cm in five cases. mean active knee flexion was 90°. knee flexion was more than 110°in 9 patients. conclusions: external fixation is a useful technique for the stabilization of severe open and close highly comminuted femoral shaft fractures. it is safe procedure to achieve temporary rigid stabilization of femur fracture in critical polytraumatized patients before delayed internal fixation (damage control orthopedics). purpose of this study was to determine the factors predicting mortality.methods: a retrospective study was performed on 174 cases of pelvic fracture who visited to emergency department from january 2003 to june 2008. data were collected regarding demographic characteristics, mechanism of injury, injury severity score (iss), abbreviated injury score (ais), simplified acute physiologic score ii (saps ii), transfusion requirements, fluid requirements, the finding of angiography, hemoglobin, platelet, prothrombin time ( fractures were managed by using an intraarticular, chevron-shaped olecranon osteotomy in all patients. methods: the mean age was 39.1 years. a straight posterior surgical incision was performed. a thin oscillating saw was used to begin the olecranon osteotomy. a small osteotome was then inserted and the osteotomy was completed through the subchondral bone. the posterior elbow capsule was incised. the olecranon fragment and the triceps muscle were reflected proximally to expose the distal humeral articular surface. osteotomy fixations were performed with two intramedullary kirschner wires and dorsal tension band in 23 patients. in four patients, an intramedullary screw and a tension band were used for fixation. results: at the final control, the jupiter classification system was used for the evaluation of the patients. eighty one percent of the patients revealed good and excellent results at the long-term followup. none of the patients showed osteotomy nonunion. the most frequent complication was skin problem due to subcutaneous prominence of the implants.conclusions: the goals of treatment of distal humerus fractures are anatomic articular restoration and rigid fixation. olecranon osteotomy provides good visualization for rigid fixation especially in type c distal humeral articular fractures. this is a useful method for excellent anatomic reduction of the articular surface. conclusions: there could be some steps during primary treatment for discussion. but real mistake was vacillation and delay of reosteosynthesis and spongioplasty even it was cause by risk for infection and possible failure of flap. our case demonstrate that sometimes too much care could be hurtful. introductıon: the population who applied to the public emergency services due to the injuries related to butchering the sacrificial animals during the feast of sacrifice were evaluated. materıals-method: eighty-nine patients who admitted to the emergency services in kirikkale during the feast of sacrifice in 2008 were evaluated according to age, sex, application day and time, state of experience, type and mechanism of injury and medical treatment. results: the age average was 43 ± 13 and 80% of them were male. eighty-eight percent of the patients admitted in the first day. seventy percent of the injuries were penetrating injuries and 30% of them were blunt. the average time passed after the trauma was 120 min. almost half of the cases were wounded with a knife, 18% were wounded unintentionally by the others and 36% of the cases were due to hit of animals. fifty-seven percent of the patients had butchering experience before. ninety-one percent of the cases were hand injuries. thirty percent of the cases had fractures. nine percent of all cases had tendon injury, 55% of the cases were treated primarily skin suturation. conclusıon: the injuries related to butchering of the sacrificial animals sometimes can be serious. in extremity injuries, the number of tendon cuts and bone fractures can not be underestimated. both equipments and medical staff support for the injured people should be provided and preliminary arrangements should be done during the feast of sacrifice. every butchering job in this period should be given to professionals. introduction: osteoporotic fractures of the trochanteric area are often treated with a gamma-nail or similar implants utilizing a screw applied into the femoral head. one of the main problems of these techniques is the cut out in the femoral head. we biomechanically evaluated a novel technique of cement augmentation of the bed of the screw in a standardised osteoporotic bone model and its capability to reduce the cut out rate. material and methods: utilizing a polyurethane-foam osteoporotic model that has been previously described (specific gravity 0.192 g/cm 3 ), a biomechanical testing of a neck of femur screw (tgn, stryker, duisburg, germany) was performed. the screw was implanted according to manufacturers instruction, the migration characteristics were then biomechanically tested (zwick testing machine) with a static stepwise load increase (50 n). first these tests were performed without, in a second series with the augmentation of a fast hardening biopolymer (corthoss, orthovita, usa). each series was repeated five times. the transfer from a stable to an unstable condition was biomechanically determined. results: on average the applied load at the moment of failure with critical cut out was 1431 n for the non-augmented screws. with augmentation, the average load was 1,987 n, the difference was statistically significant.discussion: it appears in biomechanical testing that augmentation of the femoral head can improve the load bearing capabilities and thereby possibly reduce the rate of cut-out failure in osteoporotic bone. we proceed now with further biomechanical testing, grant of the local ethics committee for human testing has been applied for. introductions and objectıves: the aim of this study was to examine the relationship between childs' favourite cartoon stars who can fly and falling down from a high place in two cases. methods: in this paper we presented two similar cases who were seen with a history of falling down from a high place. the first case was a 4-year old girl who fell down from the third floor of their apartment. on her examination it was learned that she wanted to fly like her favourite magical cartoon star girls. the second case was a 5-year old boy who fell down from the second floor. while falling down he was screaming to his friends that he was flying.results: on the physical examination of the first case, deformity and crepitation in right femur were found. x-rays showed right femur distal epiphysis salter harris type iv fracture. she was hospitalized due to the pneumothrax in pediatric surgery intensive care unit. the procedure of closed reduction and fixation with multiple kirschner wires was performed under general anestesia. closed body fracture in the left femur was found in case ii. introductıon: the purpose of this study was to compare the biomechanical properties of different possibilities of screw placement in multidirectional palmar fixed-angle plate in distal radius osteotomy cadaver model under loading conditions. methods: an extra-articular fracture was created in 16 pairs of fresh frozen human cadaver radii. the 32 specimens were randomized into four groups. all radii were plated with a volar fixed-angle plate. there were 4 different possibilities of screw placement in the distal fragment:group a: 4 screws were used in the distal row of the plate. group b: 4 screws were used alternately in the distal and proximal row. group c: 3 screws were used in the proximal row. group d: 7 screws were used filling all screws holes in the distal and proximal row of the plate.the proximal fragment was fixed with 3 screws each. the specimens were loaded with 80 n under dorsal and volar bending and with 250 n axial loading. results: group d had the highest stiffness of 429 n/mm under axial compression and was statistically significant stiffer than the other groups. group b had a stiffness of 208 n/mm followed by group a with 177 n/mm. group c showed only a stiffness of 83 n/mm. there were no statistically significant differences under dorsal and volar bending.conclusıons: occupying all screw holes in the distal fragment offered the highest stability. using only the proximal row with 3 screws showed an unstable situation. it is therefore recommended to use at least 4 screws in the distal fragment. perilunate dislocations are the most common type of carpal dislocation. they can be produced by high-energy injuries. the population primarily at risk is male young adults. in perilunate dislocations, the proximal articular surface of the lunate retains contact with the distal radius. the dorsal-perilunate/volar-lunate dislocation is more common. we performed a retrospective study of perilunate dislocations from 2006 to 2008. a total of 5 were reviewed. mean age of the patients was 28.6 (range 18-48). all the patients were male. the trauma mechanism was fall from height in 3 and motor vehicle accident in 2. all the dislocations were dorsal-perilunate/volar-lunate dislocations. all the dislocations were together with ipsilateral scaphoid fractures. all were closed injuries and all were reduced by closed reduction maneuvers. percutaneous pinning was applied for the dislocation and scaphoid fractures. mean follow-up time was 11 months (range 6-18 months). when compared with the non-injured wrist, there was limited range of movement in only one patient.no limitation of range of motion in the other patients could be obtained. the patients did not have pain and instability. radiologically no arthrosis of the wrist could be obtained but in all patients there was scaphoid pseudoarthrosis. functional range of motion of the wrist after a perilunate dislocation is independent of the concomitant scaphoid fractures. bostjan sluga, tomaz malovrh 1 1 traumatology department, university clinical centre, ljubljana, sloveniainfective complications of tibia fractures result in nonunion, bone defects and soft tissue envelope impairment. several methods of treatment have been described to deal with bone defect including callus distraction, fibula transfer, muscle flap and bone grafting. there are many possibilities to encourage bone healing; bone morphogenic proteins, platelet rich plasma, electrical, ultrasound or shockwave stimulation and hyperbaric oxygen therapy. a patient with both tibias infected nonunion is presented. high energy trauma primarily and inadequate debridement secondarily were probably the cause of the healing complications. a middle-age man was injured in a gas explosion and suffered comminuted closed fractures of both distal tibias. after an immediate external fixation we operated him on the 28th day after the injury, anatomical reduction and internal fixation on both sides was done. an infection developed after 3 weeks. ankle joint arthrodesis was necessary on one side and implant removal, repetitive debridement with bone grafting on the other. we could not cure the infection and the fracture did not heal. after 2 years, 7 operations, 277 days of ciprofloxacin, 60 days of gentamicin, 57 days of vancomycin, 40 days of implanted gentamicin antibiotic beds and the use of cultivated autogenous steam cells clinically evident nonunion was still present. surgery was performed again, a resection of 9 cm of bone and callus distraction with an unilateral frame. despite a fast progress in knowledge and improvement of methods, a radical debridement, preservation or reconstruction of soft tissue coverage, systemic and local antibiotic therapy and appropriate stabilization is still a keystone in infected nonunion treatment. some people who live in some regions of our country trust in bonesetter's skills more than these ones of professional orthopaedist in the hospitals. the fact that some bonesetter's particular skills to cure the non-operative back pain seems to make them credible on closed reduction too. in this case report, right humerus proximal body fractures due to falling were discussed. the case was 9-year-old male. in the treatment of this case, velpau bandage, closed reduction and plaster cast-splint has been applied after that he was called to the clinic control, but he did not come to control. the parents of the case were aware of the fact he cannot raise enough the right upper extremity and he was taken along to the hospital. from his anamnesis, it has been learnt that the bonesetter has removed the castsplint and, tried to perform closed reduction. actual physical examination showed that there was an arm pain, crepitation and deformity. a diagnose has been made: there was an union right humerus proximal body fractures, so he has to be hospitalised. under general anaesthesia, closed reduction and bandage velpeau were applied. on the 3rd day of the hospitalisation, the case was externed and was advised to come for a polyclinic control. because of the importance of epiphysis lines of bones and of other complications from the upper extremities fractures, the treatments have to be performed by the orthopaedists or in accordance with them. about this medical issue, families should be made conscious by healthy authorities. there were 3 women and 20 men. the mean age was 39.7 years (range 19-55 years) and mean follow-up period was 23 months (range 9-56 months). posterior kocher-langenbeck approach was used at 21 patients and ilioinguinal approach was used at two patients.results: there were 10 both column, 6 posterior column with posterior wall, 4 transverse with posterior wall and 3 posterior wall fractures. anatomic reduction was obtained at 18 patients and adequate reduction at 5 patients according to matta criterias. harris scoring system revealed excellent at 13, good at 4, moderate at 2 and bad at 4 patients. over 70% of these patients had satisfactory function. there were any pulmonary embolism, deep infection or nonunion detected. one of four patients whom had developed osteoarthritis, managed with total arthroplasty. postoperative sciatic nerve injury was developed at one patient. conclusıon: secondary arthrosis, nonanatomic reduction, unstable fixation and nerve injuries were associated with poor results. our clinical experience for acetabulum fractures were similar to that reported previously at the literature with over 70% of satisfactory results sedat kocak, birsen ertekin, esma erdemir, abdullah sadik girisgin, basar cander 1 introduction and objectives: quadriceps muscle tears are usually seen in middle-aged and older people. particularly people with chronic diseases (such as diabetes mellitus, renal failure and gout) are prone to develop quadriceps muscle ruptures. we present a case of partial rupture of the quadriceps muscle in a 4-year-old girl after intramuscular injections. we thought that this patient could be the youngest patient reported with a quadriceps muscle rupture. methods: patient presented to our clinic with left knee pain, limitation in knee flexion and a localized palpable swelling at the anterolateral side of thigh. there was no blunt trauma but it happened while she jumping on the sofa. in her detailed history we learnt that she had a serious upper tract respiratory infection a week ago and used some parenteral antibiotics (twice a day, intramuscular clindamycine for 7 days).results: plain radiographies were normal. mri showed a partial tear of the vastus lateralis muscle matching with the injection sites. the patient was placed in a long leg half-cast which was maintained for 3 weeks. she treated with conservative treatment successfully.conclusions: mr imaging is useful to diagnose and differentiate in this pathology. multiple intramuscular injections may contribute to damage muscles and make them prone to tears with muscle contractions. quadriceps muscle ruptures in children can be treated successfully with conservative treatment. twenty year old female attempted suicide by jumping from a four story high building, resulting in multiple fractures of the limbs and a complex fracture of the body of the fourth lumbar vertebra (l4) resulting in paralysis of the inferior limbs. the l4 fracture was treated by a neurosurgeon with the extraction of the body of the vertebra, insertion of a cage device and arthrodeses of the third and fifth vertebras using a metal plate and screws, thereby stabilizing the affected segment and decompressing the medullar channel. the approach was achieved by a general surgeon using the technique of localio, that consists in a paramedian incision of the abdomen and the dissection of the retroperitoneal space without entering the abdominal cavity, dissecting and isolating the left ureter and the main vascular structures (iliac vessels and the left iliolumbar vein) in order to allow a good exposure of the three vertebra bodies involved. the patient recovered the complete function and control over the limbs, resulting no neurological sequelae from the fracture. it is of major importance that this procedure be performed by a multidisciplinary team of surgeons, involving a neurosurgeon and a general surgeon, in this way achieving a better result and a lower risk of complications. josef märz 1 1 department of surgery, regional hospital karlovy vary, czech republicabdominal ultrasonography or ct were applied to 5 (62.5%) patients with blunt trauma and 8 (34.7%) patients with penetrating trauma. one (12.5%) negative laparotomy was applied to patients with blunt trauma. 2 to 3 splenic injuries was splenectomy. 1 sigmoid perforation, 1 diaphragm rupture, 1 bladder rupture were observed and were fixed primarily. one patient died during surgery due to liver and vena cava injuries. patients with penetrating injury were operated due to firearm injury in 6 (26%) and stab wound in 17 (74%), mortality was not. negative laparotomy was applied to 5 (21.7%) patients. multiorgan injury was observed in 6 patients. tube thoracostomy was inserted to 4 patients. 6 of the intestine injuries and stomach injury was fixed primarily. two resection and anastomose and three diversionary ostomy were done. conclusion: proper examination must be considered according to the formation of trauma. _ imaging methods have been used less in penetrating trauma, and negative laparotomy is reported to be applied more than in cases of blunt traumas introductıon: chest tube insertion is frequently used by thoracoabdominal surgeons in urgent conditions. occasionally, this invasive procedure may be associated with lethal complications in inexperienced hands. in this study, we analyzed 6 patients with visceral and/or diaphragmatic injuries due to chest tube insertions. methods: six patients with diaphragmatic and visceral injuries subsequent to chest tube insertions between 2003 and 2006 were evaluated. the diagnosis was established with roentgenogram, biochemistry of the fluid drained from the chest tube and confirmed with computerized tomography in all patients. results: pleural effusion accompanying respiratory distress was the main indication for chest tube insertion in all patients. in five patients, coexistent gastric perforations with diaphragmatic ruptures were detected, also the esophagus was additionally perforated in one patient. partial gastrectomies were performed in three patients, whereas total gastrectomy in one and primary repair required in two patients respectively. five of the patients died from septic complications. the only survived patients with early diagnosis and primary repair was discharged from the hospital on the 12th day. conclusıon: penetration of a drainage tube through viscera is a wellrecognized but seldom reported phenomenon. in the majority of patients with diaphragmatic rupture, abnormalities can be found at initial chest radiography. if transdiaphragmatic herniation is missing, diaphragmatic rupture is difficult to diagnose by chest radiography alone. computed tomography is often necessary to reveal the correct diagnosis. early diagnosis and treatment are extremely important in the management of these patients. bronchobiliary fistula is a rare condition, arising as a complication of hydatid disease of the liver, hepatic tuberculosis, hepatic malignancy, chronic pancreatitis, hepatic trauma or surgery. conservative treatment is directed at non-surgical approaches of relieving biliary obstruction to allow for normal flow of bile into the duodenum via endoscopy or percutaneous routes. however in complicated cases which failed conservative non-surgical therapy, surgical intervention is usually required. we report a 35-year-old man who presented with bilioptysis from a bronchobiliary fistula resulting from firearm injury after 15 days. for his current admission, the patient reported a 5-day history of cough productive of yellow-green sputum coupled with fevers and malaise.this was successfully treated surgically with a right medial lobectomy and t-tube drainage. paget-von schroetter syndrome(pss) refers to spontaneous thrombosis of the subclavian vein and constitutes 0.5-1% of all venous thromboses. it is prevalent among young and healthy adult males who engage in sports. a 42-year-old male presented with pain and swelling of the left arm after a sequence of intense, repetitive weight lifting exercises. upon questioning, he disclosed that he had been engaged with weight lifting for a long time and had complaints for a while. bases on these findings, upper-extremity effort thrombosis was suspected. contrast-enhanced mr angiography revealed near-complete occlusion of the proximal left subclavian vein and collateral formations in the distal were observed. color doppler us showed a heterogeneous thrombotic mass that filled almost the entire proximal segment of the left subclavian vein thrombosis extended into the proximal segment of the left internal jugular vein. furthermore, extensive venous collateral formations were present the left proximal cervical localization. both mr angiographic and sonographic findings were consistent with pss. as the patient had already developed extensive venous collaterals, no surgical intervention was performed. instead, treatment with lowmolecular weight heparin and anticoagulants, was initiated and was continued along with the follow-up for bleeding parameters. as of 3 years clinical follow-up the patient is doing well, and treatment is continued with oral anticoagulants and acetylsalicylic. pss should be considered in the differential diagnosis of effort induced upper extremity pain and swelling. conservative non-operative treatment is acceptable and can be successfully used with favorable long-term outcomes. although, blunt trauma of the extremities is a common diagnosis in emergency clinics, compartment syndrome associated with vascular injury following blunt trauma may be difficult to diagnose. urgent diagnosis and treatment of compartment syndrome is of particular importance for limb salvage or even to save the patients' life. 43 years old male patient was referred to emergency clinic due to blunt trauma of the right lower extremity. right thigh was echimotic and swollen. pallor, coldness and severe pain were present at the lower part of the trauma level. distal pulses were not palpable. acute compartment syndrome of the right thigh was diagnosed that led to an emergent operation. intraoperatively, popliteal artery rupture was diagnosed and repaired with end-to-end anastomosis. fasciotomies were performed at the anteromedial and anterolateral portions of the right leg and anteromedial part of the thigh for the treatment of compartment syndrome. in early postoperative period, distal pulses were palpable. preoperatively present pallor and coldness improved in the first few h. fasciotomies were closed with skin grafts at the 10th postoperative day. patient was discharged at the 19th postoperative day with palpable distal pulses and failure of dorsal flexion of the right ankle representing mild neurological injury. possible vascular injury should be kept in mind in a patient with compartment syndrome following blunt trauma of extremities. success of surgical repair depends on the early diagnosis and treatment. late repair may result in neurological complications or even the loss of extremities.conclusıon: acute mesenteric ischemia is highly mortal emergency which should always be suspected in elderly patients with cardiac disease suffering from abdominal pain.624 acute ischemia of the lower member after injury by firearm -case report patient with 48 years, male sex, admitted at the urgency department after injury of the left lower member by firearm. at the admission presented loss of substance and hemorrhage in the medial and lateral faces of left leg and foot with signs of ischemia. an arteriography of the member was carried out showing infrapopliteal arterial lesions of the three axes. during surgery, fracture and losses of peroneum substance was observed with macroscopic tibial and peroneal common nerves integrities. he was submitted to tibial interposition grafts with subsequent reversed contralateral internal saphena vein bypass.in the 21th postoperative day it was carried out surgical debridement and plastia with partial skin graft. he presented good cicatricial evolution, with hospital discharge 7 days after, oriented to external consultations of vascular surgery, plastic surgery, physical/ rehabilitation medicine and pain consult. five months after surgery, pain was controlled with the medication instituted, with improvement of the left lower member limitations with physiotherapy, good cicatricial evolution and posterior tibial and dorsalis pedis pulses palpables. dıscussıon: the incidence of arterial wounds following penetrating injury of the members is 10%. the vascular trauma occurs more frequently in the lower extremities, being the most common clinical presentation acute isquemia. the most frequent causes are vehicle accidents, falls and firearm wounds. in the united states, injuries by firearm represents the first cause of death in young individuals of male sex. the arterial bellow-knee injuries by firearm remain like a challenge, with an associated rate of amputation of 20 to 54%. jorge pereira, luis filipe pinheiro 1 1 surgery department, sã o teotó nio hospital, viseu, portugaltrauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease.recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the next stage of treatment implies surgery. the dstc course, and other similar ones, allow the teaching of surgical damage control to surgeons. in this courses, the surgeon not only learns the theoretical basis of the surgical techniques but also acquires the skills to perform them. more importantly, he learns trauma pathophysiology, so he can perform the difficult task of surgical decision-making. using the same computer-animated drawing technique as in a previous video (primary survey), the authors continue to present a trauma patient, after the stabilization of the primary survey, at the operating room. the patient has a severe abdominal trauma and needs damage control of his lesions, for he is already suffering from the deadly triad: hypocoagulation, acidosis and hypothermia. a 66 year-old male patient was admitted to our hospital for severe abdominal pain. thoracoabdominopelvic ct scan demonstrated incarcerated bowel loops in the right hemithorax. strangulated transverse colon segment and omentum through the defect at the dome of right diaphragma was found at diagnostic laparoscopy. diaphragmatic hernia was primarily repaired with endostitches, and supported with a polipropylene mesh fixed with endotuckers subsequent to reduction of strangulated organs to the abdomen. resection of necrotic intrabdominal organs and a side-to-side stapled colocolonic anastomosis was performed through a subcostal minilaparotomy. drainage of right hemithorax was provided with a tube thoracostomy. the patient was discharged on the 5th post-operative day without any major complications. introduction and objectıves: single incision laparoscopic procedures are accepted as a step towards pure natural orifice transluminal endoscopic surgery. however, loss of requirement of any perforation of visceral organ and an endoscopic equipment make this technique more popular and easily performable. here in we report our first appendectomy case who was performed with single incision laparoscopic surgery (sils) technique. methods: 32 years old male patient with the diagnosis of acute appendisitis underwent single incision laparoscopic appendectomy. a key: cord-015368-a0qz4tb9 authors: nan title: 48th annual meeting of the austrian society of surgery, graz, june 7–9, 2007 date: 2007 journal: eur surg doi: 10.1007/s10353-007-0330-8 sha: doc_id: 15368 cord_uid: a0qz4tb9 nan background. aortic valve replacement (avr) in the elderly with significant co-morbidities is associated with increased operative risk. trans-apical catheter based avr is being evaluated in a phase 1 study. we report the initial results of the first generation equine pericardial cribrieredwardsvalve. methods. access is through a small antero-lateral thoracotomy with direct puncture of the apex. after initial balloon valvuloplasty the ascendra delivery system is used to position the balloon mounted crimped bioprosthesis under fluoroscopic and transesophageal echo guidance in the native aortic annulus. results. 30 high risk patients (log euroscore 23.8 ae 13, 16 female and 3 male) with a mean age of 81 ae 6.6 years were operated. valve positioning was successful in 27 pts (valve size 23 in 9 pts and size 26 in 18 pts) and 3 were converted to full sternotomy and conventional valve replacement performed. deployment time was 11.9 ae 6.6 min. delivery was achieved without cardiopulmonary bypass in 67% of patients. however in 7 pts cpb became necessary to treat bleeding complications. there were 3 deaths within 30 days (1 valve related, 1 cardiac, 1 abdominal). operative revision was necessary in 6 patients for bleeding and was related to the apical access in 1, intercostals artery 1, lung laceration 1 and was diffuse in 3. hemodynamic evaluation showed satisfactory results in regard to aortic insufficiency (none: 9, minimal 7) and excellent gradients (peak gradient: 13.1 ae 12.4 mmhg). conclusions. we conclude from our data that trans-apical aortic valve replacement with the cribrier-edwards bioprosthesis can be performed in high risk patients successfully. cardiopulmonary bypass may be avoided. complications may be attributed to the high risk profile of the elderly population treated in the early learning curve. excellent imaging technology in the operating room and excellent collaboration between surgeons and cardiologist as well as anesthetists appears crucial for the successful implementation of this new treatment modality. 008 aortic valve replacement through partial upper sternotomy: a safe alternative to full sternotomy erate to good left ventricular function and without any previous cardiac surgery at our institution. we reviewed retrospectively data on 353 patients (183 males, 170 females) who underwent avr through a partial upper sternotomy between 1998 and 2006. mean age was 69. 1 (28-95) years. mean logistic euroscore and mean peak transvalvular gradient were 6.9 (0.88-47.94) and 92.7 (40-150) mmhg, respectively. results. mean cross clamp time, mean bypass time and mean operation time were 69. 1 (33-138) min; 113.1 (52-344) min and 192.5 (95-424) min, respectively. in 17 patients (4.8%) a conversion into full median sternotomy was necessary. 15 patients (4.2%) had to be reexplorated due to bleeding. the mean intraoperative and postoperative red blood cell transfusions were 1.3 and 0.8, respectively. deep sternum infection occurred in 5 patients (1.4%) . mean icu and total hospital stay were 2.2 and 11.9 days, respectively. there were 15 hospital deaths giving a perioperative mortality of 4.2%. conclusions. avr through a partial upper sternotomy is a safe and effective technique with a similar perioperative morbidity and mortality to conventional aortic valve surgery showing superior cosmetic results. 009 state-of-the-art 2007: mitral valve repairminimally invasive or median sternotomy? background. more than ten years have passed since minimally invasive mitral valve surgery employing different access and different techniques has been introduced. in spite of obvious advantages acceptance by cardiac surgeons is generally low. to define its current position in clinical practice the development of our program, actual indications and results are presented. methods. minimally invasive and conventional mitral valve procedures from 2001 to 2006 were documented prospectively. indications for the minimally invasive vs. conventional approach through median sternotomy are compared. results. seventy-five patients had minimally invasive mitral valve surgery through a 5 cm minithoracotomy. carpentier type i, ii and iiia lesions involving the posterior, anterior or both mitral leaflets were treted using carpentier repair techniques. combined procedures of the tricuspid valve, asd and modified maze operations were performed in 23% of cases, 4 patients had prosthetic mitral valve replacement. 1 patient died at home on postoperative day 26 from unknown causes. functional results: residual mi grade 0: 89%, grade i: 8%, grades i-ii: 1.3%, grade ii: 1.3%, grade iii or iv: 0. reoperations after 21 months: 0. in 2006 in our department 62% of all mitral valve repairs needing no concomitant cabg or aortic valve operations were performed minimally invasive. conclusions. more than 60% of mitral valve repairs can be performed minimally invasive with excellent results. as the procedure is superior concerning cosmesis, the procedure is favored by patients and referring cardiologists. at this time disadvantages are neither proven nor suspected, advantages concerning surgical complications and rehabilitation are assumed. 010 insights from 133 cases of remote access perfusion for minimal invasive cardiac surgery n. bonaros 1 , t. schachner 1 , a. ö hlinger 1 , o. bernecker 1 , g. feuchtner 2 , g. laufer 1 , j. bonatti 1 background. remote access perfusion (rap) is a prerequisite for performance of minimal invasive cardiac surgery on the arrested heart. during implementation several technical challenges may be encountered. in this study we assess the incidence and the influence of these challenges on the perioperative outcome and we describe clinical results in a large patients' series. methods. we retrospectively analyzed 133 patients who underwent minimal invasive cardiac surgery (totally endoscopic coronary artery bypass grafting: 96, endoscopic atrial septal defect repair: 35, totally endoscopic mitral valve repair: 2) using rap (estech: 118, heartport: 15). intra-and postoperative parameters were analyzed according to the occurrence or not of technical challenges attributed to remote access perfusion. results. we observed no perioperative mortality and no severe complications in this patients' series. technical problems occurred in 23 patients (17%). three patients (2%) underwent conversion to other operative method as severely atherosclerotic peripheral vessels did not allow positioning of the balloon in the ascending aorta. another 2 patients required an additional arterial cannula in the contralateral femoral artery to ensure adequate perfusion. balloon migrations occurred in 66 patients (50%). in 7 cases was a cannula replacement required (5%), in four of which due to balloon rupture. in 4 patients (3%) positioning of the balloon in the ascending aorta required the use of fluoroscopy, as this was not possible under echocardiographical guidance. patients with technical difficulties (group 2) had no worse outcome than those in whom no rap-associated problems occured (group 1) with the exception of longer total operative time (group 1: 348 ae 116 min group 2: 404 ae 134 min, p ¼ 0.04). ventilation time, intensive care unit stay and hospital stay were all similar in the study groups (p ¼ ns). a comparison between the two cannula types showed only a higher balloon pressure needed for positioning of the estech cannula vs the heartport system (456 ae 61 vs. 352 ae 45, p < 0.001) although comparable injection volumes were used. conclusions. we conclude that technical difficulties are not rare during rap but in most of the cases can be easily managed at the cost of increased operative time. the postoperative outcome is not compromized provided that major complications are avoided. 012 neoangiogenesis after combined transplantation of skeletal myoblasts and angiopoietic progenitors leads to increased cell engraftment and lower apoptosis rates in ischemic heart failure background. we report on a modified minimally invasive and cosmetic approach of surgical repair of atrial septal defects (asd) i with emphasis on infant patients weighing below 15 kg. methods. from august 2005 to july 2006, 13 patients underwent this procedure (mmit-modified minimally invasive technique). the heart was exposed by a limited midline skin incision and partial sternotomy (newly developed sternal spreader, fa. fehling, germany), and the atrial septal defect was closed through a right atriotomy using special new aortic and dual venous cannuals. basic results were matched to those obtained from 10 patients (st-standard technique) . results. atrial morphology was more complex in mmit pts (3 overriding svcs, 3 sinus venosus defects), nevertheless op times were accurate and similar to st pts. early extubation was forced and made possible by fast-track methods. totally, 14 asds were directly closed, 9 pts had patch repair. postoperatively we observed 3 mild postpericardectomy syndroms, 1 cholecystitis and 1 pneumothorax requiring drainage in st pts, only 1 pt with mild pericardial effusion was found in mmit group. retention of pericardial effusions was not a risk factor and hospital stay was also not prolonged. conclusions. this approach achieves a cosmetically superior result with newly developed but standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions even in dysmorphic, low weight congenital patients. mmit (pts) . clinical data and follow-up were collected prospectively and analyzed retrospectively. statistical data are shown as mean values and standard deviation. in larger tumors a preoperative interventional embolization was performed. postoperatively pts were seen as outpatients once per year including ultrasound control. results. of the 35 pts with a mean age of 53.6 þ 15.5 years there were 26 female and 9 male pts. in 18 pts the unilateral tumor was located on the right side, in 10 pts on the left side. at time of diagnosis 7 pts (7=35 pts ¼ 20%) presented with bilateral paraganglioma. histological analysis showed benign paraganglioma in 34 pts and malignant paraganglioma in 1 pt. after a follow-up of 1 to 188 months (mean: 77.3 þ 17.0 months) 32 pts were alive and well whereas 3 pts were lost to follow-up. duplex ultrasound gave no evidence for recurrence of npg in 32 pts. the patient with the malignant tumor is alive and free of recurrence after 14 years and 5 months. the most recent patient with bilateral paraganglioma tested positive for sdh-d mutation. two brothers and 1 sister of this patient were diagnosed with phaeochromocytoma. conclusions. more female patients were affected than male pts. in male patients there was a higher incidence of bilateral paraganglioma of the neck. long-term survival in patients after surgical removal of neck paraganglioma appears not limited. because of the possibility to identify mutations in the sdhgene (sdhd, sdhb, sdhc) further testing of patients with bilateral paraganglioma is mandatory. screening for phaechromocytoma in these pts and evaluation of patients' families is recommended. background. endarterectomy remains the treatment of choice for ica stenosis. one major complication of surgery is cni (3-25%) , encouraging transfemoral stent placement for ica stenosis. the aim of this study is to evaluate a possible reduction of this complication by the use of eversion endarterectomy (eea) compared to standard patch endarterectomy. methods. prospective study design in patients treated at a tertiary university based care center. 100 consecutive patients were enrolled into the study. age (median 66 years, range 53-86 years), sex (male 58, female 42), medical risk factors (smoking 51%, hypertension 60%, diabetes mellitus 49%) and indication for surgery (asymptomatic stenosis 82%) were equally distrtributed among both groups (50 patients each). all patients were evaluated pre-and postoperatively for cni by an independent neurologist and ent specialist blinded for the operative procedure. results. one patient in the conventional group suffered patch rupture with consecutive stroke 2 days postoperatively. two patients in the conventional group developed cni (1 recurrent larygeal and facial nerve deficit, 1 hypoglossal and glossopharygeal nerve deficit). after 5 months of follow up the latter patient showed spontaneous resolution of cranial nerve symptoms. no patient developed cni after eea. conclusions. cni has been detected in 2% after endarterectomy of the ica in our series. symptoms of cni may be transient, but are disturbing if no clinical improvement is observed. eea requires less operative dissection in the neck compared to standard patch endarterectomy, and therefore seems to be favourable technique with regard to cni development. eea has the potential to curb the current trend toward application of endovascular surgery for ica stenosis. background. total occlusion or stenosis of the common carotid artery is rare and the indications and techniques of surgical treatment are still a matter of controversy. we demonstrate the feasibility of retrograde common carotid endarterectomy. methods. retrospective case report study. participants. in a period of fifteen years thirty-nine patients underwent retrograde endarterectomy of the common carotid artery. twenty-nine patients were males, middle age 71 (min 50, max 86). ten patients were females, middle age 75 (min 51, max 89). symptoms of brain ischemia were present in fifteen patients. retrograde endarterectomy of the common carotid artery and endarterectomy of the internal carotid artery were done together in all patients. indication for retrograde tea was a verified stenosis >70% or occlusion of the common carotid artery diagnosed by duplex ultrasound and arteriography. in three patients iatrogenically dissection of the common carotid artery was seen as indication for that procedure. main measurements. postoperative early mortality, stroke rate, medium and long-term endarterectomy patency. results. in all patients who underwent that procedure there was no occurence of major complications or statistically increased mortality. the 30 day mortality was 5.1% (2 patients). one of them died in cause of a heart attack and one because of a cerebral bleeding. there was one ipsilateral stroke (2.56%) eight month after the procedure. three patients were lost to follow-up. mean follow-up was 50 months (1 to 180). there were 12 (30.7%) late deaths caused by cardiovascular related problems, pneumonia and cancer. in all living patients, controlled by duplex ultrasound, no occlusion or stenosis was found. conclusions. retrograde tea can be done through only one cervical incision for common carotid artery stenosis= occlusion, for tandem lesions of the carotid arteries as well as for iatrogenic dissections of the common carotid artery. compaired to bypass grafting this technique is a faster and easier method. our retrospective study indicates a long-term patency and freedom from neurologic events. 019 stenosis and occlusion of the proximal subclavian artery -surgical or interventional treatment? an analysis of our own patients and international studies m. tomka, a. baumann, p. konstantiniuk, t. ott, t. cohnert division of vascular surgery, department of surgery, medical university of graz, graz, austria background. seventeen percent of all supraaortic occlusions concern subclavian artery, but only 24% of them fulfil the clinical and angiographic qualification of steal syndrome. methods. since 1988 50 patients with stenosis or occlusion of the proximal subclavian artery were treated on our department. 20 patients underwent end-to-side transposition of the subclavian into the common carotid artery; a carotid-subclavian bypass using synthetic grafts was applied to 30 patients. surgical treatment and evaluation, complications, short and long term patency of our patients were compared to interventional techniques and international literature. results. the primary success rate of both operative techniques achieved 100%. 30-days mortality was 0%, 30-days morbidity 5% (1=20) in the transposition group and 3.3% (1=30) in the bypass-group respectively. median follow-up time was 50 months in the transposition-group vs. 55 months in the bypass-group. only in the latter one late occlusion (3.3%) was seen. conclusions. our data show a slight (not significant) favour for the transposition, which is consistent with results from other studies. concerning long term patency and infection rates the transposition of the subclavian into the common carotid artery by single incision is to be recommended first choice of treatment. avoiding synthetic grafts leads to optimal compliance. flow in natural direction and less mortality and morbidity rate are ensured. critical, because preoperative ef is predictive for long-term survival. here, we report results from a genomic study in patients with as in compensated and decompensated state and present candidate genes that could be predictive for the progression of heart failure. methods. biopsies from the lv septum of male patients (73â a ae 6 yrs) with isolated as undergoing biologic aortic valve replacement (carpentier edwards magnaâ a + ) were harvested either from hearts with normal ef (>50%, n ¼ 3) or from a group with low ef (60%, n ¼ 3) and served as controls. total rna was analyzed on affymetrix hg-u133a genechips, which allowed to measure expression levels of more than 22.000 human gene transcripts. low level expression analysis was performed using the gc-rma algorithm and statistical significance analysis was done by bayesian t-test. class prediction was performed using the brb arraytools package (nci). results. expression levels clearly distinguished as from cad. annotation of these transcripts revealed a close correlation with the hypertrophic response and progressive fibrosis. these targets completely reflected the current understanding of key processes involved in heart failure. within a list of several (7) as classifier genes that revealed well-known markers such as the natriuretic peptide precursors a and b and troponin i, we identified: (1) the connective tissue growth factor (1169 vs. 29; p < 0.000001), known to be triggered by mechanical stress in fibroblasts; (2) periostin (1139 vs. 22, p ¼ 0.000038), an important matricellular component recently shown to be responsible for ventricular dilation. when specifically searching for low ef class predictors, we found 2 potential candidates of unknown function, which were consistently expressed at a higher level only in as with ef <30%: (1) the pom and zp3 fusion gene (163 vs. 16, p ¼ 0.0004) and (2) the transcription factor ets variant 1 (268 vs. 105, p ¼ 0.0006). conclusions. in this study we could clearly identify patients with cad from those with as by the help of gene expression profiling. moreover, we were able to identify gene expression signatures that could be predictive for the progression of heart failure. background. despite tremendous advances in immunosuppressive therapy acute rejection still remains a problem following solid organ transplantation. proteome analysis has emerged as a valuable tool for the study of large scale protein expression profiles and biomarker detection. here we applied this novel technology to identify specific biomarkers for acute cardiac allograft rejection. methods. cardiac allografts of c57bl=10 mice were placed into fully mhc-mismatched c3h=he recipients. syngeneic transplants served as controls. protein expression analysis was performed using fluorescence two-dimensional difference gel electrophoresis (2d-dige) on day six post transplant. spots of interest were subjected to nanospray ionization tandem mass spectrometry (ms=ms) for protein identification. expression of selected proteins was confirmed by western blot analysis. results. median graft survival of untreated hearts was 8.3 ae 0.6 days whereas all syngeneic animals showed indefinite graft survival > 100 days. analysis of the 2d-dige gels revealed a total of 95 protein spots that were significantly regulated by more than 1.5-fold during acute rejection when compared to syngeneic controls. spots with highest altered regulation identified with ms=ms were derived from coronin 1a, vimentin, protein disulfide isomerase a3 precursor, skeletal muscle lim-protein 3, aconitate hydratase, and fumarate hydratase. peroxiredoxin 6 and pyruvate kinase isozyme m2 were selected for further analyses. western blotting and immunohistochemistry showed significantly higher expression of these proteins during acute rejection compared to syngeneic grafts. conclusions. this study demonstrates that proteomics is a powerful method to detect biomarkers of acute cardiac allograft rejection. identified proteins like peroxiredoxin 6 and pyruvate kinase isozyme m2 represent novel indicators of acute rejection and may become useful surrogate markers for monitoring the alloimmune response. 023 impact of endothelin-a receptor blockade on myocardial gene expression post mi w. dietl 1 , g. mitterer 1 , m. bauer 1 , k. trescher 1 , w. schmidt 2 , b. k. podesser 1 background. despite promising experimental results of endothelin-a (et-a) receptor blockade in treatment of heart failure (hf), clinical trials failed to confirm these findings. in order to elucidate this discrepancy, we decided to evaluate the impact of et blockade on myocardial gene expression (ge) post myocardial infarction (mi). methods. mi was induced in male sprague-dawley rats using lad ligation. three days post mi, rats were randomized to receive either tbc3214-na or placebo and to survive either 7 or 42 days. sham-operated rats served as control group. prior scarification, rats underwent echocardiography. following excision, hearts were analyzed morphometrically. rna was extracted from non-infarcted areas of the lv. targets for quantification were identified using affymetrix gene chip + technology and subsequently quantified by real time pcr. results. et-a blockade did not influence morphology or hemodynamics on day 7, while it significantly improved both parameters on day 42. in contrast, ge analysis revealed that the majority of mi-induced changes in ge occur early after mi, with the majority of genes returning to baseline after 42 days. five days of et-a blockade resulted in an attenuated expression of 38 mi-induced transcripts (e.g. tnc, spp1, sparc, mmp14) involved in post-mi remodeling. conclusions. apparently, endothelin receptor blockade influences early post-mi remodeling. this data adds further evidence that timing is crucial in et therapy post mi: administered to early, myocardial wound healing is disturbed and lv function deteriorates. given in time, excessive ventricular remodeling is attenuated and lv function improves. 024 identification of sex-specific targets in experimental heart failure m. bauer 1 , g. mitterer 1 , w. dietl 1 , k. trescher 1 , w. m. schmidt 2 , b. k. podesser 1 background. sex-specific differences have been reported in ischemic heart failure. the aim of the present study was to screen for diferentially expressed genes in experimental ischemic heart-failure using genechip + technology. methods. mi was induced in male (n ¼ 9) and female (n ¼ 9) sprague-dawley rats by ligation of the lad. 7 and 42 days post-mi, surviving animals were sacrificed and samples of the non infarcted free wall gained to perform transcription analysis. sham-operated males (n ¼ 6) and females (n ¼ 6) served as control. extracted rna of 3 animals per group was pooled and affimetrix genechip + technology was used to screen for differentially expressed targets. genechips + were analyzed using the mas5.0 algorithm and the following rules employed comparing mi vs. corresponding sham to identify sex-specific targets: 1) increase in expression in one sex and a decrease in the other, 2) increase in expression one sex and absent in the other, 3) decrease in expression one sex and present in the other. results. our strategy revealed 82 targets differentially expressed. 53 of these targets were expressed differentially on day 7 only, 28 on day 42, only one target was expressed differentially on both 7 and 42 days post-mi. of this targets 9 were selected for further analysis including: keratins, caspase-8, aldehydoxidase-1, cdkn-1a and triadin and will be evaluated using rt-pcr. conclusions. 1) there are sex-specific targets in post-mi gene expression. 2) this targets can be identified using gene-chip as screening tool. 025 bilirubin rinse suppresses early mapk activation in cardiac ischemia-reperfusion injury r. ö llinger 1 , p. kogler 1 , f. bösch 1 , c. koidl 1 , r. sucher 1 , m. thomas 2 , j. troppmair 1 , f. bach 2 , r. margreiter 1 background. heme oxygenase-1 (ho-1) expression is crucial in preventing ischemia reperfusion injury (iri). bilirubin, a product of heme catabolism by ho-1 at least in part accounts for the protective effects mediated by ho-1, however, the mechanisms by which bilirubin mediates these effects remain to be elucidated and strategies to apply the bile pigment are needed. mitogen activated protein kinases (mapk) are activated upon stress and play an important role in the early phase of iri. we hypothesized that in a mouse model of heart transplantation, a brief rinse with bilirubin of the graft before reperfusion would affect mapk activation. methods. isogenic c57bl=6 hearts (n ¼ 4=group and time point) were harvested, stored in uw solution at 4 degrees for 18 h and then rinsed with bilirubin at 0.125 mm or ringer lactctate as a control before anastomosis. anastomosis time was kept constant at 15 min by using a cuff-technique, subsequently thereafter perfusion was restored. samples were collected at various times. western blot analysis was carried out for total (t) and phosphorylated (p) forms of akt, erk 1=2, jnk 1=2 and p38 mapk. p=t ratio was quantified by imagej and statistically analyzed using anova. results. after anastomosis and before any reperfusion phosphorylation of erk and p38 mapk was increased when compared to 18 h of ischemia allone. this was not seen when grafts were rinsed with bilirubin. further, at 15 min after reperfusion, phosphorylation of all mapks being investigated was dramatically increased when compared to the non-reperfused isografts. at this time point, bilirubin significantly inhibited phosphorylation of erk and jnk (p < 0.001) as well as p38-mapk and akt (p < 0.05). conclusions. bilirubin rinse of mouse cardiac isografts causes a dramatic decrease of mapk activation associated with the proinflammatory response to the stress of iri. bilirubin rinse of allografts before implantation might be a potent aproach to avoid early organ dysfunction. 026 improvement of myocardial protection by a selective endothelin-a receptor antagonist added to cardioplegia in failing hearts background. ischemia=reperfusion (i=r) injury due to cardioplegic arrest is a problem in patients with reduced lv function. we investigated the effect of chronic versus acute administration of the selective endothelin-a receptor antagonist tbc-3214na during i=r in failing hearts. methods. male sprague-dawley rats underwent coronary ligation. three days post infarction group 1 (n ¼ 11) was administered tbc-3214na continuously with their drinking water, groups 2 and 3 received placebo. seven weeks post infarction hearts were evaluated on a blood perfused working heart during 60 0 ischemia and 30 0 reperfusion. in group 2 (n ¼ 10) tbc-3214na and in group 3 placebo was added to cardioplegia during ischemia. results. at similar infarct size postischemic recovery of cardiac output (group 1: 91 ae 10%, group 2: 86 ae 11% vs. placebo: 52 ae 15%; p < 0.05) and external heart work (group 1: 90 ae 10%, group 2: 85 ae 13% vs. placebo: 51 ae 17%, p < 0.05) group was significantly enhanced in both tbc-3214na treated groups while recovery of coronary flow was only improved in group 2 (group 2: 121 ae 23% vs. group 1: 75 ae 13%, placebo: 64 ae 15%, p < 0.05). evaluation of blood gas measurements showed enhanced myocardial oxygen delivery and consumption with acute tbc-3214na therapy. in addition high energy phos-phates were significantly higher and transmission electron microscopy revealed less ultrastructural damage only under acute tbc-3214na administration. conclusions. acute endothelin-a receptor blockade is superior to chronic blockade in attenuating i=r injury in failing hearts. ultrastructural and biochemical evaluation indicate an improvement in capillary perfusion by acute tbc-3214na administration during reperfusion resulting in a better cardiac function post ischemia. therefore acute andothelin-a receptor blockade might be an interesting option for patients with heart failure undergoing cardiac surgery. background. except in inguinal hernia with strong fascia, treatment of these hernias requires a reinforcement of the inguinal wall. different methods have been established based on different approaches and different degree of reinforcement: partially (lichtenstein, rutkow=robbins) or totally (rives, stoppa, wantz, tipp, tep, tapp) . in danish and swedish hernia register a surprisingly high number of female (especially femoral) recurrencies were found emphasizing the problem, as mainly lichtenstein procedure was performed. increasing knowledge of reasons of fascial insufficiency give further hints towards using a total reinforcement of the inguinal region. among these procedures the transinguinal preperitoneal hernioplasty with a memory-ring armed polyprolylene patch (polysoft patch tm ) is new and promising. methods. between 15.12.2004 and 15.01.2007 524 inguinal hernias in patients have been treated by tipp with polysoft patch tm (387 bassum-suhlingen, 137 idstein). operation and patient data were recorded prospective. we operated 475 male and 49 female hernias. after 6-12 month patients were interviewed with a standard questionaire. 138=183 patients (75.2%) answered. results. 195 medial, 192 lateral, 133 combined and 4 femoral hernias were done. 58=525 recurrent hernias (11.04%), 13=525 incarcerated hernias (2.5%). intraoperative complications: 6=525 (1.14%). postoperative complications have been 3 bleedings, 1 infection, 2 wound dissections. haematomas= seromas we have seen preperitoneal in 15 cases, subcutaneous in 80 cases. 2 re-operations and 12 punctions have been performed. a hydrocele has been seen in 3=524 cases, an ileoinguinal syndrome we have noted in 4 cases (no resection has been performed). under intention of a preperitoneal repair, 6 patients have got another treatment: 2 lichtenstein, 2 rutkow and 2 shouldice procedures. in 6=524 patients (1.1%) the positioning of the patch was difficult mainly due to very small or fatty anatomy. longterm results (1 year postoperative): 5.1% had some pain or heavy pain, 21.6% had occasional pain and 10.3% had little or some movement problems. there was 1 recurrent femoral hernia (5 mm hole with fat; 8 months post op), only one patch has been removed because of strong pain in riding or sitting in low seats. conclusions. tipp is a safe procedure which fulfills the requirement of a total reinforcement of the inguinal wall. the memory-ring armed polypropylene patch covers the inguinal region and makes the procedure easier compared to the predecessors (e.g. wantz). results. there were 9 primary and 1 recurrent hernias. in 8 cases local and in 2 spinal anaesthesia was used. no intraoperative complications occured, all meshes could be placed easily. 1 patient had local pain for 4 weeks. at followup 8 patients were symptom-free, 1 had paresthesia and 1 infra-inguinal swelling. conclusions. parietene mesh is easy and fast to use and gives satisfying early results. since part of the mesh will resorb within 1 year long-term results will have to be awaited. 030 light versus heavy meshes for laparoscopic inguinal hernia repair -a biomechanical study the incidence of recurrence, first of all, has been lowered by a laparoscopic technique. methods. during the last 3 years we have operated on 56 patients for incisional and abdominal wall hernias. results. there were 30 men and 26 women with a mean age of 58.1 years. we applied an intraperitoneal onlay meshtechnique (ipom) by a laparoscopic way. twenty-three patients had an abdominal incisional hernia, 13 an umbilical hernia, 15 an epigastric hernia, 4 a trocar-hernia and one patient a spigelian-hernia. the diameter of abdominal wall defects was 2-12 cm. in 30 patients a parietex composite-mesh has been used, in 22 a proceed-mesh, in 3 a bard composix-mesh and in one patient two 15 â 15 cm 2 timeshes. mesh-size was 10 â 15 cm 2 to 20 â 30 cm 2 . hernia sacs were left in place, hernia contents, mostly omentum, were replaced into the abdominal cavity. meshes were fixed using endo-clips in 4 patients, tacks in 22 and the salute fixation-system in 30 patients. postoperative follow-up includes a control at 1 week, 1 month and 1 year postoperatively. there were no problems during operation. patients were discharged on the second postoperative day. after a mean follow-up of 18.1 months (1-43 months) two patients have a hernia recurrence, three patients had local pain for one month and one patient had an umbilical infection, which could be managed without the removal of the mesh. conclusions. laparoscopic incisional and abdominal hernia repair has a low incidence of complications and shows a rapid postoperative recovery of patients. long-term follow-up is necessary for evaluation of mesh reactions with regard to infection as well as to adhesion formation with the intestine. background. the fixation of hiatal meshes with perforating devices, such as tacks or sutures, can be associated with potentially life threatening complications [1] . fibrin sealant (fs, tissucol, baxter biosciences, vienna, austria) is successfully used for atraumatic mesh fixation in inguinal and incisional hernia repair [2, 3] . the rationale of this study was to test the potential of fs fixation of hiatal meshes in pigs. methods. in general anaesthesia, 6 domestic pigs were subjected to laparotomy and designated meshes (ti-sure, gfe, nuremberg, germany) were implanted at the hiatus. the titanized polypropylene material was found to be favorable in combination with fs in a previous study [4] . meshes were sealed with 2 ml of fs, which was applied with a spray system. the observation period was 4 weeks in all animals in order to assess tissue integration after the fs was already degraded. results. all meshes showed excellent integration and no sign of dislocation or perforation into the neighbouring organs. histology was used to confirm. conclusions. fs for hiatal mesh fixation provides a safe and effective alternative to perforating fixation devices in an animal model of repair. background. we aimed to assess the incidence for esophageal, cardiac and gastric cancer. methods. annual incidence data and age adjusted rates for the years 1990 to 2003 were obtained from statistics austria which operates the nationwide austrian cancer registry. according to icd-o-3 (international classification of diseases for oncology, third edition), the following categories were considered: esophageal squamous cell carcinoma (c15, 805-808), esophageal adenocarcinoma, (c15, 801-804), cardiac adenocarcinoma (c16.0, 801-804) and non cardiac gastric adenocarcinoma (with known and unknown subsite, c16. [1] [2] [3] [4] [5] [6] [7] [8] [9] [801] [802] [803] [804] , esophageal and gastric tumors with ill-defined histology and death certificate only (dco)-cases. results. annual incidence of esophageal squamous cell carcinoma increased from 93 cases in 1990 to 170 in 1997, peaked in 1998 (176 cases) towards 2001 (170) , declined towards 137 and 135 cases in 2002 and 2003 , respectively. from 1990 to 2003 adenocarcinoma of the esophagus increased 3 fold (33 vs. 100). the number of unspecified epithelial neoplasms of the esophagus remained stable (39-35 cases). dco cases, comprising no histological information, were stable from 1990 (n ¼ 66) to 1996 (n ¼ 61), decreased until 2001 (35 cases) and increased in 2003 (73 cases). from 1990 to 1993 adenocarcinoma of the cardia increased 1.38 fold (93 vs. 128) and remained rather stable with about 120 cases per year until 2002; 2003 130 cases were registered. non cardiac gastric adenocarcinomas and gastric adenocarcinomas with ill-defined location decreased 1.16 fold (214 vs. 184) and 1.59 fold (851 vs. 536), respectively. the numbers of histologically unspecified cases of malignant cardia tumors and dco cases remained rather stable (unspecified: 29 in 1990 and 19 in 2003; dco: 14 cases in 1990 and 10 cases in 2003) . gender distribution shows an increase of esophageal squamous cell carcinoma in females (male:female 87: 6 ¼ 14.5 in 1990 to 98:37 ¼ 2.6 in 2003) and esophageal adenocarcinoma (male: female ratio 1990 vs. 2003; 26:7 vs. 86:14; ratio 3.7 vs. 6.1) and cardiac adenocarcinoma for males (65:28 vs. 100:30; ratio 2.3 vs. 3.3) . age adjusted rates per 100.000 population of non-cardiac gastric carcinomas decreases for both sexes (data not shown). we observed an increase of esophageal squamous cell carcinoma in females and esophageal and cardiac adenocarcinoma for males and a decrease of non-cardiac gastric carcinomas for both sexes. 036 endoscopic versus open esophageal resection: a prospective case-control study within the learning curve background. esophageal resection for cancer is followed by remarkable morbidity. endoscopic surgery has been established to reduce the physical burden. in our institution endoscopic and open esophageal resection is performed transthoracally (tse) or transmediastinally (lstme) as appropriate. we aimed to compare outcomes of case matched open and minimal access esophageal resection by a case-control analysis. methods. endoscopic minimal access esophageal resection (mae) has been performed since 2004 (mae). a retrospective case control study including patients (prospectively collected data) who underwent mae (tse, 17, lstme, 3) has been undertaken with matched (pairs matched for sex, age, tumour type and type of resection) historical open (oe) cases operated between 2004 and 2006 (transthoracic esophageal resection tte, 14, transmediastinal esophageal resection tme, 6). groups were comparable regarding age, sex distribution, tumour type (as consequence of matching) as well as regarding tumour stage and comorbidities. results. forty patients (males, 28; females, 12; mean age 60 ae 12 yrs) were included in the study. there were 19 adenocarcinomas and 21 squamous cell cancers. 15 patients had neoadjuvant chemotherapy (fu=cis). duration of surgery, number of resected lymphnodes, duration of intubation, icu stay and hospital stay was 424 vs. 373 min (p ¼ 0.01), 19 vs. 23 (p ¼ 0.2), 0.8 vs. 3.4 days (p ¼ 0.1), 4 vs. 10 days (p ¼ 0.03) and 16.2 vs. 28 days (p ¼ 0.02) in the mae and oe group, respectively. due to preexistent anemia 2=20 mae patients received erythrocyte substitution preoperatively, 7=20 patients of the oe group needed erythrocyte subsitution perioperatively. 1=20 and 5=20 patients underwent reoperation for a complication in the mae and oe group. overall surgical morbidity was 20% (4=20) and 40% (8=20). postoperative pneumonia was observed in 1=20 and 4=20 among mae and oe patients. conclusions. during the learning curve duration of mae is significantly longer when compared with oe. morbidity was reduced, icu and hospital stay were significantly shorter after mae, regarding duration of postoperative ventilation there was a trend towards mae. oncological quality was comparable between groups with respect to the number of resected lymph nodes. the need for blood substitution and reoperation was higher in open esophageal resection. even during initial establishment mae seems advantageous for the patient in this case-control study. randomised trials are still missing. 038 does the route of gastric pull-up influence the oxygen supply of the anastomosis? background. microcirculation and oxygen supply at the level of oesophagogastric anastomosis following oesophagectomy are among the crucial factors determining anastomotic healing. methods. twenty-nine patients (mean age 61.7 yrs) were evaluated during oesophagectomy and on the intensive care unit by inserting a micro-probe (licox) and continuously recording the interstitial po2 of the tubulated stomach in the anastomotic region. two different surgical procedures were applied: group 1 (15=29) had gastric pull-up via a retrosternal, group 2 (14=29) via an orthotopic route. the interstitial po2 values were averaged over specific consecutive periods: intraoperatively after ligation of the short gastric vessels, after ligation of the left gastric artery, after forming the conduit and after gastric pull-up. postoperative measurements were recorded during intubation, while breathing oxygen by mask or by nose delivery, respectively and finally while breathing air. results. before ligating the left gastric artery the interstitial po2-levels were significantly higher (mean 76.14 mmhg) than after ligation (mean 44.93 mmhg; p < 0.05). comparing the retrosternal (24.64 mmhg) versus the orthotopic pull-up route (68.21 mmhg) a significant difference (p < 0.05) in favour of the orthotopic route could be found after gastric pull-up as well as during each postoperative measurement period. no differences could be detected when comparing the various oxygen supply systems. conclusions. these data suggest that the oxygen supply at the anastomosis of the pedicled gastric conduit reaches higher levels after orthotopic than following retrosternal gastric pull-up. 039 p53 tailored therapy for esophageal cancerpilot study in reported 3-year survival rates of 64% in this group. factors identifying this subgroup of responders and selecting optimal drugs for non responders could dramatically enhance treatment efficacy. several studies suggest that mutations in the p53 gene may induce drug resistance especially for agents whose effect is based on apoptosis induction, like cisplatin. methods. in order to test the hypothesis that the p53 genotype is predictive for chemotherapy response, a prospective study was conducted. thirty-eight patients with potentially respectable esophageal cancer were evaluated for the relation between p53 genotype and response to two different neoadjuvant treatments. p53 gene mutations were assessed by complete direct sequencing of dna extracted from diagnostic biopsies. response to neoadjuvant chemotherapy was assessed pathohistologically in the surgical specimen. results. twenty squamous cell carcinoma and 18 adenocarcinoma were included. overall the p53 mutation rate was 58% (22=38), with 66% for squamous cell and 53% for adenocarcinomas, respectively. 30 patients received cis=5fu (cisplatin 80 mg=m 2 d1 5-fu 1000 mg=m 2 d 1-5, q21,2 cycles), 8 received docetaxel (75 mg=m 2 , q21,2 cycles). the overall response rate was 48% (18=38). patients with p53 mutation did not respond to cis=5-fu (0=16), while all mutant patients responded to docetaxel (6=6). the overall response to p53 adapted neoadjuvant therapy was 94%. p53 adapted treatment was associated with a significant survival advantage (p ¼ 0.042) after a median follow up of 15.4 months. conclusions. a prospective randomized trial was initiated to test the interaction between the predictive marker p53 and response to respectively. 040 a new method of anti-ischemic graft protection in retrosternal colon esophagoplasty a. albokrinov 1 , a. pereyaslov 2 , r. kovalskiy 1 1 lviv children's regional clinic hospital, lviv, ukraine; 2 lviv d. halytsky national medical university, lviv, ukraine background. retrosternal colon esophagoplasty is the operation of choice in infants with esophageal atresia with great diastasis. although complications are rare, some cases of graft ischemia are registered. epidural block have beneficial effect on splanchnic blood flow because of drug sympathectomy. methods. we retrospectively analyzed rate of graft ischemia in infants with retrosternal colon esophagoplasty and conventional postoperative course with anticoagulants and antiaggregants (group 1, n ¼ 17). group 2, n ¼ 11 was investigated prospectively with preoperative catheterization of epidural space (th10-th11 level, lost of resistance test, g20 size) and 0.25% bupivacaine administration in daily dose of 2.5 mg=kg every 4 h. the rest of therapy was equal in all patients. graft status was determined visually. gut motility was considered to restore when stool have been obtained. results. rate of graft ischemia was significantly lower in group 2 then in group 1 (0 vs 4, p < 0.05). besides this, gut motility restoration in group 2 was significantly earlier (2.4 ae 0.2 vs 4.5 ae 0.3 days, p < 0.05). conclusions. epidural block with local anesthetic is an effective method of anti-ischemic protection of neo-esophagus and powerful instrument in gut motility restoration. background. atrial fibrillation (af) is often associated with thromboembolic complications, heart failure and stroke; in addition an increase in mortality, even with adequate anticoagulation, is observed. the maze operation is an effective and accepted method to terminate af, nevertheless the risk for intraoperative bleeding is increased compared to left atrial ablation procedures using variable energy sources. left atrial ablation is an alternative method to convert af into sinus rhythm (sr), as with this procedure linear lesions connecting the four pulmonary veins and the posterior mitral annulus are created with microwave or high frequency technique. methods. a consecutive series of 108 patients (51 females, 57 males; age 66a, range 38-85a) underwent ablation during various cardiac surgical procedures between 2001 and 2006. endocardial ablation using either microwave or radiofrequency energy was performed 103 times (95.4%) and epicardial with microwave energy in five cases (4.6%) . preoperative parameters: ejection fraction 53.6% ae 9.9%; diameter left atrium 54.7 ae 9.7 mm. forty-one patients underwent mitral valve repair (mvp), 37 patients obtained mitral valve replacement (mvr), 18 patients received aortic valve replacement (avr), 8 patients underwent coronary bypass surgery (cabg) and 4 patients had combined valve surgery (others). results. others combined valve replacement: mvr þ tvp, mvr þ avr; af atrial fibrillation; aflut atrial flutter; pm pace maker no intraoperative or postoperative complications related to the concomitant ablation procedure were observed. one patient died because of multiple organ failure. after a mean follow up period of 75 months ae 52 70 patients remained in sr (64.8%), 32 patients into af (29.6%), 5 patients changed rhythm into atrial flutter (4.6%) and one patient required a pace maker (0.9%). conclusions. in approximately two thirds of patients left atrial ablation is effective in restoration and maintenance of sr in patients with structural heart disease and af. this method represents a valid alternative to the maze technique, reducing myocardial ischemic time and risk of bleeding. midterm results are promising; however for determination of a long term benefit especially regarding thromboembolic events, a higher number of patients and a longer follow up period are desired. background. the study aim was to evaluate the efficacy and outcome of endocardial and epicardial atrial fibrillation (af) ablation in patients undergoing heart surgery. methods. between february 2002 and december 2006, 81 patients (mean age 67 years, range 48-80) underwent left atrial ablation combined with other type of cardiac surgery. in 73 patients endocardial left atrial ablation using a unipolar radiofrequency device (cardioblate tm , medtronic, usa) was performed, mainly in combination with mitral valve (mv) surgery (43 mv repair, 27 mv replacements) . in 8 patients epicardial pulmonary vein isolation using microwave energy (flex 10 tm , guidant-boston scientific, usa) was done during aortic valve replacement (4) and bypass grafting (4) . indication for atrial ablation was permanent af in all patients. endocardial ablation was performed during extracorporal circulation (ecc) with a mean time of 9 min (5-17), epicardial ablation before ecc with a mean ablation time of 16 min (14) (15) (16) (17) (18) (19) . 91% of the patients (74) received amiodarone postoperatively, 9% (7) betablocker. 21 patients underwent epicardial cardioversion with synchrus tm (guidant, usa) wires postoperatively. results. the overall mortality was 2.4% (2 patients during mv replacement due to posterior bleeding) complications were posterior rupture (4) , lco with the need of intraaortoc pallon pump (3), 2 resternotomies for bleeding, and and 11 (13%) pacemaker implantations (13.5%). there were no ablation procedure related complications. sinus rhythm (sr) was achieved in 71% after operation, 42% at discharge and 68% at the 3 month follow up. a nodal rhythm was found in 20% after operation, 5% at discharge and in 4% after 3 months. 4 patients developed atrial flutter (3 in the group of endocardial and 1 in the group of epicardial ablation). af persisted in 28% of the patients at 3 month. conclusions. af ablation combined with cardiac surgery is safe and effective. recurrent af is frequent during the first three months after ablation also under therapy with antiarryhthmic drugs. background. patient-prosthesis mismatch is a frequent cause of high postoperative mortality and gradients. the objective of this study was to determine whether mismatch can be predicted at the time of operation. methods. indices used to predict mismatch were valve size, indexed internal geometric area and projected indexed effective orifice area (eoa) calculated at the time of operation, and results were compared with the indexed eoa measured by doppler echocardiography after operation in 1097 patients. results. the sensitivity and specificity of these indices to detect mismatch, defined as a postoperative indexed eoa of 0.85 cṁ =ṁ or less, were 30% and 84% for valve size 47% and 86% for indexed internal geometric area, and 79% an 87% for projected indexed eoa. conclusions. the projected indexed effective orifice area calculated at the time of operation accurately predicts mismatch, where as valve size and indexed internal geometric area cannot be used for this purpose. 048 excellent long-term results after emergency cardiac surgery d. martin, a. yates, h. mächler, l. salaymeh, d. dacar, b. rigler division of cardiac surgery, department of surgery, medical university of graz, graz, austria background. data from all adult patients undergoing emergency heart surgery between 1991 and 2003 at the division of cardiac surgery, medical university of graz, austria, were reviewed retrospectively. methods. data were stored in a local cardiac surgery database. the registery included all relevant patients data and euro-score. no patient was lost to follow-up. a series of relevant perioperative data were collected. recorded complications were use of the intra-aortic balloon pump (iabp) and low cardiac output syndrome. hospital and late mortality data were collected from the austrian national populations register. multivariante analysis was performed to determinate predictors for cardiac related death. results. between 1991and 2003 568 patients underwent emergency cardiac surgery at our institution. there were 342 men (60.2%) and 226 women (39.8%) with an average age of 56.5 years. coronary artery bypass was performed in 40.59%, 2.46% combined valve and bypass, 14.08% valve, 17.60% aortic dissection and 25.27% had other procedures. eighty-seven patients (15.3%) had a postoperative low cardiac output syndrome. the intra-aortic balloon pump was used in 85 patients (15.3%). variables identifying as high risk for perioperative cardiac related death were diagnosis other then coronary artery disease, patients with iabp and high catecho-lamine demand. there were no postoperative wound infections. eighteen patients (3.1%) had excessive postoperative bleeding and 6 (1.04%) required a late re-intervention. hospital mortality was 18.16% and the late mortality after 13 years was 34.17%. conclusions. the hospital mortality was higher in the emergency group but there was no difference in the long-term results for elective and emergency surgery. early mortality was significant higher in patients operated for other reason than coronary artery disease. background. acute renal failure is a serious adverse event after cardiac surgery, which is associated with high perioperative mortality and prolonged hospitalization. the aim of our study was to evaluate pre-and intraoperative risk factors for the development of acute renal failure requiring hemofiltration (arf) after cardiac surgery. the influence of different methods for evaluation of renal function was investigated. methods. from 01=2002 through 12=2005, 2652 patients underwent cardiac surgery at our institution. 197 patients developed arf (7.4%), patients suffering from chronic end-stage renal insufficiency were excluded from the study. patient characteristics and operative variables were analyzed. a multivariate logistic regression analysis was performed to determine risk factors for arf. results. patients, who developed arf, were older (p < 0.003, or: 1.037) as compared to patients who did not develop arf. furthermore, diabetes mellitus (p ¼ 0.001, or: 1.884), peripheral artery disease (p ¼ 0.003, or 1.979), cardiogenic shock (p ¼ 0.043, or: 2.957), congestive heart failure (p ¼ 0.013, or: 1.601) und emergent surgery (p ¼ 0.001, or: 3.032) were predictive for development of arf. preoperative serum creatinine was not predictive for arf (p ¼ 0.064, or: 1.366). classification of preoperative serum creatinine into normal ( 1.2 mg=dl), slightly elevated (1.2 to < 2 mg=dl) and severely elevated (!2 mg=dl), reveals a correlation with the development of for severely elevated creatinine levels (p ¼ 0.014, or: 3.826), as well as for slightly elevated levels (p ¼ 0.014, or: 1.871). calculation of creatinine clearance mwith the cockcroft-gault formula demonstrated a strong correlation with the development of arf (p ¼ 0.026, or:0.983). calculation of creatinine clearance with the mdrd formula, however, failed to reveal any correlation with (p ¼ 0.122, or: 1.012). conclusions. our data indicate, that advanced age, diabetes mellitus, peripheral artery disease, cardiogenic shock and congestive heart failure, as well as emergent surgery independently predict arf after cardiac surgery. even slightly elevated creatinine levels are a risk for the development of arf after cardiac surgery. calculation of creatinine clearance with the cockcroft-gault formula is more suitable for preoperative risk stratifica-tion as compared to calculation of creatinine clearance with the mdrd formula. background. the matricellular protein tenascin-c (tn-c) induces production of matrix metalloproteinases (mmps), inhibits cellular adhesion and mediates cellular deadhesion. these effects are crucial in the dynamic process of cardiac remodeling. it has been reported that tn-c expression is up-regulated in ventricular remodeling following myocardial infarction (mi) in the border zone between scar tissue and non-infarcted area. we analysed the expression of tn-c in the post mi infarcted and non-infarcted area after the treatment with the selective endothelin a (et a )-receptor antagonist tbc3214-na. blockade of the et a -receptor decreases cell proliferation, lv hypertrophy, and secretion of pro-inflammatory mediators. methods. mi was induced in male sprague dawley rats by lad ligation. three days post mi, rats were randomised to receive either the endothelin antagonist tbc3214-na (n ¼ 6) or placebo (n ¼ 6), as control rats were sham-operated without lad ligation (n ¼ 4). after 7 days hearts were harvested and tissue samples from scar, peri-infarct and free wall were analysed by western blot using a monoclonal antibody specifically recognizing the egf like domain of tn-c. tissue was homogenized in urea buffer and protein samples were subjected to 6% polyacrylamide gel sds-page, transferred on to a membrane and immunostained with the anti-tn-c monoclonal antibody and antimouse alkaline phosphatase antibody. additionally on day 7 and 42 echocardiography and morphological analysis were performed to assess the effect of tbc3214-na therapy on cardiac function. results. infarct size was comparable in all groups (et agroup 44.07 ae 9.56%, placebo group 44.59 ae 7.35%). during early remodelling on day 7, in the placebo group, tn-c was upregulated in scar tissue. in contrast, in the et a -group, tn-c was down regulated in scar tissue. on day 42 post mi, no differences were seen in the tn-c levels. echocardiography showed significant improvements in hemodynamics in the et a -group in contrast to controls. conclusions. from these results, we can conclude that (1) endothelin-a receptor blockade attenuates the development of heart failure post mi, (2) reduction of tn-c expression seems to have a positive effect on postinfarct remodeling, (3) tn-c regulation is influenced by et a -blockade and (4) that tn-c is a marker for lv remodeling after myocardial infarction. background. diabetes is a risk factor for neurocognitive and neurological complications after cardiopulmonary bypass. we sought to determine if temperature management during cardiopulmonary bypass (cpb) affects the incidence of neurocognitive and neurological complications in diabetic patients. methods. in this prospective randomized study, we measured the effects of mild hypothermic (32 c, n ¼ 40) vs. normothermic (37 c, n ¼ 40) cpb on neurocognitive function. all patients underwent elective coronary artery bypass grafting (mean age 64. 2 ae 4.8 years, mean es 4.4 ae 2.2) . neurocognitive function was objectively measured by objective p300 auditory-evoked potentials before surgery, 1 week and 4 months after surgery, respectively. clinical data and outcome were monitored. results. p300 evoked potentials were comparable between patients operated with mild hypothermic (368 ae 39 ms) and normothermic cpb (370 ae 33 ms) before the operation (p ¼ 0.674). patients operated with mild hypothermic cpb, showed marked impairment ( ¼ prolongation) of p300 evoked potentials 1 week (387 ae 30 ms; p< 0.001) and 4 months (380 ae 37 ms; p ¼ 0.042) after surgery. in contrast, patients operated with normothermic cpb did not show impairment of p300 evoked potentials 1 week (374 ae 33 ms; p ¼ 0.098) and 4 months (373 ae 39 ms; p ¼ 0.143) after surgery. group comparison revealed prolonged p300 peak latencies in the patient group operated with mild hypothermic cpb (p ¼ 0.046) 1 week after surgery. four months postoperatively, no difference between the two groups could be shown (p ¼ 0.173). operative data and adverse events were comparable between the two groups. conclusions. normothermic cardiopulmonary bypass reduces neurocognitive deficit in diabetic patients undergoing elective coronary artery bypass grafting. ergebnisse. die paclitaxelbehandlung führte zu einer dosisabhängigen reduktion der intimalen hyperplasie im vergleich zur kontrollgruppe (p ¼ 0.022 bei 1 mmolar, p ¼ 0.035 bei 10 mmolar, p ¼ 0.03 bei 25 mmolar und p ¼ 0.011 bei 50 mmolar). in der elasticafärbung fanden sich sowohl in der media als auch in der intima meist nur vereinzelte elastische fasern, wohingegen sich in der trichromfärbung in der media insbesondere subintimal reichlich kollagene fasern fanden, die intima selbst jedoch hierfür negativ blieb. immunhistochemisch zeigte sich die media und die intima praktisch vollständig positiv für sma. bei der desmin-färbung fand sich die media ebenfalls fast durchgehend spezifisch positiv für desmin, die intima hingegen färbte sich hierfür jedoch in unterschiedlichen ausmaß (5-90%) an. in der proliferationsfärbung mit ki67 zeigten sich vorwiegend die längsverlaufenden muskelfasern der media stark proliferierend, wohingegen der subintimale mediabereich und die intima nur vereinzelt ki67 positiv war. schlussfolgerungen. paclitaxelbehandlung reduziert die intimale hyperplasie in der vena saphena im organkulturmodell. elastische fasern, kollagenfasern, sma positive und desminpositive zellen sowie ki67 positive (proliferierende) zellen weisen unterschiedliche bevorzugte lokalisationen innerhalb der gefässwand auf. 053 heat shock proteins 27= = =60= = =70= = =90a and 20s proteasome in on-versus off-pump coronary artery bypass graft patients background. heat shock protein (hsp) 27, hsp60, hsp70, hsp90 and 20s immune-proteasome are known chaperons. they play a prominent role in housekeeping processes, in the intracellular regulation of the immune system and in apoptosis. serum levels of circulating chaperons are not known in patients undergoing the on-versus off-pump coronary artery bypass graft (cabg) procedure. methods. forty patients were prospectively included in the study (on-vs. off-pump cabg, each n ¼ 20). elisa technique was utilized to detect levels of soluble hsp27, 60, 70, 90 and 20s immune-proteasome in serum samples. results. on-pump cabg procedure is associated with an increased leakage of heat shock proteins into the vascular bed when compared to off-pump cabg technique. these differences were highly significant for hsp27, 70 and 90 60 min after initiation of cardiopulmonary bypass (cpb) (all, p< 0.001). concentrations of soluble 20s immune-proteasome were increased 24 h after operation in on-and off-pump cabg patients (p < 0.001) and correlated significantly with the serum content of hsps 27, 70 and 90 at 60 min after initiation of cpb (p < 0.001). conclusions. our data evidence the spillage of chaperons, normally intracellular restricted proteins, into the systemic circulation. as these proteins are related to immunomodulatory and apoptotic processes, we conclude that the innate immune system is more activated in on-pump as compared with off-pump cabg patients. however, the precise immunological consequence and interpretation requires further investigations. background. in the treatment of ruptured abdominal aortic aneurysm (raaa) the results of open graft replacement (ogr) remained constant but discouraging over the last four decades. provided patients have a suitable vascular anatomy, elective endovascular abdominal aortic aneurysm repair (evar) turned out to be less invasive than ogr and led to improved perioperative mortality especially for patients with severe comorbidities. thus, it is reasonable to assume that endovascular treatment should improve the results of patients with risk factors heavily impaired by rupture of their aaa. the purpose of this study was to test whether the use of both endovascular and open repair for raaa was able to improve results. methods. retrospective analysis of a consecutive series of 89 patients presenting with raaa from october, 1999 , until july, 2006 . observation period was divided in two periods of 41 months, respectively. during the first period 42 patients were treated by ogr exclusively. period two started with the availability of an evar protocol to treat raaa, according to which 31 patients received open repair while 16 patients underwent evar. kaplan-meier survival estimates were calculated and possible differences were analyzed by log-rank and wilcoxon-test. results. kaplan-meier survival estimates revealed a statistically significant reduction in overall postoperative mortality following the introduction of evar in 2003 (p < 0.027). ninety day overall mortality was reduced from 54.8% during period one to 27.7% during the second period (p < 0.011). especially survival of patients older than 75.5 years was improved (75% vs. 28.6%, p < 0.014). in parallel there was a significant reduction of the 90 day mortality rate after ogr from 54.8% (i.e. overall mortality) to 29% (p < 0.034). conclusions. offering both evar and ogr in the treatment of raaa led to significant improvement of postoperative survival. especially older patients seem to benefit from the less invasive endoluminal technique. 055 fast track concept for infrarenal aortic aneurysm repair c. senekowitsch 1 , r. schwarz 1 , a. assadian 1 , w. hartmann 2 , g. hagmü ller 1 background. the aim and main benefit of the fast track concept in surgery are increased patient comfort and reduced perioperative morbidity and mortality. in abdominal surgery, this concept has proven efficient. we present our experience of fast track aortic surgery. methods. retrospective analysis of prospectively collected data. since initiating this method of perioperative patient management in january 2006, 22 patients underwent infrarenal aortic reconstructions for aortic aneurisms applying the fast track concept. this comprises of modified nutrition and fluid management, anaesthesiological management and a special retroperitoneal access allowing aggressive postoperative mobilisation. results. 22 patients were included in the study, their mean age was 68 years (range 59-76 years) none of the patients had surgical complications, no mortality was observed. the icu days were reduced to 1 for all 22 patients. the mean hospital stay was 9 days (range 6-14 days). conclusions. hospital stay and icu days could be reduced dramatically compared to standard therapy at our institution. this new concept in aortic surgery is a valid alternative to evar for selected patients. 056 aneurysma der a. lienalis: fallbericht über interventionell-chirurgisches management e. gü nen, j. demmer, c. groß department of cardio-thoracic and visceral surgery, general hospital linz, linz, austria aneurysms of splenic arteries are seldom (0.1% of all aneurysms). nevertheless they are disastrous when ruptured since they bleed into the free abdominal cavity without any means of self-tamponade. occurrence of splenic aneurysms is related to female gender, esp. after multiple gravidities. these aneurysms are usually symptomless and tend to rupture during labour pains. this fact explains the reports on ruptured splenic aneurysms in young women from developing countries whereas in western countries most findings are incidental in routine imaging scans. we report on a 37 yo female from chechnya with a huge splenic aneurysm and splenomegaly. she complained about chronic fatigue and nausea. splenomegaly and a pulsating growth in the mid epigastrium were palpable in the physical examination. the wbc blood counts showed severe pancytopenia. ct-scan revealed a calcified aneurysm (ø 12 cm) of a tortous splenic artery and an enlarged spleen (32 cm). we decided to occlude the origin of splenic artery interventionally and and to perform a ''lone splenectomy'' leaving the unperfused aneurysm in situ. the intervention achieved total angiographic occlusion. however during surgery the aneurysm was still under pulsatile pressure. the pulsation ceased on surgical ligation of the proximal splenic artery. subsequently the splenectomy was performed. the patient recovered without surgery related complications. a year after surgery she has normal blood counts. the aneurysm has not shrunk but shifted to left to adopt the space left over by the spleen. background. the transilluminated powered phlebectomy (tipp; trivex + , smith and nephew) was introduced in the year 2002 in our hospital. trivex + is a procedure for minimal invasive vein surgery including an illuminator device, a powered vein resector, a light source and a controll unit. the use of tumescent solution allows hydrodissection and facilitates ablation (rotating inner blade of vein resector combined with suction). methods. in an retrospective study we report 214 patients (42 males and 172 females; mean age 48.7 years; 310 limbs) treated with this technology during the years 2005 and 2006. we used a combination stripping the saphenus veins (207 ligations of the sapheno-femoral junction, 46 ligations of the popliteo-femoral junction) or ligations of perforantes (62) if necessary according to sonography. twenty-seven patients underwent single trivex + treatment. 83.41% were done in general anaesthesia. a follow up is proposed to all patients after 3 to 9 months (64 patients, 29.90%). results. the average time of surgical treatment was 67.12 min, with single trivex 42.37 min. the trivex + procedure for one single leg took about 15 min. the average stay was 3.3 days. regarding to postoperative complications one patient experienced laceration of the femoral vein (0.5%), one profound bleeding caused a revision the same day (0.5%). 2 patients developed lokal wound infektion within the first 2 weeks (0.9%). during the follow up period complications like swelling (2), seroma (3), brown scars (3), nerve injury=numbness (3), haematoma (2) occured. there was no skin perforation, no phlebitis, none of our patients died. conclusions. according to these results the trivex + procedure seems to be a quick and safe treatment for minimal invasive removement of superficial varicosities. background. this randomized, patient and observer blinded trial compared early postoperative outcomes in saphenectomy with either a new bipolar coagulating electric vein stripper (evs) or invagination stripping. methods. the primary outcome was pain at rest and following physical stress (climbing stairs), as assessed by a visual analog scale (vas) 24 h after surgery. secondary outcomes included haematoma formation (diagnosed and measured by ultrasound), duration of postoperative compression, and disability. quality of life was assessed by a disease-specific chronic lower limb venous insufficiency questionnaire (civiq), and the generic short form 36 (sf-36). results. two hundred patients were assigned to three vascular centers, with 99 patients randomized to the evs and 101 to the conventional arm. there were no complications or conversions. pain at rest averaged 1.6 in the evs and 3.3 in the conventional group (mean difference 1.7, 95 per cent confidence interval (c.i.) 1.4 to 1.9, p < 0.001). following physical stress, mean ratings were 3.3 and 5.5 (mean difference 2.3, 95 per cent c.i. 1.9 to 2.6, p < 001). no measurable haematoma was found in the stripping canal of the evs group, while in the conventional arm 74 patients had haematomas within this region (risk difference 73 per cent, 95 per cent c.i. 65 to 82 percent). duration of compression therapy was significantly decreased in the evs group (mean difference 20 days, 95 per cent c.i. 17 to 23 days). in the evs group, 30 patients returned to work after 1 week and 95 after 3 weeks, compared to 12 and 40 patients in group 2. civiq and sf-36 ratings favored the evs. conclusions. the evs is a safe instrument. it is effective in avoiding painful haematomas following saphenectomy, reduces recovery time and improves patients' ratings of quality of life. 059 elt in combination with pin stripping in the treatment of epifascial truncal veins a. j. flor background. in the treatment of varicose truncal veins, endolaser treatment has widely been accepted as the method of choice. yet laser treatment -in particular in epifascial veins -may result in a painful contraction. we examine the functional and cosmetic results as well as the patients' comfort, combining elt and pin stripping in patients with epifascial truncal veins. methods. preoperative evaluation is carried out by color duplex sonography. emphasis is laid on patients with a partially epifascial course of the greater saphenous vein (gsv). following extensive evaluation and information of the patient, the decision is made to use endolaser treatment (biolitec, 980 nm) in combination with pin-stripping (retriever-pin by oesch, salzmann medico). a guiding wire is inserted, duplex-controlled or through miniphlebectomy, into the gsv at the point of perforation through the fascia. a laser fiber is then positioned at the sapheno-femoral junction, and laser energy is applied to the intrafascial part of the truncal vein (40-70 j=cm) depending on the vein diameter. the epifascial part of the vein is then retrieved by the pin stripper. results. until now the combination of endolaser plus pin stripping has been applied in 17 patients. following observation periods of 6 to 12 months, endolaser treatment provides an occlusion rate of 92%. skin incisions need not be wider than 4 mm. crossectomy can be avoided. patients tend to have more hematomas in the pin-stripped region, yet a hardened, sometimes brown coloured and often painful strand -as often seen in patients treated by endolaser only -can be avoided thereby. conclusions. in about 15-30% of the cases, an epifascial position of the gsv might been detected by duplex sonography. in cases of epifascial course of the truncal vein, decision to use elt treatment alone should be considered critically. in such cases, endolaser treatment combined with pin stripping should result in a higher degree of patient comfort, apparently providing an optimal solution for a minimally-invasive approach. 060 endovenous laser treatment with the 810 nm laser system; 5 years of experience, follow-up of over 2800 veins k. freudenthaler background. chronic venous insufficiency is a common desease. the aims are to offer a minimal invasive alternative to traditional surgery such as crossectomia and stripping with less pain for the patient and a short reconvalescence. methods. since 5 years over 1800 patients with more than 2800 veins have been treated by evlt, by 44 grand saphenous veins a valve repair by venocuff ii was possible. only 3 patients have been treated by traditional crossectomia and stripping. usually the grand and the short saphenous vein as well as the acessoria vein, insufficient perforaters and the giacomini anastomosis are treated by evlt. the treatment is done in general or in local anaesthesia and monitored by permanent ultrasound control. in no case a surgical crossektomia was necessary. after treatment the patient has to wear a compression stocking for two weeks dayover and should not lift heavy duties. results. after treatment the results are verified by ultrasound. the patients are controlled after one week, 6 month and yearly thereafter. the total sucess rate is 93% in all cases (complete resorption of the treated vein). there were no complications like pulmonal embolia, infects or skin burns. conclusions. the evlt is a very safe treatment of chronic venous insufficiency and offers a minimal invasive alternative to traditional surgery such as crossektomia and stripping. ö sterreichische gesellschaft fü r chirurgische forschung: die zukunft hat schon begonnen -bedeutung der molekularen biologie fü r diagnostik, prognose und therapie in der gastrointestinalen chirurgie 061 proteomic profiling of the secretome of human liver endothelial cells (hlec) background. liver endothelial cells play significant roles in the physiology and pathology of the liver. they are not simply barrier cells regulating the traffic of blood components to the parenchyma and vice versa, but highly specialized cells with complex roles, including scavenger functions and regulation of inflammation, leukocyte recruitment and host immune responses to pathogens and shaping of the microenvironment by secretion of functionally relevant proteins. thus, investigation of the functional and physiological properties of lec is critical in understanding liver biology and pathophysiology. the aim of this study was to establish techniques to isolate and cultivate human liver endothelial cells and to obtain a protein profile of the secretome of quiescent and vegf-activated hlec. methods. hlec from unaffected tissue of resected liver segments from patients undergoing surgery for liver tumours were isolated using magnetic beads coated with anti-cd31-antibodies. cells where cultured in medium ebm-2(mv) supplemented with vegf, bfgf, igf, egf, heparin, endothelial cell growth supplement and 10% fetal calf serum. expression of endothelial cell surface markers cd31, cd34, cd62e, cd54 and podoplanin as well as fibroblast marker cd90 was investigated by facs. hlec where starved for 24 h in protein free medium and activated with vegf for further 24 h. supernatants were collected and subjected to shotgun proteomics. human umbilical vein endothelial cells (huvec) served as a control. results. isolated cells where morphologically similar to huvec. 98% of cells where positive for cd31, cd34, and cd54. 2% expressed cd90. 6% of cd31 positive cells where positive for podoplanin. expression of cd34 was low, but consistent. cd62e was induced in 70% of cells and expression of cd54 was upregulated 4 fold after 6 h activation with tnf-. shotgun proteomics of the secretome revealed a distinct differ-ence in the secretion pattern of several functionally relevant proteins compared to huvec. conclusions. our results point towards a significant and persistent difference in secretion patterns of functionally relevant proteins between hlec and other endothelial cells both in quiescence and after vegf activation. these findings may lead to a better understanding of physiology of the liver. finally, this study demonstrates the suitability of magnetic bead isolation in combination with in vitro cell culture and proteomics for investigation of hlec functions. 062 hypermethylation of sfrp1 gene in stool dna test: a future technology in colorectal cancer screening w. zhang, w. hohenberger, k. matzel background. stool dna test is considered as a future technology in screening for colorectal cancer (crc). both genetic and epigenetic changes in shed cells from gastrointestinal tumours into stool could be detected. epigenetic hypermethylation can result in transcriptional silencing of tumour suppressor genes and is considered to be a key event of sporadic colorectal carcinogenesis. sfrp1 is a tumour suppressor protein that contains a domain similar to one of wnt-receptor proteins and inhibits wnt-receptor binding to its signal transduction molecules. detection of hypermethylation of sfrp1 gene in human dna isolated from stools might provide a novel strategy for the detection of sporadic crc. our study aims to prove the methylation status of sfrp1 gene in stool samples, and compare the dna methylation status before and after neoadjuvant radiochemotherapy. methods. to explore the feasibility of stool dna test, fecal samples were obtained from 40 crc patients (crc patients post neoadjuvant radiochemotherapy n ¼ 10). twenty fecal samples were obtained from patients without evidence of gastrointestinal disease or neoplasia. isolated genomic dna from stool was modified with sodium bisulfite and analyzed by specific pcr for methylation of sfrp1 promoter. results. with stool dna test we were able to detect the hypermethylation in the promoter region of sfrp1 gene in the fecal dna from colorectal cancer patients (p ¼ 0.001). sensitivity was 89%, specificity was 86%. methylation status of sfrp1 gene was significantly changed after neoadjuvant radiochemotherapy (p ¼ 0.050). conclusions. the hypermethylation of sfrp1 gene in the stool dna test has a high sensitivity and specificity for crc and may be valuable for screening purposes, especial for the sporadic crc. compared with current colorectal cancer screening methods, stool dna test is more patient-friendly, non-invasive, more sensitive and specific. the cost-effectiveness of screening may also be improved by using single dna stool test with one sensitive dna marker. the methylation status of sfrp1 seems to be changed after neoadjuvant radiochemotherapy, which may open new fields for crc research. summarized this new diagnostic tool may yield ben-efits in earlier detection and in the design of better antitumour interventions. background. although the function and interaction partners of the glycoprotein dickkopf-3 (dkk-3) still remain unclear, gene expression of dkk-3 has been shown to be upregulated in tumor endothelium of colorectal cancer. for the first time, we analyzed expression of dkk-3 protein and its potential as a marker of neoangiogenesis in colorectal cancer. methods. we utilized tissue microarrays (tmas) to evaluate dkk-3 protein expression in microvessels of colorectal cancer samples from 403 patients, in microvessels of 318 adjacent tissue samples from the same patients compared to 127 normal colorectal mucosa tma samples. a second microarray section was stained with cd31 to quantify neoangiogenesis by defining the microvessel count. results. out of 257 cancer samples with cd31 positive microvessels, 67.7% were dkk-3 positive in all microvessels. these samples showed a significantly higher mean microvessel count (9.70 vessels) than dkk-3 negative samples (6.82 vessels; p ¼ 0.001). dkk-3 protein expression increased with rising numbers of microvessels per sample (p < 0.0001). out of 268 cd31 positive adjacent tissue samples, 56% were dkk-3 positive. these samples also had a higher mean microvessel count (14.51vessles) than dkk-3 negative samples (6.64 vessels; p < 0.0001). similar to colorectal cancer tissue, dkk-3 expression in non-cancerous adjacent tissue increased with rising numbers of microvessels (p < 0.0001). in contrast, all microvessels in normal colorectal mucosa samples demonstrated a negative staining reaction for dkk-3. univariate analysis of several clinicopathologic variables in correlation to dkk-3 expression revealed significant differences in tumor site (colon vs. rectum; p ¼ 0.020) and mean age (p ¼ 0.018). survival analysis according to kaplan-meier method showed a statistical trend toward a higher diseasefree survival for patients with dkk-3 negative samples (p ¼ 0.057). conclusions. our study demonstrates for the first time that microvessels of colorectal cancer and adjacent non-cancerous tissue are identical concerning dkk-3 protein expression, but distinct from normal colorectal mucosa. therefore, dkk-3 can be considered as a putative pro-angiogenic protein in the process of neovascularization, may have the potential to serve as a marker for neoangiogenesis, and may represent a target structure for novel therapeutic approaches. nevertheless, it is mandatory to further confirm these findings using normal tissue sections. background. we have developed the first genetically engineered oncolytic influenza a viruses (ns1 deletion viruses), which replicate and lyse cancer cells but are apathogenic in normal tissue. infection of influenza a viruses are usually highly dependent on the presence of a serine-like protease (i.e. trypsin), which cleaves the viral entry protein, the hemagglutinin. cancer cells are known to endogenously produce proteases. methods. we here investigate, whether colon cancer associated proteases support lytic growth of the oncolytic influenza viruses in those cells. results. ns1 deletion viruses grew to high titers in the colon cancer cell lines caco2 or ht-29 independent of the addition of trypsin. correspondingly, viral infection rate, cleavage of the hemagglutinin and virus-induced cytopathic was not compromised by the lack of trypsin in these cell lines. zymogram analysis indicated that the caco2 and ht-29 associated protease is not trypsin itself but trypsin unrelated. conclusions. the specific activation of the influenza a virus in colon cancer cell lines suggests an effective use of this virus for oncolysis in colon cancer in vivo. background. for decades the bile pigment bilirubin has been considered a toxic waste product of heme catabolism. however, serveral clinical studies show an inverse correlation between elevated plasma bilirubin levels in healthy individuals and the incidence=mortality of colorectal cancer. based on these findings, we hypothesized that bilirubin and its precursor biliverdin may suppress tumor cell growth in vitro and inhibit tumor progression in vivo. methods. in vitro hrt-18 colon cancer cells were treated with bilirubin at various concentrations or pbs as a control. a casy cell counter was used for proliferation assays. cell cycle progression and apoptosis were analyzed by facs. western blot analysis was carried out using antibodies directed against p27, rb, p53, parp-1 and caspase 7 as well as total and phosphorylated forms of erk, mek and akt. further, cells were treated with pharmacological inhibitors of mek and pi3-kinase in presence or absence of bilirubin. in vivo, nude mice bearing hrt-18 tumors were treated with bilirubin i.p. at 70 mg=kg=day or pbs as a control. tumor size was measured using a caliper. statistical analysis was performed using anova. results. bilirubin significantly inhibited proliferation of hrt-18 colon cancer cells in a dose dependent manner. this mainly was mediated by induction of g0=g1 cell cycle arrest and apoptosis through strong activation of akt, mek and erk resulting in overexpression of the cell cycle regulators p27, p53, hypophosphorylation of rb as well as an increase of parp-1 and caspase 7 cleavage. the antiproliferative effects were dependent on akt and erk activation, in that inhibition of upstream pi3-kinase and mek reversed the effects observed under bilirubin treatment. in vivo, bilirubin dramatically decreased tumor growth by 80% (sd ae 13.7) when compared to the control. conclusions. bilirubin is a potent inhibitor of hrt-18 colon cancer cell growth in vitro and in vivo, presumably by modulating mitogen activated protein kinase signaling pathways resulting in cell cycle arrest and apoptosis. background. tetrahydrobiopterin (bh 4 ) is an essential cofactor for nitric oxide synthases and thus a critical determinant of no production. recently we have shown that bh 4 depletion contributes to ischemia reperfusion injury (iri) after pancreas transplantation. here we analysed the therapeutic potential of bh 4 supplementation during organ procurement and the early post-transplant period. methods. murine cervical heterotopic pancreas transplantation was performed with a modified no-touch technique. pancreatic grafts were subjected to 16 h prolonged cold ischemia time (cit) and different treatment regiments: untreated (i), bh 4 160 mm to perfusion solution (ii), bh 4 50 mg=kg i.m. at reperfusion (iii). nontransplanted animals served as controls (iv). intravital fluorescence microscopy was used for analysis of graft microcirculation by means of functional capillary density (fcd) and capillary diameters (cd) after 2 h of reperfusion. quantitative assessment of inflammatory responses (mononuclear infiltration) and endothelial disintegration (edema formation) was done by histology (h&e) and peroxynitrite formation assessed by nitrotyrosineimmunostaining. results. fcd was significantly reduced after prolonged cit, paralleled by an increased peroxynitrite formation, when compared with controls (all p < 0.05). microcirculatory changes correlated significantly with intragraft peroxynitrite generation (spearman: r ¼ à0.56; p < 0.01). pancreatic grafts treated with bh 4 either during retrieval (ii) or systemically (iii) displayed markedly higher values of fcd (p < 0.01) and abrogated nitrotyrosine staining (p < 0.05). cd were not significant different in any of the investigated groups. histologic evaluation showed increased inflammation, interstitial edema, hemorrhage, acinar vacuolization and focal areas of necrosis after 16 h cit in group i, which could be diminished by both bh 4 treatment regiments (p < 0.05). conclusions. bh 4 treatment significantly reduces postischemic deterioration of microcirculation as well as histologic damage and might be a promising novel strategy in attenuating iri in clinical pancreas transplantation. methods. forty-seven biopsies obtained from the endoscopic esophagogastric junction in 23 patients (10 females, 13 males; age 53; range 28-73 years) with symptoms of gastroesophageal reflux disease were processed for histopathology and immunohistochemistry. biopsies were stained with routine h&e and immunofluoresence staining using an antibody directed against hydrogen=potassium atpase (h þ =k þ atpase beta) (pot) for detection of parietal cells (pot ¼ monoclonal clonal mouse igg1 antibody, 2g11 clone, dilution 1:2000; product numberma30923 affinity bioreagents d-20354 hamburg, germany). pot detects the beta-subunit of hydrogen= potassium atpase in bovine, human, canine, porcine, rabbit, mouse, ferret, and rat tissues. histopathology in h&e stained sections was conducted according to the paull-chandrasoma classification of columnar lined esophagus (cle) including oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) with or without intestinal metaplasia (im ¼ barrett esophagus). 18 out of 44 biopsies also contained gastric oxyntic mucosa (mucus, parietal and chief cells) and served as controls (these biopsies contained both cle and om). the detection of parietal cells in h&e and pot-staining was compared. results. h&e staining showed that 19 out of 23 patients had cm with im (barrett esophagus), 4 had cm without im. a total of 88 slices was investigated (44 h&e 44 pot). pot stained the cytoplasma of parietal cells indicating the presence of biologic active acid pump. in 4 biopsies parietal cells were only detected in pot stained slices, whereas in the other biopsies parietal cells were detected by both h&e and pot-staining. parietal cells were detected in all biopsies containing gastric om. therefore pot did not significantly increase the parietal cell detection rate in cle compared to h&e staining. conclusions. detection of ocm within biopsies from columnar lined esophagus is not significantly increased by the use of an antibody directed against h þ =k þ atpase. h&e staining is adequate for detection of parietal cells within cle. 068 lymphovascular invasion and lymphangiogenesis in adenocarcinoma of the esophagus: impact on patient survival e. rieder 1 , s. schoppmann 1 , s. kandutsch 2 , f. wrba 2 , f. langer 1 , c. neumayer 1 , p. panhofer 1 , g. prager 1 , j. zacherl 1 background. a special feature of esophageal cancer is its early lymphatic spread in comparison with other cancers of the gastrointestinal tract. due to the discovery of specific markers for lymphatic endothelium, selective staining of lymphatic vessels has become possible. in recent studies the prognostic value of peritumoral lymphangiogenesis and lymphovascular invasion in various human malignancies has been shown. tumor-associated macrophages (tam), expressing the lymphoangiogenic growth factor vegf-c, were shown to be related to tumor-associated lymphangiogenesis, lymphovascular invasion and lymph-node metastasis. aim of this study was to assess tumor-associated lymphangiogenesis as well as the role of tams in a cohort of adenocarcinoma of the esophagus. methods. fourty formalin-fixed, paraffin-embedded surgical specimens of patients (age range: 47-77) presenting with adenocarcinoma of the esophagus at the university hospital of vienna were included into this study. specimens were stained with antibodies against podoplanin, vegf-c and anti-cd34. semiquantitative measurements of lymphatic microvessel density (lmvd) and lymphatic vessel invasion (lvi) were carried out. results. it could be demonstrated that lymphangiogenesis occurs in barrett adenocarcinoma and is correlated with lvi. statistical analysis revealed that lvi is associated with disease-free (p ¼ 0.007) as well as overal survival (p ¼ 0.011) of patients with barrett carcinoma. furthermore over-expression of vegf-c was seen in barrett carcinomas and vegf-c expressing tams were detected peritumoral and therfore may play a role in lymphogenic metastasis of esophagus carcinoma. conclusions. these preliminary data demonstrate that lymphovascular invasion as well as tumor-induced lymphangiogenesis is associated with patient survival in barrett adenocarcinoma and anti-lymphangiogenic therapies might be a beneficial approach. background. the role of tissue-inhibitor of metalloproteinases-1 (timp-1) in cancer progression is still unclear. although timp-1 is an important inhibitor of metastasis-associated proteases, it is often correlated with a bad prognosis. in an animal model, elevated levels of timp-1, achieved by adenoviral-gene-transfer, led to induction of hepatocyte growth factor (hgf)-signaling and expression of several metastasispromoting genes in the liver, representing a host-microenvironment with increased susceptibility to a challenge of tumor cells. we examined the expression of candidate metastasis-promoting factors by qrt-pcr. methods. liver-tissues of 6 consecutive metastatic colorectal cancer patients (4 males, 2 females; mean age, 63.3 ae 4.4 y) were obtained. to determine timp-1-associated gene expression signatures in the normal liver tissue, specimen were harvested from zones greater than 5 cm away from visible liver metastases and analyzed by quantitative-real-time-pcr (qrt-pcr, taqman + -low-density-arrays) of 95 metastasis-associated genes. results. human liver tissue with elevated timp-1 levels was associated with an identical pro-metastatic gene expression signatures as previously identified in the animal model, namely increased expression of hgf, pcna, upa, upar, tpa, matriptase, mmp-9, mmp-2, adam-10, cathepsin g, and neutrophil elastase. conclusions. we reveal here for the first time a ubiquitous (human and mouse=different tumor types) timp-1-related gene expression profile. this profile, consisting of metastasis-promoting genes, can explain the correlation between tumor aggressiveness in cancer patients and increased levels of timp-1 and demonstrates the impact of the host microenvironment on its susceptibility to invading tumor cells. this concept is important for future considerations of cancer therapies. ö gth -herz: varia 079 rv-lv depolarisation-interval as a predictor of longterm-survival of crt-patients: a criteria for intraoperative quality control t. schwierz 1 , s. winter 2 , h. nesser 2 , r. fü gger 1 1 surgical department, elisabethinen-hospital, linz, austria; 2 cardiological department, elisabethinen-hospital, linz, austria background. for cardial resynchronisation therapy the left-ventricular lead should stimulate the most delayed myocadial area. we introduce a method, established in or dayly routine, for intraoperative verification of the hemodynamically best lead-position. methods. the electrical distance between rv-and lv-lead we verify by measurement of the time between rv-pacing and lv-sensing (depolarisation-intervall). by a cox regressionmodel we analized the data of 250 patients with regard to possible predictors of patients-survival following crt. results. significant predictors of survival were the age of patients (p ¼ 0.002), lvef (p ¼ 0.01), biventricularly stimulated qrs-duration (p ¼ 0.001), reduction of qrs-duration under biventricular stimulation in relation to rv-pacing in % (p ¼ 0.009), depolarisation-intervall (p ¼ 0.04), depolarisation-intervall in relation to qrs-duration under rv-pacing in % (p ¼ 0.03). conclusions. out of the predictors significant for the patients-survival following crt only the depolarisation-intervall can be influenced activly during the implantation procedure. the rv-and lv-lead should be implanted so that the depolarsation-intervall is as long as possible. ideally, the depolarisation-intervall covers the entire qrs-duration under rv-pacing. in that case the lv-lead stimulates exactly the latest depolarisized myocardial area. 080 the fibrin derived peptide b-beta 15-42 ameliorates ischemia-reperfusion injury in a rat heart transplant model background. the purpose of this study was to evaluate the protective effect of the fibrin-derived peptide b-beta 15-42 on ischemia=reperfusion injury in a rat cardiac transplant model. methods. lew hearts were flushed with chilled (0-1c) custodiol preservation solution and either transplanted immediately or stored for 4 or 8 h in the same solution and then transplanted into syngeneic recipients. b-beta 15-42 was given i.v. at a dose of 1.2 mg immediately after transplantation or added to the preservation solution prior to harvest. at 24 h and 10 d, graft function was assessed and hearts were retrieved for morphological evaluation. at time of harvest, serum samples were collected for troponin level analysis. results. hearts transplanted immediately or after 4 h of cold ischemia did neither show any morphological damage at 24 h nor at 10 days. in contrast, 8 h of ischemia resulted in severe myocardial ischemia associated with an inflammatory response at 24 h. lesions further progressed at 10 days. administration of b-beta 15-42 resulted in a significant amelioration of myocardial necrosis together with a diminished inflammatory response. a protective effect towards myocyte damage was further underlined by reduced troponin levels in groups receiving b-beta 15-42 . 081 acute cellular rejection after cardiac transplantation -is there a way to reduce the number of biopsies? background. acute cellular rejection significantly contributes to mortality and morbidity after cardiac transplantation (htx). routine endomyocardial biopsies (embs) are performed to early detect and treat cellular rejection. although emb can be performed with little risk, a number of potentially fatal complications are inherent in the procedure. the aim of our investigation was to evaluate the incidence of acute cellular rejection after heart tranplantation and to evaluate possibilities to reduce the number of embs. methods. 119 patients underwent cardiac transplantation from january 1999 through december 2004 at our institution. the mean age of the patients was 52.6 ae 13.8 years. 17.6% were female. indication for htx was icmp in 54.6%, dcmp in 34.5% und others in 10.9% of the cases. according to our institutional standard, patients underwent emb weekly during the first month after htx, biweekly during months 2 and 3, monthly up to month 6, once in month 8, 10 and 12. a total of 1209 embs were investigated over a follow-up period of 217 months after htx. results. the majority of embs showed no signs of rejection (65.2% ishlt 0 ). mild signs of rejection without therapeutical consequence (ishlt ia) were found in 23.7% of embs. rejection ishlt ib was found in 6.4% of the evaluated embs. the incidence was 3.6% during the first month after htx, in the second month 7.0%, in 3rd month 7.5%, in 4th and 5th month 5.1%, in 6th and 7th month 9.0%, and from the 8th month 9.8%. a moderate rejection (ishlt ii) was detected in 2.3%. during the first month after htx, the incidence was 1.2%, during 2nd month 2.1%, during 3rd month 2.8%, in 4th und 5th month 2.5%, in 6th und 7th month 4.5% and from the 8th month 2.7%. more severe rejections were rare (7x ishlt iiia ¼ 0.5%, 1x ishlt iiib ¼ 0.08%) and occurred in month 2, 4, 6 and 7. conclusions. severe cellular rejection after htx is seldom. mild to moderate rejection episodes, however, occur more frequently. in contrast to the traditional emb schedules, rejection hardly ever occurs during the first weeks after htx. most rejection episodes are observed between the second and seventh month after htx. afterwards, the incidence of rejection lowers again. based on these findings, the number of routine embs can safely be reduced, especially during the first weeks after htx. background. renal dysfunction has consistently been one of the greatest risks for mortality with the use of left ventricular assist devices (lvad). we aimed to determine the impact of renal function on survival and time-dependent changes in renal function after lvad implantation. methods. we retrospectively reviewed 100 patients with advanced heart failure (mean age 53.4 ae 11.2 yrs, 86% male, 40% ischemic cardiomyopathy) who received lvad implantation as a bridge to transplant therapy from 1994 to 2006. renal function was assessed using the modification of diet in renal disease (mdrd)-derived glomerular filtration rates (gfr). patients were divided into 2 groups based on renal function pre-lvad implantation; group 1: normal (gfr !60 ml=min=1.73 m 2 , n ¼ 51), group 2: impaired (gfr <60 ml=min=1.73 m 2 , n ¼ 49) renal function. results. patient survival was comparable between the 2 groups. the 1, 3 and 6-month kaplan-meier estimate of survival was 88.1%, 78.9% and 64.6% for group 1 and 91.6%, 71.8 and 60% for group 2 (p ¼ 0.551). gfr paired sample analysis in group 1 showed an early increase in gfr from preimplantation (79.5 ae 14.2 ml=min=1.73 m 2 ) to postoperative day (pod) 3 (92.5 ae 32.5 ml=min=1.73 m 2 ; p ¼ 0.001). there was no increase in gfr from pre-implantation (82.7 ae 15.4 ml= min=1.73 m 2 ) to heart transplantation (83.8 ae 16.1 ml=min= 1.73 m 2 ; p ¼ 0.811). in contrast, gfr paired sample analysis in group 2 showed an early increase in gfr from pre-implantation (41.03 ae 11 ml=min=1.73 m 2 ) to pod 3 (58.8 ae 21.7 ml= min=1.73 m 2 ; p< 0.0001), and a further increase in gfr from pod 3 (59.3 ae 22 ml=min=1.73 m 2 ) to pod 7 (68.7 ae 32.4 ml= min=1.73 m 2 ; p ¼ 0.005). there was a significant increase in gfr from pre-implantation (39.06 ae 11.6 ml=min=1.73 m 2 ) to heart transplantation (62.2 ae 16.2 ml=min=1.73 m 2 ; p< 0.0001). conclusions. renal function improves rapidly after lvad implantation. renal dysfunction does not adversely affect outcome after lvad implantation. methods. 12 bed interdisciplinary paediatric intensive care unit, university hospital. patients. 140 patients after open heart surgery; prospective controlled study. group a received 10 mg tc=kg bodyweight pre-and post operation and 24 h after operation, whereas group b received 15 mg tc=kg bw in the same period. drug levels and routine laboratory parameters were investigated daily in the picu. the aim of both groups was a tc serum concentration of 20-30 mg=l by adapting dosage after 24 h. results. in group a tc concentration were 11.4 ae 0.7 and 20.2 ae 0.8 mg=l after 24 and 48 h, in group b 19.5 ae 1.0 and 24.8 ae 1.8 mg=l (p < 0.01 both), respectively. crp values were in group a 87 ae 4.9 mg=l and 111 ae 7.9 mg=l and in group b 61 ae 5.54 mg=l and 86 ae 10.2 mg=l (p < 0.01 and p < 0.05), respectively. there were no differences in physiological scoring. conclusions. to achieve drug levels of tc higher than 20 mg=l during the first 48 h after surgery, the higher dosage of 15 mg=kg bw had to be administered initially. the high tc dosage was well tolerated and was associated with significantly lower crp in the first two days. background. the fontan operation eliminates the systemic hypoxemia and ventricular volume overload in congenital patients with single ventricle physiology. retrospectively, we report on our longtern results of surgical palliation and on different concepts concerning tcpc (total cavo-pulmonary connection). methods. between 1987 and 2007, a total of 78 patients (mean age 4.8 ae 1.7 years) underwent surgical fontan palliation at our institution by tcpc technigue. in 38% of all patients, a staged concept was carried out, 28 patients had a central fenestration (4 mm). all of our latest 21 patients in the operation series were palliated -according to the new ''fontan concept'' -with an extracardiac conduit as second step. in 1993, inhalative no (nitric oxyde) therapy was also introduced in the early postoperative phase. results. kaplan-meier overall survival after a mean followup of 8 years was 85.6% (in patients with staged procedure 87.5%, 86.3% in patients with fenestrated fontan). 2 out of 3 patients survived a periopertive fontan take-down. without any exception, we lost 10 patients in the learning curve phase, 3 of them because of neurologic complications, 7 patients died due to low cardiac output (lco). in those patients who were palliated with an extracardiac fontan, mortality was 0%; furthermore under no-therapy, perioperative mortality also was 0%. after 82 ae 18months of follow-up, 81% of all patients were in nyha i, 19% in nyha ii, 89% of all patients were in sinus rhythm. pleuropericardial effusions were found in 29% of all patients. conclusions. definitive palliation by means of tcpc in patients with congenital single ventricle physiology leads to more than acceptable clinical results. staged palliation, fenestration procedures, extracardiac fontan and inhalative no-therapy were introduced as ''modern'' surgical therapy concepts and resulted in a significant positive influence on perioperative and longterm clinical results. neue erkenntnisse in der mund-, kiefer-und gesichtschirurgie background. as we are living in an aging society, the number of active patients older than 65 is increasing. the impact of age on trauma related injuries, e.g. femur neck fractures, and their outcome has been well documented in the literature. so far, data on a broad cohort suffering from oraland maxillofacial injuries (omfi) are missing. thus it was the aim of the present retrospective analysis to observe the effect of increasing age on trauma related omfi. methods. the records of 12572 patients with omfi were collected at the department of cranio-maxillofacial and oral surgery at the medical university of innsbruck in the period from 01=01=1991 to 31=12=2003. according to the who definition of elderly people the collected values were divided into persons older than 65 years of age and younger. 11798 were younger and 774 were older than 65 years. data were registered regarding: diagnosis, age and gender, cause, type and localization of the injury and concomitant injuries. subsequently the data of both groups were compared and statistically analysed. statistical analysis was performed in spss (version 7.5) using chi-square-test, fisher 0 s exact test and mann-withney u test. this was followed by a logistic regression analysis in order to investigate trends and to demonstrate significant differences between the groups. a value of p< 0.05 was considered significant. results. with increasing age the risk for a domestic accident was raising. the accident mechanism in the elderly people was mainly a fall (72.2%) or was not reproducible (11.5%). there was a significant difference between both groups regarding concomitant injuries. 25.97% of the older and 14.8% of the younger patients suffered from additional neurological symptoms (p < 0.001). until the age of 65 the risk for concomitant neurological injury is increasing, beyond there is no significant higher risk. the injuries in the older patients were mainly referred to the soft tissue and the mid face. conclusions. thanks to major progress in general health care the percentage of elderly and most notably active old people in our society has been constantly stepping up in the past three decades. the increased number of concomitant injuries in elderly people requires a detailed investigation of the injured patient. furthermore medication and possible cardiovascular disease of the older generation restricts the indication for surgical treatment of these patients. influence of different surface termination on surface energy and subsequently on connective tissue attachment in vivo background. connective tissue attachment is of major significance for the longevity of transdermal=-mucosal implants. a tight soft tissue sealing around the implant prevents from acute and chronic infections. major focus of former investigations has been the influence of different surface roughness on the connective tissue attachment to the implant surface. the aim of the current investigation was to demonstrate the influence of different surface terminations of nano-crystalline diamond (ncd) on surface energy and subsequently its influence on in vivo connective tissue healing. methods. ncd coated titanium membranes were terminated either by hydrogen or oxygen and were compared to pure titanium membranes. these samples were evaluated by contact angle measurement, scanning electron microscopy, atomic force microscopy and electrostatic force microscopy to evaluate the surface potentials. to assess the in vivo integration, the different substrates were randomly distributed and inserted into the sub-dermal layer of 18 wistar rats. animals were sacrificed after 1, 2 and 4 weeks to investigate the adjacent connective tissue histologically. cell number, connective tissue=implant contact ratio and scar formation were evaluated. statistical analysis was performed using wilcoxon-rank test and kruskal-wallis h-test. p < 0.05 was considered significant. results. the ncd coating of the titanium membranes preserved its microstructure. contact angle measurement confirmed h-termination hydrophobic and o-termination hydrophilic. o-termination resulted in a strong polarity, whereas no electrostatic interactions were observed at the hydrophobic surface. the histological evaluation demonstrated a comparable cell number after 1 week in all groups. after four weeks a significantly increased cell number at the o-terminated ncd with a less tight scar formation was observed. furthermore a markedly higher connective tissue=implant contact was observed after 4 weeks at the hydrophobic surface. conclusions. o-termination of ncd renders the surface electrostatically active. the surface polarity promotes connective tissue healing in vivo. furthermore the surface energy is of higher importance compared to the structure of the surface. the o-termination of surfaces thus is a promising technique for a controlled influence of connective tissue adhesion in vivo. the risk of concomitant injuries and complications in cranio-maxillofacial trauma. das risiko von begleitverletzungen und komplikationen in der kiefer-gesichtschirurgie background. the registration of concomitant injuries on patients with cranio-maxillofacial trauma is an important criteria to optimize the healing process and to minimize the incidence of complications due to unlevied diagnostic findings. interdisciplinary, cranio-maxillofacial trauma management includes exact documentation. therefore a large collective of patients was examined against the background of their maxillo-facial trauma to diagnose the additional injuries. methods. between 2001-2003 at the department of oraland maxillofacial surgery among 3028 patients with craniomaxillofacial trauma, 505 patients (16.7%) with concomitant injuries were registered. data of patients were recorded including age and gender, cause and type of injury, location and frequency of their additional trauma. statistical analyses performed including descriptive analysis, chi square test, fisher's exact test and mann-whitney 0 s u-test. logistic regression analysis determined the impact of different ages on the type of injury. results. within 505 patients (mean age ¼ 39.15; #:$ ¼ 2.53) the most common sort of concomitant injury occured during sports, household and play (27.3% each). the most frequent type of additional injury was the commotio cerebri in 31.5% (159 patients). fracture of the base of the skull occurred in 73 patients (14.5%), 30 patients had a fracture of the skull and 24 patients suffered from contusio cerebri. even one patient had a paresis of the facial nerve. in 132 patients 190 injuries of the eye were denoted, among them 11.2% had a contusio bulbi and 2 patients a retrobulbar hematoma. contusio of the lung appeared in 5.3%, blunt abdominal trauma in 1.8% and a fracture of the cervical spine in 3.8% of patients with concomitant injuries. in 379 patients 867 fractures of the facial bone were recorded. soft tissue injuries of the face were found in 459 patients (90.9%). in concomitant injuries male persons aged between 40 to 60 are prone to cervical spine fractures (increase of 316%=year of age) and thoracal injuries (increase of 165%=year of age), as well as neurological trauma (increase of 93%=year of age) mainly found in traffic accidents. conclusions. in the catchment area of our department injuries of the neurocranium and the eye were often associated with trauma of the viscerocranium. interdisciplinary and coordinated management is not only important for the initiation of preventive measurements but also for forensic causes. to minimize the complication rate and to optimize the therapy a neurological-, neurosurgical-, as well as eye-consiliary examination should be preferably accomplished at a preoperative stage on the awakened patient. background. orbital injury may lead to incarceration of periorbital tissue and to ocular motility disturbances and diplopia on a long-term basis. however, orbital surgery is not free of risks. the treatment of periorbital lesions demands a precise planning approach in order to secure high success rates without causing iatrogenic damage. we want to demonstrate computer assisted surgery as part of the surgical routine of posttraumatic orbital reconstruction. methods. four cases of posttraumatic orbital deformities are presented. two patients showed protruding bone fragments after unrecognized fractures of the orbital walls. two patients presented with foreign bodies in the orbital cavity after shotgun injuries. in all four patients preoperative acquired ct-data was reformatted on a commercially available 3d-navigation system. image guided surgery in the orbital cavity was performed using an intraoperatively calibrated high-resolution endoscope. results. the shotgun pellets and the protruding bone fragments were easily detected and removed via a minimal invasive access. diplopia and bulb motility improved significantly. postoperative rehabilitation was restricted to a few days. conclusions. according to our opinion computerized navigation surgery of the orbit can improve the results of surgery in terms of safety and accuracy. these extended techniques should lead to a more direct and less invasive method for approaching orbital lesions or posttraumatic deformities giving the surgeon a high degree of security in sparing vital anatomic structures. background. surgically assisted rapid maxillary expansion (sarme) has become a widely used and acceptable technique to expand the maxilla in adolescents and adult patients. sarme takes the advantage of bone formation at the maxillary edges of the midline, while they are separated by an external force. sarme is indicated in patients with isolated, considerable (more than 5 mm) transverse maxillary deficiency. while surgically assisted palatal expansion is performed in patients after closure of the sagittal palatal suture, conservative rapid maxillary expansion can be used in younger patients. studies concerning such cases show, that just 30% of the expanded width is located in the area of the palatal suture, while the rest of the extention (70%) are reached by dentoalveolar movements like tipping. the aim of this study was to evaluate the amount of expansion caused by expansion of the maxillary suture and by the dentoalveolar complex. furthermore changes of the nasal cavity should be discussed. methods. all patients included in the study showed a tranverse maxillary deficiency of at least 5 mm. all patients were older than 18 years (18 min, 43 max). in all patients a fractional le fort i osteotomie consisting of sagittal osteotomie and osteotomie of the anterior maxilla and the pterygoid bone was performed. ct scans were performed preoperatively and about 8 weeks postoperatively (after the needed expansion). measuring points were defined to evaluate the skeletal and the dental changes after maxillary expansion. conclusions. the results of the current study will be presented. background. the main indication for microvascular reconstruction of the face is the best possible functional and aesthetic outcome. here every special kind of missing tissue is to be substituted. by using the chimera-flap technique a combination of different transplants for individual defect coverage is possible. methods. in seven patients with extended or penetrating defects of the lower face, reconstruction was performed with a double flap technique. a combination of microvascular iliac crest transplants or microvascular femur transplants for mandibula reconstruction and an anterolateral thigh perforator flap (altpf) or saphenus perforator flap for soft tissue reconstruction was performed after ablative tumour surgery. the pedicle of the altpf or saphenus flap was used for elongation of the microvascular bone flap pedicle. all patients had radiotherapy 6weeks after surgery. results. all patients had good functional and aesthetic results and have been successfully treated with implant retained prostheses. there were no severe postoperative complications. there was no tumour relapse within 14-32 months postoperatively. conclusions. the chimera-technique makes good aesthetic and functional outcome possible. the iliac crest transplant is of a good dimension for reconstruction of non-high atrophic mandibles after complete resection. the microvascular femur is well suited for covering partial defects of the mandible. implant placement is possible in both transplant types. the altpf and the saphenus perforator flap have a low incidence of complications and donor site morbidity and can be shaped adequately to a soft tissue defect of the lower face. 094 parry-romberg-syndrom (hemiatrophia faciei progressiva) -interdisziplinäre zusammenarbeit mehrerer ü bergreifender fächer bei der definitiven diagnosestellung und den daraus resultierenden therapiemöglichkeiten zugt gesichts-und schädelskelett. die hemiatrophia faciei progressiva (v. romberg) ist primär durch einen schwund der betroffenen gesichtsseite, an der die haut, das subcutane fettgewebe und bindegewebe und später auch die muskelatur und die gesichtsschädelknochen beteiligt sind. die ausgeprägte gesichtsasymmetrie ist häufiger als ein funktionsausfall ursache der behandlung. nur eine effiziente diagnostik sichert eine gute therapie und gute resultate bei einem romberg-syndrom-patienten. bei der diagnostik wird nicht nur die mund-, kiefer-und gesichtschirurgie herangezogen, sondern interdisziplinär mit der dermatologie, hno, mund-, kiefer-und zahnheilkunde, augenheilkunde, neurologie, psychiatrie, plastischen chirurgie und radiologie zusammengearbeitet. es werden die jeweiligen disziplinen mit ihrem abklärungsgebiet beim romberg-syndrom präsentiert und dargestellt. in jeder disziplin werden die patienten in der dermatologie auf eine sklerodermie, in der neurologie -anhand eines mrtsdie neuralgiformen symptome und in der augenheilkunde die ophthalmologischen symptome, in der radiologie -anhand von bildgebungsverfahren (ct, szintigraphie) die knochenaktivität in bezug auf die fortschreitende knochenatrophie untersucht und abgeklärt. die therapieform wird nach der diagnosestellung und der daraus resultierenden diagnosebestätigung und anhand der symptomatik beim patienten bestimmt. verschiedene therapieoptionen wie eine autologe lipoinjektion, eine fettgewebstransplantation, eine freie mikrochirurgisch-anastomosierende fettgewebslappenplastik oder injektion allogener materialien werden angewendet. die diagnostik und das chirurgische vorgehen werden an zwei fallbeispielen demonstriert. die grundlegenden behandlungsstrategien stammen aus der zeit der beiden weltkriege. ä nderungen der konzepte ergaben sich im bereich der sekundären rekonstruktion verlorengegangener strukturen sowohl im weichgewebe als auch im hartgewebsbereich durch etablierung neuer operationstechniken, welche die erzielung besserer ästhetischer und funktioneller ergebnisse ermöglichen. neben der beschreibung des traumamechanismuses erfolgt anhand von klinischen fällen die darstellung der versorgungsprinzipien. responsible for preventing fecal incontinence as well as enabling defecation. methods. works on anorectal vascularization are presented and diagnostic tools for clinical practice are discussed. results. filling and drainage of the internal hemorrhoidal plexus can be visualized by transperineal color doppler ultrasound. the terminal branches of the superior rectal artery exclusively contribute to the arterial blood supply of the internal hemorrhoidal plexus. according to anatomical studies an intramural network of anastomoses exists between the superior and inferior rectal arteries. ultrasound studies of the anorectum clearly highlighted a stage-dependent alteration of the morphology and perfusion of these terminal branches in different grades of hemorrhoids. conclusions. hypervascularization of the anorectum is proposed to contribute to the growth of hemorrhoids rather than being a consequence of hemorrhoids. pre-and postoperative assessment of the anorectal vascularization helps to judge the success of a technique for treatment of different grades of hemorrhoids. the doppler-guided haemorrhoidal artery ligation is a new, minimally invasive technique in the treatment of haemorrhoidal disease. since february 2000 486 patients with symptomatic second and third degree haemorrhoids have been treated this way at our department. postoperative complications occurred in 1, 6%. one month after treatment 82% of the patients were symptom-free and satisfied with the results. since there are very little data regarding the efficiency and the patient comfort on the long term, we questioned 250 consecutive patients which had undergone surgery between february 2000 until december 31 st 2002. the questionnaire was done via telephone using standardised questions. patients with persisting or recurring symptoms were invited for a control re-examination. the results of this follow-up will be presented. background. guidelines may be helpful to standardize the management of hepatocellular and cholangiocellular carcinoma as the diagnostic and therapeutic spectrum has been considerably enlarged by recent developments. methods. ''state of the art'' guidelines deducted from the literature and from recent consensus conferences are elaborated; issues that remain controversial or not sufficiently documented by data are discussed. results. some standards have been introduced in hepatic surgery such as preoperative evaluation of liver function (and portal branch embolisation if required) or intraoperative ultrasonography. for other essential items such as techniques used for transsection of liver parenchyma or for hemostasis a variety of possibilities is at choice and the decision often depends on the personal attitude of the surgeon. as success of surgery is influenced by so many factors and imponderabilities, exact clinical evaluation is delicate and statements fulfilling the strict criteria of evidence based medicines are rarely found. only in a minority of patients with hepatocellular carcinoma transplantation or resection is possible. for the remaining patients, a variety of therapeutic procedures are warranted with effects difficult to compare given the bias of patient selection and the great inter-patient and inter-institutional variability. in the treatment of patients with bile duct carcinoma, surgery (liver resections for klatskin tumors stage bismuth i-iii, whipple's procedure for more distally localized tumors), if feasible, plays a key role as well. conclusions. excellent interdisciplinary cooperation is the clue to providing ''state of the art'' management of hepatocellular and cholangiocellular carcinoma. treatment not only has to consider tumor type and stage, but also the individuality and the overall condition of every single patient. background. colorectal carcinoma is one of the most common malignant diseases primarily diagnosed in the industrialized world. thanks to standardized surgical procedures and multimodal treatment concepts, the prognosis has improved considerably in recent decades. methods. state-of-the-art treatment of colorectal carcinoma is presented and discussed on the basis of the current literature, including the current status of minimally invasive techniques in the surgical treatment of malignant colorectal disease. results. carcinomas of the colon and rectum are two separate entities as far as biology, probability of local recurrences, metastasis patterns, surgical strategy and multimodal treatment regimes are concerned. operative treatment of colon carcinoma is generally standardized, but the concept of sentinal node biopsy is a new aspect. a metaanalysis of stage ii colon carcinoma showed a survival advantage of up to 5% for adjuvant therapies including 5-fu. the mortality rate for stage iii colon cancer could be reduced by 10-15% with adjuvant chemotherapy. the operative standard for rectal carcinoma is heald's technique of total mesorectal excision. for proximal rectal carcinomas, a partial mesorectal excision with a greater distance (at least 5 cm) to the edge of the tumor is adequate. with rectal carcinoma, neoadjuvant radiochemotherapy is more effective at reducing local recurrences and involves fewer complications than does postoperative treatment. accordingly, neoadjuvant radiochemotherapy is indicated at least for t-3 tumors of the lower and middle thirds of the rectum. in all, total survival and fewer local recurrences are seen with combined radiochemotherapy for rectal carcinoma. a number of randomized prospective studies published since 2005 showed comparable long-term results for laparoscopic and open colon surgery. the results of such studies on rectal carcinoma are not yet available. conclusions. the key factors for improving the prognosis of colon and rectal carcinoma are, besides early diagnosis, standardized surgery and multimodal, individualized treatment concepts. 115 prophylactic operations in palliativ surgerya conflict? background. to date approximately 25% of the eu-citizens decease on malign tumors. here an increased tendency was noticed in the past. this circumstance is present in the surgical day-to-day life. patients with predictable and linited prognosis often require the decision whether a prophylactic surgical procedure would prevent further complications or may declerate progression of malign tumors. methods. the status and progression of patients with oncological focus were analyzed in the department of surgery of the helios-hospital schwerin. two groups were studied. first surgical procedures due to general symptoms of the tumorous disease. second, surgical therapy of specific symptoms as a consequence of the tumor. results. inter-disciplinary diagnosis and discussion were crucial for the decision whether a palliativ-prophylactic operation was necessary or not. futhermore, prophylaxis in palliative medicin and surgery required a multi-disciplinary therapy regime. for the inter-disciplinary decision, guidelines proposed by the established ''tumorboard organization'' were applied. for general symptomatic treatment, palliativ-prophylactic procedures due to pain therapy, gastro-intestinal symptoms, emesis, ileus, ascites, icterus, cachexia, respiratory and urological complications, and wound management were accomplished. conclusions. prophylactic operations are frequent and represent the reality in palliative surgery. the ''tumorboard organization'' was administrable for a structured ultimate therapy decision. here forensic guidelines regarding self-determination, protection of integrity, autonomy of the patient, and euthanasia have to be considered. the perception of the personally responsibility of the attending physician still possess highest priority. background. within the last decade thyroid surgery has been radicalized. two parties have emerged from the discussion. one group, trying to preserve thyroid as central element of the body -the other one, in light of an easy replacement therapy, does not feel the need for that. methods. we compare patients operated from 2003-2005 at our department. one group underwent dunhilloperation (dh) n159, the second thyroidectomy (t) n56. complication rate and change of therapy were compared, remaining tissue was sonographed. the patient's opinions were sought using questionnaires. results. monitoring period lasted 12-36 months. recurrensrate showed no significant difference (dh:0.6=t:1.7) and bleeding results also didn't show any differences. we did notice a higher hypoparathyroidismus rate with the thyroidectomy group (dh:1.8=t:7.1). 32% of all sonographies in the dunhill group required further investigation because of remaining nodulare tissue. changes with substitution therapy didn't show any differences. the patient's opinions were identical in both groups. conclusions. both techniques require a simple substitution therapy. they are both safe methods, although the hypoparathyroidism is higher with thyroidectomy. on the other had we observed a progress in learning over the years thus we noticed no significance in 2005. when using dunhill procedure, remaining tissue must be checked regularly. in our opinion, it is no benefit for patients with replaced tissue. 118 evaluation of a new needle for thyroid fine needle aspiration biopsy p. wretschitsch 1 , m. glehr 1 , t. kroneis 2 , a. leithner 1 , r. windhager 1 background. to verify the destinction of thyroid tumors, the volume of harvested cells in fine needle aspiration biopsy is one of the significant parameters for histological criteria and diagnosis. in consequence of the new aeration valve, the new needle is deaerated after the aspiration. thereby no blood or other not thyroid-cell elements are aspirated and more thyroidcells are harvested. methods. under blinded setting 45 punctures, 15 for each needle (standard needle, 1-needle with air valve and multi needle system with air valve), from fresh pig thyroid gland were made and recorded. the measurement was done according the manufacturers recommendations for casy (casy + technology, reutlingen). the aspirated cell material was evacuated into 10 ml casyton (cell-culture liquid, casy + technology, reutlingen) and calculated with the casy (casy + technology, reutlingen) cell counter. total cell amount and amount of vital cell was counted and recorded. statistical analysis was performed using t-test (p < 0.05 was considered significant). results. per needle respectively 15 punctures were made and counted. the mean cellular amount of the standard needle was 215 941 cells=ml. the mean cellular amount of the 1-needle system with aeration valve was 1 125 378 cells=ml. the average of cell amount for the multi needle system (thyrosampler + kurtaran-frass, vienna) was 1 723 137 cells=ml. the mean difference between the standard needle and the 1-needle system with air valve was significant with total cells (p ¼ 0.03) and with vital cells (p ¼ 0.032). the difference between 1-needle and multineedle system was not significant with total cells (p ¼ 0.35) and with vital cells (p ¼ 0.6). tag 0 conclusions. the needle systems with the air-valve lead to a significant higher cell amount in needle aspiration biopsy. according to the requirement of cytological diagnosis more cell volume could be harvested, which is a well-defined benefit. 119 does the lunar phase influence the incidence of postoperative haemorrhage after thyroid surgery? a preliminary report background. it is claimed by non-scientific sources that operations carried out at waxing moon or especially at full moon are associated with a higher incidence of postoperative complications. therefore patients referring to lay press confront surgeons with the lunar phase's influence and claim for special dates for surgery. postoperative haemorrhage is a typical complication after thyroid surgery with an incidence of about 1.5%. thus it is a suitable to assess this assumption by evidence-based data. methods. we retrospectively evaluated 203 patients requiring reoperation after thyroid surgery. the exact time of skin incision was evaluated by anaesthesia's reports and its lunar phase was calculated by an online-calculator. results. in a timeframe of 3 days (in all) around full moon 21 patients had to be reoperated, 3 days around new moon 22 patients needed surgical reintervention. 104 patients were operated during waxing moon, the phase that is believed to be a risk for postoperative complications, and 99 patients during waning moon. no differences were seen between the categories 1st þ 4th quarter (102 operations), the quarters around new moon, and 2nd þ 3rd quarter (101 operations), the quarters around full moon. conclusions. our study shows no correlation between postoperative haemorrhage after thyroid surgery and lunar phase at initial surgery. these evidence-based data prove, that lunar phase does not influence the risk of bleeding after surgical interventions. these results should serve as information for those patients, who are convinced, not to be operated during full moon phase. the result should also bring the ''superstition'' to a halt. background. recently gender-specific medicine has become the focus of interest. after thyroid surgery we observed more hypocalcaemia-related symptoms in women than in men. our goal was to find out gender-specific differences in the postoperative calcium-and parathyroid hormone (pth)-kinetics. methods. pth-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. a total of 319 women and 83 men underwent extensive thyroid surgery. postoperative calcium levels revealed a non-significant difference of 0.05 mmol between women and men on the 1st postoperative day. perioperative pth-kinetics showed no significant differences too, neither in symptomatic patients, nor in the whole study population. the rate of postoperative hypocalcaemia-related symptoms was about higher in women than in men (18-11%, respectively). conclusions. despite of similar perioperative pth-and calcium-kinetics women suffer more often from postoperative hypocalcaemia-related symptoms. the mechanism remains unclear and needs further research in gender-specific postoperative calcium-metabolism. background. grave's disease (gd) is thought to be associated with a higher incidence of postoperative hypocalcaemiarelated symptoms. methods. parathyroid hormone (pth)-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. preliminary data were analysed for patients with an observation period of more than 12 months. results. total or near-total thyroidectomy was carried out in 44 patients with gd and 198 patients with benign euthyroid multinodular goitre. differences between patients with gd and patients with benign euthyroid nodular goitre were found for postoperative hypocalcaemia-related symptoms (34.1, 14.1%, respectively). these findings were statistically significant (p < 0.5). furthermore, no significant differences were found in perioperative pth-and calcium-kinetics between the groups. patients with gd were of a significant (p < 0.001) lower mean age (40 ae 13) than patients with benign euthyroid multinodular goitre (56 ae 12). conclusions. there is a significant higher risk of postoperative hypocalcaemia-related symptoms after surgery for gd compared to benign euthyroid multinodular goitre. there is no significance concerning the risk of permanent hypoparathyroidism in our preliminary data set. background. intraoperative parathyroid hormone [pth] monitoring is an important prerequisite for minimally invasive parathyroid surgery. thus, surgical success essentially depends on the correct intraoperative interpretation of the pth-decay. pth-''spikes'' caused by unintentional ''manipulation'' of the hypersecreting glands during dissection may lead to interpretation problems. it is unclear how often these ''spikes'' occur and how they influence the operative strategy. we evaluated manipulated pth-excretion during surgery in a large number of patients and analyzed its influence on the interpretation of the intraoperative pth-curve. methods. intraoperative pth-values (intact pth, nichols, san jose, california) of 401 patients with primary hyperparathyroidism and single gland disease were analyzed. of these 401 patients, 263 (65.6%) were successfully treated with open minimally invasive parathyroidectomy (omip), 106 (26.4%) with primary bilateral neck exploration (bne) and 32 (8%) patients had to be converted from omip to bne. to evaluate the occurrence of manipulation, patients were divided into 4 groups: ''moderate'' pth-increase (<150 pg=ml), ''extensive'' increase (>150 pg=ml), ''no'' increase (ae50 pg=ml) and ''decrease'' before excision. changes were referred to the ''baseline''-level which was sampled right after induction of anaesthesia and before incision. intraoperatively, pth was measured before, 5, 10 and 15 min after removal of the enlarged gland. results. overall 36 (9%) had a moderate increase and 22 (5.5%) an extensive increase. no increase occurred in 162 (40.4%) and a decrease in 181 (45.2%) patients. in 263 patients undergoing omip, 17 (6%) glands were manipulated moderately, another 17 (6%) glands were extensively manipulated, 98 (37.2%) had no increase and 131 (49.8%) had a decline. in 106 patients undergoing primary bne, 14 (13.3%) glands were manipulated moderately, 5 (4.7%) extensively and 46 (43%) had no increase. a decrease was observed in 41 (38.7%) patients. a conversion from omip to bne was performed in 32 patients because of incorrect preoperative localization by sestamibiscintigraphy and=or sonography. five (16%) of them had moderate manipulation and no patient had extensive manipulation. eighteen (56%) showed no pth alterations and 9 (28%) a decrease, retrospectively. in none of the converted patients a misinterpretation of pth-''spikes'' were the underlying cause. conclusions. the data show that intraoperative manipulation is documented in bne and omip. the ''spikes'' caused by unintentional manipulation were identified by a subsequent prolonged pth-decline but did not lead to a change in the surgical strategy. parathyreoideakarzinome zählen zu den seltenen tumoren und sind für weniger als 1% aller primären hyperparathyreoibackground. at international meetings, delegates from many countries report an increasing lack of young doctors willing to choose operative specialities. the aim of this study was to evaluate the working conditions for surgeons in austria and to define the most crucial items calling for amelioration. methods. an anonymous survey was prepared and by e-mail all the members of the austrian surgical society were asked to complete a questionnaire which could be reached online by a direct link. it comprised twenty questions and was kept deliberately short in order to require a minimum of time for response. results. just some examples of the essential items can be given here: working conditions (such as working hours and payment) have to be improved. notably the young surgeons require career perspectives that are better and defined more clearly. the time spent for non-medical duties such as organization and documentation must be reduced. more priority is needed for surgical training both in the operating room and in practically oriented courses. conclusions. this evaluation provides the basis for further discussion at a session dedicated to this topic during the austrian surgical congress of 2007. background. surgical training and education is neither standardized nor regulated. there is no validation, no obligatory training goal and no implementary rotation system. recently, the training permission for surgeons in education in the surgical department of kaiserin elisabeth spital has been shortened by the austrian medical association from 4 to 2 years without evidence based data i.e.without the consideration of the underlying number of operations performed in the clinic. methods. the surgical department is a center of thyroid and parathyroid surgery, which also covers the extended oncological cases, minimal invasive surgery, hernia operations and has the largest capacity for acute abdominal diseases in vienna. to analyze the quality of surgical education, the whole number of operations as well as the number of trainees in 2 nd and 4 th training year are tallied for analysis. results. in 2006, a total number of 2160 operations (1008 thyroid and 1152 non thyroid operations) have been performed in our surgical department. trainee a (4 years of education) performed 1552 (822 thyroid and 730 non thyroid operations), trainee b (2 years of education) 195 operations (115 thyroid and 80 non thyroid operations). the non thyroid operations of trainee a included 123 cholecystectomies, 53 herniotomies, 57 appendectomies, 27 operations of colon or small bowel, all other will be listened in detail. trainee a had 487=289, trainee b 534=253 gastroscopies=colonoscopies performed. conclusions. the number of operations prove that the goal of training for 2 surgeons in education is easily achievable. the reduction of training permission by the vienna medical chamber was not evidenced by data. however, this procedure has once again raised the insufficient structures in surgical education, the lack of valid training program and standardized approaches for a defined rotation and the obligation for both, senior surgeons and trainees to perform a certain number of teaching operations. a structured reform of rules and regulations for training is necessary. background. the purpose of this study was to review our hospital's experience in a retrospective single-center analysis of all patients undergoing surgery for posttraumatic thoracic pathologies between 1972 and 2006. methods. from 1972 to october 2006 a total of 635 aortic procedures were performed at our institution. eighty eight patients (14.9%) underwent an intervention (79 surgical procedures, 12 stentgraft implantations) due to a posttraumatic injury of their thoracic aorta. in >90% the descending aorta was involved, the injuries consisting of 50% aortic rupture, 42.7% posttraumatic pseudo-aneurysms and 18.9% aortic dissection. in the surgical cohort 50.6% of the patients had to undergo an emergency procedure, 16.9% an urgent and 32.5% an elective procedure. there were 8.3% female patients and 81.7% male patients with a mean age of 39.2 years (range 15-82 yrs). results. during the three decades total hospital mortality was 10.39% with a decrease over the years, thus resulting in a hospital mortality of 5.8% (1995-2006) versus 13.95% (1974-1994) . hospital mortality in the emergency group dropped from 20. 8% (1974-1994) to 6.6% (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) . improved outcome is mainly due to preoperative aggressive control of blood pressure and aortic shear forces using -blockade, intraoperative the use of heparin bounded circuits with cardiopulmonary bypass and most of all, a selectively delayed operative procedure (!). conclusions. although endovascular stent graft techniques continue to evolve, emergent=urgent patients will be anatomically not suitable for stent grafts and long term outcomes have yet to be determined. we therefore still consider selectively delayed surgery in patients with posttraumatic aortic pathology as a cornerstone in the choice of treatment for these patients. 133 combined surgical and endovascular repair of complex aortic pathologies with a new designed hybridprosthesis background. in the present study the use of a new combined surgical and endovascular approach in the treatment of aortic dissection or aneurysm is evaluated. the aim of this technique is to treat extensive aortic diseases in a single stage procedure. the operative and follow up data are summarized in this report. methods. between 08=05 and 12=06 six patients (62 ae 11 years; 2 female) with different aortic pathologies (4 dissections, 2 aneurysms) underwent replacement of ascending aorta, aortic arch and stentgraft implantation into the descending aorta using the e-vita open endoluminal stentgraft under circulatory arrest in moderate hypothermia with selective antegrade cerebral perfusion. the stentgraft was deployed under direct vision through the open aortic arch into the true lumen. results. intraoperative antegrade stenting of the descending aorta combined with distal ascending aorta and aortic arch repair was performed successfully in all patients. all patients survived the procedure one patient had neurological deficit, which recovered completely. a complete thrombosed perigraft space was observed in 4 patients after one to eleven days. in two patients a partial thrombosis of the false lumen of descending aorta was observed. one patient underwent thoracoabdominal repair five months later. conclusions. this report shows that a combined surgical and endovascular approach of extended aortic lesions is a feasible option and extends aortic repair in a single stage method without increase of risk. background. to evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. methods. from 2002 through 2006, 27 patients (mean age 72 yrs) with aortic arch diseases were treated (arch aneurysms n ¼ 18, type b dissections n ¼ 5, perforating ulcers n ¼ 4). strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in 17 patients. strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in 10 patients. endovascular stent-graft placement was performed metachronously thereafter. results. two in-hospital deaths occured (myocardial infarction on the day prior to discharge n ¼ 1, rupture while waiting for stent-graft placement n ¼ 1). at completion angiography, all reconstructions were fully patent. four patients had small type ia endoleaks, two of them resolving spontaneously. mean follow-up is 15 months (1-43 months) . three late deaths occured (myocardial infarction n ¼ 2, sudden unknown death n ¼ 1). one year survival was 83% and three year survival was 72%, respectively. redo stent-graft placement was performed in one patient after 25 months (type iii endoleak). the remaining patients had normal ct scans with regular perfusion of the supraaortic branches without any signs of endoleaks. conclusions. mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. extended applications provide safe and effective treatment in patients at high risk for conventional repair. background. to determine mid-term durability of endovascular stent-graft placement in patients with perforating atherosclerotic ulcers (pau) involving the thoracic aorta and to identify risk factors for death as well as early and late adverse events. methods. from 1997 through 2006, 27 patients (mean age 66 yrs) presented with pau, seven patients had rupture. seventy-eight percent were unsuitable for conventional repair. mean numeric euroscore was 11 and mean logistic euroscore was 35. median follow-up was 35 (2-86) months, being complete in all patients. outcome variables included death and occurrence of early and late adverse events. results. in-hospital mortality was 11%. primary success rate was 100%. actuarial survival rates at 1, 3 and 5 years were 93, 78 and 70% and actuarial event-free survival rates were 89, 74 and 62%, respectively. hemodynamic instability as well as logistic euroscore was identified as independent predictos of early and late adverse events. conclusions. endovascular stent-graft placement in patients with pau is an effective palliation for a life-threatening sign of a severe systemic process. hemodynamic instability at referral and a high preoperative risk score predict adverse outcome. during mid-term follow-up, patients are mainly limited by sequelae of their underlying disease. background. the performance of endovascular stent-graft placement in patients suffering from aneurysms involving the descending aorta originating from chronic type b dissections is unclear. methods. within a two-year period, we treated six patients with this pathology. four patients required extension of the proximal landing zone (autologous double transposition n ¼ 2, subclavian-to-carotid artery transposition n ¼ 2) prior to stentgraft placement. results. supraaortic rerouting procedures and endovascular stent-graft placement were performed successfully in all patients. closure of the primary entry tear, full expansion of the stent-graft and consecutively, thrombosis of the false lumen was achieved in five patients. in one patient with a short proximal landing zone, a persisting type ia endoleak had to be observed. in all patients with successful primary entry closure, a reduction in aneurysm diameter could be seen. mean follow-up is 16 months (4-25 months). conclusions. endovascular stent-graft placement of aneurysms involving the descending aorta originating from chronic type b dissections may serve as a valuable treatment option in a complex pathology. the chronic dissection membrane can be successfully approximated to large parts of the native aortic wall. a sufficient proximal landing zone is mandatory for early and late success. background. the aim of the study was to determine late vascular events in patients after endovascular stent-graft placement of thoracic aortic diseases. methods. between 1996 and 2006 a total of 174 patients (mean age 67a; % male ¼ 73) underwent endovascular stentgraft placement of thoracic aortic diseases at our institution. indications were aneurysms (n ¼ 87), acute and chronic type b dissections (n ¼ 42), penetrating ulcers (n ¼ 33) and traumatic transsections (n ¼ 12). results. during a median follow-up of 42 months (1-108 months), in 21% of patients, late vascular events were observed. the highest incidence was observed in patients after stent-graft placement for type b dissections (29%), closely followed by patients after stent-graft placement for penetrating ulcers (24%). the incidence after stent-graft placement for aneurysms was 18%. no events were observed in patients after traumatic transsections. interestingly, patients undergoing stent-graft placement due to dilatative arteriopathy developed further dilatations in other regions and patients undergoing stent-graft placement due to obliterative arteriopathy were more prone to sustain obliterative diseases in other vascular beds. conclusion. this study clearly outlines the necessity of a close follow-up in these patients, not only to assess long-term outcome of endovascular stent-graft placement, but also to monitor these patients for new vascular pathologies. 138 tenascin-c as a key factor in the remodeling of the ascending aorta leading to chronic dilatation and acute type a dissection background. the extracellular matrix molecule tenascin-c (tn-c) plays an important role in embryonic development, wound-healing, cancer invasive fronts and myocardial remodeling by loosening the linkage between connective tissue and cells lying within. as there is clear evidence for an involvement in vascular remodeling as well, we hypothesized tn-c being a mediator in the pathogenesis of chronic dilatation of the ascending aorta and acute aortic dissection. methods. ascending aortic wall specimens were obtained from patients undergoing aortic reconstruction due to chronic dilatation of the ascending aorta (n ¼ 12) and acute aortic dissection stanford type a (n ¼ 10). specimens of patients (n ¼ 5) undergoing aortic valve replacement with a macroscopically normal aorta served as controls. formalin-fixed paraffin-embedded specimens were morphologically evaluated by hematoxylin-eosin staining and immunostaining for tn-c expression. results. there were no differences in clinical characteristics concerning age and gender between patients with acute dissection, chronic dilatation and control. patients with a known connective tissue disorder or bicuspid aortic valve were excluded from the study. histologic examination showed a clear difference between chronic dilatation and acute dissection. in chronic dilatation tn-c staining was homogenously distributed throughout the media parallel to the orientation of vascular smooth muscle cells. in contrast specimens in acute aortic dissection showed a focal strong positive staining especially surrounding vasa vasorum and sites of intramedial hemorrhage and subsequent dissection throughout the whole vessel wall with tn-c negative areas in between. whereas in control aorta tn-c expression was almost absent. conclusions. these data suggest a role for tn-c in the remodeling of the ascending aorta leading to chronic dilatation and type a dissection. keeping in mind the differences in tn-c expression between chronic dilatation and acute dissection one may speculate that changes of the vascular wall leading to aortic dissection are mediated or at least accompanied by a change in tn-c distribution. 139 a complicated type b-dissection: how (not) to do it j. demmer 1 , m. alavian 1 , p. pichler 2 , c. groß 1 1 chirurgie 1, akh linz, linz, austria; 2 radiologie, akh linz, linz, austria complex type b-dissection is still accompanied with high mortality. we report on a 49 years old male with a 2 weeks ongoing history of thoracic pain. he was admitted to another hospital where a left renal artery stenosis in ct scan was suspected and a stent was applied into the false lumen of this artery. then the patient was transferred to our institution. angiogram revealed a type b-dissection with a hugh entry distal to the left subclavian artery, the coeliac trunk arising from the false lumen but the hepatic arteries adequately collateralized by the superior mesenteric artery. though guidewire insertion to the true lumen of the common hepatic artery was feasible, stent application was not possible.the entry in the proximal descending aorta was covered with an endostent, thoracic pain disappeared immediately. though a slight pain in the right upper abdomen and a moderate raise of got, gpt and y-gt was to be seen for a few days, the patient could be discharged 2 weeks after stenting in good condition without having pain or signs of cholecystitis. another 10 days later he was readmitted in bad condition with signs of peritonitis in the right upper abdomen, 20,000 wbc and a massive increase of liverenzymes. laparatomy was performed immediately. the gallbladder presented necrotic, the whole liver dark blue without any pulsation in the hepatic arteries. after choecystectomy an autologous venous bypass from the common iliac to the propriet hepatic artery was performed. the postop. course presented uneventful, angio-ct at postop. day 4 showed a well contrasted bypass. the patient could be discharged at postop. day 11 without any signs of infection and only slightly elevated liverenzymes. background. endovascular aneurysm repair (evar) evolved as a treatment option for high risk patients, in whom previously open graft replacement (ogr) could only be carried out with a high, nearly prohibitive risk or open repair even had to be denied. by employing evar the mortality rates (mr) were lowered to 2-3% in specialized centers. unsolved is the problem of how to deal with patients unsuitable for evar. the hypothesis of this study was to test whether thoughtful watching combined with management of present risk factors or ogr were second best to evar in asa class iv patients with abdominal aortic aneurysms (aaa). methods. out of a total of 854 aaa-patients two groups of asa class iv patients were selected and compared. group 1 consisted of 34 patients who underwent ogr from 1995-2005. group 2 included 27 patients unfit or unwilling to undergo evar in the period from 2001-2005. kaplan-meier survival estimates were calculated and possible differences were analyzed by the log-rank-test. results. the 30 day survival was 84.59% in group 1 versus 100% after 30 days following the denial of operation in group 2 (p < 0.0380). the 90 days survival was again significant with p < 0.0116, group 2 100% versus group 1 77.95%. after one year survival was not significant anymore, i.e. group 1 67.46% versus group 2 75.52% (p < 0.3554). conclusions. ogr has a significantly worse survival than conservative treatment in asa class iv patients in the first 3 months after operation. after one year both treatment options show similar results. background. abdominal aortic aneurysm (aaa) size has been recognized as risk factor of rupture. several reports presented evidence that aaa with diameters exceeding 5.5 cm are associated with increased risk of rupture compared to smaller aneurysms. regarding these findings a diameter of more than 5.5 cm is generally considered as indication for exclusion. this analysis was undertaken to determine the influence of aneurysm diameter on long term outcome after either type of elective aaa repair. methods. eight hundred and sixty four consecutive patients underwent elective repair of an infrarenal aaa either by open graft replacement (ogr, n ¼ 425) or endovascular aneurysm repair (evar, n ¼ 439) from january, 1995, through june, 2006. median aaa diameter was chosen as threshold to discriminate between small and large aneurysms. patient characteristics, distribution of preoperative risk factors and postoperative outcome after either type of aaa exclusion were assessed. survival was compared using kaplan-meier estimates at 7 years. results. overall median aaa diameter was 5.8 cm as well as in both treatment groups. analysis of risk factors only re-vealed that patients with larger aneurysms were significantly older (ogr 66.2 years vs. 70.7 years, p < 0.0001; evar 73.6 vs. 75.4 years, p < 0.013) but comparison of individual health status expressed by the american society of anesthesiologists (asa) score did not reach statistical significance. at 7 years, overall survival was higher in patients with small aneurysms (52.0 vs. 39.6%, p < 0.0002). similar results were obtained in patients undergoing ogr (56.6 vs. 42.3%, p < 0.005) as well as evar (48.7 vs. 37.2%, p < 0.013). conclusions. patients with aneurysms smaller than 5.8 cm have improved survival at 7 years after either type of elective aaa repair. large aneurysm diameter is accompanied with increased age, which might negatively influence long term outcome. thus, the provoking issue to exclude small aaa before they reach 5.5 cm may rise again. background. about microsurgical techniques without sutures many references in literature databases are found. among facilities like rings, clips, stents, laser and adhesives the vessel coupling system (coupler + ) is mentioned. thereby two coupling rings interlock, which anastomose the vessels. methods. over the last two years in our division the coupler + was used in nine cases of free tissue transfer for breast reconstruction. in six of them the arterial and venous anastomosis were performed with the coupler + , in three cases only the venous anastomosis was done mechanically. in all cases the anastomosis was end-to-end. results. because of insufficient arterial adaptation in two cases we switched to a conventional procedure with sutures. all the other anastomosis showed a normal flow. except of one partial necrosis of a flap, which was not due to the coupler + , all flaps survived. the mean duration of doing the anastomosis was less than five minutes. conclusions. the coupling system (coupler + ) is a useful, secure and time saving tool for the venous anastomosis when performing a free tissue transfer. for the arterial anastomosis the conventional method is preferable, especially in cases of arteries with thick walls. background. non-operative management of splenic injuries is beneficial compared to surgery in hemodynamically stable patients. aim of this study was to assess whether conservative treatment would also translate into better quality of life post injury. methods. all consecutive patients with splenic injuries between january 2000 to february 2006 were included. splenic injuries were graded according to aast recommendations [1] . patients were identified from our electronic inpatient index and stratified by non-operative treatment (non-operative group, nog) or primary surgery (splenectomy) (surgical group, sg). postdischarge quality of life was evaluated by a standardized telephone questionnaire. data are reported as total numbers (%) and statistical analysis performed using chi2-tests. significance was assumed if p < 0.05. results. of a total of 48 patients enrolled, 27 (56.24%, nog) were treated non-operatively, and 21 (43.75%, sg) underwent splenectomy. splenic injury grading was comparable between both groups. after trauma, most patients were able to leave their bed three days after trauma (3 rd postoperative (po) day: nog 18 (66.67%) vs. sg 12 (57.14%), p ¼ 0.353; 1 st week po: nog 6 (22.22%) vs. sg 3 (14.29%), p ¼ 0.377; 2 nd week po: nog 3 (11.11%) vs. sg 5 (23.81%), p ¼ 0.217), and the majority felt seriously ill during hospitalization (critically ill: nog 9 (33.3%) vs. sg 12 (57.14%), p ¼ 0.087; seriously ill: nog 11 (40.74%) vs. sg 6 (28.57%), p ¼ 0.286; not very ill: nog 7 (25.93%) vs. sg 3 (14.29%), p ¼ 0.268). unlike sg patients, about half of the nog patients could be discharged one week after trauma (1 week: nog 12 (44.4%) vs. sg 4 (19.05%); p ¼ 0.060). sg patients significantly longer felt severe pain compared to nog patients (2 weeks: nog 12 (44.44%) vs. sg 3 (14.29%), p ¼ 0.025; >3 months: nog 1 (3.7%) vs. sg 7 (33.33%), p ¼ 0.009). after discharge, nog patients were able to resume daily life activities earlier compared to patients after surgery (2 weeks: nog 6 (22.22%) vs. sg 1 (4.76%), p ¼ 0.096; <1 month: nog 18 (66.67%) vs. sg 8 (38.10%), p ¼ 0.046; !3 months: nog 3 (11.11%) vs. sg 12 (57.15%), p ¼ 0.281). conclusions. patients with non-operative management reported less pain and were earlier able to resume daily life after splenic trauma compared to patients undergoing splenectomy. plantation in order to prevent cmv disease. we recently evidenced immunomodulatory properties of pooled human immunoglobulines. the aim of this study was to evaluate influence of cytotect + and cytoglobin + a) on proliferative properties of peripheral blood mononuclear cells (pbmcs), b) on cell viability and c) on natural occurring cell mediated cytotoxicity. methods. pbmcs from healthy donors (n ¼ 10) were stimulated with anti-cd3 (10 mg=ml) or in an allogeneic mixed lymphocyte reaction (mlr). proliferation was determined by incorporation of 3[h]-labeled thymidine. apoptosis was measured by flow cytometric analysis (annexinv, 7-aad, cd4, cd8, cd19, cd56). transmission electron microscopy (tem) was utilized to support facs data. antibody dependent cell mediated cytotoxicity (adcc) was determined utilizing a standard europium release assay. cmvig (cytotect + biotest, cytoglobin + bayer) was used at therapeutic concentrations in all experiments. results. cytotect + and cytoglobin + evidenced anti-proliferative properties in t-cell specific stimulation and in mlr blastogenesis assays. this effect was dose dependent and ceased at concentrations of 0.031 mg=ml (p < 0.005). facs analysis and tem pictures revealed that the reduced proliferation was associated with induction of apoptosis in stimulated as well as in resting pbmcs (p < 0.05). furthermore, adcc against panc-1 and jurkat cell lines was significantly reduced after preincubation of effector cells with cmvig (p < 0.001). conclusions. our results provide evidence that cmvig containing drugs possess, in addition to their known application as passive cmv immunization, immunological features related to tolerance induction. background. multichannel intraluminal impedance (mii) monitoring is a new diagnostic tool for esophageal bolus transport and reflux assessment. methods. review on mii technology for diagnosis of esophageal disorders. results. impedance is a measure of resistance to the flow of an alternating electrical current. a low voltage current is applied to surface ring electrodes on a nonconductive catheter. impedance is determined by the conductivity of the medium bridging these electrodes. entry of liquid into the esophageal lumen produces a drop of impedance. gas entry results in a sudden rise of impedance. monitoring impedance in several channels detects direction, velocity and extent of the movement of liquid or gas through the esophagus. stationary equipment combining manometry and impedance is used for simultaneous esophageal motility and transit studies. transport studies using impedance only can also be done with probes intended for reflux testing. saline and a viscous gel are used to assess transport through the esophagus. in a recent study with combined impedance and manometry a significantly higher proportion of patients with incomplete transport of both liquid and viscous boluses (32=56, 57%) presented with dysphagia than patients with complete transport of both (50=216, 23%) or incomplete transport of only one (21=69, 30%) of the test substances. equipment joining impedance with high-resolution manometry is currently being developed. a higher sensitivity and specificity for regional motility and transport abnormalities is to be expected from this technical advancement. portable recorders are available for 24-hour mii-and ph-monitoring. refluxes are detected by retrograde impedance changes: liquid refluxes are characterised by retrograde drops, gas refluxes by rapid increases and mixed liquid=gas refluxes by a sequence of both deviations from the baseline. the main advantage of impedance technology over conventional ph-monitoring is the detection of refluxes independent of ph. off antisecretory medication refluxes with ph > 4 are mainly encountered postprandially, at a time when regurgitation is commonly experienced by reflux patients. the diagnostic yield of symptom to reflux association analysis is significantly increased by the inclusion of refluxes with ph > 4. distribution of impedance channels along the catheter facilitates the calculation of reflux exposure at different levels above the lower esophageal sphincter. conclusions. mii is a valuable new diagnostic tool for esophageal transport assessment without radiation exposure. combined mii-and ph-monitoring significantly increases the diagnostic yield of reflux testing. both applications of impedance technology have implications on surgical decisionmaking. 146 trans-illuminated powered phlebectomy w. mayerhoffer the trans-illuminated powered phlebectomy was introduced in austria in about 2000 by smith and nephew as the ''trivex system''. a 3.5 mm shaver, as used by orthopaedists for cartilage, was used in order to mill out subcutaneous veins in a transilluminated technique. due to only a few and small incisions needed, the method seemed very attractive, so many surgical departments started using this orthopaedic equipment. most surgeons had a lot of complications, such as disastrous extensive haematomas, which made them stop using this method. mean while the trans-illuminated powered phlebectomy has been further developed. instead of the orthopaedic tools, a special phlebologic equipment is used now which allows the vein to be ''sucked'' out in a very non-traumatic order, instead of being milled out. the procedure is standardized and can be reproduced easily. it shows to be a non-traumatic and minimal invasive method to extract subcutaneous varicose veins, leaving a minimum of scares. large clusters of varicose veins are the best indication to use this procedure. the veins are made visible by transillumination in order to be accurately removed through a minimal number of small incisions. the new equipment and the technique will be described and explained. examples and results will be shown. background. total endoprosthesis in wrist joint is a rather new procedure compared to hip and knee surgery. biomechanics of the wrist joint is very complex and therefore designing the carpal and radial component of the prosthesis should respectfully consider this. indication for joint replacement and total endoprosthesis are posttraumtic and degenerative arthrosis of wrist joints. generally we tend to perform a partial fusion depending on where the arthrosis is located, but we have stopped to perform total arthrodesis of the wrist joint due to unsatisfying long term results, according to literature. we perform total endoprosthesis in all cases when a partial fusion is impossible for any reason or a total arthrodesis would be indicated. methods. nine males [55-72a] four females [56-67a]. seven of nine men suffered from a posttraumatic arthrosis (4 slac 3 snac). all patients sufferd from serious reduction of range of motion and severe pain. in one case a partial fusion was converted into a total prosthesis. two women had degenerative alterations of their wrists based on rheumatoid desease. the follow up covered 6 months to 2 years. results. in 11=13 cases range of motion was improved impressively and pain was relieved almost completely. seven men displayed a rom of s50=0=40; pro-supination totally unaffected and free. in one case we found rds. x-ray examination revealed a slightly false implant position of the radial component to us. rom in women was at least s60=0=40. conclusions. in the beginning of wrist joint endoprosthesis results were less well and it was shown that this was due to misunderstanding biomechanical basics of the wrist joint. the fixation of the carpal element was a severe problem, like passing through the cmc 3, 4 and 5 joint line distally into the basis of the metacarpal bones and since cmc 4 and 5 joints have a rather high rom the distal element consequently often loosened immediately. recent implants respectfully avoid passing through these joints and loosening of the distal element has never been seen in all our cases. in our opinion the endoprosthesis of wrist joint is a real alternative to common procedures in the treatment of wrist arthrosis. background. volar fixed-angle plate osteosynthesis of distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without incurring the disadvantages of the dorsal approach. the aptus + plate is a new fixation implant that was introduced specifically for the purpose of managing dorsal displaced fractures (colles fracture) from the volar aspect. the aptus + system provides stepless multidirectional placement of screws. the range of swivel ae15 in all directions, can be freely selected by the surgeon. methods. between april and september 2005 (6 months) we have seen 753 patients with a distal radius fracture. eighty five patients (55 women, 30 men; mean age 58.4 years) were treated with the medartis + aptus + plate. our therapy regimen: closed reposition in the operating room palmar access along the radial side of the flexor carpi radialis (fcr) muscle plating with subchondral screw placement begin of physiotherapy on the first postoperative day and removeable orfit splint for 5 weeks. results. the clinical and radiological follow up after ø 7 months showed no secondary loss (relative protrusion of the ulna, dorsal or radial tilting) of correction. compared to the contralateral side the range of motion was decreased for 19% in extension=flexion, 11% in ulnar=radialduction, 7% in pronation=supination. the grip strength was decreased for 35% compared with the contralateral side. the castaing score shows 30 perfect results, 49 good results, 1 adequate result and no moderate, poor or bad results. conclusions. our data clearly show that secondary correction loss can be avoided with the aptus + system. the system provides a reliable subchondral screw placement and solid support for the joint surface. this new plate makes meaningful early mobilization possible. the palmar approach provides exact fracture reposition and with its good soft-tissue coverage not only reduces the risk of infections but also offers the possibility of not having to remove the plate. a cancellous bone graft is not necessary. background. the arthrosis of the first carpometacarpal joint is one of the most common problems in handsurgery. primarily elderly women are affected by rhizarthrosis. under conservative treatment the continuing progress leads to operation indication, for pronounced pain and insufficiency of conservative therapy options. the huge amount of well-know operation methods shows, that no satisfying option could have been described. next to simple resection procedures, today interposition and suspensionarthroplasties play a key role in the care of arthrosis of the thumb saddle joint. the amount of endoprothetic procedures in the first carpometacarpal joint has been rather small, the results often remained unsatisfying. a rather new concept is the prosthesis elektra, developed by fixano in 2002, that reminds of the classic de la caffiniere prosthesis, first described in 1974. methods. in the years 2004=2005 in our department 51 patients (ø 56.3 years 38-76, male:female ¼ 42:9) with advanced saddle joint arthrosis were treated with different operation methods: 26 patients received an elektra-prosthesis, 25 patients a resection-suspension arthroplasty martini. thirty seven of these were recorded in the follow-up study. the rest of the patients were deceased, removed or not accomplishable. the follow up examination contained following criteria: dash score, subjective pain scale, range of motion and radiology. results. in the follow-up examination of 37 patients no significant differences in average results of the different operation methods could be investigated. thus, the group of patients with very good results contained significantly more patients with elektra prostheses than patients treated with martini operation. in the opposition a higher complication rate could be seen in patients with elektra prostheses. especially the loosening of the implant cup was a frequent complication in average dash score, subjective pain scale and range of motion showed similar results in both methods. conclusions. our results show that the elektra prosthesis is a good and efficient alternative method to other well-known treatment concepts of rhizarthrosis. the amount satisfying results of the elektra group excel the good results in the martini group. the biggest problem concerning the elektra prosthesis is the high frequency of cup loosening, that is unacceptable high. the treasons for that matter could be complex: 1. biomechanical problem, because of the converting of a saddle joint to a universal joint, 2. metallurgic problem that could be solved by the use of different surface material, 3. vitality problem of the os trapezium because of an unfavourable quotient of metal and bone. unsettled remains, if revision or cementing of the cup could be a possibility to salvage of the implant. a conversion of the procedure to resection methods is possible anytime. so the use of the elektra prosthesis still is a good alternative under the condition of a clear indication and information of the patient about the possibilities of loosing. background. posttraumatic arthrosis as well as loss of function in the pip joint due to rheumatoid disease mean for the patient to be afflicted with pain. in many cases this leads to serious diminution of quality of life and in some cases the patient looses his occupation. it is the goal of implantation of total endoprosthesis to sustain movement and improve the range of motion, but most importantly to exterminate the pain. certainly removement of pain can be obtained by a simple arthrodesis but this of course is less satisfying in comparsion with mobility in the pip joint provided by the prosthesis. since pip joint endoprosthesis is a relativley young and new procedure there are only view experiences found in literature. methods. nine pip-endoprostheses have been implanted without cement so far. in 6 cases posttraumtic arthrosis was the indication for this procedure; in 3 cases rheumatoid destruction of the joint. in all cases the collateral ligmantes were intact. four lpm and 5 sr avantas were used. postoperative the finger was placed on a splint for one week in intrinsic plus position. after 4 days we commenced passive ergotherapiy and after one week we started with active motion. results. mobility was improved impressively in 5 cases. all patients were almost completely free of pain. all pipjoints were stable. there was one patient who suffered from a new trauma after the operation and the proximal component had gotten loose, so we had to convert it to an arthrodeses. in 4 cases we found a significant loss of extensor tendon function. conclusions. development and design of pip endoprosthesis has not found its final goal; this can be told by the variety of pip-joints which are found in the free market. passing throgh the extensor tendon is a sensitive point in the procedure and it should be noted in the preoperative information that there might be a decreased extensor tendon function. nevertheless in our eyes the pip prosthesis represents an intersting alternative to pip-arthrodesis and in cases of failure of the prosthesis it can be easily converted into a classical arthrodesis. 151 osteosynthesis of proximal humeral fractures using a dynamic angular stable plate e. aschauer 1 , l. schmid 1 , c. maier 2 1 unfallchirurgie, bad ischl, austria; 2 fa. hofer, fürstenfeld, austria background. fractures of the proximal humerus are frequent and represent a therapeutic problem. the proximal humerus plate of the dfd system (double-fix-dynamic) fixes the fragments angular and rotational stable and is implanted minimally invasive. a special instrument allows precise closed reduction. due to the dynamic character of the osteosynthesis bone healing is stimulated. methods. two plates are connected with short screws in linear holes so that they can move against each other. the head fragment is fixed to the main plate with 3 long screws coming steeply from distally. the dynamizing plate fixes this situation to the humeral shaft. for implanting the plate is fixed to a guide instrument, which therefore can be used as a joy-stick. so it is possible to reduct the shaft to the head exactly. to implant the dfd only two small incisions are required. one of 4 cm to slip the plate under the delta muscle and to insert the head screws. and a second of 1 cm proximally to fix the guide instrument and insert the shaft screws. in bad ischl the dfd-php is in use since november 2004. up to now 63 patients were operated. fourty three were female, 20 male. the average age was 69.8 years (19-100). in 25 cases it was a dislocated subcapital fracture. nineteen had a threepart-, 9 a fourpart fracture. four fracture dislocations and 2 true headsplits also could be done with closed reduction on this technique. four fractures were located at the anatomical neck. results. our first experiences were very well. currently we cannot report any complications due to the implant. there was no loosening or breakage. we watched no loss of reduction. noticeable was lack of pain immediately after the operation. so the patients came back to their former level of activity very fast. our complications were one infection forcing us to remove the implant -the case came to an end in pseudarthrosis which the patient bears well. another lady suffered a repeated fracture caused by a slight injury. one pseudarthrosis happened due to too early removal. conclusions. with the dfd-php now an implant is available that enables us to expand the indications for head preserving therapy of proximal humeral fractures. especially older people benefit from this method because there is hardly soft tissue damage but nevertheless a reliable stable situation that leads to bone healing in correct position and a good shoulder function. background. treatment of unstable distal metaphyseal tibial fractures with intramedullary nailing remains challenging even in fractures without intra-articular involvement. proximity to the ankle and biomechanical aspects makes the surgical treatment more complicated compared to fractures of the midshaft. intramedullary nailing (imn) is the ''golden standard'' for midshaft fractures but can be challenging in distal metaphyseal fractures. therefore, optimal surgical treatment of these fractures remains controversial. the aim of our study was to evaluate 4 different tibial nails of the newest generation in a biomechanical approach. methods. defined osteotomy was performed in 12 sawbone composite tibial fractures to create an unstable distal tibial fracture model. after nail insertion, distal tibial locking was performed with 3 or 4 locking screws. samples were cyclically loaded with 60,000 cycles and increasing load from 700 ae 600 n to 1400 and 2600 n. defined parameters such as alignment, varus, valgus deformation, antecurvation and recurvation were recorded. samples were then statically loaded until failure. acoustic emission technique was used to detect microfractures of bone, screws and nail. data according to failure of screws and nail were obtained. results. in case of physiological loading (20,000 cycles; 700 ae 600 n) loss of stability and damage of screws, nails and bone could not observed. failures occurred in loading series. stiffness was significantly higher in tibial nails with 4 distal locking screws. stability of nail-bone construction was significantly higher in nails with 4 distal locking options and in nails with diameter of distal locking screws more than 4 mm. conclusions. intramedullary nailing can be recommened in unstable distal metaphyseal tibial fractures without intra articular involvement. four distal locking screws with 4.7 mm diameter should be used. our data suggests that immediate full weight bearing is possible postoperatively in young healthy patients without osteopenia even in this fracture type. because of the rising number of implantation rates of hip and knee arthroplasty as well as the increase number of osteosyntheses of the femur in geriatric patients the periprosthetic fractures are becoming more importance in orthopedic and trauma surgery. osteoporosis and the high rate of comorbidity makes a strong preoperative planning of the operation procedure necessary. prosthesis loosening or defects of the periprostetic bone may indicate a revision arthroplasty. in the new literature ostheosynthesis is usually conducted with locked screw plates as well as with intramedullary locking nail systems. a traditional alternative is the application of a 95 condylar plate. usually used in trochanteric and subtrochanteric fractures of the proximal femur as well as in complex distal femur fractures it is also an effective implant system in periprosthetic fractures. several examples are shown and discussed. we respect to the classification of periprostetic fractures of johanson in our report about 25 patients. six of them underwent a revision arthroplasty and in 19 cases an osteosynthesis was done. five of them include the implantation of a 95 condylar plate. 156 the improved trauma room management by installation of a four-phase watch g. fronhöfer, m. kerl background. since 2001 the parameters of the severe traumatised patients of the trauma hospital graz have been collected and analysed at the trauma register of the dgu. according to the recommendation of the dgu a special four-phase watch was installed in 2006 to improve the effectiveness of the diagnosis and treatment process optimize in the trauma room. methods. the watchface has the typical colour coded phases and a flipchart shows the prepared standard sequence of trauma room management which has been developed interdisciplinary by surgeons, anesthetists, radiologists and carers. the parameters and the time process are further documented according to the guidelines of the trauma register of the dgu. results. the timelapse to x-ray or ct is reduced, the diagnoses are found quicker and patients can therefore be treated earlier at their adequate therapy. the motivation of the medical team is increased. conclusions. the four-phase trauma room watch has a many advantages and as recommended by the dgu should be installed in each trauma room. background. the treatment of an acute abdomen is without a doubt a domain of the surgical department. there are already specific treatment algorithms in place. due to the ever-present pressure to keep costs to a minimum, as well as the ever-changing technical advancements of diagnostics, it is vital to re-think and possibly modify existing treatment algorithms. therefore, patients in our facility were analyzed. methods. in erlangen, 444 patients with an acute abdomen were treated in the timeframe from january 1, 2004 to december 31, 2005 . the average age was 54 years, and the ratio males:females was 1:1.094. all data were collected prospectively through patient histories as well as clinical documentation. consequently, they were retrospectively evaluated. following the case history, labarotory tests and physical examination, sonography of the abdomen was used as the baseline diagnostic modality, as well as conventional radiography of the abdomen. results. of the 444 treated patients, only 187 (42%) required surgery. the average length of stay was 7 days. in 78 patients, a clinical diagnosis of appendicitis was made. in 74% of these patients, the confirmation of their diagnosis could be made, using the baseline diagnostic modalities. for the rest of the patients, further diagnostic modalities were needed (such as ct). in 117 patients, a primary diagnosis of coprostasis was made. in 55% of these patients, a conservative treatment could be offered, and the patients left our facility without symptoms. in 45% of the patients, further diagnostic modalities (radiological and=or endoscopic) showed a finding that required surgical attention. conclusions. in the normal=routine clinical picture of appendicitis, baseline diagnostics are sufficient. however, behind apparently harmless diagnoses such as coprostasis, there are serious illnesses that may be masked. therefore a different course of action must be considered (ct). as a possible side-effect of this course, patients without pathological manifestations could be treated on an out-patient basis, thus reducing total costs. background. the aim of the study was to investigate: i) relevant and combined determinants of the development, management and outcome of a representative patient cohort (n ¼ 9.991) with acute appendicitis enrolled in a prospective unicenter study through a time period of 27 years (middle europe), and ii) the frequency and impact of specific categories (e.g., characteristics of the medical history, clinical and intraoperative findings, complications), correlation and relative risk factors of the disease and its prognosis. methods. by the mean of a prospective unicenter observational study, numerous characteristics as mentioned in the ''aims'' were documented and influencing variables with significant impact on the outcome were statistically determined. results. 1) the wound abscess rate was 10.9%. perforation, surgical intervention on time, acute, gangrenous and chronic appendicitis, age, adverse diseases such as obesity, arterial hypertonus, diabetes mellitus, sex and missing pathological finding intraoperatively showed a significant impact on the postoperative development of a wound abscess. 2) the longer the specific appendicitis-related medical history lasted, the i) more frequent a perforated appendicitis occurred (interestingly, this rate significantly increased up to 13.1% through the various time periods), ii) greater the false-positive appendectomy rate was (p < 0.001), and iii) higher the rate of the required second (subsequent) interventions was (4.3%; p < 0.001), which occurred significantly more often in obesity (6.5%) and wound abscess (5.8%). 3) the mean postoperative hospital stay was 11 days. 4) there was a significant decrease of the percentage of patients with no pathological finding of the ''appendix vermiformis" intraoperatively, who underwent appendectomy, in particular, to only 6.8% through the last investigation period from 1997 to 2000 (1974-1985, 15.5%; 1986-1996, 10 .3%). 5) the mortality was 0.6% showing no significant difference between male and female patients (p ¼ 1.0), between the 3 investigation periods (p ¼ 0.077) and between the patients with false-positive appendectomy (0.4%) and that with acute appendicitis (0.6%; p ¼ 0.515). conclusions. in summary, this study demonstrated a substantial progress of the quality of surgical care within the participating clinics with regard to the rates of false-positive appendectomies, of postoperative wound abscesses and, in particular, to mortality, one of the strongest criteria of quality control. despite this, there is an increasing rate of perforated appendicitis in the investigated cohort. in conclusion, quality control remains an indispensable tool for evaluation and assessment of surgical care even in the most frequent diseases of the daily practice, which can be further improved by a multicenter study setting. 159 acute mesenteric ischaemia -looking at the past, learning for the future e. schröpfer, a. thiede, t. meyer background. acute mesenteric ischaemia (ami) is a rare disease with still -despite all progresses in medicine -a high mortality rate ranging from 70 to 90% according to literature. the aim of this study was to analyse the outcome of our patients after traditional therapy, in order to be able to conduct new strategies of treatment. methods. in this retrospective study all clinical reports (since 03=2003) containing the diagnosis ami (icd10: k55.0) were analyzed with regard to initial laboratory findings, pre-operative diagnostics, surgical methods, intra-operative results, etc. results. the diagnosis ami was encoded for 69 patients in the aforementioned period of time. twenty patients had to be excluded from the study, due to other collateral diseases. among the remaining 49 patients (with an average age of 70.2 years) 30 died initially (initial mortality 61.2%). the main risk factor (51.0%) was arrhythmia absoluta. 32.7% of the patients presented the symptoms of an acute abdomen, 24.5% were suffering from progressive abdominal pain. besides anamnesis, physical examination and laboratory only 20.4% of the patients obtained an abdominal ct and 10.2% obtained a dsa. because of the unambigousness of the anamnestic and clinical findings 18.4% of the patients received an immediate explorative laparotomy without any further diagnostic. conclusions. despite the typical triphasic progression of the ami (intense abdominal pain -apparent recovery -acute spreading peritonitis) and all modern possibilities of diagnostics the mortality rate of ami is still appallingly high. looking at the past, diagnostics as well as therapy should be included in modern findings and open up new possibilities. bckground. data are rare about the impact of infection on postoperative mortality in an unselected surgical population. aim of the study was to analyze whether infection is a significant cause of death in these patients. methods. at a department of general, vascular and thoracic surgery in a secondary to tertiary referral centre, all patients operated from 1=05 to 9=06 (n ¼ 6101) were included in a prospective database and analyzed retrospectively. overall mortality rate 1.26% (n ¼ 77 (38 abdominal, 33 vascular, 6 thoracic surgery)). 71.4% emergency -28.6% planned operations. cause of death was defined by clinical chart review and post mortem section. stratification criteria (sex, age group, asa, malignancy, infection prior to surgery, abdominal surgery, emergency operation) were analyzed by multivariate regression analysis. results. cause of death: n ¼ 34 (44.2%) infection, n ¼ 28 (36.4%) cardiovascular, n ¼ 13 (16.9%) progression of malignancy, n ¼ 2 (2.6%) pulmonary embolism. subgroup analysis of postoperative death due to infection revealed that 55.9% (n ¼ 19=34) of patients had infection already prior to surgery and 44.1% (n ¼ 15=34) developed postoperative lethal infection. mortality caused by infection was 60.5% (n ¼ 23) in abdominal, 24.2% (n ¼ 8) in vascular and 50% (n ¼ 3) in thoracic surgery. regression analysis identified infection prior to surgery (p ¼ 0.000) and abdominal surgery (p ¼ 0.018) as statistically significant independent risk factors for postoperative mortality due to infection. conclusions. postoperative mortality is highly associated with infection. in an unselected cohort of surgical patients those presenting with infection prior to surgery and those undergoing abdominal surgery are at highest risk of death from infection. 162 management of complications in laparoscopic colo-rectal surgery m. hufschmidt, u. obwegeser, a. haid, e. wenzl background. laparoscopic colo-rectal surgery is considered to be a standardized procedure for the two main-indications: diverticular disease of the sigmoid colon and complicated crohn's disease of the ileo-cecal region. moreover these procedures seem to have served as a sort of pacemaker to so-called fast-track-protocols. while the extension of laparoscopic procedures to oncological indications is in a wide-spread controversial discussion, only few publications are considering the impact of complications in the outcome of surgical therapy of benign diseases. methods. a retrospective study of 106 laparoscopic colorectal procedures performed between 08=2001 and 01=2007 was undertaken. indications and technical approaches as well as rates of conversion, duration of intervention and hospital-stay are detailed. complications leading to relaparotomy, interventional or conservative therapy are reviewed in detail to analyse their reasons. results. with a conversion-rate of 4.8%, a mortality of 1.8% and an overall morbidity of 22.3% the occuring complications may be categorised in different groups, distinguishing intra-operativly, early or late, major or minor and procedurerelated or intercurrent-ones solicitating either conservative, interventional (5.9%) or surgical (5.9%) treatment. several causes are being isolated such as learning-curve, body-mass-index, comorbidity, sequelae of previous operations and severity of intraoperative findings. conclusion. as for conversion, complications influence parameters as hospital-stay or feasibility of fast-track-protocols somewhat watering the advantageous results of laparoscopic colo-rectal surgery. a careful analysis is therefore advisable not only to avoid reiterating complications but also to permit the access to oncological colo-rectal laparoscopic surgery as well. background. the value of quality control in general surgery is actually soaring. unplanned reoperation is seen as one of the most important quality measures. however, there is a lack of data regarding the impact of infection as an indication to unplanned reoperation. methods. at our department of general (including kidney transplant), vascular and thoracic surgery in a secondary to tertiary referral centre, all patients undergoing unplanned reoperation from 10=04 to 08=06 were included in a prospective database. unplanned reoperation was defined as unplanned return to the or within 30 days during hospitalization. targets were unplanned reoperation due to infection, type of infection, type of primary surgery, mortality and a comparison to a former data collection from 01=03-09=04 after starting a monthly review of reoperation data in terms of a morbidity-=mortality conference 10=04. results. one hundred and thirty nine (2.16%) of 6399 patients were undergoing unplanned reoperation. 40 (28.8%) due to infection, 43 (30.9%) due to postoperative bleeding and 56 (40.3%) due to other indication. subgroup analysis of those reoperated due to infection identified leakage of the anastomosis in 50% (20=40) and abdominal wall rupture in 22.5% (9=40) as predominant causes to reoperation. other indications to unplanned reoperation were small bowel perforation (4=40), abscess (2=40), leakage of ileostoma (1=40), thoracical phlegmon (1=40), ureter-necrosis (1=40), recurrent infection of lung parenchyma (1=40) and superficial surgical site infection (1=40). mortality in the infection subgroup was 7.5% (3=40) compared to 8.6% (12=139) of all reoperated patients. overall mortality was 1.2% (79=6399). furthermore we could achieve a decrease of mortality in infection subgroup from 20 to 7.5% comparing to our former data collection of 01=03-09=04. an additional analysis of infection germs was not striking. conclusions. postoperative infection is the underlying mechanism leading to reoperation in a significant number of patients. data analysis showed a much higher mortality in these patients. the reported decrease of mortality from 20 to 7.5% maybe attributed to the consequent prospective monitoring and monthly review of reoperation data we had introduced 10=04. 164 gallstone-ileus -nowadays still a remaining important differential-diagnosis to consider at presence of acute abdominal pain r. hammer 1 , p. habertheuer 1 , w. brü nner 1 , c. bauer 1 , n. schreibmayer 2 , f. flü ckiger 2 , p. steindorfer 1 1 department of surgery, lkh graz-west, graz, austria; 2 department of radiology, lkh graz-west, graz, austria background. 1-3% of all mechanical obstructions in small bowel are represented by gallstone-ileus as a complication of cholelithiasis. as it is frequent in the elderly population (it accounts for almost 25% of non-strangulated intestinal obstruction in patients >65 years), there is a high mortality-rate of 10-15% depending on age and co-morbidity. in less than 1% of patients with gallstones cholecystoenteric fistula occurs (most likely cholecystoduodenal in 60%, cholecystocolic, cholecystogastric-and cholecystodochoduodenal have also been described). methods. between october 2002-december 2006 we performed cholecystectomy on 776 patients and laparatomy on 505 patients due to mechanical obstruction of the small bowel. the frequency of gallstone-ileus can be reported on 10 patients, which underwent surgery due to intestinal obstruction because of gallstones. one recurrence of gallstone-ileus due to the lack of exploration on finding massive postinflammatory adhesions and adherence of the major omentum was seen. in all patients clinical evidence of intestinal obstruction detected pneumobilia as well as ectopic gallstones was confirmed by either plain x-ray or ct-scans. results. at our department a frequency of 10 patients (average age 78.5 yrs (range 64-84 yrs) 2 males, 8 females) presenting with gallstone-ileus (in a total of 776 patients undergoing cholecystectomy and 505 patients undergoing laparotomy due to small-bowel-obstruction) were treated, that means a rate of gallstone-ileus in 1.28% (10=776) compared to the patients with che, and 1.98% (10=505) in 505 laparotomies due to small-bowel obstructions performed at this period. all patients underwent an one-stage operation, in 6 cases consisting of enterolithotomy and stone-extraction as single procedure only (without dismantlement and exploration of the fistula), in further 5 cases cholecystectomy and suturing of the entero-biliary fistula synchronously were additionally performed. the obstruction occurred 2 â duodenal, 4 â jejunal and 5 â ileal, the location of the fistula situated duodenal in 7 times, once jejunal and 3 â non-explored. the diameter of the obstructing stone varied between 3 and 7 cm (average of 4.3 cm), 9 patients recovered well, one expired because of the development of ards. conclusions. gallstone-ileus is a rare diagnosis, nevertheless it should still be kept in mind and considered as important differential-diagnosis in acute abdominal pain as shown on the numerous cases at our department. for reducing perioperative mortality the treatment has to be adapted on patients conditions, if necessary performing enterolithotomy as a single procedure only, and considering to correct the fistula in a second procedure on symptomatic patients. in the program of the austrian surgical convention 19 different working groups and specialised societies are listed up, stating that the specialisation in surgery is increasing. however, the question remains, which fields of specialisation are realistic for a general surgical department with a limited staff? in the last 20 years a main focus of interest has been established for the following fields: endoscopy: gastroscopy, sigmoideoscopy, colonoscopy with interventions is performed by all, ercp by two surgeons of the staff. minimal-invasive surgery: choleystectomy, appendectomy, hernia surgery is performed by all surgeons, colon resections, gastro-oesophageal surgery by three of the staff. endocrine surgery: surgery of the thyroid and parathyreoid gland by three surgeons. specialized breast surgery: such as oncoplastic surgery and breast reconstruction by two surgeons. varicositas surgery: crossectomy and stripping, evlt, trivex, venocuff by two surgeons. the development of specialization in a general surgical unit will be presented. methods. review on cle. results. due to reflux esophageal squamous epithelium is damaged and replaced by cle, which is of esophageal origin and interposed between squamous and gastric oxyntic mucosa (om). the paull-chandrasoma histopathology cle classification includes oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) without or with intestinal metaplasia (im ¼ barrett esophagus). via low (lgd) and high grade dysplasia (hgd), im may progress towards eso-phageal adenocarcinoma (ac; annual incidence 0.2-2.0%). presence of cle is associated with pathologic esophageal acid exposure and impaired esophageal motility and dysfunction of the lower esophageal sphincter, as assessed by ph monitoring and esophageal manometry, respectively. cle without and with im is assessed in 100 and 14-30% of symptomatic gerd patients, respectively, irrespective of presence or absence of endoscopic visible cle. surveillance endoscopy and biopsy sampling are recommended after 3-5, 2-3 and 0.5 years for cm, im and lgd, respectively. treatment of hgd and ac stage ia include endoscopic mucosal resection or esophagectomy. esophagectomy is recommended for ac > stage ia. recent studies indicate that antireflux surgery may reverse im and low grade dysplasia (lgd). seven years after ph-monitoringproven effective (n ¼ 49), but not ineffective (n ¼ 9) nissen fundoplication, im reversed towards cm without progression towards ac. fourty months after nissen fundoplication and bile diversion (n ¼ 78), 60% regressed from im to cm, 40% remained at im. 2.5 years after gastric bypass (n ¼ 15), im-patients regressed (n ¼ 8) or had im (n ¼ 7), none progressed. a recent study compared the effect of proton pump inhibitor (ppi) (n ¼ 19) vs. fundoplication (n ¼ 16) in patients with cle containing low grade dysplasia (lgd). eighteen months after ppi treatment and fundoplication, 12 out of 19 (63.2%) and all out of 16 patients, respectively, reversed from lgd towards intestinal metaplasia. conclusions. cle is defined by histopathology. evidence justifies to investigate impact of effective fundoplication on cle within prospective studies. background. during endoscopy the stomach is considered to commence at the level of the rise of ''gastric'' rugal folds. anatomy studies suggested that rugal folds may contain columnar lined esophagus (cle), the morphologic consequence of gastroesophageal reflux disease (gerd). we investigated the histopathology of endoscopic ''gastric'' rugal folds in gerd patients. methods. seventy-five consecutive gerd patients (34 males), age: 51 (23-80) years, prospectively underwent endoscopy, including biopsy sampling from the endoscopic esophagogastric junction (egj): 0, 0.5, 1.0 cm distal and 0.5 and 1.0 cm proximal to the rise of the rugal folds. cle was cataloged according to the histopathologic paull-chandrasoma classification. results. normal endoscopic esophagogastric junction, visible cle 0.5 and >0.5 cm was assessed in 33 (44%) and 37 (49%) and 5 (7%) patients, respectively. histology: all patients had cle at the level of rise of the ''gastric'' folds. in 33 and 85% of patients cle extended 1.0 and 0.5 cm, respectively, distal to the rise of the rugal folds. gastric oxyntic mucosa was not assessed above the level of the rise of rugal folds. intestinal metaplasia (¼ barrett esophagus) was assessed histologically in 14 (19%) patients. conclusions. regarding the diagnosis of cle, the esophagogastric junction (egj) cannot be assessed by endoscopy, but by histopathology (i.e. level of transition from cle towards gastric oxyntic mucosa). presence or absence of barrett esophagus can not be excluded by endoscopy. histopathology of multi level biopsy sampling should be considered for definition of egj and exclusion of barrett esophagus in gerd patients. 185 pre-clinical trial of a modified gastroscope that performs a true anterior fundoplication for the endoluminal treatment of gerd background. laparoscopic fundoplication provides good reflux control but side effects due to the surgical procedure are known. different endoluminal techniques have been introduced but all with disappointing results. evaluation of the feasibility and safety of a new device, that enables a totally endoluminal anterior fundoplication for the treatment of gerd. methods. the device is a modified video gastroscope, which incorporates a surgical stapler (using standard 4.8 b shaped surgical staples) and an ultrasonic sight. the cartridge is mounted on the shaft and the anvil is at the tip. this enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and the cartridge. sixteen female swine of mixed breed were used in the study, 12 underwent the endoscopic procedure, and 4 were used a controls to monitor weight gain. the 12 study animals were sacrificed at 2, 4, and 8 weeks (4 pigs each time) and visually inspected for complications, healing and fundoplication. the study was sponsored by medigus ltd. and monitored for compliance with glp regulations by an external company (econ inc.), which is glp certified by the german federal government. it was conducted at the animal testing facility of the charite virchow clinic in berlin. results. the procedure went smoothly in all pigs, median procedure time was 12 min (range 9-35 min). at sacrifice the stapled area had healed well, all animals had a satisfactory 180 anterolateral fundoplication, and there were no procedure related complications. conclusions. creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. proof of efficacy must await clinical trials, which are underway. 186 design and instrumentation of new devices for performing appendectomy at colonoscopy g. silberhumer 1 , e. unger 2 , w. mayr 2 , t. birsan 1 , g. prager 1 , j. zacherl 1 , c. gasche 3 background. appendectomy is the most common operation in the gastrointestinal tract. there is increasing interest in interval appendectomy as a treatment for refractory ulcerative colitis. a less-invasive flexible endoscopic method for removing the appendix might offer advantages especially for interval appendectomy in patients undergoing colonoscopy. aim: to design, develop and test new devices for removing the appendix via natural orifice transluminal endoscopic surgery (notes). methods. tests were performed on the bench in 11 colons from adult human cadavers. various prototypes were tested, which could be inserted into the appendiceal orifice to its tip and could invert the appendix at its base in a controlled fashion into the lumen of the cecum. the advantage of using a tubular structure as counter force to aid inversion of the appendix was evaluated. after partial inversion the growing strain was relieved by endoluminal incision of the mesenteric side of the appendix. closure methods with endoloops, clips and thread ties were studied. appendiceal resection was completed by snare diathermy leaving an inverted intraluminal stump. results. the position of the appendix was retrocecal in seven cases, pelvic in two, and pre-ileal or post-ileal in one each. the median length and luminal diameter was 85 mm (52-125 mm) and 5.5 mm (3-7 mm), respectively. partial obstruction of the lumen was present in 4=11 cases. it was possible to advance the guide-wires and retraction devices to the tip of the appendiceal lumen in all cases. partial inversion of the appendix was successful in 10=11 tests. the median length of the inverted stump was 13 mm (3-18 mm) . the tension and volume (due to fat deposit) of the mesoappendix was the main reason for incomplete inversion. complete inversion was achieved by endoluminal incision in 10=11 tests. the mean volume of the resected tissue (inverted appendix incl. its mesoappendix) was 6.8 ae 1.9 ccm. conclusions. despite high individual variability, appendectomy at flexible colonoscopy proved to be feasible and relatively easy. new devices to allow appendix inversion were successfully tested. 187 endoscopic necrosectomy -a feasible and safe alternative treatment option for infected pancreatic necroses in severe acute pancreatitis (case series of 18 patients) u. will 1 , r. gerlach 1 , i. wanzar 1 , f. meyer 2 1 department of gastroenterology, municipal hospital, gera, germany; 2 department of surgery, university hospital, magdeburg, germany background. endoscopic necrosectomy of infected pancreatic necroses in severe acute pancreatitis is considered an alternative but minimally invasive treatment option instead of the more traumatic open surgery. the aim of the study was to investigate feasibility and outcome of endoscopic necrosectomy in infected organized pancreatic necroses (iopn). methods. through a 4-year time period, all consecutive patients with symptomatic iopn who underwent this novel endoscopic approach were prospectively documented in a computer-based registry and were retrospectively evaluated (systematic case series). the endoscopic approach comprised: 1. necrosectomy via the transgastric route under eus guidance; and (optionally). 2. additional a) transpapillary stenting of the pancreatic duct; or b) percutaneous drainage if indicated. feasibility was characterized by success rate (clearence=downsizing of iopn, hospital stay) and outcome by complication rate (frequency of bleeding or perforation), mortality and shortterm follow-up. results. from 09=13=2002-03=16=06, 18 patients with symptomatic iopn (maximal diameter, 4-19 cm) who underwent endoscopic necrosectomy were enrolled in the study. sixteen of them (88.9%) were necrosectomized from all nonviable tissue using 1-3 (range) necrosectomies (mean, 1.7). in 2=18 cases (11.1%), iopn were incompletely removed. the pancreatic duct was drained through the papilla because of duct disruption or dilatation in 4=18 cases (22.2%). a percutaneous drainage was placed into fresh, non-organized necroses or because of acute septic problems in 8=18 patients (44.4%). complications occurred in 3=18 subjects (rate, 16.6%): bleeding (n ¼ 2) managed endoscopically; cardiac arrhythmia (n ¼ 1); no perforation. at the time of discharge (mean hospital stay, 21.8 d), i) internal drainage was still in situ (range, 3-8 double pigtails) in 15=18 individuals (83.3%), which was extracted in the post-hospital range of 56-340 d; ii) 17=18 patients (94.4%) were asymptomatic indicated by normal inflammatory laboratory parameters; iii) 7=17 subjects (41.2%) showed no further iopn whereas in 10=17 patients (58.8%), there was a 6-fold (mean) down-sizing of iopn. one patient (5.6%) died from cardiac infarction on the 68th day of hospital stay (intervention-related mortality, 0%). follow-up investigation (range, 12-588 d): 2=18 subjects (11.1%) developed pancreatic pseudocyst, which was endoscopically approached. conclusions. endoscopic necrosectomy combined with endoscopic placement of a internal (transgastric) drainage or transpapillary stent into the pancreatic duct is a feasible and safe treatment option even in the case of extended iopn with large pieces of necrotic tissue. background. leakage and fistulization of the gastrojejunostomy have been the major drawback of gastric bypass surgery since its first description. most authors agree that operative treatment is the mainstay of therapy in all patients with signs of sepsis. however, intestinal contents causing localized infection may impede healing of sutured leaks in some patients and fistulas develop. as the anastomosis cannot be disconnected or exteriorized for anatomical reasons other forms of treatment have to be applied. results. leakage of the gastro-jejunostomy occurred in three patients after gastric bypass and resulted in formation of a fistula; one fistula developed in a patient 63 days after surgery. coated self-extending stents were implanted endoscopically in all patients. enteral nutrition could be started six days later. stents were removed two months after implantation without problems. weight loss and quality of life after stent removal were excellent in all patients. conclusions. in our experience implantation of coated selfexpanding stents represents a very effective and minimally invasive therapy of gastro-jejunal anastomotic fistulas after gastric bypass when surgical repair is not possible. in these cases application of stents allows septic source control without any other intervention. methods. fetal mri studies were performed on a 1.5 t (philips) superconducting unit using a five-element surface phased-array coil, usually after 17th gestational week. no sedation is necessary. in addition to routine t2-weighted (w) sequences, t1w sequences (mainly to demonstrate meconium-containing bowel loops), t2 ã w-sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusionweighted sequences (for further tissue characterization) were done. results. one hundred and twenty-six fetuses with extra-cns malformations, prenatally examined with fetal mri, had postpartal or postmortal follow up at the medical university clinic of vienna: among these, congenital diaphragmatic hernias (cdh, 20) could be selected for primary repair (12) because of adequate lung maturity, 4 with extreme lung hypoplasia underwent extra corporal membran oxygenation. cystic adenomatoid malformation (8) and lung sequestration (5) were diagnosed, requiring immediate postnatal or later repair. abdominal anomalies (45): stenosis, obstructions or atresias of small bowel (6) were treated by adequate therapy from the very beginning. anal atresias (4) were differentiated into high and low forms, cases which needed colostomy or could be corrected in an one stage repair. nine gastroschisis (6) and omphaloceles (5) were delivered pretermly dependent on the amount of eventerated bowels. ovarial cysts (7) were differentiated from abdominal tumors (4), the latter requiring immediate surgery, the former only depending on size and content. urologic pathologies (29) could often be treated conservatively. conclusions. the results of fetal mri do not have an impact on the type of surgical procedure. however, early accurate diagnosis of pathology, including information about vital functions (such as the degree of lung maturity) may influence the decision of the time to perform the operation, to achieve a most successful outcome for the patient. background. common bile duct (cbd) stones represent a diagnostic and therapeutic challenge in pediatric age group. the aim of the study was to evaluate our management of children with suspected cbd stones and to develop an algorithm for the rational use of perioperative ercp, mrcp and intraoperative cholangiography (ioc). methods. between 1999 and 2005, 38 children that had undergone laparoscopic cholecystectomy (che) were evaluated for preoperative findings suggestive for cbd stones, preoperative use of ercp or mrcp, use of ioc and findings during surgery. a diagnostic and therapeutic algorithm for cbd stones was developed. results. twelve children (32%) had preoperative findings suggestive for cbd stones. of the 7 children with elevated liver enzymes and abnormal ultrasound findings, 6 (86%) were identified to have cbd stones. five had preoperative ercp which detected and successfully cleared stones in 3 patients. ioc identified cbd stones in 3 children, including one patient with a preoperative negative ercp. of the 5 children with either elevated liver enzymes or abnormal ultrasound, only one stone in the cystic duct was identified by a gall bladder edema in the preoperative mrcp followed by ioc. three children received preoperative mrcp and ioc was performed in 4. no retained stones were detected postoperatively. conclusions. cases with high suspicion for cbd stones should undergo a preoperative ercp followed by intraoperative cholangiography, if no stones could be found. in case preoperative findings are ambiguous, prevalence of cbd stones is low and we suggest mrcp or ioc as the diagnostic methods of choice. 191 pure esophageal atresia with normal outer appearance -a new subtype? -case report m. sanal 1 , b. häussler 1 , w. tabarelli 1 , k. maurer 2 , c. sergi 3 , j. hager 1 background. isolated esophageal atresia (vogt type ii) is characterized by an agenesia of the midportion of the esophagus. this paper presents a case of such a form of esophageal atresia with a 1 cm long fibrous segment between the two esophageal pouches resembling the subtype ii3 according the kluth's atlas. methods. thirty-seven week gestation boy born by uneventful vaginal delivery with 2000 g birth weight was transferred to our department because of inability to pass a nasogastric catheter. resection of the fibrous segment and primary anastomosis of the esophagus was performed succesfully. results. the postoperative course was uneventful and the patient was discharged on the postoperative 21 day. histological examination of the atretic segment showed an haphazard distribution of not functional lumina and blood vessels. conclusions. kluth has described ten types of esopageal atresia in his atlas; pure esophageal atresia is classified as type ii in which the proximal and distal segments are atretic without a tracheo esophageal fistula. matsumoto described a subtype in which the midportion of the esophagus is atretic and there is a cyst located in the atretic strand. loosbroek also described in 1991 a new type of isolated esophageal atresia that included double membranes with a 2 cm gap between them. we describe here a similar case of pure esophageal atresia, showed neither a cyst nor a membrane. extensive review of the literature failed to disclose any similar case showed this kind of histological character. we report our experience with the minimal invasive method of surgical reconstruction of pectus excavatum recurrence. since 2001 at our department 135 pectus excavatum patients have been operated on by the modified minimally invasive method of reconstruction (modified nuss technique). seven patients aged 19.6 ae 9.8 showed a severe recurrence (6 patients after ravitch-welsh-rehbein method primarily operated elsewhere, one after explantation of the ''nuss bar'' operated in our department). five patients suffered on reduced physical effort and 3 patients aim for a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with 3-d reconstruction and spirometry. the following intraoperative events deserve mention: 1. severe retrosternal scarred tissue complicate the retrosternal preparatory mobilisation of the pericardial sac and the sternal portion of the diaphragm n ¼ 3. 2. intraoperative thoracoscopy showed pleural adhesions which were divided thoracoscopically n ¼ 3. 3. non compliant stiff thorax due to sternal kinking and=or ossification of the regenerated ribs after ravitch procedure made the following procedures necessary: a. additionally osteotomies of the ossificated ribs (n ¼ 2). b. implantation of a second bar (n ¼ 3). c. an oblique wedge shaped partial sternal osteotomy (n ¼ 3). due to preparation we had 2 intraoperative bleeding episodes of the internal mammaric vessels, 1 lesion of the pericardial sac (scar tissue) and 1 superficial lesion of the right visceral pleura (adhesions). vertebral index changed from 31 preoperatively to a normal range of 25 postoperatively. postoperative cosmetic results were perfect in 90%. in summary cases with pectus excavatum recurrence are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. former surgical approaches to laparoscopic repairs of morgagni hernias in children involved pros-thetic as well as nonprosthetic repairs. we simplified a nonprostethic laparoscopic method to an easily feasible procedure. methods. two boys with retrosternal diaphragmatic hernias (morgagni) underwent primary laparoscopic repair. a nonabsorbable suture was inserted directly through the anterior abdominal wall and the hernia was tightened in a lateral to medial fashion by a continous suture and tied in the subcutaneous tissue of the xiphoid region. results. two boys, 22 months and five-year old, with coincidentally diagnosed bilateral retrosternal diaphragmatic hernias (morgagni), underwent laparoscopic repair of their hernias. they had an uneventful postoperative recovery, apart from a port site hernia in one. conclusions. this technique for primary laparoscopic repair of morgagni hernia is safe and easy to perform. laparoscopic closure of the defect by suturing the posterior rim of the hernia to the anterior abdominal wall with a continous nonabsorbable suture provides a safe and effective therapy for this type of diaphragmatic hernias. 195 our experience of post-natal diaphragm paralysis treatment in newborns a. kuzyk 1 , a. pereyaslov 1 , r. kovalsky 2 , o. leniv 2 background. the paralysis of right cupula of diaphragm in newborns in many cases is the result of birth trauma and is indicated as erb-duchene syndrome. the paralysis declares itself by the high standing of diaphragm and its paradoxical movements during respiration, displacement of mediastinum and lung compression which bring to heavy respiratory distress, cardiovascular insufficiency development and requires artificial pulmonary ventilation in first post-natal hours. methods. in the period of 2003-2005, 3 children with post-natal paralysis of diaphragm right cupula and 1 child with post-natal paralysis of diaphragm left cupula have been treated in our clinic. the body weight at birth was 1800-3200 g. the basic symptoms were: hard respiratory distress and cardiovascular insufficiency, pulmonary hemorrhage, depression of the central nervous system. two children with low body weight had been on artificial pulmonary ventilation during period from the birth to surgical treatment. conservative therapy was done from 1 to 2.5 months without positive clinical effect -respiratory insufficiency had not been reduced, the children had retarded in physical growth and development. all children were operated on diaphragm goffering from thoracotomy on the affected side. results. after surgery all patients needed artificial pulmonary ventilation during 3-7 days. with good clinical results all children were discharged from the hospital. conclusions. the newborns with post-natal diaphragm paralysis with not effective treatment during 2-3 weeks needed surgical correction -diaphragm goffering on the affected side. 196 long term experience with the paulprocedure in a large animal model background. this study was designed to assess the long term efficacy of the paul-procedure for abdominal wall defect repair in a large animal model (lam). methods. we created 10 â 6 cm 2 full-thickness abdominal wall defects in goettinger miniature piglets (n ¼ 10; body weight: 7.0-10.0 kg). the defect was repaired by the paul-procedure, using an extracellular matrix of xenogeneic origin as an interpositional graft. a weekly examination of the animals followed, including measuring of bodyweight and observation the possible development of a hernia. additional the abdominal cavity was evaluated laparoscopically at 3, 6, 9 and 12 months after paul-procedure. the adhesions to the intestine were measured and the neo-abdominal wall was taken for histological examination. results. (1) the paul-procedure could be performed technical easily in lam. (2) background. gastroschisis is a relatively rare congenital anomaly in which eviscerated fetal abdominal organs are exposed to amniotic fluid in utero through an anterior abdominalwall defect. since the first surgical treatment of gastroschisis by fear in 1878 the evolution of therapeutical concepts is steadly proceeding. methods. a retrospective study enclosing all children with gastroschisis treated at vienna general hospital from 1994 to 2006 was carried out using patient charts. statistics was performed using spss 12.0. the results are compared with the literature. results. fifty-five children with gastroschisis were treated. birth was performed between 28 and 40 week of gestation (92% caesarean section). diagnosis was established between 11 and 40 week of gestation. in 75% of the patients primary surgical closure was performed. oral feeds were started on 8.2 day, mechanical ventilation was stopped after 4.4 days. twenty children developed infection=sepsis=pneumonia (36.4%) 18 children developed ileus=perforation=vovolus=nec=patch infection (32.7%). thirty four children had single gastroschisis related surgery (61.8%), secondary surgery up to 7 operations. mortality was 3.6% (2 deaths). conclusions. since bianchi's publication of minimal intervention management for gastroschisis in 1998 traditional surgical concepts have often been questioned. our results are comparable with international data. although very tantalizing there are no large prospective randomized multicenter studies that show clear superiority of one or another strategy. epidemiologic data show an increasing incidence of gastroschisis which shows the importance of standardized successful procedures for the future. background. colorectal cancer is one of the most common cancers in western countries with incidence rates that are quite stable through the last 10 years. while surgical therapy with high central vessel ligation and adequate lymph node dissection seems well standardised -in laparoscopy as well as conventional surgery -great efforts have been made in new adjuvant treatment strategies and in treatment of colorectal liver metastases. methods. we report about a consecutive series of more than 600 patients treated with colorectal cancer since 1.1.1998 . data about epidemiology, localisation of the primary, surgical methods, tumor classification, complication and mortality rates and survival will be presented in detail. results. the median age was 71 years, 2% of the patients were more than 90 years old, 51.8% were female. fifteen percentage were treated with an acute onset like ileus or perforation. thirty five percentage had right sided primary, hartmann procedure was performed in 6%. about 22% of patients were operated as stage 4 (uicc), the 5 year survival rates of all groups including stage 4 was 45%. pathohistological assessment showed 78% r0 resections (stage 4 included) and a median lymph node count of 24 (pn). perioperative mortality was 4%, complication rate with the necessity for at least 1 surgical reintervention was 8.8%. conclusions. we demonstrate that surgical therapy of colorectal cancer is safe and effective in terms of oncological outcome and perioperative morbidity and mortality, although colon resections in our department are typical teaching operations. modern anaesthesia and intensive care allows radical oncological surgery even in the elderly. interdisciplinary treatment keeps its way, exact pathohistological processing and cooperation with the pathologist still is the most important factor in quality assessment of oncology surgery of the colorectum. background. although adjuvant 5-fu-based chemotherapy showed to increase 5-year survival in stage iii colon cancer, the role of adjuvant chemotherapy in stage ii colon cancer is still unclear. p53, a frequently mutated tumour suppressor gene needed for correct induction of apoptosis, is a promising marker to define subgroups of patients who benefit from adjuvant chemotherapy in stage ii colon cancer. methods. in order to evaluate the clinical relevance of p53 mutations, we investigated 145 stage ii colorectal tumor biopsies from a previous randomised study of adjuvant chemotherapy, who were randomly assigned to adjuvant chemotherapy or surgery alone. for detection of p53 mutations we used singlestranded conformation polymorphism analysis. results. p53 mutation was detected in 51 (35%) of 145 informative tumor dnas. when receiving 5-fluorouracil-based adjuvant chemotherapy, patients with p53 mutation turned out to have a significant better disease-free 5-year survival (95.5 vs. 77.7%, p ¼ 0.044). in contrast, when assigned to the surgery alone group there was no significant difference in 5-year disease-free survival between patient with p53 mutation and patients with wildtyp p53. the difference between the patients receiving chemotherapy as compared to those which did not in respect to the presence of p53 mutations was significant (p ¼ 0.024). conclusions. in our patient cohort patients whose cancer had a mutation of p53 had a significantly better benefit from 5-fluorouracil-based therapy, what is contrary to previous observations. this discrepant result emphasise the need for a standardisation and validation of the methodology, patient selection and interpretation of clinical data before any prognostic marker can be routinely used. 201 is tme an adequate treatment for low rectal cancer? p. lechner, g. humpel background. two patients who had had neo-adjuvant chemotherapy followed by surgery for cancer in the lower rectum presented with metastases in pre-aortic lymph-nodes after 6 and 17 months, respectively. this rose our suspicion that distant spread may in some cases follow the lymphatic vessels along the aorto-iliac axis. methods. after having performed very low anterior or even abdomino-perineal resection for cancer in the lower third of the rectum, biopsies are taken from nodes at the pelvic wall, along the iliac arteries, and the aorta. these are all compartments that remain untouched during routine tme. results. in one out of four patients we find at least one of the above mentioned groups of nodes to be involved. this is most often the case in patients, in whom the mid rectal vascular bundle requires ligation on at least one side. so there are obviously metastases that cannot be detected during the pathological work-up of the tme-specimen. twenty five p.c. of the patients considered to be n-o are already in dukes' stage c, thus requiring additional treatment. these findings -confirmed by the recent literature -suggest, that metastases may arise via lymphatic vessels along the mid rectal arteries and -further onalong the aorto-iliac vessels. conclusions. after standard tme for low rectal cancer lymph node biopsies should be taken in order to avoid understaging of the disease and to allow accurate patient stratification in clinical trials. 202 transanal endoscopic microsurgery for rectal carcinoma: own experiences after 59 cases p. patri, r. schmiederer, a. tuchmann background. transanal endoscopic microsurgery (tem) is an one access technique for local excision of rectal tumours using gas dilatation of the bowel and a stereoscope for unrestricted vision on the operation field. the tem-technique was invented by buess, theiss and hutterer and has been performed at our department since 1993. sessile benign adenomas of the rectum inappropriate for colonoscopic resection represent the vast majority of cases indicated for tem-procedure, using the advantages of sphincter preserving resection in all thirds of the rectum without considerable access trauma. furthermore, tem can be applied to a highly selected group of rectal carcinoma patients in curative objective, including t1g1 or g2l0v0 lesions, classified as low risk carcinomas after hermanek's criteria for malignant potential, with recurrence and 5-yearsurvival-rates equal to radical surgery. under palliative purposes tem can be considered in more advanced carcinomas such as high risk carcinomas (t1g3) or in t2-3 carcinomas without stenosis in patients with high risk for general anaesthesia, rejection of stomal construction or present distant metastases. methods. from 01=1997 until 12=2006 198 tem procedures were performed in 194 patients, 104 males, 90 females, mean age was 68.9 years (38-91), the median hospital stay was 8 days . following diagnoses were included: rectal adenomas (n ¼ 127), rectal carcinomas (n ¼ 59), carcinoids (n ¼ 4), fistulas (n ¼ 2), gist (n ¼ 1) and melanoma (n ¼ 1). all patients underwent tem-procedure as described by buess et al., the median operation time was 101 min (20-275). highlighting the carcinoma patients regarding to postoperative histopathology tem was performed in n ¼ 19 tis-lesions, n ¼ 25 t1 low risk carcinomas, n ¼ 1 t1 high risk carcinoma, n ¼ 10 t2 and n ¼ 4 t3 carcinomas. results. in carcinoma patients undergoing tem for curative objective recurrence rate was 3.3%. if tem was performed in primarily palliative intention recurrence rate was 66%. no conversion to open technique had to be performed, no postoperative surgical complications were observed, one patient died 4 weeks postoperative due to liver failure following esophageal varices bleeding. conclusions. transanal endoscopic microsurgery is a technically highly demanding but excellent procedure for curative therapy of rectal adenomas and low grade early carcinomas. furthermore, tem is feasible in more advanced carcinomas for palliative purposes. besides the technical advantages the procedure can prevent patients of rectal resection or stomal construction. background. anastomotic leak is the most feared early complication in the postoperative period after low anterior resection. the incidence varies between 3 and 21%. use of tme technique lessens the percentage of local recurrences but increases the incidence of an anastomotic leak. a surgeon has to assess the risk factors and decide whether to create a protective stomy that protects the patient from fatal consequences of an anastomotic leak. methods. one hundred and three patients who had a low anterior resection without a protective ileostomy in the period 2004-2005 were included in the analysis. data of those who developed an anastomotic leak and those without were compared and the connection between specific risk factors and the incidence of an anastomotic leak was assessed. results. eleven patients (10.7%) developed a clinically confirmed anastomotic leak. death after low anterior resection occurred in 5 cases (4.1%), in two cases in patients who developed a leak, resulting in a 18.2% mortality rate for anastomotic leakage. there was no difference between males and females (p ¼ 0.25) and age groups (<60 vs. >60 years), (p ¼ 0.15). tumor localization in the lower third of the rectum was roughly showing statistical importance (p ¼ 0.085). the stage iv. of disease showed obvious connection (p ¼ 0.018). connection between the anastomotic leak and preoperative radiotherapy or high asa score (>2) was not established (p ¼ 0.31 and p ¼ 0.25). conclusions. the incidence of an anastomotic leak was comparable with results of other studies. localization of a tumor in the lower third in advanced disease represents an important indication for protective ileostomy. background. while adverse events occur in up to ten percent of all patients admitted to hospitals sentinel events do not happen often. however, these events represent great risks for medical institutions and persons involved. a thorough analysis of sentinel events is mandatory and can be achieved by root cause analysis (rca). methods. root cause analysis has been designed in order to assess underlying human, technical, and organizational factors contributing to adverse events. rca has to be performed in a standardized way by a team approach. the main goal of this analytic technique is to establish a relationship between causal factors and events under systemic aspects. after identifying incidental findings causal statements are formulated and actions are developed. conclusions. root cause analysis is a standardized investigative technique which allows to identify causes of severe adverse events and to develop preventive actions for the future. background. thyroid surgery can be followed by 3 typical complications i.e. recurrent laryngeal nerve injury, postoperative hypoparathyreoidism and postoperative haemorraghe. refined surgical technique has improved the outcome and lowered the risk of complication to a minimum. methods. we analyzed global outcome and individual performance in more than 20,000 thyroid operations. the complication rates were compared in 4 consecutive periods representing different surgical techniques and individual surgical performances. the data were repeatedly presented to the surgeons. the effect of this quality control procedure was reevaluated. results. exposure of the recurrent nerve and the parathyroid glands significantly reduced the global rate of post-operative=permanent rlni and hypoparathyreoidism. some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent rlni rates ranged from 0 to 1.1%) and refined dissection of the parathyroid glands (e.g., parathyroid insufficiency ranged from 0 to 2.7%). global outcome and individual performance were compared in 4 periods and presented to the surgeons. the effect of this quality control procedure and the selective improvement of outcome will be shown by data. the extent of resection and the individual refinement of surgical technique was the source of variability. conclusions. refined surgical dissection significantly reduces the risk of complications in thyroid surgery. quality control can improve the global outcome and identify the variability in individual performance. this cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes. 208 recent developments in medical litigation and liability in austria d. schaden 1 , j. pritz 2 1 krankenhaus der barmherzigen brüder, graz, austria; 2 amt der steiermärkischen landesregierung, graz, austria the recent medical judgements of the highest court (e.g.: wrongful birth ogh 5ob165=05 h) have been debated very controversially in medical profession and have attracted closer attention to the legal aspects of medical documentation and enlightenment. particularly in the surgical disciplines the patient should be made fully aware and get a detailed information about the risk of treatment failure, possible complications, limits to the procedures and long term outcome. exact information by the doctor is the condition necessary for the patient to give valid consent to the treatment and to avoid medical negligence litigation in these risky specialties. unfortunately these often for the doctors existentially important aspects are not part of the medical or surgical training nor are there any compulsory guidelines of medical enlightenment in the austrian legal practice which creates widespread individualism in all disciplines. we want to give an overview of the latest medico-legal lawsuits and judgements and their consequences for the daily working routine focussing on issues that can result in a doctor or facility being sued. background. every patient has the right to be informed about the consequences of surgery enabling him to give his informed consent. until recently the process of giving this information was not well organized. in the context of improving quality control at the hospital, a uniform process for patient information was established and the training of interns for giving informative talks was standardized and intensified. to measure whether these changes are reflected by an improved patient satisfaction, patients were surveyed before and after the changes. methods. two surveys were performed on patients before and after the improvements were introduced, and the results were compared. results. in each survey 186 and 165 questionnaires were returned. with the improved process the number of patients satisfied with the length of the informative talk rose (78-99%, p < 10 à9 ), less patients wanted a more detailed talk (16-9%, p ¼ 0.055) and more patients considered the sketches on the informed consent protocol helpful (87-95%, p < 2 â 10 à5 ). fewer patients thought the surgery was worse than expected (34-22%, p ¼ 0.013). conclusions. using the new information process, a measurably better patient satisfaction could be observed. thus, by relatively simple means a highly efficient information process can be established even at a large hospital. 210 the discontented patient j. pritz 1 , d. schaden 2 the number of claims after surgical procedures (not only bariatric or cosmetic surgery) is still increasing and patients nowadays are getting better informed about medical malpracti-ce=error in the media and the various possibilities to assert their rights. in austria various kinds of out-of-court settlement are installed to facilitate patient's compensation without the risk of litigation. in many cases misconceptions in the patient-doctor relationship can be solved without motion to court. but how can the terms ''malpractice'' or medical error be defined at all? which conditions must be fulfilled for the motion to court or the medical arbitration committee? we want to give a survey of the activity of the arbitration committee, the members, and the possibilities of compensation. moreover, the different consequences between criminal and civil law should be explained. the role of the expert witness, the course of procedure at the arbitration committee and possible consequences for the doctor or the facility will complete the presentation. background. negative resection margins are significant for prevention of recurrence in liver surgery. preoperative 3d models of imaging data provide significant improvements for visualization and planning, but intra-operative realisation is still a challenge. possibly navigation technology can improve oncological safety in liver resections. methods. fifty-four of 130 liver resections for liver metastases were selected for intra-operative navigation due to complex anatomical situations. exact surgical plan was documented on virtual 3d models. planned resection margins were assessed and measured preoperatively. intra-operative 3d ultrasound data were acquired and localized with an optoelectronic tracking system, thus navigation of surgical instruments was provided in a virtual environment of these registered ultrasound data. surgical resection margins were compared with the surgical plan. results. navigated surgery was realized in 52 of 54 resections. r0 resection was achieved in 49 of 52 patients. mean histological resection margins were 9 (0-15) mm. maximum deviation from the surgical plan was 8 mm. conclusions. 3d ultrasound-based optoelectronic navigation is a feasible device for liver surgery, provides optimal anatomic orientation and can realize precise resection margins. background. during liver resection, a low central venous pressure plays a crucial role in reducing blood loss and intra-as well as post-operative morbidity. however, excessive volume restriction could lead to microcirulatory impairment and organ hypoperfusion. in the present study, we evaluated a standardized intra-operative protocol for optimal fluid replacement therapy. methods. in a prospective study, 32 patients for elective liver resection were included. intra-operative fluid replacement was restricted to 8 ml=kg=h in patients with thoracic epidural analgesia or 6 ml=kg=h for patients without thoracic epidural analgesia. following target parameters were defined: central venous oxygen saturation >70%, intra-operative lactate levels <1 mmol=l, urine output >15 ml=h, central venous pressure <10 mbar, and norepinephrine dosage <0.15 mg=kg=min. in patients where at least one of the parameter values exceeded the predefined limit, fluid replacement therapy was intensified and dobutamine 2.5 mg=kg=h was started. patients were monitored for intra-operative blood loss, intra-and post-operative complications, and length of hospital stay. results. patients that remained within the intra-operative target parameters for central venous oxygen saturation, lactate levels, urine output, central venous pressure, and norepinephrine dosage had lower blood loss, fewer complications, and shorter hospital length of stay. conclusions. the standardized protocol is a good approach for optimal intra-operative fluid replacement and to minimize blood loss, post-operative complications and hospital length of stay. background. bile duct injuries (bdi) are still the most feared complication of laparoscopic cholecystectomy. the patient has to face prolonged postoperative treatment, even life threatening complications; the hospital and the surgeon rising costs and pricely and possibly time-consuming malpractice procedures. the repair of bdi requires special hepatobiliary expertise, but the long-term results even in the best centres are still sobering. there are different types of bdis requiring a tailored approach. we analyzed predisposing factors and types of bile duct injuries treated in our institution. methods. we analyzed our operative and endoscopy database from 1999-2006 for patients treated with bile duct injuries after cholecystectomy. bile duct injuries were classified according to a system proposed in 1994 by siewert and colleagues. results. between 1999 and 2006 a total of 2850 cholecystectomies were performed at our institution. there were 2422 laparoscopic (lc) and 428 open procedures (oc; inculuding procedures with conversion from lc to oc); during the same period, 55 patients (30 females=25 males, mean age 45 years; range: 34-93) were treated for bile duct injuries; 5 of these patients were initially operated in an other hospital. there were 34 patients with class i lesions (bile leak of the cystic duct or lesion of luschka ducts), 26 patients with class ii leions (stricture of the cbd). two patients with class iii injuries (incomplete trans-section of the common bile duct) and 12 patients with class iv lesions (transsection of the cbd or chd). thirty four of the initial 50 (68% -all open and converted and 9 laparoscopic) operations were considered difficulty by the surgeon performing the cholecystectomy. 30 of 55 operations were laparoscopic (52-1%), 10 converted from lc to laparotomy (18%) and 15 laparotomy from the incision (30-3.5%). of the original operations, 31 had been performed by an experienced surgeon, 24 by a novice. conclusions. cystic duct leakage is still the most common type of biled duct lesions after cholecystectomy. bile duct injuries occur a s commonly in operations performed by by novices as in procedures done by experienced surgeons. in order to present the current concept for treatment of bpl patients suffering from traumatic brachial plexus lesion (bpl) who underwent microsurgical reconstruction were analysed. within one year in our institution 11 male patients, aging from 21 to 63 years were scheduled for surgery. three suffered from complete, 8 from upper bpl. six patients were diagnosed as supraclavicular lesions and 5 as infraclavicular lesions. patients with diagnosed supraclavicular lesions were scheduled for surgery between 2 and 5 months after trauma. surgical exploration revealed root avulsion and or rupture in all cases. classic intraplexual reneurotisation was performed in 4 patiens, whereas all 6 patients received extraplexual reneurotisation procedures, utilising the spinal accesssory, the ulnar and intercostal nerves. three patients received secondary reconstructive procedures. patients with infraclavicular lesions were treated surgically between 6 and 12 months after injury. in all 5 patients nerve grafts were used to reconstruct the injured fascicles, a nerve transfer was used in 1 case only. one patient required secondary reconstructive surgery. the reconstructive strategy in bpl surgery has been changed dramatically during the last 10 years. the strategy changed from a single surgical intervention one year after the trauma to a prozessual concept consisting of early primary nerve reconstruction and secondary reconstructive procedures. nerve grafting with use of autologuous nerve grafts for ''intraplexual'' reconstruction is still state of the art, additionally nerve transfers were introduced to utilize ''extraplexual'' sources for reeinnervation. regarding this concept most of the patients regain not only some motor function but functionality of their impaired upper extremity. 229 teaching means learning -who benefits from academic teaching duties? p. lechner, g. humpel background. in 2005 the department of surgery at the danube clinics intulln, a level i hospital, has been named a teaching institution associated with the vienna medical university. this has certainly led to various organisational changes the results and consequences of which we attempt to identify. methods. all teaching institutions are subject to continuous evaluation by the students. in addition to that, we undertook an extra evaluation aiming at potential organisational and medical improvements from which patients, personnel, and students may benefit. results. 1) as the students are available only from 7.30 through 12.30 o'clock, all organisational routines at the department (staff-rounds, meetings, lectures, etc.) now follow a more rigorous daily schedule. 2) bed-side teaching means explaining everything that is undertaken in the presence of the patients. so the patients receive more information on their diseases and treatments. 3) students tend to question everything, and so we also call in question many routines ''that have always been performed like that''. this allows us to simplify numerous operating procedures and means continuous organisational learning to the institution. 4) for the same reason lecturers -and all those who are involved in teaching (physicians, nurses, and others)have to keep their academic knowledge up-to-date any time. 5) teaching during meetings and ward rounds is of course not ''limited'' to university students, but also comprises interns and residents. conclusions. the department's current status as an academic teaching institution turned out beneficial for patients, personnel, and students, concerning professional, technical, and organisational aspects. though the additional workloadespecially in the beginning -must not be under-estimated, the advantages clearly exceed the burdens. background. necrotizing enterocolitis (nec) is the most common gastrointestinal complication of prematurity at the neonatal intensive care unit. the first aim of the study was to investigate the correlation between clinical parameters, extent of disease and mortality, and the second purpose was to analyse the surgical procedures and their outcomes. methods. in a retrospective study we reviewed medical charts of 37 patients who were operated within a five years periode. preoperative blood results and demographic data were collected and evaluated. according to the extent of disease, birth weight and operative procedure different groups were analysed. results. a total number of 37 patients underwent surgical procedures for nec from 2000 to 2005, and 75% (n ¼ 28) weighted less than 1050 g. in 14 patients focal disease, in 15 patients multifocal disease and in 8 children panintestinal disease were found. preoperative blood tests revealed a median crp level of 4.3 mg=dl (normal range 0.6), median wbcc of 12.1g=l and a median platelet count of 146 000 g=l. primary laparotomy with defunctioning enterostomy was performed in 89%. overall mortality was 51%. conclusions. the extent of disease and the condition of the infants still determines the survival. preoperative blood results are of limited prognostic value. primary laparotomy with defunctioning enterostomy was the preferred technique in our unit, and even in the group of vlbw and elbw neonates surgery was well tolerated. discussion regarding the best operative procedure is still going on and no consensus in the management of nec is agreed on. methodik. während der letzten 8 jahre wurden 14 neugeborene (gestationsalter 24-32 wochen, geburtsgewicht 530-1220 g, alter bei der darmperforation 3-15 tage) mit einer oder mehreren dünndarmperforationen beobachtet. die symptome waren jeweils etwa ident: abdominelle distension mit verfärbung der flankenhaut bei initial insgesamt stabilem allgemeinzustand. bei ,,nur'' 10 der 14 kinder zeigte sich im abdomen-leer-röntgen freies gas in der bauchhöhle, bei allen aber war sonographisch intraabdominell freie flockige flüssigkeit festzustellen, ohne nec-typische veränderungen am intestinaltrakt. 2 kinder wurden aufgrund ihres schlechten zustandes nur punktiert=drainiert und antibiotisch behandelt. 12 patienten wurden laparotomiert: bei 3 kindern fand sich die perforation im bereich des jejunum, bei weiteren 3 im unteren jejunum=oberen ileum und bei 6 im terminalen ileum, davon hatte eines 2 und eines 4 perforationen. der betroffene darmabschnitt wurde jeweils reseziert; bei 4 kindern wurde eine end-=end-anastomose durchgeführt, bei den verbleibenden 8 patienten wurde wegen der peritonitis eine doppelläufige enterostomie angelegt. eines dieser 8 kinder verstarb aufgrund einer sepsis-bedingten gerinnungsstörung. eines der beiden drainierten kinder wurde 7 wochen nach der intervention wegen eines ,,verwachsungsbauches'' adhäsiolysiert. ergebnisse. die ü berlebenschance sehr kleiner frühgeborener nahm während der letzten jahre deutlich zu. parallel dazu mußte bei diesen kindern eine zunahme umschriebener, ätiologisch nach wie vor nicht ganz geklärter darmperforationen zur kenntnis genommen werden. zur behandlung stehen 2 grundsätzlich differente vorgehensweisen zur verfügung: im vordergrund steht eine resektion des lädierten darmabschnittes und, abhängig von den lokalen gegebenheiten (peritonitis ja=nein), entweder eine end-zu-end-anastomose und=oder nur eine doppelläufige enterostomie. als zweite prinzipielle therapieform gibt es die möglichkeit, die bauchhöhle zu punktieren= drainieren, wodurch die affektion auch beherrscht werden kann; im einzelfall kann sie letztlich aber doch nur chirurgisch zu sanieren sein. dieses vorgehen gilt für uns als ultima ratio. schlussfolgerungen. auch wenn eine isolierte darmperforation bei einem kleinen frühgeborenen relativ gut behandelbar ist, sollte durch klärung ihrer ä tiologie eine prävention dafür möglich werden, da diese kinder wegen ihrer kritischen voraussetzung bereits per se außerordentlich gefährdet sind. 232 the endorectal pull-through procedure (erpt) for hirschsprung's disease g. schimpl background. whereas in the past various operative techniques in patients with hirschsprung's disease (hd) were used, erpt was introduced as a single-stage operation. methods. sixteen patients with hd (3 females, 13 males) aged 2 months to 5 years were treated using the erpt procedure and the level of bowel resection was determined by intraoperative biopsies. results. the length of hd was in 12 patients up to the sigmoid colon, in 3 patients up to the transverse colon and one patient had a total colonic hd. two patients required a laparoscopic mobilisation of the left colonic flexure. in the patient with total colonic aganglionosis, the resection of the entire colon and sauer's procedure was performed using a periumbilical laparotomy. oral nutrition was started in all but on the first post operative day and they were discharged after 5-7 days. complication occurred in two patients: one had to be reoperated due to misinterpretation of intraoperative biopsies and a second patient with 5 years of age developed a retrorectal abcess which was treated coservatively. in a follow-up, 1-6 years postoperatively, all patients are continent and have normal bowel movements. conclusions. erpt is an advance in the treatment of hd and can be performed at any age. it avoids the creation of enterostomies, is a single step procedure with excellent functional results and low complication rates. in long segment hd this procedure can be combined with laparoscopic or open surgical procedures. 233 single-port appendectomy in obese children -a useful alternative? t. petnehazy, h. ainoedhofer, s. beyerlein, j. schalamon background. the rapidly increasing prevalence of obesity among children poses challenging problems in abdominal surgery. there is a growing body of evidence that single-port appendectomy (spa) is a feasible and safe alternative to open appendectomy (oa). very little is known about the clinical outcome of spa in overweight children. we present our experience with the treatment of suspected appendicitis in obese children using spa. methods. from january 2003 to december 2005 we performed 21 spa in obese children with suspected appendicitis (14 females, 7 males, median age of 12.8 years). obesity was defined as a bmi > 95th percentile for age and gender (median weight 69.3 kg). in the procedures a 10-mm instrument was introduced through the umbilicus (combination of a 10-mm 6 wide angle optic with 5-mm working channel). after exploration of the abdominal cavity and meckel's search, the appendix was exteriorized through the umbilical trocar and removed by open technique. patients' records were evaluated regarding anaesthetic time, complications, time until reintroduction of solid diet and histopathological findings. results. average operating time was 53.3 min (range 32-75 min). neither intra-nor postoperative complications occurred. reintroduction of solid diet to all patients was possible on the first postoperative day. the histology is presented in the below table. our results indicate that the advantages of spa such as: excellent evaluation of the peritoneal cavity, minimal rate of intraoperative incidents and superior cosmetic results make this technique a valid alternative for the treatment of appendicitis in obese children. background. ovarian torsion is a surgical emergency. because of unspecific clinical findings, diagnosis can be delayed and therefore may result in oophorectomy. recently preservation of ovarian function by means of laparoscopic detorsion has been proposed even in advanced cases. methods. we retrospectively reviewed 41 patients with diagnosis of ovarian torsion who presented at our institution between 1995 and 2005. a total of 27 ovarectomies and 14 detorsion were performed. twenty patients underwent minimal-invasive surgery, in 30 cases laparotomy was performed. in 9 cases a conversion was necessary. the accuracy of preoperative imaging modalities, surgical technique, correlation with postoperative histopathologic findings, complications and outcome were assessed. results. all patients were investigated by means of ultrasound. mri was applied in 13 patients whereas ct-scan was done in 7 patients. histopathological and intraoperative findings revealed 16 simple torsions, 17 twisted cysts and 8 twisted teratomas. sensitivities to detect ovarian torsion were 75% for ultrasound (us), 87% for mri, and 100% for ct. entirely 27 oophorectomies and 14 detorsions in 41 patients were performed. one of these patients presented with asynchronous bilateral ovarian torsion caused by a unilateral benign teratoma. in 4 patients a laparoscopic contralateral oophoropexy was done. mean hospital stay was 4 (laparoscopic) versus 7 days (open approach). the complication-rate was marginal in both groups. conclusions. preoperative imaging is essential to improve the diagnostic accuracy. however, sensitivity only approaches 75%, emphasizing the importance of surgical exploration when symptoms are compatible with torsion. when a neoplasm is suspected, mri or ct imaging is essential. in order to preserve ovarian function and fertility, laparoscopic detorsion without primary resection should be the procedure of choice. it constitutes an easy, quick and equally safe procedure. the need for contralateral oophoropexy has to be discussed. background. differential diagnosis of lower abdominal pain include beneath common causes such as appendicitis and gastrointestinal infections some not so common diseases as ovarian pathologies in female patients. this may be ovarian cysts but can also be pathologies like ovarian torsions or tumours that have to be operated. however, the differential diagnosis between ovarian cysts and ovarian torsions is often radiologically inclonclusive and therefore makes a surgical intervention mandatory. methods. we analysed retrospectively the data from 29 female patients hospitalised for ovarian pathologies in between 2000 and 2006. twenty nine patients underwent surgical intervention for different causes. results. most patients presented with acute abdominal pain demonstrated signs of peritonitis and required pain relief. on the other hand we had patients with only mild clinical signs such as newborns with already prenatally diagnosed ovarian cysts. we found in our patients 11 cases of benign ovarial cysts, 4 cases of benigne teratomas, 2 cases of serous cystadenomas, 1 case of serous cystadenofibroma, 1 case of yolk sac tumor and 10 cases of ovarial torsions. conclusions. diseases of the ovaries are a rather rare but important cause of lower abdominal pain in children and adolescents and requires a mediculous diagnostic procedure and often an urgent surgical intervention. background. adrenal tumors, other than neuroblastoma, are rare in children. the aim of the study was to present the outcome of functioning tumors of the adrenal gland in children. methods. we reviewed medical records of 5 children with adrenal tumors treated in our unit from 1995 to 2005. demographic datas, clinical features, operative details, histopathological details and follow up were studied. results. there were 5 children with the mean age 5.6 ae 3.6 years. two patients had virilizing tumors and presented with an acute abdomen, one patient had conn's syndrome, one patient cushing's syndrome and one patient presented with severe haemorrhagic shock syndrome. all patients were treated surgically. histopathological diagnosis were adrenocortical carcinoma (acc) in two patients, adrenocortical adenoma (aca) in two patient and adrenocortical cyst in one patient. ultrasound sonography, computerized tomography and magnet resonance imaging were used for diagnosis and follow up. patients with acc had advanced-stage disease and died despite total surgical resection and agressive chemotherapy. patients with aca and adrenocortical cyst were cured by surgical resection. conclusions. adrenal tumors constitue less than 1% of paediatric neoplasm. aca and adrenocortical cyst are cureable by surgical treatment, but the outcome is still poor in cases of acc. endoscopic subureteral injection of bulking agents has become an established alternative to long-term antibiotic prophylaxis and ureteral reimplantation. we evaluated the effectiveness of dextranomer=hyaluronic acid copolymer (deflux + ) and predicting factors for success or failure. a total of 156 ureters=113 patients with a mean age of 4.4 years underwent endoscopic treatment with dextranomer= hyaluronic acid (dx=ha) copolymer. vur in duplex ureters was treated in 10 patients. the presence of voiding dysfunction and renal scars, the volume of deflux injected and the endoscopic appearance of the ureter were recorded. dextranomer-hyaluronic-acid was injected submucosally beneath the intramural part of the ureter at 6 o'clock, but if the appearance was not satisfying or the ureter opens during flow an additional injection at 4 and 8 o'clock was performed. all patients received antibiotic treatment till a voiding cystourethrography (vcug) was performed 8 weeks after injection. ultrasound examination was performed after 24 hours, 3 months, 6 months and one year. success was defined as no reflux on postoperative voiding cystourethrography. a total of 156 ureters underwent 1 to 2 treatments. the overall success rate was 83%. the cure rate according to reflux grade was 100% for grade i, 81% for grade ii, 74% for grade iii. in vur grade iv and v the endoskopic treatment failed in most cases. there was no case of obstruction at up to 24 month postoperatively. haemorrhage occurred in one patient. in five ureters an increase of vur grade developed. new contralateral vur was seen in six patients. in 0.7% vur was found on postoperative vcug at 2 years after endoscopic treatment. there was no statistic significant difference in volume injected when successes were compared with failures. among children with a small kidney the response rate was 54%. a positive response was observed in 80% of children with duplex ureters. the presence of voiding dysfunction had no influence on success. patients in whom endoscopic treatment failed underwent open surgery. the subureteral injection of dextranomer=hyaluronic acid is an effective and well tolerated alternative to open surgery or conservative treatment, also in patients with duplex ureters. in patients, who subsequently require reimplantation, the operative repair does not appear to be compromised. background. almost all patients with symptomatic vur were treated with a cohen procedure and a very high success rat. since 2002 we offer the endoscopic procedure with deflux. the outcome of the endoscopic treatment is evaluated. methods. between 1=2002 and 1=2007, 99 patients with 164 refluxing units were treated (i ¼ 15, ii ¼ 80, iii ¼ 58, iv ¼ 10, v ¼ 1). the control after treatment was between 2 and 66 months. additional urological diseases are: solitary kidney (3), double kidney (13), neurogenic bladder with mmc (3), bladder trabeculation w=o neurological disease (6), cloacal malformation (2), bladder exstrophy (2), urethral valve (1) . age at treatment was between 8 mths and 14 yrs. injection was performed under general anesthesia, bolus was between 0.2 and 3.2 ml. three patients were additionally treated with botox. results. sixty patients need no further treatment after 1 injection (48 resolved and 12 patients have 1 reflux). in 17 of 19 patients, who need a second injection (9 overactive bladder), reflux resolved as well as in 2 patients after third injection. in 2 patients with neurogenic bladder and mmc we had no success and further treatment (augmentation) was necessary. in 4 patients reflux worsened and cohen operation was performed. in 9 patients a vcug will performed in the near future and three are lost for control. conclusions. in cases of moderate reflux with no neurogenic bladder it is an excellent method to treat reflux. in cases of neurogenic bladder, we cannot recommend it and cases with bladder trabeculation need an additional medical treatment or operation with a higher success rate. all these patients need a long term follow-up. background. bariatric surgery in austria has a long tradition since 1973, but has always been different to the international trends. in order to obtain an overview of growth and time trends of obesity surgery in austria a nationwide review has been done by the austrian national federation for surgery of obesity every two years since 2002. methods. e-mail requests are sent to every department of surgery in public hospitals and clinics to collect the recent number of operations including revisional procedures. results. the last reviews (including 2004) showed a steady increase of obesity surgery particularly in the years 1998 through 2001 the number of operations increased 500%. since 2001 a constant number of interventions of about 1400 per year (2004:1445) had been observed. predominant operation techniques were restrictive procedures: 1992-1998 vbg (vertical banded gastroplasty) and since 1998 agb (adjustable gastric banding). since the late nineties austria is a gastric-banding country (75% in 2004) compared to the worldwide review data (25% in 2003), but since 2002 we observe a steep increase of gastric bypass paralleled by a decrease of agb. by the time of the conference data of the review starting in january 2007 will be presented a showing the trend of the last two years. conclusions. bariatric surgery as the only effective treatment against the alarmingly increasing disease of severe obesity is already an important part of the surgical work of some austrian surgical departments. in view of this fact quality control by continuous data collection is of major importance. 240 restrictive bariatric procedures -long term results and complication management k. miller background. vertical banded gastroplasty (vbg) has been in clinical use since 1979 and the adjustable gastric band (agb) since 1985. as promising results were achieved with the adjustable gastric bands available in the market, some surgeons came to the conclusion that vbg might be entirely abandoned and replaced by the adjustable gastric band. the aim of this study was to compare the long term outcome of the two different restrictive procedures. methods. within a period of 7 years (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) , 1117 gastric restrictive procedures were performed in the course of a prospective non-randomized comparative trial. we report the outcomes of 563 vbgs and 554 agbs performed by two surgeons. the mean bmi was 46.9 ae 09.9 for vbg and 46.7 ae 07.8 for agb. patient selection was performed by admittance to one of the two surgeons. vbg was performed via laparotomy and agb by the laparoscopic procedure. the bariatric analysis and reporting outcome system (baros) was used to evaluate the postoperative health status and quality of life. results. the mean duration of follow-up was 92 months, with a minimum of 5 years (range, 60-134 months). the overall follow-up rate was 92%. in the short-term follow-up of 3 years, no statistically significant difference was registered between agb and vbg in terms of weight loss, reduction of co-morbidity or improvement of quality of life. the 30-day mortality rate was 0.4% (2 patients) for vbg and 0.2% (1 patient) for agb. the overall re-intervention rate in the long term was 49.7% for vbg and 8.6% for agb (p < 0.0001, or 0.0937, 95% ci 0.065-0.133), the re-operation rate 39.9% for vbg and 7.5% for agb (p < 0.0001), respectively. the excess weight loss (ewl) was significantly higher in the vbg group after 12 months (58% for vbg vs. 42% for agb; p < 0.05). in the long-term follow-up with a mean value of 92 months, no significant weight loss was registered between the study groups (59% for vbg and 62% for agb; p ¼ 0.923). the baros score in the short term (3 years) was good to excellent in 94 and 90% of the vbg and agb groups, respectively. in longterm follow-up the baros score was significantly in favor of the agb group (83.9 vs. 57.8%; p < 0.0001, or 3.797, 95% ci 2.072-7.125). the overall loss of co morbidities was 80% in both groups. conclusions. this long-term follow-up study shows that vbg and agb are effective restrictive procedures to achieve weight loss, and loss of comorbidities. a statistically significant lower re-intervention and re-operation rate and an improved health status and quality of life were registered for agb. 241 pilot study on the effects of gastric electrical stimulation (tantalus tm ) on glycemic control in morbidly obese patients with type 2 diabetes (t2dm) a. bohdjalian 1 , b. ludvik 1 , s. shakeri-manesch 1 , r. weiner 2 , c. rosak 2 , g. prager 1 background. previous work suggests that non-excitatory electrical stimulation, synchronized to the gastric refractory period and applied during meals, can induce weight loss in morbidly obese subjects. the tantalus tm system (metacure n.v.) is a minimally invasive implantable gastric stimulation modality that does not exhibit malabsorptive or restrictive characteristics. aim: to investigate the potential effect of the tantalus tm system on glycemic control and weight in morbidly obese subjects with t2dm. methods. in this european multi-center, open label study, 24 t2dm obese (9 m, 15 f, bmi: 41.7 ae 0.9 kg=m 2 ) subjects treated either with insulin (7) or oral anti-diabetic medications (17) were implanted laparoscopically with the tantalus tm system. the system includes a pulse generator and three bipolar leads and delivers a non-excitatory signal initiated upon automatic detection of food intake. results. twenty subjects have completed one year and exhibit a decrease in hba1c from 8 ae 0.2% at baseline to 7.5 ae 0.2% (p ¼ 0.06) and in fasting blood glucose from 180 ae 15 mg=dl to 150 ae 8 mg=dl (p< 0.05). sixteen subjects on oral anti-diabetic medications showed a decrease in hba1c from 8.11 ae 0.3% at baseline to 7.37 ae 0.2% (p< 0.05) and an average weight loss of 5.5 ae 2 kg (p< 0.05), self glucose monitoring available at 9 months post-op from 12 subjects shows a significant (p< 0.05) decrease in 2 hours post-prandial glucose (184 ae 11 mg=dl vs.148 ae 11 mg=dl). in a subset of 9 patients at 9 months of post-operative follow-up we could find an increase in adiponectin (9.5 ae 2.3 vs. 11.5 ae 2.3 mg=ml, p < 0.05) and a decrease in fasting ghrelin (428 ae 80 vs. 252 ae 20 pg=ml, p < 0.05). the areas under the curve (auc) measured during meal tolerance test were significantly higher for adiponectin and lower for ghrelin (p < 0.05) compared to pre-therapy. four insulin subjects have completed one year and showed no significant changes in hba1c and weight. conclusions. interim results with the tantalus tm system suggest that this stimulation regime can potentially improve glucose levels and induce weight loss in obese t2dm subjects on oral anti-diabetic therapy. further evaluation is required to determine whether this effect is due to induced weight loss and=or due to direct signal dependent mechanisms. background. gastric sleeve resection was initially devised as the first step of the duodenal switch operation in bariatric surgery. later, it was performed as an isolated restrictive procedure, mostly laparoscopically. we present intermediate to long-term results from a large series of laparoscopic sleeve resections (lsg) in three austrian centers. methods. ninety-eight patients (19 males, 79 females) who all met the ifso criteria for bariatric surgery were included in this study. the mean bmi was 48.17 kg=m 2 (range, 36-80 kg=m 2 ). patients with symptoms of gastro-esophageal reflux or large hiatal hernias as well as ''sweet eaters'' were excluded and allocated for a different procedure (usually roux-en-y gastric bypass). ninety-five of the operations were performed laparoscopically: after establishing a pneumoperitoneum of 14 mmhg, four to five working trocars were introduced. beginning opposite the crow's foot, the greater curvature was dissected from the omentum up to the angle of his. the left crus of the diaphragm was always identified to ensure complete resection of the gastric fundus. the stomach was then reduced to a tube over a 48f gastric bougie with several magazines of an endostapler, the staple line was finally oversewn with a continuous 2-0 pds suture. three patients had sleeve resection via an open access. results. after a median follow-up of 15 months, patients had lost 11.3 kg=m 2 of their bmi or 51% of their excessive weight on the average. there were six failures of lsg: three patients had gained weight despite lsg and three patients had lost less than 25% of their ew within one year. three of these patients underwent gastric bypass operations that were successfully performed laparoscopically. major complications included leaking of the staple line necessitating reoperation (three patients), severe wound infection (two cases, one of them after conventional sg), minor wound infections (three cases), and postoperative gastro-esophegeal reflux (one case), resulting in an overall complication rate of 5.1% for severe and 4.8% for minor complications. there was no operative mortality. conclusions. laparoscopic gastric sleeve resection is an effective and safe procedure with encouraging intermediate results. there is no implantation of foreign material, the procedure is less invasive than malabsorptive techniques. in the case of failure, it can readily be converted to gastric bypass or duodenal switch (with or without biliopancreatic diversion). on the other hand, this method has yet to stand the test of time within the spectrum of bariatric surgical procedures. background. bariatric surgery is indicated in patients with a bmi exceeding 35 and presenting comorbidities or bmi !40. lgb is accepted as one of most successful surgical procedures to treat obesity. aim of study: a prospective analysis of the first 30 patients who had been treated with lgb in our centre. methods. according to our treatment protocol at least 3 dietetic attempts have to be failed to enrol the patient in the surgical program. lgb is performed in patients with a bmi !35 with comorbidities or a bmi ! 40 when gastric banding is unlikely to succeed. thirty patients (f:m ¼ 21:9) with a mean age of 47 (35-75), mean bmi 44.6 (sd 6.11%) underwent an antecolic, laparoscopic gastric bypass, performing the gastro-enteric as well as the entero-enteric anastomosis with linear stapler, closure of the enterotomies with manual continuous suture with pds, closure of the mesenteric defect with a non absorbable running suture. the postoperative controls had been performed on month 1., 2., 3., 6. and 12. calculating the corresponding bmi. results. perioperative morbidity: two reoperations due to intestinal obstruction, two intraluminal bleeding of the anastomotic suture line, one case treated endosopically, one conservatively, no mortality was observed. the ewl 12 months after performance of lgb was calculated to be 54% (sd 15%). conclusions. this series document that acceptable results may be achieved even during the learning curve of laparoscopic gastric bypass. background. in up to twenty five percent of morbidly obese patients restrictive procedures as vertical banded gastroplasty (vbg) or adjustable gastric banding (lagb) do not lead to adequate weight losses. transformation to a gastric bypass represents a therapeutic option in these patients. methods. from 2002 to 2006 revisional gastric bypass was performed in 50 patients (24 after vbg, 25 after lagb, and 1 after sleeve gastrectomy). the main indication for redo surgery was inadequate weight reduction. results. four (8%) surgical complications (incarcerated trocar hernia, intra-abdominal abscess, subphrenic abscess, leakage gastro-jejunostomy) occurred and had to be treated by a reoperation. one patient died of septic shock caused by a subphrenic abscess resulting in gastro-jejunal leakage and peritonitis (mortality rate: 2%). on follow-up patients after complications lost equal amounts of excess weight compared to uncomplicated cases. conclusions. revisional gastric bypass is a safe and potentially effective option for patients with inadequate weight loss after restrictive surgery. however, postoperative morbidity and mortality rates are higher compared to primary operations. operational cost accounting reflects in an impressive manner the medically already evident advantages for our patients. a laparoscopically performed colon resection with fast tracking costs e 8.251,57 including pre-and post-surgical hospitalization. the same procedure without fast tracking results in costs of e 8.470,50. open colon resection including fast tracking adds up to e 8.720,05. conventional procedure without fast tracking even amounts to e 13.455,59. furthermore combining the operational results with the economical calculation results in a cost cutting potential of an extra e 608,71 per person, who has undergone laparoscopic surgery and was treated with fast tracking. in conclusion it can be stated, that this strategy of treatment means not only a severe post-surgical improvement of quality of life but in addition also shows significant economical advantages. the best method of treatment from both the medical but also the economical point of view is therefore the combination of laparoscopic colon surgery with fast tracking. 246 is the laparoscopic sigmoid resection with a primary anastomosis in acute sigmoid diverticulitis the optimal surgical therapy? background. the late elective laparoscopic sigmoid resection for diverticulitis has become an acceptable therapy for diverticulitis, but the optimal surgical procedure of the acute diverticulitis has not been established. the optimal waiting period after acute symptoms of diverticular disease is still discussed controversial. the resection and primary anastomosis in acute diverticulitis may advance the challenging process for this surgical approach. methods. from may 2005 to january 2007 a laparoscopic sigmoid resection was performed in 55 patients (male: 28, female: 27) with a sigmoid diverticulitis. the average age was 54 years for the males and 61 years for the females. 19=55 patients were operated early elective within 10 days after acute signs of diverticular disease (according to hansen and stock grade iia and iib) by a single surgeon, and 36=55 patients late elective by different surgeons. from all patients the clinical course, the operative time, the length of the sigmoid resection, the post-operative hospitalization and the complication rate were evaluated. results. according to the asa-classification 14=55 patients were graded as asa i, 36=55 as asa ii and 5=55 as asa iii. patients were divided in three groups. group i (19=55): early elective operations, group ii (11=55): late elective operations but with intraoperatively signs of an acute diverticulitis and group iii (25=55): late elective operations without manifestations of an acute process. the average operative time in minutes was in group i: 119 (range 60-168), group ii: 154 (range 91-240) and group iii: 126 (range 67-286). the length of the resection specimen was comparable in group i and iii with an average length of 174 mm, in group ii 191 mm. the average extent of hospitalization was in group i: 7.6 days, group ii: 7.1 days and group iii: 8.6 days. none of the patients had conversion to laparotomy. complications were: group i one wound seroma, group ii one ureteral injury, one incision hernia and group iii three wound infections, one anastomotic leak and one incision hernia. since the localization and operative technique of the wound suturing was varied, an incision hernia was not observed. conclusions. the advantage of the early elective sigmoid resection after acute sigmoid diverticulitis is a short one-stage hospitalization with a low complication rate. in experienced centers the laparoscopic early-elective sigmoid colectomy seems to be a feasible and optimal surgical procedure for the acute sigmoid diverticulitis. 247 laparoscopic resections for colorectal diseases: indications, operations, results s. riss, c. bittermann, p. dubsky, f. herbst background. laparoscopic assisted surgery for colorectal diseases has potential advantages over the traditional open technique. several studies reported that the laparoscopic approach offers multiple benefits such as faster recovery, better cosmesis, a lower incidence of adhesion-related complications and incisional hernias. the current study was designed to assess the role and feasibility of laparoscopic procedure in colorectal surgery. methods. from 1997 to 2006 309 patients (174 females, 135 males) underwent laparoscopic colorectal resections. mean age was 42 (range 15-99 years) with a mean body mass index of 20.9 kg=m 2 (range 14.0-52.2 kg=m 2 ). indications included benign (inflammatory bowel diseases, diverticulitis, slow transit constipation, colon adenoma, fap) and malignant conditions with curative and palliative intent. all operations were performed or directly supervised by one single surgeon. intraand postoperative parameters were documented and statistically analysed retrospectively. results. over a 10 year period 404 operations in 309 patients were performed, including 352 bowel resections (66 malignant) and 350 anastomoses. average duration of operation was 150 min (range 50-420). the mean time of hospital stay was 8 days (range 3-30). the total conversion rate was 2.2%. postoperative complications were observed in 37 patients: surgical complications occurred in 24 cases, with 10 patients requiring reoperation (bowel obstruction n ¼ 3, anastomotic leak n ¼ 4, trocar hernia n ¼ 2, anastomotic bleeding n ¼ 1). thirteen patients developed medical complications after operation and were treated conservatively. one patient (0.3%) died due to cardiorespiratory failure. conclusions. the present study included a wide range of indication criteria. notable, despite a high number of patients with inflammatory bowel diseases, there was a low rate of surgical complications. thus the minimal invasive approach seems to be safe and effective for a broad spectrum of colorectal diseases. 248 rectal carcinoma in the era of ''minimal invasive''-and ''fast track''-surgery p. razek, c. kienbacher, a. tuchmann background. laparoscopic surgery for colon cancer is feasible and effective with good results in regard of postoperative recovery. fast track protocols are changing perioperative treatments to the same aim. at the time there are no randomized studies available to compare the effect of laparoscopy and fast tract strategies to an open and conventional procedure for rectal carcinoma, which is still surgical standard. methods. from 2002 to 2006 60 patients were operated laparoscopically for rectal cancer (31 males and 29 females; mean age 64a, 48a-83a). patients staged t4 were excluded. excessive preoperative surgery (i.e. right hemicolectomy, sigmoid resection, prostate resection), severe cardiac and pulmonary diseases or a high bmi did not effect the indication for laparoscopy. 20 patients, (33%) staged t3 preoperatively, received chemotherapy and long time radiation. in the first period (-ii=2004) 17 patients were treated according to a conservative perioperative management. thereafter (2004) (2005) (2006) a fast track protocol was applied to the following patients. results. abdominoperineal extirpations (n ¼ 12), anterior resections in double stapler technique (n ¼ 36) and coloanal anstomosis (n ¼ 12) were performed. conversion to open surgery was necessary in two cases (3.33%), [bulky disease and a narrow male pelvis (n ¼ 1), anatomical reasons (n ¼ 1)]. operation time was long and varied from 145 to 500 minutes (mean 237 minutes). r0 was achieved in 94% (2 patients with metastatic disease were staged r1, one patient with a colonic wall lesion and potential spillage). postoperative stay for the laparoscopic group was 14 days, for the combined laparoscopic þ fast track group was 8 days (in comparison with 21 days for conventional and open surgery). complications, mortality and side effects were reported. conclusions. exceptional view inside a narrow pelvis by the means of laparoscopy creates good conditions for total mesorectal excision and nerve sparing technique. minimal invasive surgery reduces the surgical trauma as a basis for an early postoperative recovery. the combination with a fast track protocol furthermore helps to establish even better results. 249 the importance of laparoscopy in the management of postoperative complications c. kienbacher, p. razek, p. patri, a. tuchmann background. postoperative complications, especially anastomotic leakage after laparoscopic colon surgery are a hazard for all surgeons. most important is to recognize the early signs of complications such as abdominal pain, fever, chill, persisting nausea and vomiting and increasing abdominal swelling. the erlier a reintervention is done the better is the outcome for the patient. requesting a single and sufficient procedure, most surgeons don't even think about a minimal invasive reintervention. from 07=02 until 01=07 389 patients underwent laparoscopic colon surgery, 35 patients had to be reoperated. twenty-five patients had a relaparoscopy, only two times we converted to the open procedure. 4 patients had to underwent primarily open abdominal surgery, 8 patients had abdominal wall problems and did not need an intraabdominal procedure. methods. concerning the intraabdomial complications we performed 8 laparoscopic washouts, 2 patients had a laparoscopic incisional hernia repair, 2 patients bleeded from the trocarincisions, a laparoscopic anastomosis resection was performed, 5 patients got a laparoscopic ileostomie, 4 times it was necessary to perform a laparoscopic bowel diversion and 5 times the hartmann procedure was performed minimal invasive. results. the traditional open reinvention was required in 4 patients, all showed a peritonitis and a colon diversion with stomatherapie was done. eighteen patients had a single reintervention. after laparoscopic redos the median postoperative stay was far shorter than after open procedure. 4 patients died. conclusions. laparoscopic reinterventions are feasable in most cases, the advantages are less postoperative pain, shorter hospital stay, quicker return of bowel fuction and improved cosmetic results. 250 compensatory sweating after endoscopic sympathetic block at t4 background. endoscopic thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis (hh). compensatory sweating (cs) is the most frequent unwanted side-effect of this surgical procedure. recently, clip application (endoscopic sympathetic block, esb) has been introduced as it provides reversibility. furthermore, sympathetic block solely at the level of the 4 th thoracic ganglion (t4) was proposed to reduce cs and still effectively cure palmar hh. the aim of the study was to analyze the outcome of patients treated by esb at the level t4 with special reference to cs. methods. between 2001 and 2005 112 patients (mean age 30.4 ae 9.1 years) prospectively underwent 223 procedures (one unilateral and 111 bilateral operations). satisfaction rates and quality of life scores have been evaluated. mean follow up was 21.9 ae 10.1 months obtainable from 106 patients (94.6%). results. one hundred and three patients (92.0%) had palmar, 87 (77.7%) axillary and 75 (67.0%) combined hh. at follow-up, all patients with palmar and 88.3% with axillary hh were completely or nearly dry. cs was observed in 18 (17.0%) patients. most frequently, the back (72.2%), the thighs (38.9%), the abdomen (33.3%), the feet (33.3%) and breasts (22.2%) were affected. in 38.9% one single body region was affected, in 27.8% two and in 22.2% three regions became humid. cs significantly diminished quality of life (p < 0.05 for both questionnaires). consequently, 16.7% were unsatisfied with the final outcome. however, the vast majority of patients were completely or almost completely satisfied. conclusions. esb at t4 gives excellent results for palmar and good results for axillary hh. however, cs primarily affecting the back and the thighs diminishes patients' quality of life and satisfaction. right donor nephrectomy, a major challenge is adequate renal vein length, due to vascular anatomy. methods. all patients undergoing laparoscopic donor uretero-nephrectomy between 2004 and 2006 were included. side of nephrectomy was selected based on selective renal function assessment and vascular anatomy. standard laparoscopic access was gained through 4 trockars, the kidney dissected from its capsule, the vessels isolated, and the ureter transsected. following transsection of the renal artery (proximal closure with clips to maximize retrieved vessel length), and the renal vein (proximal closure with vascular stapler), the organ was procured through a mini-laparotomy connecting two trokars. in laparoscopic assisted right nephrectomy, the vein was retrieved with a vena cava patch using a semi-open approach: following isolation of the vascular structures and ureteral transsection, the confluens of the renal vein with the inferior vena cave was excluded using a curved clamp through a mini-laparotomy in the right upper quadrant. the caval patch was created by cutting the vein closely distal to the clamp, with reconstruction of the vena cava by a running blalock suture. patients undergoing laparoscopic assisted right resection (study group sg) were compared to patients with laparoscopic left nephrectomy (control group cg). data are reported as mean ae standard deviation or total numbers (% . total morbidity was 9 (31.0%), including 3 (10.3%) infections, and 2 (6.9%) postoperative lymphatic leaks. two (6.9%) major complications (bleeding (1) and intraabdominal abscess (1)) resulted in reoperation (sg 0 vs. cg 2; p ¼ 0.680). conclusion. the laparoscopic assisted approach to right kidney procurement is feasible, allows for sufficient length of the right renal vein for transplantation, and donor morbidity is comparable to laparoscopic left nephrectomy. 252 clinical implementation of radius surgical system in mis w. feil, i. pona, t. filipitsch, p. jiru, u. satzinger limited mobility of instruments and absence of depth perception are significant issues in advanced laparoscopy. by that procedures including complex suturing and anastomoses in narrow operating fields in difficult angles of visualisation exceptionally challenge experienced surgeons. the radius surgical system (tübingen scientific medical gmbh, tübingen, germany) consists of 2 manipulators for mis (right and left hand) suitable for 10 mm trocars allowing a 360 freedom of movement comparable to robotic devices. the instrument tip can be deflected by 70 by handle deflection and rotated 360 via handle knob. compressing and releasing of the instrument jaws works conventionally. radius system was implemented in the ekh vienna by 12=06. in advance a 2-day training course was absolved by the surgical team. radius system was used for a series (n ¼ 12; 01=06) of reflux operations to perform hiatal suturing and fundoplication. in practice handling of radius taking advantage of all features turned out so physically mandatory, that a training course is unanimously recommended even for surgeons with experience in all mis suturing techniques. in pratice the needle could be guided with significantly higher precision if compared to convention needle-holders. even suturing in narrow cavities and in difficult angles became feasible (video). after full accomodation to radius the next step of implementation is the creation of handsewn anastomoses, esp. in bariatric surgery. precision, reliability, safety and tightness of sutures and sewn anastomoses are crucial for the outcome quality of advanced mis procedures. for that the radius surgical system has shown to be extremely beneficial. 253 does lifting of the abdominal wall for the set up of the pneumoperitoneum for laparoscopy increase the safetiness? a. shamiyeh 1 , j. zehetner 1 , h. kratochwill 2 , k. hörmandinger 1 , f. fellner 2 , w. u. wayand 1 background. to evaluate the intraabdominal changes while lifting the fascia with regard to the distance between the fascia and the retroperitoneal vessels and the intestine for access in laparoscopy. fifty percent of all complications during laparoscopic procedures occur during the establishment of the pneumoperitoneum. the blind insertion of the veress needle is the most popular way of access. elevation of the abdominal wall or the fascia is recommended, though the benefit has not been proven yet. methods. for 10 patients scheduled for laparoscopic cholecystectomy the operation started in the ct scan. after orotracheal intubation a ct scan was performed of the umbilical region with 10 cm proximal and distal margin. after a supraumbilical incision the fascia was freed and elevated with stay sutures. during maximal elevation, a second ct scan was performed. the distance between the fascia and the intestinal structures (small bowel) and the retroperitoneal vessels (iliac artery, aorta, vena cava) was measured after both scans and the difference was evaluated. results. lifting of the fascia increased the distance between the fascia and the intestinal structures with a mean of 1.92 cm (range 0.87-2.67 cm), the distance between the fascia and the retroperitoneal vessels with a mean of 7.83 cm (range 3-11 cm). conclusions. elevation of the fascia at the umbilical region prior to the first entering into the abdominal cavity for laparoscopy does increase the safeties due to enlargement of the distance between the fascia and the intraabdominal and retroperitoneal structures. background. despite many years of experience in breast reconstruction even as an immediate one stage procedure, there are still rumours about this technique, even among oncologic surgeons. these are concerning the influence on the oncological outcome, radio-and chemotherapy, severity of the operation, possible complications and patient's satisfaction. the presentation offers answers to most of these rumours from our own experience and the recent literature. methods. one hundred and eighty breast reconstructions were performed between 2003 and 2006 in our department, 95 as immediate and 85 as delayed procedures. eighty-seven were done with microsurgical autologous flaps and 54 with a latissimus dorsi flap, in the rest various techniques like prostheses and expanders were applied. patient data were collected concerning early and late complications, oncological outcome, influence on radio-and chemotherapy and patient's satisfaction. results. reconstructions with prostheses required shorter operating times, but mostly late revisions were more frequently, especially in combination with radiotherapy. among the group of patients, in whom flaps were applied, only one was lost. with increasing experience, the need for blood transfusions, the postoperative morbidity and the length of the hospital stay decreased. in no case radio-or chemotherapy had to be delayed due to immediate breast reconstruction. secondary axillary lymph node dissection due to a positive sentinel node was possible even after a flap which was pedicled in the axillary vessels. our experience is well reflecting the results of the recent literature. conclusions. despite many existing rumours breast reconstruction, even as an immediate single stage procedure, can be regarded as an operation which does not inflict the oncological therapy. to optimise the results, however, indications must be set very carefully. background. positron emission tomography with the glucose analog [18f]-fluorodeoxyglucose (fdg-pet) has been used for response evaluation in patients with esophageal squamous cell carcinoma (escc) during neoadjuvant radiochemotherapy (rtx=ctx). this prospective study was undertaken to compare fdg-pet assessment of tumor response during rtx=ctx with histopathology in patients with escc, and to correlate the findings with survival. methods. sixty-one patients with histologically proven escc (ct3, cn0=þ, cm0) underwent preoperative, simultaneous rtx=ctx followed by esophagectomy between 1996 and 2004. the patients underwent fdg-pet prior to and 2 weeks after the begin of rtx=ctx (20gray). histopathological response was quantified as the percentage of residual tumor cells. the threshold pre-therapy-to-during-therapy decrease in standardized uptake value by fdg-pet used to define metabolic responders (ásuv r ) was à30%. results. receiving-operator-curve analysis (roc) for determination of metabolic response revealed an area-under-curve (auc) of 7140 (p ¼ 0.005) with a sensitivity of 76%, specificity (70%), a positive predictive value of 81% and a negative predictive value of 64% (p < 0.0001). responder by fdg-pet during the neoadjuvant treatment (p ¼ 0.016) as well as histopathology (p < 0.0001) showed substantially better survival compared to nonresponders. conclusions. changes in tumor metabolic activity by fdg-pet during neoadjuvant rtx=ctx allows an accurate determination of response due to the multimodal approach in patients with escc. this stratification may lead to a change of the neoadjuvant into a definitive therapy concept in nonresponders (individualized tumor therapy). background. totally endoscopic coronary artery bypass grafting (tecab) requires telemanipulation technologies because attempts using conventional thoracoscopic instrumentation have completely failed. these complex operations take individual and team learning curves and a stepwise approach is necessary. methods. from 2001 to 2006 161 cabg procedures were performed using the davinci tm system. a low risk patient population (age 59 (31-76) years, euroscore 1(0-7)) was treated. the following procedures were carried out: endoscopic ima takedown in midcab, opcab, and cabg (n ¼ 25), robotic suturing of lima to lad anastomoses through sternotomy (n ¼ 30), single vessel tecab (n ¼ 95), double vessel tecab (n ¼ 11). results. the number of totally endoscopic approaches through ports only increased from 13% in 2001 to 94% in 2006. there was no hospital mortality and cumulative risk adjusted mortality (cram) plots showed that 2.48 predicted events did not occur. given 161 event free procedures clopper pearson estimations revealed a 95% confidence interval between 0.0% and 2.3% for perioperative mortality. cumulative 5 year survival was 99%, and 5 year freedom from angina was 97%. conclusions. introduction of robotic totally endoscopic coronary artery bypass grafting seems to meet current cabg safety standards. initial application in low risk patients and a stepwise approach to completely endoscopic versions of the operation seem worthwhile. using this way single and double vessel tecab can be performed. intermediate term survival and revascularization results appear to be very satisfactory. icu stay was a mean of 1 day in both groups and hospital stay lasted on average 8.667 ae 3.000 days in the bh group and 7.000 ae 0.943 days in the ah group (p ¼ 0.133). the advantages of arrested heart tecab are various -more space through the relaxed heart, -superior anastomosis quality through the arrested heart, -no manipulation of the lad with tapes and a clear operating field through the use of crystalloid cardioplegia, -no occlusion of the lad with the risk of ischemia, and result in shorter anastomosis as well as operating times and do not increase icu and hospital stay. methods. initially an experienced gi-surgeon was trained in an experimental centre in the application in both, open and laparoscopic application of the flexible shaft stapling system. after 4 experimental sessions the system was used in clinical open surgery in 20 cases before the laparoscopic approach was used. for laparoscopic procedures a stepwise learning curve was applied (from laparoscopic appendectomy, colon resection to laparoscopic gastric resection and esophageal resection). for intraabdominal application of the linear stapling device a 15 mm trocar and for the circular stapling device a 33 mm trocar was used. technical problems, operation time and operative complications were prospectively documented. results. the flexible stapling device was used in 134 patients (77 conventional, 57 laparoscopic surgery). a mean of 2 stapling procedures (range 1-6) was performed per patient. during the early phase technical problems were observed in 4 patients (1 formation of gastric tube for esophageal reconstruction, three formations of colonic anastomoses). all problems were solved by repetition of the anastomoses. nine leakages (6.7%) were observed: two after esophageal surgery (2=16; 12.5%), one after gastric surgery (1=21; 4.8%) and six after colon surgery (6=76; 7.9%). conclusions. the flexible shaft stapling device is safe in open and laparoscopic surgery. technical problems in the early phase were not due to malfunction of the device. the problems and complications are within the limits of conventional stapling. since there is a learning curve for handling, proper training in laparoscopic and open surgery is advised. the new flexible stapling device showed beneficial in special indications in laparoscopic surgery. the handling of the device is possible in any location in the abdomen, which makes procedures like collis-plasty feasible to be performed laparoscopically. circular stapled anastomoses of the colon above the rectosigmoid junction can easily be performed in circular stapling technique. background. intra-und extraplexuale nerventransfers kommen routinemäßig in der rekonstruktion posttraumatischer plexus brachialis läsionen zur anwendung. in den letzten jahren wurden einige neue selektive distale nerventransfers beschrieben, welche ein geringes defizit an spendernerven hervorrufen, möglichst nur motorische fasern beinhalten und ein hohes maß an funktioneller synergie besitzen. in der vorliegenden retrospektiven arbeit werden die operativen details, und langzeitergebnisse von patienten bei welchen diese techniken zur anwendung kamen vorgestellt und analysiert. methodik background. long lasting brachial plexus lesions (bpl) require free functional muscle transplantation to restore some distinct motor function. methods. five patients, receiving a total number of 7 free vascularized muscle transplants are presented. all patients were male, aging 9, 10, 11, 30 and 45 years. 2 patients suffered from obstetrical, 3 from traumatic bpl. unstable shoulder (n ¼ 4) and lacking biceps function (n ¼ 3) were the indications for surgery. the gracilis muscle was used in 6 cases to replace deltoid (n ¼ 3) and biceps (n ¼ 3). in one case a rectus femoris muscle was transferred into deltoid position. reinnervation of the muscle transplants at the shoulder was perfomed end-to-side to the spinal accessory nerve. in biceps position the motor nerves of the gracilis were coaptated end-to-end with the ulnar nerve (oberlin procedure, n ¼ 2) or intercostal nerves (n ¼ 1). results. surgery was successful in all cases primarily. all transplants showed reinnnervation starting 6 months after surgery. stabilisation of the shoulder was achieved in all 4 cases, furthermore 3 of these cases regained active shoulder abduction= flexion up to 90degree. 1 gracilis in biceps position reached m4, 2 are reinnervating. conclusions. free vascularized muscle transplantation seems to represent an useful tool for reconstruction of some distinct, essential motor function in paretic limbs due to bpl. background. since viterbo presented his exquisite results from terminolateral coaptation in small animals a new source for neurotisation seemed to be provided. viterbos results and our own good experience with free functional muscle transplantation encouraged us to use the technique in brachial plexus surgery. in a retrospective analysis we wanted to prove whether or not terminolateral neurorrhaphy produces functional results in brachial plexus surgery. methods. in 6 patients, suffering from minimum c5,6 avulsion and=or rupture a total of 8 terminolateral procedures was carried out: 6 times the suprascapular nerve was connected with the spinal accessory nerve and 2 times the biceps motor nerve with the ulnar nerve, after creation of an epineureal window in all cases. results. patients were investigated 24.5 (ae10) month after surgery. the modified oberlin procedures (n ¼ 2) showed m0. the ss to xi procedures ranged from m1 (n ¼ 1) to m3 (n ¼ 5). multichannel emg evaluation did not reveal isolated function of the reinnervated muscles but action in parallel with the ''source muscles''. in 5 out of 8 procedures the terminolateral neurorrhaphy was sufficient to regain useful muscle function, i.e. to stabilise the shoulder and to add some minimal active function. conclusions. with respect to the severity of the lesions one might consider this an acceptable result. actually we did expect better results from the procedures, as we did achieve m4 and m5 function with free functional muscle transplantation and terminolateral neurorrhaphy in children. regarding our experience, the technique represents an useful tool for reinnervation, provided an unimpaired function of the donor nerve. 275 current concept for treatment of obstetrical brachial plexus lesions w. girsch background. for a long time the treatment of obstetrical brachial plexus lesions (obpl) consisted of conservative treatment mainly. surgery was indicated only in severe cases suffering from persistant complete flail arm. gilbert introduced a much more aggressive concept with surgical intervention whenever the biceps is not working at three months of life, a strategy which caused discussions permanently. as a result of this discussion and with respect to clarkes work the concept was modified in the last years again. methods. the diagnosis of an obpl has to be followed by monthly clinical examinations. testing for muscle regeneration is not only focussed on biceps muscle but also on time and topographic course of regeneration. lack of shoulder and biceps activity at three months of life or negative ''handkerchief-test'' at six months represent indications for immediate surgical revision of the brachial plexus (primary early nerve surgery). in cases showing ongoing regeneration the conservative treatment is maintained. relevant deficiencies in motor function (less than 50% of rom or power in correlation with the unaffected side) at twelfe months of life represent an indication for brachial plexus surgery again (primary late nerve surgery). further nerve procedures, usually isolated nerve transfers (secondary late nerve surgery), can be performed in selected cases up to two years of life. after that time musle transfers and osteotomies (secondary procedures) are perfomed to achieve further increase in function. results. in brachial plexus surgery new concepts of ''extraplexual neurotisation'' and ''end-to-side neurorraphy'' have increased the possibilities of reconstruction by increasing the amount of nerve sources. secondary procedures, including free functional muscle transplantation, have become an integrative part of the overall treatment strategy. conclusions. although obstetrical techniques have improved in the industrialized countries, there still exists an incidience of 1-2 obpl per 1000 newborns, last but not least with regard to an increasing number of babies weighing more than 4500 g. it is known that 8 of 10 obpl recover spontaneously. new investigations have revealed relevant deficiencies in 4 out of 10 of these children at an age of 15 years. actually the number of children requiring surgery is small. but for these children it is important to make the right decisions in time to minimise deficiencies and achieve optimal results. 276 external derotation osteotomy of the humerus in patients with erb's palsy -effects on upper extremity kinematics b. gradl, m. mickel, m. schmidt, g. weigel, a. kranzl, w. girsch orthopädisches spital speising, kinderabteilung, wien, austria background. patients with untreated upper brachial plexus lesions frequently develop an internal rotation contracture of the shoulder, deficient active shoulder abduction and especially external rotation. the humeral derotation osteotomy combined with muscle transfers is one of the most common secondary reconstructive procedures to correct this deformity and improve the upper limbs function. the aim of this study was to investigate the patients' benefit of the surgical intervention. in order to objectively assess the functional outcome an optoelectronic motion analysis system was used to capture and analyze the kinematics of the involved limbs pre-and postoperatively. methods. eight children with secondary deformities following an obstetrical erb palsy were investigated before and after humeral derotation and muscle transfers. the patients' movements were captured by tracking the reflective markers which were applied to the upper limb and the trunk. the motion analysis was finished on the pc, resulting in various kinematic parameters, such as joint angles, motion curves, velocity and acceleration. static data was calculated to measure the amount of the shoulder malposition. results. results of the motion analysis document a dynamic as well as a static improvement of the involved limb in all eight patients. the average effective external derotation of the upper arm was 30 , which means a correction to a nearly physiologic rotational positioning. active abduction increased in 7 of 8 patients with enhancement between 5 and 27 . active shoulder rotation improved in all patients ($10 ). the maximum active elbow flexion did not increase, but the motion curves describing the movement changed: the velocity increased (24%), the compensatory shoulder abduction, which was observed during elbow flexion preoperatively in all patients, was reduced to a physiologic extent (compared to healthy probands). conclusions. derotation of the humerus as a secondary procedure allows functional improvement in patients with erb's palsy. this can be assessed by using a 3d motion analysis system. following global or lower brachial plexus lesions with intact biceps function in combination with missing radial nerve and weak median nerve function a supination contracture of the forearm is resulting. the supinated position of the forearm is functionally useless and often causes neglect of the extremity. five patients underwent surgical correction of this deformity, 3 females (aging 10, 19 and 28 years) and 2 males (aging 8 and 10 years). the biceps tendon was rerouted to the outside of the radius in 4 cases and to the medial side of the ulna in one case. additionally correction osteotomies of radius and ulna had to be performed in the 28 y old patient. reconstruction of extensor function was done in classical manner by tendon transfers. the tendon transfers did not only reanimate the extensors of carpus and hand but also augmented the light pronation of the forearm. all patients regained normal biceps and some simple hand function. regarding this, all patients started to use the extremity during adl for some, mostly bimanual tasks. correction of the supination contracture was highly beneficial for the patients. the procedure changed a useless extremity into a functioning part of the body. background. reconstruction of the distal weight-bearing area of the foot is surgical challenge, especially in diabetic patients. skin grafts do not provide adequate and permanent coverage of a weight-bearing region. local surgical options to cover these distal skin defects include forefoot amputation, a toe fillet flap and a reverse medial plantar island flap. the reverse medial plantar island flap is based on a very thin and possibly damaged intermetacarpal network. conventional angiography often is not a helpful tool for preoperative assessment, because foot vessels often remain occult. methods. the purpose of this study was to evaluate the viability of the distally based medial plantar flap in 40 cadavers. angiographic imaging was possible in only 19 cadavers reflecting the clinical preoperative assessment. distally based medial plantar flap dissection was done in all cadavers, as well as vascular dissection of the superficial and deep plantar arch. results. we found a well developed deep plantar arch in all cases. the deep plantar artery formed the main feeder of the deep plantar arch in 79%, while the second proximal perforating artery contributed to the deep plantar arch in 41%. the superficial plantar arch usually appeared slender and incompletely. conclusions. the distally based medial plantar flap could be dissected in all cadavers, whereas the quality of vessels was varying explicitly. the results of dissection always showed a constant vascular supply, but varying quality of supply. no clinical conclusions can be drawn, considering the slender vas-cular supply of the distally based medial plantar flap. optimized diagnostic angiographic procedures like mra or biplane selective dsa are essential for preoperative assessment planning distally based medial plantar flap. 282 limberflap -salvage procedure for the non healing pilonidalis sinus t. kapp, h. marlovits, j. beck, f. hetzer kantonsspital st. gallen, switzerland background. surgical treatment of pilonidal sinus disease has a significant morbidity and recurrence rate. the rhomboid flap of limberg is a transposition flap that has been advocated for treatment of this condition. we present the technique and our experience. methods. in a prospective study starting in january 2006 we analysed 16 consecutive patients (6 females), median age 24 years (range 19-38 years), with recurrent pilonidal sinus disease. we performed a complete rhomboid excision and closed the lesion by an excentric transposition flap designed to obliterate the middle cleft. morbidity was recorded and patient's satisfaction was analysed by a visual analog scale (vas). results. the median hospital stay was 5.9 days (4-7 days). we found in all patients a primary healing. minor complications were found in two patients. there was one flap oedema and one wound dehiscence, which were conservatively treated. no wound infection was observed. during the median followup of 8 months (2-12 months) no recurrence occurred and high patient satisfaction was noticed. conclusions. although the limberg flap results in a slight asymmetric gluteal region patient's acceptance is high. fast healing, low complication and recurrence rate are the important advantages for this procedure. 283 treatment of human painful neuromas and complex regional pain syndromes (crps) by co 2 laser welding and regional subcutaneous venous sympathectomy (rsvs) -a new surgical approach w. happak, l. kriechbaumer background. since nearly 200 years the treatment of painful neuromas is an unsolved problem. up to 150 techniques are described with a recurrency rate of the pain between 20 and 50%. the intramuscular transposition, the implantation into a vein and the end-to-side coaptation of the nerve stump are the state of the art operations. besides for 140 years the treatment of complex regional pain syndromes type ii (crps ii) has been an unsolved problem. therapeutic approaches have included conventional pain medication, physical therapy, sympathetic blocks, transcutaneous or spinal cord stimulation, injections or infusion therapies and sympathectomy. alone or in combination these therapies often yielded unfavorable results. the majority of physicians, dealing with crps patients are convinced that surgical treatment only exacerbates the symptoms, and after the third neuroma pain-operation no improvement can be expected. after unsuccessful anaesthesiologic pain therapy over more than 6 months, 160 patients, with chronic neuroma or phantom pain were operated by co 2 laser welding of the nerve stump in the last 10 years. one third of the patients had 3 or more pain operations. subsequently 16 patients developed a crps type ii at the upper or the lower limb. the exact pain area was determined and the most proximal part where the crps commenced was infiltrated with 2% xylocain. when the sympathetic, deep, burning pain could be blocked, the subcutaneous veins in the previously determined area were removed surgically in a second step. a visual analogue scale (vas), the nottingham health score (nhs) and physical examinations were used to evaluate outcome of the operation. results. ninety-five percent of surgically treated painful neuromas and crps type ii patients showed significant improvement of limb function, the visual analogous scale (vas) and the nottingham health score (nhs). the medical pain therapy could considerably be reduced. conclusions. the presented data show that the superficial epicritical pain of neuromas can be treated successfully with co 2 laser welding. the sympathetic, deep pain of the complex regional pain syndrome type ii can be treated successfully by a regional subcutaneous venous sympathectomy (rsvs). 284 first clinical study of successful erbium-yag laser vaporisation of cutaneous neurofibromas l. kriechbaumer, w. happak background. with a prevalence of 1 in 3000 births neurofibromatosis type i is one of the most common genetic defects. the mode of inheritance is autosomal dominant and affects a gene (nf1), which is responsible for the production of the tumor suppressor protein neurofibromin. the consequence is an uninhibited expansion of neural tissue which leads to cosmetic disfigurement of the patients. in comparison to the plexiform neurofibromas the cutaneous tumors do not undergo malignant transformation. excision and co 2 laser vaporisation were established as standard treatment but cause unattractive scars. methods. in 6 operations on two patients more than 2000 neurofibromas were removed with an erbium:yag laser. the tumors were dissected by shooting holes into the skin and vaporising the neurofibromas in-between or underneath. from test areas several biopsies were harvested for er:yag-, co 2and electrosurgical treatment in vitro to evaluate the difference of thermal necrosis histologically. photographs were taken to assess the cosmetic results. results. the fast healing by second intention as well as the minimal discomfort and scar formation following er:yag laser vaporisation was judged as excellent by patients and surgeons. we did not observe any hypertrophic scarring or lasting dyspigmentation. histologic evaluations revealed minor thermal damage to adjacent tissue resulting from this laser. conclusions. scars and changes in pigmentation resulting from excision or co 2 laser-vaporisation often yield unfavourable results and the treatment is time consuming. er:yag laservaporisation of huge numbers of cutaneous neurofibromas is an uncomplicated and rapid procedure that achieves excellent cosmetic effects. background. lichen sclerosus usually presents a precancerous skin lesion of the genital region. skin grafting of penile defects is difficult because of the flexibility of the underlying recipient bed. this leads to disruption of the vascular ingrowth into the skin graft and compromises the results of the reconstruction. methods. we successfully used a circumferential vacuumassisted closure dressing with an incorporated urethral catheter to secure penile skin grafts in place during the early postoperative period. results. we achieved perfect take-rate of the graft and postulate good functional result concerning the stretched penile position during application of the vac-device. conclusions. a vacuum-assisted closure dressing can be used successfully to secure large and circumferential skin grafts, as well as skin grafts on concealed penises. background. there is a trend in reconstructive surgery towards modern techniques of defect coverage. such techniques are expected to combine high levels of safety, low donor-site morbidity, high aesthetic claims, short patient immobilisation and inpatient periods. the speculative applications for free, microvascular tissue transfers are expanded monthly while traditional reconstructive flap designs are no longer accepted as ''state of the art''. we present a case where modern defect coverage was not successful due to multiple comorbidities, localisation and complexity of the defect, and a step back to traditional flap designs was inevitable. methods. a previously healthy 60-year-old woman found a tumour on her back four years ago. diagnostic imaging and multiple biopsies revealed a 13 cm-diameter chondrosarcoma with partial osteolysis of th 11=12, tumour reaching into the spinal canal. she underwent radical resection and orthopaedic stabilisation from th9-l2, followed by chemotherapy and radiation of 52 gy. one year after the operation metastatic lesions were found in both lungs. they were resected by video assisted thoracic surgery. due to resection of the erector trunci, the spine stabilisators loosened, two screws broke and the metal parts penetrated the skin. after local necrectomy, vac-therapy was performed for more than one year. severe headache and massive exsudation of the wound started in 2006, suggesting dural leakage. a reversed latissimus dorsi-flap was performed, additional microanastomosis could not be done due to the very small calibre of the intercostal vessels. after one week, the metal-covering part of the flap showed muscle necrosis and had to be resected. a large fasciocutaneous transposition flap was designed and cautiously raised in 4 steps of delay and could finally cover the defect. results. in this rare case of a chronic vertebral defect including spinal instability and liquorrhea reconstructive aims could not be reached by microsurgical techniques but by returning to traditional local flap designs. the patient is mobile and painfree, and there is no recurrence of liquorrhea since discharge. conclusions. technical advances and refinements in defect coverage are the basis for progress in reconstructive surgery. selected indications for traditional flap techniques still remain in modern reconstructive surgery dominated by microsurgical tissue transfer to cover problem defects. 287 the missing link between tradition and innovation: skin tissue engineering l. kamolz, m. frey background. the need to achieve rapid wound closure in patients with massive burns and limited skin donor sites led to the investigation of in vitro cellular expansion of keratinocytes. the use of cultured epithelial grafts was first reported in the treatment of major burns. since 1981, support for the use of keratinocytes has varied. the factors potentially limiting the use of cultured keratinocytes were cultivation time, reliability of 'take', vulnerability of grafts on the newly healed surface and long-term durability. the aim of this review is to evaluate the real impact of the clinical use of keratinocytes. one of the main aspects is to introduce new methods, which found or will find their way into clinical practice. methods. this study is mainly based on our long lasting experience in cultivating and transplanting cultivated keratinocytes (more than 350 patients and 5600 sheets). results. the coverage of burn wounds with viable keratinocytes renders constant and reliable results. understanding keratinocyte-matrix interactions has not only allowed us to influence keratinocyte outgrowth, adhesion, and migration, but also has guided us to modify matrices for enhancing keratinocyte take. due to these improvements we have achieved a proper material in the adequate situation. conclusions. as surgeons, our goal is to help burn patients with the best quality of skin in the shortest time possible. as tissue engineers, we have not achieved the goal of a universal skin product yet, but by continually reviewing new options and using them, the anatomy and physiology of engineered skin substitutes will improve and they will become more similar to native skin autografts. thereby tissue-engineered skin may match the quality of split-skin autografts in future. background. the survival of patients with major burns goes hand in hand with early escharectomy and the survival of skin grafts. methods. the application of topical negative pressure has improved increased graft take especially in difficult anatomic regions. results. securing skin grafts in 18 pediatric burn patients enabled a near 100% graft take. perfect protection from shear forces, early mobilisation, patient comfort, nursing comfort and abandonment of splinting are major advantages concerning conventional dressings. conclusions. we postulate the application of vac for securing skin grafts as a valuable tool in pediatric burns management. wide meshed grafts and including donor sites protected by silicon layers into the dressing in extensive burns should be evaluated carefully because of possible bleeding. background. versajet is a high -pressure hydrosurgery system, which enables a very precise surgical procedure. this single device technique combining lavage, excision, cleansing and aspiration allows a sharp debridement on any surface, or space. there are lot different indications for the use of versajet in plastic and reconstructive surgery. this system is appropriate for a variety of burn and traumatic wounds. because of the precise handling the use of this device is also in cosmetic surgery possible. methods. in this device a high velocity stream of sterile saline jets across the operating window and into an evacuation collector. because of a physical effect, a localised vacuum is created across the operating window. this holds and cuts targeted tissue while aspirating tissue from the site. therefore it enables to precisely target damaged tissue and spare viable tissue. surgical techniques can be enhanced, for instance the device holds targeted tissue during irrigation and excision. in addition, versajet cleans and cools at the same time as debriding, so additional cleaning techniques are not required. the depth of the skin -debridement is absolute predictable. in about 100 cases the versajet has been used. the range of indications included burns, infected wounds (decubitus ulcers, traumatic wounds, fournier gangrene, necrotizing fasciitis). the advantage of this hydrosurgery system compared to sharp debridement using scalpels, dermatome, etc. is a more rapid and precise debridement, therefore the preservation of viable tissue, the precise and easy treatment of concavities and convexities and a reduction of blood loss could be achieved. histological findings proved the feasibility of an exact abrasion into different layers of the dermis. results. by using the versajet device, a reduction of the debridement procedures, an earlier reconstruction and a shorter time of hospitalisation could be achieved. the most important indication is the treatment of 2b burn-wounds. in 3 burn cases the necrosectomy with some other devices may be quicker and more useful. although there is a learning curve which is very short, this tool is easy to handle. there has been no adverse effects. conclusions. the versajet-handpiece is a disposable product, but because of the advantages it is at least cost-covering. debridement is highly effective since it enables selective tissue targeting. removal of non-viable tissue is more complete as a result. background. in 2005 more than 3500 children (age <5 years) were suffering from burns. the gold standard of surgical care is still under discussion. the aim of the study was to evaluate an optimised treatment regime for scalds in children. methods. between 1997 and 2002, 124 children underwent surgical intervention due to salds. thirty-six of them were enrolled into the study. twenty-two children with deep dermal scalds (total-body-surface-area burned (tbsa) 18.5%) were treated by early excision and keratinocyte-coverage (keratinocyte-group). fourteen children (tbsa 17.2%) were treated with autologous skin grafts (skin-graft-group). both groups were comparable according to age, burn depth and tbsa. the complete clinical follow-up was at least 17 months. the scar formations were classified (vancouver-scar-scale (vss) and the need of blood transfusions were administered. results. the use of keratinocytes led to complete epithelialisation. no secondary skin grafting was necessary. skin take rate was 100% in the skin-graft-group. the mean volume of transfused blood was 63.9 ml in the keratinocyte-group and thereby significantly lower than the volume of 151.4 ml, which was administered in the skin-graft-group (p ¼ 0.04). the vss observed in the keratinocyte-group was 2.33 and thereby significantly lower than the vss of 5.22 in the skin-graft-group (p ¼ 0.04). conclusions. in children the use of keratinocytes renders constantly reliable results in deep dermal scalds. it minimizes the areas of skin harvesting and reduces the amount of blood transfusions. the fact that also less scarring is observed leads to the conclusion that skin grafting should be restricted to full thickness scalds. background. ventriculo-peritoneal (vp) shunting is the treatment of choice for hydrocephalic children. however, serious complications related to infectious and non-infectious reasons may subsequently appear during lifetime of these patients. as we attend nearly all our patients from birth to adulthood we had to face various kinds of abdominal problems over the years. 364 hydrocephalic children underwent vp shunt placement. outcome and follow-up of these patients were discussed. results. our analysis showed that non infectious complications like: shunt dislocation, kinking and obstruction including some rare phenomenon are well described in literature and can hardly be avoided. but being confronted with various infectious complications we had to change our strategy over the years. severe shunt infection appeared after appendicitis in 9 patients. therefore we consequently performed elective appendectomies since 1980. consecutively we had to face problems with following malone procedure. because of abdominal pseudo cysts after recurrent shunt revisions bacterial culturing methods and antibiotic therapy regimen changed. treatment of post haemorrhagic ventricular dilatation in premature very low birth weight infants had changed over the years from intervention with external drainage, early lumbar punctures, repeated ventricular punctures to implantation of the new ''side-inlet integra reservoir''. conclusions. the lesson we learned out of this retrospective analysis is that treatment of these hydrocephalic patients needs to be designed concerning all problems of the disease during life time period. therefore we think that experience and retrospective analysis is a very important point of view for the future. 292 12 years' experience with lymphangiomas in children j. burtscher, e. horcher background. the management of lymphangioma in children is still challenging. complete resection is difficult to achieve in some cases and recurrences are common. methods. a retrospective study over a period of 12 years was carried out. fifty-one patients were treated. 32 males and 19 female patients. the involved sites were head and neck, trunk and extremities as well as retroperitoneal, intraabdominal or intrathoracic location. prenatal mri was introduced to plan operative strategy especially for cervical location. results. there were 43 recurrences. recurrence rate was highest in intrathoracal location. there was so significant differences, in terms of outcome, between those who had their surgery immediately at the time of diagnosis and those who had delayed surgery. conclusions. prenatal mri is a helpful tool in planning operative strategies like exit-procedure (ex utero intrapartumprocedure). risk factor for recurrence included location, size or complexity of lesion. background. hemangioma is the most frequent tumor in childhood. in more than 50% of cases hemangiomas are located in the face and the decision about the need for treatment, and the type of treatment may be difficult. complex hemangiomas need emergent systemic drug therapy, which may be combined with other types of interventional therapy, such as surgery or laser treatment. the aim of this study was to evaluate our experience in the treatment of complex hemangiomas. methods. analysis of complete records of patients who were treated in the period between 1.1.2001 and 31.12.2006. results. out of 547 patients referred to us, 196 patients (36%) needed hospital treatment (60% girls), mainly because of rapid growth, and complications which were present in 27 patients (14%). the most frequent localization of hemangiomas were the head and neck region (52%) and 21% of patients had multiple hemangiomas. median age at first referral was 4 months, with 65% of patients referred to us before 6 months of age. more than half of patients received their first treatment before 5 months of age, and within 7 days after referral. treatment consisted in laser therapy (61%), excision (26%), and additional (or exclusive) drug therapy in 13% of patients (cortisone, interferon). interdisciplinary treatment was necessary in 34 patients (17%), involving mostly plastic surgeon, dermatologist, pediatric oncologist, pediatric radiologist, ophthalmologist, and psychotherapist. the majority of interdisciplinary treated patients (60%) received initial treatment in other centers, 12 patients (35%) presented with complications, and rapid growth was present in 90% of patients. parotid hemangiomas (n ¼ 6) were treated solely by systemic cortisone treatment (n ¼ 3). intra-tracheal hemangiomas (n ¼ 5) required often a laser treatment (n ¼ 3), in addition to administration of systemic cortisone. massive segmental facial hemangiomas (n ¼ 8) needed additional treatment with interferon (n ¼ 5). in one case a phaces syndrome was diagnosed and the patient needed a complex therapy. conclusions. the need for treatment of hemangioma must be made on the individual basis. most hemangiomas need only observation. however, patients with complications and=or facial localization of hemangioma with rapid growth require often emergent treatment in medical centers with the possibility for an interdisciplinary management. early therapy may be a precondition for a good cosmetic result. background. treatment of appendicular peritonitis is closely connected with prophylaxis and treatment of surgical complications during postoperative period. the abscess of omentum major is one of such a complications, elsewhere discussed in medical literature. the aim of the study was the reduction in frequency of this complication. methods. during 1995-2005 years we treated 7 patients with the abscess of caul. all of the patients were also treated for the appendicular peritonitis in the past. the time since the discharge from outpatient department to re-admission to the hospital varied within 21-83 days. the disease manifested with abdominal pain, increase in body temperature to the febrile grade. all the patients presented with tumour-like abdominal mass of various size. two patients presented with umbilical fistula and purulent effusion. abdominal ultrasound elicited masses with fluid content in 4 patients. laboratory work-out revealed significant increase of tests relevant to endotoxicosis. all patients were operated. five patients underwent dissection of infiltrate, and the total resection of caul. two patients passed drainage of abscess through the anterior abdominal wall. results. all the patients recovered. complications of early and late postoperative period were not observed. patients were on the close follow-up for 1 to 7 years without any sequalae. hospitalisation span was 22.7 ae 1.4 days. conclusions. 1. abscess of caul can manifest during early as well as late postoperative period. 2. management of omental abscess: -complete resection within visually intact tissues; -careful washing of abdominal cavity with antiseptic solutions; -vigorous antibacterial therapy in postoperative period. 295 beneficial effects of mixed hyperalimentation in children with septic form of acute hematogenic osteomyelitis a. albokrinov 1 , a. pereyaslov 2 1 lviv children's regional clinic hospital, lviv, ukraine; 2 lviv d. halytsky national medical university, lviv, ukraine background. septic form of acute hematogenic osteomyelitis (aho) is severe sepsis with multiple organ dysfunction syndrome (mods) according to accp=sccm consensus conference committee, 1992. mortality and morbidity rates from this remain unacceptably high, in spite of achievements in intensive care medicine. nutritional support is the method of intensive care with proven efficacy, but the ''perfect'' regimen of it is unknown. methods. in 2002-2006 in our clinic 12 children with septic form of aho were treated. they received standard therapy of severe sepsis which included surgical treatment (osteoperforation, suppurative focus drainage, pleural drainage in case of pyopneumothorax), antibacterial therapy, hemodynamic support. all of patients were mechanically ventilated (mv) because of acute hypoxemic respiratory failure on the basis of metastatic pneumonia. regarding to nutritional regimen patients were randomized on two groups: control (enteral alimentation with isocaloric isonitrogenic diet fitting basic energy expenditure (bee) multiplied by coefficient 1.6), and basic (mixed enteral (1.6bee) plus parenteral (protein ¼ 2 g=kgãday, energy ¼ 1.6bee) hyperalimentation). results. there was strong tendency of patients in basic group to have less pulmonary complications, better gas exchange values, less ventilation days and less intensity of hypermetabolic-hypercatabolic syndrome (see table, ã p < 0.05). conclusions. mixed enteral-parenteral hyperalimentation in children with septic form of aho is an effective method of prevention of pulmonary tissue destruction and respiratory function improvement. background. the aim of this study was to gain information about the mechanisms of injuries and injury pattern at primary and secondary schools in austria. methods. at the department of pediatric surgery in graz and six participating hospitals (klagenfurt, salzburg, steyr, krems, schladming and innsbruck) all children from 0 to 18 years presenting with trauma were included within a two year study period. in total, 28983 pediatric trauma cases were filed. data were analyzed regarding personal data, site of the accident, circumstances and mechanisms of accident and the related diagnosis. results. at the department of pediatric surgery, medical university of graz, 21582 questionnaires were completed, out of which 2148 children had suffered from school accidents (10%). 7401 questionnaires from outside hospitals included 890 school accidents (12%) with a mean age of 11.5 years in the children from graz and 11.3 years in children from participating hospitals. the male=female ratio was 3:2. in general, sport injuries lead to a higher rate of severe trauma (42% severe injuries) compared with other activities in and outside of the school building (26% severe injuries) with ball-sports being the most dangerous activity with a 44% proportion of severe injuries. over all, the upper extremity was most frequently injured (34%), followed by lower extremity (32%), head and neck area (26%) and injuries to thorax and abdomen (8%). conclusions. half of all school related injuries occur in children between 10 and 13 years of age. there are typical gender related mechanisms of accident: boys get frequently injured during soccer, violence, and collisions in and outside of the school building and during handicrafts. girls have the highest risk of injuries at ball sports other than soccer. background. objects and notably coins are frequently swallowed by children 3-5 years old. their precise management on asymptomatically passing the gastro-esophageal junction remains controversial. this study was performed to assess dissolution of specific metals from coins immersed in simulated gastric juice. methods. four types of euro and us coins were immersed in simulated gastric juice for 4, 24, 72 and 120 hours. six metals were evaluated by inductively coupled plasma-atomic control group (n ¼ 7) basic group (n ¼ 5) sofa, mean (sd) 8.5 (0.9) 9. conclusions. coins retained in the stomach will release a number of heavy metals well known to cause dose-dependent poisoning. studies to evaluate their toxicity and absorption are needed to optimize treatment. 298 the surgical tactic on the splenic injury in children a. pereyaslov, s. chooklin, i. korinevska, a. troshkov medical university, lviv, ukraine splenectomy in children often leads to various complications. retrospectively, results of the management of 45 children (range from 3 to 14 years), which underwent surgery due to the liens' injury, were examined. the immunological and hormonal investigations were performed. out of 45 operations in 33 the splenectomy, in 6 cases the splenectomy with the tissue autotransplantation of the lien in the greater omentum and in 6 cases the organ-preservation operations were performed. purulentseptic postoperative complications were noted in 7 (15.6%) patients, which connected with the inadequate of the immune answer. the obvious t-cellular immunodeficit, low concentration of igm, decrease of phagocytosis were observed in this category of patients. by that, on the background of activation of the renin-aldosteron system and changes of the eicosanoids synthesis, the danger of the sepsis and septic shock development were arisen. the autotransplantation of the lien tissue did not protect the organism from the purulent-septic complications in the nearest postoperative period. as the answer to the transplanted tissue and necrobiotic processes, which had been occurred in it, the autoimmune processes and reactions of the hypersensitivity of the immediate type (the increase of ige and dna antibodies levels) were intensified. with the goal to prevent complications in the postoperative period the thymic hormones, interferon a, aspirin and dipyridamol were applied. in the remote terms, the postsplenectomy syndrome manifested itself in patients, which underwent the splenectomy in childhood. predisposition to the infections and thrombohemorrhagic processes prevailed. the disturbances of hemostasis are linked with the significant increase of the t-helpers that connected with the intensifying of the il-1 action, which also evokes the proliferation of the preactivated b-lymphocytes, and, as the result, the obvious synthesis of igg. igg in the composition of the immune complexes can stimulate the function of the neutrophyles. all this promotes to transfering the hageman factor in the active condition, activation of the coagulative and kininogen-kinin blood system, intensification of the fibrinolysis, the deposit of fibrin and the development of the hemorrhages. the autotransplantation of the lien tissue could not enhance defence of the organism in full value. thus, at the traumatic injury of the spleen the prevalence must be given to the organpreserving operations. background. mri of the breasts has been described the most sensitive imaging modality for detection of multicentric or multifocal malignant tumor manifestations. in 1995 we began with routine preoperative mri-staging in breast cancer patients. the aim of this study is to analyse the benefit of preoperative mr-imaging regarding surgical treatment and follow up in patients with invasive breast cancer. methods. the retrospectice study (n ¼ 275) includes all female patients with histologically verified invasive breast carcinoma, which have been operated at our department between 1995 and 2002. exclusion criteria were carcinoma in situ, local recurrence, inflammatory carcinoma and neoadjuvant therapy. demographic, radiological, operative and histological data, standardized follow up (dfs, os) and recurrence rate were analysed. results. surgical treatment consisted in bct (57.6%) and mrm (42.4%). 83% of tumors showed an invasive ductal differentiation. lymph nodes were positive in 35%. tumor size showed the following pattern: pt1 67%, pt2 29% and pt3=4 4%. grading was 4.2% (g i), 75% (g ii) and 19.8% (g iii), respectively. mr-imaging revealed multifocal or multicentric tumor manifestations in 24% of patients, the mri results changed surgical treatment in 15% of cases. mean follow up was 66 months. the local recurrence rate was 2.5%, 1.6% of patients developed carcinoma in the contralateral breast, incidence of distant metastases was 10.8%. conclusions. the data confirm the importance of routinely performed mr-imaging in preoperative staging of breast cancer patients. mri-identification of multifocal or multicentric tumor manifestations is essential to choose the optimal surgical treatment and reach a minimal recurrence rate. methods. between july 2001 and october 2006 567 patients with operable breast cancer were treated at general hospital feldkirch. of 360 subsequent patients with non-palpable lesions intraoperative sonography was used in 299 (group 1), wire localisation in 61 cases (group 2). the study was conducted as nonrandomised trial with prospective data collection. results. breast-conserving surgery was performed in 88% in group 1 and 75% in group 2. primary r0-resection was significantly higher in group 1 (81%) than in group 2 (62%, p < 0.01) while median clear margins were 4.7 and 6.8mm in these groups (p < 0.01). both wire localisation and intraoperative sonography proved to be feasible with tumor identification rates of 100%. conclusions. intraoperative sonography proved to be reliable and feasible in breast cancer patients in the hands of the surgeon. clear advantages next to tumor identification and topographic orientation for excision were organisational acceleration and improvement: discomforting, time and labour intensive wire localisation can be avoided and breast lesions can be excised in a tissue-sparing and breast-conserving technique in a very high percentage. background. extensive intraductal disease represents an important clinical problem in the management of patients with invasive or in situ breast cancer. we present a new method for intraoperative ductoscopy with intraductal biopsy of suspicious lesions. methods. intraoperative ductoscopy was performed in 109 women undergoing operation for breast cancer or nipple discharge. a rigid gradient index microendoscope (0.7 mm) with a special biopsy device for vacuum assisted biopsy was used for all examinations. ductoscopy findings were documented prospectively and correlated with preoperative mammography and histology of the resection specimen. results. ninety-two percent of the patients were examined successfully. ductoscopy identified intraductal lesions (ie, red patches, ductal obstruction, or microcalcifications) in 64% of the patients. abnormal ductoscopic appearance was found in more than 80% of the patients with extensive intraductal disease 82%. patients with an abnormal ductal appearance on ductoscopy, compared with those with a normal ductal appearance, had a greater incidence of extensive intraductal spread of cancer (76% vs. 16%) and a greater incidence of positive surgical margins (44% vs. 12%). ductoscopic biopsy of intraductal lesions was technically successful in all but one case. generally, the quality of the biopsy samples was good. diagnostic biopsy samples were obtained in 26 of 28 patients (93%). two samples contained necrosis and were considered to be non-representative. histological analysis of the biopsy specimens showed 22 papilloma, 2 in situ carcinoma and 2 invasive carcinoma. conclusions. high-resolution ductoscopy is able to detect extensive intraductal disease in a considerable number of women with breast cancer. vaccum assisted biopsy allows intraductal tissue sampling of very small lesions. in selected patients, a combination of both preoperative imaging and intraoperative ductoscopy may help to avoid incomplete resections and re-excisions. background. preoperative chemotherapy (pc) for breast cancer was initially focused on locally advanced tumors. later on it has been established to downstage operable tumors primarily not suitable for breast conserving surgery. now pc is often used as an invivo test for chemotherapy regimens. methods. since 1991 the austrian breast and colorectal cancer study group (abcsg) conducted 3 trials with pc. abcsg-07 analysed the effect of pre-and postoperative versus postoperative chemotherapy alone with cyclophohamide= methotrexate=fluorouracil. abcsg-14 compared 3 versus 6 cycles of epirubicin=docetaxel þ g-csf regarding the rate of pathologic complete response (pcr). abcsg-24 analysis the rate of pcr between 6 cycles of epirubicin=docetaxel and 6 cycles of epirubicin=docetaxel=capecitabine ae trastuzumab for her-2 positive patients. results. from 1991 to 1999 abcsg-07 enrolled 423 eligible patients. after a follow up of 9 years recurrence-free survival is worse in the pc arm (hr 0.7, 0.515-0.955; p ¼ 0.023), overall survival doesn't differ significantly (hr 0.8; 0.563-1.136; p ¼ 0.213). 292 patients were accrued to the abcsg-14 trial between 1999 and 2002. the rate of pcr was significantly higher in patients after 6 cycles than in those after 3 cycles (18.6% vs. 7,7%; p ¼ 0.0045). also significantly more patients had a negative axillary status after 6 cycles than after only 3 cycles (56.6% vs. 42.8% p ¼ 0.02). recruitment of abcsg-24 started in 2004 and is still ongoing. conclusions. while pc fails to improve prognosis so far, regimens which improve the rate of pcr have been found and we are still hoping to tranpose this effect in better prognosis. 316 sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer p. schrenk 1 , c. tausch background. sentinel node (sn) biopsy following preoperative chemotherapy (pct) in breast cancer patients is associated with a lower identification rate (ir) and an increased false negative rate (fnr) compared to sn biopsy in patients with primary breast cancer. methods. sn biospy was performed in 45 breast cancer patients with a clinical negative axilla prior to pct. following chemotherapy sn mapping was repeated and the current lymph node status was assessed with axillary lymph node dissection (alnd). results. sn mapping prior to chemotherapy successfully identified a mean of 2.3 sns in all patients (ir 100%). 19 patients revealed a negative sn, 26 a positive sn (micrometastasis in 6=26). following pct re-sn mapping was successful in 29=45 patients (ir 64%). ir for re-mapping was 80% for patients with a primary negative sn or a micrometastatic sn compared to 45% for patients with primary macrometastatic sns. none of the 19 patients with a negative sn biopsy and none of the 6 patients with micrometastasis prior to chemotherapy revealed positive lymph nodes following pct. contrary to that 17=20 patients with a macrometastasis prior to pct revealed positive nodes following chemotherapy, and this was irrespective of the type of tumor remission due to pct. the fnr of remapping was 50% and false negative sns were only found in patients with macromatastatic sns in the primary sn mapping. conclusions. patients with a negative sn biopsy or with a micrometastatic sn prior to pct may forego complete alnd following pct, whereas this may not be valid for patients with macrometastatic sns. sn biopsy following pct is associated with a low ir and a high fnr. background. standard pancreatoduodenectomy (pd) for the treatment of resectable tumors of the periampullary region or the pancreatic head involves a radical pancreatoduodenectomy with an extensive gastric resection. the modified whipple operation aims to preserve the stomach, pylorus and proximal duodenum so as to decrease postgastrectomy complications and improve the patient's quality of life. however, there were still many postoperative complications after pylorus-preserving pancreatoduodenectomy (ppd). unfortunately, in some retrospective studies tumors of the periampullary region and the ductal carcinoma of the pancreatic head are still not differentiated. this methodological problem and the improved surgical strategy (lymphadenectomy, etc.) in combination with the excellent histopathological diagnosis by experienced pathologists are decisive factors in determining the ultimate outcome as demonstrated. methods. patients (all treated at smz-süd -kaiser franz josef spital department of surgery) with a exocrine malignant tumor of the pancreatic head or periampullary region were retrospectively analyzed by comparing a 10 year period before and after 1995. results. in the last period of observation the complication rate and lethality was reduced (there was one cases of death because of technical reasons). the number of r0 resections (incl. mesoduodenum) improved from 68% to 85%. also the number of the resected lymphatic nodes increased from 15 to 20 (13-60). the actuarial 5 year survival rate in patients after resection of a pancreatic ductal adenocarcinoma at r0, n0 stage increased from 21% up to 40%. an increase in long-term survival could also be observed in the n-positive group. conclusions. at an oncologic center with optimal interdiciplinary collaboration of the different departments (internal medicine, surgery and pathology) a respectable actuarial 5 year survival (40%) of the pancreatic ductal adenocarcinoma can be achieved without interfusing different tumorentities. the lethality caused by technical reasons should be almost 0%. detailed information will be discussed during the presentation. background. complete surgical resection remains the only potentially curative treatment, improving 5-year survival, for patients diagnosed with pancreatic cancer. preoperative administration of chemotherapy or combined radiochemotherapy may present a way in increasing the number of patients were radical surgical therapy is reasonable and feasible. lower perioperative mortality and morbidity rates are reported in high volume centres. methods. between jan. 2000 and dec. 2004 47 patients, diagnosed with locally advanced non metastatic pancreatic cancer, received preoperative chemotherapy with neoadjuvante intent. 88 patients had curative surgery at time of diagnosis and adjuvant chemotherapy depending on their stage of disease. a subset of 66 patients have been diagnosed at an far advanced stage of disease and were treated in palliative ways. results. the observed perioperative mortality rate was 4.8% (5=104). a total of 14 (13.5%) patients required reoperation because of complications after curative resection. minor complications, which have been treated in conservative ways, occurred in 22.1% of patients. sixteen patients (16=47, 34.1%) demonstrated sufficient tumor response to undergo surgical curative resection after neoadjuvante chemotherapy. in this group the median survival time was 15 month (12.3-19.6 95% ci). median survival time for patients who underwent curative tumor resection at the time of diagnosis, was 16 month (12.3-19.6 95% ci). for patients, unable to undergo curative surgery after neoadjuvant therapy (n ¼ 30), median survival (8 month, 6.1-9.8 95% ci) did not differ from life expectance of primary palliative treated patients (6.4-9.5 95% ci). conclusions. we suggest that in several patients, suffering from nonresectable cancer of the pancreas, preoperative chemotherapy significantly rises overall survival to a level so far reserved to patients with operable carcinoma. in other malignancies neoadjuvante chemotherapy is an accepted standard of cancer treatment. there are many potential advantages of neoadjuvant chemotherapeutic regimes for both resectable and advanced pancreatic carcinoma. novel targeted molecular therapies and their combination with established chemotherapeutic agents may lead to higher conversion rates after neoadjuvante therapy and improved 5-year survival rates in the near future. background. haemodynamic impairments after pneumonectomy are rare complications and present in two different forms or a combination of both. changes in the anatomical situation of the left atrium and elevated pulmonary artery pressure can lead to a significant right-left shunt via a previously closed foramen ovale (pfo) and diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, compressing the right atrium with subsequent inflow obstruction. methods. we retrospectively analysed our patient cohort from 1997 to 2006 for occurrence of haemodynamic complications requiring surgical intervention after pneumonectomy. results. five patients (1 female, 4 males, age 59 ae 9 years) were identified. all underwent right pneumonectomy due to nsclc (n ¼ 4) or atypical carcinoid (n ¼ 1). two patients were readmitted 3 months and 2 years postoperatively due to increasing platypnoea and orthodeoxia. after closure of a pfo which was found as the underlying pathological mechanism respiratory symptoms were resolved. one patient required reintubation already 2 hours postoperatively; after surgical closure of a pfo the respiratory situation significantly improved. one patient was readmitted due to right atrial inflow obstruction 17 months after right pneumonectomy. underlying cause was a severe diaphragmatic relaxation with compression of the atrium by the liver. after diaphragmatic plication all symptoms resolved. one patient was readmitted 3 months after pneumonectomy and partial atrial resection due to cyanosis and dyspnoea. diagnostics revealed a pfo and a massive raise of the right diaphragm with compression of the right atrium. after surgical correction of the contorted foramen ovale and diaphragmatic plication symptoms vanished. conclusions. haemodynamic alterations due to a reopened foramen ovale or right atrial inflow obstruction are rare however severe complications after pneumonectomy. they occur at variable points in time after pneumonectomy. closure of the pfo either surgical or interventional and=or plication of the elevated diaphragm are mandatory. in our experience these complication occur only after right pneumonectomy. 324 chronic sequels after thoracoscopic procedures for benign disease -long-term results j. hutter, s. reich-weinberger, h. j. stein background. video-assisted thoracic surgery (vats) is recognized to be as effective as open surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity. chronic postoperative pain (cpp) is defined as persisting more than 2 months after the procedure. cpp and other neurological sensations like disesthesia or numbness are found frequently, but little is known about the outcome of those patients many years after the primary procedure. methods. in 1999 we retrospectively investigated a group 46 (31.9%) out of 144 patients who were identified with sequels at a mean of 32 months after a vats procedure. now at 123 months post-operation we reinvestigated those patients for ongoing sequels. results. from 46 patients 36 were still alive and could be reached for an interview. 18 (50%) were now free of symptoms while 18 (50%) still suffered from sequels. from the group of 144 patients operated on, sequels were now present in 18 (12.5% at 123 months vs. 31.4% at 32 months, p ¼ 0.0002) patients. pain was present in 17 (11.8 vs. 20.1%, p ¼ 0.11), in three (2.1 vs. 18.1%, p< 0.000001) even at rest, and in 4 (2.7 vs. 12.5%, p ¼ 0.0002) patients only at exercise. ten (6.9 vs. 28.5%, p ¼ 0.096) patients suffered from pain occasionally e.g. due to changing weather. painkillers were only taken by one (0.7 vs. 16.6%, p< 0.0001) patient occasionally, and the sequels impacted the life of one woman (0.7 vs. 13.2%, p< 0.0001) badly. numbness was present in 16.9 vs. 1.3% (p ¼ 0.0013) of patients. conclusions. early postoperative sequels are frequently found in vats procedures, but patients with pain even after years have a nearly 50% chance to eliminate their problems. in addition, numbness and disesthesia seem to disappear almost completely several years after the procedure. 325 intrapulmonary injection of fibrin glue as a treatment of persistent parenchymal fistulas after pulmonary surgery: a case series s. b. watzka 1 , h. redl 2 , b. el nashef 1 background. persistent parenchymal fistulas are a major problem after pulmonary operations particularly in lung emphysema patients. conventional surgical remedies, like over-suturing or stapling of injured lung surfaces are rarely efficient. here we present our preliminary experience with a novel application of fibrin glue as a sealant of persistent parenchymal fistulas. methods. patients with postoperative parenchymal fistulas persistent for more than six days, and not responding to conservative measures, underwent re-operation. lung surfaces not anymore suitable to reconstruction by suturing were sealed by peripheral intrapulmonary injection of fibrin glue. after discharge, the patients were regularly followed-up. in addition, the macroscopic distribution of injected fibrin within lung tissue has been investigated in a porcine in vitro lung preparation. a total of six patients underwent the above described procedure. the primary operation was upper lobectomy in four cases, laser resection in the upper lobe in one case, and empyema evacuation by vats in one case. the mean volume of injected fibrin was 18 ae 6.8 ml. in five out of six patients the fistula was stopped permanently. in one case, however, the parenchymal fistula re-appeared and had to be treated by combined application of fibrin glue and hemostyptic tissues. after a mean follow-up of 71.5 ae 25.5 days, all patients are well and symptom-free. in the animal tissue preparation, the fibrin was macroscopically distributed exclusively in peripheral lung parenchyma. conclusions. in selected cases of persistent postoperative parenchymal fistulas, peripheral intrapulmonary injection of fibrin glue offers a low-risk and efficient surgical option. background. recent case-matched studies demonstrate that stage i non-small cell lung cancer (nsclc) in functionally inoperable patients can be treated by limited resection approaches without compromising the oncological result. the recently introduced 1318-nm nd-yag laser enables the highly selective and parenchyma-saving excision of pulmonary lesions, and was thus originally designed for the removal of multiple lung metastases and more central lesions. in this prospective study, we are evaluating for the first time the mid-term results after local resection of stage i primary nsclc by laser knife in functionally inoperable patients as defined by predicted postoperative fev1 (ppofev1) less than 40%. methods. between 2001 and 2005, 15 functionally inoperable patients underwent local resection of stage i nsclc by 1318-nm nd-yag laser. we assessed their postoperative course, tumor recurrence, and survival by statistical means. results. postoperative mortality was zero. three patients (20%) had minor surgical complications in the postoperative period (persistent air leak, delayed wound healing). the postoperative respiratory function was unchanged as compared to the pre-operative value. the median follow-up was 13.7 months (range 4-25 months). recurrence rates (6.6%) and actuarial 2-year survival (68%) were comparable to standard lobectomy results, as reported in the literature. none of the three deaths observed during the follow-up period was cancer-related. conclusions. the 1318-nm nd-yag laser enables the resection of stage i nsclc in functionally inoperable patients under complete preservation of respiratory function, but without jeopardizing the oncological outcome. zentrumsbildung 332 breast-cancer centers -between european visions and regional feasibility h. hauser background. there have been major improvements in the western world in recent decades in early diagnosis of breast cancer, breast conservation and survival. nonetheless, there are blank spaces on the map of europa and very likely of austria as well, where diagnosis and treatment of breast cancer are not optimal. collecting and treating patients with diseases of the breast in a few defined ''breast centers'' should give every patient with breast cancer the same highest quality treatment. methods. in 1998, a working group was formed in florence, italy, to define the tasks to be met by such a center. in 2000, the results produced by this group were published (eusoma 2000) . the aim of this guideline was to improve quality and quality control in the treatment of breast cancer. one of the main demands made of a breast center is to treat at least 150 new primary breast cancer cases per year. further, a multidisciplinary nucleus team specialized in the treatment of breast cancer should be in place and should hold regular interdisciplinary tumor conferences. this team should include a surgeon=gynecologist, radiologist, pathologist, medical oncologist, radiotherapist, breast-care nurse, data manager, etc.). results. as early as 1998, roohan et al. (am j public health 88, 454) showed that the probability of survival of breast-cancer patients was directly proportional to the treatment volume of the hospital. regardless of tumor stage, patients treated in a hospital that saw less than 10 cases per year had a 60% higher mortality risk than those treated in hospitals with more than 150 operated cases per year. an operation performed by a breast cancer specialist reduces the mortality risk by 16% in comparison to operations performed by non-specialists (gillis cr, hole dj 1996 bmj 312, 145) . the results of dubois et al. (2003) and others also indicate a better outcome for breast cancer when patients are operated in a specialized hospital with a large number of cases and a suitable interdisciplinary environment. the minimum number of 150 cases of primary new breast cancer cases per year and center recommended by eusoma (but with an evidence level of 3 and so not scientifically verified) would reduce the number of breast centers in austria to about 30. an analysis of the austrian situation nonetheless showed that many small surgical units produced excellent results, with interdisciplinary cooperation, in some cases together with external services. conclusions. certified, highly qualified interdisciplinary breast centers are intended to provide breast-cancer patients with highest quality care. the extent to which the eusoma criteria can be adapted to the austrian situation remains to be seen. 333 breast cancer centres -can quality only be achieved in high-volume-institutions? b. zeh, g. humpel, p. lechner background. discussion is ongoing about institutional caseload and technical equipment that both may be required for up-to-date-treatment of breast cancer. we present the network architecture our department of surgery at the danube clinics in tulln is part of, aiming at multi-disciplinary diagnosis and treatment of approx. 35 cancer patients per year. methods. 1. diagnosis: mammogram, ultrasound and mri can -and shall -be performed in an outpatient setting, considering that a close partnership with an experienced radiologist has been established. this is true also for the imaging techniques for staging. 2. interventional diagnosis with core needle biopsy, mammotome + , ecc., should be left to the surgeon! this may facilitate localisation of a non-palpable lesion during the subsequent operation. 3. surgery for breast cancer is not that demanding per se, on condition that the technical equipments for sentinel biopsy, specimen radiography, and frozen section are at hand. the procedures must be left to permanent team if surgeons with an individual experience of more than 150 cases each. 4. systemic adjuvant treatment requires the availability of a clinical oncologist, at our institution on a consultant basis. patients are treated in clinical trials whenever feasible, preferably in those launched by abcsg. 5. radiotherapy is typically performed on an outpatient basis, disregarding at which institution the previous operation was performed. 6. follow-up needs to be co-ordinated by a qualified physician. we have established an oncological outpatient department, but co-ordination could also be left to an office-based oncologist. the mandatory management tools for close follow-up as well as for the prevention of unnecessary examinations are it-support and a patient log-book. conclusions. being embedded in a multi-disciplinary network, our institution's self perception is that of a part in a ''virtual centre of excellence''. we think that we are not only able to provide high medical quality, but that this quality is also subject to external control by our partners. background. the expectancy of life of patients with intraabdominal malignancies and peritoneal dissemination is usually poor. the surgical approach of a combination therapy of complete resection of the primary cancer, the peritonectomy and a perioperative intraperitoneal chemotherapy was developed to improve the prognosis of these patients. this treatment is cost-intensive and associated with special technical expertises. the aim of this study was to determine the modalities and to discuss the feasibility of this approach. methods. since june 2005, a combination-therapy of visceral resections, cytoreduction of the peritoneal cancer and a heated intraoperative intraperitoneal chemotherapy was performed in 10 patients (6 female, 4 male, average age 51.4 years) with visceral malignancies and peritoneal carcinomatosis as a curative approach. the same procedure was designated for six more patients but was not performed because of inoperable tumor masses. mitomycin c (40 mg=m 2 ) was utilized for the intraperitoneal chemotherapy and applied to the abdomen using a heartlung machine to guarantee a steady circulation and to keep the intraperitoneal fluid at 42 c. the handling with the chemotherapeutic substance required special protective clothing for the staff as well as the competent disposal of all used materials. results. a multi-visceral resection was performed in 8=10 patients. a complete cytoreduction (cc-0) was obtained in eight patients, in one a cc-1 and in another one a cc-2 situation remained. the average operative time was 595 minutes (range 456-895 minutes). a peridural catheter was necessary for a sufficient postoperative pain therapy. the average time at the intensive care unit was 4.3 days (range 1-16 days) and the average hospitalization was 21.2 days (range 14-32 days). no complications were observed associated with the surgery. morbidity was determined by gastrointestinal symptoms like prolonged postoperative ileus. in the follow-up three patients had a recurrence of the malignancy, 2=3 with a cystadenocardinoma of the pancreas after three and five months, respectively, and 1=3 patients after 3 months with a metastatic sigmoid carcinoma. one patient died eight months after surgery because of malignancy progress. the average expense of this treatment was 13.752 eur. conclusions. specialized centres may provide the logistics and expenses to establish this treatment innovation to the surgical approach of intraabdominal malignancies to extend the long-term survival of patients with otherwise poor outcome. prospective studies are needed for additional adjuvant and neoadjuvant concepts in diseases with peritoneal malignancies. background. rectal carcinoma needs careful preoperative staging. in our department neoadjuvant treatment with long term radiation and chemotherapy is standard in patients with carcinoma of low and middle part of the rectal wall. main prognostic factors for long term survival are r0 resection, sharp dissection of the mesorectal fascia without coning, distal resection margin of at least 10 mm and complete lymph node dissection along the mesentery vessels. there is no recommendation about the lymph nodes that should minimally be dissected in this group of patients until now. methods. we consecutively evaluated patients after neoadjuvant radiochemotherapy (rct) and surgery in terms of survival, local recurrence, perioperative mortality and morbidity. tumor regression grading (trg) and number of dissected lymph nodes (ypn) were analysed and correlated with survival. results. in our series local recurrence rate was lower than 7%, the r0 resection rate reached 82% and sphincter preserving surgery was possible more than 80%. the median number of dissected lymph nodes (ypn) reached >20, the perioperative morbidity was lower than 20%. especially leakage and anastomotic stenosis with the need for reoperation or dilatation are typical complications of radiation therapy. the tumor regression grade clearly correlates with outcome. conclusions. multimodality treatment of rectal carcinoma including preoperative radiochemotherapy (rct) is well standardised with good results in outcome and morbidity. we show that high numbers of lymph nodes even after rct can be collected and suggest a minimum account of at least 15. tumor regression grading is a marker with prognostic significance and should be taken into clinical-pathohistological classification. we suppose that some patients are overtreated with preoperative rct. to proof this hypothesis, a randomised multicenter trial -together with german cancer centers -based on mri diagnostic is currently planned. background. the incidence of (hpv)-associated disease of the anal canal is rising. efficient anal screening by cytology is hampered because of poor specificity. hpv testing is proposed in addition to pap testing for the detection of cervical neoplasia. the purpose of this study was to determine the usefulness of a hpv-dna detection test (hc2) to detect hpv-associated disease and to compare two different methods of sample collection. methods. in 555 patients anal samples were obtained using a cervix brush and a dacron swab to test for hr-and lr-hpv-dna. qualitative (positive=negative) and quantitative (rlu's, relative light units) were obtained. patients positive for hpv dna underwent anoscopy. biopsies were taken from visible lesions. results. lr-hpv-dna was found in 325 of 555 patients (58.6%) and hr-hpv-dna in 285 of 555 patients (51.4%). dacron swab sampling yielded more positive results than sampling by cytobrush (2.3% vs. 4.3% for lr-hpv, p < 0.0001; 3.1% vs. 4.9% for hr-hpv, p < 0.001). a positive correlation of rlus was found for both sampling methods in the total cohort (p< 0.0001), and patients with positive results (p< 0.0001). sampling with dacron swabs yielded higher rlu values compared to sampling with cervix brush for lr-hpv-dna and hr-hpv-dna. conclusions. anal screening for hpv-dna by hc2 is a useful method for detection of hpv-associated disease. sample collection using dacron swabs identifies more hpv-positive patients, and yields higher rlu values, than using the cervix brush. background. persistent human papilloma virus-(hpv-) infection, immunedeficiency (hikv, immunosuppression after organ transplantation) are known risk factors for anal intraepithelial neoplasia (ain) and squamous cell cancer (scc) of the anus. the incidence in high rik groups is rising (hivpositive, men who have sex with men (msm)). screening programms employing anal cytology or anal colposcopy have been implemented in these risk groups. however, sensitivity and specificity are low for both screening methods. since persistent hpv-infection seems to be a prerequisite for ain and scc it seems reasonable to use hpv-typing as an adjunct to screening in risk groups. methods. three hundred and eighty-five consecutive patients with hpv-associated anal disease were included. sexual orientation, hiv-status, smoking habits and psychological strain were documented. all patients underwent clinical examination, rigid sigmoidoscopy and anal hpv-testing. biopsies from macroscopically visible lesions were taken and categorized in condyloma or the three grade-scale of ain according to the bethesda terminology for reporting results in cervical histology. hpv-testing for low-risk (lr) and high-risk (hr)-types was performed using hybrid capture 2 (hc2). qualitative (positive=negative) and semiquantitative results (relative loight units, rlu's) as an indirect measure of ''viral load'' were obtained. results. hiv-status was the only significant risk factor for hr-hpv-infection in univariate and multivariate analysis. in univariate analysis positive hiv-status and patients tested positive for hr-hpv-dna or both types of hpv-dna were significant risk factors for presence of any type of ain. smoking habits, presence of psychological stress and detection of lr-hpv-dna did not significantly influence presence of ain. in multivariate analysis only presence of hr-hpv-dna was a significant risk factor for ain. univariate interclass correlation showed a significant correlation between grade of anal dysplasia and presence of hr-hpv-dna, grade of anal dysplasia and smoking, grade of anal dysplasia and positive hiv-status, presence of lr-hpv-dna and hr-hpv-dna and presence of hr-hpv-dna and positive hiv-status mean number of rlus for hr-hpv-dna was 213.3 for hiv negative patients and 559.7 for hiv positive patients. there was also a significant difference in the number of rlus for hr-hpv-dna for different grades of anal dysplasia. this difference was only seen in hiv-positive patients, but not in hiv-negative patients. conclusions. our results show the strong relation between persistent hr-hpv-infection and grade of dyplasia. this warrants hpv-typing to be introduced as an adjunct to screening for ain in risk groups. 343 human papillomavirus and anogenital lesions: burden of illness and basis for treatment f. aigner, e. gander, f. conrad background. human papillomavirus (hpv) infections in the anogenital region have become an immanent disease pattern in daily clinical routine. still there is ignorance concerning the etiology and course of hpv associated anogenital lesions, thus demanding an interdisciplinary approach to this disease, which affects more frequently younger individuals. high recurrence rates and the propensity of high-risk hpv associated lesions for malignant transformation (cervical=anal cancer) led to the assessment of diagnostic and treatment options within our association. methods. the results of a consensus meeting in the framework of the 3 rd innsbruck coloproctology winter meeting based on this topic are presented. results. the incidence of anogenital hpv associated lesions (anogenital warts, anal and cervical intraepithelial neoplasia, ain and cin, and anal=cervical carcinoma) has dramatically increased over the last years. in our centre the number of patients presenting with anogenital warts has been doubled from 1996 to 2001, closely associated with an increase of diagnosed anal cancers. in the last two years 22 new cases of ain iii (mean age 43 years; 9 males, 13 females), 10 cases of ain ii (mean age 48 years; 8 males, 2 females) and 5 cases of ain i (mean age 48 years; 4 males, one female) were treated in our proctologic unit and introduced to the gynaecologists. treatment algorithm includes excision, electrocauterization or laservaporisation of perianal or anal warts or ain i, ii and anal ain iii on the one hand and radical excision of perianal ain iii on the other hand. immunomodulatory treatment with imiquimod (aldara + ) should be preferentially applied for recurrent anogenital warts. histological examination of suspect lesions has to be performed routinely. conclusions. hpv associated anogenital lesions should be treated by a multidisciplinary approach. histological investigation of the excised material should be performed routinely as well as patients' surveillance including standard anoscopy and colposcopy in a specialized unit. gigip: tissue engineering und implantat induzierte immunologische reaktionen 344 th2-immunresponse to xenogeneic matrix grafts t. meyer 1 , k. schwarz 2 , b. höcht 1 1 pediatric surgery unit, department of surgery, würzburg, germany; 2 department of anatomy, saarland university, homburg=saar, germany background. extracellular matrix (ecm) biomaterials of xenogeneic origin, such as lyoplant + , pelvicol + or surgis + are beginning to be used as acellular, resorbable bioscaffolds for tissue repair in pediatric surgery. although a vigorous immune response to ecm is expected, to date there has been evidence for only normal tissue regeneration without any accompanying rejection. the purpose of this study was to determine the reason for a lack of rejection. methods. full-thickness abdominal wall defects were created in 15 wistar-wu rats and reconstructed with either a lyoplant + -matrix (b=braun aesculap, germany) or prolene +matrix (polypropylene-matrix [ppp], prolene + , ethicon germany). animals were checked daily for local and systemic complications in both treatment and control groups. bodyweight was recorded and the possible development of a hernia was monitored. after 6 weeks the abdomen was reopened and adhesions to the intestine were determined. histopathology and immunohistochemistry were performed to evaluate the immunological reaction to the xenograft. results. compared to the untreated animals, all rats had a physiological growth and body weight curve: no wound infection could be observed throughout the experiment. only in one rat, treated with a ppp-matrix, an abdominal hernia developed at the implant site. all other animals showed excellent clinical recovery and cosmetic results. ppp animals showed a pronounced inflammatory response indicated by an increased number of fibroblasts. the lyoplant + -matrix implantation induced an infiltration of cd4 and cd68 positive cells. in addition an active neovascularization was found, observing a remodelling process. this inflammatory response was significantly milder than in ppp implanted rats. interestingly some cd8 positive cells were detected in the lyoplant + -group. conclusions. xenogeneic extracellular matrix, such as lyoplant + , induces an immune response, which is predominately th2-like, comparable with a remodeling reaction rather than rejection. background. mesh graft infections after hernia repair are an awkward complication. in more extensive infections many surgeons recommend removal of the mesh, due to the difficulty to treat microbes in th infected artificial material. the vac system now offers a new possibility in the treatment of complicated wounds, including mesh infections. methods. in this study, records of patients with mesh graft infections after incisional abdominal wall hernia repair were retrospectively analysed who have been operated on between january 1st 2000 and february 28th 2005 at the department of surgery, general hospital vienna. results. 32 of 445 patients (7%, 15 female and 17 male) operated in the period of investigation were suffering from mesh graft infections (13 vypro ii mesh, 14 composix mesh and 5 surgipro mesh). mean age of patients was 60 years. mean duration of wound therapy was 128 days. 56% of the patients had an extensive infection. in those, topical negative pressure therapy (vac) was used. this led to a preservation of 50% of meshes in this group. in patients with a wound smaller than 2 cm, infection could be successfully treated in 5 of 8 cases (63%). the type of mesh had an influence, whether it could be preserved. all 13 of 13 vypro ii-mesh grafts (100%), 3 of 14 composix mesh (21%) and 1 of 5 surgipro mesh (20%) could be preserved by conservative treatment. conclusions. data suggest that vypro ii mesh grafts are superior to composix and surgipro mesh regarding mesh graft preservation in case of postoperative mesh graft infection. vac therapy should be considered for successful treatment of more extensive infection. finally, small wounds (<2 cm) seem to have a good prognosis for mesh graft preserving healing. background. revisional procedures after restrictive bariatric operations are necessary in increasing numbers of patients. these procedures may be performed laparoscopically but represent demanding and in some cases risky operations. a meticulous technique is mandatory in order to achieve good postoperative results. methods and results. laparoscopic roux-y gastric bypass is performed as revisional procedure after laparoscopic gastric banding, sleeve gastrectomy and vertical gastric banding. the indication for a transformation to gastric bypass is inadequate weight loss or weight regain and technical failures of procedures. formation of the gastric pouch may be difficult because of adhesions and formation of a capsula in case of banding. gastro-jejunostomy may be performed by different techniques. conclusions. revisional gastric bypass is a more complicated procedure than primary bypass. in order to achieve good results a number of technical details have to be respected. background. laparoscopic sleeve gastrectomy has become a standard bariatic procedure in the last five years. this procedure has been performed with a number of different techniques using laparoscopic staplers and mobilizing the greater curvuture as primary step of the operation. methods. sleeve gastrectomy with a modified technique starting with the formation of the gastric sleeve prior to mobilisation of the greater curvuture is demonstrated. stapling is performed with linear straight staplers. conclusions. the advanages of performing laparascopic sleeve gastrectomy by a modified technique are shorter operating times, and a better overview especially near the his angle. the modified technique may therefore become a surgical standard in bariatric surgery. we present a video showing the technique of laparoscopic approach for reoperation on 2 cases with complications due to ''lost gallstones'' after laparoscopic cholecystectomy. case 1 is a 71 years old female patient, operated for symptomatic cholecystolithiasis in august 2005. in august 2006 she presented with right upper quadrant pain, the computertomography revealed a liver abscess in the right lobe and a retroperitoneal abscess. case 2 is a 77 years old male patient, operated for symptomatic cholecystolithiasis in november 2005. in july 2006 he presented with right upper quadrant abdominal pain, the computertomography showed a small suspected abscess formation between liver segment 6 and the right kidney. laparoscopic reoperation was performed the day after diagnosis. in case 1 after adhesiolysis the liver was elevated and the abscess opened to perform rinsage and drainage of the cavity. the ''lost gallstones'' were taken out with a suction device. in case 2 multiple stones were found in the upper abdomen under the peritoneum and in the abscess cavity. adhesiolysis and rinsage was performed. if abscess formation around the liver is seen even years after laparoscopic cholecystectomy, the diagnosis of a complication from ''lost gallstones'' should be suspected. reoperations for ''lost gallstones'' after laparoscopic cholecystectomy can be performed by laparoscopy if the abscess formation is accessible; results will be superior to ct-guided drainage due to the stone extraction by laparoscopy. grundlagen. die isr ist eine technik, bei der auch tiefsitzende karzinome des rektum sphinktererhaltend reseziert werden können. wir haben kürzlich eine operationstechnik entwickelt, bei der dieser eingriff laparoskopisch ohne großen zusätzlichen zeitaufwand durchgeführt werden kann. methodik. dieser eingriff wird nach genauer präoperativer abklärung durch 1) digitalbefund, 2) endoskopie und biopsie, 3) mrt des rektums und 4) sphinktermanometrie geplant. ausschließungsgründe für die operation sind: undifferenzierter tumor, t4-stadium und schlechte sphinkterfunktion. der abdominelle teil wird im 4 trokarttechnik (1â 11 mm 2 optikport, 3â 5 mm 2 arbeitsport) durchgeführt. die präparation erfolgt entweder mit dem 5 mm ultracision oder dem 5mm ligasure-atlas. der eingriff wird synchron von abdominell und peranal von 2 teams durchgeführt. dafür wurde eine eigene lagerungstechnik entwickelt. die operation verläuft in folgenden phasen: 1) totale mesorektale exzision, 2) peranale intersphinktäre resektion des rektum 3) bildung eines axialen kolonpouches, 4) durchzug des kolon und koloanale anastomose, 5) protektive transversostomie oder ileostomie. die präparatbergung erfolgt von peranal, sodass keine zusätzliche inzision am abdomen notwendig ist. der stomaverschluß erfolgt nach 6 wochen. ergebnisse. von den insgesamt 160 intersphinktären resektionen wurden 7 laparoskopisch durchgeführt. die mittleren operationszeiten betrugen bei der offenen isr 175 min, bei der laparoskopischen 237 min. schlussfolgerungen. die laparoskopische intersphinktäre resektion ist ein praktikables operationsverfahren, dass mit vertretbarem zeitaufwand durchgeführt werden kann. die vorteile der laparoskopischen vorgangsweise können derzeit bis auf das hervorragende kosmetische ergebnis noch nicht abgeschätzt werden. schlussfolgerungen. der konsequente einsatz eines hochthorakalen pdks mit adäquater füllung zur schmerztherapie und sympathikolyse war von unserer anästhesieabteilung nicht regelhaft umsetzbar, so dass wir in der oralen gabe von oxycodon plus oraler stimulation des gastrointestinaltraktes eine hervorragende alternative zur durchführung der fast-track-rehabilitation gefunden haben. unsere ergebnisse decken sich mit den resultaten die derzeit von den chirurgischen zentren publiziert werden. die wiederaufnahme-(1.4%) und die gesamtkomplikationsrate (12%) ist bei längerer verweildauer etwas niedriger. unsere ergebnisse zeigen, dass das konzept der fast-track-rehabilitation gut in einem nicht ausgewählten patientengut umsetzbar ist. aufgrund der ausbildungssituation ist die zahl der lap. eingriffe relativ gering.in der oralen opiod-analgesie haben wir eine unerwartet gute alternative zum pdk gefunden. 354 fast track surgery without thoracic peridural anaesthesia? background. thoracic pda is considered to be one of the main pillars of fast track surgery (fts). our anaesthetists being reluctant to perform thoracic pda as a routine, we decided to make an attempt to do surgery without thoracic pda yet following all other criteria of fts. methods. between jan. 2005 and dec. 2006 we have performed 69 elective colonic procedures following our modified criteria. in these patients we have prospectively examined those parameters which could be expected to be influenced the most by pda: -postoperative intestinal paralysis -postoperative pain control -rate of complications results. the postoperative need of antiemetic drugs and the time of the first clinical signs of bowel activity (passing winds or stool) were examined as criteria for postoperative paralysis: -85.5% of patients never needed an anitemetic drug -79.7% of patients were having bowel activity not later than on po day 2 standard postoperative pain control regimen contained two doses of 500 mg paracetamol and two doses of 75 mg diclofenac iv. as long as needed followed by the same combination given orally. 15 mg of piritramid sc. was presribed as reserve treatment. -13% of patients needed the standard iv-regimen for longer than three days -84% of patients never needed a single dose of piritramid -1.4% of patients needed more than two doses of piritramid in the last 20 months of the study only 2 patients (4.1%) needed piritramid for sufficient pain control (learning curve of nurses and doctors!). overall we have seen 8 complications (11.6% of procedures): background. multimodal fast track rehabilitation is based on modified perioperative fluid management, avoidance of preoperative fasting, effective analgesic therapy using epidural anesthesia, early postoperative mobilisation and immediate oral nutrition in order to accelerate recovery, reduce general morbidity and decrease length of hospital stay. young people seem to be the most suitable patients for fast track rehabilitation, but majority of the patients requiring colorectal surgery is older than 65 years and often has several comorbidities. in this analysis we compared ''fast track'' feasibility and efficacy in young and old patients to examine, whether an age dependent management is required. methods. during one year all patients scheduled for colorectal surgery for colorectal cancer or sigmadiverticulitis on one ward were treated according to our multimodal ''fast track'' program. demographic and perioperative data, postoperative follow up (e.g. first bowel movement, vomiting, intravenous infusion therapy, fluid balance), local and general complications were prospectively assessed and evaluated on the basis of two groups (group a: age< 65a, n ¼ 26; group b: age> 65a, n ¼ 32). results. median postoperative hospital stay was 6 days (a) and 7.5 days (b) with one readmission in both groups. the incidence of local and general complications was 3.8% and 21%, respectively. a 85 aged patient with stenotic rectal cancer with liver metastases and parkinsons disease died because of multiorgan failure. conclusions. the multimodal ''fast track'' rehabilitation concept is feasible in young and old patients. although older patients have a higher morbidity, our data show, that especially older patients benefit from enhanced recovery programs. background. the restrictive perioperative intravenous (i.v.) fluid management is an important element of multimodal fast track surgery. recent studies have shown a better outcome for patients with moderate or restrictive intravenous i.v. fluid therapy, but adequate interdisciplinary standards are missing and therefore optimal perioperative fluid management still remains controversial. in october 2004 we started ''fast track'' treatment in colorectal surgery on one ward, in this study we present our experience with modified perioperative fluid management. methods. during one year 66 consecutive patients underwent elective surgery for colorectal cancer or sigmadiverticulitis (30 laparoscopically, 36 conventionally). demographic, pre-, intra-and postoperative data (e.g. fluid supply, urine excretion, creatinine, electrolytes, first bowel movement, vomiting), local and general complications were prospectively assessed and evaluated, median age of patients was 63 years (33-80 years). results. intraoperative i.v. fluid administration was 11.3 ml=h=kg. on the first postoperative day patients oral intake was 1600 ml (0-3500 ml) with an urine excretion of 2300 ml (500-5000 ml). no hypovolemia associated complications were observed, creatinine and electrolytes showed no significant pre-and postoperative changes. general morbidity was 12% (urinary tract infection, pneumonia). median postoperative hospital stay was 7 days (no readmissions). conclusions. reduced intraoperative and restrictive postoperative i.v. fluid therapy is feasible and has no negative impact on water and electrolyte balance. early oral fluid administration guarantees a sufficient hydration with adequate urinary output and contributes significantly to fast (track) rehabilitation and improvement of patients comfort. background. malignant pleural mesothelioma is a mainly asbestos-related neoplasm with increasing frequency associated with a poor prognosis. extrapleural pneumonectomy was initially performed as a stand-alone treatment in patients with respectable disease, however is currently almost uniformely applied as part of a multi-modal approach. its value and advantage over other therapeutic strategies remain point of discussion. we therefore analysed our experience with extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. methods. we retrospectively reviewed our institutional experience with all consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma from 1994 to 2005. patients were analysed with regard to hospital data and outcome. results. forty-nine patients (10 females=39 males, mean age 58 ae 12 years) underwent extrapleural pneumonectomy during the observation period. median icu stay was 1 day, median postoperative length of hospital stay was 13 days. after a mean follow-up of 2573 days median survival was 376 days (mean 672 ae 121 days, range 9-3384). 1 year survival was 53.06%, 3 years survival 27.06% and 5 years survival 19.28%. conclusions. extrapleural pneumonectomy as part of a multi-modal treatment regimen is a good treatment option for selected patients with malignant pleural mesothelioma. the long term results of this limited series compare favourable to non-surgical treatment regimens. larger randomised prospective multi-center trials are warranted to establish clear guidelines. background. the accelerated progress in genomics and data analysis technologies give a new view to customized treatment for stage iii lung cancer. the histopathological diagnosis will be accompanied by molecular classification. present treatment for advanced lung cancer is unsatisfactory and nearly 90% of newly diagnosed patients will die within two years. methods. from 2000 to 2006 54 patients underwent neoadjuvant treatment with platin-based chemotherapy followed by surgical resection. a panel of genes (p21, p53, mib-1, cyclind1, cycline, ercc1) were identified in pre-and posttherapeutic specimens. the expression profile was correlated to the histological regression grade and survival. results. the investigated different pathways allow an explanation of platin-based chemotherapy resistance and short duration of response according to the gene expression levels. conclusions. a prediction of a patient's prognosis could be improved by combining standard clinical staging methods with molecular-pathological evaluation. background. in the last 15 years the video assisted approach (vats) has become the standard of care for persistent or recurrent (after tube drainage) spontaneous pneumothorax (sp) . but what is the standard treatment in recurrent pneumothorax after primary operation in the era of vats? moreover, we only have little information about the rate of contra lateral pneumothorax in those patients. to find answers to these questions we investigated the patients operated for sp in recent years. methods. we retrospectively analysed patients with sp treated by vats between 1=2000 and 12=2006. only patients with 45 years of age or younger without any underlying chronic lung disease were included. the treatment of choice was bullectomy or apical lung resection with apical partial pleurectomy (app) by vats. results. we identified 50 patients at a mean age of 27 years (17-42) with the female: male ratio of 1:3.2. the interval of the study and the operation was at mean of 35 months. the primary vats for sp was successful in 94% (n ¼ 47 patients). in three patients with primary failure persisting pneumothorax was reoperated by vats (postoperative day 4, 20, 27) . none of these three patients had a recurrence. of 47 patients treated successfully for spontaneous pneumothorax 6.3% (n ¼ 3 patients) suffered from recurrence at a mean of 19 (6-30) months with one case of a second recurrence. only minor or no adhesions were found at the apex of the thoracic cavity, a bulla was found in one woman. moreover, in all patients an intact neopleura was found. major morbidity was postoperative hemothorax treated conservatively in 4% (n ¼ 2 patients). interestingly, 12% (n ¼ 6 patients) developed primary pneumothorax on the contra lateral side at a mean 13.2 (0-45) months. all these patients underwent vats without recurrence. conclusions. 1. successful treatment of sp can be achieved by vats with low recurrence rate, low morbidity and a high primary success rate. 2. in sp with bullae the role of app is not defined as yet and in recurrence or primary failure a thoracoscopic pleurodesis e.g. with talcum, should be considered. 3. in the light of the high rate of almost 12% of contra lateral sp a primary intervention on both sides should be considered. 4. a study to identify patients of risk for contra lateral sp with e.g. low dose ct in the first event should be considered. background. surgical treatment of myasthenia gravis and thymoma necessitates the complete resection of the thymus with the whole fatty tissue adherent to the pericardium. the aim was to investigate the efficacy and safety of robotic approach. methods. from 12=2004 to 12=2006 20 patients with myasthenia gravis (n ¼ 12) or thymoma (n ¼ 8) (mean age 48 ae 18 years, male to female ratio 8:12) were operated with the intention to perform a totally endoscopic, complete resection with the davinci telemanipulator system. in all but one patient a left sided approach was chosen. results. in 18 out of 20 patients the operation was carried out totally endoscopic. two patients had to be converted because of bleeding (patient 2) and thymus carcinoma (patient 4) requiring extensive resection. in the remaining patients, operative time was 175 ae 6 minutes, intubation time 120 ae 262 minutes. icu stay was 1 day, in hospital 4 ae 1.8 days. in all patients it was possible to identify both phrenic nerves and the complete fatty tissue above the anonymal vein along the supraaortal vessels was resected. histology revealed normal persisting thymus tissue (n ¼ 8) and thymoma (n ¼ 6) -who stage b2 and b3 (in 3 cases each); masaoka stage i (n ¼ 2), ii (n ¼ 3) and ivb (n ¼ 1), respectively. all resection borders were free of tumor. in all myasthenia gravis patients acethylcholinereceptor antibodies decreased during follow up. conclusions. complete endoscopic thymus surgery with the da vinci surgical system, is feasible and safe to implement into clinical practice. due to the minimal trauma, patients can return to full activity in a short time period. 362 self-expandable covered metal tracheal type stent for sealing cervical anastomotic leak after esophagectomy and gastric pull-up: pitfalls and possibilities background. the rate of anastomotic leakage after cervical esophagogastrostomy following esophagectomy and reconstruction with the tabulated stomach ranges between 10 and 30%. the treatment options comprise redo-surgery, endoscopical stapling, glueing or insertion of plastic stents, or conservative management with drainage procedures. the aim of this study was to evaluate the efficacy of self-expandable covered metal tracheal type stents for sealing the anastomotic leak. methods. from 01=00 to 06=06, 6 patients with leakage of the cervical esopahgogastrostomy following esophagectomy and reconstruction underwent endoscopic stenting using the self-expandable covered tracheal type device. the extent of the dehiscences ranged from 10 to 30% of the anastomotic circumference. mortality, morbidity, healing rate of the anastomosis and hospitalisation time were evaluated. results. in all cases stenting was done without any complication. stent extraction could be performed after an average period of 91 days, ranging from 13 to 230 days. in all cases, healing of the anastomosis was satisfactory. 3 patients developed stenosis after removal which was successfully managed by bouginage. stent migration was observed in 2 patients, treated by repositioning in one and two attempts of re-stenting followed by eventual suturing of a small residual leak in the other. conclusions. endoscopic insertion of a self-expandable covered metal tracheal stent represents a safe approach resulting in immediate closure and subsequent healing of cervical anastomotic leakage. there was no leakage-related morbidity, oral intake of food was resumed one day after successful stenting. however, stent dislocation and stricture after stent removal may occur. background. squamous-lined cyst of the pancreas is a rare entity with only about one hundred reported cases. three types of cysts are differentiated: lymphoepithelial, dermoid and accessory-splenic epidermoid cysts. the literature on this entity is limited to reports of single or small numbers of cases. the two most common cystic tumors of the pancreas are serous cyst adenoma and mucinous cystic neoplasms. we herein report the case of a lymphoepithelial cyst of the pancreas. case report. a 41-year-old man presented with a 6 month history of upper abdominal pain and bloating. the disorders were related to food ingestion and were not followed by nausea or vomiting. he experienced low weight loss. he was in good general health with a normal physical examination and no tenderness in the upper abdomen. laboratory investigation including ca 19-9, cea and hcg were within the normal range. imaging studies with ct, mrt and eus showed a 2 â 3 cm 2 mass in the uncinate process of pancreas with contact on 270 to the mesenterial vessels. the mass presented in ct=eus as a solid, expansive tumor, whereas mrt showed a cystic mass. fine-needle biopsy revealed squamous epithelial cells with sebaceous material, but without atypia. because of the progressive symptoms with compression of the duodenum and to rule out malignancy we resected the cystic tumor. no encasement, invasion or other aspects of malignancy were found. the resection defect was drained with a jejunal y-roux-loop. histological findings showed a benign lymphoepithelial cyst and the patient had an uneventful postoperative and four-month follow-up period. conclusions. establishing a preoperative diagnosis of a lymphoepithelial cyst is not possible. squamous-lined cysts of the pancreas have a low malignant potential, however, there are reports of mature dermoid cysts developing into malignant forms. to distinguish squamous-lined cysts from other cystic lesions of the pancreas, particularly malignant processes, is rather difficult. therefore we recommend a complete surgical removal of every cystic lesion suspicious to be a squamouslined cyst to avoid or treat malignancy. 367 ten year experience with duodenum preserving pancreatic head resection in chronic pancreatitis r. j. klug, f. kurz, m. aufschnaiter kh barmherzige schwestern linz, chirurgie, linz, austria background. the chronic head accentuated pancreatitis is on the rise in industrialised countries. alcohol is the predominant aetiological factor.the incidence is 13 per 100.000 inhabitants. in up to 30% of patients with chronic pancreatitis the head of the gland will be grossly enlarged by an inflammatory mass, often associated with bile duct stenosis and duodenal hold-up.in our institution the standard whipple operation has been replaced by the duodenum preserving pancreatic head resection (dpphr). methods. we present our meanwhile 10 year experience with dpphr. our patients are analysed retrospectively. results. between november 1996 and november 2006 we performed 39 dpphr in 31 males and 8 females patients. the average age was 49.6 years (30-77 years). the follow-up was done by the aid of an inventory referring to postoperative pain control, development of diabetes, postoperative weight gain and subjective success assessment. the complications are described and discussed as well. the results are presented. conclusions. the dpphr developed by beger about 35 years ago has become the standard procedure for the operative treatment of.chronic head accentuated pancreatitis in our institution. the intervention is demanding but offers the advantages of maximal organ preservation, satisfactory endocrinological and functional results, a justifiable low complication rate as well as a high degree of satisfaction on the part of the patients. 368 segmental duodenectomy at periampullary lesions -an adequate therapy? j. karner, b. sobhian, m. klimpfinger, g. udvadi, f. sellner smz-süd kaiser franz josef spital, vienna, austria background. the radical surgical procedure for treatment of the resectable periampullary tumors is the partial pancreatoduodenectomy or the pylorus-preserving pancreatectomy. in rare selected cases a segmental duodenectomy with reinsertion of the pancreatic and choledochus duct might be suitable alternative to improve the patient's quality of life. methods. about 30 to 40 patients were hospitalized annually with the diagnosis of a pancreatic or periampullary tumor at the smz-süd -kaiser franz josef spital department of surgery. to ensure radical resection either a partial pancreatoduodenectomy or a pylorus-preserving pancreatectomy was performed. in two patients with low-and=or high-grade dyspla-sia of the papilla and the peripapillar mucosa a segmental duodenectomy with resection of the papilla vateri was performed. after radical excision (proven by an intraoperative frozensection diagnosis) a duodeno-duodenal anastomosis with reinsertion of the splinted pancreatic and choledochus duct was performed. results. the postoperative course was uneventful. three months after the operation, clinical follow-up including gastroscopy revealed a normal mucosa of the duodenum and an excellent quality of life. conclusions. accurate surgical technique and pre-(gastroscopy), intra-and final histopathological diagnosis by an experienced pathologist are decisive factors in determining the ultimate outcome. if the histological findings as to benignity are uncertain, resection of the head of the pancreas with or without preservation of the pylorus by an experienced surgeon is indicated. the segmental duodenectomy might be an adequate therapy of the periampullary lesions in carefully selected cases. background. five randomized trials and an increasing number of phase 2 studies confirm the opinion that the combination of peritonectomy-procedures and intraperitoneal chemotherapy positively influence the outcome in patients suffering from peritoneal carinomatosis (pc) of appendiceal tumors, colon cancer, ovarian cancer and gastric cancer as well as rare tumors of the peritoneum per se. nevertheless, according to the literature postoperative mortality was observed in 0-15%, postoperative minor and major morbidity in 11-40%. methods. in the last 13 years 202 patients (pts) suffering from pc arising from different primary tumors were treated at our institution in cooperation with surgical, gynecological or oncological departments in austria and germany. at the time of writing complete records from 151 patients (mean age: 55.4 ae 11 yrs, others 21) are evaluated for analysis. primary objectives to assess were overall survival and time to progression of intraperitoneal or general disease. factors influencing these parameters were determined. secondary objectives to assess were postoperative mortality and morbidity. results. completeness of cytoredutive surgery, favourable histology (ovary, appendix, colon) and n -stage 0-1 (n ¼ 70 pts) made a 5-year survival rate of 44% and a 10-year survival rate of 37% possible. (updated extended analysis of the different groups of patients will be presented) postoperative mortality within 30 days was 2.6%, within 90 days 4.6%. conclusions. cytoreductive surgery in combination with intraperitoneal, hyperthermic chemoperfusion ae systemic chemotherapy has a curative potential in selected patients. background. an increasing amount of patients confronted with an incurable or chronic progressive disease demands a special palliative procedure in physical, psychosocial and spiritual treatment. medical and nursing staff members in the hospital are not always prepared to handle with these patients and their relatives in a proper way. reasons behind may be lack of time, skills and experiences. deficits in management and in multiprofessional communication complicate the situation. a palliative liaison service provides, in this context, support in pain management, control of severe symptoms, treatment of terminal patients, coordination of professionals, discharge management, cooperation with mobile hospiz teams and support in ethical conflicts. methods. in 2004 we asked 230 medical and nursing staff members for the importance and the need of palliative support in their daily routine. from may to december 2005 we documented 442 consultations of 104 patients, which means an effort of 201, 2 hours. in 2006 we asked 40 members of the medical and nursing staff in leading positions about the amount of satisfication with the provided support and the acceptance of the instution pls 1 year after the implementation. results. in 2004 89% of the staff members asked, confirmed the importance of palliative care and 67% agreed to the cooperation with a palliative liaison service. from may to december 2005, 58, 7% of the demands for support came from surgical wards. the primary reasons for the first contact were pains and other severe symptoms. about 60% of the patients had cancer in the diagnosis. in 2006 the extent of satisfaction with the performances of the palliative support team was between 1, 2 and 1, 6 (satisfaction is defined until 2, 5 within a range of 1 to 5). 53% to 89% from the provided performances were already requested. conclusions. the service of a palliative support team in the hospital was highly accepted already after a short time. more than the half of the consultations took place on surgical wards. we conclude that a palliative support service provides benefits for staff and patients in a difficult situation. especially in a time of rapid medical progress, limited resources and increasing ethical demands of autonome patients, the public health institutions may request for the right balance between curative and palliative settings. background. the ileus is often the sign of an advanced stage of malicious illnesses that require palliative treatment. medicine and especially palliative medicine has changed medical treatment in the way that it now aims at an improvement of life quality. methods. in our hospital 104 cases with 87 patients were analysed. these patients suffered from ileus in connection with an advanced malicious illness. results. an ileus was localised with 78 patients in the field of the small intestine and with 26 patients in the field of colon. 37 cases were treated in a conservative way, 67 cases required operative treatment. primary tumors were found predominantly in the colon and also in the feminine genitals as well as in the stomach. on average the remaining life time was two months. 45% of the patients with ileus in the field of the small intestine were treated without operation. conclusions. the life time of patients with ileus and advanced malicious illness is short. operations with high risk should be avoided. patients with ileus in the field of the small intestine should be given conservative treatment which in case of failing may be converted into interventional or operative treatment. operation can hardly be avoided with patients with ileus in the field of colon. if available, interventional therapy for the removal of stomach and intestine contents should be applied. the patient's wish is to be considered. treatment should aim at improving the patient's life quality. 372 penetrating abdomino-thoracic injuriesreport of four impressive cases z. halloul, f. eder, f. meyer, h. lippert department of surgery, university hospital, magdeburg, germany background. penetrating wounds are distinguished in impalement and gun shot or stab wounds (stab=impalement injuries more frequently in europe), which are often very spectacular. the aim of the representative case reports is to analyze the kind of injury þ the adequate surgical, in particular, the complex wound management. methods. the impressive case series includes 4patients with abdomino-thoracic penetrating traumas (2stab=impalement wounds each) who were treated in a surgical university hospital centre during 12 months. results. (1) impalement injury by a steel pipe i) entering the body above the right kidney behind the liver, through the mediastinum via the right thorax, passed heart and aortic arch up to the left clavicle, ii) approached with sternotomy=median laparotomy to remove the rod including suture of the left subclavian vein only (postoperatively, residual lesion of the left brachial plexus=temporary pneumonia). (2) one leg of a chair drilled into the left ''foramen obturatorium'' leaving the body at the right anterior iliac spine: initial removal=excision of the gluteal penetration canal. developing abdominal signs= symptoms indicated explorative laparotomy revealing peritonitis because of perforated ileum: segmental resection= anastomosis (postoperatively, i) right inguinal wound necrosis requiring excision=vacuum-assisted closure sealing; ii) remaining paresthesia in the left leg due to sacral plexus lesion). (3) due to a violent conflict, 2 stabs entered the right thorax while one injured the right pulmonary lobe=diaphragm=liver dome between segment viii&v þ a big scalp avulsion at the left= right parietooccipital site þ a transection of the right biceps muscle approached with right subcostal incision=anterior thor-acotomy=liver packing (2 towels removed after 2d)=suture of the diaphragm=pleural drainages. (4) stab injury at the left thorax (pneumothorax=lesions of the diaphragm & left third of the transversal colon) and neck (lesions of the pharynx=internal jugular vein) approached with left thoracic drainage=suture of the colonic & diaphragmatic lesions (postoperatively, i) right thoracotomy because of a right pleural empyema due to bronchopneumonia as a consequence of the blunt right thoracic trauma; ii) relaparotomy because of an abscess within the douglas' space; iii) billroth-ii gastric resection because of recurrent forrest-ia bleeding). conclusions. important aspects of such trauma care are immediate life-saving measures, transferral to a trauma centre, first care, prompt diagnostic=initiation of an adequate surgical treatment provided by trauma=general=abdominal=vascular and=or cardiac surgeons (e.g., surgical interventions at vessels= organs=soft tissue) as well as the postoperative course and rehabilitation. if these measures are provided with high medical standards and an interdisciplinary setting, optimal outcome can be achieved in order to prevent fatal outcome, to ensure maximal organ function, and to minimize permanent damages. background. today infections with clostridium perfringens are rare, but still most of the cases turn out lethal, although receiving timely medical treatment. this report deals with three different patients, who were transferred to our surgical department since june 2006. the first patient (male 47), with the suspected diagnosis ''femoral hematoma'', a second patient (male 73) because of an ''acute abdomen'' and the third patient with suspicion of gas gangrene after chronic ulcer of the right food. methods. first patient: already at the physical examination of the femoral an impressive crepitation was palpable. besides this the man was suffering from myelodysplasia and showed a marked ulcer on the left side of the scrotum. on suspicion of gas gangrene we performed an exarticulation of the left femoral after intensive-care stabilization. besides all efforts this patient died the same day because of an acute circulatory failure. second patient: because of an acute abdomen the second patient received a ct and in suspicion of appendicitis an explorative laparotomy was indicated. furthermore a known haematoma at the right shoulder began to extend in sizeand shortly after the typical crepitation was palpable as well. even though the arm was exarticulated during an immediate operation the patient died because of the massive progressing infection. third patient: this patient was sent to our hospital because of the suspicion of gas-gangrene. during physical examination the typical crepitation was palpable at the right femoral and lower leg with associated emphysema. during operation the wound seemed unsuspicious. immediate examination of the tissue (department of hygienic and microbiology) showed a negative result concerning an infection with clostridum perfringens, so it could be refrained from an amputation of the femoral. entirely some incisions of the skin and the fascia were done. postoperative we kept watch on the wound in short intervals -showing consistent results the patient was transferred to our general ward to be treated because of his chronic ulcer on the right leg. conclusions. once pandora's box has been opened, still 100% of all gas-gangrene-infections pass off lethal. the first two cases demonstrate that (besides the low incidence of 1.5 events per 100 mio. persons and year) infections of clostridum perfringens should always be kept in mind, especially in high-riskpatients. in contrast to this the third patient shows, that severe consequences because of a precipitate indication can be avoided by experience and careful evaluation. results. altogether 16 patients were treated for rsh at our institution during the study period. seven patients were on oral anticoagulation, 3 patients were taking acetylsalicylic, 1 was on clopidogrel and 1 patient was on anticoagulation with low dose heparin, whereas 4 patients had no anticoagulation. a previous trauma event was apparent in six of the cases, one of this patient was on oral anticoagulation, one on acetylsalicylic, one was taking clopidogrel and three had no anticoagulation. rsh was correctly identified by means of ultrasound in 7 of 12 cases, in which this investigation was performed. a ct scan investigation demonstrated the haematoma in all (12 of 12 cases) cases. thirteen patients were managed conservatively, 3 patients underwent surgical treatment. eight patients needed blood transfusion and four patients received vitamin k medication. all patients could be discharged from hospital in good general condition. clinical re-evaluation (median follow up 3 years, range 1 month-6 years) showed all patients were free of symptoms at this time. conclusions. our data confirm the multifactorial aetiology of rsh and the strong association with different forms of anticoagulation. ct scan is the diagnostic tool of choice, whereas identification with ultrasound is strongly dependent on the experience of the examiner. conservative as well as surgical management have good results, with good restitution to fine health of all patients. surgery seems to be only indicated when complications appear (homodynamic instability, severe pain, which cannot be managed conservatively). background. intestinal metaplasia (im) in specialized columnar lined epithelium in the distal esophagus is a precancerous lesion with a cancer risk of 0.5% or 1 case in 200 patientyears. there are no prospective multicenter-data available for germany regarding the cancer-risk and also no data regarding different therapeutic treatment options. the purpose of this study was to evaluate the progression of dysplasia in barrett's esophagus (be) in patients under antireflux therapy -laparoscopic fundoplication (lf) or treatment with proton pump inhibitors (ppi) -based on the data of the german barrett esophagus registry. methods. in a consensus process a protocol was established by pathologists (n ¼ 3), gastroenterologists (n ¼ 22) and surgeons (n ¼ 9). patient history, findings on endoscopy, histopathology and functional diagnostics were collected in a multicentric database. patients gave their informed consent for a central data registration. barrett's esophagus was defined as specialized, intestinal metaplasia in the endoscopic visible columnar lined epithelium of the esophagus independent of its length. the natural and posttherapeutic course of patients with im was registered prospectively. participating centres were free to decide for their own treatment approach for each patient regarding im as well as the underlying reflux disease. patients were followed with routine endoscopy and biopsy every 3-6 months. results. since january 2000, 555 patients with be were prospectively registered and analysed. of fourteen participating centres three were surgical (n ¼ 397) and 11 gastroenterological (n ¼ 158). symptoms of reflux were present in 56% of patients daily or weekly, in 25% they were absent. the mean age of patients was 57 years (range 10-89). two hundred and ninety six were male and 159 female. three hundred and fifty patients (63%) had short-segment-be and 205 (37%) long-segment-be. intraepithelial neoplasia was initially diagnosed in 35 patients (low grade intraepithelial neoplasia (lgien) in 24, high grade intraepithelial neoplasia (hgien) in 5, indefinite in 6). in the second histological confirmation 3 hgien, 9 lgien and 2 indefinite ien were confirmed. in the other patients ien was excluded. from all patients 2 (1 insufficient and on competent lf) have shown progression from im to lgien and one from im to cancer (ppi) in a total of 1560 patient-years. conclusions. the current analysis shows a low rate of progression of im to ien for ppi treatment as well as antireflux surgery. this confirms recent reports on barrett's esophagus, that progression is a rather infrequent problem, which cannot be prevented by antireflux surgery or ppi. background. impaired esophageal motility plays an important role in the pathogenesis of gastroesophageal reflux disease (gerd) and its evaluation is important for the assessment of a therapeutic effect. the comparison of szintigraphic, manometric and symptomatic evaluation has not been shown yet. methods. sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying and assessment of symptoms prior to treatment (operation or medical therapy) and 6 months later. in 20 gerd patients with normal esophageal peristalsis the nissen fundoplication was performed, in further 20 patients with impaired esophageal peristalsis a partial posterior fundoplication was chosen and further 20 patients received continous medical treatment with ppi. all groups were comparable regarding age and gender of the patients. esophagitis was most pronounced in those patients who underwent partial posterior fundoplication. results. on endoscopy acute esophagitis resolved in all patients after fundoplication, whereas after 6 months of medical therapy 2 patients still had an acute esophagitis. on manometry there was a significant improvement of the competence of the lower esophageal sphincter postoperatively regardless of the performed technique. however, les relaxation was complete only after the toupet fundoplication but incomplete after the nissen fundoplication. esophageal peristalsis measured manometrically did not improve after medical therapy, was significantly strengthened after partial posterior fundoplication but was worsened by the nissen fundoplication. on szintigraphic evaluation of esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after partial posterior fundoplication. after the nissen fundoplication there was a significant deterioration of esophageal emptying. there was a strong correlation between szintigraphic and manomteric evaluation of peristalsis, preoperatively (rs ¼ à0.87 p < 0.05) and postoperatively (rs ¼ à0.82 p < 0.05). evaluation of symptoms showed no change regarding dysphagia after medical therapy and after the nissen fundoplication but a significant improvement after partial posterior fundoplica-tion. globus sensation was significantly improved after partial posterior fundoplication but did not change after medical therapy or the nissen fundoplication. postprandial bloating and inability to belch were significantly more common after the nissen than after partial posterior fundoplication. conclusions. antireflux surgery controls gerd better than medical therapy with ppis. however, partial posterior fundoplication is the more physiologic approach than the nissen fundoplication. background. combined impedance-and ph-monitoring (mii-ph) is a recently introduced diagnostic tool to assess gastro-esophageal reflux. we report our experience with this technology. methods. three hundred and fifty-seven mii-ph studies were performed in patients with clinical signs of gastroesophageal reflux disease (gerd) between may 2005 and december 2006. a catheter was introduced into the esophagus via the nose and connected to a portable data logger. ph was monitored 5 cm and impedance 3, 5, 7, 9, 15 and 17 cm above the manometrically located lower esophageal sphincter. symptoms were entered by the patients by pushing buttons on the data logger. diagnostic criteria for gerd were: pathologic acid exposure: ph < 4 during >6.3% of total, >9.7% of upright, or >2.1% of recumbent recording time. pathologic impedance monitoring: >73 liquid or mixed liquid=gas refluxes detected by retrograde impedance drops >50% from the baseline. positive symptom to reflux correlation: >50% of >3 symptom events within a 5-minute time window after a reflux episode detected by mii-ph. results. three hundred and nine mii-ph procedures were performed after discontinuation of antisecretory medications for !10 days in patients without prior esophageal or gastric surgery (age 51.8 ae 12.3 years). recording time was 22.9 ae 1.1 hours. the diagnostic yield of mii-ph is summarized in table 1 . median total acid exposure was significantly higher in males than females (5.0 vs. 2.65%; p < 0.01) as was the median number of reflux episodes detected by impedance (76 vs. 36; p < 0.001). the median number of symptoms was almost equal (11 vs.12; n.s.). positive symptom correlation was significantly more frequent in females than males (p ¼ 0.006). the overall diagnostic yield of mii-ph was not significantly different between genders. conclusions. mii-ph is a valuable new tool for the diagnosis of gerd with significantly increased diagnostic yield over conventional ph-monitoring. acid exposure and the number of reflux episodes were significantly higher in male than female patients. sensitivity to reflux was significantly higher in females. diagnosis of gerd based on acid exposure alone lacks diagnostic sensitivity, especially in female patients. background. the surgical treatment is the most effective method for weight reduction in morbid obesity laparoscopic adjustable silicone gastric banding (lsgb) for morbid obesity has been reported to provide long term weight loss with a low risk of operative complications. nevertheless, esophageal dilation leading to achalasia-like and reflux symptoms is a feared complication of lasgb. patients undergoing obesity surgery were prospectively included in an observation study. this study evaluates the clinical benefit of routine preoperative esophageal manometry in predicting outcome after lasgb in morbid obese patients. methods. before surgery, each of the patients underwent pulmonary functional test, esophageal manometry and gastroscopy. drug medication and esophageal symptoms were recorded. a review of prospectively collected datas on 357 patients (male 282, female 75), who underwent esophageal manometry routine prior to lasgb for morbid obesity from january 2001-december 2006 were performed. aberrant motility and other non specific esophageal motility disorders noted on preoperative esophageal manometry defined patients of the abnormal manometry group. outcome differences in weight loss, emesis, band complications were compared between patients of the abnormal and normal manometry groups after lsagb. results. of the patients tested 112 had abnormal esophageal manometry results, whereas 245 had normal manometry results before lsagb. there was no significant difference in wheight loss between the groups after gastric banding. severe postoperative emesis and achalasia like esophageal dilation occurred more frequently in patients with abnomal manometry results. band related complication were found in both groups. there was no difference in the prevalence of reflux symptoms or esophagitis before and after gb. the lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakend after lsagb. conclusions. postoperative esophageal dysmotility and gastresophageal reflux are not uncommon after lsagb. preoperative testing should be done routinely. low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindication to lsagb. patients with such findings should be offered an alternative procedure, such as laparoscopic sleeve gastrectomy or gastric bypass. background. laparoscopic implantation of an adjustable gastric band (agb) still represents the most frequently performed bariatric operation in austria. however, in recent years a general tendency to gastric bypass procedures can be observed. a mayor cause for this development may be long term problems such as the development of an esophageal dilatation. methods. from january 2000 until november 2006, 206 patients (172 female, 37 male) were treated with agb for morbid obesity at the krankenanstalt rudolfstiftung in vienna. adjustments of the band were performed under radiologic control 6 weeks after the operation and on demand thereafter. of these 206 patients, 36 patients (35 female, 1 male, median age: 40 years, range: 22-67 years), an equivalent of 17%, developed an esophageal dilatation during follow up. the median time from the operation to the occurrence of esophageal dilatation was 35 months (range: 4-68 months). at the time of esophageal dilatation the median excess weight loss was 52% (range: 2-111%), the median filling volume was 7 ml (range: 5.5-9.5 ml). twelve patients had to be reoperated in a median of 5 months (range: 1 month-17 months) after the dilatation occurred. eleven patients had a gastric bypass operation after band explantation and one was converted into a sleeve gastrectomy. in the other 24 patients a conservative approach has been persued so far, consisting of a deflation of the band and careful refillings after approximately 1 month. eleven patients were already available for follow up a median of 7 months (range: 1 month-24 months) after the dilatation. ten patients significantly gained weight again. the median excess weight loss was reduced from 56% (range: 6-111%) at the time of the dilatation to 35% (range: à24-87%) at follow up. only one patient managed to lose further weight without radiologic signs of esophageal dilatation after refilling of the band. conclusions. esophageal dilatation is a serious long term complication after agb which occurs approximately 3 years after the operation and leads to a failure of this bariatric procedure in the majority of cases. further studies are needed to identify potential candidates for esophageal dilatation after agb. 380 oversewing of gastric pull up staple line in reconstruction after esophageal resection: counterproductive or helpful procedure? considerable postoperative morbidity and mortality. recent studies have emphasized a notable improvement in morbidity rates at specialized centers. in our analysis we put special considerations on the need for an invaginatig suture of the mechanical staple line used for gastric tubulization. methods. between 2000 and 2006, 156 patients were treated for esophageal cancer by resection. perioperative data were collected prospectively. among those 156 patients 111 (71.2%) underwent gastric pull-up reconstruction. the gastric tube has been constructed by gias using 3 mm staple cartridges. these patients were included in the presented study. it was put upon the discretion of the treating surgeon, whether the staple line has been oversewn by an interrupted invaginating suture or not in a non-randomized manner. the main endpoint measure of the study is leak rate at the longitudinal staple line of the gastric tube without signs of major gastric ischemia. results. the mean age of the patients was 62.4 ae 9.2 years, 74.3% of the patients were male. in 61=111 (55.1%) patients an adenocarcinoma was diagnosed, whereas 48=111 (43.1%) patients had a squamous cell carcinoma and 2=111 (1.8%) were classified as others. in 68=111 (61.3%) patients the gastric staple line was not oversewn (group a). in 43=111 (38.7%) patients the gastric staple line has been reinforced by an invaginating interrupted suture (group b) . a leak at the staple line has to be reported in 4=68 (5.9%) patients in group a, whereas no leak was seen in group b (p ¼ 0.09). two=111 patients (1.8%, a:1, b:1) experienced ischemic gastric tip necrosis. other surgical complications were anastomotic leakage (13=111 patients; 11.7%; a:5=68, b:8=48), temporary recurrent nerve injury (13=111 patients; 11.7%; a:4=68, b:9=48), anastomotic stenosis (8=111 patients; 7.2%; a:2=68, b:6=48) and chylus fistula (6=111 patients; 5.4%; a:5=68, b:1=48). conclusions. no significant difference was found between group a and b. however, all staple line leaks of the gastric tube developed, when the gastric tube staple line has not been oversewn. background. cardia carcinoma (ca) is characterized by different features compared with the remaining gastric ca; its incidence in western countries is increasing. the aim of the study was to investigate diagnostic, therapeutic and outcome measures of cardia ca in daily surgical practice. methods. all consecutive patients with cardia ca out of a pool of patients with histologically confirmed diagnosis of gastric ca who were treated in surgical departments were enrolled in this prospective observational multicenter study through a period of 12 months. detailed patient, diagnostic and treatment characteristics were recorded in a computerbased format for analysis. short-term outcome was characterized by hospital stay, complication rate, morbidity and hospital mortality. results. from 01=01-12=31=2002, 1.139 patients with gastric ca from 80 surgical departments of each level of care were registered out of them 198 subjects (17.4%) with cardia ca. tumor localization was classified in 186 patients according to siewert: typi, n ¼ 44 (22.2%); typii, n ¼ 80 (40.4%); typeiii, n ¼ 62 (31.3%). one hundred and seventy two patients underwent surgical intervention (operation rate, 86.9%) of whom 145 individuals underwent resection (rate, 84.3%). a potentially curative resection could be offered to 111 patients (r0 resection rate, 56.1 vs. 82.3% in all gastric ca). fresh frozen section was only used in 72 resections (rate, 49.7%). of 142 standard resections (distal esophagectomy with proximal or total gastrectomy), systematic d1, d2 and d3 lymphadenectomy was performed in 81.0, 67.6 and 7.7%, respectively. histologic investigation revealed uicc stage i=ii in 39.5% of all operated patients: iii=iv, 54%; not classified, 6.5%. distant metastases occurred most frequently at the peritoneal site (15.2%), liver (10.6%) and non-regional lymph nodes (7.1%). postoperative morbidity was 33.7%. anastomotic leakage occured in 13 patients (9.1 vs. 5.8% in total of all gastrectomies in gastric ca) from whom 8 subjects (5.6%) underwent surgical reintervention. hospital mortality was 8.6% (n ¼ 17) compared to 8.0% in all patients with gastric ca. conclusions. more than 50% of patients diagnosed with cardia ca show an advanced tumor stage at the time of surgical intervention. not all resections estimated as potentially curative were accompanied by d2 lymphadenectomy. in particular, to further improve hospital volume and r0 resection rate, to consequently use intraoperative fresh frozen section for the detection of an adequate tumor-free resection margin and to lower the rate of anastomotic insufficiency, it is suggested to treat patients with cardia ca at surgical centres for optimal outcome (5-year survival rate is being under investigation). 389 deep brain stimulation therapy for psychiatric diseases g. m. friehs brown university, providence, usa background. obsessive-compulsive disorder (ocd) and major depressive disorder (mdd) causes tremendous suffering in those affected and in their families. neurosurgical lesioning procedures have been in existence for several decades and the overall reported success rate is widely quoted in the 35-70% range. over the past years deep brain stimulation (dbs) has become available for a variety of conditions including ocd and mdd and has largely replaced lesoining procedure. methods. we report on our experience with 10 patients with ocd (5) and mdd (5) treated with dbs of the anterior limb of the internal capsule (al-ic). patients who did not have multiple medication trials of adequate length and dose and trials of psychotherapy or behavioral therapy were excluded. also, mdd patients were required to have had a full course of electro-shock therapy (ect). patients were evaluated by a panel of independent psychiatrists before being referred for neurosurgery. all patients underwent a routine dbs surgery with implantation of bilateral electrodes into the al-ic. the stereotactic coordinates were 4-5 mm anterior to the anterior commissure (ac) and 5-10 mm lateral to anatomical midline, the electrode tip reached into the area of the nucleus accumbens. all patients had pre-and postoperative neuropsychology evaluations with testing batteries including the yale-brown-obsessive-compulsive-disorder scale (ybocs), global assessment of functioning scale (gaf) and hamilton-depression scale (ham-d) or the montgommery depression scale (mds). results. patients were followed for 24-60 months (average: 3.5 years), follow-up was complete for all patients (100%). 3=5 patients (60%) with ocd had improvements in their ybocs scores of more than 35% which was found to be significant (p < 0.01). also, these patients showed a significant (p < 0.01) improvement in their overall gaf. it was furthermore noted that the depression scores had a tendency towards improvement. of the five patients with mdd 4=5 patients (80%) had a significant improvement in their ham-d scores and gaf scores (p < 0.01). complications included one postoperative seizure, slight wound healing problems which did not require surgical intervention (1=10, 10%). of note is the fact that the dbs batteries have to be changed very frequently (on average every 9-18 months). conclusions. dbs for ocd and mdd is a viable treatment for patients who have failed all other known therapeutic options. it is currently reserved for research centers who have a team of psychiatrists dedicated to the treatment of such patients. controlled studies will be necessary to develop guidelines for electrode placement and programming parameters. background. the number of patients demanding endoscopic neck surgery is rising. the access trauma of the axillary, breast and chest approaches is bigger than in open or video assisted surgery. we tested the feasibility of he sublingual transoral access which is in our opinion the only real minimally-invasive extracollar endoscopic access to the thyroid gland. methods. we performed an experimental investigation in a porcine model. in 10 pigs we made 10 endoscopic transoral thyroidectomys with a modified axilloscope with the help of ultrasonic scissors and a neuro-monitoring system for identification of the recurrent laryngeal nerve. results. the average operation time from the introduction to the removal of the obturator just above the larynx was 57 seconds. the mean operation time was 43 minutes. with the help of the neuro-monitoring system we proved in all cases the function of the recurrent laryngeal nerve on both sides. the pigs were observed for another two hours after operation. during and after the operation no complications appeared. conclusions. we could show that the endoscopic transoral thyroid resection in pigs is possible and save. our results might be useful for using this access for endoscopic thyroid resection in humans. background. actually, the surgical community receives some new impulses from interventionally orientated and skilled gastroenterologist by the so-called ''n.o.t.e.s.'' -natural orifice transluminal endoscopic surgery. this seems to be challenge enough to cooperate and contribute some surgically constructive ideas and critics. the surgical answer -with the intention to develop the arguments for a surgical engagement -to the presently still extra-clinical concept of ''notes'' may be given through an alternative procedure named ''flexible endoscopic minimally invasive transperitoneal'' (f.e.min.in. tra.p.) cholecystectomy. methods. after presentation of ''notes'', it's principles and aims, it's supporting societies and boards and their self-definition, a summary of already existing ''notes''-procedures and description of instrumental developments will be given. in contrast surgical considerations will be focused on more or less established surgical transluminal or even natural-orifice-transluminal techniques. in this context a special attention will be paid to surgical history and the life and times of e.mü he and the fact of a nearly-missed change of paradigms. as testimony for surgical endoscopic competence in interventional procedures the hybrid-model of f.e.min.in. tra.p. cholecystectomy will be opposed as surgical pendant to the conceptual idea of ''notes'' throughout a short clip-sequence. results. arguments for a surgical engagement in the development of ''notes'' are based on the following items: conclusions. only a close interdisciplinary cooperation may show weather the idea of ''notes'' will lead to clinical usefulness. it's invasivity as well as it's apparent strangeness to surgical behaviour and thinking should incline to an at least active interest. background. sacral nerve stimulation (sns) proves to be an effective therapy in patients with faecal incontinence. during the past years there were as well some promising results in the therapy of chronic obstipation. this study describes the experience with sns in patients with outlet obstruction. methods. four patients suffering of outlet-obstruction (3 women), median age 64 years (range 53-75) underwent test stimulation with a permanent electrode (tined lead). all patients had multiple previous conservative and operative unsuccessful therapy attempts. when complaints could be reduced by at least 50% with external stimulation, a permanent stimulator was implanted (two staged procedure). success of treatment was evaluated by: clinical examination, patient satisfaction (visual analogue score;vsa), cleveland-clinic-obstipation-score, and morbidity. evaluations were performed before start of treatment, before implantation and 6 months after implantation. results. three of four patients completed the test stimulation stage successfully and received a permanent implant; median duration of stimulation stage was 22 days (range 16-26). all these patients had a clear improvement according to their vas and cleveland-clinic obstipations-score. there was no postoperative morbidity. the median follow-up was 8 months (6-8). conclusions. chronic obstipation can be treated successfully with chronic sacral nerve stimulation even after other therapeutic approaches have failed. however, this observation has to be confirmed in larger, controlled trials. background. the stapled transanal rectum resection (starr) is an accepted technique for the treatment of the obstructed defecation syndrome (ods). however, the technique with a circular stapling device (pph-01) is limited in large prolapse and the resection is performed ''blind''. a new device, the contour trans-starr (str5g), has been designed with the aim of overcoming pitfalls of the current starr technique. this study describes the new technique and the initial experience in treating outlet obstruction or rectal prolapse. methods. all patients had multiple previous conservative or operative unsuccessful therapy attempts. the procedure was performed in lithotomy position and under spinal or general anaesthesia. the prolapse was sutured at the apex with the goal to obtain a uniform circumferential traction (parachute technique). then the new device was introduced into the rectum and a circumferential resection was performed step by step. success of treatment was evaluated by: clinical examination, ods-score, and morbidity. evaluations were performed before the treatment and 3 months later. results. the study started in january 2007 and we estimate to enrol eight patients until the end of may 2007. indications, patient's inclusion and exclusion criteria, morbidity and short term outcome will be discussed. conclusions. with the new device the starr procedure may become easier and more effective in the treatment of ods. however, safety and effectiveness has to be confirmed in larger, controlled trials. leber-gallengang 396 therapeutic options for pyogenic liver abscesses h. cerwenka background. clinical management of pla (pyogenic liver abscess) has changed in the last decades due to constant improvements, for instance, in inventional radiology and antibiotic therapy. in surgical departments, we usually treat a selected group of patients with particularly severe forms. methods. our clinical study comprised a series of 76 patients with pla. antibiotic treatment was modified according to sensitivity testing. additional therapy consisted of percutaneous puncture=drainage, endoscopic papillotomy=stenting and surgical interventions when indicated. results. fifty-eight patients (76%) had single and 18 patients multiple pla. the disease was confined to the right hepatic lobe in 76% and to the left lobe in 7%; both lobes were affected in 17%. etiology was biliary in 38%, hematogenous in 11%, posttraumatic in 9% and cryptogenic or attributable to rare reasons in the remaining patients. microbiological culture was sterile in 24%, which was at least partly due to antibiotic pre-treatment. staphylococci, streptococci and e. coli were most often identified. anaerobes were found in 15%. factors associated with the need for surgery included: empyema of the gallbladder, underlying malignancy, perforation, multicentricity, vascular complications (hepatic artery thrombosis) and foreign bodies (e.g., toothpick, infected ventriculo-peritoneal shunt). in patients with biliary fistulae it was crucial to ensure prompt bile flow (for instance, by papillotomy=stenting). conclusions. assessment of underlying diseases is decisive for timely identification of patients requiring more invasive treatment. microbiological testing provides clinically important information for treatment monitoring and modification. special attention must be paid to diagnosis and treatment of concomitant biliary fistulae. 397 therapy methods of hydatid disease from the tradition to the future m. sanal 1 , h. guvenc 2 , j. hager 1 in europe. however there are some regions: upper bavaria, suedwuerttemberg (swabian alb), bathing (black forest), furthermore tirol, kaernten and steiermark, switzerland and north italy involved with this parasite. also people from turkey and the balkans bring the illnesses again and again. this lead to the necessity for physicians to be aware of its clinical features, diagnosis and management. methods. thirty patients with cyst echinococcus (ce) in liver, lung, kidney and spleen were in three different pediatric surgery departments innsbruck, bursa and kocaeli surgically treated. in the patients were cystotomy capitonage, simple cystotomy, unroofing, splenectomy, cyst excision performed. seven patients underwent minimal invasive surgery. results. postoperative bronchopleural fistula resolved spontaneously under negative pressure in five cases. the long-term postoperative results are considered good, with no recurrences observed. conclusions. surgery has remained the mainstay for the treatment of ce. the basic steps of the surgical procedures are eradication of the parasite by mechanical removal, sterilization of the cyst cavity by injection of a scolicidal agent, and protection of the surrounding tissues. pair technique in ce; performed using either ultrasound or ct guidance, involves aspiration of the contents via a special cannula, followed by injection of a scolicidal agent for at least 15 minutes, and then reaspiration of the cystic contents. in the last years video assisted intervention has also been performed successfully. background. group milleri streptococci (gms), a heterogeneous group of streptococci, are associated with purulent infections. methods. retrospective analysis of all consecutive biliary infections due to gms in a four-years period. results. out of 452 gms positive patients the innsbruck medical university within the study period, the biliary tract was affected in 99 (21.9%). the mean patient age was 60.84 ae 15.69 years, with a female:male ratio of 1:1.2. polymicrobial infections were present in 56.60%. thirty percent of all patients were immuno-compromised after liver transplantation (30=99). seventy-nine patients (79.80%) had clinical signs of infection, which was confined to the gallbladder in 30 (30.30%) (group i), while 49 patients (49.50%) presented with cholangitis (group ii). underlying diseases in the cholangitis group were biliary complications following liver transplantation in 24, other causes for mechanic cholestasis in 12, malignant intrahepatic disease in 6, ascending infections in 5 and a ductus choledochus cyst in one patient. twenty patients (20.20%) had gms positive bile cultures without clinical signs of infection (group iii) obtained during evaluation of cholestasis (12), status post liver transplantation (6), bilioma post liver resection (1), and psc (1). antibiotics were administered to 19 patients (63.33%) in group i, all patients (100.00%) in group ii, and one patient (5.00%) in group iii. in group i, all patients also underwent cholecystectomy. interventions were required in 15 patients (75.00%) in group ii (ercp (10), external drainage (3), surgery (2)), and 42 patients (85.71%) in group iii (ercp (27), external drainage (7), surgery (8)). gms isolates were susceptible to all penicillins, clindamycin and most cyclosporins, but were resistant to aminoglycosides and showed intermediate susceptability to ciprofloxacin. conclusions. the biliary tract was affected in one out of five patients with group milleri streptococci (gms). gms cause infection in 80% of all cases, and are often associated with mechanical cholestasis. background. peritonitis ossificans is a rare disorder with only few reported cases in literature. metaplastic bone formation in abdominal scars seems to be an own entity with only several descriptions mostly associated with trauma, gun shot wounds and repeated abdominal surgery. we report about a case with development of metaplastic bone formation and peritonitis ossificans after multiple acute surgical interventions. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''peritonitis ossificans'' and ''metaplastic bone formation'' via pub med. results. our patient developed multiple nodular lesions with massive calcifications between the small bowel mesentery (heterotopic mesenteric ossification) after primary adhesive ileus and revision surgery because of colonic leakage. the situation developed within 9 days from a prior abdominal situs without calcification. small bowel fistula occurred and we used abdominal vac therapy. ten weeks later partial secondary closure was performed and no sign of calcification could be observed. histological features showed fatty necrosis and scary tissue with metaplastic cartileage and bone tissue. literature is rare, pathophysiology, therapy and prognosis remains unclear. conclusions. male gender, multiple abdominal surgery or trauma with peritonitis, peritoneal dialysis and pancreatitis seem to be predisposing factors. extensive activation of myofibroblasts appears to be the major cause for hyperproliferation. the prognostic impact depends on secondary complications including postoperative fistula and leakage and intestinal obstructions. actually, literature shows no causative therapy. background. the differential diagnosis of dysphagia predominantly includes gerd, neoplasm, diverticula or achalasia. infrequent causes are diffuse esophageal spasm, scleroderma and other systemic diseases. eosinophilic esophagitis as a cause for dysphagia is found increasingly in recent literature and as a headline topic at congresses. methods. case report of a 30a old adipose male patient with multiple allergies who was suffering from dysphagia and bolus events for about 15 years. they have been independent from pain, stress, temperature or consistency of food. gastroscopic examination showed a narrow esophagus with fragile, slightly corrugated mucosa. barium radiography and mri did not show any pathology. the patient underwent an esophageal manometry which showed a normal les with normal relaxation, but pressure peaks of 241 mmhg on swallowing and 20% simultaneous waves. iced water or metoclopramide had no effect. ppi and nitro showed no improvement. sample biopsies of the whole upper gi during a second endoscopy revealed massive eosinophilic infiltration of the whole esophagus. results. the diagnosis eosinophilic esophagitis was herewith confirmed. the patient was treated with orally administered topic steroids (pulmicort spray bid orally for three months). his symptoms improved markedly. conclusions. eosinophilic esophagitis is an uncommon disorder. only 22 publications with all over 325 patients are published. male to female ratio is 3 to 1. in 52% of the patients, food allergies can be found. peripheral eosinophilia can be detected in 31% and high ige in 50%. most of the patients are in the range of normal weight. the main symptoms are dysphagia in 93%, food impaction in 62% and heartburn in 24% of patients. endoscopically mucosal fragility can be detected in almost all patients, furthermore edema 59%, rings 49%, strictures 40%, corrugated esophagus, papules 16% and small caliber esophagus in 5%. eosinophilic infiltration (20=hpf) in the upper and lower esophagus without presence of eosinophils in the stomach or duodenum are detected histologically. the recommended therapy is oral administration of fluticasonpropionate or bethametason spray for two months. the initial response is about 95%, but relapse is common. systemic steroids are also effective. dilatation should not be performed because of a significantly elevated perforation risk and a high relapse rate. sample biopsies of the upper gi should be taken in every patient with unclear dysphagia since eosinophilic infiltration exclusively in the whole esophagus is pathognomonic for eosinophilic esophagitis and consequently dilatation should not be performed. p04 cholangiocellular carcinoma of the bile duct after resection of a congenital choledochal cysta rare manifestation background. the risk of malignant degeneration of a bile duct cyst is reduced by an early resection, but the risk of malignant change persists, as we show in our case. only few cases are published in the literature. as the prognose of a malignant degenerated choledochal cyst is very poor, the only useful possibility to minimize the risk of carcinoma is the early cystectomy. based on our case we like to discuss the indication for surgery, incidence of malignant change, risk factors, discovery and diagnosis, detection and prevention, the surgical procedures for the treatment of chledochal cysts and especially whether the typ of surgery have an impact on malignant transformation? methods. we report about a female patient who was examinated by ercp because of recurrent cholangitis. in her medical history we found out that on our patient a cholecystectomy has been carried out at the age of 8 years and in addition to that procedure a congenital choledochal cyst typ i was resected, nevertheless the patient developed a massive cholangiocellular carcinoma which leaded to death at the age of 42 years. after examination using multiphase ct we diagnosed a carcinoma to a great extent, which was inoperable. with the intention to obtain an operable condition, our patient was treated with neoadjuvant chemotherapy which remained unsuccessful. results. there are series of theories in the literature which try to explain the genesis of choledochal cysts, the real reason of their development is not clear, many possibilities for their emergence are discussed: i.e. weakness of the bile duct, distal obstruction, pancreatico-choledochal reflux caused by a long common channel, a wrong estuary of the pancreatic duct in the choledochus or also a pathologic distribution of ganglion cells on the wall of the choledochus. reviewing the worldliterature, the risk of degeneration of choledochal cysts is described differently, but the early resection is always recommended. conclusions. choledochal cysts are associated with an increase in the incidence of bile duct carcinoma. as it is shown, excision of a choledochal cyst is not protection by itself against the development of cancer in the future. after resection patients should have long term follow up. any patient, especially any adult, with recurrent symptoms following cyst related surgery must be evaluated for malignancies in the biliary tract. a surgical treatment after diagnosis of a choledochal cyst is necessary to avoid bile duct carcinoma. background. sporadic lymphangioleiomyomatosis (lam) is a nonmalignant proliferation of immature smooth muscle cells, usually in the lung but occasionally in the retroperitoneal lymph nodes as well. there is perilymphatic, perivascular and, with pulmonary manisfestation, peribrochiolar proliferation and invasion. it is an extremely rare disease (prevalence 1:1 000 000) that exclusively afflicts women of childbearing age. the most common presenting symptoms are dyspnea, cough, recurring pneumothorax or chylous ascites. the definitive diagnosis is obtained by biopsy. lam has a typical histological picture featuring diffuse, sometimes nodular proliferations of immature smooth muscle that stain specifically with the marker hmb-45. unlike tuberous sclerosis (ts), sporadic lam is triggered by a mosaic mutation of the tsc-2 gene in the involved tissue. ts in contrast is caused by a somatic mutation of the tsc-2 gene. this somatic mutation leads above all to neurological symptoms (a trias of epilepsy, cognitive impairment, dermatological manifestations) but, in some cases, to a pulmonary manifestation of lam. at present, there is no curative treatment for lam, though a trial with gestagens is an option. terminal pulmonary failure is an indication for lung transplant. case report. in the course of a routine sonographic examination, a 35-year-old woman was found to have an expansive cystic process in the retroperitoneum. abdominal ct showed a pre-aortal lesion measuring 4.5 â 4 â 3 cm 3 with a partially cystic, partially soft-tissue structure suggestive of a cystic lymphoma or a cystic lymphangioma. the cyst was drained and partially resected laparoscopically. the histological diagnosis was lymphangioleiomyomatosis without indication of malignancy. preoperative chest x-ray and spirometry were within normal limits, but high-resolution thorax ct showed the cystic alterations typical for pulmonary lam. at present, the patient is free of complaints but due to the typical chronic course of the disease, close follow-up is indicated. conclusions. although it is a very rare disease, the diagnosis of a cystic retroperitoneal expansive process should suggest lam as a differential diagnosis. a definitive diagnosis can only be obtained with histology. because pulmonary involvement tends to be the rule, a thorax ct is indicated with primary abdominal manifestation. if there are neurological or dermatological manifestations, tuberous sclerosis should also be considered in the differential diagnosis. fetal mri: what is its worth outside the central-nervous system in extra-central-nervous system regions as it is mandatory in pediatric surgery. since 1998 fetal mri is performed at our institution, whenever a congenital malformation is suspected in the prenatal ultrasound. methods. fetal mri studies are performed on 1.5 t (philips) superconducting unit using a five-element surface phased-array coil, after 18th gestational week to avoid the possibility of magnetic fields interfering with organogenesis. no sedation is necessary. in addition to routine t2-weighted (w) sequences, t1-weighted sequences (mainly to demonstrate meconium-containing bowel loops), t2-sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusion-weighted sequences (for further tissue characterization) were performed. results. fetal mri is applied the following pediatric surgery cases: suspected lung anomalies (26 cases), abdominal anomalies (58), anal atresias (4), esophageal atresias (17 suspected), congenital diaphragmatic hernias (cdh) (30), head-and-neck diseases (5) and for urologic cases (38). conclusions. detailed morphological description of congenital malformations is possible with fetal mri which may have a bearing on prognosis. it has become mandatory for antenatal counseling. in some findings such as esophageal atresia, gastroschisis or cdh an antenatal transport can be arranged to a perinatal center. background. in inflammation, activation of coagulation and inhibition of fibrinolysis lead to microvascular thrombosis. thus, clot stability might be a critical issue in the development of multiple organ dysfunction syndrome. activated fxiii (fxiiia) forms stable fibrin clots by covalently cross-linking fibrin monomers. in recent studies, multiple polymorphisms have been described in the fxiii-a subunit gene. the val34leu polymorphism affects the function of fxiii by increasing the rate of fxiii activation by thrombin, which results in an increased and faster rate of fibrin stabilization. in the present study, we analysed the influence of the common fxiii val34leu polymorphism on inflammatory and coagulation parameters in human experimental endotoxemia. methods. healthy volunteers received 2 ng=kg endotoxin (lps, n ¼ 62) as a bolus infusion over 2 min. blood samples were collected by venipunctures into edta anticoagulated vacutainer tubes before lps infusion. for determination of the fibrinogen promoter polymorphism, we developed a new mutagenic separated polymerase chain reaction assay. results. fxiii levels were higher for homozygous carriers of the fxiii v34l polymorphism in comparison to wild-typ and heterozygous. homozygous carriers had lower levels of tnf and il-6 in comparison to wild-type. interestingly, subjects homocygous for the fxiii v34l polymorphism had lower monocyte and neutrophil levels throughout the timecourse. the fxiii v34l genotype was not associated with clinically relevant differences in plasma d-dimer or f1 þ 2 levels after lps challenge, which is consistent with the lack of effect on early thrombin generation. conclusions. our findings indicate, that the common fxiii v34l polymorphism is associated with differences in the selected inflammation parameters and in monocyte and neutrophil cell counts in response to systemic lps infusion in humans. those findings may have an impact on clinical treatment for patients with inflammatory diseases. p08 stamm-kader gastrostomy or peg w. h. weissenhofer time-honoured or forgotten? the stamm-kader gastrostomy, introducing a nelaton catheter via a stab incision through the upper abdominal wall, guided by direct vision after laparotomy or using a minilaparotomy or even by laparoscopy can be considered an easy alternative to the widely used peg or similar endoscopic procedures. the ''old'' and simple stamm-kader procedure offers not only direct vision, possibilities of local anaesthesia and a minimum of instruments and therefore costeffectiveness, but is also a welcomed addition to the surgical armamentarium -once learned. the actual procedure includes an abdominal accesswhether minimal or already present in case of operations for bowel obstruction, further a double pursestrig suture between large and small curvature of the stomach, stab incision and introduction of a large lumen balloon catheter, the double pursestring sutures are tied in such a way that a short channel in the stomach wall is formed and then covering sutures between abdominal wall and stomach are tied. the catheter can be used immediately for decompression and early feeding. obviously this is a surgical method and has therefore a much smaller following and tends to be forgotten as there are no ''progressive'' endoscopic devices to be advertised and there is minimal economic interest to be generated for medical companies. nonetheless it is in my opinion and experience an useful route in more ways than the peg or button gastrostomies can ever offer. the blood levels of c-reactive protein (crp), interleukin (il) 6, 18, and icam-1 were measured using the elisa technique in all patient before, immediately after operation, at the first and third day after surgery. the pre-operations levels of crp and all mediators had no differences in both group of patients. significant increase of il-6, il-18 and icam-1 level was noted in the first group vs. insignificant changes of mediators' levels in patients of the laparoscopic group immediately after operation. the gradually increase of all mediators' plasma levels were noted in first group up to the third day after operation. crp was peaked at the third day in both group, but the increase after open adrenalectomy was more pronounced (p < 0.001). levels of il-18 and icam-1 had strong correlation with the hematological changes that observed in the postoperative period. the cytokines play a pivotal role in the orchestration of the immune response. the increased levels of il-6 and il-18 pointed on enhance of th1 response. activation of th1 cytokines may provoke the immunosuppression and the catabolic stage and may have adverse consequences for patient recovery. thus, there is a clear correlation between the changes in cytokine levels and the degree of surgical trauma. methods. combined retroperitoneal pancreas-kidney transplantation was performed in a 48-year-old patient with type-idiabetes and diabetic nephropathy. the patient had a bmi of 31 and had undergone renal transplantation in the right iliac fossa 6 years ago. after mobilization of the colon and mesocolon ascendens, the graft was anastomosed end-to-side to the aorta and to the inferior caval vein. the graft was in a retroperitoneal position. for exocrine drainage a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the colon mesentery. results. the anastomoses could be performed with ease. duration of the pancreas implantation was 90 minutes, 100 minutes for implantation of the kidney in the left iliac fossa. ischemic time was 5 hours. a revision was necessary due to obstruction of the graft ureter. from day 2 after transplantation the patient required no more insulin, and lipase and amylase levels were within the normal range. conclusions. the first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed, that the technique was safe, and had technical advantages as compared with the classic method. it should be especially applied in high risk patients (obesity, severe atherosclerosis). background. recell + is a new medical product for yielding a cell suspension of the skin. in this process cells are removed from the basal layer of a thin split skin graft. the removal of the skin graft, the preparation of the cell suspension and the covering of the defect can be done in one treatment session in the operating theatre. recell + could be used for the coverage of superficial defects in burns, scars, skin resurfacing and vitiligo. the advantages of this new technique are a shorter healing period, better scar quality and the ability of repigmentation. methods. for yielding cell suspension, which is quickly available, a thin split skin graft (thickness 0.2-0.3 mm) is taken. depending on the defect, the size of the split skin biopsie is from 1 â 1 cm 2 for coverage of 80 cm 2 to 2 â 2 cm 2 for coverage of 320 cm 2 treatment area. after separation of the different layers of the skin, the special cell suspension could be prepared. then the cell suspension is immediately sprayed or trickled on the prepared wound area. a special laboratory is not required. the first change of the wound dressing is done 1 week postoperatively. conclusions. the result of this new treatment option is a skin of good quality, colour and function -comparable with the original skin. the first experiences show recell + as an interesting amendment to the previous therapeutical options. however, other studies should be done to fathom the spectrum of the indications and to confirm the first results. p12 early experience with ductoscopy guided minimal invasive surgery for intraductal breast lesions c. tausch, p. schrenk, e. grafinger-witt, t. gitter, s. wölfl, s. bogner, w. wayand background. intraductal breast lesions which have been diagnosed by radiological ductography are sent to breast surgery. by a cirumareolar incision a poorly defined extent of tissue will be removed. it can be supported by presentation of the main duct by injection of blue dye. taking into consideration that papillomas are benign in 88-96%, it is worthful to minimize the extent of the intervention. this fact and the aim to visualize the origin of most types of breast cancer -the terminal ductolobular unit (tdlu) -induced the development of endoscopes for the milk ducts. methods. after canulating the ductus lactiferous it will be distended by a special dilatator. the endoscope (laduskop + , polydiagnost comp.) is inserted through this dilatator and the inspection of the ductal system is possible til over the fourth bifurcation. endosopes are available with device for flushing and working ducts for biopsies. results. this a first report about the experience with ductoscopy in 23 patients presented with unilateral secretory disease. after successful localisation of an intraductal leason a tissue sparing excision of the affected duct follows guided by the in situ lying ductoscope. conclusions. endoscopy of the mammary duct system is a precious diagnostic tool for onesided secretory disease und is able to minimize the extent of the removed tissue. the role of the method in the perioperative visualisation of intraductal diessemination of breast malignancies needs further evaluation. p13 ruptured aneurysma of arteria lienalis with massive bleeding because of fibromuscular dysplasia background. fibromuscular dysplasia (fmd), a non-ather-osclerotic=non-inflammatory vascular disease, is a rare cause of visceral artery aneurysmas (vaa). in about 22% of all cases, vaa presents first with rupture and leads to a overall-mortality of 8.5%. about 10% of fmd are familial, most likely in female and often as multifocal lesions. patient's history. a 45 years old female patient was admitted to our department with nausea and epigastric pain. former history showed an aneurysma of the iliacal artery treated by iliacofemoral bypass (pathohistological examination of the aneurysma showed fmd), and several episodes of spontaneous subcutaneous haematomas. abdominal ultrasound, x-ray and gastroscopy showed no abnormalities. moderate anaemia without any sign of gastrointestinal bleeding made us perform a ct-scan which showed an intraabdominal and peripancreatic haematoma without any sign of a recurrent aneurysma. under icu-monitoring the patient showed another episode of acute epigastric pain and developed signs of haemorrhagic shock. we performed an acute median laparotomy and found no cause of intraabdominal bleeding. exploration of the peripancreatic haematoma showed the cause of bleeding as a ruptured aneurysma of the central splenic artery. resection of the aneurysma and splenectomy had to be performed. the patient was discharged from the hospital on the 17 th postoperative day. conclusions. ruptured vaa caused by fmd as rare reasons for acute abdominal pain need most aggressive treatment to avoid postoperative mortality. background. today, iatrogenic injuries are the most common cause of hemobilia. the hepatobiliary system is at risk for damage as side effect from procedures such as percutaneous bile drains and liver biopsies. complications of open and laparoscopic surgical procedures can also be responsible for hemobilia. methods. we report of a rare case of iatrogenic hemobilia occurring after laparoscopic cholecystectomy. results. a 49-year-old patient was readmitted to our department, 14 days after laparoscopic cholecystectomy, complaining about upper abdominal pain and presenting with signs of jaundice (bi ¼ 0.7 mg=dl but ap ¼ 572 u=l) and anaemia (hb ¼ 7.5 g=dl). the patient, who was a jehovah's witness, refused blood transfusions. on readmission ercp demonstrated fresh active bleeding from the papilla of vater. cholangiography demonstrated obstruction of the common bile duct by intraluminal blood clots. blood clots were retrieved by means of an endoscopic ballon-catheter. ct scan and angiography showed a 3.5 cm contrast retaining pseudoaneurysm in the hilus of the liver oroginating from the stump of the cystic duct. interventional radiological selective stenting of the hepatic artery could not be performed for technical reasons. the patient was re-operated, the site of bleeding was identified as the cystic artery stump and surgically controlled with sutures. the patient's further postoperative course was uneventful with quick recovery and without the need for blood transfusion. conclusions. hemobilia is a rare complication after cholecystectomy, which may stem from a pseudoaneurysm of damaged vessels, e.g., the stump of the cystic artery. when management by interventional radiology fails, surgical intervention is mandatory. background. we describe on of the rare cases with a perforated barrett-ulcer resulting in an esophagopleural fistula. the importance of recognizing esophageal disorders and catastrophes in the management of acute abdominal emergencies is emphasized. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''esophageal perforation'' via pub med. results. a young, male, alcohol-addict patient presented to the emergency department after a fall over staircase with serial rips-fracture and only little discomfort. chest x-ray and blood sample were inconspicuous. on the following day patients general condition got worse, a pneumothorax occurred. so it was necessary to install a bulau drainage which encouraged food out of the left pleuracave -therefore an ''esophageal perforation'' was supposed. the patient was transferred, now with a mediastinial sepsis and multi organ-failure, to our medical surgery unit, where primarily a esophageal stent and a thoracotomy with cleansing and drainage of the mediastinum and the pleural cavity was set. but within a week the stent became insufficient and an esophagectomy and a gastrostomy were necessary. after 4 weeks therapy on the intensive care unit, the patient underwent again a thoracotomy with decortication of a pleura callositiy because of the persistence of a fluidopneumothorax. the patient is now disposed to a colon interposition. conclusions. possible risk factors for perforation in general and in this patient included alcoholism, severe gastroesophageal reflux, noncompliance with antacid and ppi blocker therapy and the presence of acid-secreting parietal cells in the barrett's epithelium. misdiagnosis is the most important contributing factor in the continuing high morbidity and mortality of esophageal-perforation as shown by all reported cases. background. the use of ergotamine, e.g., suppositories for migraine headaches, may have systemic as well as local side effects. systemic poisoning is known as ergotism, historically mostly due to the ingestion of rye infected with claviceps purpura fungi. local complications, like rectal ulcers and rectovaginal fistula may require surgical management. methods. we report about the case of a 51 year old female patient with deep anal necrosis, insufficiency of the anal sphincter, anovaginal cloaca and rectal prolapse, as long-term sequelae of ergotamin suppository application. results. the patient was hospitalized for treatment of the rectal syndrome mentioned above. the anoderm appeared completely destroyed, with extensive scarring and manifestation of an anaovaginal cloaca. anal manometry showed almost no anal pressure. anal sonography demonstrated an anterior semicircular defect of the internal as well as the external anal muscles. the patient had already been seen in our hospital two years previously, when a perineal necrosis had raised suspicion of a locally advanced anal cancer. that time, she had refused to undergo further diagnostic work-up (including re-biopsy, etc.) and treatment, after endosonography had suggested an infiltrative process affecting the anal sphincter and the histopathologic diagnosis spoke of a ''tumor necrosis . . . but without viable tumor cells''. now, after exclusion of a neoplastic process, the patient underwent a complex surgical procedure for management of her incontinence syndrome: a laparoscopic resection of the rectum and rectopexy was performed. furthermore sphincter and perineum were reconstructed using an anterior levator plasty and ventral sphincter-overlapping repair. a temporary protective loop ileostomy was created in addition. conclusions. this case describes the -to our knowledgemost extensive local complication due to ergotamine suppositories, in the world literature. it suggests that ergotamine suppositories should be used with precaution, and a close followup by the prescribing practitioner is mandatory. furthermore, patients with unclear inflammatory destructive alterations of the perineum and unexplained rectal syndrome should be asked for ergotamine suppository (ab)use. p19 intrapancreatic accessory spleen: a differential diagnosis of pancreatic tumour background. according to autoptic studies, accessory spleens may be found in 10 to 15% of the population and most of them are usually located at or near the splenic hilum. only in 1 to 2% they are located in the pancreatic tail. we report a rare case of intrapancreatic accessory spleen which radiologically mimicked a tumor in the tail of the pancreas. methods. a 54-year-old man was diagnosed with a tumor at the pancreatic tail. in the preoperative computed tomography (ct), there was a lesion (2.6 cm in diameter) in the pancreatic tail and two locoregional lesions (1.0 and 1.5 cm in diameter), which had intensive contrast enhancement. it was diagnosed as a nonfunctioning endocrine pancreatic tail carcinoma with lymph node metastasis. results. intraoperative examination showed two accessory spleens nearby the pancreatic tail. as pancreatic cancer could not be excluded because of the local findings, an oncological left pancreatectomy was performed. histological examination excluded cancer and revealed an intrapancreatic accessory spleen and two accessory spleens nearby the pancreatic tail. conclusions. intrapancreatic accessory spleen should be included in the differential diagnosis of pancreatic neoplasm. a useful diagnostic tool is scintigraphy with technetium-99 marked, heat shock denaturated autologous erythrocytes. background. sacral nerve stimulation (sns) is a widely accepted therapeutic options for patients suffering from faecal incontinence based on a neurogenic dysfunction. more recently case reports have been published showing a positive effect of this treatment in patients suffering from faecal incontinence after low anterior rectal resection. the purpose of this study was to perform a nationwide survey for this selected indication for sns in order to gain more information by recruiting a larger number of patients. methods. in the period 2002 to 2005 three austrian departments reported data of patients who underwent sns for faecal incontinence following rectal resection. data were available of 8 patients (3 females, 5 males) with a median age of 57 years (min 42-max 79). six patients had undergone rectal resection as a treatment for low rectal cancer. one patient had undergone rectal resection for crohn's disease, one patient subtotal colectomy and ileorectostomy for slow colon transit constipation. results. in all patients test stimulation was performed in the foramen s3 unilaterally over a median period of 14 days (2-21 d) . seven patients reported a marked reduction of incontinence in the observation period. five patients reported a marked improvement compared to the baseline of their continence situation. three patients had no further incontinence episodes following the permanent implant. two patients reported ''rare events'' (1-2 incontinence episodes= month). one patient who had previously reported an improvement of his continence function during his test stimulation complained about repeated urgency problems as well as incontinence episodes. conclusions. despite our observations and the promising results of others the role of sns in the treatment of faecal incontinence following rectal resection needs further research as well as more clinical data by a larger number of patients. p21 lymphatic vessel invasion in upper gi cancer: an indication for an additive or adjuvant therapy? and ac had significant lower lvi-rates compared to nonresponders. these data warrant prospective data and might result in the future into an additive or adjuvant multimodal therapy. [up to now 1=410 recurrencies (0.2%) were seen.] all patient data were collected prospectively. in the present study we compared all patients with an operations time of 45 minutes or more with those with operation times <45 minutes and compared patient related factors (asa, bmi, type of hernia, recurrent hernia, scrotal hernia, incarcerated hernia and situs-related problems) and operation related factors (surgeon's experience, intraoperative problems, anaesthesiologic problems). results. mean operation time was 34.02 ae 12.96 minutes. operation time did not increase with asa and bmi (pearson coefficient 0.174 resp 0.083). direct hernia were faster operated than indirect, combined or recurrent hernias in total (average time 30.9 ae 12.7; 34.5 ae 11.4; 34.9 ae 13.7; 38.24 ae 16.18). the proportion of recurrent (13.54%) and scrotal hernia (3.44%) in operations longer than 45 minutes was significantly higher (n.s. resp. p < 0.05), in incarcerated hernia (3.56%)and hernias with long anamnesis and difficult scarred situs (2.7%) or combined with additional operations (0.74%) as well. in operation related factors individual designed ring-armed patches demanded 8-15 minutes more operation time and thus clearly prolonged the operation (p < 0.05), unexpected intraoperative problems (e.g. in positioning the patch) or complication (bladder injury) as well. in rare cases anaesthesiological problems (insufficient spa) caused delay as well. most important seems to be surgeon's experience. with increasing experience the average operation time and the proportion of long lasting operations decrease. conclusions. while patient's asa and bmi do not influence the tipp operation significantly, hernia type, recurrency, incarceration and scrotal hernia resp scared situs influence the operation clearly. in operation related factors surgeon's experience seems to be most important, intraoperative problems or complications result in an unexpected delay as well. in preoperative planning knowledge of recurrency (previous operation method), scrotal hernia or incarceration or scar-inducing anamnestic factors give hints to a prolonged hernioplasty. p24 biomechanical analysis of the ventral abdominal wall for incisional hernias c. hollinsky, c. yiwei, j. ott, s. sandberg, m. hermann background. for the therapy of ventral abdominal wall hernias, different reinforcement techniques with mesh are available. nevertheless the outcome of treatment for ventral abdominal wall hernias is currently unsatisfactory. biomechanical load flow calculations are introduced in this study. methods. we took peritoneum and abdominal wall muscles of recently deceased cadavers to determine the friction coefficient for mesh protheses. therefore we placed the mesh between peritoneum and muscles and loaded them with tension. furthermore we analyzed the different fixation elements for their load resisting capacity. results. the prostheses demonstrated a frictional coefficient of m 0 ¼ 0.4. the elasticity module e of polypropylene is ¼ 1200 n=cm 2 . for laparoscopic techniques, leight meshes showed an unproportional high bending and sheared off at low loads. for the reinforcement elements, large differences between different tensile load capacities were detected. conclusions. the overlap of the protheses over the hernia orifice should be selected proportionally to the hernia size. light meshes are unfit for the laparoscopic techniques and should not be used for the therapy of ventral wall hernias. p25 the axillary access in unilateral thyroid resection k. witzel 1;2 1 universitätsklinik für chirurgie, salzburg, austria; 2 the new european surgical academy (nesa), berlin, germany background. with this study, we intended to find out if it is possible to avoid the typical scar after thyroid resection by using a 20 mm axillary access and a 3.5 mm incision in the jugulum. methods. we present the results of our proof-of-concept study with 12 patients. for this technique, a modified axilloscope and ultrasonic scissors were used, which permit a total resection of the unilateral thyroid. results. the feasibility of this endoscopic technique was shown by the successful operation of these patients with uni-lateral pathological findings. furthermore, we showed that this technique allows to resect tissue up to a whole lobe while at the same time finding and identifying the recurrent laryngeal nerve and subsequently verifying the findings by using the neuromonitoring system. conclusions. this study shows that endoscopic thyroid surgery approximates the norms of endocrine neck surgery. the presented method is useful in thyroid surgery for patients with single nodules and a small thyroid gland. background. ventral incisional hernias have a high incidence after laparotomy closure. laparoscopic hernia repair is a minimal invasive technique with less operative trauma. the aim was to assess the reccurence rate and morbidity after the laparoscopic repair. methods. data of all patients with laparoscopic incisional hernia repair operated in our department between december 2000 and november 2006 were recorded in a prospective data base. forty two patients (m:f ¼ 17:25) with a mean age of 57 years (25-84) and a mean bmi of 30 kg=m 2 (21-45) were operated. results. conversion rate was 10% due to intraoperative lesions to small bowel during adhesiolysis. mean operation time was 106 min (39-284). in 17 patients the dual-mesh, in 9 patients the bard composite ex mesh and in 12 patients the parietex mesh was implanted. mean hospital stay was 7 days (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) . the morbidity-rate was 7.14% (3 hematomas) . four patients complained about prolonged pain. in the long term follow up 1 patient had to be reoperated due to mesh related complications. mean follow up time was 26 months, 2 patients presented with a recidive hernia. conclusions. laparoscopic ventral hernia repair can be performed with acceptable recurrence rate (4.8%) and low morbidity (7.14%) independent of the used mesh. p27 outcome of clip removal after endoscopic sympathetic block anecdotal reports are available on clinical outcomes after cr. the aim of the study was to investigate whether cr actually resulted in reversal of compensatory sweating (cs), and whether the initially obtained therapeutic effect on hyperhidrosis of the upper limbs (hh) and the face (fh) and facial blushing (fb) diminished with time. methods. between 6=2001 and 11=2006 a total of 23 patients (6 females, 17 males) with a mean age of 34 ae 7 years underwent cr after esb. three patients underwent unilateral clip removal due to mild ptosis (one patient with esb2, 2 patients with esb3). twenty patients had their clips removed due to unbearable cs. levels of hh, fh, fb and cs were graded by a visual analogue scale ranging from 0 (no sweating= blushing) to 10 (most severe sweating=blushing). mean followup after cr was 19 ae 16 months obtainable from 20 patients (87%). results. the 3 patients who suffered from ptosis started to improve 2 weeks after cr, complete relief was observed 3 months thereafter. in each group with esb2 and esb3, 9.5% of patients underwent cr. only one patient after esb4 had to be reoperated (0.7%, p < 0.05 compared to esb2 and esb3). four patients (20%) reported no change in cs after cr, in 3 patients (15%) cs dissolved completely. overall, cs improved from 8.4 ae 1.3 to 5.1 ae 2.4 (p < 0.05). hh, fh and fb recurred to about 40% of the initial levels, 4 patients (20%) reached preoperative levels. conclusions. clip removal because of unwanted side effects is more common in patients after esb2 and esb3 than after esb4. cr results in partial reversibility of cs and causes partial recurrence of the initial complaints. although some patients do not benefit from cr, our study provides valid data that esb is a reversible technique. p28 acute reinterventions following laparoscopic transabdominal preperitoneal inguinal hernia repairs (tapp) b. walzel, p. patri, p. razek, a. tuchmann background. today the tapp method is a frequently used surgical procedure for treating inguinal hernia. although this type of operation has some advantages compared to open procedures, some complications typical for laparascopy might arise. we report about managing such complications as based on our experience. methods. between january 2000 and december 2006 tapp was applied in our hospital to 531 (n ¼ 531) patients. from among those 6 patients (n ¼ 6), (6 m, aged 38-78) laparoscopy had to be repeated because of acute complications which occurred between the 1 st and 8 th postoperative day. three patients presented post op a bilateral tapp. reasons for interventions were: obstruction of the small intestine due to incarceration with a dehiscent peritoneal suture (n ¼ 3), hematoma in the area of surgery applied (n ¼ 2) and one hemorrhage caused by a trocar (n ¼ 1). in three patients (n ¼ 3) with a mechanical obstruction of the small intestine, repositioning by laparoscopy of the incarcerated ileus was carried out, followed by a peritoneal suture. in two cases with intraabdominal hemorrhage, the bleeding was stopped and the prolene nets were removed via laparoscopy. in only one of the cases replacement of the net was possible, in the other one the procedure was changed to open surgery for inguinal hernia because of an infected net. in one patient (n ¼ 1) hemorrhage due to injury by trocar repair was possible by a simple suture. results. in 4 out of 6 cases the complication was successfully repaired by way of laparoscopy. in one case the shouldice repair was applied. in the other a paralysis of the ileus occurred post laparoscopy, requring a smoothing of the ileus by laparotomy. conclusions. among our patients severe complications following tapp needing surgical intervention occurred but rarely (1.1%). frequently treatment by way of laparoscopy was successful. p29 clip displacement does not effect postoperative outcome after endoscopic sympathetic block p. t. panhofer 1 , c. neumayer 1 , s. nemec 2 , r. jakesz 1 , g. bischof 3 , j. zacherl 1 background. endoscopic thoracic sympathectomy is the treatment of choice for patients with severe primary hyperhidrosis (hh). recently, clip application (endoscopic sympathetic block, esb) has been introduced providing potential reversibility. the clips are visible on x-rays allowing postoperative evaluation. at our institution ganglion oriented procedures are performed taking rib levels into account. the aim of the study was to investigate if failures, recurrences and unwanted sideeffects (compensatory sweating, cs) can be explained by clip displacement. methods. between 2001 and 2005, 129 patients (mean age 32.1 ae 9.7 years) prospectively underwent 255 esb procedures. esb2 was performed in 30 patients (23.3%) with facial blushing (fb), esb3 in 21 patients (16.3%) with facial sweating (fs) and esb4 in 78 patients (60.5%) with hh of the upper extremities following the lin-telaranta scheme. a 5 mm titan clip was placed above and below the corresponding ganglion. two quality of life scores have been evaluated. mean follow up was 21.9 ae 10.1 months obtainable from 114 patients (88.4%). results. ninety-eight patients (76.0%) had palmar, 89 (69.0%) axillary hh, 40 (31.0%) fs and 30 patients (23.3%) fb. cs was observed in 25 (19.4%) patients. a total of 14 clips (5.5%) were displaced in 11 patients (8.5%). two patients with fs (9.5%) and 6 with hh of the upper extremities (7.7%) showed up with side differences regarding placement. in each group, one single patient was found with clips one level below the expected destination (3 patients, 2.3%). four patients (36.4%) were completely and 5 patients (45.5%) partly satisfied after esb despite displaced clips. two patients have been lost to follow-up. moderate cs was observed in one patient (9.1%) in each of the fb and fs groups. the patient from the latter group suffered from a mild transient ptosis additionally. two recurrences (9.1%) were documented. methods. blood samples were collected from 1444 patients before major surgery. whole blood was incubated with escherichia coli lipopolysaccharide (lps) and il-12 production in supernatants was assessed by enzyme-linked immunosorbent assay. the prognostic impact of ability to synthesize il-12 before surgery was investigated in patient subgroups with respect to sepsis-related mortality using multivariate binary logistic regression analysis. results. il-12 synthesizing capability in patients who survived sepsis was significantly higher than that in patients who developed fatal sepsis (p ¼ 0.006). in multivariate analysis only il-12 was associated with a lethal outcome from postoperative sepsis (p ¼ 0.006). the prognostic impact of il-12 was evident in patients with underlying malignancy (p ¼ 0.011) and in those who had undergone neoadjuvant tumour treatment (p ¼ 0.008). when patients were analysed according to the type of neoadjuvant therapy, preoperative ability to synthesize il-12 had a significant prognostic impact in patients who had neoadjuvant radiochemotherapy (p ¼ 0.026), but not in those who had neoadjuvant chemotherapy. conclusions. il-12 production after stimulation of whole blood with lps appears to be useful for the preoperative assessment of risk of sepsis-related death after operation in patients who have undergone neoadjuvant radiochemotherapy. p33 lipocalin-2, regulator or byproduct during ischemia and reperfusion? background. the main focus of this work was to analyze the possible implication of lipocalin-2 (lcn-2) upregulation for the course of ischemia=reperfusion (ir) during heart transplantation and effects on polymorphonuclear cells (pmn) as well as to investigate the nature of the lcn-2 producing cell. methods. male inbred c57bl=6 and the lcn-2 à=à mouse were used in our transplantation experiments. pmn from wildtype and lcn-2 à=à mice as were isolated and promyeloid cell lines (32d) used to demonstrate the effect of lcn-2 on cell physiology. western blot, rt-pcr, immunohistochemistry and tunel assay were performed to determine lcn-2 expression and apoptosis in the graft. cell viability and migration assays after various stimuli (e.g. ir) were applied to elucidate cell growth and viability. results. infiltrating pmn were the major contributors to lcn-2 expression during ir peaking 24 h after reperfusion. the number of infiltrating pmn was significantly reduced in lcn-2 à=à recipients. no difference was observed in the apoptotic rate between wildtype and lcn-2 à=à donors and lcn-2 expression also increased during acute graft rejection. migration of pmn during reperfusion was negatively influenced by the absence of lcn-2 or lack of lcn-2 specific cell surface receptors in the lcn-2 à=à mice. the promyeloid cell lines responded to ir with increased lcn-2 mrna and protein levels. conclusions. our data suggest a chemoattractant function of increased lcn-2 expression in the transplanted heart due to infiltrating pmn. lcn-2 is a novel inflammatory marker upregulated during ir and acute graft rejection. our observations shed light on a possible function of lcn-2 to the recruitment of pmn to the site of ir and identify possible targets for therapeutic intervention. p34 preliminary results of a tumour-lysate loaded dendritic cell vaccination therapy in patients with recurrent or metastatic skeletal malignancies p. t. background. vaccination with tumour-lysate loaded dendritic cells (dc) has shown to modulate potent immune response in several animal models and clinical trials. this study presents preliminary data of patients treated with dc-vaccination for recurrent or metastatic skeletal malignancies. methods. in 11 patients suffering recurrent chondrosarcoma (1), haemangio-endothelioma (1), ewing's sarcoma (2), osteosarcoma (3), or osseous metastatic disease of renal cell carcinoma (4) dc-vaccination was applied additional to standard therapy such as surgery and=or chemotherapy and=or radiation. dc precursor cells were obtained from peripheral blood mononuclear cells by apheresis and incubated with autologuous tumor cell lysate gained by surgery. in each patient 6 vaccinations of 1 â 10e6 cells ( ¼ 0.5 ml) were administered intranodally under sonographic guidance in weekly intervals. delayed type hypersensitivity (dth) controls and standard clinical and radiological follow-up was performed before and after treatment. results. no adverse or side effects were observed in any patient throughout treatment. dth reaction was negative in all patients after therapy. six patients died of disease, 3 patients showed progressive state of disease in terms of local recurrence or pulmonary metastasis, 2 revealed stable disease. helper as well as cytotoxic t-lymphocytes of 3 patients showed in vitro reactivity in terms of cd4 expression against tumour antigens and against the tracer antigen klh by both cd4 and cd8 expression. one patient had no increase of cd4 and cd8 expression neither against tumour nor tracer antigen, one patient showed positive immunological reaction against klh but not tumour. conclusions. in all patients with recurrent or metastatic skeletal malignancies investigated in this study dc vaccine therapy was primarily administered at very late stage of disease. the best clinical results could be achieved in patients with metastases of renal cell carcinoma, who both revealed stable disease over more than 12 months. all patients with metastatic disease of recurrent sarcoma showed poor clinical response to therapy, though some showed immunological reaction. the absence of adverse reactions and uncomplicated therapeutic regimen, however, together with monitored immunological responses suggest that the effects of dc-vaccination should be investigated in earlier stages of sarcoma to improve clinical outcome in these patients as well as in all stages of metastatic disease of renal cell carcinoma. p35 analysis of the risk factors helicobacter infection, overweight, sex, and age in gallstone disease and gallbladder carcinoma in germany background. helicobacter infection of the hepatobiliary system has been proposed as a novel risk factor in the pathogenesis of gallstone disease (gsd) and gallbladder carcinoma (gbc). because there seem to be differences in the incidences of helicobacter infection in various populations, we investigated whether helicobacter infection of the biliary tract is present in germany, a region with a high incidence of gsd, but with a low incidence of gbc. methods. gallbladder tissue from 99 patients who had undergone cholecystectomy were investigated: 57 patients with gsd, 20 cases with gbc, and 22 control patients. the presence of helicobacter spp. was investigated by culture, immunohistochemistry, and a group-specific pcr targeting the 16s rrna and detecting all currently known helicobacteraceae. results. of the 99 cases investigated, only one patient with gsd was pcr-positive for helicobacteraceae. in this subject, sequence analysis of the 16s rrna showed closest homology to the 16s rrna sequence of h. ganmani. helicobacteraceae were not detected by culture or immunohistochemistry. there was a higher body mass index in patients with gsd compared to controls (p < 0.05). mean age of patients with gbc was significant higher than for gsd (p < 0.01) or control patients (p < 0.005), whereas there was no difference between gsd and controls. conclusions. these data suggest that helicobacteraceae play no predominant role in the pathogenesis of gsd and gbc in the german population. the low prevalence of helicobacteraceae in the gallbladder mucosa of german patients could be a possible explanation for the relatively low prevalence of gbc although gsd is frequent. background. apoptosis is implemented in colorectal cancer (crc) development and has emerged as a potential target for cancer treatment at various stages of tumor progression. measurement of the apoptosis (m30)=necrosis (m65) ratio may have a role in therapy monitoring. to define the value of preoperative assessment of apoptosis and necrosis we measured these parameters in the sera of crc patients and correlated these values with conventional clinical parameters. methods. we used an enzyme linked immunosorbent assay (elisa) to detect an apoptotic product and necrosis (m30 and m65-antigen) in the sera of 51 patients with crc; uicc i: n: 17; uicc ii: n: 7, uicc iii: n: 12; uicc iv: n: 10; relapse: n: 5 and 27 healthy controls. results. patients with colorectal cancer showed significant higher m30 antigen levels than healthy controls (p < 0.001). when stratified to tumor stages the different preoperative m30 antigen expressions between healthy controls and tumor patients remained throughout all stages. detailed results are depicted in the following table: m65 results and the clinical applicability of the m30=m65 ratio are under investigation and will be presented at the meeting. conclusions. levels of circulating m 30-antigen are increased in patients with colorectal cancer. clinical follow up studies will reveal the usefulness of a ratio value of apoptosis and necrosis. methods. expression of fgf18 in tumor tissue was determined from tissue specimen obtained from 38 patients with colorectal carcinoma by rt-pcr relative to gapdh. furthermore immunostaining in carcinoma, adenoma, normal mucosa and liver metastases was performed. the biological function of the growth factor was analysed using cell lines expressing high (sw480) or low fgf18 (caco2, lt97, vaco235) as a model. low expressors received exogenous fgf18 while expression in sw480 cells was knocked down by sirna. the effects on tumor cell growth was determined by mtt and colony formation assays. signaling events were investigated by western blotting. in addition paracrine effects on fibroblasts and endothelial (huvec) cells were investigated using scratch assay for migration and tube formation for blood vessel formation. results. addition of the growth factor to the culture medium of slowly growing colorectal tumor cell lines lt97, vaco235 and caco2 stimulated growth within 48 hours. the stimulatory effect involved increased phosphorylation of erk1=2 5-10 minutes after factor addition and increased phosphorylation of s6 5-15 minutes after fgf18 addition. sw480 cells that produce large amounts of autocrine fgf18 were not affected within this time frame, but fgf18 supported tumor cell survival under conditions of serum starvation. in addition down-modulation of fgf18 production by sirna significantly reduced colony formation after plating at low density in sw480 cells and restored sensitivity to exogenous fgf18. secreted fgf18 also affected colonic fibroblasts inducing growth and migration and stimulated huvec cells to differentiate. conclusions. fgf is upregulated during tumor progression in the majority of the investigated patients. we showed that fgf18 can induce both autocrine and paracrine effects on the epithelial as well as the stromal compartment of colorectal tumor cells to further tumor growth, spread and neovascularization. this makes fgf18 an oncogene. further studies should prove the clinical relevance of fgf18 as a prognostic marker and as a potential target in antitumor therapy. p38 immunohistochemical peculiarities of gastric carcinomas in patients younger than 50 years c. w. schildberg 1 , a. dimmler 2 , s. merkel 1 , t. littwin 1 , w. hohenberger 1 , t. horbach 1 background. young patients ( <50 years) comprise 7-15% of all gastric carcinomas. therefore, immunohistochemical peculiarities were analyzed in our facility. methods. the examined group had 40 patients. the median age of the group was 46 years (28-49 years), the ratio male= female was 2.1=1. tumor tissue, which was embedded in paraffin, was initially marked, so that it could be further examined using the tissue array technique and consequently immunohistochemically stained. following this, the following markers were analyzed: cox2, egfr, e-cadherin, p53, tff1 and cdx 2. after semi-quantitative representation, a link to data of the tumor register was performed. results. in the younger patients, the diffuse type (laurén-classification) was overwhelmingly represented with 77%. early tumor stages (i and ii) were distributed similarly with 52% as advanced stage carcinomas with 48%. the 5-year survival rate was 57%. notable was that stage iiia had a distinctly better 5-year survival rate with 65% than those patients with stage ii (55%). in our evaluation of the immunohistochemical stains, it showed that younger patients with the diffuse type showed significantly more down-regulation of cox 2. this is particularly noticeable when one compares tumor stages ii and iiia (16 vs. 0%). with tff1, there was a notable over-expression shown (p > 0.05) in stage ii and iiia (16 vs. 3%). cdx 2 and e-cadherin were significantly more frequently extracted for the diffuse type. conclusions. it is known that younger patients with worse histological results (diffuse vs. intestinal 77=13%) display a better 5-year survival rate. in particular, there seems to be a difference between stages ii and iiia. this could be contributed to and explained by a down-regulation or an over-expression of cox 2 or tff1. p39 toxic responses and side effects using various antineoplastic drugs in an experimental setting of peritoneal carcinomatosis in rats a. hribaschek 1 , k. ridwelski 2 , f. meyer 1 , d. kuester 3 , w. halangk 1 , h. lippert 1 background. during the last decade, intraperitoneal (i.p.) chemotherapy against peritoneal tumor spread originating from gi-cancers has been increasingly used. the aim of this systematic comparative study was to investigate various toxic responses=side effects of various cytostatic substances, which had been primarily tested for their efficacy to prevent=treat experimentally induced peritoneal carcinomatosis in rats. methods. using a basic experimental trial, established= novel antineoplastic drugs such as mitomycin (10 mg=m 2 ), cisplatin (25 mg=m 2 ), 5-fu (425 mg=m 2 ), oxaliplatin (60 mg=m 2 ) and cpt-11 (300 mg=m 2 ) (limited dosage adapted according to their ld50) were applied i.p. to prevent=treat peritoneal carcinomatosis induced in rats by transfer of 1,000,000 tumor cells (colon adenocarcinoma cell line cc-531; cell-lines service, heidelberg, germany) via laparotomy (groups of 8 animals per drug; 2 control groups [sham operation ae tumor cells]). animals were sacrificed under general anesthesia on the 30 th postoperative day and autopsied. toxic responses=side effects were characterized by occurrence of i) necrosis assessed as ''þ'' vs. ''à'' (equal to yes=no) at the peritoneal surface, ii) hepatic necrosis, iii) bleeding at the mesenteric tissue, and iv) death. the cytostatic effects were used as control for the therapeutic efficacy of the 5 agents indicated by tumor weight and '' ae '' detectable tumor growth, which were correlated with the nonfavorable adverse phenomenons. results. (table 1) : mitomycin and cisplatin were the most toxic substances (e.g., peritoneal necrosis in 5 and 7 animals out of 8, respectively) comparing the 5 chemotherapeutic drugs but, however, this correlated with the most pronounced cytostatic effect (no detectable tumor growth). though the use of oxaliplatin showed also a high rate of necrosis (n ¼ 8=8) and death (n ¼ 4=8), its therapeutic potential was only low (tumor detectable in each animal). it was not surprising that the occurrence of necroses at the peritoneal surface was the most sensitive characteristic of toxic responses=side effects. in addition, the induction of a treatment-related bleeding was associated with earlier death prior to the 30 th day after tumor cell transfer, the end of the experimental observation period, in the majority of cases. interestingly, cpt-11 provided the best compromise in decreasing i.p. tumor growth on one hand and an acceptable rate of side effects on the other hand. conclusions. the results suggest that, despite some favorable effects of novel=established cytostatic drugs in i.p. chemotherapy, toxic responses=side effects need to be simultaneously tested even in earlier stages of drug development as well as experimental=clinical studies for an appropriate dose escalation=adaptation. further studies should also focus on other parameters=study characteristics, e.g., i) combination of drugs, ii) various application time=mode (e.g., i.p.=i.v.), and iii) effects on wound=anastomosis healing as well as iv) induction of peritonitis. p40 retrograde reperfusion via inferior vena cava reduces ischemia= = =reperfusion injury after orthotopic liver transplantation in a rat model methods. in a pilotstudy 20 patients with a significant internal carotid stenosis will be investigated prae-and postoperatively for visual field changes. results. at the time of the congress we will present the study design in detail and early results. conclusions. in case of no changes perioperatively, the study will be closed. in case of perioperative changes a larger prospective trial with additional neurological assessment will follow. p43 occlusion of the common femoral artery after misplacement of an angio-seal tm vascular closure device t. ott, p. konstantiniuk, t. cohnert background. femoral closure systems are becoming increasingly popular. they promise to shorten both the time to hemostasis and to mobilization. the most frequently used systems are angio-seal(tm), perclose + and vasoseal + . case report. a 70-year-old male patient underwent successful percutaneous transluminal coronary angioplasty, stenting and hemostasis with angio-seal tm , which, however, was followed by acute deterioration of pre-existing stage iib peripheral arterial occlusive disease (paod) with incomplete ischemia of the right lower extremity and development of a dry necrosis of the right great toe. magnetic resonance angiography showed occlusion of both superficial femoral arteries (afs) and of the right common femoral artery (afc). intraoperatively, the right afc was found was found to be completely occluded by a collagen plug from the angio-seal(tm), which was removed without difficulty. the symptoms improved significantly after the operation. due to the patient's critical cardiac situation, no further reconstructive measures were undertaken. conclusions. the literature indicates that femoral closure systems have led to complications in the form of vascular stenoses or occlusions that are unknown with conventional compression. these systems may be contraindicated in patients with known paod. background. ablation of the vein by endovenous laser treatment (evlt) is a new procedure that is less invasive than surgery and has a lower complication rate. evlt works by means of thermal destruction of venous tissues. methods. we retrospectively analysed the results of the endoluminal laser-treatment, which we applied at 80 patients in a time frame of 3 years (2004-2006) . we compared them with the effect of the traditional surgical approach ligation and division of the saphenous trunk and all proximal tributaries followed by the stripping of the vena saphena magna. results. there was no significant difference in the rezidiverate between endoluminal laser technique and the traditional stripping of the vena saphena magna. the biggest problem of the laser technique appeared to be a lower sensibility in the range of the inner ankle during a year (50%). in 13% of the cases the vena saphena magna was rechannelled. and also 13% reported about a still noticeable cord for a year. ninety six percentages demonstrated remarkable improvement. conclusions. the evlt-procedure is simple and effective. it takes less than an hour and get patients back to their everyday activities right away. with a high success rate and minimal side effects evlt is a new standard in varicose vein treatment. although we know that saphenofemoral recurrence occurs even after correct saphenofemoral ligation, it does not imply that this ligation has become obsolete. background. this study presents long-and short-term results after surgery of currently active, chronic venous leg ulcers, focusing on the effects of ulcer healing, recurrence and concomitant risk factors. methods. between january 1997 and march 2004, 173 patients (239 legs) with a currently active, chronic venous leg ulcer were surgically treated, based on the two main steps of functional phlebologic surgery: the surgical interruption of reflux in the superficial and perforating veins to reduce venous hypertension in the entire leg and=or the affected area and occasionally, the surgical procedure involving the ulcer. a total of 123 patients (173 legs) who came to the follow-up were examined. the data collection included a preoperative examination incorporating medical history and clinical diagnoses and various measurements at the follow-up. results. initial ulcer healing occurred in 87% of the cases (151 legs), 13% (22 legs) of the venous ulcers never healed, and recurrent venous ulcers occurred in 5% (9 legs). conclusions. we conclude that surgery is indicated before an ulcer is intractable to treatment. based on the understanding and identification of the causes and symptoms of venous ulceration we recommend standard surgical methods for the therapy of venous leg ulcers at any stage. background. popliteal artery aneurysm (paa) is a rare condition with an incidence of approximately 1% in men (65-80 years). it involves the risk of peripheral embolism or progressive thrombosis that may result in acute or chronic ischemia with claudication or loss of the extremity. distal vessels are increas-ingly embolized through a persistent dispersion of mural thrombi, and the possibilities for surgical vascular reconstruction are limited by the absence of open outflow vessels. case report. a 66-year-old male patient with an acute ischemic left leg was referred for emergency treatment. he presented with a 2-year history of intermittent claudication in his right leg. no signals were detected by duplex screening above the foot arteries of the left leg, and typical symptoms of acute occlusion were present. imaging tests revealed a paa on each side (diameter left 3 cm; right 4.3 cm). the left paa was completely occluded, the right paa was partially open but the distal popliteal artery and the the posterior tibial artery were already completely occluded. a vascular bypass reconstruction to improve circulation was not possible due to occlusion of the outflow vessels. the patient was treated conservatively (systemic heparinization, i.v. prostacyclin administration). circulation in the left leg gradually improved, with remaining claudication, a free walking distance of 50 m, and rest pain. amputation was prevented for the time being. conclusions. elective surgery for asymptomatic paa >2 cm is recommended to prevent permanent limited mobility or amputation. the procedure of choice is to ligate the aneurysm and to restore blood flow by a concurrent interposition of a vein segment, from the superficial femoral artery to the open infragenual popliteal artery. the male risk population (65þ) should undergo duplex screening of the popliteal artery. while asymptomatic aneurysms >2 cm should be treated surgically, smaller ones should be observed, since aneurysms <2 cm in diameter have a distinctly lower occlusion and amputation rate. in symptomatic cases a revascularisation with venous bypass should be attempted, if there are open outflow vessels to connect the venous graft to. if a vascular bypass reconstruction is not promising a conservativ treatment may prevent amputation. background. three dimensional motion analysis is a new evaluation method of upper extremity function. this video based system provides accurate and reproducible 3d kinematic data by tracking movements. the method is derived from clinical gait analysis which has already reached global acceptance within this field. it should overcome the deficiencies of subjective investigations. in order to demonstrate the use of the system the analysis of patients with brachial plexus lesions before and after surgical treatment is presented. methods. a 3d optoelectronic camera system with passive markers was used to capture the possible active rom. twenty seven markers coated with retroreflective tape were applied over anatomical landmarks on both upper limbs and recorded simultaneous by 6 cameras. a 3-dimensional reconstruction of the position of the markers was done by special designed software. joint centres and joint movements were calculated by using the expert vision and orthotrak software (motion analysis corporation). healthy probands and patients suffering from brachial plexus lesions and receiving primary nerve surgery or secondary reconstructive procedures were investigated. results. the motion curves of all, probands and patients with different questions argue for a reproducible motion sequence. we were able to produce and analyse static data, rom and position of segments as well as kinematic data, especially motion curves of distinct movements. moreover compensatory movements could be investigated. obtained pre-and postoperative kinematic data document the enhancement of the involved limbs' function. conclusions. the method enabled objective analysis of patients suffering from brachial plexus lesions. measured angles are reliable and reproducible but generally lower than angles obtained from physical measurements. this is due to several reasons concerning the biomechanical model. because of the more complex nature of upper limb kinematics the transfer of the system from lower to upper extremity still involves unsolved problems. p52 thoracic outlet syndrome: objective criteria to indicate surgery g. weigel, b. gradl, m. mickel, w. girsch background. reviewing the literature the indication for thoracic outlet syndrome (tos) -surgery is based on clinical findings only in the majority of the cases due to lack of objective findings. in a retrospective study we have analyzed our cases in order to evaluate objective criteria for surgical intervention. methods. seventeen patients (2 men, 15 women aging from 12 to 59) were diagnosed clinically 20 times for tos (duration of symptoms 44 months, nrs 6). additionally objective investigations were performed: x-ray of the cervical spine to detect a cervical rib; a comprehensive electroneurographic investigation to detect signs of nerve compression; mr-angiography of the subclavian artery with elevated and adducted upper extremity to detect a stenosis of the artery as an indirect sign of compression of the brachial plexus. results. concerning the objective assessment a cervical rib was present in 50% of our cases. the electroneurographic investigation revealed signs of nerve compression in 47% of our cases. in nearly 90% of our cases a stenosis of the subclavian artery confirmed the clinical diagnosis. all patients underwent tos-surgery via a small single supraclavicular incision and recovered from their symptoms. conclusions. in our series we did base the indication for tos surgery not only on clinical examination but also on objective findings, either the presence of a cervical rib and=or positive electroneurographic findings and=or a stenosis of the subclavian artery. the mr-angiography was the most significant investigation to objectify the clinical findings. the presented investigation setup seems to be appropriate to objectively diag-nose tos and indicate surgery. the small supraclavicular incision gave adequate access to perform neurolysis of the brachial plexus, scalenotomy and resection of cervical or first rib without major complications in all cases. background. the necessity of antibiotic prophylaxis in the clinic of child surgery is caused by following: -increase invasive method of investigation; -increase cases of postoperative supurative complication; -high economic expenses; -spreading of polyresistent microorganism. methods. the clinic retrospective investigation of the 164 patients, who were treated in the surgical department of lviv regional children's hospital ''ohmatdyt'' from 2002 till 2004 yr. the antibiotic prophylaxis was performed in surgical operation of ii category (conventional purity) and iii category (contaminational) of purity, which are accompanied by middle or high individual risk of the development of pyo-septic complications. eighty two of the patients took combined medications of clavulane acid with amoxicillin (augmentin, amoxuclav in dose 30 mg per kg, the others 82 patient took cephalosporinus of i-ii generastion (cephazolinum, cephuroximus in dose 100 mg per kg) conclusions. effective abp allows to reduce the amount of the postoperative complications (1 group-3%, 2 group-14%), postoperative fever (1 group-12.3%, 2 group-74.5%), duration of the hospital treatment in the 1 group-6.3 days, in the 2 group-8.4 days), and treatment expenses. optimal drugs of choice for abp in the clinic of pediatric surgery are combined preparations of clavulane acid with amoxicillin. the goal of this study was to improve the results of management children with bat. one hundred twenty-eight children with the age ranged from 4 weeks to 15 years were enrolled in this study. among these patients the splenic injury was established in 26 (20.3%), liver injury -in 10 (7.8%), intraperitoneal hematoma -in 36 (28.1%), and retroperitoneal hematoma -in 5 (3.9%) of patients. according to the moor's classification grade i of the liver damage was established in 2 patients, grade ii -in 3, grade iii -in 4, and grade iv -in one patient. according to the classification of american association of trauma surgery the grade i of splenic injury was diagnosed in 7 patients, grade iiin 9, grade iii -in 4, grade iv -in 3, and grade v -in 3 patients. laparoscopic drainage of abdominal cavity was performed in 12 patients with active bleeding, which stopped by the surgicel + (ethicon) and electrocoagulation, from the hematoma of mesocolon and mesojejunum and in 10 patients with grade i liver and splenic injury. the laparoscopic coagulation with applying of surgicel was performed in all patients with grade ii liver and splenic damage and in 3 patients with grade iii. laparotomy was performed in 5 patients with grade iii and in all patients with grade iv-v. resection of the spleen was applied in 2 patients with grade iii and in two patients with grade iv. for the bleeding control, the surgicel nu-knit + (ethicon) was used in one patient with the grade iv of splenic damage. splenectomy was performed in patients with the grade v. parenchymal suture was used in 3 patients with the grade iii of the liver damage and non-anatomical resection -in one patient with grade iv. retroperitoneal endoscopy with coagulation was performed in all patients with retroperitoneal hematoma. one child died with the grade iv of the liver damage. thus, the endoscopic coagulation with applying of surgicel + is effective in the management of patients with bat. the choice of management dependent of the grade of damage. we used malone antegrade continence enemas (mace), administered through a continent cutaneous appendicostomy or a caecal flap to achieve reliable evacuation and faecal continence in seven children with myelomeningocele and after surgery of anorectal malformation. postoperative complications included one subcutaneous pericaeceal abscess requiring exploration and in one case stenosis of the stoma. except well known and already described complications all seven patients are continent of stool at a mean of 60 months follow-up. despite our efforts to develop an effective bowel management program regarding application of the enema regimen this procedure provided some technical problems especially for children who have had prior appendectomy. so we developed a new simple technique to perform a caecal tube stoma. we also want to demonstrate a new device to simplify handling and application of enemas. the basic idea of a simple method of bowel cleansing like mace is followed by significant improvement in quality of life and more social acceptance of patients. but overall success will be achieved by improvement of technical procedure and handling. extended caecum. the appendix could not be detected. a surgical intervention was decided with the intention for an appendectomy. at the operative sight a caecum duplex was revealed. the lumen of the blind caecum was completely filled by a large fecolith. also the appendix vemiformis was inflammated. caecal duplex resection and an appendectomy was performed. the pathology report described ulcerations and segmental ischemia of the resected caecum. an oxyuriasis of the vermiform appendix was also reported. there was no immediate or delayed post-operative complication. conclusions. approximately 75% of duplications have been reported to be located within the abdominal cavity. small bowel lesions are the most commonly described (50%), while colonic lesions are found in 10% of cases. a review of the literature has revealed 84 cases of colonic duplications, that occurs mostly in pediatric patients. surgical intervention is indicated in case of complicated colonic duplications such as obstruction of the colon as a result of direct compression, volvulus, hemorrhage, ulcerations, ischemia or perforation. in most instances duplications can be completely excised as described in our case. special care should be taken of the possible abnormal blood supply to the adjacent intestinal segment. background. reports on complications are part of every medical scientific investigation. regarding the definition of a surgical or post-interventional complication there are different views. this is one reason for the variation width in complication reporting concerning the same interventions in the surgical literature. the following work presents the advantages of a prospectively standardised documentation of complications in a surgical department as a part of a hospital quality management. methods. over a period of one year in patients data sheets about post surgical complications were collected and entered in a electronically data base. all abdominal procedures, including the abdominal wall and additionally varices surgeries were enclosed in the following evaluation. patients were excluded from the investigation when treated in the surgical ambulatory or treated as day-surgical patients. the complication system according to clavien was used to classify the complication grades. this system encloses five grades, lower grading indicating lower level of complication whereas grade three is divided in subclasses a and b (dindo et al. (2004) ann surg 240: 205-213) . for statistical analysis the mann-whitney u-test and spearman correlation were used (p < 0.05). results. out of 875 operations there were 496 (53.6%) operations according to our inclusion criteria with patient's average age of 62.5 ae 17.8 years (51.2% male patients). the overall complication rate according to clavien averaged 10.7% (differences between different surgical methods and surgeons are given in a table). referring to general used grading the mean complication rate ranged between 2.6 and 6.0%. conclusions. using the system of clavien complication rates appear higher than usual. this is caused by the fact that all post surgical events apart from normal stay slip into the system. the system allows a good comparability between single surgeons and between different operations. results from prospectively entered data evaluation can be used to detect weak points in a team, and to find out technical as well as personal problems. as a consequence, for instance education programs could be provided to compensate weaknesses or the team could be restructured. periodical evaluation of a standardized data bank allows fast reactions to occurring problems and guaranties an adequate surgical complication management. lymphatic vessel invasion (lvi) has been rtx=ctx þ esophagectomy). (2-ac): n ¼ 292: n ¼ 146 (esophagectomy) vs. n ¼ 146 (ctx þ esophagectomy). results. (1-escc): rtx=ctx led to a lvi-reduction detectable lvirate: (1-escc): rtx=ctx led to significant lower lvi-rates compared to primary resected patients tyrolean cancer research institute, innsbruck, austria; 4 department of pathology germany p37 the role of fgf18 in colorectal carcinogenesis institut für krebsforschung p04, p13, p15 sachsenplatz 4-6, 1201 wien, ö sterreich. -datenkonvertierung und umbruch: manz crossmedia druckerei ferdinand berger & söhne gesellschaft m. b. h., 3580 horn, ö sterreich. -verlagsort: wien. -herstellungsort: horn. printed in austria p. b. b.= = =erscheinungsort: wien= = =verlagspostamt 1201 wien background. survival of patients with lung cancer is strongly affected by lymph node metastases. identification of n2 disease is thus crucial. we compared the diagnostic accuracy of image fusion of positron-emission tomography (pet) and computed tomography (ct) with that of ct only and that of pet only for mediastinal lymph node staging in patients with non-small-cell lung cancer (nsclc).methods. in 35 patients with proven nsclc a preoperative fdg-pet and ct examination of the body trunk were performed. pet, ct and pet-ct image fusion were evaluated separately; nodal stations were identified according to the mapping system of the american thoracic society. a lymph node was considered to be infiltrated by tumor if the minimal diameter was 1cm or more in ct, or the standard uptake value (suv) was larger than 2.5 in pet. all patients underwent mediastinoscopy, biopsies from 87 lymph node regions were taken (ats 2 5.7%, ats 4 65.6%, and ats 7 28.7%). if primary pulmonary resection was achieved, ipsilateral lymph nodes were dissected and the histological findings were considered for statistical analysis. histological findings were compared with results of ct, pet and pet-ct image fusion. sensitivity and specificity were obtained using the confusion matrix.results. histopathological assessment revealed 12 positive mediastinal lymph nodes out of 87, sensitivity was 83.3% for ct, 66.6% for pet and 91.7% for image fusion, specificity was 62.6% for ct, 77.3% for pet and 78.6% for pet-ct fusion.conclusions. pet-ct image fusion improves sensitivity, specificity and accuracy in mediastinal staging of nsclc patients. the high negative predictive value of pet-ct image fusion (0.983) may abandon mediastinoscopy in nsclc patients with negative mediastinal pet-ct image fusion. however, larger series are mandatory in order to gain statistical significant power.328 local resection of stage i primary lung cancer by 1318-nm nd-yag laser in functionally inoperable candidates: a prospective study s. b. watzka 1 , w. grossmann 2 , p. n. wurnig 1 , f. lax 1 , m. r. mü ller 1 , p. h. hollaus 1 background. hydatid disease is a parasitic infestation by a tapeworm of the genus echinococcus. it is not endemic background. in 2000 a pathway regarding the management of liver trauma was established in our hospital. the aim of the study was to assess the outcome after implementation of the guidelines.methods. data on all patients with liver injuries managed in our institution in the past 6 years was evaluated. liver trauma was classified using moore's trauma score. additionally, coexisting injuries were assessed.results. from 2001 to 2006 a total of 57 patients with liver trauma (motor vehicle accidents 44, falls 6, horse riding accidents 3) were admitted to our trauma unit (median age of 37.5 years). grade iii traumas (36.8%) were the most common injuries, followed by grade iv (28.1%), grade i (12.3%), grade ii (10.5%), grade v (8.8%) and grade vi (1.8%). the laparotomy rate varied from 28.6% in grade i injuries to 60% in grade v injuries, resulting in an overall laparotomy rate of 38.6%. two patients required second look laparotomy for removal of liver packing and one patient required puncture of a posttraumatic bilioma. the most common associated concomitant injuries were right or bilateral rib fractures (27), pelvic fractures (22), long bone fractures (22), laceration of the spleen, spine injuries (19), and head injuries (18). the mortality rate of patients with liver trauma ranged from 25% in grade iv injuries to 14% in grade i injuries with an overall mortality rate of 12% (7). all patients with grade v or grade vi traumas survived (6). if laparotomy was required because of hemodynamic instability or concomitant abdominal injury the mortality rate increased to 27%.conclusions. the clinical pathway of management of hepatic trauma in our patients showed favourable results. apart from the grade of liver injury the overall laparatomy rates and mortality rates largely depend on concomitant injuries. colitis cystica profunda is a rare benign disorder of the large intestine characterized by submucosal cyst formation. the clinical appearance of the disease can be highly variable; it can be associated with rectal prolapse and chronic inflammatory bowel disorders such as crohn's disease and ulcerative colitis.we describe a case of colitis cystica profunda associated with rectal prolapse. the female patient had a one-year history of constipation and rectal pain. an altemeier procedure was performed to correct the rectal prolapse. histology confirmed the presence of colitis cystica profunda. the operative and postoperative course was uneventful.it should be borne in mind that colitis cystica profunda can be associated with rectal prolapse. conservative management is usually satisfactory, but a mucosal resection (delorme's procedure) or perineal protectomy (altemeier procedure) is recommended when there is rectal prolapse.p02 peritonitis ossificans -a rare situation after acute major abdominal surgery m. ruzicka 1 , s. thalhammer 2 , s. stättner 2 , m. mostegel 3 , b. sobhian 2 , j. karner 2 background. treatment of the congenital intestinal obstruction of newborns is one of the main problems of the pediatric surgery.methods. patient p. had been hospitalized to the intensive care unit 2 days after birth with symptoms of absence of stool from birth, frequent vomiting, full-blown abdominal distension. the signs of endotoxicosis, the intestinal loops posterized image through the anterior peritoneal wall, dilatation of the venae anterior peritoneal wall, abdomen lower sections and scrotum edema were noted at the time of admission. x-ray of the abdominal cavity reveals the signs of the low intestinal obstruction, bowel perforation -presence of liquid and free air at the abdominal cavity. diagnosed -the intestinal obstruction, peritonitis and after a short-term of the preoperative preparation patient underwent surgery. atresia of the sigmoid colon, necrotic enterocolitis with the affection of the 2=3 of the large bowel, perforation of rising section of the large intestine, the meconium peritonitis were established during surgery. the right side hemicolectome, terminal ileostomy and transverse colostomy. the reoperation at the 11 month was done: ileotransversostomy, descendosigmostomy with the preserving of transverse colostomy were performed. the diameter of the descending large bowel exceeded the diameter of the sigmoid colon by 3-3.5 times, that's why the anastomosis had been raised by the type ''side to side''.results. within the course of 2 weeks after the radical surgery the child started to have stool passage through the rectum. presently the child's condition is satisfactory, the physical development corresponds to the age norms, stool passage takes place only through the rectum. the final stage of the treatment will be the closure of the transverse colostomy with the complete restoring of the passage of the chyme through the bowels.conclusions. the bringing of the intestinal stomas out with the delayed radical surgery in some case of newborns may significantly improve the prognosis of the results of treatment. background. different inguinal hernia operationtechniques must be compared to their recurrency rate, acute and long term complication rate, patients comfort and duration before returning to daily life, return to work and to sports etc. under economical aspects they should be safe, quick, and require limited resources (personal, equipment, implantate). with increasing economical pressure the latter features gain increasing importance. we therefore made a comparative time analysis between tipp and lichtenstein.methods. between 1.9.2005 and 30.9.2006 195 hernias were operated in tipp technique and 73 hernias in lichtenstein (lich) technique. patients were from an identical district and comparable in epidemiological data, comorbidity, hernia distribution and in-resp outdoor treatment. each series was performed by 1 surgeon in the same operation unit. implantates used were polysoft hernia patch tm (tipp) and ultrapro mesh tm (lich). total operation time was recorded (min). additionally, 4 operation phases were defined:opening phase: from skin split to preparation phase: from opening of the external aponeurosis to introduction of the mesh repair phase: from introduction of the mesh to the end of the suture of the external aponeurosis closing phase: end of repair phase to skin closure.assuming individual differences between the surgeons and management-associated differences as well as intermethodical differences relative phase intervals were deduced from the original recordings and compared. statistical comparison was done by t-test and pearson correlation coefficient.results. average operation time of lich was 61 ae 14.6 min (range 41-127 min, median 59 min), average operation time of tipp 29.29 ae 9.83 min (range 16-73 min, median 27 min). up to now there was 1=163 recurrent hernia in tipp and 0=73 in lich (n.s.). the correlation of preparation phase time and operation time was high (pearson coefficient: tipp 0.890; lich 0.906) and lower for repair phase (tipp 0.655; lich 0.529). there was no difference in the correlation of the preparation phases in tipp and lich (p < 0.05). on this basis we estimated the expected time of the compared method to each series, i.e. presumable time for lich in tipp series and vice versa. comparison of lich vs. tipp (expected) and lich (expected) vs. tipp revealed that tipp was faster and required 92.2% time of lich (p < 0.05).conclusions. tipp and lich show a comparable time effort towards preparation, tipp is significant faster in repair phase enabling a quicker total operation time.p23 transinguinal preperitoneal hernioplasty (tipp) using a memory ring armed polypropylene patch: which factors influence the operation?quality of life improved significantly in all patients with clip displacement.conclusions. esb has a displacement rate of less than 6% and gives excellent results for quality of life, which are not diminished by inappropriate clip application. grundlagen. post anal repair ist eine methode zur verbesserung der kontinenzfunktion bei diffuser schädigung des schließmuskels. die methode wurde in den letzten jahren kontrovers diskutiert. langzeitergebnisse wurden nur sporadisch publiziert. methodik. die operation wurde in der technik von parks [i] in steinschnittlage und allgemein-, oder spinalanästhesie durchgeführt. eine präoperative darmreinigung und eine perioperative antibiotikaprophylaxe wurden routinemäßig durchgeführt. prä-, und postoperativ wurde eine sphinktermanometrie in der durchzugstechnik mit einem perfundierten dreilumigen katheter vorgenommen. die auswertung erfolgte mit einem programm der firma gastrosoft. bei der klinischen untersuchung wurde der kontinenz-score nach williams verwendet.ergebnisse background. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in only 17 cases. we report a 54-year-old woman with a perforated duodenal ulcer, who underwent laparoscopic roux-en-y gastric bypass surgery for morbid obesity 15 months ago.methods. on physical examination, the patient's abdomen was marginally tender to palpation. laboratory findings were unremarkable except for an elevated leucocyte count of 11.200=ml (normal 4.000-10.000=ml). abdominal radiography and sonography showed no pathology. because of the persistent abdominal pain we performed an abdominal computed tomography scan, which demonstrated free air.results. she was successfully treated by a laparoscopic repair of the perforated duodenal ulcer. after surgery, a standardized analgesic regimen was administered for pain relief. intravenous piperacillin-tazobactam was continued for at least 4 days, then a helicobacter eradication therapy was performed. feeding was resumed on the first postoperative day and the patient was discharched on day six without any complications.conclusions. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in 17 cases. the pathogenesis of ulcer perforations in the excluded sto-mach=duodenum is unclear. of the 18 total cases, free air in the abdominal radiography was only noted in one case. recognizing that free air under the diaphragm will be absent is one of the most important diagnostic considerations when gastric or duodenal ulcer perforation is suspected in the postgastric bypass patient. abdominal ct scan and early surgical exploration remain the treatment of choice.chirurgische forschung p32 blood interleukin 12 as preoperative predictor of fatal postoperative sepsis after neoadjuvant radiochemotherapy background. a serious impediment in transplantation medicine especially after liver-transplantation is the damage by ischemia and reperfusion. we compared different types of reperfusion within a rat model and investigated the different consecutive ischemia=reperfusion injuries.methods. arterialized orthotopic liver transplantation (olt) was performed in syngenic male lewis rats. the animals were divided into 3 experimental groups: i-and ii-control groups with antegrade reperfusion and group iii with retrograde reperfusion. laboratory parameters as well as histopathological changes of the liver-graft-tissue were evaluated 1, 24 and 48 hours after olt.results. the got-values showed 24 hours after olt significant differences between group i=ii (antegrade reperfusion) and group iii (retrograde reperfusion) (2613.3 ae 343.9 u=l vs. 1186.4 ae 252.9 u=l; p < 0.001). gpt-as well as got-values were significantly lower in group iii (retrograde reperfusion) 48 hours after olt. evaluation by histopathology revealed significant less areas of necrotic liver tissue within group iii compared to group i=ii (p < 0.002).conclusions. these results show that the retrograde reperfusion (by order of: infrahepatic inferior vena cava -opening suprahepatic inferior vena cava -hepatic veins -retrograde reperfusion of the liver) has a protective effect on the graft in regard to the ischemia=reperfusion injury. background. clamping of internal carotid artery during carotid endarterectomy (cea) leads to cerebral ischemia in 8-15% of patients. routine carotid shunting has a high morbidity as described in literature. selective carotid shunting under general anaesthesia requires an intraoperative monitoring. the registration of somatosensory evoked potentials (sep) is a well accepted technique.methods. from 2002 to 2006 we assessed prospectively 477 consecutive cea under general anaesthesia and sep monitoring, without primary shunting. routinely preoperative neurological assessment, duplex sonography and mr-angiography were performed. the onset of a clinical neurological deficit after carotid artery clamping was related to changes in the n20=p25 waveforms in sep-recording. sep was evoked by stimulating median nerve. criteria for shunting was reduction in sep-amplitude >50%. routinely postoperative neurological examination and duplex sonography were performed.results. 477 patients underwent cea between 2002 and 2006. intraoperativ sep-monitoring was available in 390 patients. in 14 patients (3.6%) sep-monitoring was inadequate (primary shunting). in 330 procedures (87.8%) sep-monitoring didn't show deviations. significant sep-alterations appeared in 46 of 376 cases (12.2%). in 42 cases sep-alterations normalised after shunting without neurological deficits. in 4 cases sep-alterations were reversible after shunting, but were associated with postoperative neurological deficits (2 permanent, 2 transient). 10 cases (2.6%) had normal sep-findings (false negative), but postoperative neurological deficit occurred (7 permanent, 3 transient).conclusions. the selective use of carotid shunting during cea requires an intraoperative monitoring technique. based on our data and literature findings, sep-monitoring is a reliable method to prevent neurological vascular deficits and effectively minimizes shunting frequency.p42 perioperative changes in internal carotid endarterectomy p. konstantiniuk 1 , t. ott 1 , u. gratzer 1 , i. steinbrugger 2 , a. wedrich 2 , t. cohnert 1 p56 poland syndrome with partial heart ectopia and dextrocardia r. kovalsky 1 , a. kuzyk 2 , o. leniv 3 , i. avramenko 3 1 lviv regional children hospital, lviv, ukraine; 2 lviv national medical university, lviv, ukraine; 3 lviv regional children hospital ohmatdyt, lviv, ukrainebackground. poland syndrome is seen in 1=30 000 of the newborns. it can declare itself by its different components and joining of the additional defects in every concrete patient.methods. a girl, born by the cesarean section, with the weight of 2930 g and 39 week gestational age was brought to the pediatric surgery clinic on the 25.10.02 in a couple of hours after birth. when examined the skewness and chest distortion attracted attention, especially on the right side. the oval form defect of the chest wall 5â 6 cm 2 was seen in the anterior of the chest parasternal on the right in the ii rib level from the costal margin, an also thinning of body of sternum. a part of liver with the size of 5â 1.5 cm 2 covered with peritoneum was projecting form the lower part of the latter. a gastric part of the heart, covered with pericardium and non-epithelized membrane with the upper part directed to the right was projecting over it from the defect. there were no signs of heart and respiratory failure. during the echocardiography the following was discovered: heart rotation in the chest, right ventricular and atrial hypertrophy, good running of the great vessels, not violated valve function and good myocardial contractility. ejection fraction from the left ventricle 68%. during the intraoperative inspection the diaphragm defect in the right place parasternal triangle with the size of 4â 5 cm 2 through which the part of liver prolapses. the hepatic lobectomy was done as well as diaphragma defect repair.results. in eight months the plastic operation was done on the defect through the replacement of the front edge of the costal arch and musculocutaneous flap, formed from the greater pectoral muscle. the child was discharged from the hospital in a good shape.plastische, ä sthetische und rekonstruktive chirurgie background. traditional abdominoplasty aims at elimination of redundant fat tissue and skin as well as tightening of muscular aponeurosis on the abdomen. in the massive weight loss (mwl) patient this procedure often yields only mediocre results. specific areas such as hips, buttocks and the lateral thigh are addressed inadequately.methods. patients after mwl are treated with a central or lower body lifting according to the specific needs at our institu-tion. the central body lift includes a circumvertical dermolipectomy concentrated on the central torso without significant mobilisation of caudal tissues. in the lower body lift, the circumvertical dermolipectomy is located more inferior on the torso with an additional extensive mobilisation of the subcutaneous tissue down to the level of the knee.results. these new innovative techniques led to a much improved contour and results compared to the traditional abdominoplasty procedure. although there is an increase in operative time, postoperative recovery and complications appear comparable according to our initial limited experience. we present in detail representative cases with step-by-step explanation of operative techniques.conclusions. especially after mwl, such as after bariatric surgery, the surgeon has to deal with a tremendous amount of redundant tissue on the lower part of the torso and thighs. traditionally this problem was solved in a staged manner with multiple surgeries, such as abdominoplasty, buttock lift or medial thigh lift. however, in many cases this approach led to unsatisfying results. new innovative techniques allow for an optimal repositioning of the descended tissues und most often to a much improved postoperative result compared to the traditional techniques. a. m. rokitansky, r. j. hahn background. we report our experience using the modified minimal invasive method of pectus excavatum repair in adults. thirty one adults with a mean age of 24 (18-39.2) suffering from pectus excavatum have been corrected using by the extended modified minimally invasive repair method. the ravitch= welsh=rehbein technique, performed elsewhere, has corrected 2 patients insufficiently. reduced physical capacity, mild cardiac valve dysfunctions (prolapse, pulmonary valve insufficiency), chest pain in the area of the funnel and reduced ventilatory function were detected. two thirds of the patients emphasized the wish of a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with 3-d reconstruction and spirometry.methods. retrosternal mobilization and intraoperative stretching of the anterior thorax by long lasting sternal elevation modified the original nuss technique. additionally an oblique wedge shaped partial sternal osteotomy and=or osteotomies of the ossificated ribs were performed. in adults usually 2 pectus pars (ps -implant + fa. hofer austria) should be used.results. due to preparation we observed 1 intraoperative bleeding episode from the internal mammaric vessels, 1 superficial lesion of the right visceral pleura (adhesions). postoperatively we saw 5 pleural effusions, 1 subcutaneous hematoma and two prolonged wound-healing episodes (superficial infections with no necessity of bar removal). vertebral index changed from 33.3 preoperatively to a normal range of 23.7 postoperatively. postoperative cosmetic results were perfect in 90%. in summary adults with pectus excavatum are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. minimal invasive av-valve surgery is an increasingly popular procedure in cardiac surgery, but -due to the complexity -still reserved to few selected centers. aim of this study was to present learning curve issues for program introduction. methods. a total of 76 minimal invasive av-valve procedures were performed by a single surgeon and were successful in 75 (98.7%). seventy one patients (94.7%) underwent av-valve repair, 4 (5.3%) received mitral valve replacement. in 10 patients (13.3%), concomitant asd closure and=or tricuspid valve repair had to be performed. one intraoperative conversion to valve replacement had to be performed due to residual mitral regurgitation. for calculation of learning curves, regression models with logarithmic curve fit for operating time (ot), aortic cross-clamp (axt) and cardio-pulmonary bypass time (cpbt) for all patients and for patients with posterior mitral leaflet prolapse were applied.results. within approximately 30 consecutive minimal invasive procedures, a steady decline of either ot, axt and cpbt could be observed for the overall surgical population even despite the increasing number of concomitant procedures and was similar in patients with posterior mitral leaflet prolapse. after overcoming this steep learning curve, a mean axt of 116 ae 45 min, a cbp time of 165 ae 46 min and a total ot of 285 ae 45 min is required to treat isolated posterior leaflet prolapse.conclusions. minimal invasive av-valve surgery can be safely introduced into a heart surgery program. however, sufficient number of cases per year are required per surgeon to come over this learning curve. case report. a 43-year-old male patient without clinical symptoms presented an enlarged heart shadow in a routine radiological examination. the following ct revealed a structure in the pericardial sac that was initially classified as a pericardial cyst. in order to confirm the diagnosis, an ecg-triggered multi-slice ct was performed resulting in the diagnosis of a gigantic coronary fistula originating from the left main coronary artery leading to the right atrium. the shunt volume of the coronary fistula was estimated to be 50%. echocardiography demonstrated dilatation of the right chambers due to volume overload. since operative mortality was deemed extremely low in this patient surgical correction was advised. after median thoracotomy, initiation of heart lung machine and extensive cardioplegia, the coronary fistula was identified to originate from the left main coronary artery meandering around the posterior side of the left heart with a mean diameter of 2 cm and entering the right atrium at the level of the vena cava superior. the fistula was ligated in the right atrium and at its origin at the branching site of the circumflex artery. to secure optimal surgical outcome bypass grafting was performed to lad (left anterior descending) and its diagonal branch as well as the circumflex artery. postoperatively performed ecg-triggered multislice-ct evidenced successful repair of this anatomical malformation. the postoperative course was uneventful. background. to document severity of illness and to evaluate the predictive value of clinical scoring systems in infants and children after cardiac surgery. prospective study with follow up to hospital discharge. a 12 bed multidisciplinary paediatric icu in a university hospital. between 1=1990 and 12=2006 1463 infants and children were admitted after open heart surgery.methods. data relevant to the acute physiologic score for children (apsc), pediatric risk of mortality (prism iii), therapeutic intervention scoring system (tiss 28) and organ system failure (osf) score were collected in all patients during the first 4 days of postoperative intensive care. eighty one percentages of the patient underwent a total repair, 19% had a palliative correction.results. the mean age of the patients was 4.0 ae 5.5 years. there were 1416 survivors (s) and 49 non survivors (ns). the mean duration of mechanical ventilation was 4.8 ae 16.8 days for survivors and 8.9 ae 8.8 days for non survivors. on the first postoperative day the mean apsc and prism iii scores of survivors and non survivors were 7.04 ae 4.9 vs. 19.9 ae 9.2 (p < 0.0001) and 1.61 ae 3.3 vs. 11.5 ae 10.7 (p< 0.0001), respectively. the mean tiss 28 and osf scores of survivors and non survivors were 31.7 ae 12.0 vs. 42.2 ae 15.7 (p< 0.0001), and 1.12 ae 0.89 vs. 2.5 ae 1.91 (p< 0.0001), respectively. the overall hospital mortality rate was 3.3%. patients with an apsc score <10 and a prism score <4 had a survival rate of 99%, whereas patients with an apsc score >26 and a prism score >20 had a mortality rate of 81%. the area under the receiver operating characteristic (roc) curve for apsc, prism, osf and tiss was 0.889, 0.893, 0.898 and 0.729, respectively.conclusions. apsc, prism and tiss describe accurately the severity of illness in infants and children after cardiac surgery, and all physiologic scores identify those patients at increased risk for mortality.p62 non-bacterial pyopericardium leading to lethal sepsis in a patient with severe humoral immunodeficiency k. mészáros 1 , i. knez 1 , b. rigler 1 , g. p. tilz 2 1 klinische abteilung für herzchirurgie, graz, austria; 2 abteilung für klinische immunologie, graz, austriabackground. pyopericardium is the accumulation of pus in the pericardium mainly caused by bacterial infection. purulent pericarditis most commonly occurs as a direct extension of an infection from an adjacent pneumonia or empyema. alternatively, a distant infection can haematogenously seed the pericardium. primary pericardial infection is rather rare. pyopericardium is an illness requiring acute intervention by the heart surgeon (pericardial drainage) and adequate medication.methods. a 55-year-old man was admitted with diffuse chest pain, dyspnoea, tachycardia and nausea. laboratory examination revealed massive leukocytosis and elevation of creactive protein. echocardiogram showed circumferential pericardial effusion without valvular vegetations. after a subsequent clinical impairment to a highly septic state, he underwent surgical pericardial drainage. the pericardium was full of pus of creamy aspect. after continuous pericardial lavage and operative revision in several steps, final sternal closure took place ten days later. no infectious agent could be identified to be responsible for the purulent pericarditis.at the term of next surgery, 1.5 litres of serous ascites and 0.5 litres of serous pericardial effusion were drained. the patient developed a gangrenous cholecystitis, op-site findings revealed a non-purulent ascites, intra-operative cholangiography was without pathological findings.results. detailed immunological analysis showed a severe decompensated immunodeficiency with adentritocytaemia. the therapy with polyvalent immunoglobulin and imutin was ineffective, the patient died one day later from a therapy-refractory septic shock.conclusions. in cases with unclear non infectious purulent pericarditis, it is of high importance to carry out the correct diagnosis as soon as possible to provide an adequate therapy. background. early results of mi treatment of proximal humeral fractures using the ncb + -ph plate showed promising results reaching 62 points (86% of age related normal value) in the constant score 6 months postoperatively and an acceptable complication rate (23.5%). the purpose of this study was to analyze the long-term results focusing on functional outcome and complications.methods. so far out of a total number of 90 cases we have gained the data of 35 patients (24 women, 11 men; age 68 in the mean) who sustained fractures of the proximal humerus treated mi with the ncb-ph + plate (zimmer company, winterthur, switzerland). in 16 cases (46%) osteoporosis had been diagnosed preoperatively. radiological follow-up in two planes and functional outcome is assessed clinically (rom) and using visual analogue scale (vas) for pain and function, constant score and a modified adl score (activities of daily living).results. average rom (in degree) for anteversion was 101, glenohumeral abduction 87, external rotation 31 and internal rotation 81. average vas for pain was 1, 9 points (10 ¼ worst) and for function 6, 4 points (10 ¼ best). average constant score was 65 points, average adl score was 16 points (30 ¼ best). between 6 and 12 months postoperatively one case (2, 9%) of sintering of the humeral head and one case (2, 9%) of avascular necrosis was detected. in 3 cases (9%) of reversed impingement we performed total removal of hardware. four younger patients (11%; age 60 in the average) underwent the same procedure demanding it though not suffering of limited rom or pain.conclusions. in the early results ncb-ph + proved to be an effective mi method of treatment of fractures of the humeral head. the 1 year follow up data show further functional improvement (approx. 5% of constant score). the complication rate remains low (5=35 ¼ 14%). especially, no cases of lesions of the axillary nerve or frozen shoulder were seen. the latter we believe is due to the mi procedure and the early functional treatment which is possible since the ncb-ph + plate creates high primary stability. the long-term results prove the ncb-ph + plate to be a safe and effective method of treatment reaching a functional outcome that enables the mostly old patients to regain an acceptable level of activity. removal of hardware is easy to perform and offers especially in the younger patient a possibility to at least improve patients' subjective outcome. background. the gastrointestinal duplication in adults is a rare congenital abnormality and only few cases are described in the literature. although intestinal duplications are considered to be benign lesions, mostly asymptomatic, they may result in significant morbidity and mortality, if left untreated. this study reports of one case of caecal duplication with an overview of the literature.methods. a 31-year-old female patient was hospitalised with pain in the right lower abdomen. a relocatable and solid tumor (7 cm dm) was palpable. blood examination revealed a slight increase of leu and crp. the gynaecologic examination was entirely unremarkable. the sonography showed only an key: cord-010980-sizuef1v authors: nan title: ectes abstracts 2020 date: 2020-05-11 journal: eur j trauma emerg surg doi: 10.1007/s00068-020-01343-y sha: doc_id: 10980 cord_uid: sizuef1v nan the gertality-score: a feasible and adequate tool to predict mortality in geriatric trauma patients introduction: a large number of prediction models and subsequent outcome scores for trauma mortality have been developed over the last decades. however, feasible scoring systems for the severely injured geriatric patient are lacking. the aim of this study was to develop a new mortality prediction model for severily injured geriatric patients. materials and methods: the german trauma registry was utilized and all geriatric individuals (c 65 years) admitted between 2008 and 2017 with an iss [1] c 9 were included. patient and trauma characteristics, diagnostics, therapy and outcome data were gathered. the specific odds of all variables for mortality were calculated. relevant variables were added to the novel gertality-scoring system. subsequently, this score as a sole predictor for mortality was compared with the geriatric trauma outcome score 2 , iss, patient's age and max ais. results: a total of 58.055 trauma patients with a mean age of 77 years were included. based on the univariable analysis, the following five variables were included in the gertality-score: age c 80 years, pbrc-transfusion requirements from admission to ward, asa-score c 3, gcs b 13, ais c 4. the values of a given parameter are added to reach the total gertality-score (range 0-5 points). the auc found in the novel gertality-score was 0.803, whereas the geriatric trauma outcome score had an auc of 0.784. conclusions: the novel gertality-score is a simple and feasible scoring system that enables an adequate prediction of the probability of mortality in severely injured geriatric patients by using only five specific parameters. references: 1. champion hr, et al. the major trauma outcome study: establishing national norms for trauma care. j trauma. 1990; 30:1356-65. 2. zhao fz, et al. estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. j palliat med. 2015; 18(8) :677-81. the longer the better! 'extending thawed plasma shelf life to 14 days' introduction: major bleeding is one of the most common causes of death after severe polytrauma. one of the most recent interventions that aims for bleeding control is resuscitative balloon occlusion of the aorta (reboa). this study aims to compare macro-and microcirculatory changes of intraabdominal organs and the lower extremity during the use of reboa. materials and methods: six pigs were anesthesized and received a median laparotomy. the reboa catheter (reliant balloon, medtronic) was inserted via the inguinal artery and occluded in zones 3, 2 and 1. the occlusion of the reboa was vizualized with fluoroscopy. the balloon was inflated for 10 min per zone. during this time the local microcirculation was measured with oxygen to see (o2c, lea). between each zone the balloon was deflated for 10 min. blood pressure was measured at the carotis artery and the femoral artery. results: baseline values of microcirculation differ significantly among organs. the flow rate is significantly higher in intraabdominal organs (colon 205.7 a.u., stomach 170.2 a.u.) compared to the extremity (67.0 a.u., p \ 0.001). blood pressure measured at the carotic artery increased significantly after inflation of the balloon (p \ 0.001). this increase depends on the zone of inflation (increase of ? 60 mmhg in zone 1 compared to baseline). the increase of blood pressure after inflation in zone 3 is comparable to the baseline value. the colon is most sensitive to changes of microcirculation whereas the stomach and the extremity are most robust. conclusions: reboa is a new device to control for massive bleeding. different organ systems react differently to the same occlusion of the aorta. the systemic blood pressure does not mirror the local microcirculation of the abdominal organs. during emergency resuscitation with reboa these changes should be kept in mind. none of the authors have any conflicts of interests to declare. investigation of coagulopathies and its relevance with mortality and transfusion rates using thromboelastography in trauma patients introduction: fibrinolysis shutdown after injury is a common and lethal coagulopathic phenotype. patients with polytrauma, especially those with brain hemorrhage, require delayed initiation of prophylactic or therapeutic anticoagulation despite a measurable hypercoagulable state. to understand and modulate the post-trauma coagulation milieu, we assess patients with daily thromboelastography(teg). we hypothesized that persistently high clot strength and low dissolution is associated with thrombotic adverse outcomes in severely injured patients. materials and methods: adult patients with blunt or penetrating injuries admitted to the icu of a level i urban trauma center from jan-jul 2019 were included. adverse outcomes were defined as death, ventilator-free-days (vfd) = 0, acute lung injury (ali), acute kidney injury (aki), and venous thromboembolic events (vte). we assessed trends of clot dissolution (fibrinolysis, ly30%) and strength (maximum amplitude, ma) in the first 5 icu days using linear mixed models to account for repeated measures and missing observations. ly30% was box-cox power-transformed to approximate normality. significance for pairwise comparisons at each time was adjusted by false-discovery-rate. results: 175 patients: median age 48-years, 23% female, iss 15 (iqr 9-24), 89% blunt mechanism, median 4 icu days . overall, 16% developed one or more of the following; 9%vfd = 0, 8%ali, 14%aki, 5%vte, 7%death. ly30 was persistently lower in patients with adverse outcomes compared to those without (interaction time*adverse_outcomes p = 0.046), with fdr-adjusted significant differences at icu days 1 and 2 (fig 1) . conversely, ma did not differ significantly by adverse outcome status(interaction time*complications p = 0.44, fig 2) . conclusions: low clot dissolution, not clot strength, is associated with adverse outcomes in severely injured trauma patients. additional work is underway for earlier identification of sd phenotypes and strategies to mitigate impaired fibrinolysis. introduction: angioembolization (ae) is can be both diagnostic and therapeutic in management of a hemodynamically unstable trauma patient. however, patients who would benefit from ae typically require emergent surgery for their injuries. the critical decision of transferring a patient to the operating room versus the interventional radiology suite can be bypassed with the advent of intra-operative angioembolization (ioae) . while the ability to perform such an intervention was previously limited by the availability of costly rooms termed raptor (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using c-arm digital subtraction angiography (dsa) is a comparable alternative. this case series aims to establish the feasibility and safety of ioae. materials and methods: we conducted a retrospective anlaysis of all trauma patients at our level 1 trauma centre who underwent ioae with a concomitant surgical intervention from january 2011 to april 2019. results: a total of 49 patients (79.6% male, 43.9 ± 17.3 years, 91.8% blunt) underwent ioae using the c-arm dsa. all but one patient underwent exploratory laparotomy, 20.4% of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopaedic). either gelfoam (89.8%), coils (2.0%), or a combination of both (8.2%) were used for embolization. internal iliac embolization was performed in 85.7% of cases (57.1% bilateral) and five patients (10.2%) required hepatic embolization. ae was successful in all but one case, inferior vena cava filters were placed in 71.4% of cases, and 12.2% of patients required a second ae. the 30-day mortality was 30.6%. conclusions: our results suggest ioae is a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control. introduction: partial resuscitative endovascular balloon occlusion of the aorta (reboa) is a new concept of aortic occlusion to reduce the ischemic injuries below the occlusion level. it is, however, difficult to determine when the occlusion is partial in a clinical setting. end-tidal carbon dioxide (etco2) is a product of aerobic metabolism and its production is reduced during ischemia and anaerobic metabolism. the aim of this study was to investigate if etco2 is a good predictor of the degree of aortic occlusion during normovolemia and hemorrhagic shock in a porcine model. methods: nine pigs, 25-32 kg, were anesthetized and surgically prepared. then, gradual zone 1 aortic occlusion by 33%, 66% and 100% was induced, during first normovolemia and then controlled hemorrhagic grade iv shock. hemodynamic/respiratory variables, blood gases, aortic/mesenteric blood flow, blood pressure of common femoral artery and etco2 were measured continuously. oxygen consumption and carbon dioxide production were calculated for each timepoint for correlation measurement to different methods for partial occlusion determination. background: acute appendicitis is one of the most common surgical emergencies worldwide. the aim of this meta-analysis of randomized controlled trials was to compare the safety and efficacy of antibiotic treatment versus appendicectomy as the primary treatment for patients diagnosed to have acute appendicitis. methods: a systematic online search was conducted using the following databases: pubmed, scopus, cochrane database, the virtual health library, clinical trials.gov and science direct. only randomized controlled trials (rcts) that compared antibiotics treatment (a) versus surgical treatment (s) as primary treatment of appendicitis were included. results: eight rcts with 1.849 patients were included: 897 in the antibiotics group and 952 in appendicectomy group. higher rate of treatment success was noted in appendicectomy group 96.5% versus only 67.8% in the antibiotics group (p \ 0.00001) (fig. 1 ). follow up period for recurrence was one year in all studies and the recurrence at 1 year was reported in 15.2% (136/897) of patients treated with antibiotics and 69.9% (95/136) of them underwent appendicectomy. moreover, rate of overall were 8.3% in a group and 16.2% in s group (odd ratio 0.44 [0.21-0.94], ci 95%, p-value: 0.0002) (fig. 2) . a longer length of hospital stay was reported among antibiotics group (2.96 ± 0.52 in a group versus 2.51 ± 0.56 in s group, p 0.02). conclusions: appendicectomy has significantly higher efficacy rate but higher complications rate when compared to antibiotics treatment. most of the studies included in this meta-analysis conveyed a high risk of bias, hence more well-designed rcts are recommended. introduction: post-operative adhesions are associated with increased risk of morbidity and mortality. up to date no effective measures has been introduced to decrease intra-abdominal adhesions following laparotomy. oxiplex-ap gel has been used in extra-abdominal surgical procedures to prevent adhesions. in the current study oxiplex-ap was tested in a mural animal model to investigate its efficacy in reducing post-surgical intra-abdominal adhesions. materials and methods: forty rats subjected to laparotomy were randomly divided into 4 groups of 10. a serosa injury was made on the small intestine and three different treatments were applied: simple suture, simple suture ? oxiplexap, and oxiplex-ap only; the last group received no treatment of the injury before closure of the abdomen. all animals were kept alive for 14 days, and a second laparotomy was done to measure the intra-abdominal adhesion by the nair classification. results: at second look laparotomy a significant difference in adhesion was noticed between the simple sutures and simple suture ? oxiplex-ap were the latter had developed less adhesions. there was also a trend towards less adhesion development between the simple sutures and oxiplex-ap only group, with less adhesions in the latter. conclusions: the use of oxiplex-ap was associated with decrease adhesion formation in the current animal model particularly without suturing. further investigations into these findings are needed. introduction: emergency abdominal surgery is known to result in high morbidity and mortality. furthermore, evidence suggests that unplanned admissions to the intensive care unit (icu) are associated with higher in-hospital mortality than those patients with planned icu admissions 1 . the aim of the study was to describe the patient population who required an unplanned admission to icu following emergency laparotomy at the royal melbourne hospital. materials and methods: a single-centre retrospective observational study was performed using prospectively collected data between 2012 and 2017. patients who underwent an emergency laparotomy and experienced an unplanned icu admission were included. patients who underwent a trauma laparotomy were excluded from the study. results: 764 emergency laparotomies were performed. of these, 94 (12.3%) required an unplanned admission to icu. fourty-two patients (45%) were female, and 60 patients (64%) were aged 60 years and above. sixty-three (67%) were admitted due to single organ dysfunction (clavien-dindo iva). the median time to icu admission was 5 days in patients classified to have experienced clavien-dindo iva, while it was 6 days in patients who experience multi-organ dysfunction (clavien-dindo ivb). thirty-seven patients (39%) were admitted to icu due to complications classified as cardiopulmonary. conclusions: recognising that emergency laparotomy is a high risk procedure, with the elderly patients accounting for the majority of unplanned icu admissions, it is imperative to utilise risk stratification methods to guide optimal peri-operative management. this should result in improved utilisation of critical care resources and overall patient outcomes. introduction: the way of reconstruction following intestinal resection in the emergency settings is still controversial. the question which is better between hand-sewn and stapled anastomosis in trauma and emergency surgery occasionally arises; however, there have been few reports comparing these methods. materials and methods: a record-based retrospective study was performed to compare hand-sewn with functional end-to-end anastomoses in trauma and emergency operations from october 2014 to october 2019 in one of the largest trauma and emergency centers in japan. the patients who had intestinal resection with functional endto-end or hand-sewn anastomosis in an emergency surgery were included. the patients who had covering ileostomy or colostomy, or who underwent surgery as an elective operation were excluded. the primary outcome is the rate of complication associated with anastomosis. the statistical analyses were performed using a chi introduction: injuries are the fourth leading cause of death in europe. laparotomy is the standard treatment for penetrating abdominal wounds. because of the morbidity and the high rate of negative laparotomies, the nonoperative treatment is effectively developing. the aim of this study is to analyze the complications and the quality of life of the patients after laparotomy for this kind of wounds. materials and methods: a retrospective cohort of patients was studied between 2007 and 2016 at the laveran military teaching hospital in marseille. one hundred and eighty-six trunk gunshot or stab wound were recorded, including 74 abdominal wounds. thirtyfour patients were managed by laparotomy and included in this study. the patients and their referring general practitioners were contacted to complete missing data and the sf-12 quality of life score. results: among the 34 patients included, the average age was 39 years and most of them were men. the indication for laparotomy was mainly based on the hemodynamic instability, then according to the results of the computed tomography in case of suspicion of specific lesions: bowel injuries, major vascular injury, mesenteric or mesocolic vascular injury, diaphragmatic injury and intraperitoneal bladder rupture. only 5 laparotomies were negatives. eleven complications after laparotomy were found (32,4%), including 7 early (within the 30 days) and 4 late. no complication was found after negative or non-therapeutic laparotomies. the quality of life of the patients after one year is similar to those of the general population. conclusions: the most common indication for laparotomy for abdominal penetrating trauma is hemodynamic instability. the rate of laparotomy complications for penetrating abdominal trauma is similar to those of scheduled surgeries. the quality of life after this care remains unchanged. these results may insist on the fact that the ''gold standard'' treatment for penetrating abdominal injury remains the laparotomy objectives: splenic artery embolization (sae), a routinely used adjunct in the non-operative management (nom) of splenic injuries(si), was widely adopted in trauma about two decades ago. we examined complications that occurred with this modality at a level 1 trauma center over a recent 8-year period and compared this to the prior 11 years. methods: patients who had sae for si between 2011-2018 were identified. sae complications were noted. splenic abscess, splenic infarction and contrast-induced renal insufficiency were considered major complications. coil migration, fever and pleural effusions were regarded ''minor'' complications. the results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010. fishers exact test was used for comparison. results: there were 716 patients admitted with si in the recent period, of which 159 (22%) underwent immediate splenectomy. sae was performed in 74 (13.3%) of the 557 patients who underwent nom. of these sae patients, 50% had a contrast blush and 41.9% were either aast grade 4 or 5. five sae patients (6.8%) had splenectomy for continued bleeding. the overall complication rate was 28.4%. major complications occurred in 11 patients (14.9%) and minor in 13 patients (17.6%). embolization location in the splenic artery was proximal in 54.1%, distal in 20.3% and in both in 25.7%. there was no association between complications and coil location by logistic regression. differences between the two periods shown in table 1 . conclusion: sae continues to be a useful adjunct in nom of si and has seen increased utilization. complications continue to occur,although fewer minor complications were noted in the second period. no association between embolization location and complications was noted in the recent period. judicious utilization of sae is imperative given the complications that continue to be noted from this procedure. the effect of the time spent in the emergency department on the mortality rates and cause of death in patients who underwent emergent laparotomy introduction: the purpose of this study was to a) examine the effect of the time spent in the emergency department (ed) on hypotensive patients in need of emergent laparotomy and b) to determine the mortality rates and cause of death in these patients. materials and methods: between 2007-2017, 184 patients were included (99 men and 85 women, mean age 45.2 years) who underwent laparotomy less or equal to 90 min from ed admission. of the 184 patients, 107 (group 1) had a systolic blood pressure (sbp) greater than 90 mmhg and 77 had a sbp less or equal to 90 mmhg. all patients had abdominal injuries with an injury scale score (iss) between 3 and 6. the in-hospital mortality represented the primary outcome, while secondary outcomes included cause of death and time to death. results: in this study both groups spent a median of 51 min in the ed, but the time from the ed to the operating theatre was shorter in the group 1 (40 min versus 76 min). in total, the mortality rate was 27%, but in the group 1 the mortality was 49%. the sbp on arrival in the ed was strongly associated with the risk of death. furthermore, we observed significant positive correlation between the probability of death and the time spent in the ed, with an increase of probability of death equal to 0.40% per minute spent in the ed. in both groups the hemorrhage was the commonest cause of death (62%). the results of this study indicate that, in patients with abdominal injuries requiring emergent laparotomy, the probability of death is proportional to both extent of hypotension and the length of time spent in the ed. especially, in patients who were presented with a sbp inferior of equal of 90 mmhg, this probability increased as much as 2% for each 5 min. despite many advances in trauma surgery, half of hypotensive patients are going to die in the first 24 h. introduction: injury to the pancreas may lead to significant morbidity and mortality. we studied the prevalence of pancreatic endocrine and exocrine functions and evaluated the morphological regenerations in pancreas following partial pancreatectomy. materials and methods: patients with pancreatic trauma were recruited ambispectively from january 2010 to december 2017. endocrine functions were assessed at the time of admission and at 6 months follow up with 75 g oral glucose tolerance test (ogtt), serum insulin and c-peptide levels, hba1c estimation and exocrine functions were assessed with faecal elastase test. pancreatic volumetry was done with imaging studies at 1-and 6-months post discharge. results: twenty patients were studied with a median age of 30 years at the time of injury. all the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus requiring insulin on follow up. 7 patients (35%) were found to have prediabetes by american diabetes association (ada) criteria. 11 patients (55%) had pancreatic exocrine insufficiency. pancreatic volume increment, from mean pancreatic volume of 48.65 cm3 to 54.29 cm 3 , was noted in partial pancreatectomy patients. conclusions: overt endocrine and exocrine insufficiency is rare in pancreatic trauma patients. but subsets of patients are biochemically predicted to have higher risks of endocrine dysfunction and exocrine insufficiency. hence, while dealing with pancreatic trauma patients, one should remember the possible metabolic disorders associated and the need for specific investigations. pancreatic volume increment is a new finding which opens up more opportunities for further research. hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal, 2 hospital de santo espírito da ilha terceira, orthopedics and traumatology, angra do heroísmo, portugal introduction: rope bullfights are traditional events in the azores islands, where a bull is set on the streets, arrested by a rope on its neck. around 220 events happen every year and it is already part of the island's touristic attractions. inevitably, every year, people get injured either from direct trauma with the bull or from falls when trying to escape from the animal. the aim of this study was to characterize the type of injuries that occur in these bullfighting events, as to their incidence, mechanism of injury, anatomical affected area and severity. materials and methods: we prospectively registered all cases of injured people who suffered any type of trauma during rope bullfights and received emergency therapy in the local hospital, between 2018 and 2019. results: 56 patients recured to the emergency department, 16.1% female, with mean age of 44.2 years. regarding the mechanism of injury, 66.1% occured due to direct trauma to the animal while in the remaining 33.9% resulted from falls during escape or handling of the rope. the most commonly affected anatomical areas were the limbs (39.3%) followed by the head and neck (23.2%) and thorax (7.1%). in 26,8% of the cases, patients suffered from multiple traumas. in 76.8% of the cases the treatments performed were wound care, wound closure and/or symptomatic therapy. in total, 10 patiens were hospitalized, 5 patients required interventions in the operating room (4 closed fracture reductions and 1 exploratory laparotomy with splenectomy) and 2 patients were hemodynamically unstable upon admission (hypovolemic shock due to splenic fracture and cet). conclusions: the rare articles published describe the mechanisms of injury associated with bullfights in spanish centers and injuries resulting from wild cow accidents in indian cities. this is the first local descriptive study on the prevalence of traumatic injuries associated to this specific type of rope bullfights. introduction: the two-stage splenic rupture is seldom, its risk is unpredictable and a precise diagnosis of a ct and/or mri imaging unexpectable or unexcludable. generally, and due to our experience and current literature a two-stage rupture occurs within one week after trauma. though dramatic courses after two or three weeks are known. therefore, it is suggested to perform a prophylactic angioembolization in (still) hemodynamically stable patients. materials and methods: a retrospective study in a level-one trauma centre of switzerland did analyse all patients that underwent a prophylactic angioembolisation after an explicit diagnose by ct and/or mri of a splenic parenchymal lesion after trauma between 2010 and 2016. further inclusion criteria were hemodynamical stability (sys rr [ 90 mmhg) and missing indication for immediate laparotomy. results: 11 patients (4 f, 7 m) with an average age of 44 ± 15 years underwent preemptive angioembolisation after traumatic lesions of the spleen. the ais abdomen was 3 in 9 and 4 in 2 patients. besides a splenic injury 3 patients did also have a kidney injury. the overall iss was 22 ± 5 points. 8 patients suffered additional thoracic or head trauma. in 5 patients the angioembolisation was performed on admission, in 1 on the 1st, in 3 at the 2nd and respectively 1 in the 3rd and 4th day of. in 1 case an uncomplicated selective embolization of a main duct of the splenic artery was performed. in 10 patients the trouble-free proximal embolization of the splenic artery was done. the average stay was 11 ± 6.0 days. no deaths or complications seen due to angioembolisation or splenic rupture. there were no complications or operative introduction: traumatic abdominal wall hernias (tawhs) are uncommon, and the optimal management is debated. tawhs most often result from blunt trauma and are associated with severe intraabdominal injuries. our institutional protocol mandates primary repair only if the patient undergoes laparotomy for other reasons and is without mesh. since 2011, primary repair of lumbar hernias included bone anchors when indicated. we wanted to describe the tawh patients treated operatively during initial hospitalization focusing on injury mechanism, diagnosis, associated injuries, operative techniques, early complications and outcomes. materials and methods: we performed a retrospective, descriptive cohort-analysis of data from the institutional trauma registry from 2007-2018. all operatively managed tawhs were identified based on ais codes, ncsp codes and relevant key words. results: of the 30 identified patients, 14 (47%) were women. median age was 37 years (range 10-73). median iss was 20 and 21 patients had iss [ 15. injury mechanism was blunt except for one explosion. 25 patients (84%) had been in a mvc, and 23 of these (92%) had seat belt injuries. 22 of these patients had a disruption of the muscle from the iliac crest, and one had a hernia through a fractured iliac wing. 3 bicycle falls and 1 fall from height had hernias in the anterior abdominal wall. two meshes were placed, with no known complications. bone anchors (twinfix ò 3,5 mm) were used in 7 patients. no recurring hernias were identified in the 18 patients with routine follow-up (1-21 months) . conclusions: surgery for tawh is uncommon in our institution. tawh is often associated with severe torso injuries and primary repair is only done when laparotomy for other reasons is indicated. primary suture of the muscle, including use of bone anchors seems to be adequate treatment, as we have identified no recurrences. a longterm follow-up study is warranted for operated and non-operated patients with tawh. a comparison of sub-specialty operative adolescent patient outcomes in adult and pediatric trauma centers introduction: adolescent trauma victims may be treated at either an adult (atc) or pediatric trauma center (ptc). these centers have different resources, surgeon training and overnight in-house coverage. it is not known how outcomes compare with regards to the very small subset of patients that actually undergo a surgical trauma intervention. we hypothesized that presentation to a ptc would yield increased mortality when subspecialty intervention was required and that this would be most pronounced at night when in-house attending coverage is absent at all state ptcs. materials and methods: a review of the pennsylvania trauma outcome study (ptos) database was performed to capture patients aged 12-18 who underwent any non-orthopedic trauma surgery. cohorts were created for cranial, thoracic, abdominal or vascular surgery from 2007-2017. trauma centers were divided as adult level 1 (atc1), adult level 2 (atc2) or pediatric (ptc). groups were created based on time of arrival with 7am-7pm being dayshift and 7:01pm-659am being night shift. age, race, mechanism of injury, vital signs, gcs, iss, los and mortality were evaluated. ancova was utilized to control for iss variation. spss was used for all analyses. results: 1851 patients met initial criteria. atc1s saw more minority patients and more males than other center types. atc1s saw an overall older cohort (16.9 years vs 16.6 years in atc2 and 14.6 years in ptc, p \ 0.001). despite this age difference, presenting systolic blood pressure was lowest at the atc1s (117.8 mmhg vs 125.7 mmhg at atc2 and 125.34 mmhg at ptc, p \ 0.001). iss and triss and overall mortality were not different and this included when grouped by day or night shift. of note, trauma thoracotomy was more likely to be performed at night in adult centers. hospital length of stay was significantly lower for atc2 (8.33 days vs 10.41 in atc1 vs and 11.38 in ptc). conclusions: adult and pediatric trauma centers see different patients. operative trauma cases are surprisingly low at our state's ptcs and trauma thoracotomy was more likely to be performed at night in atcs than ptcs. broader study is needed to uncover differences in operative care and outcomes. treatment of dislocation of the patella as a result of sports injuries in children. forecast and consequences in adulthood k. furmanova 1 , o. loskutov 1 , a. naumenko 1 1 medinua clinic and lab, ortopedics, dnepr, ukraine introduction: dislocations of the patella with a rupture of the medial patellofemoral ligament (mpfl) account for 8-10% of acute injuries of the knee joint [1, 2] . inadequate therapeutic tactics of these injuries in childhood and youth, as a result of sports injuries, are fraught with complications in the form of the instability of the knee joint, residual deformities and contractures in patients in adulthood [2, 3] . materials and methods: in the period from 2014 to 2018 349 cases of rupture of mpfl among children aged 7-18 years who were involved in sports were observed. the examination included conducting a clinical examination, axial radiography with flexion of the joint at angles of 45°and 90°, mri of the knee joint. results: in 87.9% (307 cases) the integrity of the mpfl(with a reduced number of sutures) was restored using a yamamoto suture, and in 42 cases (12.1%), the autoplasty of the mpfl was performed. excellent medium-term (5 years) clinical and functional results according to the ikdc scale were noted in 80.2% of cases, good in 14.9%, satisfactory in 4.9%. in 12 patients (3.4%) there was a relapse of dislocation after performing an mpfl suture during the first year after surgery mainly due to noncompliance with the recommendations. conclusions: injury to the knee joint with the patella dislocation in childhood and adolescence, associated with a sports injury is an indication for surgical treatment in order to adequately restore the integrity of the mpfl and prevent disabling complications. our yamamoto suture technique is more optimal for treating young patients with instability of the patella and is recommended for widespread use in pediatric orthopedists due to its undeniable clinical advantages. osteotomy with a defect 1 cm placed 8 cm below tibial plateau. 4 types of fixation have been simulated: plate fixation of only a medial pillar, plate fixation of only a lateral pillar, plate fixation of both pillars, and locking intramedullary nailing. results: in case of plate fixation of only a medial pillar, the injury to an interosseal membrane causes an expressed valgus deformation at axial loading, leading to a reasonable (1095.2 mpa) overload of the fixator in the osteotomy area. the use of a lateral plate leads to excessive loading on an external pillar, while the medial pillar remains unsupported. this causes overloads of the fixator in the osteotomy area (880.6 mpa). the double plate fixation is typical of the lowest extent of bone fragments displacements (1.25 mm) . this is a super-rigid type of osteosynthesis, able to cause a stress-shielding syndrome in the adjacent bone. it has been estimated that the method of im nailing is an optimal fixation method, with minimum loading of the fixator (250.4 mpa) and the best distribution of changed elastic strains in the bone-implant system. conclusions: the mathematical simulation demonstrates that fixation by a medial plate is possible only if support functions of the ligament system and interosseal membrane remained intact. if an injury is a high-energy one, nailing is preferable. introduction: treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. grafts are necessary to support bone healing. a well-established allograft is demineralized bone matrix (dbm) prepared from donated human bone. a recent development is a new fibrous demineralized bone matrix (f-dbm) with a high surface-to-volume ratio. in this study we examine toxicity of an innovative dbm fibers preparation. materials and methods: f-dbm was transplanted to a 5 mm, platestabilized, femoral critical-size-bone-defect of 5 mm in sprague-dawley (sd)-rats (n = 6). healthy animals were used as control. after 3 months histology, hematological analyses as well as serum biochemistry was performed. were measured as indicators of free radical exposure. there were no significant differences between the control group and animals receiving f-dbm. hematology as well as biochemistry did not differ between operated animals and control. histologically no evidence of damage to liver and kidney and a good bone healing could be observed in most cases. conclusions: taken together, these results provide evidence for no systemic toxicity of the bone allograft. i have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. • i hereby confirm that my abstract is based on previously unpublished data and that i own the rights to the written summaries of research or observations presented in the abstract, or that i have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. • in submitting an abstract i hereby agree that the copyright of my abstract is transferred to the european society of trauma and emergency surgery. • i hereby confirm that i will present my abstract at the congress in case it is accepted. sponsor: german institute for cell and tissue replacement (dizg, gemeinnützige gmbh), berlin, germany. intramedullary nailing through suprapatellar approach in distal tibia fractures: a retrospective study evaluating clinical and radiographic results d. bustamante recuenco 1 , a. gómez 1 , j. m. pardo garcía 1 , e. garcía 1 , p. castillón 2 , p. caba doussoux 1 1 hospital 12 de octubre, madrid, spain, madrid, spain, 2 hospital mutua terrasa, orthopaedics, barcelona, spain introduction: distal tibia fractures (dtf) can be operated either by intramedullary nailing (imn) or by orif with plates. the current literature shows a higher rate of malalignment and consolidation delay with imn when compared to plates. in these studies, an infrapatellar approach for the imn is performed. recent studies show a better alignment in dtf treated with imn by suprapatellar approach, though functional and biological outcomes have not been analyzed yet. our goal is to assess the clinical and radiographic results of the treatment of dtf with imn using a suprapatellar approach. materials and methods: a two-center retrospective study was performed, collecting the cases with dtf treated with suprapatellar imn from 05/2011 to 08/2018. results: a total of 82 patients were obtained, with a mean age of 45.5 years. the average follow-up was 13 months. 82% of the fractures were ao type 43a, presenting the remaining 18% intra-articular involvement. 6 patients presented complications, corresponding in 4 of them to superficial infections. as for clinical results, complete mobility in the knee and ankle was obtained in almost all cases. at the radiographic level, a total of 15% (12) of distal malalignment cases were detected, defined as more than 5°deviation from normal axis in the coronal and sagittal planes. most of the fractures consolidated in a period of 3-4 months. there were 13 cases of delayed consolidation, from which 2 developed pseudoarthrosis. conclusions: intramedullary nailing through a suprapatellar approach for dtf offers good clinical and radiographic results, with low rates of malalignment and lack of consolidation. more studies are required to compare the results obtained with other fixation methods for these fractures. reference: avilucea fr, triantafillou k, whiting ps, perez ea, mir hr. suprapatellar intramedullary nail technique lowers rate of malalignment of distal tibia fractures. j orthop trauma. 2016;30(10) :557-60. the clinical consequences of follow-up radiographs in ankle fractures are unclear and indications for these radiographs are seldom well-defined. routine radiographic imaging in the follow up of patients with an ankle fracture adds to treatment costs, although retrospective studies dispute its usefulness. the aim of this study was to assess if a protocol with a reduced number of routine radiographs would lead to cost savings, without compromising clinical outcomes. materials and methods: a multicentre randomized controlled trial was conducted. patients were randomly assigned in a 1:1 ratio to usual-care (consisting of routine radiography at one, two, six and twelve weeks) or reduced-imaging (radiographs only obtained for a clinical indication at six and twelve weeks). functional outcome was assessed using the omas and aaos ankle questionnaires, quality of life was measured with eq-5d-3l and sf-36 questionnaires. other outcome measures included complications, pain, the number of radiographs, health perception and self-perceived recovery. costs were measured with self-reported questionnaires results: the study group consisted of 247 participants, of which 154 (63%) received operative treatment. patients in the reduced-imaging group received median 4 radiographs, whilst patients in the usual care group received median 5 radiographs (p \ 0.005). omas, aaos scores, quality of life, pain, health perception and self-perceived recovery did not differ between groups. we observed 32 complications in the reduced imaging group. this did not differ significantly from the usual care group (29 complications p = 0.51). a significant reduction in radiographic imaging costs was observed (-€48 per patient, 95% ci -72 to -25). overall costs per patient were comparable (130 [95% ci -2975 to 3723]). conclusions: implementation of a reduced imaging protocol in the follow up of ankle fractures leads to cost savings and more importantly does not lead to worse functional outcomes. results after percutaneous and arthroscopically assisted osteosynthesis of calcaneal fractures w. grün 1 , m. molund 2 , f. nilsen 2 , a. stødle 1 1 oslo university hospital, orthopaedic department, ullevål, oslo, norway, 2 østfold hospital, orthopaedic department, grålum, norway introduction: operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. during the last years there has been a trend towards less invasive fixation methods. percutaneous and arthroscopically assisted calcaneal osteosynthesis (paco) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. materials and methods: we conducted a clinical and radiographic follow-up of 24 patients with 25 calcaneal fractures treated by paco with a minimum follow-up of 1 year. there were 16 sanders ii and 9 sanders iii fractures. the mean follow-up period was 17.6 months (sd 6.7). our primary outcome was the american orthopaedic foot and ankle society (aofas) ankle-hindfoot score. secondary outcomes were the calcaneus fracture scoring system (cfss), the manchester-oxford foot questionaire (moxfq), the visual analog scale (vas) for pain and the incidence of complications. radiographs were obtained to evaluate the reduction of the fractures as well as the presence of subtalar osteoarthritis. results: the median aofas score was 85 (range, 50-100), the cfss score 85 (26-100), the moxfq score 26.6 (0-76.6). the vas pain score was 0 (0-5.7) at rest and 4.05 (0-8.2) during activity. the böhler angle improved from mean 3.5 degrees (sd 12.6) preoperatively to 27.8 degrees (10.7) postoperatively. however, the follow-up radiographs showed subsidence of the fractures and a böhler angle of 20.4 degrees (13.2). 96% of the operated feet showed signs of posttraumatic subtalar osteoarthritis. there were no wound healing complications. two patients were reoperated with screw removal due to prominent screws. conclusions: our results suggest that paco gives good clinical results and a reduced risk of complications in selected calcaneal fractures. prospective longterm studies will be necessary to better evaluate the potential advantages and limitations of paco. with the nascent state of microsurgical services in the region the application of negative pressure wound therapy (npwt) has proven to be very helpful. an improvised npwt has made it locally available to patients. this report aims to show how this has improved the management of open fractures of the lower limb in a resource restricted setting. materials and methods: a 30-month review of cases of lower limb open fractures managed at a regional trauma centre in nigeria was done. the type of wounds were classified based on region and need for soft tissue coverage. results: a total of 256 cases were reviewed approximately 53% of these case were gustilo and anderson type iii. of these 87 had npwt as part of their management. some of the benefits of observed were; reduced frequency of wound dressings, and shorter time to optimize wound for closure. conclusions: the locally improvised npwt has proven to be an affordable and cost-effective tool in the management of open lower limb fractures. it remains an invaluable alternative of care in the absence of microsurgical skills and patented device with are far from reach owing to financial constraints. references: 1. hussain a, singh k, singh m. cost effectiveness of vacuum assisted closure and its modifications: a review. isrn plast surg. 2013; 2013:1-5. 2. isiguzo c, ogbonnaya i, uduezue a. modification of negative pressure wound therapy in the economically constrained region: a preliminary report. vol. 8, nigerian j plast surg. joytal printing press; 2012. p. 39-43. 3 . mba u, nevo a. challenges of limb salvage in a resource limited environment: case report and review of literature. niger j plast surg. 2018;14(1): 5. 4 . novak a, wasim sk, palmer j. the evidence-based principles of negative pressure wound therapy in trauma and orthopedics. open orthop j. 2014; 8:168-77 . introduction: lower extremity vascular trauma may result in limb loss or mortality. this study examined outcomes of lower extremity vascular trauma (levt) and potential associations to amputation/mortality. materials and methods: a retrospective cohort study of patients (n = 79; 82 limbs) with levt between 2000 and 2018 in a single trauma center. only patients requiring a vascular procedure were included. data were extracted from the swedish vascular registry (swedvasc) and the swedish trauma registry (swetrau). results: mean age 35 ± 17 years; men 85% (67/79); trauma mechanism 49% (39/79) blunt and 51% (40/79) penetrating. 71% of patients underwent preoperative cta; 30% of patients (23/76) were transferred to hybrid operating room. arterial injury was present in 73/82 limbs (89%) and venous injury in 43/81 limbs (53%). the most frequently injured artery was popliteal artery (25/73; 34%) followed by superficial femoral artery (23/73; 32%). most common vascular operative procedure was arterial bypass/interposition graft (45/82; 55%). a vascular shunt was used in 32% of cases (25/78). fasciotomy was performed in 49% (40/81) of limbs. four patients were lost to follow-up after less than five days. there were eleven limbs (11/75; 15%) amputated within 30-day postoperative follow-up. all amputations were caused by blunt trauma. 28% (7/25) of arterial injuries below-the-knee led to amputation. thirty-day mortality rate was 5.3% (4/75) . univariate analysis showed that fractures (p \ 0.001), soft tissue injury (p \ 0.001), multiple injuries (p = 0.011), and blunt mechanism (p \ 0.001) were associated with amputation and mortality after levt. conclusions: this study showed that amputations after levt are caused by blunt trauma. also levt combined with fractures, soft tissue injury, or multiple injuries increased the risk of amputation and mortality. multi-center study enabling multivariate analysis to adjust for potential confounding factors is imperative to confirm these findings. incidence, treatment and financial burden of tibial plateau fractures in belgium between 2006 and 2018 describe the incidence, evolution in management and financial burden of tpf in belgium between 2006 and 2018. we compare national data with data from uz leuven (uzl), the largest university hospital in belgium. materials and methods: this study includes all tpf treated in belgium between 2006 and 2018. we identified 35.226 tpf, of which 861 fractures were treated in uzl. despcriptive statistics were used to analyze the data. results: the annual incidence increased from 20.6 to 29.1/100,000/y. an increase in number was true for both operatively treated patients (otp) and non-operatively treated patients (notp), but was more pronounced in the latter (31% vs. 68% increase). the rate of surgery (ros) decreased from 41.4% to 35.5%. the mean ros for uzl was 49.0%. the total financial burden in belgium increased with 36%, mainly driven by increasing costs in otp. hospitalisation rates for notp decreased from 34% to 16%, as day hospital admission occured more commonly. the mean hospitalisation cost was €8,754 for otp and €9,103 for notp. costs for uzl inpatients were €10,358 and € 9,163. nursing days accounted for 64% of the cost in otp and 75% in notp. the mean los was 15.8 days for otp and 18.7 days for notp. uzl patients had a mean los of 16.3 and 11.7 days. conclusions: tpf are associated with increasing hospital related healthcare costs. as nursing days determine the majority of the financial burden, measures should be taken to avoid prolonged los. introduction: rotational malalignment (rm) is a common postoperative complication after intramedullary (im) nailing of tibial shaft fractures. computed tomography (ct) is commonly used for detection of malrotation, however reliability is frequently questioned. the purpose of this study is to evaluate the intra-and inter-observer reliability of low-dose protocolled bilateral postoperative ct-assessment of rotational malalignment after im nailing of tibial shaft fractures. materials and methods: a total of 155 patients were prospectively included with tibial shaft fractures that were treated with imn in a level-i trauma center. all patients underwent postoperative bilateral low-dose ct-assessment (effective dose of 0.03784-0.05768 mgy) as per hospital protocol. four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. the intra-class coefficient (icc) was calculated to evaluate intra-and inter-observer reliability. the intra-and inter-observer reliability was categorized according to landis and koch. results: intra-observer reliability for quantification of rotational malalignment on postoperative ct after imn of tibial shaft fractures was excellent with 0.95 (95% ci = 0.92-0.97). the overall inter-observer reliability was 0.90 (95% ci = 0.87-0.92), also excellent according landis and koch. discussion and conclusion: first, bilateral postoperative low-dosesimilar radiation exposure as plain chest radiographs-ct assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following imn of tibial shaft fractures and it allows for early revision surgery. second, it may contribute to our understanding of the incidence, predictors, and clinical relevance of postoperative tibial rotational malalignment in patients treated with imn for a tibial shaft fracture, and facilitates future studies on this topic. the trauma emergency laparotomy audit (tela) t. collaborators 1 , m. marsden 2 , p. vulliamy 2 , r. carden 2 , o. najiuba 2 , n. tai 2 , r. davenport 2 1 tela collaboration, natric, n/a, united kingdom, 2 queen mary university of london, centre for trauma science, london, united kingdom introduction: mortality for shocked trauma patients undergoing emergency laparotomy remains unchanged for 20 years. the tela study aimed to describe the contemporary peri-operative management and patient outcome following abdominal injury. materials and methods: a prospective multicentre observational study of all patients undergoing emergency abdominal surgery within 24 h of injury was performed in the uk and ireland for six months from the 1st january 2019. shock was defined as the receipt of blood transfusion, with clinical or biochemical evidence of hypoperfusion. results: the study included 363 patients from 35 hospitals, of whom 159 (44%) were shocked and received a median of 6 units red blood cells. shocked patients were more likely to have a blunt mechanism of injury (56% vs 32%, p \ 0.01) and had a 20% mortality (32/159). half of these deaths occurred in the operating room (or). patients that died were more severely injured (injury severity score 35 (iqr 24-50) vs 25 (iqr 16-36), p = 0.01) and had a greater degree of shock at hospital arrival (base deficit 13.0 (iqr 7.7-18.1) vs 6.3 (3.2-11.1) , p \ 0.01). processes of care were equivalent or better among non-survivors, with a higher proportion of patients that died undergoing laparotomy within 90 min of arrival in the emergency department (54% vs 26%, p = 0.01) and a lower proportion receiving crystalloid in the or (29% vs 75%, p \ 0.01). however, delays to achieving definitive haemorrhage control and delivering balanced blood transfusion ratios were observed among both survivors and non-survivors. conclusions: damage control resuscitation principles are followed most closely in patients that die. despite better processes of care, 1 in 5 shocked patients died in this study justifying the continued search for novel therapeutic approaches. pre-operative temporary haemorrhage control and pharmacological mitigation of the effects of shock may be productive avenues of research to improve patient outcomes. introduction: tranexamic acid (txa) has been shown to reduce mortality in bleeding trauma patients, with greater effect if administered early. normally administered intravenously, txa can also be administered intramuscularly, which could be advantageous in low resource and military settings. intramuscular use has only been tested in healthy patients, and it is likely that shock will reduce intramuscular uptake. materials and methods: in a prospective experimental study norwegian landrace pigs (40-50 kg) utilised in a surgical course in haemostatic emergency surgery were subjected to various abdominal and thoracic trauma. after 1 h of surgery the pigs were injected with 15 mg/kg txa either intravenously or intramuscularly. blood samples were drawn at 0, 5, 15, 25, 35, 45, 60 and 80 min. the samples were centrifuged and analysed with liquid chromatography-mass spectrometry (lc-ms/ms). results: preliminary results from 3 animals in the intramuscular and 2 animals in the intravenous group. mean plasma concentration with sd of txa as a function of time is shown in figure 1. plasma concentration in the intramuscular group was near 10 ug/ml 15 min after administration, and rose above 14 ug/ml after 60 min. conclusions: plasma concentrations reported to inhibit fibrinolysis in vitro is 10 -17.5 ug/ml (1, 2) . if this extrapolates to the clinical situation intramuscular administration would yield plasma levels within the lower end of therapeutic range after 15 min. in ongoing haemorrhagic shock plasma concentrations of txa after intramuscular administration were considerably lower than after intravenous administration, but within therapeutic range . introduction: fallowing laparoscopic cholecystectomy(lc), patients suffer from postoperative pain, especially in the abdomen. intraperitoneal local anesthesia (ipla) reduces pain after laparoscopic cholecystectomy(lc). acute cholecystitis(ac)-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent lc with ipla application. the aim was to determine the postoperative analgesic efficacy of high-volume lowdose intraperitoneal bupivacaine in urgent lc. materials and methods: fifty-seven patients, american society of anesthesiologists(asa) physical status i or ii were randomly assigned to receive either normal saline(group a) or intraperitoneal bupivacaine(group b) at the beginning or at the end of the surgery in urgent lc. the primary outcome was the scores of postoperative pain by visual analogue scale score (vas) after surgery. results: postoperative vas scores at 1st and 4th hours were significantly lower in group b than group a (p \ 0.001). postoperative vrs scores at 1st, 4th and 8th hours were significantly lower in group b than group a (p \ 0.001, p:0.002, p:0.004). anelgesic use was significantly higher in group a at 1st postoperative hour than group b (p \ 0.001). shoulder pain was significantly lower in group b than in group a (p \ 0.001). patient satisfaction was significantly higher in group b than in group a (p \ 0.001). conclusions: high-volume low-concentration intraperitoneal bupivacaine instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and analgesic consumption in comparison to control group in urgent lc. introduction: in-hospital resuscitative thoracotomy is an established procedure for patients with penetrating cardiac injuries. the survival rate is dismal in patients with cardiac arrest prior to admission. prehospital resuscitative thoracotomy (prt) was introduced by the london hems with the highest published survival rate of 18%. we aimed to identify the number of patients who could potentially benefit from prt in our major trauma center catchment area. materials and methods: data from 2010 to 2017 were collected from the institutional trauma registry and electronic records. we included patients [ 17 years, with penetrating cardiac injury, or penetrating chest trauma and cardiac arrest, or penetrating chest trauma and sbp \ 70 mmhg. commonly used criteria for prt are tamponade with cardiac arrest lasting \ 10 min at the time of ambulance arrival and with [ 10 min remaining transportation time to hospital. results: cardiac injury was found in 25 of 54 included patients. of these 25, 14 arrived at the hospital with signs of life and survived. 8 of the 11 patients who died had tamponade. criteria for prt were not met in 6 of 8 patients with tamponade. two patients could have been eligible for prt. one patient was found in oslo with cardiac arrest lasting 10 min. the patient had multiple stab wounds to the chest and had several perforations of the right atrium, not technically manageable in a prehospital setting. the second patient was injured outside our primary catchment area and arrested with prehospital personnel present. prt was performed and the tamponade relieved, but compression of the aorta was necessary. the patient was declared dead shortly after hospital admission. conclusions: in 8 years in a population of 1.6 million, two patients met london hems criteria for prt. prt was performed in one patient who was declared dead shortly after hospital admission while one patient suffered from injuries which are unmanageable in a prehospital setting. isolated tissue injury leads to fibrinolytic shutdown, tpa resistance and alterations in clot structure in a porcine model introduction: trauma-induced coagulopathy includes a spectrum of hypo-to hypercoagulable phenotypes with differing levels of fibrinolysis and tpa sensitivity. fibrinolysis shutdown is associated with increased late mortality and shown in small animal studies to be driven by tissue injury. utilizing a novel method of clot structure analysis, we hypothesize that isolated tissue injury provokes fibrinolysis shutdown, tpa resistance and is associated with altered clot structure resulting in enhanced clot stability. materials and methods: all male pigs (n = 13) underwent anesthesia, intubation, femoral artery cannulation and mini-laparotomy. tissue injury (n = 9), was inflicted with bilateral chest wall muscular cutdowns and bilateral femoral fractures using a captive bolt pistol. mean arterial pressure was maintained at [ 50mmhg. timed blood samples analyzed using tpa challenged and citrated native teg to evaluate tpa resistance and fibrinolytic shutdown respectively. after 3 mm punch biopsy induced splenic injury, clot was collected, washed, and chemically fractioned by strong cation exchange chromatography. tandem mass spectrometry and bioinformatic analysis were used to evaluate clot structure and factor xiiia cross-linking patterns and covalently associated proteins. results: tissue injury pigs showed increased tpa resistance (change tpa-teg ly30: -39.1% vs -10.1% p = 0.0028) and a trend of fibrinolytic shutdown evidenced by teg compared to control (fig. 1) . splenic clot structure analysis demonstrated altered clot structure (fig. 2) and identified elevated levels of protease inhibitors such as alpha 2 macroglobulin and alpha 2 antiplasmin at 6 h post tissue injury compared to baseline. conclusions: in a porcine model, isolated tissue injury provokes fibrinolysis shutdown and tpa resistance resulting in altered clot structure with an increased incorporation of anti-protease proteins resulting in enhanced clot stability. there is a high incidence of rotational malalignment after intramedullary nailing of tibial shaft fractures: a prospective cohort series of 155 patients n. j. bleeker 1 1 amsterdam medical centre, flinders university, department of orthopedics and trauma surgery, amserdam, netherlands introduction: intramedullary nailing (imn) is the treatment of choice for most tibial shaft fractures due to its minimalistic surgical approach, superior fracture healing, and rapid recovery. however, an iatrogenic pitfall is rotational malalignment (rm). the aim of this prospective cohort study was to determine the incidence of rm and to evaluate the efficacy of protocolled bilateral postoperative computed tomography (ct) assessment of rotational tibial alignment. materials and methods: between 2009 and 2016 we prospectively included 155 patients (111 male (72%)), with a mean age of 41 years, with a unilateral tibial shaft fracture. as per hospital protocol, patients underwent a routine low-dose bilateral postoperative ct to assess rm. forty-two patients (27%) suffered open injuries; 29 (19%) were involved in a multi-trauma sustaining more than one injury. according to the ao/ota classification, there were 95 simple (61%), 35 wedge (23%), and 25 complex fractures (16%). fracture location within the tibial shaft varied with six patients (4%) being within the proximal third, 47 (30%) middle third, and 90 (58%) distal third. there were 11 segmental (7%) fractures that involved more than one third of the tibia. results: fifty-five patients (35%) had post-reduction rm including 46 patients (30%) between 10°-19°, seven patients (5%) with a rm between 20°-29°, and two patients (1%) with a rm greater than 30°w hen compared to the uninjured side. of the patients with rm, the tibia was externally malrotated in 29 patients (53%). three patients (2% of cohort or 5% of those with rm) underwent revision surgery to correct the rm as detected on ct scan. conclusions: this study reveals a high incidence of rm following tibial nails (35%) with a surprisingly low revision rate (5% of those with rm). a subsequent study should aim to assess clinical relevance of rm in terms of functional outcome and gait analysis. for now ctrotational-profiling provides a platform for early recognition and correction of rm secondary to tibial imn. level of evidence: therapeutic level ii -prospective cohort study. materials and methods: the tarn database was analysed retrospectively to quantify the number of trauma team activations, patients with major trauma (mt), causes of injury, and subspecialty-specific trauma procedures. crude and risk-adjusted mortality rates, observed to expected (o/e) mortality ratio, and risk-adjusted rates of survival from mt were also calculated. results: the number of trauma team activations has risen by a factor of 5. the predominant injury mechanism that resulted in mt was a fall from less than 2 m. there has been a fivefold increase in the overall number of trauma surgical procedures. orthopaedic surgeons have performed 84% of trauma procedures, followed by neurosurgeons, oral and maxillofacial surgeons, and visceral trauma surgeons. the rate of trauma laparotomies per consultant fluctuated between 0.4 and 0.8 per month. a fall from less than 2 m, road traffic accident and a fall from more than 2 m were the three leading causes of death from mt. the overall o/e mortality ratio was 1.1. conclusions: aintree trauma profile has significantly changed since 2011. this change highlights the potential need for a review of how mt services are offered at aintree to reduce the o/e mortality ratio. this may be achieved through more co-ordinated provision of trauma care, prevention, audit and research programmes. the role of visceral trauma surgery should be reconsidered within the context of the surgical patients' needs and demands, and fundamental requirements of the profession. inter-hospital variation in surgical intensity for trauma admissions: a multicenter cohort study l. moore 1 , m. p. patton 2 , i. farhat 2 , p. a. tardif 2 , c. gonthier 3 , a. belcaid 3 , f. lauzier 2 , a. turgeon 2 , j. clément 2 1 université laval, social and preventive medicine, québec, canada, 2 chu de québec-université-laval, québec, canada, 3 introduction: guidelines for trauma patients are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. we aimed to assess inter-hospital variation in surgical intensity for trauma patients and identify determinants of surgical intensity. materials and methods: we conducted a retrospective multicenter cohort study based on the 57 trauma centers of an inclusive canadian provincial trauma system. we included adults admitted for major trauma between 2007 and 2016. analyses were stratified for orthopedic (n = 17,001), neurological (n = 12,888) and thoracoabdominal surgery (n = 9816). surgical intensity was quantified with the number of surgical procedures during the first 72 h. inter-hospital variation was assessed with the intra-class correlation coefficient (icc) from multilevel poisson regression models. relative risks (rr) were generated to identify determinants. results: moderate inter-hospital variation was observed for orthopedic surgery (icc = 14.4%, 95% confidence interval [ci]: 12. 1-20.4) whereas variation was low for thoracoabdominal surgery (icc = 2.7%, 95% ci: 1.7-3.1) and neurosurgery (icc = 0.8%, 95% ci: 0.8-1.2). level iv centers had similar surgical intensity for thoracoabdominal injuries (rr: 1.20, 95% ci: 0.65-2.25) but lower intensity for orthopedic injuries (rr = 0.31, 95% ci: 0.17-0.57) than level i/ii centers. during the study period, we observed a decrease in intensity for neurosurgery (rr for 2015 (rr for -16 versus 2007 .76, 95% ci: 0.68-0.84) and thoracoabdominal surgery (rr = 0.74, 95% ci: 0.63-0.87). conclusions: the observed inter-hospital variation in risk-adjusted surgical intensity suggests that there may be opportunities for quality improvement in surgical care for injury admissions. a better understanding of how surgical intensity influences clinical outcomes is needed to inform quality improvement activities. pre-hospital injury diagnosis a. easthope 1 , m. marsden 2 , g. grier 2 1 barts and the london medical school, london, united kingdom, 2 royal london hospital, centre for trauma science, london, united kingdom introduction: accurate pre-hospital diagnosis of a patient's injuries may improve care by facilitating effective intervention at the scene and reducing time to definitive treatment in hospital 1 . we sought to assess the diagnostic accuracy of injuries by london's air ambulance (laa) clinicians and identify conditions in which clinical accuracy may deteriorate. materials and methods: a retrospective review was undertaken of all patients conveyed to the royal london hospital by laa from october 2017 for six-months. pre-hospital injury scores, coded using the abbreviated injury score (ais) were compared to hospital discharge ais. patient outcomes were evaluated in the case of underscored injuries. results: during the study period 688 patients were seen and 177 met eligibility. mean clinical sensitivity and specificity was 62% and 93% respectively. chest injury identification was most sensitive (77%) and pelvic injury least sensitive (41%). the relative risk (rr) of underscored injuries to the chest, abdomen and pelvis increased with decreasing glasgow coma scale (gcs) peaking at 1.7 (iqr 1.3-2.0). the average accuracy of injury identification was 88% with a negative predictive value of 90%. no overt patient morbidity resulted from a missed, or under-scored injury. all missed injuries were subsequently identified in the emergency department. conclusions: the pre-hospital diagnosis of injuries has reasonable sensitivity and excellent specificity. accurate pelvic injury diagnosis is more challenging than chest or abdomen. with decreasing gcs, the risk of missing injuries increases. clinicians should be aware of the potential for error when treating trauma patients with impaired conscious levels. comorbidities, injury severity and complications predict mortality in severe thoracic trauma: a retrospective analysis from the norwegian national trauma registry of epidemiology, clinical factors and risk factors for mortality of patients with thoracic injuries. materials and methods: adult patients treated for severe thoracic trauma (injury severity ais c 3), between 2009 and 2016 at haukeland university hospital were included. data were extracted from (1) the haukeland university hospital local trauma registry, and (2) the norwegian trauma registry. additional data on comorbidities and complications was collected from patient records. the factors age, gender, comorbidities [charlson comorbidity index (cci)], anticoagulant use, injury severity [revised trauma score (rts)], [injury severity score (iss)] and complications [clavien-dindo scale (cds)] were analyzed for being predictive of in-hospital mortality. multivariate logistic regression analyses with backward selection methods were used. results: data of 399 patients were analyzed, of which 55 (14%) patients died. median iss was 34 in the non-survivors (iqr 22, 43) and 17 (iqr 13, 25) in survivors (p = .001). data of 282 patients were used in the risk factor for mortality analysis. two or more comorbidities measured by cci (or: 7.02, p = 0.006), injury severity measured with the rts (or: 0.41, p = \ 0.001), and grade c 3 complications on the cds (or: 7.66, p = 0.001) were significant predictors for mortality. conclusions: severe comorbidities significantly decreased the chances of survival after thoracic trauma. injury severity was also found to be a significant predictor of mortality. physiological injury severity, measured by rts, appeared to be a stronger predictor of mortality than iss after thoracic trauma. finally, severe complications led to considerably higher risk of mortality following thoracic trauma. the psychosocial impact of e-bike accidents and changing values of older patients in the netherlands, a qualitative study s. berben 1 , l. vloet 1 , e. c. t. tan 2 , m. edwards 2,3 , a. brants 2,3,4 , g. olthuis 2, 3, 4, 5 , a. oerlemans 2, 3, 4, 5 , f. haverkamp 2, 3, 5 introduction: the mechanical impact of e-bike accidents, increasingly used by older persons, has shown to be higher compared to regular bike accidents. however, the psychological impact of e-bike accidents in older trauma patients, their experiences in emergency and follow-up care, and the possible change in values and beliefs in response to the accident is still unknown. materials and methods: we used a qualitative design and included older patients (65 ? years) with a variety of (severe) injuries, who were admitted to the emergency department after an e-bike accident (n = 12) and their relatives (n = 11). they were interviewed within one month (t1) and after three months (t3) of the date of accident. interviews were transcribed verbatim and analyzed via a thematic analysis approach using an ethical perspective. results: many patients required (in)formal care after hospital discharge. in general patients were satisfied with the provided emergency surgical care, although some patients reported limited and insufficient information on rehabilitation and homecare support. the analysis yielded impaired physical condition, anxiety, increased vulnerability and dependency of care givers as psychosocial impact. freedom impairment, shifting relational autonomy, and confrontation with vulnerability and mortality were reported changes in values. central values as mobility and freedom, vitality and health, social participation and recreation were put under pressure and needed to be negotiated again after the accident in order to decide whether to use the e-bike again. conclusions: follow-up information of surgeons and emergency physicians after initial hospital care for older trauma patients with an e-bike accident shows room for improvement, with more specific consideration for the psychological impact of trauma and changes in values after e-bike accidents. eur j trauma emerg surg. 2018. https://doi.org/10.1007/s00068-018-1033-5. traumatic subaxial cervical fractures: functional prognostic factors and survival analysis introduction: the main goal of this study is to identify the risk factors for poor functional outcomes and to analyze the overall survival (os) and complications rate in patients with traumatic cervical spinal cord injury (sci) and subaxial cervical fracture (sacf) treated with open surgical fixation. materials and methods: the authors retrospectively reviewed sixtyfive consecutive patients from one single center with traumatic unstable sacf and associated sci treated surgically between 2010 and 2017. we exclude cervical fractures with concomitant severe head injury, brachial plexus injury, lumbar plexus injury, superior or inferior limb fractures and patients who were lost during the followup period. statistical analysis using a chi square test, student's t-test and logist regression were used to identify factors associated with poor functional outcomes after surgical treatment. os analyses were performed using kaplan-meier curves. results: the 5-year survival rate was 81.8%. four patients died in the first 30 days after surgery and 6,7% need a reoperation. the median time from injury to surgery was 3.6 days. the complication rate was 62%, being respiratory failure the most common one. preoperatively, 64% had an asia \ c. about 57% of the patients with asia between a-d had improve one or more asia grades. logistic regression analysis show that older age, sacf above c5, asia \ c pre-surgery and long time from injury to surgery were related with poor prognosis. the os rate was higher in patients with neurological improvement, without signs of neurogenic shock at presentation and in sacf bellow c4. conclusions: our results suggest that sacf should be treated as soon as possible in order to improve the os rates and functional outcomes. older patients, lower asia at presentation and sacf above c5 are related with worst functional outcomes. introduction: compression fractures of multilevel vertebral bodies are common in children. due to segmental plasticity, several adjacent vertebral bodies are compressed to a lesser degree at each body. plain ap and lateral x-ray is the first diagnostic examination in the emergency department (ed), but a proper diagnosis is often delayed or missed. materials and methods: this is a retrospective, monocentric study in children falling on their back who showed up at the orthopedic ed, between december 2017 and september 2019. nine children (4f, 5 m) with an average age of 11.1 years were included. trauma occurred playing games and doing sports in all cases. all children were subjected to x-ray, followed by mri scans for doubtful findings on the plain x-ray or persistent mild pain (t1, t2, t2-stir sequences). results: cuneiform vertebral fracture or vertebral body height reduction was diagnosed with x-ray in five vertebrae while mri showed fractures in 32 vertebrae including compression and edema of adjacent vertebrae in the t2-stir sequence. therefore only 15.6% vertebral fractures have been detected by plain x-ray. the injured vertebral bodies were so distributed: t3 n = 1, t4 n = 2, t5 n = 3, t6 n = 4, t7 n = 3, t8 n = 3, t9 n = 4, t10 n = 3, t11 n = 2, t12 n = 2, l1 n = 2, l3 n = 1, s4 n = 1, s5 n = 1. the most involved spine section was between t3 and t10 with 20 fractures. conclusions: vertebral fractures are not always related to hyperflexion or forward hinging mechanism. mri showed vertebral compression fractures and the t2-stir sequence showed edema as post-traumatic evidence that had not been detected by x-ray. in absence of a radiologically visible lesion, the persistence of pain should be investigated by performing mri scans. the middle thoracic spine level appeared to be the most involved one in pediatric vertebral fractures. introduction: occipitocervical fixation (ocf) is an effective surgical method to treat various craniovertebral junction (cvj) pathologies. a rigid fixation achieved from ocf displaces other techniques of cvj stabilization unfortunately during procedure deep and wide wound is performed. aim of this study is to share our experience in ocf and lately performed percutaneous ocfs with intraoperative ct guided navigation system. materials and methods: of 34 patients who underwent ocf 6 were performed percutaneously. o-arm ct scans were used to illustrate and measure radiologic parameters. screws were implanted in c1 lateral masses (2) , isthmus of c2 (68) and c3 pedicles (68) and assessed according gertzbein robbins (gr) in modification of bredow classification from a to e. results: a total 138 screws were implanted, 114 of them was performed in open surgery and 24 percutaneously. outcome in gr classification for screws implanted in open surgery was: a 58 (50,88%), b 22 (19,3%), c 16 (14,04%), d 9 (8,77%) and e 9 (7,02%) while in percutaneous: a 21 (87,5%) and b 1 (12,5%) . in open surgery one screw was revised. conclusions: percutaneous occipitocervical fusion seems to be a good option to achieve desirable effect in cervical pedicle screws implantation. during procedure whole nuchal muscles are preserved. ct guided surgery and microscope view are necessary to perform percutaneous ocf. introduction: studies have found higher risk of traumatic deaths in rural areas in norway combined with a paradoxically decreased prevalence of severe, non-fatal injuries (1) . this study investigates the risk of fatal and non-fatal injuries among all adults in norway in the period 2002-2016. materials and methods: all traumatic injuries and deaths among persons with residential address in norway from 2002-2016 were included. data was collected from the norwegian patient registry and the norwegian national cause of death registry. all cases were stratified according to six groups of centrality based on statistics norway's classification of centrality 2017. mortality-and injury rates was calculated per 100,000 inhabitants per year. results: the mortality rate differed significantly according to the levels of centrality (p \ 0.05). the mortality rate in the most urban group (1) was 64.2 and in the most rural group (6) 78.6. the lowest mortality rate was found in centrality group 2 (57.9). there was an increased risk of death between centrality group 1 and group 6 with a relative risk of 1.23 (ci: 1.0-1.5, p \ 0.05). the most common cause of death was transport injuries, self harm, fall injury and other external causes. the highest urban-rural gradient was seen in transport injuries with a relative risk of 3.0 (ci 1.7-5.3, p \ 0.001) comparing group 6 to group 1. group 2 had the lowest risk of nonfatal injuries (1531) and group 6 the highest (1803). the risk of nonfatal injuries increased with higher grade of rurality, comparing group 1 and 6 revealed a relative risk 1.07 (ki 1.02-1.11, p \ 0.001). conclusions: the more rural the higher risk of traumatic deaths and non-fatal injuries. transport injuries had the highest urban-rural gradient. references: 1. bakke hk, hansen is, bendixen ab, morild i, lilleng pk, wisborg t. fatal injury as a function of rurality-a tale of introduction: virtual fracture clinics (vfcs) are an alternative to conventional fracture clinics for management of musculoskeletal injuries. they have been shown to be a safe and effective model for upper and lower limb injuries. there is limited data to support their use for specialist thoracolumbar fracture follow-up. materials and methods: lean methodology including process mapping was applied to identify a safe virtual alternative for the pathway. first cycle analysis of 100 consecutive referrals to a traditional specialist thoracolumbar fracture clinic. second cycle analysis of 100 consecutive referrals six months after introduction of a vfc. results: mean time to first outpatient review in first cycle was 84 days. referrals led to 240 booked outpatient appointments and 66 were missed (28% non-attendance). 54% of referrals had 3 or more scheduled appointments. 82/100 were ao type a1-3 and all of these received non-operative treatment. 9/100 were ao type a4 or b and 8 of these received non-operative treatment. 1 patient received operative stabilisation (ao type b). process mapping identified two pathways-virtual review with advice letter and physiotherapy referral (outcome a-ao type a1-3) or face to face review (outcome b-ao type a4 or b). mean time to outpatient review in second cycle was 10 days. 79/100 received outcome a. 8/79 (10%) made a telephone call for advice and only 2/79 (3%) asked for a face to face appointment. 19/100 received outcome b and all were discharged after one visit. 0 patients in cycle 2 required operative stabilisation. statistically significant reduction in number of scheduled face-to-face reviews (240 versus 19; p \ 0.001) and mean time to first review (84 days versus 10 days; p \ 0.001). conclusion: virtual thoracolumbar fracture clinics are a safe and clinically effective alternative to traditional fracture clinic models. lean methodology can be uses to extend virtual clinic pathways to specialist trauma clinics. treatment prognosis of 340 cases of fragility fracture of pelvis m. yoshida 1 1 fujita health universityhospital, emergency, aichi, japan introduction: the number of cases of fragility fracture of pelvis in the elderly has been increasing in recent years, but there are still not enough reports of surgical treatment as a treatment method, but there is still no certainty how to treat. so we investigated prognosis of 340 cases of fragility fracture of pelvis. materials and methods: subjects were 340 fragility fracture of pelvis treated at a single center from april 2012 to april 2019, 40 males, 300 females, average age 82 ± 9.5 years. only cases that had ct scan were included. we examined rommens classification, the presence of injury, presence of hip implants, functional prognosis, and 1-year mortality. results: the breakdown of rommens classification is type ia 78 cases, ib 2 cases, iia 14 cases, iib 74 cases, iic 51 cases there were 32 cases of iiia, 3 cases of iiic, 1 case of iva, 50 cases of ivb, and 4 cases of ivc. surgical treatment was indicated in 16 cases (4.7%) (iic 1 case, iiia 7 cases, ivb 5 cases, ivc 3 cases) there were 28 cases (8.2%) with no injury mechanism and 61 cases (18%) with hip implants. 109 cases (32%) were able to follow up for more than 1 year including telephone surveys, and 42.3% of them did not recover to functional level before injury. the one-year mortality rate was 10.2%. conclusions: in the 340 cases studied here, 16 cases (4.7%) were indicated for surgery. the prognosis and mortality rate are almost the same as those reported overseas, and as with proximal femoral fractures, there is a possibility that it may be greatly involved in adl decline in the elderly. we think that further study is needed in the future. conclusions: patients with a femoral neck fracture who received a hip hemiarthroplasty and used anticoagulation had no significant longer delay to surgery and had a higher mean loss of hemoglobin points. as a clinical consequence of this, more packed cells were supplemented. also more postoperative hematomas were found in the population with anticoagulation. no differences were found in mortality rates at 30-days and one year. results: on all eight patients the easy-approach was applied without adverse events. in four cases the plate osteosynthesis was done completely endoscopically with excellent results for the patients regarding pain relief and scar development. in the remaining four cases the endoscopic stabilization was not performed for the following reasons: in the first overall case primarily only the endoscopic approach was planned. in the fourth overall case, ventilation showed high end-expiratory co2-levels after endoscopic situs preparation, so we converted to the open plating. in the fifth overall case, the easyapproach was applied to evacuate a retrosymphyseal hematoma in a patient with a stable pubic rami fracture. in the eighth overall case, the anterior pelvic ring injury was a bilateral multifragmentary pubic rami fracture in combination with a disruption of the symphysis. after endoscopic situs preparation with clipping of the corona mortis vessel, reduction of the displaced symphysis could not be done endoscopically. conclusions: we demonstrated that the endoscopic plate osteosynthesis of the anterior pelvic ring is feasible with existing standard laparoscopic instruments. the evaluation of the easy-approach in the clinical setting is going on, while the development of suitable reduction tools is one major goal of future studies. introduction: retrograde intramedullary pubic ramus screw fixation is less invasive method and biomechanically stable compared to the plate fixation. the purpose of this study is to examine the feasibility of screw insertion using computed tomography (ct). materials and methods: we analyzed sixty ct data (30cases in male and female each). by using ct analyzing software, the virtual column with 6.5 mm diameter was inserted so that we analyzed the feasibility of the screw insertion. and the intramedullary diameter of the pubic ramus at the parasymphyseal area, base, and acetabulum were measured. results: the virtual 6.5 mm diameter screws could be inserted in 100% (30/30) in male and 23.3% (7/30) in female. the cause that screws insertion was impossible was penetration to the hip joint in all cases. the screw inserting point was 19.2 mm and 21.5 mm from the medial border of the pubic symphysis and 11.5 mm and 9.8 mm from the upper border of the pubic symphysis in male and female respectively (p [ 0.05). the intramedullary diameter of pubic ramus was 15.7 mm, 13.8 mm and 12.5 mm at parasymphyseal area, 13.2 mm, 11.4 mm and 9.4 mm at the base of pubis, and 14.5 mm. 13.5 mm and 11.7 mm at the acetabulum in male, female who had the screw corridor and female who didn't have the screw corridor respectively. the diameter of the pubic ramus of the female who didn't have the screw corridor was significantly small compared to male and pubic ramus in three measuring points (p \ 0.05). , 5% of the screws were revised. there were no neurovascular or urologic complications. radiographic nonunion was observed in 10% with a minimum follow-up of 6 months, this correlated with a peri-implant infection (p 0.001), operation [ 6 months after trauma (p 0.02) and non-significantly with implant loosening (p 0.076). there was no correlation of nonunion with patient's age, the fracture mechanism or a non-excellent reduction. in total, 12.5% of the patients were re-operated, in 5.1% a re-osteosynthesis was conducted. conclusions: retrograde trans-pubic screws show good clinical results with lower or similar complication rates compared to alternative methods as plate fixation or external fixator. fracture union did not depend on fracture mechanism or age. hence, this minimal-invasive method is especially attractive in elderly patients with an ffp. because it is an internal fixation of the superior pubic ramus with relative stability, an anatomic open reduction is not necessary to achieve fracture union. the need for extraperitonal pelvic packing -finally confirmed to be vanishing? introduction: the presence of cerebral venous thrombosis (cvt) is increasingly recognized in traumatic brain injury (tbi), but its complication rate and effect on outcome remains undetermined. in this study, we characterize the complications and outcome-effect of cvt in tbi patients. materials and methods: in a retrospective, case-control study of patients included in the oslo university hospital trauma registry and radiology registry from 2008-2014, we identified patients with cvt (cases) and without cvt (controls). groups were matched regarding abbreviated injury severity (ais) head region score 3-6. cases were identified by ais or icd-code for cvt and a ct/mr venography confirmed to be positive for cvt, whereas controls had no ais or icd-code for cvt and a ct/mr venography confirmed to be negative for cvt. risk of mortality was assessed using multivariate logistic regression adjusting for initial gcs, iss and rotterdam score. results are also reported for subgroups according to cvt location ( fig. 1 introduction: the aims of this prospective cohort study were (i) to identify trajectories of recovery in patients with mild traumatic brain injury (mtbi) during the first two years after trauma and (ii) assess patients and injury characteristics for these trajectories. materials and methods: all adult trauma patients with mtbi (aisseverity 1 or 2 and an injury severity score \ 9) who were admitted to a hospital in a region of the netherlands from august 2015 to november 2016 were asked to complete questionnaires. the questionnaires could be completed at 1 week, and 1, 3, 6, 12 and 24 months and included the euroqol-5-d for health status, including a cognition dimension, the hospital anxiety depression scale (hads-d and hads-a for symptoms of depression and anxiety respectively) and the impact of event scale (ies) (for post-traumatic stress symptoms). latent class trajectory analysis was used to determine trajectories of recovery in latentgold 5.1, patient and injury characteristics of the classes were assessed in ibm spss 24.0. results: a total of 1027 patients (47% of total) completed at least one follow-up questionnaire. the number of classes (trajectories) ranged from 3 for cognition to 11 for depression. poor recovery classes of cognition and health status consisted of mostly females, patients with low education, higher age, longer length of stay at the hospital and frail patients. the class with full recovery consisted of young patients, with most recovery occurring during the first six months after injury. patients who reported poor health status before injury scored significantly lower health status after injury and showed no recovery over time. conclusions: different recovery patterns were present in patients with mild traumatic brain injury. especially frail elderly patients who reported poor health status before injury have poor outcome up to 24 months after injury. post-concussive symptoms in children and adolescents with traumatic brain injury: a center-tbi study introduction: acute respiratory is associated with high morbidity and mortality. in addition, its etiologies are heterogeneous and the outcome depends on the underlying cause. the aim of the present study is to analyze, whether the mortality of posttraumatic ards is affected (1) over time, (2) attributable to geographic distribution, (3) related to the used definition and (4) introduction: many factors of trauma care have changed in the last decades. this review investigated the effect of these changes on overall and cause-specific mortality in polytrauma patients admitted to the intensive care unit (icu). moreover, changes in trauma mechanism over time and differences between continents were analyzed. materials and methods: a systematic review of literature on overall mortality in polytrauma patients admitted to the icu was conducted. overall and cause-specific mortality rates were extracted as well as the trauma mechanism of each patient. linear regression on changes in overall and cause-specific mortality rates was performed. results: thirty studies, which reported mortality rates for 83,502observed patients, were included and showed a decrease of 0.4% in overall mortality per year ( fig. 1 ). brain-related death has become more common over the years, whereas multiple organ dysfunction syndrome (mods), acute respiratory distress syndrome and sepsis became less prevalent (fig. 2) . mods was the most common cause of death in north america and brain-related death was the most common in asia, south america and europe (fig. 3a) . penetrating trauma was most often reported in north and south america and asia (fig. 3b) . conclusions: overall mortality in polytrauma patients admitted to the icu has been decreasing as a result of the improvements in trauma care. a shift from mods to brain-related death could be observed. more research on preventative measures for the latter is required to ensure a further decline in mortality. moreover, we have shown geographical differences in cause-specific mortality, which may provide learning possibilities between similar trauma centers resulting in improvement of trauma care introduction: aim of the current study was to assess an association between trauma patient volume of the intensive care unit and inhospital mortality. materials and methods: from data of the japan trauma databank, this retrospective cohort study selected adult (c 16 y) trauma patients hospitalized in the intensive care unit with the injury severity score of c 9. after applying a multiple imputation on all the study variables, a logistic regression generalized estimating equation after adjustment for age, sex, mechanism of trauma, and the injury severity score as covariates and hospitals as a cluster assessed an association between quartile of patient volume in intensive care unit and hospital mortality. introduction: quality and content of early fracture hematoma (fh) dictate the healing process in long bone fractures. different reaming protocols for intramedullary nailing (imn) are available. however, the impact of reaming strategies on immune cell characteristics of early fracture hematoma is unclear. we hypothesized that the application of reaming irrigation and aspiration (ria) techniques optimizes cellular content of fracture hematoma. materials and methods: twenty-four pigs underwent standardized femur fracturing. then, animals were exposed to different protocols of imn. group a underwent no reaming prior to imn. group b was treated with conventional reaming plus imn and group c composed of animals treated with ria and subsequent nailing. fracture hematoma was collected 6 h after reaming. fh-immune cells were isolated and studied by flowcytometry. cell viability was tested by annexin-v-labelling. neutrophil activation was determined by mac-1/cd11bcell surface expression levels, whereas fcyriii/cd16-receptor expression was utilized to investigate neutrophil maturation. results: all animals survived the observation period. propertions of white blood cell subtypes in fh did not differ between conditions. however, the percentage of viable fracture hematoma immune cells was significantly higher in the ria-group, compared with conventional reaming (respectively mean 86.7% vs. 96.5%, p = 0.04). additionally, both neutrophil cd16-expression (-35%) and cd11bexpression (-61%) were significantly lower in those animals treated with ria compared with the conventional reaming condition. conclusions: this experimental study reveals that reamed irrigationaspiration (ria) prior to imn is associated with increased immune cell viability and less neutrophil senescence/activation in early fracture hematoma. this underlines the important role of imn in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma. introduction: the study and determination of the traumatic pattern in bicyclists-delivery employees. the recording of personal protective equipment and evaluation of the selection criteria of their self protection. materials and methods: a total of 22 patients (21 men and 1 woman) with mean age of 33.8 years (18 -52 years) were included over a study period from january 2017 to march 2019. twenty-one patients admitted to the hospital with a total of 26 injuries treated operatively, whereas 15 injuries were treated conservatively. we recorded and evaluated the use of adequate personal protective equipment of these delivery employees. results: the mean hospitalization time was 7.6 days (2-12 days) . a total of 2 thoracic injuries, 3 traumatic brain injuries, 6 spine injuries, 25 lower extremity injuries and 5 upper extremity injuries were recorded. surgical treatment concerned 3 patients with upper extremities and 18 patients with lower extremities injuries and the anatomic regions involved were the distal radius (3), pelvic ring injury (1), femoral fractures (6), tibial plateau fractures (4), patella fractures (2), diaphyseal tibial fractures (6), and ankle fractures (4) . conclusions: the lack of an adequate personal protective equipment due to their low financial status in combination with the absence of driving professional education among workers in this category of delivery employees results in lower extremity injuries with the majority requiring hospitalization and surgery. further investigation is needed, as well as constant training and setting right criteria for the pursuit of such employment. results: a total of nine rct's (462 patients) and the sixteen observational studies (4245 patients) were included. the pooled nonunion rate did not differ significantly between both treatment groups (risk difference: 0%; or 0.98, 95% ci 0.68-1.42). more patients treated with nailing required re-intervention (risk difference: 2%; or 2.11, 95% ci 1.09-4.08) with shoulder impingement being the most predominant indication. more patients treated with pate fixation developed radial nerve palsy compared to nailing (or 0.43, 95% ci 0.31-0.61). notably the absolute risk difference is small (2%) and during follow-up the palsy resolved spontaneously in the majority of patients. nailing lead to a faster time to union (mean difference: 2.5 week, 95% ci 3.1-1.8), lower infection rate (risk difference: 2%, or 0.48, 95% ci 0.31-0.75) and shorter operation duration (mean difference: 20 min, 95% ci 32.0-9.4). functional scores were comparable in both groups (standardised mean difference: -0.13, 95% ci -0.46 to 0.19). there was no difference between effect estimates form observational studies and rct's. conclusion: there appears to be no difference between plate fixation and nailing for humeral shaft fractures with regard to non-union rate and functional outcome. patients treated with plate fixation have a higher risk for infection and radial nerve palsy, but lower risk for reintervention. the absolute differences, however, are small. nailing does differ significantly from plate fixation in terms of shorter operation duration and time to union. the pooled estimates from randomised clinical trials did not differ significantly from estimates obtained from observational studies. post-traumatic complications are more often after medial clavicle injuries compared to lateral clavicle injuries introduction: medial clavicle injuries (mci) are widely unexplored, especially in contrast to lateral clavicle injuries (lci). current research concerning mci assumes a higher severity of mci, e.g. concerning concomitant injuries. our aim is to evaluate by big data analysis if these rare injuries would also lead to a higher number of post-traumatic complications. materials and methods: we focused on the mci subgroup consisting of medial clavicle fracture and sternoclavicular joint dislocation. the lateral clavicle fracture and the acromioclavicular joint dislocation were summarized to the subgroup of lci. the midshaft clavicle fracture was analyzed for comparison. the data are based on icd-10 codes of all german hospitals as provided by the german federal statistical office. anonymized patient data from 2012 to 2014 were evaluated. the retrospective analysis addresses the fracture healing in dislocation, delayed union and non-union. results: the proportion of all patients suffering from complications was 3.1%, which were attributed to one of the three post-traumatic complications. each complication rate for the single injury and the single complication was rather low with a maximum of 1%. mci were more likely to be affected by post-traumatic complications than lci with a ratio of 2.7 to 3.3 times (p \ 0.005). the midshaft clavicle fracture was similarly frequently affected by complications with 41.6% of all complications as the mci (44.2%). the lci accounted for the smallest proportion at 14.2%. conclusions: we proved that mci are more often associated with post-traumatic complications than injuries of the other parts of the clavicle. this is another hint that mci appear to be more complex than lci. this could be due to a missing standard procedure and the higher number of concomitant injuries in mci. further representative clinical studies are required since miscoding is a frequent issue in research concerning clavicle injuries, especially in a big data analysis. quantification of trauma center accessibility using gis-based technology introduction: there is no generally accepted methodology to asses trauma system access and optimal geographical trauma center distribution. the goal of this study is to determine the influence of trauma center(tc) distribution during high and low traffic density using geographical-information-system(gis)-technology. methods: using arcgis-pro, we calculated differences in transport time (tt) and population coverage in seven scenarios with 1, 2, or 3 tcs during rush [r]-and low traffic [l] hours in a densely-populated region with 3tcs in the netherlands (fig. 1) . results: in the seven scenarios, the population that could reach the nearest tc within (\) 45 min, varied between 96-99% ( fig. 2) in the three-tc-scenario, roughly 55% of the population could reach the nearest tc \ 15 min in [r] and [l] . the hypothetical scenarios with two geographically well-spread tcs showed similar results as the current three-tc-scenario. in the one-tc-scenarios, the population reaching the nearest tc \ 15 min decreased by 23-36% in both [r] and [l] compared to the three-tc-scenario. in the three-tcscenario the average tt increased with about 1.5 min to almost 21 min in [r] , in comparison to 19 min during [l] (fig. 3) . similar results were seen in the scenarios with two geographically well-spread tcs. in the one-tc-scenarios and the geographically close two-tcscenario the average tt increased by 5-8 min [l] and 7-9 min [r] in comparison to the three-tc-scenario. conclusion: this study shows that a gis-model for trauma center access offers a quantifiable and objective method to evaluate trauma system configuration in areas with different geography and demography. applying this technology to one of the most densely populated areas in the netherlands shows that the transport time from accident to trauma center would remain acceptable if the current situation with three trauma centers would be changed to a scenario with two geographically well-spread centers. classifying posttraumatic stress disorder courses in physical trauma patients: an observational prospective cohort study introduction: the aim was to identify different courses of posttraumatic stress disorder (ptsd) in physical trauma patients. then, to examine whether these classes could be characterized by sociodemographic, clinical, psychological, and personality outcomes. methods: patients completed the impact of event scale-revised (ies-r), m.i.n.i.-plus after inclusion, 3, 6, 9, and 12 months after injury to examine different courses. the hospital anxiety and depression scale, neo-five factor inventory, state-trait anxiety inventory-trait, and the whoqol-bref were completed after inclusion only. latent class analysis, chi square tests, and anova were performed to analyze the aims. results: in total, 267 patients were included. the mean age was 54.1 (sd = 16.1) and 62% were male patients. the ies-r (see figure 1 ) and the m.i.n.i-plus had five classes (1: moderately, 2: little bit, 3: worse, 4: none, 5: quite a bit of ptsd symptoms). patients in class 3 are diagnosed with ptsd (cut-off score c 33). on both questionnaires, patients (proportion & 11%) in class 3 or 5, scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety compared to the other classes over 12 months after trauma. lower scores on all domains, except for social domain on the ies-r, were found compared to the other classes (ies-r; physical domain: class 3 vs. 4 (mean ± sd): 10.4 ± 3.3 vs. 14.8 ± 2.4, p-value = \ 0.001). psychological and personality outcomes were significantly different on all courses. also, patients in class 3 or 5 were younger compared to the other classes (ies-r; class 3 vs. 4: 43.5 ± 15.4 vs. 59.1 ± 14.8, p-value = \ 0.001). no medical outcomes for ptsd were found. conclusions: about 11% suffer from ptsd symptoms 12 months after trauma. different courses were defined by sociodemographic, psychological, and personality characteristics. professionals can, short after trauma, recognize patients at risk for ptsd when they focus on these characteristics. then, an intervention can be offered. six meter, the criterion for severe adult trauma to falls from heights in cdc field triage needs to be lowered introduction: trauma is one of major public health care issue which is costly to society. differences vary from region to region, but blunt trauma accounts for a large part of the total trauma, and the rates of the falls from heights among the blunt trauma is getting higher. it is serious that falls from heights is often accompanied by severe multiple trauma. therefore, authors studied the relationship between the height of the fall/other related factors and outcomes including hospital stay/mortality. materials and methods: retrospective cohort study of the 670 adult falls-from-heights patients visited a regional trauma center for 4 years (from 2014.01.01 to 2017.12.31). results: of total 670 patients, the number of d.o.a patients were 69. the height from falls of the deceased patients was statistically significantly higher than that of the survived patients. (19.4 ± 15.3 m vs. 4.3 ± 4.2, p \ 0.001) the auc of the roc curve of the height from fall to mortality was 0.879. (figure) the sensitivity of 3.75 m was 90.7% and 6.5 m was 81.4%, respectively. the traumatic brain injury, pelvis fracture, visceral organ injury, age, and the height from fall were statistically significant risk factors in multivariate analysis for mortality (p = \ 0.001, 0.11, 0,001, 0.004, and 0.03 respectively). conclusions: the height from the fall is closely related with mortality. we think the current height for the severe fall injury in cdc field triage for trauma is high and needs to be lower to 3.5 introduction: operative management of severe trauma is a team effort, requiring excellent communication skills. surgeons, anesthesiologists and nurses need to coordinate effectively in order to ensure an excellent clinical outcome. the definitive surgical trauma care (dstc), definitive anesthesia trauma care (datc) and definitive perioperative nurses trauma care (dpntc) courses provide an excellent opportunity to train efficient teamwork. we aimed to study the impact of the joint dstc-datc-dpntc courses in candidates' perceptions and skills in perioperative communication. materials and methods: study population of 39 candidates (18 surgeons, 10 anesthesiologists and 11 nurses) participating in a joint dstc-datc-dpntc course in coimbra, portugal. median age of 32 years (range 27 -52). female gender in 26 (67%) of cases. all participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. postcourse survey on several aspects of peri-operative communication, with responses on a likert scale. participants were also asked which aspects of intraoperative communication they valued the most. statistical analysis with spps, 25.0 (wilcoxon signed rank test, significance with p-value \ 0.05). results: all participants responded to the survey. results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments (p \ 0.05). postoperative team debriefing was also valued as highly relevant. closed-loop and direct, by-name communication were highly rated (p \ 0.001). self-reported communication skills improved significantly during the course (p \ 0.001). conclusions: joint training in the dstc-datc-dpntc courses provides a unique opportunity to improve candidates' self-awareness and skills in intraoperative communication. a public health approach to knife related trauma in liverpool: a geospatial study r. shellien 1 , n. misra 1,2 , j. germain 2 , m. whitfield 2 1 aintree university hospital, emergency general surgery and trauma unit, liverpool, united kingdom, 2 liverpool john moores university, public health institute, liverpool, united kingdom introduction: liverpool is a city that has undergone recent rapic socioeconomic change. despite reductions in overall deprivation, incidents of stabbings have increased by 64% in the last 7 years. this study will describe the trend in knife crime, drawing on governmental data and policies to conclude the reasons behind the trend. materials and methods: a retrospective cohort study of patients presenting to north-west ambulance service (nwas) with a penetrating injury in liverpool between 2012 and 2018. data collected included patient demographics, geography and timing of incidents and correlation to datasets of multiple indices of deprivation and knife crime prevention outreach education programmes. results: incidents of stabbings have increased by 64% between 2012 and 2018. victims were more likely to be males (82%) between the ages of 20 and 24 (13%). the peak rate was between 20:00-21:00 (7.9%) and trough between 08:00-09:00 (1.3%). there is a spike in incidents of stabbings of 15-19 year olds from 15:00 to 21:00, correlating with school closure. there appears to be statistically poor correlation between deprivation of lower super output areas and stabbings (r 2 = 0.11, 0.29 and 0.18 for 2010, 2015 and 2019 respectively). however, when the data is split into larger areas, middle super output areas (msoas), deprivation appears to be a further risk factor. this study has identified certain geographical areas as high risk. conclusions: this study allows for targeted public health interventions at populations most at risk of knife trauma, including geographical mapping of high-risk areas, so that interventions can be distributed appropriately. references: ministry of housing, communities and local government (2019 government ( , 2015 government ( , 2010 introduction: trauma teams treat complex patients with injuries posing significant resuscitative and management challenges. effective teamwork is essential to optimise patient outcomes and improve survival, with failure contributing to adverse events [1] . the role of multidisciplinary (mdt) trauma training has been demonstrated by the military operational surgical training course (most) [2] . it is imperative that civilian trauma training adopts similar methodology to optimise team work. materials and methods: the three-day multidisciplinary trauma course comprised cadaveric-based skills teaching supplemented by lectures and real-life scenario discussion. delegates were senior surgical and anaesthetic registrars and consultants, alongside trauma team leaders (ttl), scrub staff and operating department practitioners (odp). pre-and post-course questionnaires assessed perceptions of multidisciplinary trauma simulation and confidence in specialty specific skills. results: all delegates reported mdt simulation clarified each role, including their own, in the trauma team. post-course, scrub staff and odps felt confident gaining intraosseous access (p \ 0.0002), surgical delegates had improved confidence performing all skills (p \ 0.01), with anaesthetists and ttls more confident in haemorrhage control and performing resuscitative thoracotomy (p \ 0.02). conclusions: mdt trauma training improves team understanding of role and effectively teaches skills. mdt courses with experienced faculty are one way of improving mdt trauma team function. further careful evaluation is required to assess performance of trauma teams in real scenarios. introduction: despite a dramatic rise in youth knife crime, the factors associated with it remain underexplored, especially in the critical pre-college years, which hinders effective counter-knife carrying interventions. the current research is the first to addresses this deficit. materials and methods: 161 british male school students (mean age = 13.48, sd = 1.061) coming from four different schools completed a short 15-min survey. they indicated their standing on a number of dimensions (school-adapted and shortened-scale-based predictors) derived from theories of violence, developmental psychology and related research (i.e. violence acceptance, need for respect, belief in self-defence, belief in a just world, narcissism, psychopathy, impulsivity, sensation seeking, and need for closure). results: for perceived knife harmfulness (i.e., the knife's assumed value in inflicting injury and death)-the total variance explained by the model was 8.7%, r2 = 0.087; f(10, 167) = 2.585. the only statistically significant predictors were: right-wing authoritariamism (b = 0.242, p = 0.005) and need for respect (b = 0.192, p = 0.026). the other factors were not statistically significant. for the perceived value of knife defence (i.e., its assumed defensive worth in violent confrontations) -the total variance explained by the model was 26.5%, r2 = 0.265; f(10, 167) = 7.032, pviolence acceptance (b = 0.208, p = 0.007), followed by need for closure (b = 0.202, p = 0.005), narcissism (b = 0.194, p = 0.011) and psychopathy (b = 0.177, p = 0.034). conclusions: this study provides evidence for future knife-carrying prevention interventions, such as talks in schools or social media videos, to focus more on how to increase self-esteem, stimulate empathy for and better understanding of other people, and approach problems from multiple (rather than just two) perspectives, emphasizing the ultimate superiority of the human intellect over brute force. introduction: the physician's response unit (pru) is a novel service that operates from the royal gwent hospital's emergency department (ed), in newport, south wales. it involves an emergency medicine consultant and a paramedic responding to 999 calls in a rapid response vehicle. their aim is to treat and, hopefully, discharge patients at the scene, reducing ed admissions. the pru can also refer patients on to other departments, e.g. the medical assessment unit, allowing patients to bypass the ed. methods: the author spent six weeks out in the pru and in the ed to observe and speak to patients. to assess whether ed admissions were reduced, the dispositions of patients seen by the pru were recorded on a daily log sheet. the service users' satisfaction with the pru was evaluated using simple questionnaires. this included both patients and paramedics, who can request the pru for support with a patient. results: the pru saw 245 patients during the project's timeframe. 64% (n = 156) of these patients were discharged at scene, while 16% (n = 38) were sent to the ed. 100% (n = 32) of patients asked described the care they received from the pru as equal to or better than care they have received previously. 94% (n = 30) of patients rated their overall satisfaction with the pru as 10/10. conclusions: the pru is very well received by both patients and paramedics and has been shown to reduce the number of patients attending the ed. this system excellently implements the principles of prudent healthcare introduction: in germany reducing alcohol related harms in youth is still a priority, because adolescents and young adults still have the highest accident risk in road traffic. therefore, the p.a.r.t.y.-project aim to increase awareness of alcohol and risk-related issues. the purpose of this study was to analyse the risk behaviour of adolescents before and after a prevention project in two different hospitals in germany. materials and methods: during a one-day prevention project, young people within the age of 13 to 17 years got an overview of the route an accident victim go through from the ambulance until the rehabilitation. before and after the prevention day, a structured written survey was completed by the adolescents. results: 799 students participated in the p.a.r.t.y. program between 2013 and 2018. the gender distribution of the participating students were balanced. the average age of the adolescent was 15 years. according to the program, the risk assessment and risk behaviour improved through the project significantly (\ 0.05). the evaluation of the students' satisfaction was rated as good. the majority of students prefer to repeat the project day after 2 years. conclusions: the prevention program shows that the program increase for short-term the awareness for risk related trauma in youth. nevertheless, long-term studies are necessary to receive data regarding the long-lasting effect. references: the present study is funded by the ministry for energy, infrastructure and digitization of the country mecklenburg-vorpommern, germany. development of a claims-based risk adjustment model for trauma introduction: duodenal injury is rare. the diagnosis requires a high index of suspicion which might result in delayed treatment. there is limited data on the delayed diagnosis group, especially high grade duodenal injuries. the purpose of this study is to determine the characteristics and outcomes of delayed high grade duodenal injuries. materials and methods: charts of all patients from 2008-2018 who had history of small bowel injuries are reviewed. the inclusion criteria were age between 15-80 years old, diagnosis with duodenal injuries at least grade 3 with delayed operation at least 6 h after injuries. baseline characteristics and postoperative outcomes were recorded. results: of the 212 small bowel injuries, 32 (15%) were duodenal injuries. the overall mortality was 6%. delayed diagnosis more than 6 h with at least grade 3 of duodenal injuries were 9 cases. the overall in-hospital mortality rate of the delayed group was 22.2% (2/ 9) who had concomittent hemorrhagic shock and low initial systolic blood pressure. 4 cases (44.4%) were diagnosed within 72 h and had better outcomes without leakage. they could step diet within 14 days and had shorter length of hospital stay (mean = 18 days). 3 patients (33.3%) presented with delayed diagnosis more than 72 h (the maximum was 408 h after injuries). all these 3 patients had anastomosis leakage and need reoperation. they had initial low level of serum albumin (mean 2.5 mg/dl), high white blood cell count, low serum bicarbonate and presented with preoperative acute kidney injury. conclusions: delayed diagnosis and surgical treatment of high grade duodenal injuries lead to poor outcome. low initial blood pressure associated with mortality and delayed treatment more than 72 h had higher morbidity. references: gary sa, frederick am, charles sc, et al. delayed diagnosis of blunt duodenal injury: an avoidable complication. acs meeting. 1998; 187(4) :393-9. routine follow-up imaging has no advantage in the non-operative management of blunt splenic injury in adult patients modality. the aim of this study was to investigate the incidence and time to failure of nom as well as to evaluate the relevance of follow-up imaging. materials and methods: all adult patients with bsi admitted to our level i trauma center, including two associated hospitals, between 01/01/ 2010 and 31/12/2017 were retrospectively analyzed. demographic data, injury severity score, splenic injury grade, modality, results and consequences of follow-up imaging were retrospectively analyzed. results: a total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. 20 patients (16.4%) underwent immediate intervention. 102 patients (83.6%) were treated by nom. failure of nom occurred in 4 patients (3.9%). failure was significantly associated with active bleeding (or 33.75, 95% ci 3.1, 363.2, p = 0.004) , and liver cirrhosis (or 197, 95% ci 7.4, 5265.1, p = 0.001) . 80 patients (78.4%) in the nom-group received followup imaging by ultrasound (us, n = 51) or computed tomography (ct, n = 29). in 57 cases, routine imaging examinations were conducted (43 us and 14 ct scans) without prior clinical deterioration. 55 (96.4%) of these imaging results revealed no new significant findings. every failure of nom was detected following clinical deterioration. conclusions: to our knowledge this study includes the largest monocentric patient cohort undergoing ultrasound as first-line followup imaging modality in the nom setting of bsi in adult patients. the results indicate that a routine follow-up imaging, regardless of the modality, has no therapeutic advantage. indication for radiological follow-up should be based on clinical findings. if indicated, a ct scan should be used as preferred imaging modality. the association between bmi and mortality of renal injuries in adult trauma patients introduction: the role of body mass index (bmi) on solid organ injuries remains debatable. while some studies have shown no association between bmi and hepatic or splenic injuries, others have reported that severe hepatic injuries were more common in pediatric patients with bmi [ 30. the aim of this study is to examine the association of bmi and mortality, as well as any significant differences between operative vs. non-operative management. materials and methods: this was a retrospective study using the 2016 american college of surgeons-trauma quality improvement program database to identify all adult patients (ages 18 to \ 65) with traumatic renal injuries. the primary analysis showed a different pattern of mortality between patients with bmi \ 29 and those with bmi c 29 kg/m 2 . then, the study population was divided into patients with bmi \ 29 and those with bmi c 29 kg/m 2 . multivariable logistic regression was conducted to assess any association of mortality with age, gender, bmi, and injury severity score (iss). results: 3782 adult trauma patients were identified. a greater proportion of males (75.2%) and females (24.8%) had bmi \ 29 kg/m 2 (p = 0.5). the average age of patients with bmi \ 29 kg/m 2 was 32.3 (sd = 12.7) years which was significantly younger than that in patients with bmi c 29 kg/m 2 , 37.8 (sd = 13.6) years (p = 0.001). patients with bmi \ 29 kg/m 2 were found to have a significantly higher mortality rate of 6.5% vs. 4.4% in patients with bmi c 29 kg/m 2 (p = 0.02). however, there was no significant difference in type of operative or nonoperative management between patients with bmi \ 29 vs. bmi c 29 kg/m 2 . after multivariable logistic regression, mortality was associated with age, bmi and iss. no effect modification of sex was observed in the relationship of mortality and bmi. conclusions: adult patients with renal injuries and bmi \ 29 kg/m 2 have significantly higher rates of mortality compared with adult patients with renal injuries and bmi c 29 kg/m 2 . introduction: trauma is an ever-evolving surgical discipline. trauma remains a major source of global mortality. the operative and non-operative options for trauma patients has steadily increased. the development of trauma protocols, advancement in transport to trauma centres and radiological techniques has seen a shift in trauma surgery caseload. observing and understanding this shift from operative management to an increasing non-operative management of trauma cases will better prepare the acute medical team in this setting. materials and methods: prospective trauma registry data was collected and analysed retrospectively. patients presenting to a tertiary referral hospital between jan 2011 to dec 2015 with an injury severity score of [ 15 were reviewed. patients who were transferred to another facility for management were excluded. the demographic data and surgical outcome data were collected and analysed. trend analysis of the operative cases performed for each specialty. results: 2162 major trauma patients presented to the john hunter hospital between january 2011 to dec 2015. there was a non-statistically significant increase in the number of presentations (389 pt in 2011 vs 494 in 2015, p = 0.1625). there was a decreasing rate of operations performed for trauma patients (60% in 2011 vs 43% in 2015, p \ 0.0001). there was an increasing rate of orthopaedic surgery cases and operative time compared to other specialties (178 in 2011 vs 246 in 2015, p \ 0.001). general surgical major trauma operating cases noted a significant decline over the study time (82 in 2011 vs 33 in 2015, p \ 0.001). conclusions: there is a sizeable shift in the caseload of different surgical specialties in regard to major trauma patients over the course of 5 years from 2011 to 2015. orthopaedics has seen a significant increase in operative caseload and surgical time required to adequately manage major trauma presentations. the workload and experience of general surgical teams will likely be affected by these changes. the distribution of resources needs to be reflected in the changing work demands of each surgical subspecialty. traumatic internal hernia with delayed small bowel strangulation after pelvic ring injury hospitalization, follow up abdomen ct checked. there was no other specific change than increased thigh hematoma. eight days after hospitalization, ct was re-examined due to abdominal pain with abdominal distraction. an ct showed peritonitis with pneumoperitoneum and small amount of ascites. small bowel herniation through right pubic bone fracture site with ischemic change also noted. diagnosis: diagnosis was traumatic pelvic hernia with delayed small bowel strangulation. therapy and progressions: an emergency operation was performed. ileal loop was hernitated and perforation was found. emphysematouns change and fluid collection was exsited at perineal area and left high. after small bowel loop segmental resection, wound vac was applied at thigh area. comments: traumatic pelvic hernia is rare. diagnosis is challenging in the acute setting and often delayed due to lack of awareness. when diagnosed, efforts should be made to look for other serious injuries as traumatic pelvic hernia usually associated with concomitant intraabdominal injuries. the optimal management of traumatic hernia should be individualised based on the mechanism and severity of injury, presence of concomitant injuries, size of defect, and presence of incarceration. delayed treatment may read to fatal outcomes. careful inspection of the patient is important. references: vincent k, cheah sd. traumatic abdominal wall hernia-a case of handlebar hernia. med j malaysia. 2018;73(6):425-6. angio-embolization in pediatric trauma patients with blunt splenic injury: a systematicreview t. nijdam 1 , r. spijkerman 1 , l. hesselink 1 , t. hardcastle 2 , l. leenen 1 , f. hietbrink 1 1 umc utrecht, traumasurgery, utrecht, netherlands, 2 inkosi albert luthuli central hospital, trauma, durban, south africa introduction: non-operative management (nom) for children with blunt splenic injury (bsi) is nowadays a commonly used treatment in pediatric trauma departments. in adult trauma departments the addition of splenic angio-embolization (sae) is suggested to decrease the failure rate of nom in high grade splenic injuries. however, the use of sae in pediatric trauma departments is very uncommon and it is unknown if sae is of additional value in pediatric trauma patients. therefore, the aim was to analyze the available literature on sae in pediatric trauma patients with bsi. materials and methods: a literature search was performed to find eligible studies that analyzed sae in pediatric patients with bsi. the primary outcome was failure of treatment in these patients. secondary outcomes were the success rate of sae, length of stay and mortality. the relative risk (rr) was calculated to compare primary outcome between study groups. results: in total 219 studies were identified through the search, a total of 6 studies matched our inclusion criteria and were selected for this review. studies included a total of 12.310 pediatric patients, of whom 539 underwent sae. patient age ranged from &lt;1 year to 18 years, mean age was 12.1 years. both injury severity score and spleen injury grade were higher in the sae group compared to the nom group. failure rate of sae was 8%. no spleen related morality was observed in the sae group. conclusions: the literature suggests that sae might be of added value in a very selective group of pediatric trauma patients with high grade splenic injures. however, since limited evidence is available concerning the use of sae in pediatric trauma patients with bsi, no firm conclusions can be drawn about safety and effectiveness. introduction: the management algorithms for trauma have changed with the development of specialised trauma centres. the aim of this study was to review the management and outcomes of patients with traumatic small bowel (sb) and colonic injuries. material and methods: patients treated for sb and colonic injuries between 2008-2018 at aintree university hospital (liverpool) were identified using the prospective trauma audit and research network database. the management and outcomes of the patients included were analysed. results: 44 patients sustained sb and colonic injuries. there were 29 (65.91%) sb injuries and 21 (47.73%) colonic injuries (6 patients had a sb and colonic injury). 17 patients (38.64%) of injuries were due to knife stabbing wounds, 14 (31.82%) patients were due to gunshot wounds, and 13 (29.55%) patients were due to road traffic accidents/ blunt blows. damage control surgery was performed in 7 (15.91%) patients. colonic injuries included 6 (28.57%) haematomas and 15 (71.43%) perforations. a resection and stoma (rs) procedure was performed in 9 patients (42.86%), primary repair (pr) in 8 patients (38.10%) and resection with anastomosis (ra) in 4 patients (19.05%). sb injuries included 6 (20.69%) haematomas and 23 (79.31%) perforations. pr was performed in 19 (65.52%) cases and ra in 10 (34.48%) cases. the overall complication rate after sb and colonic injury was 50% (22 patients) with a significant complication rate (7 patients, p value = 0.017) for patients undergoing rs in colonic trauma. the 30-day mortality rate was 2.27% (1 patient). conclusions: pr in sb and colonic injuries appears safe. in our dataset, rs appeared to have a higher complication rate. our study highlights that such injuries are uncommon with a high complication rate. surgeons need to provide individualised treatment. introduction: nowadays, patients with high grade bsi are preferably treated using spleen preserving treatments (spt). it is assumed that patients with low grade bsi treated with spt have a good splenic function after recovery. however, there is no consensus on splenic function after high grade bsi. in several institutions, asplenic/hyposplenic infection prevention protocol will be executed in all patients who had spt after high grade bsi, where other institutions evaluate splenic function first. scintigraphy is believed to be the best flow/activity test to approximate splenic functionality. the aim of the study was to analyze whether spleen injury grade is associated with diminished splenic function. secondarily, we aimed to evaluate whether splenic function testing is necessary in pediatric patients after bsi. material and methods: a retrospective study was performed from january 1998 to january 2018. in our institution patients with bsi grade iv of v are assumed hyposplenic and will receive a splenic function test. we included all patients with a minimum follow-up test period of 5 days. all tests were analyzed by the radiology specialist. for each patient we furthermore collected clinical data, including the date of trauma, gender, age, mechanism of injury, ais of splenic injury and iss. results: 33 patients consisted of 23 male and 10 female, with a median (iqr) age of 11.8 (7. 3-13.5) . median iss was 16.0 (13-30.5) and the median spleen ais was 4 (3) (4) . nom was used in 26 patients, sae in five patients and two patients were treated with surgical mesh technique. the median follow-up time of all performed tests was 59 (22-75) days. a total of 20 patients (61%) had a grade iv or v splenic injury. scintigraphy was utilized to test most patients. a total of 32 out of 33 patients had an adequate splenic function, including all sae patients. conclusions: even high grade splenic injuries show adequate splenic function in the follow-up of pediatric trauma patients after bsi. therefore routine diagnostic follow-up by scintigraphy is not necessary in this specific patient group. evaluation of abdominal injuries treated at stavanger university hospital: occurrence, severity and mortality j. w. larsen 1 , k. søreide 1,2 , j. a. søreide 1,2 , k. tjosevik 1 , k. material and methods: retrospective evaluation of data recorded prospectively in the hospital's trauma registry between january 2004 and december 2018. patients with abbreviated injury scale (ais) code for abdominal injury were included. descriptive analyzes are presented for demographic data, injury type, mechanism, and severity, as well as 30-days mortality. results: a total of 449 patients with abdominal injuries were included (6.2% of all trauma patients). 70% where men. median age was 31. the injury mechanism was blunt in 91%. transport accidents were the most frequent cause of injury (57%). median iss was 21, and median niss 25. overall 30-days mortality was 12.5%, with a median trauma injury severity score (triss) of 0,07. multiple abdominal injuries were recorded in 44% of the patients. 86% had associated injuries in other body regions, most frequently in the thoracic region (65.5%). solid organ injury occurred in 83% of the patients, with liver injury (38%), splenic injury (33%), and kidney injury (23%) encountered most frequently. an ais score c 3 was found in 56% of liver injuries, 65% of splenic injuries, and in 43% of patients with kidney injuries. hollow viscus injuries were found in 20% of the patients. injuries to the small intestine (8%) and colon (6%) were most frequent. abdominal vessel injuries were encountered in 15%, and 94% of these had an ais score c 3. conclusions: abdominal injuries are dominated by solid organ injuries following blunt injury mechanism and are often associated with concomitant thoracic injury. patients who dies within 30 days from admission are characterized by a low probability of survival shown by triss. pancreatic trauma management in a third level centre a. gonzález-costa 1 , r. gracia-roman 1 , s. montmany-vioque 2 , a. campos-serra 1 , r. lobato-gil 1 , c. zerpa-martin 1 , f. j. garcía-borobia 3 , p. rebasa-cladera 2 , s. navarro-soto 2 management. the aim of the study is to review the management and describe the most frequent complications of pancreatic trauma in our centre. material and methods: observational study with prospective collection of data, from march 2006 to march 2019. inclusion criteria: trauma patients older than 16 admitted to the emergency department who were admitted to icu or died before admission. demographic data has been collected, also vital signs, iss, mechanism of action, mortality, complications, and lesions. results: between 2006 and 2019, 1798 polytraumatic patients were registered. only 17 had pancreatic trauma (0.95%). the male: female ratio was 11:6; with an average age of 47.7 years (sd 13.4) . mean iss of 24.5 (sd 15.1), mean ais of 2.1 (sd 0.97) and mortality of 23.5% (4 patients). the most frequent pancreatic lesion was at the head of the pancreas (9 patients; 52.9%), followed by body-tail (6 patients; 35.3%) and two patients with full section (11.7%). 64.7% of patients were treated with non-operative management. five patients required urgent surgery (29%), requiring corporocaudal pancreatectomy in 2 cases and drainage in 3 patients. an embolization of a gastroduodenal artery aneurysm was performed in 1 patient. respiratory complications were the most frequent. 4 patients developed a pancreatic fistula (23.5%), although in surgical patients this complication was much higher (60% in our series). one of them required puestow pancreaticojejunostomy and 1 patient developed necrotizing pancreatitis (5.8%). conclusions: pancreatic trauma is very uncommon. its management can be difficult, depending on the degree of injury (aast), with a high rate of complications. therefore, combined management and monitoring by the surgery and intensive care team will be very important. introduction: the aim of this retrospective study was to evaluate and compare the clinical outcomes of conservative versus surgical treatment in a series of patients with liver injury. material and methods: between 2005-2017, there were included 128 patients. according the treatment chosen, the patients were subdivided in two groups. non-operative management was considered in hemodynamically stable patients. the failure of conservative treatment was defined as need to resort to operative management after a period of strict monitoring when the reason was related to the liver or associated injuries or need for late angioembolization. all hemodynamically unstable patients were subjected surgical treatment. results: conservative treatment was selected for 101 patients and only in 8 of them was failed due to associated delayed bleeding and small bowel injury. 27 patients underwent emergent surgery which included packing, lobectomy and splenectomy. operative findings revealed grade iii liver injuries in 71% and grade iv in 28%. pneumonia, sepsis and ards were the most frequently associated complications. the overall mortality rate was 8.6%. in 19 patients of conservative group, non-surgical treatment failed with surgery being required. the mortality in the group of patients who underwent emergent laparotomy on admission was of 6 patients. conclusions: conservative treatment of blunt traumatic hepatic injuries is applicable in patients presenting hemodynamic stability with mild hepatic injuries and it could be successful even in high graded injuries with low morbidity and mortality. surgical treatment is indicated in grade v injuries. nevertheless, failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality. with the trend towards more conservative management strategies, surgeons' exposure to laparotomies for blunt injuries in rtas has decreased. the aim of this study was to examine surgeons' exposure to laparotomies following blunt trauma which remains important to maintain low patient morbidity and mortality rates. material and methods: data was collected for adult patients admitted to mater dei hospital (malta) following rtas with ctproven intrabdominal injuries between january 2008 and january 2018. results: 114 patients (74 (64.91%) males vs. 40 (35.09%) female (p value \ 0.05), mean age = 36.66 years) were included in the study. 88 patients (77.19%) were car occupants whilst 26 patients (22.81%) were pedestrians. 94 (82.46%) patients had single intraabdominal organ injury, whilst 20 (17.54%) had multiple intraabdominal organ injuries. the 30-day mortality rate was 11.40% (13 patients). liver injuries occurred in 57 (42.54%) patients, splenic injuries occurred in 50 (37.31%) patients, kidney injuries in 18 (13.41%) patients and other organs were injured in 9 (6.72%) patients. conservative management was followed in 81 (71.05%) patients, angioembolisation was utilised in 12 (10.53%) patients and operative management was performed in 19 (16.67%) patients during the 10-year period. this resulted in 2 trauma laparotomies following rtas per year. conclusions: only a minority of patients require operative management after rtas. surgeons in small countries have limited exposure to complex rta's. in view of the low exposure to emergency laparotomies following rtas, changes to our local training programme was done. trauma courses, lectures and fellowships in eu have been implemented to maintain surgical skills to an optimal level. references: european commission, annual accident report. european commission, directorate general for transport june 2017. case history: a 61 year old female presented to the accident and emergency department 10 h post colonoscopy with complaints of left sided abdominal pain. this colonoscopy was requested under a 2-week wait for a history of chronic diarrhoea. this was a complete and uneventful examination ath the time, with random colonic and ileal biopsies taken. she attended a ? e with left sided abdominal pain increasing in severity. clinical findings: she was found to have an exquisitely tender abdomen, experienced more in the left upper quadrant. she was clinically shocked with a marked hypotension and tachycardia. investigation/results: a ct of her abdomen and pelvis showed free fluid within the abdomen and pelvis, with active bleeding and large haematoma adjacent to the spleen. the grade of splenic injury however was not commented upon by the reporting radiologist. interventional radiological embolism was considered but unfeasible as patient not stable haemodynamically. diagnosis: she was diagnosed with a splenic injury post-colonoscopy, with internal bleeding and haemodynamic instability. therapy and progressions: she underwent an emergency splenectomy overnight and was transferred to the intensive care unit for postoperative care. she recovered well, was stepped down to ward level care and was discharged with post splenectomy protocols, including all necessary vaccinations. comments: splenic rupture post-colonoscopy is a very rare event, with less than 115 cases reported worldwide since 1974. however, it still should be considered as a cause of a ? e presentation in patients with upper abdominal pain and haemodynamic instability after recent colonoscopy. we wanted to present this rare case to the international audience of estes congress to raise awareness of this rare complication. clinical findings: hemorrhagic shock and consciousness disorder were observed. her abdomen was distended, and she was intubated in the emergency room. investigation/results: ct revealed massive intra-abdominal bleeding. diagnosis: massive intra-abdominal bleeding due to hepatic laceration. therapy and progression: damage control surgery (dcs) and transcatheter arterial embolization (tae) were performed. she was transported to a hybrid operating room. she experienced cardiac arrest before operation. cardiopulmonary resuscitation was immediately initiated, resulting in the return of spontaneous circulation. laparotomy with perihepatic packing (php) was performed, but she experienced two more episodes of cardiac arrest during operation. then, tae was performed for right hepatic artery extravasation. after physiological function restoration, including rewarming, coagulopathy correction and hemodynamic stabilization in the intensive care unit. she gradually became hemodynamically stable. however, incomplete hemostasis was obtained at second-look laparotomy 18 h later. because of bleeding, we repeated php. we performed cholecystectomy and abdominal closure after confirming complete hemostasis (46 h post-accident). she was discharged ambulatory without neurological deficit (day 82). comments: prognosis of traumatic cardiac arrest is generally poor, and survival without considerable neurological deficit is very rare. we reported a surviving patient with severe hepatic laceration. sharing of strategies and tactics, such as blood transfusion, tae, trauma team approach to surgery, early decision of dcs improves outcome of patients with severe abdominal trauma. references: resuscitation. 2010;10:1400-33. introduction: the spleen is the most commonly injured organ after blunt trauma. non operative treatment (nom) of splenic injuries has gained wide acceptance. transcatheter embolization of the splenic artery is considered a useful adjunct in aast lesions c 3 without active bleeding. we report a retrospective review of all patients admitted to a level 1 trauma center with blunt splenic injury from 2012 to 2019 and compare their treatment and outcome with a previous series from 2007 to 2011, when angioembolization was performed only in case of contrast blush at ct scan. patients and results: from 2012 to june 2019, 59 patients with blunt splenic injuries were admitted to the ed of a level 1 university hospital in milan, italy. men to female ratio was 5:1,the mean age 44.9 ± 20 years (range 16-90), and the iss 22 ± 11.5(range 2-57). eight patients (13.6%) underwent emergent splenectomy due to hemodynamic instability. of the 51 stable patients treated with nom, those with aast lesions c 3 (n = 25) were submitted also to angiography and 23 to embolization of the spleen (45%), either proximally (12) or distally (11). two nom failed, and the patients were submitted to splenectomy or distal embolization. the median hospital stay was 13.1 ± 11.5 days. the total spleen salvage rate was 96%. no associated abdominal injuries were missed in the nom group. in the previous series of 31 patients (mean age 34.7 ± 15.4 years, range 17-88, #:$ = 7:1, iss 18 ± 7, range 4-38), 4 underwent emergency splenectomy (13%), and 27 (87%) were treated conservatively, with only 7 embolization (25,9%) in case of aast c 3 at ct scan. failure of nom were 2, and the spleen salvage rate 80.6%. liver injury following multiple cardiopulmonary resuscitations case history: this is a case of a 44 year old woman who presented to the emergency department (ed) due to worsening dyspnea complicated by two lengthy cardiac arrests. after the first resuscitation and return to spontaneous circulation (rosc), echocardiography was done and showed severely dilated right ventricle with strain, suggestive of massive pulmonary embolism, for which rtpa was given. arrest occurred again, and post rosc, heparin was started and the patient was transferred to the icu. extracorporeal membrane oxygenation (ecmo) was initiated but complicated by severe hemodynamic instability and a third cardiac arrest, so cardiopulmonary resuscitation (cpr) was performed till rosc and massive transfusion protocol was started for suspected intraperitoneal bleeding. clinical findings: after ecmo cannulation, abdominal distention was noted with a severe drop in hemoglobin and an increased intraabdominal pressure (25 mmhg). abdominal bedside ultrasound showed significant amount of dense free fluid. the decision for an urgent exploratory laparotomy was made and the patient was taken to the operating room. therapy and progressions: deep liver laceration over the right hepatic dome with rupture of the capsule and an estimated hemoperitoneum of 3 l were found intra-op. controlling the bleeding was difficult due to the laceration site and the patients coagulopathic status, so packing was done and the patient was transferred to icu for correction of the coagulopathy and re-evaluation in 48 h. the liver was unpacked after 48 h, bleeding sites were cauterized and sutured and the liver was wrapped with a mesh with an attempt for a tamponade effect. the patient's stay in icu was complicated with kidney injury requiring chronic dialysis but otherwise recovered well. comments: liver injury is a rare but serious complication after cpr that should be considered in case of persistent hemodynamic instability along with bedside findings. this case is intriguing due to the right sided liver injury with no overlying rib fractures. blunt renal trauma after electrical injury: a series of curious events. a. nixon 1 , e. falidas 1 , d. davris 1 , a. botou 1 , g. sofos 1 1 chalkida general hospital, department of surgery, chalkida, greece case history: a 25 yr old patient was referred to the emergency department (ed) of our hospital from a primary health center after sustaining an electrical injury (220 v ac). the patient experienced loss of consciousness (loc) and promptly fell to the ground in a supine position. the patient arrived approximately 3 h after the incident. clinical findings: vital signs: bp: 90/45 mmhg, hr: 110 bpm. the patient's major complaint was left flank and abdominal pain. no obvious thermal injuries were observed or any other signs of external trauma. a left abdominal mass developed which was evident on physical examination. in addition, examination of urine revealed gross hematuria. investigation/results: ekg monitoring documented sinus tachycardia without evidence of cardiac arrhythmias. fast indicated the presence of a massive retroperitoneal hematoma. the fast exam indicated the left kidney as the probable source of hemorrhage. the initial hematocrit (hct) from the primary health facility was 44% while results from the ed recorded a hct of 22%. diagnosis: grade v renal trauma. therapy and progressions: a massive transfusion protocol was initiated. the patient underwent an emergency laparotomy and a left nephrectomy was performed. subsequent imaging did not reveal other injures. comments: the history of electrical injury could have misdirected investigation efforts towards cardiogenic shock. this case suggests that even in the absence of a high energy impact, sustained hemodynamic instability should always be attributed to hemorrhagic shock until disproven. in addition, the management of grade v renal trauma in blunt injury remains a controversial topic, however we believe that in cases of class iv shock, surgical management is imperative. case history: 56 y.o. female with a history of chagas' disease of 30 years duration and esophageal involvement in the last few months. she's admitted for a first endoscopic balloon dilatation due to dysphagia, which is performed according to protocol, and a tear of the mucosa layer is observed during it. clinical findings: she's stable for the first 36 h but with continuous thoracic pain of moderate intensity according to the gi specialist. on the second day there's a general worsening of the patient's condition, with dyspnea, fever, desaturation and tachycardia. results and diagnosis: she develops leukopenia and elevations of acute phase reactants, and a ct scan reports a distal esophageal perforation with free extravasation of contrast in the mediastinum and bilateral pleural effusions. therapy and progressions: emergency surgery is performed through a midline supraumbilical laparotomy which shows peritonitis around the epigastric area. after opening the hiatus, a very long transmural esophageal tear with devitalized tissues and severe contamination are observed. a trans-hiatal esophagectomy was decided and, given the hemodynamic stability, a gastroplasty is performed and brought up to the neck without anastomosis, along with a terminal cervical esophagostomy and feeding jejunostomy. the patient did well in the postop period. we were able to do the esophagogastric anastomosis in the neck 14 days later, during the same admission. comments: the surgical technique in esophageal perforation depends mainly on the time elapsed since the perforation, and on the condition of the patient. esophagectomy is sometimes unavoidable, and a gastroplasty can be brought up to the neck at the same time in selected cases, with reconstruction of the upper gi tract during the same admission. introduction: the spleen is one of the most frequently injured abdominal organ. the anatomy of the lesion defines the degree according to aast, ranging from grade i to v in increasing complexity. the diagnosis of splenic trauma may be difficult, as 40% of patients may show no signs or symptoms at primary survey. the approach involves two main strategies: conservative or surgical. the strategy should take into account four aspects: hemodynamic status, anatomy of the lesion, associated injuries and organizational structures of the evaluation site. this study aims to evaluate the type of approach performed on different degrees of splenic trauma during 7 years in a portuguese trauma center. material and methods: we conducted a retrospective study including all patients diagnosed with splenic trauma during a period of seven years. by consulting the patient's clinical files we evaluated and compared: demographic data, trauma kinetics, degree of splenic injury and the approach taken as well as morbidity and mortality. results: of the 119 patients studied, most were male with blunt trauma. in 58 patients the inicial approach was surgery and in 61 the option was conservative treatment. in grade iii or iv lesions conservative treatment failed in 16% of patients. patients in whom the surgical approach was first chosen had predominantly grade iv lesions, with total splenectomy being the preferred approach. in grade iii lesions, the option was mainly conservative surgery of the spleen. conclusions: the initial approach of splenic trauma results essentially of the experience of emergency teams and support structures for surveillance and intervention (intervention radiology and 24-h operating room availability). the attempt to try conservative strategy is increasing over time. introduction: for decades, helicopter emergency medical services (hems) contribute greatly to prehospital trauma patient's care by performing advanced medical interventions on scene. unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable. these cancellations contribute to overtriage and provide additional costs to society. an earlier study showed a cancellation rate of 44% in our trauma region. however, little empirical knowledge exists about reasons for cancellations for different mechanisms of injury (moi) and type of dispatch. this study aims to examine the current cancellation rate in our trauma region over a 6-year period. additionally, insights in cancellation reasons for different moi and type of dispatch are evaluated. methods: a retrospective study was performed, using data derived from the hems database of trauma region north west netherlands, between april 1st 2013 and april 1st 2019. information regarding patient's characteristics, date and time of day, moi, type of dispatch, and cancellation reason were compared. results: in total, 18,639 patients were included. hems was cancelled in 54.5% of dispatches. the majority of dispatches (76.1%) were cancelled because the patient was physiologic-and neurologically stable. dispatches simultaneously activated with ems were cancelled 58.3% of times, compared to 15.1% when hems assistance was additionally requested by ems on scene. no differences were found between dayand night-time dispatches. trauma related dispatches were cancelled more frequently compared to non-trauma related dispatches. conclusions: this study found a considerable-and increased cancellation rate compared to previous research. an explanation for this finding could be better adherence to dispatch protocols. furthermore, a great variety in cancellation rates was found among different moi's. therefore, continuous critical evaluation of hems triage is important and dispatch criteria should be adjusted if necessary. case history: two separate cases of high speed road traffic collision. the first is 31 years old female without significant past medical history. the second is 28 years old male who had short extremitis due to history of spastic quadriplegic cerebral palsy alongside congenital kyphosis and postural scoliosis. clinical findings: on examination the first patient was hemodynamically stable with soft abdomen and bruising over the left pelvic area. the second patient had left side neck and right side chest bruises; furthermore, he was tachycardic with normal blood pressure, but he was generally pale, getting clammy and significantly sweaty. investigation/results: fast scan for both patients showed free fluid in the abdomen and ct scan was uncertain of the source in the first patient. in the second, a large mesenteric haematoma was evident on ct with contrast extravasation with corresponding significant drop in hemoglobin and raised lactate levels. diagnosis: case 1: hemodynamically stable blunt abdominal trauma. case 2: hemodynamically unstable blunt abdominal trauma. therapy and progressions: the first patient was managed conservatively initially but worsened overnight with a drop in haemoglobin and increase in lactate mandating emergency laparotomy. hemoperitoneum and 60 cm of ischaemic bowel with tear in the mesentery was found. she had an uneventful recovery after resection and primary anastomosis. the second patient underwent immediate emergency laparotomy. there was evidence of hemoperitoneum (3 l) and similar mesenteric tear with ischemia involving 50 cm of the terminal ileum. resection with end to end anastomosis was done. patient was then transferred to itu; however, he developed chest infection which prolonged hospital stay. comments: hemodynamic instability is a major factor in mandating urgent exploratory laparotomy in bat and bucket-handle injury is not uncommon following road traffic accidents. introduction: incisional hernias are one of the most common complications post-abdominal surgery, affecting between 10-25% of patients undergoing a laparotomy. a number of risk factors are associated with their development such as age, bmi, type of surgery and co-morbidities. these risk factors also affect their levels of recurrence which is why the technique undertaken to repair these is of such interest. the primary purpose of this meta-analysis was to examine which repair technique is associated with the lowest level of recurrence whilst a secondary aim was to examine whether the frequency of common complications was dependent on the type of repair utilised. material and methods: this systematic review and meta-analysis was conducted by both co-authors. the following information sources were utilised; cochrane/embase/google scholar/pubmed/scopus. in relation to the eligibility criteria-papers that were published from 1990 onwards and in the english language were included with any length of follow-up. study selection was as per the inclusion/exclusion criteria below and only cohort studies/rcts/systematic reviews/ meta-analyses and case control studies were included. inclusion criteria: abdominal incisional hernias, all types of repairmesh/open/laparoscopic/sutured repair/primary repair etc. in terms of the exclusion criteria-any hernia repair that was not incisional was excluded. results and conclusions: in terms of the primary question posed by this repair, meta-analysis shows that there is a significant difference between open vs laparoscopic technique and recurrence rates in relation to the primary question posed by this paper whilst the use of mesh impacts negatively on post-operative wound infection rates. this invites an interesting debate on the merits of each technique whilst demonstrating the need for a multicentre randomised controlled trial. laparoscopic approach in penetrating abdominal trauma: case study and review of the literature b. vieira 1 , v. taranu 1 , a. silva 1 , d. galvão 1 , a. soares 1 1 hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal introduction: laparoscopy(ls) has greatly improved surgical outcomes in many elective abdominal procedures. the use of ls in acute care is becoming widely accepted. however, a number of safety issues have limited its application in abdominal trauma. notwithstanding with the reports and studies of the past decade proving its safety and accuracy, ls is slowly replacing the need for exploratory laparotomies. case report: a 34 yo male sustained with penetrating stab wound on the left flank. he was hemodynamically stable. ct confirmed intraperitoneal positioning of the knife, without free fluid or air nor any evidence of organ injury. an exploratory ls was performed and confirmed the intraperitoneal positioning of the knife. abdominal exploration revealed a jejunal transfixating lesion about 1 m from treiz's angle that was manually closed. the patient maintained a favorable po evolution and was discharged on the 4thpo day. discussion/conclusion: a number of concerns have limited the use of ls in abdominal penetrating trauma. initially, it resulted in high rates of missed injury, mainly of the small bowel, generating considerable criticism. the development of systematic abdominal explorations in ls, as described by choi and kawahara, resulted in a rate of missed injuries close to zero. moreover, direct visualization using ls has shown superior specificity and sensitivity in identifying peritoneal penetration, hollow viscus injuries and diaphragmatic lesions when compared to ct. in the case reported here, ct didn't show any image suspected of perfuration such as free air or fluid, and yet ls showed a small bowell injury. besides its advantages as a diagnostic tool avoiding negative laparotomies in more than 50% of the cases, thanks to evolving techniques and improved practice, it may also be therapeutic and allow safe definitive treatment for many types of injuries as described here. method: this is a monocentric retrospective study from a database entered prospectively. all patients admitted to the university hospital in nice with splenic trauma between 01/01/2006 and 01/06/2018 were included. the primary endpoint was performing splenectomy as a failure of a nom. results: 290 patients were included in our study. the majority of splenic lesions were severe grades, that is to say greater than 3. in total, 83 splenectomies were performed urgently, i.e. 29% of patients; 88 angio-embolizations were performed, i.e. 31% of patients with a success rate greater than 80%; 14.7% of 136 patients who had not anterior angio-embolization required secondary splenectomy; 19.7% of the 61 patients who had anterior angio-embolization required secondary splenectomy. in the patient group with successful angio-embolization, the mean age was 44 years vs 37.5 years in the nom failure group (p = 0.15). a decrease in hemoglobin between admission and 6 h after admission was found in the nom failure group compared with the successful embolization group (p = 0.064). conclusion: hemoglobin monitoring in the hours following admission of a patient with splenic trauma may be an important factor in the surveillance of hemodynamically stable patients. prospective studies could confirm these results. missed ureteric injuries in gunshot injuries of the abdomen: how to avoid? introduction: traumatic ureteral injuries are uncommon. penetrating rather than blunt trauma is the most common cause of ureteral injuries. the aim of this study is to make a strategy to avoid missing ureteric injuries in gunshot injuries of the abdomen. material and methods: 765 patients were operated in our hospital in 3 years period. all patients were managed according to atls guidelines. for stable patients, full radiological work up was done, while hemodynamically unstable patients were shifted to or immediately for laparotomy and exploration. all patients demographic and clinical data were recorded these include :patient age, sex, mechanism of injury, hemodynamic state on arrival to the rr, anatomical site of gunshot injury, associated injuries, ureteric injuries detected early or late, early repair, delayed presentation and morbidly associated with delayed discovery. results: ureteric injuries were found in 12 patients out of 765 patients who underwent laparotomy for gunshot injuries had ureteric injury in an incidence of 1.5%. ureteric injuries were missed in the first laparotomy in 3 patients. associated injuries of other abdominal viscera include; colon injuries affecting ascending and descending colon in all the patients. conclusions: ct and pyelogram are the modalities of choice in stable patient but in unstable patients the early recognition of ureteric injuries depends on high index of suspicion leading to surgical exploration of the ureter along its course. case history: we present a case of a 72 year old man, who was injured by his agricultural machine in the abdomen. clinical findings: he was transferred in the emergency department and he was hemodynamically stable. he had several traumas in his abdominal wall. from the largest one, in the left iliac fossa, omentum, transverse colon and loops of the small intestine were protruded out of the abdominal wall. the small bowel was ischemic and ruptured. investigation/results: computed tomography investigation, revealed small amounts of liquid and air in the abdominal cavity. diagnosis: the patient was immediately operated. the destroyed loop of the small bowel was resected with the use of a stapler and the field was washout. then with a midline incision the abdomen was opened. there were no other injuries inside the abdomen cavity. there was an extensive injury with a creation of a large gap in the anterolateral abdominal wall. it was impossible to identify the left rectus abdominis muscle as also the lateral muscles (external and internal oblique and transversus abdominis). therapy and progressions: a side to side entero-enteric anastomosis was created and a meticulous observation and washout of the abdomen were performed. for the closure of the abdominal wall a double-sided mesh from polypropylene coated with silicone on one side (20 9 25 cm) was placed and the operation was completed. all the other wounds of the abdominal wall were closed with loop nylon stitches no 1. a closed suction drain was placed above the mesh. the patient had a very good postoperative course. he was dismissed from the hospital after 15 days in a very good condition. comments: the usage of mesh was very useful for the reconstruction of the abdominal wall. there is no conflict of interest. strategy shift from damage control surgery to primary radical surgery improve the outcome of blunt hepatic injury involving inferior vena cava introduction: the diagnosis of abdominal trauma is a real challenge even for surgeons experienced in trauma. clinical findings are usually unreliable, and abdominal examination is made up of various factors. diagnostic tools that help the attending physician make critical decisions, such as the need for laparotomy or conservative treatment, are mandatory if we propose a favorable outcome. material and methods: the study was performed in the clinic i surgery, the county clinical emergency hospital craiova, between 2014-2018 and analyzed a number of 70 abdominal traumas hospitalized, investigated and treated in the clinic. the methods of paraclinical diagnosis are evaluated comparatively, the study analyzing the evolution and the tendencies during the studied period, from 2014, to 2018. results: the study allowed an evaluation of the diagnosis and treatment methods compared to the data in the literature. conclusions: thus ct scan remains the standard criterion for detecting solid organic lesions. in addition, a ct scan of the abdomen may reveal other associated lesions. fast ultrasound is an important and valuable alternative for diagnosing abdominal trauma, especially for patients who are hemodynamically unstable and cannot be mobilized. there is a tendency in the treatment of abdominal trauma, as evidenced by the literature data on the use of conservative versus surgical treatment for a larger number of cases introduction: antiplatelet agents and anticoagulant drugs are widely used in prevention of cardiovascular incidents, which poses a challenge in surgical emergencies. the drafting of a multidisciplinary protocol for the treatment of pharmacological induced coagulopathy in patients who require urgent surgery standardizes management and increases patients' perioperative safety. material and methods: aims of the study were to describe the results from the protocol implementation. a retrospective study was conducted by examining reports of every patient presenting pharmacological induced coagulopathy and undergoing emergent surgery, recorded in our center from 2012 to 2017 inclusive. different algorithms used were explained and data such as need of transfusion, reintervention rate and perioperative complications were analyzed. results: data from 169 patients were analyzed, median age of 79, 100 (59%) men. 107 patients (63%) used anticoagulant drugs. fresh frozen plasma transfusion and/or prothrombin complex concentrates were used according to the guideline. 73 (43%) patients used antiplatelet agents. 77% of them underwent a delayed 48 h surgery directly. tirofiban therapy was established in 7 patients on dual therapy due to medium-high risk of cardiovascular event. regarding surgical approach, 59 (35%) were laparoscopic, 96 (57%) open and conversion occurred in 14 (8%) cases, but only 1 of them due to intraoperative hemorrhagic complication. only 2 cases of postoperative hemorrhagic complications led up to reintervention and only one isolated case of thrombotic complication was reported. finally, 7 (4%) mortality cases were reported, but none was caused by hemorrhagic nor thrombotic complications. conclusions: establishment of a guideline on management of pharmacological induced coagulopathy in emergent surgery is crucial in all surgical emergency units and has proven to be effective and safe. introduction: digestive haemorrhage is a frequent pathology. most of the episodes are self-limited, but in some cases massive haemorrhage occurs, leading to a 10% mortality rate. severe problems occurs when endoscopic treatment is not effective, requiring emergent surgery with poor prognosis. the aim of this study is to evaluate the implementation of interventional radiology techniques on short-term results. methods: a retrospective descriptive study was performed reviewing patients who underwent radiological embolization after failure of endoscopic conventional treatment between 2015-2019 in our hospital. a total of 41 patients were included. results: 22 patients were male. 24 cases were from lower gi track and 17 were from the upper gi with a similar death rate between them, with a higher rebleeding rate in upper gi (35.2% vs 12.5%). 29% of the arteriographies did not show any bleeding site, 4 of them developed a new bleeding episode. overall patients who undergo embolization, urgent surgery was avoided in 8 of the 11 patients diagnosed as upper gi haemorrhage and in 15 of the 19 patients diagnosed as lower gi haemorrhage. 5 patients died, those death occurred later on the recovery of the acute bleeding episode and embolization, all of them related to patients comorbidities. conclusions: arterial embolization has become an important tool in order to treat massive haemorrhages of the gastrointestinal tract. it seems to decrease the mortality and morbidity rate, but some complications can be associated such as rebleeding or bowel ischaemia. massive transfusion protocol with early administration of platelet and fresh-frozen plasma along with packed red cells in the initial phase of resuscitation is associated with improved outcomes introduction: massive transfusion (mt) in a ratio of 1:1:1 (prbc:platelet:ffp) is the standard of care in hemorrhaging trauma patients. the aim of our study was to compare the outcomes of patients who receive near balanced resuscitation (nbr) compared to unbalanced resuscitation (ubr) during the initial phase of resuscitation. material and methods: we performed a 4-year analysis of the acs-tqip. all adult patients (age [ 18) who received mt (defined as transfusion of prbc c 10 units in 24-h) were included. patients were stratified into two groups: nbr defined as prbc:platelets:ffp in 1: [ 0.5: [ 0.5 and ubr (1: \ 0.5: \ 0.5) in the first 4 h of resuscitation. primary outcome measure was mortality. secondary outcome measures were complications, and hospital length of stay. propensity matching was performed to match the two groups. results: a total of 10,321 patients received mt. mean age was 40 ± 12 years, median iss was 29 [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] . overall 24 h mortality was 27.9%. only 36% patients received nbr while 74% received ubr in the first 4-h. using propensity score matching, patients were matched for demographics, ed vitals, iss, ais and injury parameters. patients who received nbr in the early resuscitation phase had lower mortality (23% vs. 31%, p = 0.01), lower overall complications (38% vs. 55%, p = 0.01), with no difference in hospital length of stay (17 days vs. 16 days, p = 0.53) compared to the ubr group. conclusions: only one-third of patient receiving massive transfusion receive prbc, ffp and platelet in a ratio closer to 1:1:1 in the initial 4-h and they have lower mortality and complications compared to patients with unbalanced resuscitation. material and methods: the goal is to assess mtp strategies in level-1 trauma centres in the netherlands and compare these with each other and (inter) national guidelines. a trauma surgeon or anaesthesiologist involved in compiling the mtp in each level-1 trauma centre in the netherlands and dutch ministry of defence was approached to share their mtp and comment on their protocol in a survey or oral follow-up interview. results: all eleven level-1 trauma centres responded. content of the packages and transfusion ratio (red blood cells/plasma/platelets) was 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. tranexamic acid was used in all centres and an additional dose was administered in eight centres. fibrinogen was given directly (n = 4), with persistent bleeding (n = 3), based on clauss fibrinogen (n = 3) or rotem ò (n = 1). standard coagulation monitoring are used in all centres, but most hospitals use also rotational thromboelastometry (rotem ò ) (n = 6), thromboelastography (teg ò ) (n = 1) or both (n = 1). all centres used additional medication for patients using anticoagulants, but its use was ambiguous. conclusions: mtps in dutch level 1 trauma centres differs from (inter) national guidelines in transfusion ratio and additional medication, which could be explained by misinterpretation of the 1:1:1 ratio, changes in components and following an outdated dutch national guideline. whether these differences in mtps actually leads to different patient outcomes will follow from data that is currently being collected. this study is sponsored by the dutch ministry of defence. anastomotic bleeding after colorectal surgery: incidence, management and complications introduction: postoperative anastomotic bleeding (pab) is a frequent minor complication (1-9%) that usually resolves by a conservative approach. hemodynamic instability and anemization may develop requiring urgent management. the aim of our study is to describe pab and its treatment. material and methods: observational retrospective cohort study of patients with pab collected between july 2014 and september 2019. pab was defined as an episode of lower gi bleeding after colorectal surgery with at least one anastomosis. characteristics of patients, surgery, length of hospital stay, morbidity and mortality, and management of pab were reviewed. results: a total of 38 (5.5%) patients with pab was collected. median age was of 75 years (iqr 64-80), with a median estimated asa grade of 3. the most common procedure was a right hemicolectomy (50%), followed by sigmoidectomy (24%). 95% of surgeries were laparoscopic. only 2 cases were converted to an open approach. 37% of patients had the first episode of pab during the first 24 h after surgery, while 32% after the third postoperative day. pab was treated conservatively in 84% of the cases. the remaining 16% required urgent endoscopic management identifying the bleeding through the anastomosis line, using clips in 5 patients and hemospray in 1 patient to control it. no complications were recorded after endoscopic treatment. just 1 case required surgical reintervention. a total of 12 (32%) patients required blood transfusion with a median of 2 (iqr 2-3.75) units. length of hospital stay was 6.5 days. no mortality related to pab was registered. conclusions: pab is a mild complication after colorectal surgery. most of the patients respond to conservative management. urgent endoscopic treatment seems to be effective and safe to control pab even during the first postoperative day. introduction: hemorrhagic shock and associated reperfusion injuries are davastating situations during the treatment of polytrauma patients. the aim of this study was to analyze and compare alterations of the local circulatory changes of various body regions during hemorrhagic shock and after fluid resuscitation. material and methods: this study was conducted on male pigs. they suffered a standardized polytrauma including femoral fracture, blunt thoracic trauma and liver laceration. further, the suffered a hemorrhagic shock for 1 h (aimed map 25 mmhg). fluid resuscitation with three times drawn blood volume after hemorrhagic shock. retrograde nailing for femoral fracture and chest tube in case of pneumothorax liver packing. measuring circulation at liver, colon, stomach, and extremity. results: inclusion of 27 animals. local circulation at the extremity decreased significantly compared to baseline values during hemorrhagic shock (82.3 a.u. versus 31.7 a.u., p \ 0.001). after resuscitation the flow rate at the extremity was comparable to baseline values. the stomach was least sensitive to hemorrhagic shock, whereas the oxygen delivery rate at the colon decreased during shock phase and remained decreased during fluid resuscitation (p \ 0.001). conclusions: different body regions react differently to hemorrhagic shock. the colon appears to be most vulnerable to changes based on hemorrhage. the delayed improvement of circulation in liver, colon, and extremities may represent a trigger for systemic hyperinflammation and subsequent sirs and sepsis. none of the authors have any conflicts of interest to declare. massive transfusion in penetrating trauma: the search for a specific prediction system introduction: prediction systems of massive transfusion (mt) were developed from cohorts with a small proportion of penetrating trauma. some of them required laboratory tests. we aimed to evaluate abc score and to identify independent predictors of mt in a cohort of torso penetrating trauma (tpt) material and methods: adults with tpt, managed in a level-i trauma center, who received one or more packed red blood cells (prbc), were included. variables obtained during the evaluation in the trauma bay were registered prospectively. the ability to predict mt was evaluated with simple, multiple logistic regressions and roc curves. results: we included 162 patients; 88.9% were male, and 84.6% received fire-arm wounds. twenty-one (13%) received mt. mt patients were intubated more frequently in the pre-hospital, had lower sbp, higher hr, lower gcs, and received more frequently vasopressors (p \ 0.05) when compared with the no-mt patients. trauma mechanism, number or localization of the wounds, and positive fast could not discriminate mt (p [ 0.05). hypotension, tachycardia, and alteration of the glasgow coma scale or its motor response behaved as independent predictors of mt. models created with these variables showed better discriminative ability than abc score, with adequate goodness to fit. conclusions: prediction models of mt, based on heart rate, systolic blood pressure, and neurologic alteration outperformed abc score in a tpt cohort. introduction: rectus sheath hematoma presents with abdominal pain and anterior abdominal wall mass. it can be followed conservatively and rarely causes mortality (1) . in this study we aimed to review rectus sheath hematoma cases consulted to our department and to present our management. material and methods: the data of 35 patients admitted with rectus sheath hematoma between 2009 and 2018 was collected using hospital database. treatment modalities, demographic data and complications were reviewed retrospectively. results: all the cases presented with abdominal pain and/or with a palpable abdominal mass. 82.8% of the patients (n = 29) were receiving anticoagulant therapy at the time of admission. the mean inr value was 2.34. 28 patients were followed up with es&ffp transfusion and conservative treatment. 3 patients not eligible for conservative care underwent inferior epigastric artery embolization and hematomas in 2 patients were evacuated via a percutaneous drainage catheter. 1 patient went through laparotomy for an infected hematoma and one patient underwent laparotomy plus packing. the patient who had laparotomy plus packing died due to intraabdominal hematoma and sepsis. conclusions: rectus sheath heamatoma is a rare cause of acute abdominal pain. the patients diagnosed early and have suitable indications can be treated conservatively (2) . rectus sheath hematoma should be considered in the differential when a patient with a history of anticoagulant drug use presents with acute abdominal pain in order to prevent unnecessary surgery and complications. introduction: an early delivery of blood products when massive transfusion protocols (mtp) are triggered is mandatory to improve trauma patients survival. scores predicting massive transfusion (mt) have already been described (1) . the aim of our study is to compare scores for predicting mt and identify the best trigger for mtp. material and methods: multicentric retrospective study from the trauma registry of the spanish surgeons' association. severe trauma patients (injury severity score [iss] c 15), admitted to 18 different level 1 trauma centers, from january 2017 to september 2019 were included. demographic and clinical information was recorded, and predictive scores for mt were assessed. results: 1113 patients were included. medium age was 47.1 ± 19.6 years, 861 (77.4%) were male. median iss was 22 (iqr 13). in 4% of the patients a mt (defined as c 10 units of packed rbc) was necessary, while a mtp was triggered in 13.6%. surgery was performed in 55.8%. the overall mortality was of 9.9%. predictive scores for mt were compared: gap (glasgow coma scale, age, systolic blood pressure), shock index (si), assessment of blood consumption (abc) and mabc (modified abc). auroc for gap was 0.735 ± 0.037, si 0.907 ± 0.016, abc 0.881 ± 0.034 and mabc 0.882 ± 0.036, showing differences between gap (the worst score) and the others, p \ 0.01. no differences were found between si, ab and mabc. best cut-off points were calculated. si c 0.8 better predicts mt with a sensitivity 100%, specificity 63.4%, positive and negative predictive values 10.3% and 100%. conclusions: si, abc and mabc are all good scores for predicting mt in our population. appealing by its simplicity, we recommend si as the best trigger for mtp. protocols should be standardized to improve the accuracy of mtp activation for trauma patients. introduction: the prevalence of knife-related offences is rising in the uk. successful management of trauma patients requires the co-ordinated response of specialist services, including transfusion. we aimed to assess the impact of knife-crime on transfusion support within a uk adult major trauma centre (mtc). material and methods: retrospective review of patients admitted to a uk mtc following knife injuries resulting from interpersonal violence during a three-year period (may 2015-april 2018). source material included electronic patient records, tarn database and massive transfusion protocol (mtp) logbook. patient characteristics, resource utilisation including transfusion, mtp activation and outcome were collated. results: 540 patients were identified, 502 (93%) were male. median age was 27 years. 237 (44%) were under the age of 25. 245 patients (45%) presented with circulatory compromise (sbp \ 110). 97 patients (18%) had attended our hospital previously for violencerelated trauma. 71% arrived at hospital between 1900 h to 0700 h. 346 (64%) required one or more surgical procedures. median length of stay was 3 days. 95 patients (18%) received blood transfusion. median units transfused were 4 prbc, 2ffp, 1 platelets (atd). mean component use was 6 pbrc (range 1-61), 3.8 ffp (0-36), platelets 0.6 (0-12), cryoprecipitate 0.6 (0-14). annual mtp activations increased from 99 to 157 during the study period (total 360). stabbings accounted for 25.4% of these (99 patients), of which 70 (78%) were transfused. conclusions: knife crime presents a burden to blood transfusion, accounting for a quarter of mtp activations. patients typically present out of hours with implications for service planning and delivery. patient profile together with repeat healthcare attendance and surgery requiring transfusion has implications for red cell allo-immunisation. we recommend timely baseline blood grouping and triage to optimise the safe use of rhd positive cellular components. introduction: spontaneous intramural small bowel hematoma is a very rare complication of anticoagulant therapy. nowadays, the prevalence is increasing due to the widespread use of computerized tomography and the increasing number of patients receiving anticoagulant therapy. material and methods: 15 patients admitted to our center between january 2010 and june 2019 and treated with the diagnosis of intramural hematoma were retrospectively evaluated. results: the median age of the patients was 69 years (44-84) and 9 (60%) were male. at the time of appeal, warfarin intoxication was present in 14 cases (93%) and the median inr was 7.25 (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) . one patient had known factor 7 deficiency. diagnosis was made by computerized tomography in all cases. one intramural hematoma was localized in the duodenum (6.7%), nine in the jejunum (60%), and five in the ileum (33.3%) six patients (40%) had ileus findings. all patients underwent fresh frozen plasma replacement due to high inr levels and bleeding. median tdp transfusion was 3 units (2-7). only 3 patients (20%) required erythrocyte suspension replacement. all cases were followed up conservatively and there was no need for intensive care. the median hospital stay was 4 (3-10) days. conclusions: due to the limited number of studies in the literature with a large number of cases, retrospective evaluation of 15 singlecenter cases may be helpful. spontaneous intramural small bowel hematoma should be considered in the elderly population under warfarin therapy who present with abdominal pain, especially if inr values are above therapeutic limits spontaneous regression is seen in the majority of cases. non operative management and correction of coagulopathy with fresh frozen plasma replacement is the preferred approach. references: abbas ma, et al. spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. arch surg. 2002; 137(3) :306-10. pre-hospital decision-making: identifying the challenges assessing and managing traumatic haemorrhage and coagulopathy m. marsden 1 , r. bagga 2 , k. gillies 3 , r. lyon 4 , s. kellett 5 , r. davenport 1 , n. tai 1 expert pre-hospital clinicians in making decisions about the diagnosis and treatment of patients with major haemorrhage and suspected tic. methods: semi-structured interviews were conducted with 10 senior pre-hospital consultants from london's air ambulance and air ambulance kent, surrey and sussex. interviews probed clinicians on how they make decisions relating to the pre-hospital assessment of major haemorrhage and tic and subsequent blood product transfusion. the interviews were analysed using descriptive thematic analysis. results: all clinicians agreed that identifying and treating major haemorrhage was vital. half of the clinicians reported making no conscious assessment for tic and six reported tic should be managed in a hospital setting. four broad themes were identified: collation of information, weighing utility of different approaches, influence of experience and evaluation of unknowns. collating information from multiple sources drove clinical decision-making. decisions on blood product transfusion were made after weighing potential benefits (e.g. improve microvascular perfusion) against harms. clinical experience was reported as key to nuance clinical assessment, detect subtle signs and identify patterns. uncertainty complicated clinical decision-making in two domains; incomplete knowledge of a patient's injury and uncertainty of best clinical practice. conclusion: the pre-hospital identification and treatment of major haemorrhage was recognised as challenging and fundamental. necessity of pre-hospital tic diagnosis and treatment divided opinion. identifying these four themes allows for a greater understanding of the factors involved in making these decisions and will guide the creation of more accurate decision support tools to aid pre-hospital clinicians. nothing to declare. introduction: massive transfusion (mt) is defined as the administration of c 10 packed red blood cells (prbc) in 24 h. alternative definitions have been proposed; however, there is little understanding about the discriminative ability of different mt definitions with regards to mortality and multiorgan failure (mof). we aim to assess and compare the discriminative ability of different definitions of mt concerning mortality and mof. material and methods: we included patients who arrived to the emergency department and required trauma team activation at a level i trauma center in the city of cali, colombia between 2014-2018. demographics and trauma characteristics were evaluated. the following mt definitions were measured: 50 units of blood products in 24 h (t50), 10 u prbc in 24 (t10-24), 6 u prbc in 6 h (t6-6), 10 prbc in 6 h (t10-6), the combination of t10-24 and t6 (t-combi), 5 prbc in 4 h (t5-4), 4 prbc in 1 h (t4-1) and 3 units of prbcs in 60 min. the operative characteristics were calculated for each definition. mof was defined as a sofa score of c 6 points. results: we included 394 subjects, 88.6% male. trauma mechanism was penetrating in 87.3%. the median and interquartile range (iqr) of age was 28 years iqr (22-37) and of iss 25 (16-26). lesions were located in the torso in 42.4% of patients, and 47.2% had a positive abc score. a total of 264 (67%) received at least 1 unit of prbc. tables 1 and 2 presents the operative characteristics of 10 definitions of mt with respect to mortality and mof, respectively. conclusions: although all definitions showed an association with higher odds with the outcomes of interest, none of them showed an accurate diagnostic capacity regarding mof and mortality. thus, we advise caution when relying on the classical definition of mt ([ 10 rbc units in 24 h) to guide the flow of care of severely injured patients. trauma and coagulation: trends in coagulation factors in the severely injured trauma patient introduction: trauma-induced coagulopathy (tic), affects about 25-30% of the major trauma patients. in the past, tic was considered as a consequence of the coagulation factors' dilution after a highvolume colloid administration. today tic is seen as a phenomenon that can arise after trauma; the first event is the c-protein activation by the tissue damage and hypoperfusion, resulting in the subversion of the hemostatic process. material and methods: the 40 patients of the 2018 pilot study ''trauma and coagulation'' run in irccs san raffaele scientific institute have been reviewed and analyzed using a suite of experimental coagulation factors including rotem parameters, activated protein c (apc), thrombomodulin, endothelial protein c receptor, thrombin-antithrombin complex (tat), plasminogen activator inhibitor 1 (pai-1), seselectin, interleukin-8 (il-8), interleukin-10 (il-10), d-dimer (xdp), antithrombin iii (atiii), and prothrombin fragment f1 ? 2 (f1 ? 2). new 15 patients have been enrolled to validate the results of the pilot study. results: there is a statistically significative correlation between clinical scores of severity of trauma and risk of massive transfusion (iss, abc and tash) and some of the experimental coagulation factors analyzed. case history: to evaluate the role of negative pressure wound-care systems applied to the pleural cavity in case of severe acute empyemas and frail patients not amenable to conventional surgery. clinical findings: we report the case of a 67 yrs old male critically ill patient suffering from complications of cardiac surgeries who developed a severe right empyema with broncho-pleural fistula through the site of a previous pulmonary hernia. investigation/results: we review the actual indications of negative pressure therapy in thoracic surgical emergencies especially in septic patients unfit for surgery. in our case the repeated application of negative pressure with dedicated dressings through the initial thoracotomy was the chosen damage control approach because of the sepsis and poor conditions. diagnosis, therapy and progressions: air leaks were later found to originate from a subsegmentary branch of middle lobe bronchus. subsequent video-assisted debridement procedures followed by negative pressure therapy managed to (1) control the infection, (2) reduce the thoracotomy incision into a thoracoscopic access and (3) heal the pleural cavity, restoring eventually better general conditions of the patient. the closure of the bronchial fistula required further procedures after the acute phase when sepsis was overcome. comments: negative pressure systems can be applied to the pleural cavity with many advantages in selected critically ill patients. they allow to contain, treat and resolve infections both of chest wall and pleural cavity in case of severe empyemas reducing also wound pain and eliminating the need of chest drains. air leaks may also be managed by negative pressure therapy with adequate indications and particular attention to its settings. references: sziklavari z. mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. eur j cardiothorac surg. 2015. flail chest: the renaissance of rib osteosynthesis c. leite 1 , a. oliveira 1 , a. lemos 1 , b. barbosa 1 , c. casimiro 1 1 centro hospitalar tondela-viseu, general surgery, viseu, portugal case history: we present the clinical case of a male patient of 79 years old. injury mechanism: fall from his own height over the right hemithorax. clinical findings: 5 rib fractures with flail chest and significant displacement of bone edges. symptoms: intense thoracic pain. diagnosis: rib fractures with flail chest. therapy and progressions: multimodal analgesia. on the 4th day, he presented a tension pneumothorax. after adequate intercostal drainage, the pneumothorax relapsed. on the 8th day, he underwent a right posterolateral thoracotomy, open reduction and internal fixation of 3 ribs with plates and screws and intercostal drainage. evolution: he received respiratory kinesiotherapy and was discharged on the 8th pos op day. follow-up at 1st and 5th months, without functional impairment and with preservation of quality of life. comments: rib fracture is the most common injury in the setting of thoracic trauma and is associated with a higher morbimortality. in the last 60 years, positive pressure mechanical ventilation was the first line treatment of respiratory insufficiency caused by rib fractures. however, severe complications associated with prolonged mechanical ventilation, have elicited the rising implementation of open rib reduction and internal fixation techniques. the most consensual indications are: flail chest with fracture of at least 3 ribs, significant displacement of bone edges or uncontrolled pain. rib osteosynthesis is a simple method but requires clinical experience in thoracic approaches and handling of specific instruments and material. its implementation in non-ventilated patients reduces the need for mechanical ventilation, pain, length of stay and allows preservation of quality of life. yokohama city university medical center, advanced critical care and emergency center, yokohama, japan, 2 saiseikai yokohama-shi nanbu hospital, department of surgery, yokohama, japan, 3 yokohama city university, department of general surgery, yokohama, japan, 4 yokohama city university, department of emergency medicine, yokohama, japan introduction: although americans and europeans report emergency room thoracotomy (ert) is of value in penetrating trauma patients, most of ert is performed for blunt trauma in japan. after the establishment of the local government-directed major trauma center in the city of yokohama, the unexpected trauma survivor rate increased in the single center study. we report our experience in ert and surveyed the effect of the establishment. material and methods: patient characteristics (backgrounds, mechanism of injury, indication for ert, anatomic injuries, interventions and survival) of those who underwent emergency thoracotomy compliant with the guideline of western trauma association, between october 2012 and september 2019 were analyzed. results: fifty-eight patients (42 males) underwent emergency thoracotomy. median age was 39.8 (5-85) years. fifty-seven were performed for blunt trauma (98%) and only 1 for penetrating injuries. twenty-three patients presented with cardiac arrest on arrival, while thirty-five had deep and refractory hypotension. overall, survival rate improved from 0 (0/14) to 14% (6/44) (p = 0.18) after the establishment of the trauma center. of patients presenting with cardiac arrest, only one survived. conclusions: the establishment of major trauma center seemed to affect the survival rate of the patient edt was performed. introduction: more than 45% of polytrauma events involve chest injuries. one third of these patients sustain thoracic instability due to serial rib fractures. thanks to numerous innovations in implant development several approaches currently exist for surgical rib stabilization (srs). however, no consensus exists regarding patient selection for srs to date. material and methods: retrospective single center cohort analysis in trauma patients. serial rib fracture was defined as three consecutive ribs confirmed by chest ct. cohort includes 243 patients that were treated conservatively and 34 patients that underwent srs by plate osteosynthesis. demographic patient data, trauma mechanism, injury pattern, injury severity score (iss), glasgow coma scale (gcs) and hospital course were analyzed. two matched pair analyses stratified for iss (32 pairs) and gcs (25 pairs) were performed to minimize selection bias. results: the majority of patients was male (74%) and aged 55 ± 20 years. serial rib fractures were located left/right/bilateral in 46%/ 36%/19% of cases. other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). average iss was 22 ± 7.3. overall hospital stay was 15.9 and icu stay 7.4 days. in hospital mortality was 13%. srs did not improve hospital course or postoperative complications in the complete study cohort. however, patients undergoing srs had significantly reduced gcs (7.6 ± 5.3 vs 11.22 ± 4,8; p = 0.006). matched pair analysis stratified for gcs showed a reduced need for blood substitution and shorter icu stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003) and reduced in hospital mortality (4 vs 12%). conclusions: patients with serial rib fractures and simultaneous severe cerebral injury benefit from surgical rib stabilization. tracheal and bilateral recurrent laryngeal nerve disruption injury secondary to accidental strangulation by dupatta case history: 18 year old female brought to trauma emergency with a/h/o accidental strangulation injury with dhupatta at farm field while working with thresher machine after 6 h of injury. patient had severe dyspnoea, dysphagia, paining neck clinical findings: primary survey revealed threatened airway with extensive surgical emphysema, rr-29/min, spo2-80% on high flow oxygen mask, hemodynamically stable, and had no neurological deficits. patient was immediately intubated, however ventilation could not be maintained and surgical emphysema worsened hence immediate tracheostomy was established. investigation/results: computed tomography (ct) head and ct angiography of neck with venous phase study of neck and chest with ct esophagogram revealed complete disruption of cricotracheal junction with extensive cervical and upper thoracic surgical emphysema and no other injuries. diagnosis: disruption of trachea from cricoid cartilage with crushed trachea with loss of approximately 4 cm, cricoid and thyroid cartilage fracture, complete avulsion of bilateral recurrent laryngeal nerves and serosal tear of esophagus. therapy and progressions: neck exploration with debridement of tracheal margins and anastomosis between trachea and cricoid cartilage with repair of cricoid, laryngeal cartilage and esophageal serosal repair was performed. comments: post-operatively patient underwent fibreoptic bronchoscopy and revealed paramedian location of vocal cords. at present patient is with tracheostomy tube in situ undergoing speech therapy and is able to generate comprehensible sounds. further laryngeal framework surgery is being planned. introduction: emergency resuscitative thoracotomy (ert) is a lifesaving procedure in selected patients and it is often considered a controversial ''last chance'' method of resuscitation. objectives of ert are to resolve pericardial tamponade, to repair heart injuries, to perform an open cardiac massage, to cross-clamp the aorta to redistribute blood flow to the myocardium and brain, to control intrathoracic bleeding and air embolism in the bronchial venous system. outcome mostly in blunt trauma is believed to be poor. material and methods: we retrospective reviewed 32 patients c 18 years who underwent ert at san camillo-forlanini hospital (rome, italy) between january 2009 and september 2019 with traumatic arrest for blunt or penetrating injuries. results: of 32 ert, 7 (21.9%) were for blunt trauma, 25 (78.1%) were for penetrating trauma. 65.6% of patients were male. the collectively reported overall survival was 59% (n = 19). when including erts designated as done in the emergency department for blunt mechanism, only 1 patient survived (14.3%). survival after erts for penetrating trauma was 72% (18 of 25). conclusions: our experience suggests that ert is a technique that should be utilized for patients with critical penetrating injuries. the reported outcome after ert in european civilian trauma populations is favorable with an overall survival of 43%. multicenter, prospective, observational data are needed to validate the modern role of ert in blunt or penetrating trauma. references: narvestad jk, et al. emergency resuscitative thoracotomy performed in european civilian trauma patients with blunt or penetrating injuries: a systematic review. eur j trauma emerg surg. 2016;42 (6) case history: an 81-year-old male driving a car collided with a wall at a speed of 40 km/h and was brought to a hospital near the scene. he was diagnosed with right multiple rib fractures and hemopneumothorax, and transferred to our emergency center for definitive care. clinical findings: the patient's consciousness was clear and his heart rate, blood pressure, respiratory rate, and o 2 saturation (room air) on arrival were 60/min, 120/74 mmhg, 23/min, and 90%, respectively. subcutaneous emphysema was identified on the right side of his chest and his right breathing sound decreased on auscultation. there was no tenderness and rebound on abdominal examination. investigation/results: an enhanced whole-body computed tomography scan revealed a small disruption on the right diaphragm behind the sternum and free air in the abdomen. diagnosis: the diagnosis was right traumatic diaphragmatic injury, sternum fracture, and right multiple rib fractures with pneumohemothorax. there was free air in the abdomen but without evidence of perforation of the digestive tract as there was no finding of peritonitis on physical examination. thus, pneumoperitoneum from the thorax was strongly suspected. therapy and progressions: laparoscopic observation revealed a 1.5 cm-length of disruption on the diaphragm in the right sternocostal triangle. this was covered with falciform ligament using extracorporeal knot tying method because there was little seam allowance in front of the disruption on the sternum side, and direct suture was not possible. prognosis was good following surgery, and the chest drain was removed on postoperative day 3 and the patient was discharged on postoperative day 4. comments: laparoscopic repair of the diaphragm using extracorporeal knot tying method is often used for retrosternal (morgagni) hernias. however, the method was also useful in this case because the diaphragmatic injury occurred in the sternocostal triangle. rib fractures associated with pneumo-and/or hemothorax; does everyone need a chest tube? v. snartland 1 , p. a. naess 2 , c. gaarder 2 , m. hestnes 3 , p. majak 2,1,4 1 faculty of medicine, university of oslo, oslo, norway, 2 oslo university hospital, department of traumatology, oslo, norway, 3 oslo university hospital, trauma registry, oslo, norway, 4 oslo university hospital, department of cardiothoracic surgery, oslo, norway introduction: pneumo-and/or hemothorax are often seen in trauma patients with rib fractures (rfs). standard treatment for pneumothorax (ptx), hemothorax (htx) and hemopneumothorax (hptx) is tube thoracostomy (tt). however, a non-operative approach can be applied in selected patients. we wanted to assess our practice in patients with rib fractures and associated ptx, htx or hptx. material and methods: all adult patients (c 18 years) with rf, admitted by a trauma team at oslo university hospital in 2017 were identified retrospectively and those with associated ptx, htx or hptx were then included in the study. patients who underwent tt prior to arrival and those who died were excluded. spss v25 was used for statistical analysis. results: of the 241 patients with rfs, a total of 90 patients had ptx, htx or hptx. fifty-one percent (46/90) of these patients were treated with tt and 85% (39/46) of the patients underwent tt within 6 h after arrival. the presence of opacification (p \ 0.01), chest wall deformity (p \ 0.01) and pneumothorax size (p \ 0.01) were significantly higher on chest x-ray in the tt group compared to the nonoperative group. intubation at arrival was also significantly more common in patients treated with tt (p \ 0.01). there was no difference in the presence of subcutaneous emphysema between the groups. the tt group was sicker than the non-operative group (had a significantly lower systolic blood pressure, a lower gcs and a higher lactate on arrival). oxygen saturation, heart rate, respiratory rate, ph and hemoglobin did not differ significantly between the groups. conclusions: in trauma patients with rf concurrent ptx, htx or hptx should be suspected. in our study only half of these patients were treated with tt, and 85% of tubes were inserted within 6 h after admission. size of the ptx, radiological presence of opacification and deformity of the chest wall should be addressed when choosing treatment strategy. introduction: emergency department thoracotomy (edt) is a potentially life-saving surgical procedure performed in the emergency department (ed) in patients presenting with cardiac arrest following penetrating thoracic trauma. however, it is not clear if all surgeons are prepared or motivated to perform this procedure. furthermore, not all institutions are equipped, either in terms of logistics or team training, to perform edt. our purpose was to perform a pilot study in a cohort of polish surgeons of various specializations, in order to ascertain who would and who would not (and why) perform edt in their departments. material and methods: study population of 69 surgeons (27 specialists, 42 residents) from various hospitals in poland, mean age: 31-40 years, 55.1% men, 43.5% women. study respondents were asked to fill in a questionnaire on the indications and motivation to perform edt in their clinical practice. results: most respondents (n = 54, 78%) correctly recognized the indications to perform edt. however, only 35 (51%) declared they would perform it. the reasons for not performing edt were: lack of team training (63.7%); lack of equipment (58%); lack of motivation among ed personnel (40.6%); the ed is not prepared (27.5%); the respondent is not prepared (26%). only 6 participants (8.7%) declared that their institutions had the edt protocol. conclusions: this survey demonstrates that, although most surgeons agree on the indications for edt, the level of preparedness in its execution is lacking. the main reasons are the lack of team training, the lack of equipment and the lack of motivation among ed personnel. other relevant reasons were the lack of preparation of either a surgeon or a department. these results demonstrate that improvements in institutional logistics as well as in team and individual training can translate into improved care. we strongly advise the performance of a pan-european survey on edt to address other unrecognized issues. mediastinum widening: how to manage it? a. gonzález-costa 1 , r. gracia-roman 1 , s. montmany-vioque 2 , m. s. santos-espi 3 , r. lobato-gil 1 , m. pascua-solé 1 , a. campos-serra 1 , a. luna-aufroy 2 , p. rebasa-cladera 2 , s. navarro-soto 2 1 parc tauli hospital universitari, trauma and emergency general surgery department, sabadell, spain, 2 parc tauli hospital universitari, esofagogastric general surgery department, sabadell, spain, 3 parc tauli hospital universitari, angiology and vascular surgery, sabadell, spain case history: a 23-year old male was admitted to our emergency department as a polytrauma code, because of a gunshot wound in the neck. clinical findings: his airway was compromised with expansive cervical hematoma. intubation was difficult. he was hemodynamically unstable with cervical bleeding, in which manual compression was applied. results: chest x-ray showed mediastinal widening without pneumo or hemothorax. diagnosis: urgent sternotomy while maintaining manual compression on the cervical bleeding, followed by left antero-lateral cervicotomy. injuries: section of left jugular vein and left carotid artery, lesions of unnamed vein. free cervical chylous fluid. left pleura and pericardium were opened without identifying major injuries. therapy and progressions: jugular vein was repaired with continuous suture and carotid artery with patch sutured. unnamed vein was sectioned between ligatures. thoracic duct was ligated. after surgery, ct scan showed cervical and mediastinal hematomas without signs of active bleeding, and correct permeability of the vessels, with no cranial lesions. the patient was admitted to the intensive care unit. tracheostomy was performed. fibrobronchoscopy, fibrogastroscopy and esophagogastricoduodenal discarded airway and esophageal lesions. he presented the following complications: • small mediastinal collection • right diaphragmatic paralysis. • paralysis of vi left cranial nerve (mononeuritis of vascular origin). the patient was discharged on the 30th postoperative day. comments: in this kind of trauma is essential the airway management with intubation when necessary. it is important that mediastinal widening visualized in the chest x-ray in a traumatic patient, should be an indication of surgery. in our case, it was essential to start it with sternotomy while maintaining manual neck compression, and in a second time, perform the cervical approach since that prevented the patient from suffering a greater blood loss. background: clavicular fracture is very common in childhood. otherwise, the medial third of the clavicle is the less affected. the current report describes a new pattern of clavicular injury, in which a medial third clavicular fracture and posterior sternoclavicular joint (scj) dislocation occur together in a skeletally immature patient. clinical findings: an 8-year-old boy sustained a direct impact to his left shoulder resulting from the fall of a sofa. at admission, he complained of severe pain in the clavicular and shoulder associated with functional limb impotence. physical examination revealed deformity of the proximal third clavicle, with swelling and tenderness to palpation along the medial left clavicle. no signs of skin pression or neurovascular impairment were found. the anteroposterior radiograph of the left clavicle showed a fracture of the proximal third shaft and an asymmetry of the scj. computed tomography confirmed the association of a greenstick fracture of the proximal third clavicular shaft, accompanied by a mild posterior scj dislocation. therapy and progressions: the left limb was immobilized with a sling during 3 weeks, after which physical therapy was initiated to improve range of motion using active and gentle active-assisted exercises. at the 2 months medical consultation, he presented asymptomatic, with good bone healing, full range of motion of the shoulder and absence of relevant aesthetic deformity. comments: in the immature skeleton, scj dislocation and epiphyseal fracture of the proximal clavicle are very rare entities due to the multiple strong ligaments that stabilize the scj. trauma in the proximal third of the clavicle typically results in fractures in the region of the physis and only more rarely culminate in dislocations of the scj. these injuries warrant a high index of suspicion, and early ct scanning is recommended. although treatment may be conservative, in situations of major displacement, surgery should be considered. use of rib fracture scoring systems in a uk major trauma unit: a retrospective audit and lessons learnt introduction: rib fractures are detected in 10% of trauma patients [1] . significant morbidity and admission to intensive care units (itu) is common [1] . rib fracture scores do not have strong validity as a predictor, but are a useful screening tool to identify patients at higher risk, of morbidity. the aim of this study was to audit the use of rib fixation scores in a single major trauma centre. material and methods: a retrospective audit of trauma patients with rib fractures presenting to a single major trauma centre over a 1-year period subsequently admitted to itu was performed. demographics, length of itu stay, rib fracture score (rfs) and ribscore were recorded and comparisons made between patients who had surgical rib fixation and those who did not. results: 86 patients with traumatic rib fractures were admitted to itu over 1-year, 19 of whom had rib fixation. mean age of patients undergoing surgery was 74 compared to 52 in the non-surgical cohort. average rfs was higher in the surgical cohort (14 vs 6; p = \ 0.001), as was average ribscore (3 vs 1; p = \ 0.002). incidence of flail segment was higher in surgical cohort (37% vs 10%; p = \ 0.001), as was number of rib fractures (9 vs 5; p = \ 0.001) and incidence of 1st rib fracture (20% vs 8%, p = \ 0.289). rib fractures treated surgically had a longer itu stay (12.3 days vs 5.31; p = \ 0.001). conclusions: surgical rib fixation patients were older and had longer itu stay. higher rib fracture scores correlated with need for surgical intervention. this highlights the need for careful patient selection for rib fixation, as they appear to fall in a more vulnerable patient demographic. there is a need for a score combining ribscore and rfs, ensuring the nature of fractures and presence of flail segments are interpreted in the context of patient age, to ensure this vulnerable patient group undergoes surgical fixation only when necessary. jichi medical university, shimotsuke tochigi, japan case history: an 82-year-old female individual hurt her back while walking during a hospital rehabilitation program after experiencing a brain stroke. her hemoglobin level gradually decreased to 6.0 g/dl on the 5th day after injury. a non-enhanced abdominal ct scan revealed a burst fracture of the lumbar spine. the patient was brought to our emergency center for a thorough examination. clinical findings: her vital signs on arrival were gcs: e4v4m6, hr: 79, bp: 135/75, rr: 19, and bt: 36.3. her back presented a severe kyphotic spine. the palpebral conjunctiva was anemic and there were no injuries on her surface. no abnormalities were detected upon auscultation of the thorax and no tenderness and rebound was detected upon physical examination of the patient's abdomen. investigation/results: hemoglobin level was 5.9 g/dl and lactate 2.8 mmol/l on arrival. an enhanced chest and abdominal ct scan revealed a burst fracture of the 5th lumbar spine, a large hematoma around it, and a pseudoaneurysm of the lumbar artery. diagnosis: a pseudoaneurysm of the lumbar artery and a burst fracture of the 5th lumbar spine was diagnosed. therapy and progressions: the angioembolization of the lumbar artery was abandoned because the distance between the abdominal aorta and the aneurysm was \ 5 mm. endovascular aneurysm repair (evar) was finally performed. after the successful completion of the surgery, the patient was discharged on the 11th day after evar. comments: slight injury caused the fracture of the lumbar spine, possibly yielding pseudoaneurysm of the lumbar artery. such pseudoaneurysms are rare and employing evar for its treatment is equally rare. blunt lumbar artery injury may be a differential diagnosis for the elderly patients who present burst spine fractures with extreme anemia or shock, even if it results from a minimal injury. case history: a 23 year old co-driver was hit by another car on her side. air rescue found the patient with gcs 3 and right tension pneumothorax. oral intubation, decompression with chest tube and transportation to the nearest level one trauma center was undertaken. clinical findings/investigation/results: on presentation in the emergency room the patient was hemodynamically instable with free fluid in efast-sonography and a haemoglobin of 2.2 g/dl. she was immediately taken to the operation room where laparotomy was performed. liver rupture and right diaphragm rupture was found. diagnosis: right hilar bronchial disruption. therapy and progressions: despite packing of the liver the patient remained instable. due to continuous bleeding from diaphragm rupture side right anterolateral thoracotomy was performed. bronchial disruption close to the hilus was detected leading to total pneumonectomy. after surgery the patient recovered under intensive care. six weeks after initial trauma the patient presented with ileus. a gastric tube was placed without complications. chest x-ray was performed showing intrathoracal displacement of the gastric tube. in an emergency operation the insufficient bronchus trunk was covered with an intercostal muscle flap. comments: this case shows the rare necessity of total pneumonectomy after blunt chest trauma and its typical complication with insufficiency of the bronchial trunk. after total pneumonectomy surgery covering the bronchial trunk should be performed as soon as possible to prevent insufficiency. in these patients gastric tubes should only be placed under endoscopic vision. because of the high complication rate total pneumonectomy should only be performed as a last resort procedure in the context of damage-control surgery. introduction: multiple rib fractures continue to be a challenging problem as the associated pain leads to a compromise in respiration. proper analgesia is required for physiotherapy, and to prevent development of respiratory failure. ultrasound-guided serratus plane block (spb) has recently been described as a regional anesthetic technique to provide analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. material and methods: from sept 2018 we applied the serratus plane block for pain control in 12 patients with multiple rib fractures. we administered 0.25-0.125% bupivacaine solution with easypump for 5-8 days, the infusion rate was 5 ml/h. after admission we measured pulmonary function of patients and recorded the forced vital capacity (fvc). we repeated the test after the catheter insertion on the 2-5-10 days. in our control group (14 patients introduction: rib fractures are the most frequent injury after blunt thoracic trauma. it is very important to choose the most appropriate interventions to minimize or prevent complications. but who will benefit most of those interventions remains a challenge. material and methods: a retrospective study with a prospective data collection from march 2006 to december 2018. there have been included all traumatic patients older than 16 years old, that were admitted to the icu or who were died before the admission and had a plain chest radiograph (cxr) and thoracic or thoraco-abdominal scan (ct scan) in the first 72 h. demographic data has been collected, vital signs, iss, mechanism of action, need of ventilation or intubation, lesions, complications, cause of death. a total of 553 cxr were reevaluated by one general surgeon (one of the authors) and one radiologist, who were blinded to the results of the subsequent chest ct scan, the written radiology report and the patient's outcome. rib fractures, pneumothorax, hemothorax, pulmonary contusion, laceration and atelectasis were described. results: attending to the number of fractures, the kappa between the radiologist, the surgeon and the ct report is very low: surgeon-ct k = 0.18, radiologist-ct k = 0.2, and radiologist-surgeon k = 0.46. both radiologist and surgeon under-diagnosed rib fractures. we tried to predict respiratory failure and pneumonia using the number of fractures, and scores (chest trauma score, ribscore and rib fracture score). results are shown on the table. conclusions: plain radiography seems not to be a good diagnostic method for rib fractures. both radiologists and surgeons under-diagnosed rib fractures. scores based on radiography seem un-useful given that this under-diagnoses rib fractures; but with a precision of 71% by the surgeon evaluating cxr and using a score like rfs perhaps it is enough to decide which patients require a ct scan or more specific treatment in the icu. surgical experience of traumatic diaphragm injury in a single regional trauma center for 5 years introduction: this study is a retrospective review of the experience with the management of traumatic diaphragm injury in our trauma center from 2014 to 2018. material and methods: we identified a total of 31 patients with the traumatic diaphragm injury coded from the institutional trauma registry. we reviewed the radiographic finding of radiologists and the electronic medical record (emr). results: the mean of injury severity score (iss) was 30.3 ± 13.7. except for 1 case, the plain chest x-ray was evaluated in the patients before surgery, only 3 patients were revealed positive finding for diaphragm injury (n = 3/30, 10%). the computed tomography (ct) was performed for 22 patients, the positive finding was 31.8% (n = 7/ 22). according to the clinician impression before surgery, the diagnosis for diaphragm injury was showed 48.4% (n = 14/31). approaches were laparotomy in 14 patients (45.2%), thoracotomy in 9 (29.0%), thoracoscopy in 3 (6.5%), laparoscopy in 1 (3.2%), open conversion after thoracoscopic or laparoscopic exploration in 2 (6.5%), median sternotomy in 2 (6.5%). the occurrence of herniation was 10 (32.3%). the mean of the calculated rupture size in the operation field was 5.8 ± 3.8 cm. in our study, the herniated peritoneal organ was observed in more than 3 cm size rupture of the diaphragm. 6 patients were performed surgical management of diaphragm rupture after 24 h. conclusions: without herniation of organs, the radiologic evaluation was difficult to detect diaphragm injury. and, detect of diaphragm injury with herniation of organ, the injury of the diaphragm was predicted a larger than 3 cm. case history and clinical findings: a 44-year-old man presented to the emergency room with a single self-inflicted left chest gunshot wound at the level of 2nd rib. on arrival patient was conscious, with systolic blood pressure 100 mmhg and heart rate 120 bpm. extremities were pale, cold. jugular veins distended. investigation/results: fast scan was negative. chest radiograph revealed a metal foreign body with the size of 4 9 5 mm at the projection of heart. a ct scan of chest and abdomen demonstrated bullet inside the dorsal wall of the left ventricle and blood in pericardium and left pleural cavity (figs. 1, 2) . therapy and progression: patient was taken to the operation room for median sternotomy. due to severe deterioration of patient's condition, 30 ml of blood was aspirated from the pericardium prior to sternotomy. during subsequent pericardiotomy 500 ml of blood was evacuated. main pulmonary artery wall gunshot injury was detected above the pulmonary valve. the wound was sutured, after which the hemodynamics stabilized. cardiac surgeon was consulted about the air gun bullet inside the myocardium. it was decided that removal of the bullet is not indicated. the patient was observed in the icu for the next 36 h, later transferred to the thoracic surgery ward. the postoperative course was uneventful. an echocardiogram demonstrated a perforation of the anterior leaflet of mitral valve with a mild to moderate regurgitation, otherwise no abnormalities. patient was discharged on day 10. patient has been followed up on an annual basis for the last 2 years. patient's exercise tolerance and cardiac function according to repeated echocardiography remains unchanged with no evidence of dyskinesia or other abnormalities. bullet is retained in the same location (fig. 3) . comments: this case illustrates a successful management of usually lethal injury of main pulmonary artery and reflects that retained myocardial foreign body does not necessarily cause any complications. profile of penetrating chest injuries in hostile environment: a three year study introduction: penetrating chest injuries are one of the leading causes of death and major morbidity in operations involving high energy weapon systems. this study aimed at assess the profile of penetrating chest injuries suffered during armed combat operations in a hostile environment over a three year period. material and methods: a retrospective and prospective, non-randomized study designed to assess the profile of chest injuries in armed combat operations over 3 years. all patients with penetrating chest injuries were included in the study. results: there were 967 trauma cases out of which 111 patients suffered penetrating chest injuries. the age range of patients was 20-46 years and all were male. a total of 15 casualties were brought dead (14.73%). there were 11 lung injuries and two diaphragmatic injuries. thoracotomy was required in 7 patients (7.27%) and intercostal chest drainage (icd) in 29 patients (23.64%). average blood loss was 440 ml and duration of hospital stay ranged from 4 to 62 days. conclusions: ballistic injuries to the chest are frequently fatal due to injuries to the heart, major vessels and tracheobronchial tree. prompt and efficient pre hospital treatment, expedient evacuation to a surgical facility and swift management by critical care specialists and surgeons can be instrumental in reducing mortality and morbidity. the cornerstone of management is bedside intercostal chest drain insertion as a formal thoracotomy is seldom needed. penetrating chest injuries can be managed by general surgeons with training in thoracotomy and repair of intra-thoracic structures does the number of a-or low symptomatic but intervention requiring complications justify regularly chest x-ray controls after less than 3 rib fractures? c. deininger 1,2 , f. wichlas 1,2 , s. deininger 3 , v. hofmann 1,2 1 university hospital of salzburg, orthopedics and traumatology, salzburg, austria, 2 universitätsklinikum salzburg, klinik für orthopädie und traumatologie, salzburg, austria, 3 universitätsklinikum salzburg, universitätsklinik für urologie und andrologie, salzburg, austria introduction: fractures of less than 3 ribs may still cause delayed complications (1) . the aim of this retrospective study is to determine whether standardized control imaging in a-or low symptomatic patients reveals a significant number of intervention requiring complications and therefor should be recommended. material and methods: all patients with less than 3 rib fractures presenting in our emergency department after any trauma mechanism in the study period of 3 years (2015-2017) and available for follow up were included retrospectively in the study. results: we included 249 patients in this study, 137 (55.0%) of which were male, 112 female (45.0%), with a median age of 64.2 ± 24.8 years. in 150 patients (60.2%) 1 rib was affected, in 99 patients (39.8%) 2, the fractured ribs being true ribs (1-7) in 72 cases (28.9%), false ribs (8-12) in 151 cases (60.6%) and both in 26 cases (10.4%). the affected thorax half was the left side in 124 cases (49.8%), the right side in 121 cases (48.6%) and both thorax halves in 4 cases (1.6%). the trauma mechanisms were falls at home, traffic accidents, sporting accidents, work accidents, fighting related and minor trauma in 172 (69.1%), 30 (12.0%), 19 (7.6%), 18 (7.2%), 6 (2.4%) and 4 (1.6%) cases, respectively. the median follow up time was 9 ± 4 days. 4 patients (1.6%) required delayed intervention: 1 case of hemopneumothorax and 3 cases of pneumothorax all treated with chest tube. conclusions: planned chest x-ray controls seem not to be necessary. symptom triggered reappearance for patients after rib fractures in hospitals seems to be sufficient and more economical compared to regularly re-imaging (2) is computed tomography a first line modality in stable blunt chest trauma elderly patients? a. becker 1,2 , y. berlin 1,2 , d. hershko 3,2 1 emek medical center, department of surgery a, afula, israel, 2 technion-israel institute of technology, haifa, israel, 3 emek medical center, surgery, afula, israel introduction: adult older, patients aged [ 65 years, represent up to 20-25% of all trauma patients admitted to the trauma centers. chest trauma in older patients have been recognized to strongly influence mortality. the estimated of 20% mortality and pneumonia rate for these patients was observed (1, 2) . based on low diagnostic accuracy of cxr, interpretation difficulties due to aging chest wall deformities, we hypothesized that ct chest should be the first imaging modality in stable elderly blunt chest trauma patients. patients and methods a retrospective analysis of all blunt trauma admissions at emek medical center between 2014-2018 years was performed in order to identify patients with blunt chest trauma. only stable trauma patients with abbreviated injury score (ais). results: among 473 patients that met inclusion criteria, there were 289(61%) patients aged 18-64 years old and 184 (39%) patients aged c 65. in the first group of patients (18-64), 240 had ct chest on arrival. in the second group of patients (aged c 65), there were 18 (9.7%) patients with missed injuries. in this group, patients who had ct chest on arrival, 7 of 130 (5.4%) patients had missed injuries. eleven of 54 (20%) patients who had no ct chest on arrival, diagnosed with missed injuries (p-0.014). readmission rate in the first group of patients (18-64) was 5 of 240 (2%) who had ct chest on arrival, and 2 of 49 (4%) who had cxr on arrival only (p-0.3). in the second group (c 65), readmission rate was 5 of 130 (3.8%) patients with ct chest on arrival, and 7 of 54 who had cxr on arrival only (13%) (p-0.051). conclusions: based on our study result we conclude that ct chest should be a first imaging tool in stable elderly patients with blunt chest trauma. no disclosures. efficacy and safety of small-bored tube thoracotomy for chest trauma: large-bored chest tubes will no longer be needed introduction: tube thoracostomy drainage is an important treatment for traumatic pneumothorax and hemothorax. traditionally, largebored chest tubes have been recommended for successful drainage and prevention for clogging by clots. however, there is little evidence that large-bored tubes are more effective than smaller ones. in consideration of invasiveness, in our emergency room (er), we use 20 fr chest tube for all trauma patients when chest thoracotomy is indicated. the aim of our study is to investigate the efficacy and safety of small-bored tubes for chest trauma patients. material and methods: we conducted a retrospective observational study. we included the adult patients ([ 18 years old) who had undergone tube thoracostomy with 20 fr chest tubes for chest trauma during the 5 years from october 2013 to september 2018 in our er. the patients with cardiopulmonary arrest on contact or on arrival were excluded. we evaluated tube-size related complications defined as obstruction and worsening of pneumothorax/hemothorax due to ineffective drainage. results: there were 102 eligible patients, 77% were male, mean age was 59.6 and the average injury severity score was 17.8 (± 9.6). sixty-six tube thoracostomies were performed by emergency physicians and 38 were performed by thoracic surgeons. the average duration of tube placement was 3.86 days (± 1.8). there were not any tube-size related complications nor any patients who required additional tube insertion. case history, clinical findings: 4 different stable hemodynamic cases with thoracoabdominal penetrating trauma and negative fast evaluation were enrolled in study. subsequent hemo/pneumothorax was managed initially by tube thoracostomy. investigation/results: hence laparoscopic investigation is an effective method for evaluation of diaphragmatic injuries in thoracoabdominal penetrating trauma, patients underwent diagnostic laparoscopy. in case 1, classic approach was done by open technique 10 mm port insertion in sub umbilical. two 5 mm ports inserted in lower abdomen at the level of midclavicular line. then 10 mm port was added in subxiphoid area and by introducing zero-degree camera through it a better exposure was obtained. in case 2, 10 mm sub umbilical port, 5 mm port in subxiphoid and another 5 mm working port at the level of umbilicus and right midclavicular line were applied. a 30-degree camera used. exposure, working space and exploration maneuvers were much easier to perform in compare with case 1. in case 3, port placement was identical to case 2 but zerodegree camera was used. due to poor exposure, subxiphoid port was replaced by a 10 mm one and used for camera insertion, then an acceptable exposure was obtained. in case 4, port placement of case 3 was used by using 30-degree camera which resulted in a great exposure. diagnosis, therapy, progressions: patients tolerated the operation well and underwent appropriate management according to their intra operation findings; post-op courses passed without any complications. comments: in patients with suspicious diaphragmatic injury and according to available facilities in our centers, in unilateral injuries we suggest that a 5 mm port in subxiphoid area can be used instead of contralateral midclavicular 5 mm port. in bilateral injuries, if enough exposure doesn't achieve, a 5 mm port in subxiphoid can be added. in absence of 30 degree cameras, 10 mm port use in subxiphoid can give surgeons better exposure. hemodynamic instability in patients with extremity injuries: motor vehicle accidents and shot wounds vs. explosions a. mahamid 1 , i. ashkenazi 1 1 hillel yaffe medical center, hadera, israel introduction: we previously reported that hemorrhagic instability (hs) was a complication of extremity injuries in as many as 1 of 7 of patients treated in one medical center following explosions. the objective of this study was to evaluate whether the prevalence of hs in patients with other high energetic injuries such as motor vehicle accidents and shot wounds (mva/sw) is different or not. material and methods: victims following mva/sw with extremity injuries and hs treated in one medical center during 2017 were identified with the aid of the national trauma registry and the center's blood bank. hs was defined as tachycardia (pulse [ 100/min) and/or hypotension (systolic pressure \ 100 mmhg) in need of blood transfusions to reverse instability. patients in whom hs could be attributed to injuries other than the extremity injury were excluded. these were compared to patients treated following bomb explosions (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) conclusions: the proportion of patients in need of blood transfusion is much higher in patients whose extremity injury was caused by an explosion. the relative risk for hs is almost 5 times higher in these patients. new technologies in soft tissue wound management limit reconstruction complexity and enhance recovery introduction: large soft tissue losses are associated with infection, increased morbidity and mortality, increased costs and poor outcome functionality. the purpose of this study was to evaluate the efficacy of a combination treatment of combined topclosure ò tension relief system (trs) and administration of regulated oxygen and antibiotic irrigation negative pressure-assisted wound therapy (roi-npt) in the treatment of patients suffering from significant soft tissue loss. patients with open abdomen, large infected wounds, and extensive soft tissue loss treated with trs and roi-npt. results: full wound closure was achieved in [ 100 patients treated without skin grafts or flaps. primary failure was successfully followed with secondary closure with the same system. the trs system allowed early postoperative physiotherapy with good to excellent functional results. limitations and complications will be discussed. 1. trs is a novel device for stretching, and securing wound closure, applying stress relaxation and mechanical creep for primary closure of large skin defects that otherwise would have required closure by skin grafts, flaps or tissue expanders. 2. irrigation may accelerate the evacuation of infectious material from the wound and may provide a novel method for antibiotic administration. 3. supplemental oxygen to the wound reverses reduced o2 levels in the wound's atmosphere inherent to the conventional negative pressure-assisted wound therapy restricting vacuum use in anaerobic contamination. moris topaz is the inventor and patent holder of the topclosure ò and vcarea ò . attendees' perceptions about tourniquet safety use aboard, easiness of application, and preference among four devices tested assessed. material and methods: the descriptive study design assessed employing a post-seminar survey, participants' perceptions of tourniquet safety use, application easiness, and preference among the four devices tested (cat, sam-xt, swat-t, and rats). the first two variables measured on a one-to-ten scale (being ten the easiest or safest, and one the least easy or least safe), while preference was measured by frequency count, with only one device to select as the preferred. frequencies and percentages for categorical variables and averages calculated and compared using the anova test (p \ 0.01). results: a total of 51 sailors, 12 (24%) females, and 39 (76%) males, aged between 20 and 21, participated in the workshop and completed the survey. the mean for the perception of safety regarding onboard usage was 7.5. as for application easiness, cat and sam-xt ranked equally high (8.5), followed by swat (7.9) and rats (6.9), and the only statistical difference found was for rats (p \ 0.01). cat was reported as preferred by 38 participants (74%), followed by sam-xt 10 (20%), swat-t 2 (4%), and rats 1 (2%). conclusions: jse crewmembers (non-medical personnel) considered safe the use of tourniquets on board. of the four devices assessed, cat and sam-xt were regarded as equally easy to use and rats the least of all. cat was reported as preferred by almost three out of every four respondents. introduction: surge capacity is the ability to manage the increased influx of critically ill or injured patients during suddenly onset crisis, like a mass-casualty incident (mci) or disaster. during such an event all ordinary resources are activated and used in a systematic, structured and planned way. there are, however, situations where conventional healthcare means are insufficient and additional resources must be summoned. this study investigates the possibility of using community resources such as primary health care centers, nonmedical professionals and non-standardized facilities together with educational initiatives to increase surge capacity in a flexible manner. purpose: to investigate the possibility of an increased and flexible surge capacity during a crisis, disaster or mass casualty incident (mci) by examining the main components of surge capacity (sc) (staff, stuff, structure, and system) in the västragötaland region of sweden. method: this thesis uses a mixed methods research approach with an explanatory sequential design. a literature search was performed by using standard search engines utilizing relevant keywords, questionnaires and semistructured interviews were used for data collection from primary health care centers, dental and veterinary clinics, schools, hotels and sports facilities to determine capabilities, barriers, limitations and interest to be included in a flexible surge capacity system. results: preliminary findings indicate that there is interest, capacity and capability in the investigated municipalities to partake in a fscplan: primary healthcare centers can be toned up with drills and exercises, civilians can be educated in advanced first aid procedures (immediate responders) and focused leadership (scene management), schools, hotels and sports facilities can be prepared with advanced first aids kits and be used as alternative care facilities. these alternatives together represent the concept of flexible surge capacity. conclusion: flexible surge capacity can be a possible approach to create extra resources in disaster situations, mci's, or whenever supporting infrastructure is not intact. new educational initiatives, drills and exercises, laymen empowerment and organizational and legal changes might be needed to realize a flexible surge capacity. introduction: a hospital may need partial or total evacuation because of internal or external incidents, such as in natural disasters and or armed conflicts. an evacuation aims either to transport a large number of patients to other medical facilities or to prepare enough space to receive a large number of victims. despite many publications and reports on successful and unsuccessful evacuations, and lessons learned, there is still no standardized guide for such an evacuation, and many hospitals lack the proper preparedness. we aimed to analyze the preparedness of hospitals for a total evacuation by looking into some key parameters necessary for a successful performance. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. eleven questions were sent to representatives from 15 euand non-eu countries. results: our findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the eu or other non-eu countries included in this study. some countries did not respond to our questions due to the lack of relevant guidelines, instructions, or time. conclusions: hospitals are exposed to internal and external incidents and require an adequate evacuation plan. there is a need for a multinational collaboration, specifically within the eu, to establish a standardized evacuation plan. references: nero c, ö rtenwall p, khorram-manesh a. hospital evacuation; planning, assessment, performance and evaluation. j acute dis. 2012;1(1):58-64. introduction: the importance of and the need for medical management during any armed conflict is a fact. many medical achievements have been accomplished due to wars and armed conflicts. the world is, however, divided into countries with and without related military healthcare services. there is a need for joint structure with the civilian in the former, while in the latter the civilian healthcare is responsible for offering services to the military. this study aims to identify the needs of military healthcare system and military medicine as an independent specialty. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. relevant professionals were asked about the pros and cons of having established military healthcare. the data was collected and analyzed. results: although our findings indicate a need for military medicine/ healthcare as a professional specialty, the organizational divisions between military and civilian healthcare systems seems to be changing. the current security issues worldwide, the pattern of injuries and resource scarcity indicates a need for improved collaboration and maybe a fusion between these entities. conclusions: new security threats, modern technology, the pattern of medical injuries, and the lack of adequate surge capacity may indicate a very close collaboration between military and civilian healthcare systems. such a close collaboration may develop to fusion and a total defense healthcare system that can act both in peace and during conflicts. references: ringel js. the elasticity of demand for health care. a review of the literature and its application to the military health system. https://apps.dtic.mil/docs/citations/ada403148 khorram-manesh, a. facilitators and constrainers of civilian-military collaboration: the swedish perspectives. eur j trauma emerg surg. 2018. https://doi.org/10.1007/s00068-018-1058-9. alternative methods of mandibular comminuted fracture fixation in severe maxillofacial injured patients introduction: severe maxillofacial injuries refer to significant facial trauma with communitive bony fractures and soft tissue loss. they result in violent trauma as firearm injuries (wartimes injuries, terrorist attack, suicide attempt) and high velocity motor vehicle accidents. the initial management consist of fighting hemorrhage, fighting asphyxia, wounds debridement and suture, and fractures stabilization, especially mandibular fracture stabilization. our study aims to share thoughts on the alternative methods of comminuted mandibular fracture fixation within the context: kind of injury, multitrauma patients, mass-casualty situation, precarious situation or hostile environment. material and methods: based on our experience (clinical cases), on senior surgeons questioning and on medical literature data, we sought to identify, to evaluate and to compare the different available methods to stabilize comminuted mandibular fractures in severe facial injured patients. results: open reduction and stable internal fixation (using macro plate), external pin fixation and closed reduction with maxillomandibular fixation are the methods of treatment which are the most classically used and described. however, some methods using kirschner wires are reported: in cross extrafocal pinning ( fig. 1) , external fixation and handmade splints. all these methods differ in their complexity of use, in their availability, and in their possibilities to treat one kind of mandibular fracture or another. conclusions: the stabilization method of comminuted mandibular fracture will be choose depending on material availability, on surgeon's abilities, on the time available (mass-casualty situation) and on the patient's overall condition. even if stabilization methods using wires are less commonly used, they appear to us to be useful in the initial management of the severe maxillofacial injured patient with comminuted mandibular fracture, especially in austere conditions. causes of combat casualties' death at medical treatment facilities (mtf) in modern conflicts: russian experience i. samokhvalov 1 , v. badalov 1 , k. golovko 1 , t. suprun 1 , v. chupriaev 1 material and methods: data including mechanism of injury, physiologic and laboratory variables, staged surgical treatment and cause of death were obtained from the combat trauma registry of the kirov military medical academy war surgery department. the combat trauma registry includes 5581 russian wounded in military conflicts over the past decades, 451 of them (8.1%) dead of wounds (dow) at the mtf. results: 50.3% of the total dow number died at the role ii field medical units, 17.3% died at the forward military role iii hospitals, and 32.4% died at the role iv hospitals. the causes of dow patients delivered to the mtf were nonsurvivable traumatic brain wound (19.7%), life-threatening consequences of injuries-mainly massive blood loss due to external and internal bleeding and acute respiratory failure (34.8%), as well as the late septic complications (45.5%). terms of death depended on the cause of dow. so for nonsurvivable traumatic brain injuries, they amounted to 0.5 ± 0.1 days, for lifethreatening consequences of wounds-2.1 ± 0.2 days, and in the development of complications-15.7 ± 0.3 days. conclusions: there is a high mortality rate among the combat casualties delivered to mtf in modern asymmetric warfare (8.1%). moreover, half of these patients (50.3%) die at role ii field medical units mostly from nonsurvivable injuries and from acute irreversible blood loss that occurred at the prehospital stage. the main cause of hospital combat mortality is severe septic complications of combat trauma. in consideration of the present counterterrorism practices, prevention and initial treatment for primary blast injury by shock waves constitute a particularly urgent subject because blast injuries and gunshot wounds account for the majority of terrorism deaths. in japan, due to strict ethical standards in animal experiments, there is no appropriate animal model of blast injury. we established an original small animal model of blast injury using a laser-induced shock wave at the national defense medical college (ndmc). however, since the experiments were conducted using only small animals, such as mice and rats, it was necessary to establish a medium-sized animal model aimed to test the applicability in human patients in the long term. correspondingly, we established a blast tube, which was authorized globally as a shock wave-generating device that causes blast injury based on air pressure differences, in the ndmc research institute using the budget of advanced research on military medicine of japan in 2017. this allowed us to conduct scientific studies on blast injury using mediumsized animals. in this presentation, we will introduce the structure and function of the blast tube installed in the ndmc and present some of the results of our research thus far. this research is financially unfortunately, even if hospital and their staff are an essential key for successful response to mcis, the plan are seldom well-known and, above all, exercises are quite neglected at local and national levels. due to mci rarity, simulation exercises are the only way to achieve proficiency in mci response. therefore, we tested an original mci training system (macsim ò ) adapted to the pemaf of a large university hospital in milan (italy). material and methods: the original mci training format called macsim-pemaf (emergency plan for massive influx of casualties)was developed for the italian society for trauma and emergency surgery (sicut) in 2016. it uses macsim ò , a simulation tool scientifically validated for training and assessment of healthcare professionals in mci management. between 2016 and 2018 the course was held for the emergency department staff of a single university hospital of milan (italy) (foundation cà granda-ospedale maggiore policlinico). macsim ò was used to reproduce the hospital resources, with different mci scenarios. during the simulation the participants had the opportunity to test the local pemaf, in adjunct to their knowledge and skills. course effectiveness was evaluated by a pre-and post-course self-assessment questionnaire. results: macsim-pemaf was tested in seven courses, for a total of 258 participants. pre-and post-test questionnaires showed a significant improvement in hospital staff self-perception of knowledge and skills in mci management. on a 1-10 scale, the improvement value was from 4.4 ± 2.5 to 7.5 ± 1.9 (p \ 0.001). conclusions: macsim-pemaf is a useful tool to test single hospital pemaf. it is versatile enough to adapt to specific realties, mimicking different traumatic scenarios. participants, acting in their usual professional roles, can increase their self-perception to be able to respond to a mci with in-hospital resources. introduction: emt are field health facilities, specifically structured to operate in case of disaster, where local healthcare resources are insufficient. there are 3 types of emt. ''emt2 regione piemonte'' is the first italian emt to be certificated by who. it's a type 2, meaning that more than triage and stabilization of emergency cases it's provided with an icu, a 24/7 working operation room, a test lab, radiological and ultrasound devices. it can admit up to 20 inpatients. cyclone idai made landfall on 3/15/19 in the district of dondo in mozambique. it brought torrential rains and strong winds and had heavy impacts on the city of beira and surrounding areas resulting in loss of communication and access. in addition important damage and destruction to shelter, settlements, health and wash facilities occurred. on 3/20 italian government approved the aid mission, from march 21st to 26th three italian military aircraft transported the medical staff and the boxes containing the hospital to maputo and then in beira. on 3/30, the hospital began working, treating an average of 80 patients and performing 4-5 surgeries per day, involving mozambican staff who immediately well integrated with the italian colleagues. results: 25 days of activities. 62 surgeries (28 orthopaedic, 10 general surgery, 18 gynaecology, 6 plastic surgery). 35.4% of the cases related to cyclone. mean tiss: 10 (8-13). mean age 33 (1-73) 34 females, 28 males. types of anaesthesia: 73% locoregional, 10% general, 17% analgosedation. conclusions: our first experience in a mass casualties' scenario showed how important is to refresh team skills through periodic drills. the leadership is of paramount importance to keep the team united and to support collaboration with other nations' teams and with the local population. adaptability and open-mindedness are fundamental. emts do not arrive in loco immediately so that longer periods of mission and integration with local medical staffs should be programmed. introduction: in utrecht, the netherlands, a worldwide unique major incident hospital is continuously standby to receive multiple victims during mass casualty events. each year, different types of mass casualty events are simulated with a varying number of victims, to train command and control under extreme circumstances. in utrecht, on march 18th 2019, a terrorist opened gunshot fire in crowded public transport. the aim of the study is to compare our experiences in simulation versus reality. material and methods: an internal evaluation was performed by questionnaires completed by participants and an external evaluation was performed by interviews. results: all five victims were brought to the major incident hospital, of whom two were dead on arrival, one died seven days after due to multiple organ failure and two survived after multiple surgical procedures. all victims arrived within 36 min after the major incident hospital was activated. a sufficient number of medical staff was alarmed for these five victims, however, since the event occurred during office hours, at least a double amount of staff showed up. among some medical staff on commanding key positions fear arose about their own safety and of relatives outside the hospital. this was exaggerated by incomplete and incorrect provided information from the scene. although medical care of the victims was not affected at all, occasionally the anxiety negatively influenced the command and control structure. conclusions: the combination of anxiety and a surplus of awaiting and benevolent curious medical staff resulted in occasional insufficient performance of the existing command and control structure, despite proper training. however, simulation of fear in a training is very difficult. nowadays, with the increasing threat of terror attacks, one should be aware of the influence of fear and anxiety on personnel, even with low numbers of victims. ethic and law issues during mass casualties management operations in foreign countries introduction: mass casualties incidents occur even more frequently during the last years globally. international help in order to manage them, when needed and asked, has to take into consideration special aspects of ethics and local law status in order to successfully fulfill its expectation. purpose: to demonstrate the ethic and law issues that arise during mass casualties management operations in foreign countries. material and method: literature review from recent management operations in syria, iran and sub saharan africa. results: during such operations a lot of ethical and law issues arise. the knowledge of ethics and laws in the country that these take place is essential and critical for the successful result of them. special care must be taken for the management of women, children and dead people. traditions and religion status of the local populations also must be taken into consideration and actions must take place in accordance to respect of the local authorities and social conditions. conclusions: mass casualties management operations in foreign countries is a challenging mission. ethic and law issues arise and must be taken into consideration for the success of the mission. western surgical experience is one thing, but surgical practice in countries in conflict zones is another. the pathologies are different, the thermal conditions are often difficult and the follow-up of the patients is fundamentally modified. humanitarian surgery is becoming more professional and most organizations are setting up a training program for new surgeons embarking on the humanitarian adventure. international committee of the red cross (icrc) has implemented an onboarding-surgeon experience, before to become a fully icrc surgeon. i hereby present my personal onboarding experience in south sudan: how to learn a new type of surgery, how to come with an helicopter to collect patients in the bush and then, how much you learn about yourself. conflict of interest: i only represent my own experience and i do not represent icrc. surgical clinical reasoning during the war in the period between 1992 and 1996, i was the head of operating rooms and icu at the clinic for orthopedic surgery and traumatology, in sarajevo. working in the operating room whose walls are shaking because of the sniping and shelling was not remembered by any other generation of surgeons. there were around 55000 traumatized citizens of sarajevo. thousands of injured, dying patients were seeking for help from a small number of surgeons. the duty of a surgeon working in the war conditions, without water, electricity, medicines, or heat, is not easy at all, and there were a lot of difficult situations. for example, one day, operated children were again wounded by direct shelling on the walls of pediatric department of our clinic. after we re-operated the children, we also operated the injured nurses. 27th may, 1992 , 5th february, 1994 , and 28th august, 1995 were the most painful experiences in the surgical treatment of disaster in the center of sarajevo, with a large number of massively traumatized patients. while you were helping one casualty, others were pulling our arms or legs. while you were helping one patient, others were dying in the cramp of pain. during the war, a series of traumatic events happened. above many thousands of them, i admitted a 13-year-old girl, severely injured, with traumatic lower leg amputation of the leg, and severe injuries of the thigh, pelvis, and neck. we operated on her through the night. during the surgery, she received 51 whole blood transfusions. following the surgery, she was stabilized on pediatric department of our clinic. one day, i saw her mother brought her a gift, immensely valuable in those days, a small canister of pure water. in the 2008, one girl approached me, and asked me if i remembered her. i remembered the canister of pure water. she was happy to show me how she can walk now, and told me she lives in canada and works as a university assistant. i was more than happy to see her walk proudly, as she was leaving. she injury pattern of 2019 earthquake in athens, greece: the panic-effect introduction: earthquakes are devastating events. greece is known to be in the first place of seismicity in europe and sixth worldwide. lately, a 5.1 richter earthquake shook the greek capital, and fortunately no substantial construction damage was sustained. the aim of the study is to evaluate the classification and severity of all injuries, as well as the type of orthopedic surgical procedures performed, in addition to the role that panic plays on the occurrence of these kind of trauma material and methods: prospective case-series study, conducted in the emergency department of our hospital after the july 19th, 2019 earthquake. the study included 18 patients treated by our department, who sustained injuries in their attempt to run away from the scene. age range was from 20 to 84 years old (mean 54.9 y.o), 11 were female and 7 were male. results: a total of 23 injuries reviewed. upper extremities were involved in 9 of all cases, lower extremities in 13 and one patient suffered minor head trauma. four patients required hospitalization and all of them underwent surgical treatment. open reduction and internal fixation performed in 2 patients (1 calcaneus fracture and 1 olecranon fracture), 1 patient underwent intramedullary nail fixation (tibial shaft fracture) and external fixation was applied to another (distal tibia fracture). six patients were conclusions: panic is an independent contributing factor in natural disaster associated trauma. prior education, preparedness and combined team effort are clearly needed, in order to reduce the incidence of these injuries. regardless of age, panic may result in various types of fractures, even in cases there are no substantial construction damages after an earthquake. digital and analogue record system for mass casualty incidences at sea: results, reliability and validity introduction: mistriage may have serious consequences for patients in mass causality incidences (mci) at sea. therefore, an exercise was conducted to compare the reliability and validity of an analogue and tablet based recording system for triage of sample patients. material and methods: 50 volunteers were asked to triage with the start-algorithm (black, red, yellow and green) 50 patients in a given time using an analogue and tablet based system. triage score distribution and agreement between the two triage methods and a predefined standard were reported. the present study assessed the triage results as well as the reliability through cronbachs alpha and kappa. for testing of validity and internal consistency, the sensitivity, specificity and predictive value was measured. results: forty-eight participants completed a total of 3545 triages. while the number of triaged patients in the given time was significantly higher with the analogue system compared to the digital system (p-value 0.001, t-test), the validity measured with the cronbachs alpha and unweighted cohens kappa was higher with the digital system. for each triage category, higher values were gained with the digital system. the sensitivity, specificity and predictive value for the digital system was higher than for the analogue system. conclusions: this study gives reliable and valid results comparing a digital versus an analogue triage system for a mci at sea. significant differences could be found for the number of triages and the number of under triage. the results of the study show that the used digital system has a slightly higher reliability and validity than the analogue triage system. references: the present work is part of the project improved emergency treatment and organization in the event of a mass casualty of casualties at sea (venomas), planned within the framework of the research network ''kompetenz und organisation für den massenanfall von patienten in der seeschifffahrt'' (kompass) and funded by the federal ministry of education and research (grant number: 13n13256). predicting outcome for extremity wounds in pediatric casualties of war introduction: during the early 90s, the international committee of the red cross (icrc) implemented the red cross wound classification (rcwc) for penetrating wounds. wound grades of 1, 2 and 3 describe the amount of kinetic energy transferred to the tissue (low, high and massive, respectively). currently, this classification system mostly serves as a descriptive tool, but it is hypothesized it could also support clinical decision making. the aim of this study is to assess whether the wound grade of a pediatric patient's extremity wound correlates with patient outcomes. material and methods: this study included pediatric patients (age \ 15 years), who have been treated by the icrc for conflictrelated extremity injuries between 1988 and 2012. the correlation of the following variables with the wound grade were analyzed: number of surgeries required, length of stay, and in-hospital mortality. results: the study cohort consisted of 2459 pediatric patients. the higher the wound grade, the more surgeries were performed per patient (p \ 0.05), with a mean of 4 surgeries per patient if they had a wound grading of 3. there were no significant differences in mortality rates between any of the wound grades, which were 1.0% (20/1953), 0.0% (0/342) and 1.9% (3/161) for wound grade 1, 2 and 3 respectively. pediatric patients with wound grade 3 were hospitalized for the longest period (mean 49.6 days), followed by wound grade 2 (mean 40.0 days) and wound grade 1 (mean 25.9 days; all with p \ 0.05). conclusions: the wound grade of pediatric patients' extremity wounds appears to correlate with some patient outcomes, but not with mortality. grading of extremity wounds according to the rcws could support clinical decision making in pediatric patients. introduction: during the last few decades, french armed forces have regularly deployed in asymmetric conflicts. surgical support for casualties of these conflicts occurs in nato role 2 and 3 medical treatment facilities (mtf); definitive surgical care occurs in france following a strategic medical evacuation. the aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or non-exclusively brain injuries. material and methods: this descriptive study is a retrospective analysis of the surgical management of french casualties performed in role 2 or 3 mtf in afghanistan, mali, niger, djibouti and the central african republic between january 2004 and december 2014. results: one hundred patients were included. forty had fragment wounds. the most severe lesions were of the head, neck or thorax. the average injury severity score (iss) was 34.9 (ic 95% 29.8-40). 17 damage control procedures were performed. thirty patients died with a mean iss of 61 (ic 95% 56-67); 5 deaths were considered as preventable deaths. the most frequent surgical procedures in the mtf were digestive (n = 31) and thoracic surgery (n = 19). thirty patients needed second-look surgery in france; eleven had severe complications. no patient died following medical evacuation to france. conclusions: results from this study indicate that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. introduction: telemedicine has been applied to disasters and extreme environments for more than 20 years, however, despite the many lessons learned so far, telemedicine is still not a common part of the immediate disaster response. for this reason, a review of the literature was conducted to investigate whether telemedicine technology can be used to address medical and non-medical needs in extreme environments. material and methods: this systematic review included 9 studies published in the period 2000-2019, originating from literature search bases medline, scopus, cinahl and pubmed. the case of neemo project were studied so to evaluate the diagnostical and surgical care of the patients regarding the emergency response in a remote and constricted area, with limited human medical resources and using the telecommunications and telerobotic technologies. results: the majority of the included studies have highlighted the importance of telemedicine interventions in extreme environments, stressing that it is a viable solution to health care provision. in addition, it has been found that telemedicinal technology provides the possibility of virtual collaboration between healthcare professionals with various specializations. projects neemo 7,9,12 engaged to eliminate the challenges of telesurgery. conclusions: future studies such as large multicentre randomized trials will have to be conducted that will lead to safe conclusions on the usefulness and efficiency of telemedicine applications in extreme environments. introduction: tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage. the optimal tourniquet type and effectiveness of non-commercial devices is unclear, and the aim of this study. material and methods: this prospective observational cadaverbased study was performed using a perfused cadaver model with a standardized superficial femoral artery injury bleeding at 700 ml/ min. five devices were tested: cat (combat application tourniquet), rats (rapid application tourniquet system), swat-t (stretch, wrap, and tuck tourniquet), a triangle bandage and a stick and a leather belt. 48 volunteer medical students with no prior clinical tourniquet experience participated. each student underwent a practical hands-on demonstration of each of the 5 tourniquets, prior to the test. using a random number generator, they then placed all 5 tourniquets in random order. outcomes measures included time to hemostasis, total time to secure devices, estimated blood loss (ebl) and difficulty rating. a one-way anova repeated measures was used to compare efficacy between the tourniquets in achieving the outcomes. results: participants' mean age was 25 ± 2.6 years and 29 (60%) were male. all participants were able to stop the bleeding with 4 of the 5 tourniquets. with the rats there was a 4% failure rate. among the five types of tourniquets, time to hemostasis and ebl were not statistically significantly different (p [ 0.05). the swat-t required the longest time to be secured (47.8 ± 17.0), while the belt was the fastest (15.2 ± 6.5; p \ 0.001). conclusions: all five tourniquets, including the non-commercial devices, were effective in achieving hemostasis. a standard leather belt was the fastest to place and able to stop the bleeding. however, it required continuous pressure to maintain hemostasis. nevertheless, in an emergency setting where commercial devices are not available, improvised tourniquets may be an affective lifesaving bridge to definitive care. hospital preparedness for mass gathering events and mass casualty incidents in matera, european capital of culture for 2019 introduction: mass casualty incidents (mci) may occur during mass gathering events (mge). lack of preparedness of health system increases mortality. education and training are crucial. hospital mci plans are mandatory in italy, but they are poorly known. on 2014, matera was declared italian host of european capital of culture for 2019: the local hospital decided to revise the hospital plan for massive influx of injured (pemaf) and to start a program to train the staff. material and methods: the pemaf was reviewed through simulations that involved all the staff. a partnership with mrmi-italia (italian chapter of the international association medical response to major incident and disaster-mrmi&d) leaded to the support of experts and to the organization of residential courses based on the macsim ò (mass casualty simulation) simulation tool. educational capacity of the residential events was tested through a self-assessment tool. results: alert, coordination and command sequences were defined. all the available resources were recorded and the functional areas identified. the communication network was improved. documentation and registration system was prepared. standard operational procedures (action cards) were created for the key positions. 7 residential educational events of macsim-pemaf were organized. the educational capacity was tested through self-evaluation: knowledge of participants resulted improved. conclusions: mge are a great opportunity for the hosting community but they also represent an increased risk of mci. preparedness is mandatory for health system. the format macsim-pemaf seems to be adequate to review the existing plans and transfer skills to attendants. introduction: the cruise industry is facing a constantly growth of infectious diseases. some of them are reaching the extent of mass casualty incidences (mci), which are overwhelming the capacity of the local rescue system. our aim was to improve the ability to act in a mci due to an infectious emergency regarding the situation at sea/in the port. hamburg, as one of the largest ports in europe, was chosen for analysis. material and methods: the collaborative project ''adaptive resilience management in the port'' (armihn) is funded by the german federal ministry of education and research. scenarios due to an infectiological emergency were developed together with the university central department of occupational medicine and maritime medicine and the hamburg port health center in hamburg, germany. these scenarios were specified with all key stakeholders in the port. the organizational structure of the current emergency management was analyzed and a new concept was developed. results: for the ship and the port, emergency strategies dealing with mass casualties of injured persons are available. nevertheless, current concepts regarding this special situation of an infectiological mci were missing. we developed a new concept, which based on the models concerning mass casualties of injured persons. for this purpose, emergency surgeons can be recommended as experts regarding coping with a major emergency and for developing adaptive training concepts. conclusions: new operational concepts coping with mci of infectious patients were developed. in a second step, an emergency plan and a training concept for relevant stakeholders in the port will be developed. these will be evaluated in a full exercise in the port of hamburg and tested for their suitability. the results will be transferred to comparable infrastructures to cope with a major case incident with infected people in the port area. emergency surgeons should be involved in these steps due to their expertise. the work was funded by the german federal ministry of education and research (13n14925). no further significant relationships. war surgery training, the use of swine model in military simulation center introduction: due to the international instability, our forces are deployed in many place and our military surgeons have to deal with ballistics trauma and improvised explosive devices related trauma. in order to be well prepared and effective in these isolated situation, the val de grace school (our military health service academy) provide a 2 years course to train the young surgeon. this 2 year surgical courses ended with war trauma surgery simulation on a swine model. material and methods: this use of the swine alive model is incorporated in the cesimco (military surgical simulation center) and also use for the training of our fully registered surgical team. this laboratory responds to all civilian authorizations and ethical considerations as enacted by european rules (felasa). results: the aim of this presentation is to show the different procedures and the teaching provided in this structure to improve surgical skills in war condition. all procedures are approved by the ministry in charge of the animal experimentation and respond to the animal welfare regulation. the number of swine used in these teaching is reduced to the minimum. we think that this animal model and its use in military forward surgical facilities, is the end point of the 2 years military surgical course provided by the val de grace school. conclusions: this model is actually the most reliable and ethically acceptable teaching procedure we've found. during these teaching the students have to deal with open trauma and hemorrhagic lesions in damage control situation. we try to follow the different type of war related lesions observed in french military in order to stick to the reality of the field. this teaching is now mandatory before being deployed as a military surgeon on field. case history: 29-year-old male, previously healthy, admitted to the er due to shotgun injury to the right hip. during transport, the bleeding open wound was covered, two iv catheters were introduced, and saline and painkillers were administered. on admission, the patient was conscious, eupneic and normotensive, with a gcs score of 15. clinical findings: after the primary survey and exclusion of cranial, thoracic and abdominal lesions, the limb injury was addressed, showing a 3 9 4 cm oval-shaped wound. the right leg was shortened and externally rotated. pulses were present but the patient referred calf and foot hypoesthesia. investigation/results: x-rays showed a comminuted pertrochanteric fracture and the presence of metallic foreign bodies. diagnosis: open right pertrochanteric fracture. therapy and progressions: initially, the wound was covered, and iv antibiotics and supportive therapy were given. in the or, irrigation, surgical debridement, and foreign body removal were performed, followed by orif with one dall-miles cable and a cephalomedullary femoral long nail. after surgery, the patient maintained lower limb hypoesthesia and had plantar flexion and foot dorsiflexion grade 0 motor deficit. during follow-up, soft tissues recovered uneventfully and bone healing successfully occurred. full weight-bearing was tolerated at 6 weeks post-op but the neurological deficits persisted despite physiatric treatment. electromyography confirmed severe partial lesion of the sciatic nerve. comments: generally, clean wound, fracture stability, restoration of circulation and skin closure of neurovascular structures are a priority and should be a reason for delayed nerve repair. introduction: despite mass casualty incidents (mci) are becoming a common concern, particularly regarding the care of paediatric victims, pure paediatric trauma centres (ptc) are still rare in europe. the purpose of this study is to assess the capacity of the hospitals in the metropolitan area of milan in case of mci involving the paediatric population, with focus on the pre-impact planning phase. material and methods: relevant literature and existing guidelines were reviewed by the representatives of four referral centres for the management of either trauma or paediatric patients. minimum standard requirements of care of paediatric trauma and consequently the maximal surge capacities for each hospital were defined based on the severity of injuries and personnel/equipment availability. results: overall, the four hospitals are able to treat 8 patients with the highest priority (t1), 8 to 12 patients with intermediate priority (t2), and 24 patients with deferrable priority (t3). severely injured patients \ 3 years old should be preferentially transported to the hospitals with paediatric expertise, whereas patients between 3 to 12 years of age can be managed in multi-speciality structures. conclusions: in case of mci it is not always possible to rely on the availability of a ptc. hospitals with paediatric trauma care expertise can work in synergy with ptcs, or offer an alternative if there is no ptc, and should therefore be included in disaster plans for mci involving paediatric victims. case history: we present a case of a 46-year-old male with a proximal radius and ulna gunshot fracture associated with a complete lesion of the brachial artery, which was urgently repaired by grafting in his native country. a partial proximal radius excision was also performed. three months later, after soft tissue recovery, the ulna fracture was fixed with a dcp plate plus iliac crest bone graft. at 2 months follow up x-rays showed hardware loosening, so the plate was removed and an external fixator was implanted. in this situation the patient attended to our clinic 18 months after the initial injury. clinical findings: findings included proximal pin purulence, an elbow varus deformity and a limited joint motion: flexion 45°, extension 40°, supination/pronation 20°. investigation/results: x-rays and ct scan showed proximal ulna pseudoarthrosis. diagnosis: proximal ulna pseudoarthrosis after a gunshot fracture. therapy and progressions: a two-stage procedure was performed. initially we performed a wide debridement and external fixator removal. an ulna nail combined with gentamicin and vancomycin pmma spacer was implanted. s. aureus was identified in intraoperative cultures. in a second stage, 1 year after, the nail and spacer were removed and a vascularized fibula graft with saphenous loop was implanted and fixed with a va-lcp plate. the central band of the interosseous membrane was repaired with a prosthetic device. currently, the patient presents full flexion range, hyperextension of 20°, active pronation of 50°and supination of 20°. x-rays show graft consolidation. comments: gunshot fractures are complicated lesions with significant soft tissue damage and high risk of vascular and nervous injury. a thorough study and initial systematic approach is mandatory in order to avoid later complications. introduction: the purpose of our study was to independently analyze pediatric trauma data, especially that of preschool-aged children, including demographics, injury patterns, the associated mechanism of injury, and outcomes, at a single institution in korea to gain a better understanding of current trends in non-regional trauma centers. material and methods: we conducted a retrospective review of preschool-aged children with trauma, who presented to the emergency department a single center between march 2010 and december 2018. results: overall, there were 303 pediatric patients who experienced trauma admitted during this study period. the frequency of admissions was similarly high in all seasons except winter. falls were the most common mechanism of injury at all ages, except 1, 2, and 4 years of age, according to comparative analysis by age and mechanism. the most common place of trauma at 1-3 years of age was at home, and outside the home at the age of 4 years or older. the most common injury region was to an extremity (65.7%). mean injury severity score was 5 ± 4.3, and the mean hospital stay was 5.9 ± 10.4 days. conclusions: although mortality from trauma is low in pediatric patients, we must continue to improve treatment outcomes for children. it is unlikely for a hospital to have a pediatric trauma specialist, such as a pediatric orthopedic surgeon or plastic surgeon, due to manpower constraints. in order to further improve the outcome of treatment with insufficient resources, it is necessary to recognize agespecific characteristics. question: the new safety situation in europe and the lessons learnt civilian events of damage show that hospitals have to be prepared for mass casualties. the shift of the operational mode to ''emergency medicine'' have to be planed and practiced. the reporting tool for this is the hospital action plan (hap) that every hospital should have. the efficiency of the existing plan is already proven in different largescale exercises. in germany the legislator obligates the hospitals to enable there staff to properly perform the different tasks of the hap. in addition, the have to develop and evaluate proper training and exercises. goal of this study was to establish along the hap of a level one trauma center an modular mass casualty training (manv 100) that would help to analyze the tasks to face and to deepen the existing structures of communication. method: we set a scenario with 100 casualties and evolved the different shifting phases of the trauma center (alarming-, mobilization-, constitution phase). setting the concept of training outside the regular service period we took in account that there will be a lack of resources and material. we did not exercise in a large-scale but trained in small groups modular. we also did a screen adaption of the hap of the trauma center to have a mind set for the staff and a starting point to the scenario. to teach our operative procedure we simulated our ''3 columns concept'' (medical, personal and infrastructure) to the staff. specific to the different task groups (medical doctors, technicians, nurses) we exercised and the different sectors (er, triage, or, command etc.) and the necessary shifts of the different hospital sectors when a mass casualty occurs. before and after we did a query of the staff to see how much impact the modular exercise would have on the hap-knowledge of our staff. results: we were able to simulate realistically an identical mass casualty scenario to different staff groups of our hospital. knowledge about the hap increased significant from 76 to 92% after the trainings. 97% of the staff see a clear improvement of information about the hap. also, the specific shifting-phases and the enrolment of the plan to move in an ''emergency medicine mode'' understand 85% better. 95% of the staff fell now a much better preparedness than before. 89% think that through modular exercises and small group training the communication in between working groups improved. conclusion: we could manage to improve a significant increase of knowledge about the hap in our staff. all the small group modular training in the different sector can be easily but together in large-scale exercise and other teams like police, military or fire-department can easily be added. introduction: dstc course focusses on surgical skills for trauma care. it is designed to teach surgical techniques for the definitive treatment of severe trauma. currently, it has evolved into an international trauma team course. our objective was to assess faculty members' opinion regarding course content, educational methods, and incorporation of non-technical skills. material and methods: a descriptive study was designed using an anonymous online survey issued from may 1 to august 31, 2019. senior international faculties' opinion from 19 countries assessed. the survey inquired views of courses content, duration, adequacy of hands-on practice, need for updates, and usefulness of incorporating non-technical skills to the course. results: from the 102 surveys issued, 36 were (35%) answered. the course content was valued as very satisfactory by 58%; 97% were very satisfied or satisfied with courses educational method. 80% considered the time devoted to lectures, case discussions, and skills lab very adequate or adequate. course duration (2 days) was valued suitably by 80% of responders. the inclusion of non-technical skills was considered as very important by 19%, important 31%, of some importance 11%, of little importance by 31%, and unimportant by 8%. this result reflects the insufficient sense of significance, among some, of the importance of trauma team dynamics. course content updates were seen as convenient by 97% of the surveyed population, suggesting them at least every 2-4 years. conclusions: dstc international faculty response to the online survey tool was inadequate, receiving 35% of the targeted study population. of the assessed faculty, most were satisfied with course content, duration, and educational methods. the surveyed population lacked a uniform perception of the importance of incorporating nontechnical skills. introduction: dstc is an iatsic course emphasizing on teaching surgical skills for trauma care. in many countries, it is an essential course focused on the ''second hour'' beyond atls and teamwork. initially centered on the surgeon, it currently seems to be adopting a trauma team training (ttt) model, incorporating the anesthetist to the program (ds-datc). our objective was to review this changing trend in three countries: spain, portugal, and brazil. material and methods: a descriptive study was designed by faculty from the three countries examining course records and analyzing its evolution during the last five years. number and types of courses delivered in each country from 2015 to 2019 reported, and the proportion of dstc to ds-datc scrutinized. frequencies and percentages calculated for categorical variables and the proportion of course types also determined. results: during the 5-year studied period, 70 dstc courses were issued: 34 (48%) in spain, 30 (43%) in brazil, and 6 (9%) in portugal. a total of 15 (21%) ds-datc courses in the three countries, and the percentage of total delivered in each country was as follows; spain 7 (21%), portugal 5 (83%) and brazil 3 (10%). overall ds-datc to dstc ratio was 1:5, detailed as follows: portugal 5:6, spain 7:34, and introduction: thailand is a disaster-prone country with a high dependency on tourism. it has been affected by both natural and manmade emergencies. the thai emergency healthcare system consists of emergency physicians working at hospitals and prehospital levels, emphasizing their essential role in emergency management of any incident. we aimed to investigate the thai emergency physicians' level of preparedness by using tabletop simulation exercises and three different scenarios. material and methods: using the 3lc (three level collaboration) method, two training sessions were arranged for over 50 thai emergency physicians, who were divided into three groups of prehospital, hospital, and incident command staff. three scenarios of a terror attack and explosion, riot and shooting, and high building fire were discussed in the groups. results: our findings indicate that the initial shortcomings in command and control, communication, coordination, and the ability of situation assessment increased in all groups step by step and after each scenario. new perspectives and innovative measures were presented by participants, which improved the whole management on the final day. conclusions: tabletop simulation exercises increase the ability, knowledge, and attitude of thai emergency physicians in managing major incidents in strategic, tactical, and operative managerial levels, and should be included in their professional curriculum. introduction: non-operative management of traumatic injuries has led to decreased surgical exposure for trauma trainees [1] . while simulation using cadavers may improve exposure to damage control techniques, tissue handling realism is variable depending on embalmment and perfusion techniques [2] . objective: to evaluate the feasibility of perfused thiel cadaver use for trauma surgery simulation. material and methods: thiel cadavers were cannulated in the ascending aorta and right atrium to create a left-to-right perfusion system. a magnetic pump was used to achieve a pulsatile flow with a gelatin-based solution, aiming for a flow of 4 l/min. peripheral circulation was improved with arteriovenous fistulas (carotid-jugular, femoro-femoral and brachio-brachial). a left common iliac vein injury was performed laparoscopically through the sigmoid mesentery. the surgical trainee was blinded to the initial injury and assisted by a staff surgeon. results: a trauma laparotomy was performed. the small bowel was eviscerated and all four quadrants were packed with gauze. a left, expanding zone iii hematoma was detected. the left sigmoid colon was mobilized to achieve proximal control of the left iliac vessels. the left common iliac vein was actively bleeding and ligated according to damage control principles. the left ureter was uninjured. the sigmoid mesentery was closed, without active bleeding. the remaining of the abdominal cavity was explored without other injuries. time from laparotomy to closure was 43 min. tissue handling and circulation dynamics were highly realistic due to thiel embalmment and pulsatile perfusion. conclusions: pulse-perfused thiel cadavers represent a realistic simulation option for surgical trainees. widespread implementation may provide accurate simulation for lifesaving procedures rarely performed in an era of non-operative management of traumatic injury. a new concept of intra-operative performance monitoring and self-assessment in hepato-pancreato-biliary surgery and other surgical specialties s. kharchenko 1,2 , m. yanovsky 3 1 colmar civil hospital, university of strasbourg, department of general surgery, colmar, france, 2 hepato-biliary institute henri bismuth, paris, france, 3 interceg, kharkiv, ukraine introduction: currently, the majority of learning curve studies for surgical interventions associated with simple chronometric estimation in a whole: from incision to closure. a selective approach for step-bystep time fixation of all hpb interventions (hepatectomy, others) or other surgical specialties can bring a new vision of correlation between intra-operative timing and the clinical outcome. material and methods: every operation can be divided into step items so standardized worldwide, for example, planned or urgent laparoscopic cholecystectomy e.g. incision to port placement, exposure, dissection to cholangiography, cholangiography, extraction, closure. results: the prototype named chronoi of infrastructure for automated monitoring (simulator of time tracking activities, web-service for request processing, database and knowledge base collection subsystems, learning curve representative and analytics software) is designed and to be implemented. individual self-assessment is available in a real-time fashion. the learning curve changes are shown per procedure. up to our knowledge, we can firstly in the world describe the surgeons, incl. in hpb, as speedy, standard or nonstandard depending on the surgeon's ''individual speed'' in operative performance. it's to be documented in their e-logbooks according to the current fellowship standards or practice re-certification. conclusion: the intra-operative monitoring and worldwide standardization give a new vision of the surgical practice in hpb surgery meaning an introduction of monitoring-based clinical outcomes (timing with morbi-mortality or other). only new trials will approve the role of the presented concept in hpb surgery as well as in general, emergency and trauma. introduction: the management of patients victims of war weapons and collective emergencies represents a major public health issue in france, but also abroad. terrorist events in recent years on the national territory have highlighted the need for training the population and caregivers in the management of these injuries. because of his experiment in the domain, the french military medical service (fmms) was requested to cooperate with the french prehospital teams in order to improve knowledge and teaching in this area. today, a continuing medical education, easily available and free access is needed in this area. material and methods: development of video podcasts (infographics) of a few minutes on the theme of management of patients victims of war weapons and collective emergencies. the working group ensures the production and quality of educational messages. production is provided by the communication establishment of defense. the broadcast is displayed on the channel you tube of the fmms. results: the title of the traum'cast podcast is the contraction of trauma and podcast. twelve episodes are scheduled on a 2-weeks rhythm. the podcast program is as follows: conclusion: fmms knowledge and experiment in managing patients victims of war weapons is unique. teaching can take various forms, theoretical, practical, academic, or through publications. traum'cast is a major innovation in the dissemination of this knowledge and each episode focuses on a specific skill. traum'cast will highlight the applicability of military medicine concepts in a civilian environment. traum'cast will be translated in an english version. project was supported by grants of french ministry of defense (innovation department). splenectomy in current surgical practice: a tricky and elusive procedure for the surgical resident? introduction: splenic rupture and oncologic resections are the most common indications for splenectomy, but technical expertise is progressively being taken over by non-operative and more conservative approaches. material and methods: retrospective review of all total splenectomies performed between february 2012 and january 2019 at an italian academic hospital, assessing demographics, diagnosis, operating surgeon, surgical approach, complication rate, postoperative critical care admission, and 30-day mortality. results: over 7 years, 163 consecutive splenectomies were performed by 25 different surgeons, 4 of whom surgical trainees, with 83 unplanned (i.e. emergency/iatrogenic injury) and 80 planned (i.e. benign/malignant disorders) procedures and an average of 11.9 and 11.4 procedures per year respectively. over the study period, only 9 surgeons performed at least 6 procedures and only 5 performed at least 12 procedures. laparoscopy was performed in 9.8% of cases, predominantly during planned procedures, with an overall 37.5% conversion rate mostly related to technical difficulties (i.e. spleen dimension, difficult vascular visualization). overall major postoperative complication rate (clavien-dindo c 3) was 19.6%, slightly higher in emergency procedures although not significantly different (13.7% vs. 25.3%, p = 0.08). reintervention rate was 12.3%, due to hemorrhage in more than half of cases. overall 30-day mortality rate was 5.5%, with elective 30-day mortality rate of 3.7% (p = 0.49). conclusions: splenectomy may be required ever more rarely but potential risks are not irrelevant. competence for surgical trainees should be achieved elsewhere (e.g. simulated/cadaveric training case history: an 84 year old femal patient underwent changing of the components of the tha because of aseptic loosening. due to circumstances the surgeon decided to implant a cemented femoral component. the procedure was without any significant abnormalities. the first postoperative radiograph was planned after recovery-as usual. the x-ray imaging showed a misplaced femoral component. therefore a ct-scan was performed additionally and the malposition of the cemented femoral component was confirmed. the patient had to undergo another surgery-removing of the cemented femoral component and implantation of a new well placed one. therapy and progressions: after prompt resuscitation, an emergency laparotomy was performed and an anastomotic leak was found, requiring re-do ileo-ileal anastomosis. postoperative course was complicated by intra-abdominal collection treated by antibiotics alone (clavien-dindo grade 2). the patient was discharged on 20th pod. at pathological report, segmental absence of intestinal musculature (saim) was diagnosed. the revision of past specimens confirmed the same finding. comments: usually recognized in neonates/premature infants, saim is generally an incidental finding in adults [1] , often undiagnosed and more frequently described in the colon [2] . in such scenario, main differential diagnosis is ischemia. etiology is unclear and can be classified as either primary/congenital or secondary. the former is characterized by acute onset of symptoms, whereas in the latter a longer history of intestinal symptoms is usually present [1, 3] . most authors agree upon a congenital pathogenesis. generally, saim is associated with hollow viscus perforation and treated with surgical resection. contrary to our experience, no recurrence of intestinal perforation has been reported [2] virgen del rocío university hospital, general surgery, seville, spain, 2 hospital regional de málaga, general surgery, málaga, spain, 3 hospital de estella, general surgery, navarra, spain, 4 hospital gregorio marañón, general surgery, madrid, spain, 5 complejo hospitalario de jaen, general surgery, jaen, spain introduction: specific training in the management of trauma patients is essential for surgeons. training through courses in this area (atls, dstc, musec) directly impacts the care of these patients. the aim of this study is to know the specific training in trauma care of spanish surgeons. materials and methods: a national survey has been sent to all member surgeons of the spanish surgeons association. it has evaluated their degree of participation in emergency surgery acute care, and therefore the possibility of attending trauma patients, their participation in the initial care at their hospital, as well as their specific training in this area. results: the survey has been completed by 510 surgeons from 47 spanish regions, and most surgeons who responded were from catalonia and andalusia. 456 (89.41%) of those surveyed take calls for the ed. only 171 (33.53%) report having a hospital registry of trauma patients. 72.15% of surgeons answer that in their hospital the general surgeon is not involved in the initial care of trauma patients. 66.47% have taken the atls course, 40.78% the dstc course, and 11.57% the musec course (or another course on e-fast). despite this, 85.69% consider the atls course should be mandatory during residency, and 43.33% of those surveyed consider trauma care in their hospital as very bad or deficient. conclusions: according to this survey, specific training in trauma care is still deficient in spain and with many aspects that can be improved. only 40% of those surveyed have received specific training in definitive surgical management of severe trauma. despite this, a large percentage of surgeons take calls for the ed routinely, and face the challenge of managing these patients. exploring team leaders' decision-making challenges in civilian and military complex trauma introduction: in the nordic countries professionals may work in both civilian and military trauma care. timely and effective decisionmaking in complex trauma is essential in improving survival benefits. the mindset and management priorities differ among medical professionals, and correlate with different experience levels. trauma leaders are usually senior surgeons with extensive experience and well-developed decision-making skills. simulation training has been shown to be effective in practicing decision-making. the aim of this study is to explore the team leaders' decision-making challenges in complex trauma care and structure them with the activity theory framework (at). material and methods: video recordings at a trauma center in johannesburg and live observations of complex trauma training in gothenburg focusing on team leaders' decision-making challenges were analyzed and systemized using the at. results: the team leaders' activities were mapped onto the main elements of at ( fig. 1) whereby the decision making challenges were classified into six categories (table 1) . conclusions: the at framework may benefit and inform the design of educational interventions by structuring key issues of complex activities. introduction: trauma is one of the main causes of mortality worldwide and prevention stands out as one of the main ways to modify its incidence. a prime example of such initiatives is the prevent alcohol and risk-related trauma in youth program (p.a.r.t.y.). it aims to raise awareness of the population most at risk for trauma, young people from 14 to 18 years. the study objective was to evaluate the program impact on students' knowledge and behavior. material and methods: a quantitative, uncontrolled intervention cohort study was conducted through the responses of the p.a.r.t.y. in 2017 and 2018. data collection occurred through the application of a questionnaire to participating and non-participating students of public schools in the city of campinas, after a few months of participation in the program. results: among 697 answers, 53.9% were male, 87.2% between 15 and 17 years, and 22.7% program participants. time between participation and answers was 10.4 (± 3.7) months. regarding the first conducts when facing traffic trauma, 48.7% of those who participated chose the correct answer, against 14.8% of those who did not. about the first care while the service does not arrive, 85.5% of the first group answered correctly, compared to 35.1% of the second. concerning about the service that should be called in the event of a trauma, 66.4% of participants would call correctly against 28.0% of non-participants. in questions related to traffic laws, 74.3% of participants opted for the correct answer as to what should be done in the face of a running over, against 23.20% of non-participants. conclusions: students who had participated in the program had a higher rate of correct answers, a few months after the event, compared with students who did not attend. thus, it is concluded that there is a impact over the time caused by it. introduction: currently, intraosseous (io) devices are necessary for the resuscitation of severe trauma patients. however, opportunities to learn io device insertion are limited for residents. the aim of this study was to conduct a simulation of io device insertion for residents and to evaluate its effectiveness. material and methods: in this simulation, residents inserted io needles into the sternum of pigs under general anesthesia with the instructor's guidance. comprehension tests and questionnaires about satisfaction level and self-efficacy were conducted before and after the simulation. the objective evaluation was the io access success rate, and the subjective evaluation was obtained from points on comprehension tests and questionnaires. results: thirty-six residents participated in this study. just one resident had successfully obtained io access clinically. success rate of establishing io access in the simulation was 100%. the rate of test completion was 100% and that of questionnaire with survey response was 61%. the comprehension test results improved from 9.2 ± 0.94 to 9.6 ± 0.79 (mean ± standard deviation, p = 0.01739) out of 10 points. the questionnaires concerning satisfaction level changed from 7.4 ± 2.9 to 14 ± 1.3 (p \ 0.0001) out of 15 points. the questions specifically concerning self-efficacy dramatically increased from 1.8 ± 0.91 to 4.1 ± 0.64 (p \ 0.0001) out of 5 points after the simulation. conclusions: the simulation in this study improved the knowledge, satisfaction level, and self-efficacy of the residents for io access. the success rate of confirmation of io access in this study was 100%. this experience may positively affect their clinical performance in trauma care. case history: case 1. a 37-year-old white man presented to the ed complaining of intense abdominal pain and vomiting. he referred at least two previous episodes with associated fever which resolved spontaneously. case 2. a 35 years old white man consulted at the ed for intense abdominal pain, nausea, anorexia and constipation for the last 48 h. none history of abdominal surgery were registered. clinical findings: in both cases, the abdomen was distended without bowel sounds. investigation/results: case 1. abdomen xr: distended small bowel loops localized at the right side. ct scan: an encapsulated cluster of dilated small bowel loops into the ascending mesocolon. case 2. ct scan: an encapsulated nonrotated small bowel in the right side of transverse mesocolon and mesenteric vascular pedicle displaced. diagnosis: intestinal obstruction secondary right paraduodenal hernia therapy and progressions: emergency midline laparotomy that evidenced a rpdh which was reduced before closing the mesentery defect. the postoperative was uneventful. comments: paraduodenal hernias are a type of internal hernia and a rare cause of intestinal obstruction accounting for about 0.5% of all hernias. right paraduodenal hernias are far less common than left ones. symptoms of paraduodenal hernias are nonspecific. preoperative diagnosis of pdh by imaging techniques is difficult. contrastenhanced ct scan is highly recommended as the most specific method of diagnosis for pdh. with the increased use and improved enhancement of ct scans, paraduodenal hernias currently can be diagnosed preoperatively. this advancement in diagnostics coupled with increasing experience and facility of general surgeons in using laparoscopic techniques has led to the initiation of laparoscopic repair of internal hernias. case history: a 52-year-old female patient who goes to the emergency department due to vomiting and abdominal pain. since the accident, the patient reported post-prandial discomfort and gastroesophageal reflux, as well as self-limited abdominal cramps. clinical findings: soft, depressible abdomen. bowel sounds on left hemithorax. investigation/results: cxr: right hemidiaphragm elevation. lab test: leukocytosis. thorax and abdomen ct: right anterior diaphragmatic hernia and passive atelectasis secondary to ascent of dilated small intestine and colon. diagnosis: intestinal obstruction secondary post trauma diaphragmatic hernia. therapy and progressions: emergency laparotomy due to symptoms compatible with intestinal obstruction secondary to incarcerated diaphragmatic hernia. it is right diaphragmatic chronic rupture chronic with omental incarceration, antrum, small bowel and ascending colon with reversible signs of suffering. chelotomy and content reduction, herniorrhaphy with loose spots with non-absorbable material are performed. endothoracic drainage is left removed at 48 h. the postoperative course is uncomplicated. comments: trauma events should be considered in the diagnostic process to avoid delayed treatment. case history/clinical findings: we present a 61-year-old male patient with a history of large pelvic mass in the rectum-prostate space under study, since 4 months. he were admitted into the emergency unit, 3 days after the mass biopsy, with fever up to 40°c and rectorrhagia. the patient rapidly developed septic shock with hemodynamic instability and elevation of acute phase reactants. abdominal ct was performed: pelvic mass of 11 9 9.3 9 12.5 cm, of heterogeneous content, with areas of blood density. we decided doing an emergency surgical exploration of this mass as the only suspected origin of infection. investigation/results: in the surgical exploration the mass was protruding on the anterior rectum wall. the mass was drainaged with an output of 400 ml of purulent material mixed with clots and necrotic tissue. foley no. 22 probe was placed inside the cavity. in the postoperative period, the patient showed significant hematochezia, so he was reoperated performing hemostasis and rectal tamponade. it was effective and a new foley catheter was replaced at 24 h. when the purulent drain gave way, the catheter was removed and the patient evolved favorably. diagnosis: cytology analysis: mesenchymal type lesion, morphologically and immunophenotypically compatible with gist (gastrointestinal stromal tumor). ihq profile: cd34, dog1, c-kit positive. therapy and progressions/comments: the complications of gist are usually acute abdomen due to peritonitis secondary to perforation or hemorrhage. however, the formation of intratumoral abscesses is very inusual, although is described in the literature. emergency surgery is often necessary due to the significant affectation of the general condition of the patient and the difficulty of the diagnosis. fournier's gangrene (fg) is a surgical emergency defined by an obliterating endarteritis of the subcutaneous tissue arteries of infectious etiology, with progressive necrotizing fasciitis of the perineal, abdominal, thoracic or lower limbs, which can lead to multiorgan failure. a 75 years old woman was admitted in our er presenting with a 1 week worsening vulvar pain. clinical exam showed vulvar and mons venus erythema, without lesions, bp was 111/47 mmhg and she had a fever of 38.2°c. blood work showed leukocytosis (27.68 9 10 3 /ll), neutrophilia (25.8 9 10 3 /ll) and crp of 387 mg/ l. past medical history of obesity, right thp and total thyroidectomy. vulvar cellulitis was the initial diagnosis and empirical atb was implemented. on d2, due to an evolution into septic shock and spread of an emphysematous inflammatory process to the right thigh and buttock, the diagnosis of fg was made. during emergent surgery we observed extensive fascial and tissue necrosis from the asis and suprapubic region to the proximal third of the right thigh and perineum. extensive necrosectomy, drainage of purulent exudate and transversostomy were performed. empirical second-line broad-spectrum atb was started. she underwent new necrosectomies and surgical debridements on po days 2 and 4 and needed icu stay for 5 days. daily dressing changes were performed with povidone iodine and later with octenidine. microbiology sample showed polymicrobial infection with gram positive and negative organisms as well as anaerobes, thus confirming the diagnosis of fg type i of vulvar origin. after surgical and hd stabilization, the patient underwent plastic reconstructive surgery, with local flaps and partial skin graft. the postoperative period was uneventful and the outcome was great. introduction: appendicitis is not uncommon in the elderly but may often be mis-diagnosed [1] . the aim of this study was to explore the specific traits and treatments of this group in a swedish context to better understand where to optimize the management. material and methods: all acute appendectomies registered in the southern general hospital registry between january 2015 and june 2019 constituted the cohort (n = 2687). patients were stratified into two groups; c 65 and \ 65 years of age. significances were computed with pearsons chi2 and anova. results: the older group made up 8% of the study population (n = 214). the elderly population was female to a larger extent (or 1.57, p \ 0.05), triaged higher in the emergency department (p \ 0.05) and had higher asa classifications (p \ 0.05). the elderly were also perceived as sicker at the time of decision for surgery, expressed as having higher priorities for surgery (p \ 0.05). no significant difference between the groups in time from arrival to decision for surgery was found, nor for the time from arrival to surgery. there was a higher rate of perforations in the elderly group (53.8% vs 25.0%, p \ 0.05), twice the length of hospital stay (p \ 0.05) but no significant differences in complication rates (9.2 vs 5.8%, p = 0.71). twenty-eight day mortality rate was 0% in the younger group and 1.9% in the older group (p \ 0.05). conclusions: this study shows that an elderly group of appendicitis patients are more frail and more acutely sick when presenting to the hospital. in spite of higher priority for surgery, the elderly experience longer hospitalization and higher mortality rate, but not more complications. the findings are consistent with antecedent research. introduction: existing evidence points towards the notion that patients undergoing emergency surgery receive a poorer consenting quality when compared to their elective counterparts. with 70,000 cholecystectomies in england a year, cholecystectomy is one of the most frequently performed procedures both in the emergency and elective settings. however, to date, no studies have explored the relationship between consenting quality and the setting of cholecystectomy. we aimed to measure the quality of informed consent (ic) for patients who underwent emergency vs elective cholecystectomy. material and methods: the final review included the analysis of 174 ic forms completed between 2011-2017. percentage proportions were calculated to demonstrate the degree of completeness of consenting against a total of 57 components of information. binary regression was utilised for subgroup analysis. results: patients undergoing emergency surgery were more likely than elective patients to be warned of severe perioperative complications such as cardiac disorders (46.6% vs 25.9%, p = 0.038), fluid collection (46.6% vs 25.9%, p = 0.010), and infected bile spillage (8.6% vs 1.7%, p = 0.049). elective patients were more likely to be counselled about the risk of less serious side effects of cholecystectomy such as diarrhoea (19.8% vs 3.4%, p = 0.027). patients in asa 2-3 group were more likely to be counselled about the occurrence of pulmonary embolism. interestingly, patients were more likely to receive a patient information leaflet if they were females and under 60. conclusions: the results of this study demonstrate multiple inconsistencies in the level of disclosed information to patients undergoing cholecystectomy. the results suggest that the consenting physicians make assumptions regarding the information that the patient would like to receive based on patient demographics and clinical factors, highlighting the need for more consistent consenting procedures. acute calculous cholecystitis and the timing of cholecystectomy: advocating early surgery i. moutsos 1 , r. lunevicius 1 1 liverpool university hospitals nhs foundation trust, general surgery, liverpool, united kingdom introduction: cholecystectomy cures acute calculous cholecystitis (acc) in nearly all patients and, according to nice, augis, tokyo and wses guidelines, should be conducted at the earliest opportunity, within 7 days of the diagnosis. the present audit aimed to measure whether the care of patients with acc meets the standards of best practice and to assess whether early cholecystectomy was a more beneficial and safer intervention as compared to delayed cholecystectomy. material and methods: a ''snapshot'' sample of 50 patients operated on between 12/2018 and 06/2019 with an index admission diagnosis of acc was reviewed. the selected patients were divided into three subgroups according to the timing of their surgery: 1-7 (early), 8-28, and[ 28 days. the other measures used in this audit were the rates of conversion to open surgery, subtotal cholecystectomy (stc), perioperative complication-specific morbidity, secondary interventions, and admission to intensive therapy unit (itu). results: nine patients (18%) underwent early cholecystectomy-laparoscopic (n = 8) or primary open (n = 1); 40 of the other 41 patients-delayed laparoscopic cholecystectomy. the rates of stc were similar in both subgroups-11.11% (1/9) vs 9.76% (4/41). delayed cholecystectomy was related to five side effects: higher rates of postoperative collections (three patients, 7.32%), external bile leak (one patient, 2.44%), ercp (2.44%), emergency re-operations (two patients, 5.56%), and admission to itu (5.56%). they all occurred in the delayed [ 4 weeks surgery subgroup of 36 patients. conclusions: although no significant associations were found when comparing early to delayed cholecystectomy, this analysis shows that postoperative morbidity, the rates of secondary interventions and admissions to itu were higher when surgery was delayed. this audit advocates that early cholecystectomy should become a standard of practice as per national and international guidelines. esophagopericardial fistula following primary repair for chronic esophageal ulceration presenting with pericardial tamponade: a case report and outline of management and treatment case history: a 54-year-old man with chronic esophageal ulcerations presented with substernal pain, fever, and shortness of breath. a radiograph revealed a right pleural effusion and pneumomediastinum consistent with an esophageal perforation (fig. 1 ). he underwent a right thoracotomy, primary esophageal repair with intercostal muscle flap buttress, and gastrojejunostomy feeding access. a post-procedural gastrograffin study demonstrated an anastomotic leak (fig. 2) . a right thoracostomy drain was placed for diversion. the patient was discharged home and returned 10 days later. clinical findings: he presented with substernal pain, hypotension, and fatigue. thoracic computed-tomography (ct) revealed a pneumopericardium and an esophagopericardial fistula (epf) manifesting as pericardial tamponade (fig. 3) . diagnosis: epf. therapy and progressions: the patient underwent a subxiphoid pericardial window and mediastinal drain placement for decompression. an esophagogastroduodenoscopy revealed an exposed right atrium, thus precluding esophageal stenting. sepsis and antibioticassociated clostridium difficile colitis complicated his post-operative course. once resolved, the patient underwent a partial esophageal resection, epf ligation, and esophagogastrostomy. the postoperative gastrograffin study did not demonstrate an anastomotic stricture or leak. the patient tolerated a regular diet and was discharged home. comments: esophagopericardial fistula is a rare clinical entity most often caused by benign disease. prompt diagnosis and treatmentpericardial decompression and fistula ligation-is critical. due to wide use of proton pump inhibitors and development of interventional radiology (ir), causative reasons are changing. introduction: secondary peritonitis yields high morbidity and mortality rates. besides rapid source control, adequate antimicrobial therapy is essential to improve outcomes. thus initial empiric therapy has to take suspected germ spectrum as well as possible resistance rates into account. microbial selection and resistances may pose problems during prolonged administration of antibiotics. however, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified. material and methods: intraabdominal swabs from consecutive patients from 2010 to 2018 requiring intensive care due to secondary peritonitis were evaluated retrospectively. patient characteristics and outcomes, germ spectrum and resistance rates were collected. changes over the course of therapy and development of resistance as well as influences on the clinical course were analyzed. introduction: complicated intra-abdominal infections (c-iai) represent challenging diseases with high mortality rates. depending on different selection criteria and therapy strategies the reported mortality rates vary between 7.6 and 36%. usually a distinction between community (cap) and hospital acquired peritonitis (hap) is made. hap can further be classified as postoperative peritonitis (pop) or non-postoperative peritonitis (hap-non-pop). we conducted a retrospective analysis of patients with c-iai requiring intensive care therapy. material and methods: all patients with c-iai requiring surgery and intensive care treated at the danube hospital in vienna from 2010 to 2018 were retrospectively analyzed. a total of 195 patients where included into the study and grouped as cap, hap-non-pop or pop. for each group comorbidity and patient characteristics, source and cause of infection, hospital and icu stay, apache ii, saps ii and sofa-scores, mortality and outcome were calculated and compared to each other, using fisher exact test or mann-whitney-u-test. results: a total of 195 c-iai were treated, consisting of 37.3% cap, 12.7% hap-non-pop and 50% pop. concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in pop. the postoperative (source control) apache ii and saps ii values did not differ between cap and pop (apache ii mean: cap 13.5, pop 13.29) whereas both were significantly higher in hap-non-pop (apache ii mean: 16.32). mortality rates were not significantly different in cap and pop (34.2% vs. 36.26%): however, hap-non-pop was complicated by a nearly doubled death rate (57.14%). conclusions: although patients with pop are described to have a higher mortality in the literature, this could not be shown in our study. postoperative survival was comparable between cap and pop patients. hap-non-pop demonstrated a significantly higher mortality. acute appendicitis and acute diverticulitis presenting concurrently treated surgically and conservatively clinical findings: on examination the abdomen was soft but there was tenderness and guarding in the right iliac fossa and suprapubic region. her observations were stable on admission and she was afebrile. investigation/results: laboratory tests demonstrated a wcc 24.79 (9 10 9 /l) and crp of 57.5 (mg/l). urinalysis was normal. a ct of the abdomen and pelvis with intravenous contrast demonstrated acute appendicitis with non-perforated sigmoid diverticulitis (fig. 1, fig. 2 ). diagnosis: concurrent acute appendicitis and non-perforated sigmoid diverticulitis. therapy and progressions: the patient underwent a laparoscopic appendicectomy. intraoperative findings included a retrocaecal inflamed appendix and diverticulitis in the pelvis which was not disturbed. there was no pus in the pelvis. she recovered well postoperatively and was discharged home to complete one week of oral antibiotics the following day. the histology demonstrated acute appendicitis. comments: there are very few reports in the literature of concurrent appendicitis and sigmoid diverticulitis despite these two pathologies being amongst the most common presentations of abdominal pain. this case demonstrates the value of cross sectional imaging, ct imaging is a helpful diagnostic tool and is highly sensitive and specific for both diverticulitis and appendicitis.the challenge in this case is balancing the two differing managements of these two conditions. most cases of diverticulitis are managed conservatively with dietary modification and antibiotics. operative management is only usually considered if there are associated complications such as intraabdominal perforation. this is in contrast to appendicitis where the standard treatment is to undergo surgery. references millions of people die from major trauma annually. 30-40% of these deaths are due to exsanguination, with nearly half dying prior to hospital arrival. when properly managed, these deaths are preventable. this paper summarizes data relating to the extent of hemorrhage as a cause of mortality in the traumatic arena. an overview of the pathophysiological steps occurring during massive bleeding and their clinical implication is presented. a variety of treatment options, both historical and current, is then discussed, including vascular occlusion methods and hemostatic dressings, along with their limitations and complications. finally, woundclot, a new hemostatic gauze, is introduced, which not only requires no compression when it is applied, but allows the first responder to rapidly and effectively treat more than one casualty within seconds. additionally, it is adaptable to a wide array of clinical applications, both traumatic and surgical, including situations where vascular occlusion methods are not practical or are contraindicated. i am the clinical research administrator for core scientific creations treating acute colonic diverticulitis with extraluminal pericolic air; a multi-centre retrospective cohort study background: since the emergence of acute care surgery as an entity encompassing trauma and emergency general surgery there have been several studies evaluating patient outcomes noting a higher unexpected survivorship and expedited operative times, shorter hospital stays, and fewer complications for patients undergoing procedures such as appendectomy; however, these superior outcomes have not been demonstrated across the array of emergency surgical cases. the aim of this investigation is to determine whether patients operated on by acute care surgeons in a trauma center benefit from the trauma model of in-house availability, earlier availability of surgical care, and care dictated by evidence-based protocol. we examined our health care system's data to determine if trauma centers were to able to provide more timely care with improved outcomes, by focusing on truly emergent general surgery cases. this was examined by identifying and quantitatively comparing time to operative intervention, need for re-operation, hospital length of stay, duration of stay spent in intensive care unit, and patient disposition at time of discharge. methods: this is a retrospective cohort study. patients presenting with emergency general surgery conditions (incarcerated hernia, perforated viscus, sbo, necrotizing soft tissue infection) who underwent surgery within 24 h of presentation were selected. outcomes were compared between patients presenting to our two trauma centers versus our two non-trauma centers. n = 1600 results: at this time we are nearing the finalization of our data interpretation. we are examining mean time to operation, los, icu los, need for re-operation, and disposition at discharge. discussion: although our data analysis is not complete we feel that the results of our data will shed valuable and needed light onto the care delivered to emergency general surgery patients by surgeons in this increasingly complex population. anastomosis leakage after hartmann removal, with conservative treatment at the beginning but after, bad evolution, a surgery was performed with colostomy and vac system. 3 patient. after 24 h, he develop a compartmental syndrome and a vac system was applied. investigation/results: 1 patient. after the first change the distance between the two layers was 18 cm and botulinum toxin was applied. 2 pat. the distance between the two layers of abdomen was 20 cm and botulinum toxin was applied. 3 patient. the distance between the two layers was 18 cms and toxin was applied. unfortunately, he suffered from a hepatorenal syndrome and died. diagnosis: open abdomen with distance between the two layers: 18 cm, 20 and 18 cm. therapy and progressions: we have added botulism toxin with doses of 20 units in each side of abdominal wall. 1 patient. three changes after, the abdomen wall was closed. 11 months later, the abdominal wall is ok. 2 patient. a reduction of 50% was got. comments: the use of open abdomen in patients suffer from septic shock or after an abdominal compartment syndrome often poses a challenge in the abdomen closure. we have developed a protocol, dividing our patients according to the distance between the two layers in two group: more than 10 cm or 10 cm or less. in the first group ([ 10), we present our first 3 cases in our protocol. conclusions: botulinum toxin can make easier abdomen closure when the distance between the two layers is more than 10 cms incidentally discovered splenic peliosis in a patient with no comorbidity clinical findings: a 51-year-old man with no comorbidities visited our emergency medical center based on a complaint of chest pain. the chest and abdomen radiographs, electrocardiogram, and cardiac markers showed no abnormalities; therefore, he was discharged from the hospital. two months later, he returned to our hospital with abdominal pain and distension. he was hemodynamically stable, and there were little tenderness and rebound tenderness on his abdomen, although he complained a slight abdomen discomfort investigation/results: no abnormalities were found on the laboratory examinations, including complete blood cell count, cardiac markers, and coagulation profile. an abdomen computed tomography revealed multiple hemorrhagic cysts on spleen with moderate amount of hemoperitoneum. diagnosis: ruptured splenic peliosis with hemoperitoneum. therapy and progressions: laparoscopic splenectomy was done because recurrent rupture of hemorrhagic cysts was strongly anticipated. on histologic examination, the blood-filled cysts were welldemarcated, distributed in red pulp congestion. no vascular-endothelial cells were observed, and normal lining cells were disappeared in the wall. comments: a peliosis is a rare disorder characterized by widespread, blood-filled cystic cavities within the parenchymatous organs. the liver is the most commonly involved organ, and an isolated splenic peliosis is extremely uncommon. patients are often asymptomatic; therefore, early recognition and withdrawal of offending agents is crucial. in cases with the rupture of surface lesions, which can occur spontaneously or by the minor trauma, prompt surgical management is necessarily required. splenectomy offers the advantage of a definite histological diagnosis with the complete elimination of the risk of recurrent hemorrhage. introduction: despite an evident success and advantages of endoscopic surgery, the discussion on reasonability of endoscopic surgeries in children with acute appendicitis is still going on. purpose: to assess the effectiveness of laparoscopic techniques for treating appendicular peritonitis in children. material and methods: 149 children with appendicular peritonitis were operated in our hospital (2016) (2017) (2018) . they aged 1-17 years (11 ± 3.5); 65.2% of boys, 34.8% of girls. appendicular peritonitis was registered in 7.7% cases of acute appendicitis. three ports were used for the approach: appendectomy was performed by the ligature technique with roder loop. results: laparoscopic surgery is indicated in all forms of appendicular peritonitis, except appendicular abscess stage 3, and total abscessing peritonitis. in appendicular abscess stage 3, we perform a puncture and drainage under ultrasound control. 3-6 months later appendectomy is made. total abscessing peritonitis is an indication for laparotomy. laparoscopic surgery in patients with peritonitis has the following stages: diagnostic laparoscopy; sanation of the abdominal cavity by the aspiration of purulent exudate; ligature appendectomy; in diffuse and combined peritonitis a pelvic aspiration drainage is made. in appendicular abscess stage 2, we additionally put the aspiration drainage in the cavity of destructed abscess. conclusions: laparoscopic technique applied for surgeries in children with acute appendicitis has considerably improved outcomes introduction: nighttime emergency surgery is associated with increased postoperative morbidity and mortality [1] , and delayed appendectomy due to acute appendicitis is not linked to a higher rate of postoperative complications (pc) [2] . the aim of this study was to determine whether appendectomy on-call (oc) was associated with higher risk of pc. (1) (2) (3) (4) (5) (6) (7) (8) . two patients underwent major thigh amputation. negative pressure wound therapy and hyperbaric oxygen therapy were used in 15 and 7 patients, respectively. three patients died (mortality rate = 12%). conclusions: the mortality and major amputation rates (12% and 8%, respectively) were lower than those reported previously. in this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. material and methods: a systematic search in pubmed/medline, embase, cinahl and central was performed. the primary outcomes were mortality and amputation. these outcomes were related to the following time related variables (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. for the meta-analysis, effects were estimated using random-effects meta-analysis models. results: a total of 109 studies (6051 patients) were included for qualitative analysis, of which 1277 patients died (21.1%). a total of 33 studies (2123 nsti patients) were included for the different quantitative analyses performed. mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (or 0.43; 95% ci 0.26-0.70). surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed more than 6 h. also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (or 0.41; 95% ci 0.27-0.61). patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. none of the time related variables assessed reduced the amputation rate. conclusions: average mortality rates reported remained constant (around 20%) over the past 20 years (fig. 1) . surgical debridement as soon as possible lowers the mortality rate for nsti with almost 50%. thus, a sense of urgency is essential in the treatment of nsti. altemeiers procedure in an emergency setting case history: three patients with irreducible incarcerated rectal prolapsed were referred to our department for treatment. all patients were female and their age was 57, 82 and 85 years old. all patients suffered from severe co-morbidities. clinical findings: all patients presented with incarcerated rectal prolapse. in one patient there was macroscopic evidence of mucosal necrosis, whereas the other two patients had evidence of ischemia. the former patient was febrile whereas the latter did not exhibit signs or symptoms indicative of sepsis. investigation/results: blood panels demonstrated leukocytosis and elevated levels of c-reactive protein (crp) in all patients. apart from routine imaging upon admission (e.g. chest radiography), no other imaging modalities were performed. diagnosis: irreducible incarcerated rectal prolapse. therapy and progressions: initially manual reduction of the prolapsed was attempted without success. all patients were evaluated as high risk surgical candidates. altemeier's procedure was selected as a safer alternative to an abdominal approach. all patients were successfully discharged after resumption of bowel function. comments: incarcerated rectal prolapse is a rare clinical condition. initial management involves manual reduction of the prolapse. when this is not feasible, urgent surgical management is mandatory. in patients with severe co-morbidities, altemeir's procedure is a safe and effective treatment when performed by an experienced practitioner. introduction: treatment options for sigmoid volvulus are decided by its severity. uncomplicated cases are usually treated by endoscopic detorsion followed by elective surgery and complicated cases or cases can't be detorsioned are treated with emergency surgery. in this study we aim to review a single center experience in long term management of sigmoid volvulus cases. material and methods: data of the sigmoid volvulus cases between 2009-2018 were collected using hospital database. files of 57 patients were reviewed for treatment modalities, demographic info and complications. 4 patients were dropped from the study due to inadequate long term follow-up. results: 37 were men and 16 were women. mean age was 54,9. endoscopic detorsion was attempted in 30 cases. success rate was 90% (n = 27). 10 of these patients were followed up with elective surgery. 23 patients with complicated cases and 3 unsuccessful detorsion patients were managed by emergency surgery. 16 hartman procedures, 10 anterior resections, 2 left hemicolectomies, 1 subtotal colectomy and 2 transverse loop colostomies were done. a stoma was created in 28 cases. 22 patients had their stoma created in the primary surgery and an additional of 6 stomas were created due to anastomosis leakage. mortality rate in the first 7 days was 25% (n = 7) in patients with a stoma (n = 28). asa and charlson co-morbidity scores were exceptionally high in the mortality group. in the remaining patient group, stoma closure rate was 57.1%. conclusions: endoscopic detorsion is a powerful and highly successful management option in uncomplicated cases when done by an experienced staff. emergency surgery shouldn't be delayed in complicated cases or after unsuccessful detorsion attempts. introduction: esophageal perforation has high mortality rates when not treated aggressively. treatment options are conservative approach, endoscopic intervention and surgery. purpose of this study is to review cases of esophageal perforation in a single center and to evaluate types of diagnosis and treatment options. material and methods: using hospital database we collected data of 26 patients diagnosed with esophageal perforation between 2009-2018. we reviewed treatment modalities, demographic data and complications. 1 patient was removed from the study due to insufficient long term data. results: 13 were female and 12 were male. average age was 59.9. average time between the onset of symptoms and admission was 2.2 days. the most common etiology was iatrogenic (n = 16) followed by consumption of corrosive substances in 2 patients, spontaneous perforation in 2 patients, esophageal tumour in 3 patients and foreign body ingestion in 2 patients. 11 patients were treated surgically, 8 patients were treated with endoscopic stenting and 1 patient was treated with surgery following stenting. 5 patients were managed conservatively with antibiotherapy. average time in intensive care was 8.4 days and average hospital stay was 26.6 days. mortality was seen in 3 patients treated with surgery and 2 patients treated with stents. conclusions: esophageal perforations are mainly iatrogenic but also can be caused by multiple reasons. especially in cases developed after endoscopy, rapid intervention can be a significant factor that can decrease both mortality and morbidity rates. introduction: spontaneous rupture of liver tumors (rlt) is a rare but potentially life-threatening condition. damage control techniques, namely perihepatic packing (php), is a resource for the most physiologically compromised patients, with more stable patients undergoing transarterial embolization (tae) or immediate resection. decision algorithm depends on patient status, available resources and liver function. the authors present their center experience in managing rlt and propose a management algorithm. material and methods: eighteen consecutive patients who underwent surgery for rlt in our department (january 1988-october 2019). inclusion criteria: spontaneous rupture and evidence of intraperitoneal bleeding. fourteen patients were male. mean age of 62.6 years (35-86). thirteen patients (72%) presented in hemorrhagic shock. mean tumor size was 6.72 cm (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) . most frequent pathological diagnosis were: hepatocellular carcinoma in 12 cases (67%); adenoma in three cases (17%); metastases in two cases (11%); liver sarcoma in one case (5.6%). median of seven units transfused by patient (0-25). statistical analyses with spss tm version 23.0 results: six patients (33%) needed immediate surgery (php in three and resection in three). five (28%) underwent urgent ([ 2 h and \ 24 h) and seven (39%) delayed ([ 24 h) resection. hepatectomy was performed on all (fifteen minor and two major) but one patient php only. eight patients (44%) underwent tae prior to resection, two of them (11%) between php and hepatectomy. median length of stay 10 days . major morbidity in three patients (17%); mortality in three patients (17%). number of transfused units associated with increased risk of complications (p = 0.009). conclusions: rupture of liver tumors is a severe complication. although hepatic resection, with or without preoperative tae, should be considered gold standard, damage control techniques such as php are the only option for physiologically compromised patients (fig. 1) . seasonal variability of cellulitis: a five year retrospective cohort study introduction: it is commonly purported that the incidence of cellulitis is highly seasonal but there is little empirical evidence supporting this assertion. this 5 year retrospective cohort study set out to identify whether there is a statistically significant relationship between an increase in temperature and incidences of cellulitis. as a corollary to this proposition, length of hospital stay for cellulitis was examined in relation to the level of inflammatory markers upon admission and micro-organism identified on culture. material and methods: this is a 5 year retrospective single centre cohort study of all patients admitted with cellulitis to tallaght university hospital from 2014 to 2018 inclusive. the patient cohort was identified via the use of a prospectively managed database of all surgical admissions and corroborated via examination of clinical chart records. dates of admission were correlated with the average temperature of dublin as provided by the meteorological office of ireland. site of infection, inflammatory markers and the prevalent micro-organism were also identified whilst the length of admission was extrapolated from hipe (hospital inpatient enquiry) records. results: there were 710 admissions for cellulitis with 3 cases of necrotising fasciitis. there was a statistically significant (p \ 0.05) relationship between temperature and cellulitis with admission peaking in late summer/autumn. age correlated significantly with readmission. furthermore, the level of crp had a statistically significant prognostic value as an independent predictor for the length of hospital stay with a high level resulting in a prolonged admission. conclusions: there is a statistically significant relationship between a rise in temperature and the incidence of cellulitis. furthermore age is an independent risk factor for re-admission with same whilst inflammatory markers at time of admission can be used as a prognostic marker for length of stay. case history | clinical findings: a 88-year-old female patient, with history of type ii diabetes, high blood pressure and major depressive syndrome, was admitted in the emergency room department complaining of abdominal pain. based on the patient's history and physical examination, a presumptive diagnosis of renal colic was initially made. however, after 2 days, the patient showed signs of fever, aggravated abdominal pain and vomiting. investigation/results | diagnosis | therapy and progressions: a ct scan showed the presence of a radiopaque foreign body near the duodenum, the presence of air bubbles outside the intestinal lumen and an hepatic abscess. we agreed to perform a laparoscopy, drainage of hepatic abscess and fish bone removal after successfully identification. after 4 days, the laboratory findings showed persistent leukocytosis and raised cpr, which led to a second ct scan with maintenance of the hepatic abscess. the decision was to perform a percutaneous drainage. after the second drainage, the patient had an uneventful recovery. comments: foreign body ingestion into the gastrointestinal (gi) tract is rare and typically accidental in adults. most ingested foreign bodies pass through the gastrointestinal tract without the need for any intervention. gi perforation is rare and can occur at any site. surgical intervention is required in less than 1% of the cases. fish bones are the most commonly ingested objects. preoperative diagnosis, when possible, is made with ct scan, identifying a linear high-density structure. high level of suspicion is of paramount importance. in cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation. reports of hepatic abscess secondary to fish bone perforation has been limited to isolated case reports in the literature. case history: description of two cases of appendicular goblet cell carcinoid tumors, which debuted as acute appendicitis. patient a was a 54-year-old woman with a 24-h evolution of classic symptoms of acute appendicitis. patient b was a 70-year-old female that consulted for chronic abdominal pain in rlq that recently increased pain intensity and fever. clinical findings: patient a had pain and defense in rlq without a fever. patient b had a chronic painful fluctuating mass in rlq, with fever over 38°c. investigation/results: patient's a lab test showed leukocytosis and us findings of acute appendicitis. the patient's b ctscan showed an intra-abdominal abscess fistulized to the abdominal wall, along with formation of a phlegmonous mass related to appendicular plastron. diagnosis: the anatomopathological reports for both patients were informed as appendicular goblet cell carcinoid tumor. therapy and progressions: both underwent laparoscopic exploration. after appendicectomy in patient a, when the diagnosis of gcct was made, the case was discussed at our mdt meeting and a right hemicolectomy was indicated and performed shortly after. in the patient b a right hemicolectomy was performed in the initial surgery due to the magnitude of tissue involvement. currently, both are receiving chemotherapy with xelox without signs of recurrence or tumor spread on follow up. comments: the gcc is a rare entity of appendicular tumors with a less favorable prognosis than the appendicular pure neuroendocrine tumors. it behaves like a low-grade adenocarcinoma and often presents as disseminated disease. therefore, sometimes surgical treatment with appendicectomy is not enough, needing the right hemicolectomy to avoid recurrence. this is recommended for tumors [ 2 cm, pt3 or t4 and higher grade histology. introduction: among the post-pancreatoduodenectomy complications post pancreatoduodenectomy hemorrhage (pph) is the least common complication, but severe form may be life-threatening without an urgent treatment. late pph are more likely due to a complex physio-pathological pathway secondary to different etiologies. the understanding of the etiology and such a pathway could therefore be of great interest to guide the treatment of potential lifethreatening late severe pph. results: during the aforementioned period 347 patients underwent pd, of whom 18 (5.18%) developed pph. early pph was reported in one patient (5.6%) with severe bleeding from the gastric stapler line. late pph were reported in 17 of these patients (94.4%). the most common causes were bleeding from a vascular pseudoaneurysm reported in 6 patients of which, one had mild and 5 had severe hemorrhage and bleeding from gastro-enteric anastomosis marginal ulcer in 6 patients, all with mild hemorrhage. no etiology was fond in 5 patients with mild hemorrhage. a significant association was found between the severity of late hemorrhage and the vascular pseudoaneurysm as a cause of bleeding (p \ 0.001). all pseudoaneurysm bleeding occurred in cases complicated by a postoperative pancreatic fistula (popf) with a significant statistical association (p \ 0.001). conclusions: the most common cause of pph was bleeding from a vascular pseudoaneurysm, most of them were severe bleeding with late presentation and all were associated with a popf. in these cases, early detection by cta is mandatory, allowing an urgent treatment by angiography of such a bleeding vascular complication following pd. ventral hernia in hostile situation introduction: there is no consensus about the benefit or harm derived from adding a mesh hernioplasty at the same time as an urgent intraperitoneal surgery for another cause. the use of a prosthesis in contaminated fields is controversial, but suture repair has a high risk of recurrence. the main objective has been to analyze the impact of the simultaneous repair of uncomplicated midline hernias at the same time as emergency surgery for another cause, in relation to the presentation of complications, the surgical site infection rate (isq) and recurrences. material and methods: retrospective, observational study of all urgently operated patients (surgery open and laparoscopic) in the period between 2015-2018 who underwent a simultaneous midline primary ventral hernioplasty. the background, circumstances of the surgery and postoperative complications during the first month and long term through the basis of prospective data of emergency surgery and complications of our surgery department. results: a total of 94 patients (50 female) met the inclusion criteria with a mean age of 57.2 years (sd = 17.5), average bmi of 28.7 kg/ m 2 (sd = 5.1). the most frequently performed interventions were: appendectomy (38.3%); cholecystectomy (48.9%); and lysis of adhesions (4.3%). the 89.4% of all interventions were performed by laparoscopic approach. they presented associated peritonitis in 12.8% of the cases. the 41.5% of patients presented some complication, in 13.8% surgical site infection (3.2% organ space). during the followup three recurrences were detected (3.2%), no patient has presented chronic infection related to the use of prostheses. conclusions: in our series the simultaneous performance of hernia repair of the midline in the context of emergency surgery for another cause has been safe and not associated with long-term complications and low recurrence rate. the open abdomen: our experience introduction: ''open abdomen'' refers to a solution in which the abdominal content is left deliberately exposed under a temporary cover for a variable amount of time. since 1970 this method has been used more and more for the treatment of severe intra-abdominal infections. starting from the 80s the concept has been also applied in trauma surgery. material and methods: between 2002/2019 we have treated 200 patients with this technique. in 45 cases the etiology was traumatic, in the remaining cases the abdominal pathology was inflammatory. in the last years we also started to use it in some cases of treatment of surgical complications. the techniques we used were different and changed during the time. at the beginning of the experience we've completed 4 drainages of the abdominal cavity according to mickulizt, 5 laparostomies with mesh, 18 bogota bags. these techniques have been abandoned since the negative pressure therapy came out. we started with the barker vacuum pack (36 cases), followed by the vac (vacuum assisted closure) and ab thera kci ò (33 patients) systems and in the last three years we used the cnp suprasorb ò of lohmann and raucher (104 patients case history: 79 year old lady presented at the a&e with few days history of constipation, faeculent vomiting, abdominal distension and pain in the lower abdomen. she had hysterectomy many years ago through a lower midline incision. her urgent ct scan of the abdomen and pelvis confirmed an incarcerated right obturator hernia containing a small bowel loop causing bowel obstruction. clinical findings: elderly, frail patient with mild tachycardia, distended abdomen and lower abdominal tenderness with guarding in the left iliac fossa. per rectal examination was unremarkable. investigation/results: inflammatory markers were raised, lactate, liver and kidney function was in normal limits with only mild hypokalaemia and hyponatraemia. ct abdomen and pelvis confirmed small bowel obstruction at the mid ileal level due to right obturator hernia. diagnosis: incarcerated right obturator hernia causing small bowel obstruction. therapy and progressions: patient was taken to the operating theatre for urgent laparotomy. dilated small bowel loops and incarcerated right obturator hernia was found with proximal ileal loop in it. after blunt stretching and dilatation of the obturator foramen, the involved ileal loop was reduced. it was deemed viable, therefore no bowel resection was required. the defect at the right obturator foramen was closed with suture. post-operatively the patient was transferred to the intensive care unit for further management. comments: obturator hernias are a rare type of pelvic hernias. their real incidence is unknown but it is thought to be less than 1% of all hernias worldwide and due to its non-specific symptoms and late diagnosis, they require bowel resectional surgery in nearly 50% of the cases. howship-romberg sign is helpful in diagnosing such a hernia, but the ultimate diagnostic choice is ct scanning which is the only way to find this condition early and avoid bowel ischaemia. case history: a 21-year-old woman without previous medical history presented to the emergency department with abdominal pain and dysphagia associated with nausea, vomiting and absolute constipation. during previous months, she reported having ingested hair. clinical findings: abdominal examination revealed a distended abdomen with rebound tenderness and tinkly bowel sounds. investigation/results: ct-scan showed a distended stomach with a mussel-shaped, heterogeneous and non-enhancing mass. an esophagogastroduodenoscopy revealed hair inside the lower esophagus and the stomach. diagnosis: high intestinal obstruction due to a gastric trichobezoar. therapy and progressions: the patient underwent laparotomy, gastrotomy and trichobezoar removal (fig. 3) . the postoperative period was uneventful and she was discharged home on the 8th pod with a psychiatric evaluation scheduled. comments: bezoars are rare conditions consisting of compacted material that is unable to pass through the gastrointestinal tract. 1 this condition usually involves the stomach; rarely, it can extend into the small bowel and even the colon, giving the so-called rapunzel syndrome. 2 bezoars could be composed by vegetable material (phytobezoars), hair (trichobezoars), drugs (pharmacobezoars), or other materials. 1, 3 a trichobezoar is the result of trichotillomania, trichophagia or other psychiatric disorders. 3 always consider bezoars in differential diagnosis. introduction: the effectiveness of different step-up approaches is increasingly evaluated but results are controversial. we assessed the results of a standardized step-up approach protocol in the treatment of acute severe necrotizing pancreatitis, with a special focus on patient stratification to obtain an early identification of those deserving a more aggressive strategy. matherials and methods: this is a retrospective analysis of patients with acute severe pancreatitis over a period of 10 years. the variables taken into account were: etiology and severity of the disease, sepsis, organ failure, hemodynamic stability, treatment, los, morbidity, mortality. since 2016, patients with infected necrosis underwent a standardized step-up approach: percutaneous drainage only; percutaneous and endoscopic procedure; surgery. the results were compared with the standard care delivered from 2009 to 2015. results: among 142 patients, 51 (35.9%) were identified as affected by severe necrotizing disease. overall mortality was 29.4%. the initial management was non operativein all patients. mortality in the step-up group was 20% (3/15) vs 25% (9/36) in the standard care group. conclusion: a standardized step-up approach protocol offers better results than standard care in the management of acute severe necrotizing pancreatitis. however, a better stratification of patients. introduction:the appendix stump closure in complicated appendicitis has been widely practiced in different ways such as metal clip, hem-o-lok clip, endoloop and endostapler. the treatment of complicated appendicitis with necrosis and perforation of the appendix base is controversial. we aimed evaluate the efficacy of laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and base perforation. material and methods:from january 2015 to october 2019, we evaluated 28 consecutive patients who underwent a laparoscopic partial caecum resection in complicated appendicitis with necrosis and perforation of the appendix base. partial caecum resection was performed with the endostapler to close the appendix base at ileocaecal junction. results:the laparoscopic partial caecum resection with endostapler was used in %92.8 of the cases. the mean operative time was 100.07 ± 34.12 min. there were necrosis of appendix base in 12, perforation of appendix base and diffuse peritonitis in 9, perforation of the appendix base and localized peritonitis in 7 of the patients. the wound and intra-abdominal infection rates were 9.8% and 7.2%, respectively. there were no operative complications and the conversion rate was 7.2%. the average length of hospital stay was 4.46 ± 3.10 days. there was no leakage on the stapler line. conclusions:the laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and perforation of the appendix base, is a safe and effective technique. introduction: the term ''''volvulus'''' comes from the latin ''''volvere''''meaning twist. if left unattended, sigmoid volvulus can compromise the blood supply of the involved segment,leading to ischemia,gangrene,perforation and death. the mainstay of sigmoid volvulus management has been through proctoscopic or colonoscopic decompression when feasible, followed by surgery either during the same admission or electively. the aim of our study is to identify patients which can benefit of immediate surgical approach and prognostic factors associated with failure of conservative/endoscopic treatment. materials and methods: charts of 27 patients admitted for sigmoid volvulus to our institute were retrospectively analysed. we revised ct scan images and laboratory tests of all the patients to identify risk factors for conservative treatment failure. results: 18 patients underwent surgical procedures; in 9 cases after a failure of an initial conservative approach; 9 patients were managed with endoscopic approach only. elective surgery was performed in 2 patients. case history: we report a 32-year-old male case presenting left hand middle finger pain after pressured paint gun shot in volar proximal phalanx clinical findings: on physical examination swelling and tenderness on the volar side of the hand was observed (fig. 1 ) investigation/results: pain was remarkably more intense with passive finger extension. distal nerurovascular status was unscathed. there was no fracture reported on radiography. leukocytosis and acute phase reactants rise was observed on laboratory examination diagnosis: after physical, radiological and laboratory examination the diagnosis of acute flexor tenosynovitis was made. therapy and progressions: open debridement and irrigation following bruner incisions on middle finger was undertaken within 4 h of injury. paint impregned in tissues could be observed in subcutaneous tissue, palmar fascia and flexor tendon sheath. paint affected tissues samples were analysed in microbiology laboratory (fig 2, 3) after checking nerurovascular indemnity, 14g drainage was left in deep tissues and skin suture was performed with 4-0 monofilament non absorbable suture. the patient followed 3 days intravenous antibiotical therapy followed by 4 weeks oral treatment. he attended physiotherapy program postoperatively, reporting no functional disability or wound complications after 3 weeks. comments: chemical flexor tenosynovitis is an important emergency which must be correctly diagnosed and treated due to quick progression and potential morbidity if not treated effectively (1) in our experience, case was managed by open debridement and irrigation but different treatments can be followed depending of patientsclinical situation, such as iv antibiotics with serial examinations or percutaneous drainage. it should also be noted that australia does not have a specific subspecialty in emergency surgery. the acute surgical unit at the tch was set up in 2010 in order to provide a dedicated acute unit to service the ever increasing demand acute surgery. previous model was that the acute surgical service was integrated into the elective work. 16 additional beds were provided to the unit including the positions of a dedicated director and chief nurse. the achievement of the unit has been the decreased time to theatre, less after-hours operating, standardised treatment approaches, and dedicated emergency surgery medical staff. the difficulties have included clinician engagement, competing resources with elective surgery, emergency surgical presentations increasing by 3-6% each year, and the unit''s beds being used for non-acute patients as the hospital approaches regular 100%. the acute surgical unit has evolved into a specialised acute care that enables rapid assessment and treatment of patients with staff dedicated with skills in this area. treating pyogenic liver abscesses secondary to diverticulitis in a patient using immunosuppressants for crohns disease by performing a sigmoid colectomy introduction: pyogenic liver abscess (pla) formation due to microbial contamination of the liver parenchyma is often seen secondary to intra-abdominal infections. pla formation due to crohn''s disease (cd) is a rare complication and not well-documented in current literature. as symptoms often mimic a cd exacerbation, diagnosis is often delayed and severe disease may develop. optimal treatment for this group of patients remains debatable. case presentation: a 54-year-old man was admitted to the hospital with a 2-week history of overall malaise, fever and night sweats. patient''s history solely stated a 6-year treatment of cd that was stable over the past period with infliximab and azathioprine. investigations and treatment: biochemical analysis revealed a c-reactive protein of 314 mg/l and a white blood cell count of 15.3 9 109/l. an abdominal ct scan showed multiple abscesses in the right lobe of the liver and a thickening of the wall in the transition of the descendent colon to sigmoid. the patient''s immunosuppressants were paused, intravenous antibiotics were administered and a percutaneous drainage of the biggest pla was performed. however, the clinical condition of the patient did not improve. colonoscopy and pet-ct scan did not reveal any other sites of infections. as patient remained septic and previous imaging revealed mild diverticulitis rather than active cd, an emergency hartmann''s procedure was performed. hereafter, the patient recovered rapidly and the plas resolved completely. conclusion: diverticulitis of the sigmoid colon should be considered as causative pathology in patients presenting with multiple pyogenic liver abscesses and a history of crohn''s disease that is in full remission with immunosuppression. when the abscesses exceed 3 cm in size and are multilocular, resection of the inflamed colon can be a treatment option of value. clinical findings: epigastric pain and recent episode of hematemesis. pain at deep palpation of the epigastrium, no signs of peritoneal irritation investigation/results: abdominal x-ray and ct showing a large right sided strangulated paraesophageal peh, with pneumatosis of the gastric wall diagnosis: right sided strangulated peh therapy and progressions: emergent laparotomy. peh reduced, ischemic portion of the stomach recovering viability. closure of diaphragmatic defect with non-absorbable suture, reinforcement of lower esophageal sphincter with round ligament (ligamentum teres hepatis) and anterior partial fundoplication (dor). postoperative course uneventful, patient discharged on 10th pod. comments: peh are mediastinal displacements of abdominal organs, most often the stomach, associated with laxity or a hole in the phrenoesophageal membrane, large enough to allow the gastric fundus to herniate. because the stomach is attached to the gastroesophageal junction, it tends to rotate around its axis leading to organoaxial volvulus. occurrence and size increases with age. peh account for 5-15% of all diaphragmatic hernias. in patients without prohibitive operative risk, they should be surgically corrected, avoiding the risk of acute and potentially life-threatening complications when emergent surgical repair is required. the risk of developing these complications is less than 2%/yr and associated mortality rate is approximately 5%. case history: patient was a previously healthy 40-year-old female with an unremarkable past medical history, non-smoker with a high body mass index (bmi [ 30). she first presented to a level 2 medical facility with acute left upper leg pain and swelling. one week prior to this she had a progressive cough, swinging fever, and malaise. clinical findings: patient was transferred to our hospital haemodynamically unstable, acidotic, hypoxemic and delusional. tachypnea and oliguria were present. she continued to deteriorate clinically with pyrexia (t 39,3 oc), resistant shock, and toxaemia. on examination her left leg was found to be paresthetic below the femoral-inguinal fold. investigation/results: abg samples showed lactic acidosis with a ph of 7.32 and lactate of 3.2 mmol/l. hypoxia and hypocapnea were present.her biochemical profile showed acute kidney injury (aki) with raised creatinine kinase (cpk) 850 and serum creatinine (cr) 2.08. chest x-ray illustrated bilateral lung infiltrations (ards image). diagnosis: patient was urgently referred to a ct scan of the left femur with i.v. contrast for suspected necrotising fasciitis. ct findings highlighted a deep muscular femoral abscess with multiple regional fluid collections and necrotizing inflammation from the femur diaphysis to the patella. therapy and progressions: the patient was immediately transferred to or for emergency surgical exploration and debridement. almost the entire anterior compartment of the femur was necrotic and hence an extensive excision of the dead tissues and packing with npwt was performed. comments: severe snm can cause marked systemic toxic effects, namely, the streptococcal toxic shock syndrome (stss). stss secondary to snm is a life-threatening host response to gas superantigens with a mortality rate as high as 80%. clinical findings: patient had a diffusedlty tender abdomen and had not passed flatus proceeding his admission to the a ? e department and was vomiting. investigation/results: ct abdomen showed small bowel dilatation with abrupt cut-off point proximal to the icv diagnosis: a diagnosis of small bowel obstruction was made based on the clinical and ct findings. therapy and progressions: patient was taken to theatre for laparoscopy ? -proceed and a 'slipped' bowel lopp was noted within the peritoneal flap that had been created a week prior during the original hernia repair. the 'v lock'' suture line was found to be loose which is thought to have led to this complication. the bowel loop was reduced, deemed viable and an internal hernia repair was performed. post-operative period was unremarkable and the patient was discharged day 3 posy-operatively. comments: during lap tapp hernia repair, there are currently at least 3 options avaiable for peritoneal flap closure; (sutures, tackers and glue.) suregons prefernce prevails over the chosen approach. when sutures are chosen, most surgeons prefer the self-locking v-lock stitch. by adopting this technique, meticulous periotneal closure is impoartan, as loose suturing of the peritoneum can lead to post operative complications of internal herniation and small bowel obstruction, as described in this case. a multi-centre prospective study would be welcomed, to compare efficacy and safety of all types of peritoneal closure devices. introduction: peer review assessment of medical treatment has been shown to be a robust way of improving quality of care in trauma in our institution and globally. in 2016 we introduced regular morbidity and mortality meetings at the department of gastrointestinal surgery. severe complications (revised accordion classification [ 3) after surgery were identified on a weekly basis, evaluated and data included in a local quality registry with the aim of revealing suboptimal surgical quality and continuously improving our results. material and methods: retrospective analysis of collected data from the described quality registry. all adult patients who had undergone gastrointestinal surgery in 2018 were assessed. results: of 2091 surgical procedures performed, 70% were emergency procedures. a total of 11% (239/2091) experienced a severe complication after surgery and 6% (125/2091) required reoperation. in the group of upper gastrointestinal surgery [n = 570 (27%)] 59% were emergency procedures. anastomotic leak (al) was identified in 15% (9/59) undergoing thoraco-laparoscopic esophagectomy and in 8% (3/36 patients) after gastrectomy. of 190 laparoscopic cholecystectomies, 79% were emergency procedures with 1% (1/151) reoperation. of 106 hernia repairs, 5% required reoperation. in the group of lower gastrointestinal surgery [n = 1521 (73%)] 74% were emergency procedures. al was diagnosed in 5% of 257 colonic resections and 11% of 87 patients after rectal resection. in emergency colorectal resections(n = 30) there were no al. of 497 appendectomies, 5 patients (1%) required reoperation. the most frequent cause of reoperation was revision of stoma (26), followed by reoperation for al (25), abscess (19), and wound dehiscence (13). 17 patients died after surgery of which 15 were emergency surgical patients. conclusions: systematic assessment of all severe complications helps reveal surgical procedures which can be improved but also to identify surgical procedures with low complications rates. plans are being developed to improve the quality of the identified procedures. all surgical departments should have regular and thorough assessment of their activity. acute surgical patients operated by emergency surgeons has less risk of post-operative complications and mortality d. gumaa 1 1 east kent hospitals university nhs foundation trust, general surgery, ashford, united kingdom introduction: in england and wales, we perform over 300,000 emergency laparotomy every year. 30 days mortality rate is around 10-11%. in our study we are trying to demonstrate if have dedicated emergency surgery service will make a difference in the outcome of emergency laparotomy. material and methods: retrospective study on prospectively collected data from nela database done in a large district general hospital. all patients over 18 years old who underwent emergency laparotomy for acute surgical condition between november 2017 and january 2019 were included in the study. mortality and post-operative complications were the primary outcomes. results: total of 191 patients were included in the study, 114 operations were performed by emergency surgeons (es). 30 days mortality rate was 9%, while it was 12.8% for the none emergency surgeons group (nes) post-operative complications were 13.1% compared to 15% for patients operated by nes. there was shorter itu stay with average of 2.8 days, while the itu stay for the other group was 3.3 days, but the es group had higher chance of unplanned return to theatre. 7.6% of the patients went back to theatre compared to 6% of the other group. reasons of unplanned return to theatre was mainly post-operative collection or wound dehiscence. conclusions: emergency surgeons has better outcomes when they perform emergency laparotomy, may be because they perform higher number of laparotomy compared to their peers. emergency surgery has been a growing subspeciality recently, and with no doubts having surgical emergency units has improved the patient's care around uk. the advantage of 2 g over 1 g of prophylactic cefazolin in surgical site infections in trauma surgery below the knee introduction: the rate of surgical site infections(ssi) after foot/ankle surgery remains high, despite the implementation of antibiotic prophylaxis (1) . recently guidelines suggest a single dose of 2 g instead of 1 g of cefazolin for implant surgery, this decision is largely based on pharmacokinetic studies (2) . however, the clinical effect of this higher dose has never been investigated in this region. this retrospective cohort study therefore investigated the effect of 2 g compared to 1 g of prophylactic cefazolin on the incidence of ssis in foot/ankle surgery. material and methods: all patients undergoing trauma-related surgery of the foot, ankle or lower leg between september 2015 and march 2019 were included. primary outcome was the incidence of a ssi. ssis were compared between patients receiving 1 g and 2 g of cefazolin as surgical prophylaxis. results: a total of 293 patients received 1 g and 126 patients received 2 g of cefazolin. the groups did not differ in gender, age, weight, co-morbidities or intoxications. the overall number of ssis was 19 (6.5%) in the 1 g group and 6 (4.8%) in the 2 g group. corrected for the confounders ''age'', ''smoking'' and ''blood loss'' this was not statistically significant (p = .705). conclusions: even though the decrease in ssi rate from 6.5 to 4.8% was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality and healthcare costs. research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing ssis in foot/ankle surgery. introduction:right-sided colonic diverticulitis (rd) is much rarer than left-sided (ld) and subsequently, controversies concerning the most appropriate treatment remain unsolved. our experience let us believe that mild rd can benefit from an outpatient management. material and methods: we performed a single center retrospective comparative study in which we included all our diverticulitis patients that were treated as inpatient in our unit. we divided in two groups:rd and ld group. the ld group was created by randomization from a prospective ld patients database. results: we included 24 rd and 94 ld patients treated in our unit from july 2016 to july 2019. median age was 53.9 in rd and 57.2 in ld, with a 52.2% of females in rd vs 45.2% in ld. asa classification was significantly lower in rd (asai:58.3% vs 33%, asaii:41.7% vs 46,8, asaiii:0 vs 18.1%, asaiv:0 vs 2.1% p = 0.005). the presence of neumoperitoneum in ct scan was significantly higher in ld 16.7% vs 59.6% p = 0.001) surgery was performed in 26.5% of the left-sided diverticulitis compared to 0 of the rd group (p = 0.0019). antibiotics of third line (imipenem and meropenem) were only required for ld (0 vs 26.1% p = 0.003). length of hospital stay was significantly shorter (p = 0.001) in rd (3.58 ± 1.35) than in ld group (6.11 ± 3,47) conclusions: in our series, patients with right diverticulitis had fewer perforations in the ct scan, they required lower spectrum antibiotics and did not required any surgical treatment with a shorter length of hospital stay. we consider that mild right diverticulitis could benefit from an outpatient treatment with oral antibiotic following similar recommendations to those followed for mild ld patients. when surgery should not be immediate, a night of hospitalization in a specialized environment is performed and surgery deferred overnight. in some selected patients, a return home is possible with a scheduled emergency surgery the next day. the pa.r.c.o.ur protocol is set up in the surgical emergencies of the university hospital of lille after a suitable medical treatment and enlightened information. this retrospective study assesses whether this deferred surgical management allows a return home on the day of the operation. methods: between 1/01/2015 and 1/09/2018, 3468 records of patients operated for an abscess, appendicitis, cholecystitis or symptomatic inguinal hernia were reviewed. 321 patients who did not have criteria for immediate surgical management (peritonitis, occlusion, sepsis, cellulitis, intravenous treatment need) agreed to return to their home for an os the next day. results: 286/89% interventions were performed in os and allowed a return home at day 0, within a median time of 7 h [iqr 6-9]. conclusions: the pa.r.c.o.ur protocol makes it possible to reserve the availability of the entire technical platform (operating rooms and beds) to the most serious pathologies with a failure rate of 11%. the medico-economic benefits, the efficiency in the management of the beds and the satisfaction of the patient and medical staff of this protocol must be evaluated prospectively. a 69 years old woman was admitted in our er presenting with a 12 h sharp epigastric and ruq pain, fever, nausea and vomiting, hd stable. the patient had a past medical history of tachyarrhythmia, open-angle glaucoma and lower limb venous insufficiency. her past surgical history included an hysterectomy and bilateral salpingooophorectomy, appendectomy and left inguinal hernioplasty. during clinical examination, signs of peritoneal irritation were present. ct scan revealed a small pneumoperitoneum in the luq and multiple small and large bowel diverticula, without free peritoneal fluid. blood work showed mild leukocytosis and neutrophilia. we performed an urgent exploratory laparoscopy in which dozens of small intestine diverticula were found, increasing proximally in number. one of them, 20 cm distally from the treitzs angle, showed signs of perforation, with a small abscess and surrounding fibrin. the affected bowel was externalized through a 4 cm laparotomy for segmental resection and a manual double-layer terminoterminal jejunojejunostomy was performed. in the perforated jejunal diverticulum, a 25 mm cod fishbone was identified as the cause of the perforation. the histopathological examination of the extracted 6 cm tissue sample, found several diverticular structures of the muscular wall, one of which with a 2 mm perforation and a granulocytic infiltrate with serosa involvement. complicated cases of small bowel diverticulosis are best managed by segmental resection surgery. despite being quite rare, every surgeon should be aware of such acute abdomen presentation. asymptomatic cases benefit from a watch-and-wait approach. case history: a 47-year-old female consulted to the emergency department for a 24 h epigastric pain. it was accompanied by nausea without vomiting. clinical findings: the patient was hemodynamically normal and the abdomen was soft with minimal distention. investigation/results: x-rays showed large gastric dilation. the abdominal ct scan showed mesenteric axial gastric volvulus with minimal free fluid. suddenly, the patient presented diffuse abdominal pain with diaphoresis, mucocutaneous pallor, hypotension and tachycardia. diagnosis: a gastric volvulus with gastric ischemia was suspected. broad-spectrum antibiotic therapy and resuscitation measures were started. emergency surgery was indicated. therapy and progressions: a decompressive gastrostomy, gastric reduction and devolvulation, transverse colon resection due to ischemia and splenectomy were performed. after 12 h, she required total gastrectomy and right hemicolectomy due to ischemia secondary to severe septic shock associated with disseminated intravascular coagulation. comments: the gastric volvulus is an uncommon entity, being the mesenteric-axial type so rare. there are very few cases described whose manifestation is accompanied by hypovolemic shock secondary to splenic laceration, which occurred due to the great gastric distention. early diagnosis is the key to start treatment as quickly as possible, due to high mortality the main mechanism of death is usually vascular involvement, perforation and multiorgan failure. results: we analyzed 13,621 pediatric ogis, and 23.3% of pediatric cases occurred in the 0-5 age group, 20.1% in 6-10, 19.9% in 11-15, and 36.7% in 16-20. the average age of the cohort was 11.5 years and 76.5% of cases occurred in boys. racial distribution revealed 35.8% of cases in caucasians, 17.0% in african americans, and 17.3% in hispanics. most (39.9%) cases were documented in the southern united states. of our 13,621 cases, 12.6% underwent vitrectomy, 4.2% underwent enucleation, and 1.8% developed endophthalmitis. the rate of endophthalmitis development after ogi was highest (4.6%) in the asian/pacific islander group. the average length of stay for the entire cohort was 3.51 days, and the average cost per day was $11,724.01. table 1 contains a breakdown of our statistics. conclusions: as documented in the nis, ogi occurs more commonly in boys than in girls at a ratio of approximately 3:1. the rates of vitrectomy and enucleation are higher in boys. we noted a higher of rate of enucleation in asian/pacific islanders and african americans. the plurality of ogis occur in the 16-20 age group; this age group also has the highest relative rate of enucleation. with respect to location, ogis occurring in the western united states had the highest average cost per day of inpatient stay. autologous tissue from intramedullary channel parietes for femur nonunions management introduction: a reamer-irrigator-aspirator (ria) method is deeply reliable for getting high volumes of bone graft/mscs. high rates of successful outcomes have been reported after the use of ria bone fragments to cure non-unions. material and methods: being supported by histomorphological examination of the material acquired while drilling intramedullary channels of 41 patients with femur nonunions (20-hypertrophic, 21oligotrophic), we have discovered that nevertheless, expressions of the dystrophy and necrosis in bone tissue and marrow in pseudoarthrosis areas depend on time since fracture occurrence, the microscopic study of the material 5 cm above and below a fracture line has demonstrated ordinary structures of bone tissue and marrow in all cases. introduction: this study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (pmfs) involving \ 25% of the articular surface treated with or without screw fixation. material and methods: among patients with ankle fractures and pmfs who underwent surgery between march 2014 and february 2017, 62 with type 1 pmfs involving \ 25% of the articular surface were included. of these 62 patients, 32 underwent screw fixation for pmfs and lateral and/or medial malleolar fracture fixation (group a) and 30 underwent internal fixation for malleolar fractures without screw fixation for pmfs (group b). ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (ct). clinical outcomes were determined using the american academy of orthopaedic surgeons foot and ankle questionnaire, short form-36, and american orthopaedic foot & ankle society scale. results: nonunion was not noted in either group. however, we detected union with a step-off of 2 mm or more in 2 cases from group b. with regard to ankle joint alignment, 1 case in group a and 3 cases in group b showed mild asymmetry of the medial and lateral clear spaces on ct at 12 months. clinical outcomes at 6 and 12 months after surgery were better in group a than in group b. conclusions: screw fixation of pmfs was effective for fracture healing and maintaining ankle alignment. additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with pmfs involving\ 25% of the articular surface. references: level ii, prospective comparative study. how accurate can gaps and step-offs be determined in acetabular fracture treatment? introduction: the assessment of gaps and steps in acetabular fractures is challenging. studies evaluating the value of various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. this study aimed to assess the inter-and intraobserver variability of gap and step-off measurements using pelvic radiographs, intraoperative fluoroscopy and computed tomography (ct). material and methods: sixty patients, surgically treated for acetabular fractures, were included. five observers measured the gap and step-off on all the pre-and postoperative pelvic radiographs and ct scans. intraoperative fluoroscopy images were reassessed to determine the presence of gaps and/or step-offs. the inter-and intraobserver variability were calculated for the measurements using pelvic radiographs or ct scans. kappa was calculated for the intraoperative fluoroscopy assessment. results: for the preoperative displacement, the intraclass correlation coefficient (icc) was 0.4 (gap and step-off) using pelvic radiographs, and 0.4 (gap) and 0.0 (step-off) using ct scans. for the postoperative displacement the icc was 0.4 (gap) and 0.2 (step-off) using pelvic radiographs and 0.3 (gap) and 0.4 (step-off) using ct scans. the average kappa for the intraoperative gap and/or step-off assessment using fluoroscopy was 0.2 (-0.36 to 1) both for the inter-and intraobserver assessment. conclusions: there is little agreement between the observers regarding the measurements of the preoperative displacement, the presence of gaps and step-offs intraoperatively and the measurements of the postoperative displacement. a possible explanation for this is that the acetabulum has a three-dimensional spherical shape with multiple fracture lines and fragments going in different directions. single radiographic or ct-based gap or step-off measurements do not seem to be representative for the fracture characteristics, therefore the use of 3d measurements should be considered. introduction: long-term intake of glucocorticoids leads to pathologic changes in bone and cartilage tissues. material and methods: to understand how to prevent the occurrence of the pathology, we studied the use of vitamin d, vitamin e and a combination thereof on the background of the intake of prednisolone, 0.5 mg/ 100 g of body weight. the experiment involved 68 male rats of wistar linear breed. the animals were 2 months old and weighted 100.0 ± 5.0 g. the experiment included 4 series of animals, 17 rats in each, namely: the first group-intact animals; the rest of the animals received prednisolone, 0.5 mg/100 g of body weight. the rats of the third series received additionally 100 iu of vitamin d3. the animals from the fourth group also received 0.726 iu (0.6 mg) of vitamin e. results: long-term administration of prednisolone to the experimental animals has caused significant structural and functional disorders in their bone and cartilage tissues. they can be construed as simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d3 and e has demonstrated its ability to promote restoration of histomorphologic features of bone and articular cartilage in proximal femur epiphysis and epiphyseal cartilage of proximal femur epimetaphysis in animals with simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d3 and e has demonstrated a better effect on the background of the glucocorticoid-induced osteochondropathy, compared to the vitamin d3 alone. conclusions: preventive administration of the vitamins d3 and e while treatment with prednisolone leads to avoidance of the majority of pathologic changes, resulting otherwise from glucocorticoid-induced osteochondropathy. konyang university hospital, orthopaedic, deajeon, south korea introduction: the purpose of this study was to evaluate clinical, radiological and functional outcomes of patients had osteochondral autograft harvested from the ipsilateral femoral head for a femoral head defect after posterior hip fracture dislocation material and methods: this study was approved by irb at our institution. a retrospective chart review of a prospectively performed operation was performed at two university hospital between march 1, 2014, and june 30, 2018 . all fracture was classified by the ao/ota classification. we included the patients had minimum 6 months of follow up periods. ten displaced head fractures were addressed through posterior surgical dislocation and two patients had no posterior dislocation was operated using smith-peterson approach. an osteochondral graft was harvested from inferior non-weight bearing articular surface and grafted to osteochondral defect. all patients were full weight bearing by 3 months results: we had 86 femoral head fracture dislocation. 5 patients were excluded due to lost to follow up. twelve of 81 with type i/ii pipkin fracture dislocation with the articular defect and reduced within 12 h of injury was identified for review. the patients were followed up for a mean of 13.2 months. there was no osteonecrosis. decreased joint space was identified in two patients. all fractures achieved union. the mean harris hip score of last follow up was 89.1 (56-98) one patient who operated using the smith-peterson approach had femoral nerve palsy. conclusions: the clinical and radiological results after treatment of femoral head fracture dislocation with articular defect by osteochondral autograft harvested from its own non-weight bearing articular surface show good outcomes. hospital universitario fundacion jimenez diaz, madrid, spain, 2 hospital universitario 12 de octubre, madrid, spain, 3 hospital universitario la paz, madrid, spain introduction: preoperative computerized tomography scan provides important information about ankle fractures associating posterior malleolus, helping us distinguishing fractures affecting distal tibiofibular joint. the aim of our paper is to describe our series of patients suffering an ankle fracture with posterior malleolus involvement. methods: fifty-two consecutive patients, with ankle fracture involving posterior malleolus were evaluated prospectively. all of them were assed with a preoperative ct scan, demographic data, fracture mechanism, surgical approaches, posterior malleolus size measured classification and treatments were analyzed. results: most frequent posterior malleolus pattern according to bartonicek classification was type ii, twenty-two patients (42.3%). an alternative surgical approach was performed in thirty-three patients (63%) as a consequence of information provided by ct scan. no statistical differences were observed when measuring posterior malleolus in conventional x-rays or ct scan. analysis of variance showed a p value less than 0.05 when comparing pm size and haraguchi and bartonicek classifications. discussion and conclusion: ct scan is required to perform an adequate preoperative study of ankle fractures involving posterior malleolus, using this information to provide a better outcome to our patients. effect of atorvastatin and losartan on gene expression and cell count in a rat model of posttraumatic joint contracture of the knee-a blinded and randomized animal study introduction: myofibroblasts have been associated with increased posttraumatic joint contracture, which has a massive impact on articular function. atorvastatin and losartan have shown to reduce the proliferation of cardiac, hepatic and pulmonary myofibroblasts. the aim of this study was to evaluate the effect of atorvastatin and losartan on gene expression, cell count and collagen deposition in the posterior joint capsule 2, 4 and 8 weeks after trauma in a rat model of posttraumatic joint contracture of the knee. material and methods: posterior capsular injury and kirschner-wire immobilization of the knee were performed in 72 sprague-dawley rats. atorvastatin, losartan, or placebo was administered daily orally. the rats were sacrificed at either 2 (n = 24), 4 (n = 24) or 8 (n = 24) weeks after initial surgery. rats euthanized at week 8 had their k-wire removed at week 4, followed by a remobilization period of another 4 weeks. the results were evaluated via qpcr and immunohistochemistry. results: losartan reduced the number of myofibroblasts in comparison to the control at week 2 and 4, whereas atorvastatin lowered myofibroblasts only at week 2 (p \ 0.05). atorvastatin reduced the collagen deposition at week 2, whereas losartan had no effect on collagen deposition. losartan decreased gene expression of connective tissue growth factor (ctgf) at week 4 and of tgf-b at week 8. clinical findings: positive anterior drawer test, grade iii valgus instability, and a palpable gap below the patella were assessed. no neurovascular alterations were found and ankle-brachial index scored [ 0.9. investigation/results: initial immobilization with a splint was performed. radiographs showed a high patella with no other lesions. mri revealed a complete rupture of the patellar tendon and a complex multiligamentous injury with complete anterior cruciate ligament (acl) tear, avulsion of distal medial colateral ligament (mcl), and a complex rupture of both meniscus. diagnosis: knee dislocation with patellar tendon rupture. therapy and progressions: definitive treatment was performed 7 days after the initial lesion, with arthroscopic resection of the posterior horn of the external meniscus and reconstruction of the acl with posterior tibial tendon allograft, as well as open repair of the patellar tendon and the internal meniscus, with subsequent mcl distal reinsertion. immediate partial weight-bearing with an extension orthosis was allowed. the patient is currently progressing with rehabilitation. comments: knee dislocation is a rare injury, and most cases are due to highenergy trauma. concomitant rupture of the patellar tendon is very unusual, and most cases are described in the context of open injuries. surgery is mandatory in order to restore full stability of the knee, with either one intervention or a staged surgery, including repair of the collateral ligaments and the patellar tendon followed by arthroscopic reconstruction of the cruciate ligaments. postoperative management consists on early rom restoration and weight-bearing as tolerated. introduction: apophyseal anterior inferior iliac spine (aiis) fractures are rare injuries. they most commonly occur in athletes in adolescence period. because the ossification of pelvis is not completed, apophyses are the weakest part of musculo-tendinous unit during this period, thus avulsion fractures are more frequent than muscle ruptures. aiis avulsions are the result of sudden and forceful contraction of rectus femoris muscle concentrically or eccentrically. material and methods: we report a clinical case of a aiis avulsion fracture in a young male football player, after being misdiagnosed as muscle strain. results: our patient was treated with conservative treatment including bed rest, analgesia, using crutches and toe-touch weight bearing, progressing to full weight bearing as tolerated and nonsteroidal anti-inflammatory drugs. at follow-up, he showed relief from his pain and mechanical symptoms and regained full range of motion and returned to his previous levels of activity. conclusions: diagnosis requires careful attention to the physical examination and imaging. in this case, the fracture was managed successfully with a conservative approach. good results and return to previous levels of activity can be achieved with conservative treatment. when misdiagnosed as a simple strain, the late diagnosis may cause chronic pain with decreased sportive performance in the future. therefore, a carefully taken anamnesis and physical examination with comparative anterior-posterior pelvic x-rays are needed not to miss avulsions in adolescents; also in some instances, more advanced scanning methods must be considered. introduction: the problem of meniscus damage in children is due to unsatisfactory treatment results, which is associated with the frequent execution of meniscectomies. amount of unjustified meniscectomies and the incidence of osteoarthritis can be reduced if menisci are repaired. material and methods: during the period january 2018-august 2019 66 children with injuries of the meniscus were treated in morozov children's clinical hospital. 59 children underwent meniscus repair by suturing using three techniques: ''all inside'', ''inside out'' and ''outside to inside''. meniscus suture decision was made taking into account the assessment of the severity of the damage. the period from the moment of injury wasn't taken into account. the technique of meniscus suture was determined depending on the location and type of damage. we met 4 children with damage to the discoid meniscus who underwent partial resection and meniscus suture. 7 children underwent a meniscectomy due to severe traumatic and degenerative changes. children had mri of the knee after 6 months and x-ray after 12 months. results: 30 children achieved a satisfactory functional result; 28 operated children are at the rehabilitation stage. we faced a complication-limitation of flexion in the knee joint in 1 child. in all children on the control mri, the absence of synovitis, the safety of the reconstructed meniscus contour and the decrease in the intensity of the hyperechoic signal in the gap zone in dynamics are determined. conclusions: the introduction of a technique for repair meniscus integrity in the daily practice of an arthroscopist makes it possible to reduce the number of meniscectomies, which will reduce the number of unsatisfactory treatment results for this pathology and prevent the development of early osteoarthritis of these, 97 children revealed a fracture-dislocation of the patella. in 64 children, a tangential fracture of the lateral condyle of the femur was noted. in 110 children, the dislocation was repeated. we met 89 children with bilateral damage. all children with complete damage to the medial patellofemoral ligament, fracture-dislocation of the patella and dysplastic dislocation were performed tendon plastic using the quadriceps femoris tendon. the technique includes: transplanting a graft quadriceps tendon graft without cutting off the patella. next, the transplant is subfascial carried out in the medial direction and is fixed with a bio-integrated screw in the femur. results: the rehabilitation period was 4 months. 10% of children have a satisfactory result (there is a limitation of flexion in the knee joint to 90°). 90% have an excellent clinical result: the full range of motion in the knee joint, the absence of pain and a return to sports. none of the operated children had relapses of dislocation. conclusions: it is recommended to consider the technique of tendon plasty of the medial patellofemoral ligament using the quadriceps femoris tendon as a method of choosing the treatment for patellar dislocation in children. case history: a 13-year-old boy who was injured while playing baseball. he was playing as a catcher and was bumped into the runner, therefore his ankle got twisted. he was immediately taken to the hospital. clinical findings: x-ray the distal tibial epiphyseal growth plate was irregular. although the ankle joint was not dislocated. in the ct, the proximal fibular fragment was caught behind the posterior edge of epiphysis of the distal tibia and was trapped there. investigation/results: the patient must be operated in order to repair the ankle. but the reduction of the entrapped distal tibia epiphysis was not easy without open. diagnosis: we diagnosed with bosworth like fracture. therapy and progressions: reduction was not easy, however we performed it by the pulling the fibula towards to outside, pulling out the curled anterior tibiofibular ligament, and then pushing into the tibia. we performed screw fixation after reduction of distal tibial epiphysis. furthermore, we fixed the fibula with plate. we made him to do range of motion exercise and toe touch gait from next day, and full weight bearing from 6 weeks. we removed the implant 5 months after the surgery. he did well subsequently, and at 3 years after injury, he had normal function of the ankle, and normal x-ray. and he has returned to sports without pain. introduction: judo is the most popular martial art in the world and the first martial art recognized since 1964 as an olympic sport. worldwide, the international judo federation has registered 200 countries with about 40 million judo practitioners. like martial arts, judo mainly involves grip and throwing techniques. the competition rules in judo have been subject to constant adjustment and optimization in recent years. injuries prevalence is an important factor in the contact martial arts. material and methods: a prospective cohort study of all registered international athletes (1023) at three different european judo contests in germany were accomplished with the aim to investigate the injury rate as well as the pattern of injury. the age of the athletes ranged between 15 and 20 years. injury incidence rates were calculated per 1000 athlete-exposures (iirae) and per 1000 min of exposure (iirme). independent variables were sex and weight division. subgroups were compared by calculating the injury incidence rate ratio. results: severe injuries by judo tournaments are rare. the most frequently injured regions were the hand and head. the fights of the main block are riskier than the finals. the incidence of injury in heavyweight division differed with lightweight competitors. the risk of injury for female and male competitors differed slightly. conclusions: further studies are needed to determine a judo specific injury patterns and factors especially in the pre-competitional phase. investigation of prevention-strategies like the adaptation of competition rules etc. makes sense. does garden''s classification of femoral neck fracture match between orthopedic specialist and clinical resident? t. inoue 1 , s. inoue 1 , t. muraoka 1 1 prefectural miyazaki hospital, orthopedics, miyazaki, japan introduction: garden''s classification is the most popular classification of femoral neck fractures. femoral neck fracture should be operated^24 h; however poor agreement make waiting time longer because it takes more time to prepare implants and biological clean room. we investigate the agreement of the garden''s classification (non-displacement type or displacement type) between clinical resident and orthopedic specialist. material and methods: the examiner are a clinical resident (2nd year) and an orthopedic specialist (19th year). the subjects were 55 cases of femoral neck fractures treated at our hospital between january and december 2018. first, the examiners classified them into a non-displacement type and a displacement type (test 1). second, the examiners studied the literature about unclassifiable type. third, the examiners classified 55 cases 1 month later once more (test 2). finally, we compared the first test with the second test using the agreement (the number of matched patients/total) and kappa coefficient. results: the test 1 showed that the agreement and kappa coefficient were 81.8% and 0.337. the test 2 showed agreement was 90.9%, 0.614. the intra-observer agreement of clinical resident was 90.90% and kappa coefficient was 0.6520. the orthopedic specialist was 98.18%, and kappa coefficient was 0.930. at test 1, 10 cases did not match. 4 cases of those were unclassifiable type, which were valgus type with medial fracture line. with slight displacement, agreement will get lower; some doctors consider it displacement type. conclusions: unclassifiable type makes us confused. it makes agreement better to discuss about unclassifiable type. introduction: the aim of this retrospective study was to describe the profile of missed hand and foot fractures in multitrauma patients and to elucidate risk factors for the delayed diagnosis. material and methods: from 2005 to 2017, there were included 279 patients. missed fractures were defined as fractures, which were not diagnosed during primary and secondary survey. patients were assessed for age, sex, glasgow coma scale, injury severity score, and length of stay in hospital (los). timing of hand or foot diagnosis related to admission date (measured in days) was noted. results: overall, 5.9% of patients had a delayed diagnosis of hand fracture, 7.3% ha a delayed diagnosis of foot fracture. the mean gcs for patients with delayed diagnosis was 11, whereas patients with diagnosis the day of admission had and mean gcs of 14 (p \ 0.001). patients with delayed diagnosis had a mean iss of 13.4 versus 9.1 for those diagnosed the day of admission (p \ 0.001). furthermore, patients with delayed diagnosis had a mean los of 9.8 days, whereas those diagnosed at the time of admission had a mean los of 5 days (p \ 0.001). concerning delayed diagnosis hand fractures, metacarpal and phalangeal fractures were the most common injuries overall (46.9% and 25.8%, respectively). concerning delayed diagnosis foot fractures, metatarsal fractures (52 cases) and calcaneus fractures were the most common injuries overall, followed by talus fractures and toe fractures. conclusions: this study revealed that with a decreased gcs and increase in iss, polytrauma patients are increasingly at risk for delayed diagnosis of hand and foot fractures with a concomitantly increased los. as a delayed diagnosis has significant impact on the final functional outcome, correct and careful primary, secondary and tertiary survey is essential. introduction: the aim of this study was a) to determine the methods of hemorrhage control currently being used in clinical practice and b) to analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. material and method: between 2005 and 2017, we included 98 trauma patients with pelvic fractures (group 1). a similar retrospective examination was performed on a number of 85 trauma patients without pelvic fractures (control group). there were collected injury severity score (iss), the highest abbreviated injury scale (ais) score in each anatomic region and methods of pelvic hemorrhage control. there were also recorded hospital lengths of stay (los) and in-hospital mortality. results: the average follow-up was 24-months. the average iss in group 1 and group 2 was respectively 13.8 and 9.7. in both groups the commonest mechanism of injury was motor vehicle crash (40.5%). in group 1, angioembolization and external fixator placement were the commonest used method of hemorrhage control. 8 patients underwent diagnostic angiography with contrast extravasation noted in 4 patients. patients with pelvic fracture had a mean hospital los of 17.3 days. the overall in-hospital mortality rate of patients with pelvic fractures was 11.7%, while in group 2 the overall in-hospital mortality was 6.5%. age, shock, severe head injury and increasing iss, are all significantly associated with mortality in the pelvic fracture group. conclusions: the findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient's clinical status. in healthier patients with unstable pelvic fractures, the mortality rate was similar to that of patients with stable fracture patterns. introduction: various percutaneous screw placement for pelvic and acetabulum fractures is often difficult because of complex anatomical morphology, however, it becomes very beneficial to set enough fixation stability if we can insert the long screws. 3d-ct navigation system for the screw placement is beneficial for precise screw insertion. we investigated the accuracy of screws with 3d-ct navigation. material and methods: our retrospective case series were assessed by the accuracy of screws with 3d-ct navigation for pelvic and acetabulum fractures. twenty-six patients who sustained pelvic fractures and thirteen patients who sustained acetabular fractures were included in this study and 3.5 mm cortical screws or 6.5 mm cannulated screws were inserted with 3d-ct navigation. we investigated the number of screws and screw positions which is measured by postoperative ct scan and classified by smith criteria. results: we inserted 13 tits (transiliac-transsacral) screws and 31 is (iliosacral) screws for pelvic fractures. 43 of 44 screws (97.7%) were placed in correct position (grade0 or 1). 1 screw for s1 lesion was placed in incorrect position. meanwhile we inserted 1 antegrade pubic screw, 5 anterior column screws, 27 posterior column screws and 6 infra-acetabular screws. 35 of 39 screws (89.7%) were placed in correct position (grade0 or 1). 4 screws were in incorrect position and they were all cortical screws. and there was no complication related to screw insertion. conclusions: our study highlights that 3d-ct navigation system reduced the malposition rate of screw insertion for pelvic and acetabular fractures. however, we sometimes had difficulty in inserting tits screw for s1 lesion and cortical screw for acetabular fractures. we assumed that this was caused by narrowness of s1 corridor and flexibility of drill or inserting cortical screws in wrong position manually. we should pay much more attention even using 3d-ct navigation. is operative therapy still warranted for dislocated acetabular fractures in elderly patients? introduction: the incidence of acetabular fractures in elderly patients is increasing. there is no consensus about the right treatment for the impaired elderly patient with an acetabular fracture. the aim of study was to investigate acetabular fractures in the elderly patient and the risk of a secondary tha. material and methods: a retrospective study was performed from 2004 till 2014 in the radboudumc nijmegen. all patients with an acetabular fracture were reviewed. they were divided into two groups, younger than 65 and 65 or older. ct scans were used for classification according to letournel and for the quality of the reduction according to matta. there was a follow-up of minimal 2 years. results: in total, 267 patients attended at the radboudumc with an acetabular fracture, of which 68 were 65 years or older. in the younger group, 156 patients received surgery and 40 elderly patients. according to matta, an anatomical reduction was achieved in 15% of the young patients and 8% of the elderly patients. imperfect reduction was achieved in 46% of the younger patients and 49% of the elderly patients. thirteen percent of younger group and 30% of the older group needed a tha based due to the posttraumatic arthritis, the younger group after 32 months and the older group after 22 months on average. one younger patient with anatomical reduction needed a tha, none of the elderly patients. twenty-three percent of the younger patients and 50% of the elderly patients, all with a poor reduction, needed a tha. age, the complexity of the fracture and the quality of the reduction were important factors leading to a secondary total hip arthroplasty. conclusions: elderly patients are two times more likely to need a secondary total hip arthroplasty. after an anatomical reduction, the risk is very low, even in the elderly. surgery for dislocated acetabular fractures is a good option when there is a possibility for a good reduction. references: letournel e. matta jm. introduction: in japan, as a definition of basicervical fractures of the proximal femur, a fracture line is placed into and out of the joint capsule of the hip joint. however, in fact there are various fracture types.we classified these fracture types based on treatment methods and reported on these results. material and methods: 958 cases of proximal femoral fractures treated in our hospital from january 2011 to december 2017. basicervical fractures occurred in 25 cases (2.61%). all cases diagnosed with x-ray and 3d-ct, and observed for 3 months or more after surgery. results: there are two types of basicervical fractures: the fracture line exists around the just inside of the intertrochanteric part: normal type(n type); 5 cases (0.52%), and fracture line exists subcapital at ventral side, the coronal plane in the center of the neck and the trochanteric fossa at the dorsal part: coronal shear type(c type); 20 cases (2.09%).c type was further classified by treatment method depending on existence of posterolateral fragment and anterior wall fracture. c type without comminution (2 part:c-2 type) was 12 cases (1.25%). with posterolateral fragment (3 part:c-3 type) was 5 cases (0.52%), with posterolateral fragment and anterior wall fragment (4 part:c-4 type) was 3 cases (0.31%).n type and c-2 type were treated by sliding hip screw (shs) with anti-rotation screw. c-3 type: shs with trochanteric stabilizing plate, c-4 type because of the bony contact area is very small: hemi-arthroplasty with calcar replacement was performed. cut out occurred in 3 cases of c-2 type and 1 case of c-3 type, but others obtained union.. one case of c-4 type occurred peri-prosthetic fracture intraoperatively. conclusions: we classified 25 cases of basicervical fractures, and according to its classification, treatment method was decided and good clinical results were obtained. strategies aimed at preventing chronic opioid use after trauma: a scoping review c. cô té 1 , m. berube 2 1 université laval, faculty of nursing, québec city, canada, 2 chu de quebec research center, université laval, trauma, emergency, critical care medicine, québec city, canada introduction: a high incidence of chronic opioid use (up to 58%) has been documented after trauma. 1 solutions are urgently needed considering the importance of this public health issue. we aim to identify strategies to prevent chronic opioid use in the trauma population and to assess their level of evidence. material and methods: we initiated a scoping review of literature to identify research articles and guidelines on preventive strategies. several databases and websites of trauma were searched. strategies were classified according to their types and targeted trauma populations. the level of evidence was summarized according to an adaptation of oxford center for evidence-based medicine classifications and strategies effectiveness. results: close to 10 000 items have been screened until now from which 3 studies 2-4 and one guideline were found eligible. 5 two studies 2-3 combined education with mandatory limit of opioid prescriptions (level iii) in the orthopaedic trauma population and the other study used tailored physical training after whiplash injury 4 (level i). findings showed reduction of opioid use or complete weaning at 6 and 12 weeks after trauma, however the effect was not maintained beyond 12 weeks. guidelines on orthopaedic trauma 5 made the following recommendations: prescribe the lowest effective dose for the shortest period (strong, high-quality evidence), avoid long-acting opioids in the acute setting (strong, moderate-quality evidence), and prescribe precisely (avoiding ranges of dose and duration) (strong, low-quality evidence). conclusions: chronic opioid use is an important issue in trauma patients. findings highlighted the need for more research to reduce the burden associated with chronic opioid use in this population. references material and methods: we analyzed 85 clinical cases: men-32 and women-53, mean age 53 years. trauma circumstances: habitual trauma-60 cases, traffic accident-15, precipitation-6, sport-3, aggression-1. for cohort analize schatzker classification was used: especially type i was meet in 9 cases, ii-22, iii-11, iv-3, v-26, vi-14; 81 close, 4 open. for paraclinic examination were used x-ray and ct. surgical management consisted of: close reduction, internal fixation-10 cases (8-percutaneus canulated screws arthroscopic assisted, 2-external fixator), open reduction, internal fixation-75 cases. bone graft was done in 15 cases. results: postoperative follow up was performed at 6, 12, 18, 24 weeks. patients were evaluated according to the lysholm knee scoring scale, obtaining an average score of 88 points. bone healing was achieved in a period of between 12 to 18 weeks. postoperative complication developed in 11 cases. results were depending on the stability of osteosynthesis, precocity, rightness of functional reeducation and patient compliance. conclusions: favorable functional results and less complication were met in cases of individual approach of surgical management, a good choice of implants and minimally invasive surgical techniques. fractures of the shoulder processes-a case report case history, clinical findings and diagnosis: 17-year-old male, low-speed motorcycle crash with subsequent polytrauma. he presented with right shoulder pain, swelling and pain to the touch. articular ct revealed a type i fracture of the coracoid base, type iii acromion fracture and scapular body fracture without displacement. results, therapy and progressions: he was submitted to surgical treatment 7 days later. a superior ''sabercut'' approach with open reduction and osteosynthesis of the coracoid process was performed with a cancellous screw and washer and fixation of the acromion with 2 k-wires and tension band wire. fracture of the scapular body followed a conservative treatment. immediate postoperative period was uneventful and he presented with favourable evolution in the subsequent 6-week, 12-week and 6-month follow-up. at present time, at 14-month follow-up, maintained anatomical reduction in radiological control, complete arm abduction and no limitation with efforts. comments: conservative treatment is generally indicated for all shoulder body fractures without displacement. fractures of the coracoid or acromion with [ 1 cm displacement are described as an indication for surgical treatment. fractures of the acromium without displacement may follow conservative treatment with sling immobilization. surgical fixation can be achieved with screws, plate and screws or tension band wire. although controversial, surgical treatment for coracoid fractures is preferred, especially in active young patients with open reduction and fixation with screws or, if necessary, with plate and screws. the treatment applied in the present case, all approaches described in the literature as being effective and with good results, is in agreement with the options described in the literature and constitutes a corroborative example of its efficient results. case history: a 49-year-old male, hand worker, attended to our emergency department after a traffic accident complaining about pain and swelling in his left wrist. initial radiographs revealed an isolated dorsal dislocation of the lunate that went unnoticed. two and a half months later he was referred to our clinic. clinical findings: findings included dorsal wrist deformity and pain. he presented a decreased passive wrist flexion and extension range of motion, with normal finger tendinous function. investigation/results: plain x-rays showed persistence of the lunate dorsal dislocation without any associated injuries. diagnosis: chronic isolated dorsal dislocation of the lunate therapy and progressions: open reduction was performed using a dorsal approach. the scapholunate, lunotriquetal and scaphocapitate spaces were stabilized with a compression screw and kirschner wires respectively. the patient persisted with pain and functional limitation after the surgery, showing an insufficient reduction of the scapholunate space on the x-ray. nine months after the initial surgery, he developed a purulent fistula on the ulnar edge of the carpus. after it was resolved, a total wrist arthrodesis was performed using the mannerfelt technique. at the 3 months follow up, he was clinically stable, consolidation of the arthrodesis was documented and he had returned to his previous normal activities. comments: isolated dorsal dislocation of the lunate is a rare lesion. the delay in the diagnosis of carpal dislocations is frequent. this compromises the final outcome of reconstructive techniques and the risk of residual instability, hence increasing the risk of chronic pain associated with posttraumatic osteoarthritis. in the case of chronic lesions, treatment with palliative techniques such as proximal carpectomy or joint arthrodesis should be taken into consideration. references: siddiqui n., sarkar s. isolated dorsal dislocation of the lunate. open orthop j. 2012;6:531-4 is ultrasound-guided regional anesthesia safer than landmark technique? one-hospital experience introduction: according to the literature the application of ultrasound (us) in performing regional anesthesia had a significant impact on patient safety by increasing the success rate [1] . in 2006 a donated ultrasound device became available in the institute of emergency medicine, chisinau, republic of moldova. due to lack of equipment both us guided and landmark techniques have been performed. the aim of this study was to analyze the two methods of performing regional anesthesia, in order to estimate the potentials benefits of of us guided techniques (succes rate and doses). results: the bivariate analysis showed that, out of 100 anesthetics in lmg, a number of 13 were reported as unsuccessful, compared with a number of 20 in usg. the v 2 test with corrections for continuity did not determine significance (test value 1.306, df = 1, p = .253, effect size = .007), rr being 1.67 (95% ci 0.78-3.58). linear regression for dose (lidocaine) modeling, in patients included in the research, showed a decrease of the dose by 57 mg in lmg, the confidence interval being quite wide (95% ci -.938, -.192). that is, the actual decrease is within the limits of 19 and 94 mg. conclusions: the tendency towards higher failure rate in successfully performing an us guided regional anesthesia and relative ''uncertain'' decreasing of dosage are in contradiction with the international statistical data. this in turn evidenced probable deficiencies in the training of the practitioners in field of ultrasound guided techniques in our country. the prospective research to confirme/infirme these results and estimate the complication rate follows. references: 1. barrington mj, uda y. did ultrasound fulfill the promise of safety in regional anesthesia? current opinion in anaesthesiology 2018; 31 (5) results: average age 41 years old (34-62).all were active labour patient. the most frequent mechanism was high energy trauma (traffic accident), 2 of who presented gustilo grade iiib open fractures operated in the country of origin. most frequent pattern of fracture was 23-c.2 (2 cases) and 23-c.3 (2 cases). initial conservative treatment was performed in 2 of the cases. one persistent pseudoartrhosis with osteosynthesis material failure. in every case, preoperative ct and early surgical intervention were carried. in 3 cases, an additional procedure was associated at the radioulnar distal joint. in all cases consolidation occurred. one patient required reintervention for persistent pseudoarthrosis. average consolidation time 6 months (3) (4) (5) (6) (7) (8) (9) .average follow-up of 61 months (22-116). average active joint balance: flexion 49°(15°-70°), extension 38°(10°-65°), pronation 68°(40°-70°), supination 82°(70°-85°). average dash 21.56 (0-50.8).force reduction greater than 50% compared to contralateral in 2 of the cases. radiological parameters:radial height 8.7 mm (7-12),radial inclination 15°(9-19°),volar angulation 11.8°( 0.2°-21°), ulnar variance 2.85 mm (1) (2) (3) (4) (5) . conclusions: malunion of the distal radius is an uncommon and severe complication with increasing incidence that requires early and personalized surgical treatment to achieve the correction of the deformity, preserving mobility acquiring consolidation with acceptable functional results case history: isolated ulnar translocation of the carpus is unusual. when the translation occurs without injury of the radius, ulna or carpal bones are often misdiagnosed. early diagnosis is key, to avoid further complications such as redislocation of the carpus (1). clinical findings: in our case a young male patient suffered a high energy motorcycle accident. he had no a b c d problem investigation/results: the ulnar translation of the left carpus was evident but comparison x-rays were taken on both wrist for further evaluation. the distance between the line, drawn through the axis of the radius and the center of the capitate bone was measured bilaterally. the results were 14.3 mm vs 4.7 mm. diagnosis: isolated, open ulnar translocation of the radiocarpal joint, dumontier type i, was diagnosed. treatment: the primary treatment was debridement, reposition and fixation with ex fix. after the wound healing on 18th days we made reconstruction. volar approach was used, we re-reponate the carpus and fixated the position with two 2 mm smooth kirschner wires. the radioscaphocapitate and long radiolunate and radioscaphoid ligaments were reattached to the volar margins of radius using mitek mini anchors. we put the ex fix and left the bended wires percutaneously. after 10 weeks the ex fix and the k wires were remove. wrist motion exercises were initiated under supervision of physiotherapist. comments: after 16 weeks the wrist was in good alignment, the flexion-extension were 20-20, the deviations were 15-20°. the radiographic signs of this injury are unusual and often misdiagnosed. it can be useful to compare with contralateral x-rays. the radiolunate and radioscaphocapitate ligaments is considered crucial in prevention of ulnar translation. in our opinion the radiolunate arthrodesis can be reserved for failed ligament repairs. introduction: within the orthopaedic paediatric population, there is a distinct paucity of literature in regard to post-operative paediatric analgesic regimes. supracondylar humeral fractures account for 33% of all paediatric limb fractures and there has been a marked divergence in recent literature concerning the most appropriate choice of analgesia for this cohort with recent studies recommending the routine inclusion of an opioid agent post-operatively on prescription. opioids have deleterious side effects pertinent to paediatrics. in our institution, patients'' only receive a prescription for acetaminophen and nsaids upon discharge. our study assessed postoperative analgesic satisfaction rates in all paediatric patients who underwent crpp for supracondylar humeral fractures in our institution from january 2018 to december 2018. material and methods: this is a retrospective multi-surgeon case series of all paediatric patients who underwent crpp from january 2018 to december 2018. patient data was extrapolated from theatre records and clinical charts. for each patient, all analgesic agents given were identified, the dosage, route and frequency of administration in addition to the length of their hospital stay and time from injury to operation. following discharge, patients'' guardians were contacted retrospectively and a questionnaire was administered which ascertained the efficacy and duration of analgesia used by the patient postoperatively. results: fifty patients were identified for inclusion within the study who met the inclusion and exclusion criteria. there was a 92% satisfaction rating amongst the responders with the analgesic regime recommended-acetaminophen & nsaids. conclusions: in stark contrast to papers which we discuss throughout our paper, our study conclusively demonstrates that opioid prescriptions are not required upon discharge for supracondylar fractures within a paediatric population case history: a 57-year old man suffered an isolated injury of his right hand in a motorcycle accident. clinical findings: the patient presented with a swollen hand, a subtotal amputation of the middle finger at the level of the middle phalanx and lacerations to the other fingers (fig. 1) . investigation/results: after excluding injuries to other body regions, radiographs and a ct of the hand were performed (fig. 2) . diagnosis: closed fracture dislocation of cmc joints from ii. to v. finger, comminuted fracture of the middle phalanx of the middle finger, closed fracture of the proximal phalanx of the middle finger, other lacerations to the iv. and the v. finger. therapy and progressions: urgent open reduction and internal fixation (orif) with k wires of the cmc joints. exploration of the middle finger reviled heavy contamination and comminution of the phalanx, with injury to one neurovascular bundle. a phalangectomy with acute finger shortening was performed with creation of a new ip articulation (distal to proximal phalanx) (fig. 3, 4) . progression after the surgery was uneventful. there was no sign of infection. the shortened finger was sufficiently perfused and the patient reported a sense of touch. k wires were removed after 6 weeks and physical therapy was started. the patient has limited rom in his neo ip joint with minimal pain (vas 2-3) (fig. 5) . comments: middle phalangectomy of the hand was described in the literature only in two papers which report treatment of chronical or congenital diseases. the authors propose this method as an alternative to amputation in selected trauma cases. results: 29 patients (15 m, 14 f, mean age 43 y) with 40 fractures were included. 13 kidney-tpl, 6 lung-tpl, 5 liver-tpl, 3 heart-tpl, 2 kidney/pancreas-tpl. all patients got treated with at least two immunosuppressive drugs. cause of accident: 37.5% sports/leisure, 35% work/household, 12.5% traffic accidents, 5% without trauma. the operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. patients were hospitalized for an average duration of 11.3 days and were also examined by the particular organ specialists. osteosynthesis: in 90% primary operative fracture treatment, in 10% two-step procedure. 11 plates distal radius and ulna [healing period (h) conclusions: the fracture healing was possible but significantly delayed. the wound healing took longer. the immunosuppressive therapy may be responsible for these problems. the rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing. introduction: the prevalence of fragility fractures of the pelvis (ffp) increases, including in up to 90% a lesion of the posterior pelvic ring. an operative therapy is indicated in cases of prolonged or immobilizing pain or in a displaced dorsal fracture. methods: patients suffering an ffp treated with a minimal-invasive trans-sacral bar through s1 from 2009 to 2017 were included. the patients or their relatives were contacted to ask about mortality, the present mobility and place of residence. 96% of all patients still alive could be included in follow-up. results: 73 females and 6 males with a mean age of 76.7 ± 9.5 years (50-95) were included. concomitant stabilization of the anterior pelvic ring was performed in 53%. 16.5% underwent an operative revision (5% evacuation of hematoma, 5% peri-implant infection, 10% hardware removal-combinations possible). the trans-sacral bar was removed in one case due to malpositioning. the length of stay was 20 ± 12 days. at discharge, 46% were mobile on the ward, 14% in their room, 35% for transfer to sitting position and 5% were bedridden. 24% were discharged to their home, 49% in geriatric rehabilitation unit, the remaining to other rehabilitation or to a nursing home. during follow-up, mortality was 27%, one patient died during hospital stay. the patients died in average 158 ± 109 weeks after discharge. after a follow-up of 206 ± 151 weeks, 52% lived at their home, thereof one-third with assistance. 63% needed a walking aid, 16% were mobile without walking aid, 21% were bedridden or only mobile to sitting position. conclusion: the trans-sacral bar in s1 is a valuable minimal-invasive stabilization method to recover mobility in elderly with an ffp. a relatively long in-hospital stay could be explained by the initial trial of conservative treatment and due to intra-and inter-departmental cogeriatric services. the high mortality and need for assistance reflects this geriatric, multi-morbid patient collective. case history: a 58-years-old woman was admitted in the emergency room after being run over by a bus. clinical findings: at the emergency room, she was conscient and hemodynamic stable. head, thoracic or abdominal trauma were excluded. the patient presented with an open wound in left popliteal area with massive bleeding with exposure of gastrocnemius and soleus muscles and achilles tendon investigation: radiologic images didn't show any fracture. a limb angiography showed complete perfusion of the leg, without any lesion on major arteries. diagnosis: open aquilles tendon avulsion through the popliteal fossa therapy and progressions: the patient was taken to the operating room. we approach the popliteal area and found a small laceration of popliteal vein, which was sutured with prolene 6/0. then, we reference the achilles tendon, and tunneled the posterior face of the leg, and passed the tendon through the tunnel. a distal approach, above the insertion of achilles tendon was done, and two suture anchors preloaded with 2 sutures were inserted in the medial and lateral sides of the calcaneal tuberosity, then we did an krackow suture. we also did a fasciectomy on the lateral side of the leg, to prevent compartmental syndrome. the patient was put in a posterior cast with 208 of flexion for 4 weeks. the immediate post-operative time was in an intermedia unit care, to control possible multiorgan failure. in 2 days, she was discharged to orthopedics nursery. due to the degloving of subcutaneous tissue, she evolved with some blisters which made her stay inpatient about 4 weeks. after some time, she developed some areas of skin necrosis, which needed some intervention by plastic surgery with skin graft. now, she has skin completely healed, some loss of strength in the leg, with loss of plantarflexion, and is under prolonged rehabilitation program. therapy and progressions: she was rushed into the or and submitted to external fixation of the humerus and bones of the forearm, debridement, and primary closure of the forearm and hand. successive dressings and debridement was maintained and, at 19th postoperatory day(po) the external fixator of the left humerus was removed and a nailing was performed as well as an osteosynthesis of the clavicle fracture with anatomical plate. at 40thpo the external fixator of the forearm bones was removed and an open reduction and internal fixation of the radius with lcp plate and closed reduction and internal fixation of the ulna with an anterograde ten nail was performed. at 49thpo, she underwent an autologous skin graft of the forearm and hand wounds. good clinical evolution of the wounds and fractures, all of which evolved to consolidation, although m3 fracture malunion was verified as well as deficit of thumb abduction and extension of 3rd-5th fingers. uefi of 65/80. comments: the approach of polytrauma patients should be sequential, according to the atls protocol, preserving life, limb and function. treatment of these lesions is complex and, if poorly managed, can be associated with high morbidity, as most patients combine severe and contaminated lesions, extensive skin loss, open fractures, postoperative infection. a sequential approach is required, which involves injury assessment, infection prevention, soft tissue treatment and fracture stabilization. introduction: pelvic fractures, though rare (3-8%), are often associated with high mortality (5-20%). the factual outcomes in polytrauma patients with the additional burden of pelvic fractures are unknown. the purpose of this study is to provide an in-depth analysis of pelvic fractures in seriously injured patients. material and methods: this is a retrospective analysis of prospectively maintained trauma registry from 2012 to 2018. we included all trauma patients with iss c 16. group i, which had an additional burden of pelvic fractures, was compared with group ii, consisted of patients without pelvic fractures. a double-adjustment propensity score match (psm) analysis was utilized to minimize confounding and unbiased estimation of the impact of pelvic fractures. 24.68 ± 10.86, asmd = 0.15).patients in group i had higher number of genitourinary surgery (p = 0.04), exploratory laparotomy (p = 0.03). therequirement of angio-embolization was similar in between two groups (p = 1.00). while there were no difference in mortality (or 0.69, 95% ci 0.31-2.15, p = 0.82), group i had higher odds of severe sepsis (or 1.42 95% ci 1.19-2.92, p = 0.03) and ventilator-associated pneumonia (or 3.64, 95% ci 1.74-9.72, p = 0.01) conclusions: pelvic fractures in polytrauma patients did not translate into higher mortality. however, there was an increased risk of sepsis and vap. evidence-based management at tertiary care specialized centers can further enhance the outcomes. investigation/results: ap pelvis x-ray reveals a complex left proximal femur fracture with neck and trochanteric extension. a ct-scan was obtained and showed a complex fracture pattern with subcapital and trochanteric extension. blood analysis showed a hemoglobin of 8.6 g/dl. diagnosis: therapy and progressions: at admission, patient refused erythrocytes'' concentrate transfusion and was hospitalized for pain control and hemodynamic stabilization. despite alternative measures such as intravenous iron supplementation and erythropoietin, hemoglobin values remained lower than 7.8 g/dl, thus preventing any surgical procedure. at day 12, patient finally decided to accept packed red blood cells and was then transfused. at day 14 and with a hemoglobin of 11.8 g/dl, the patient was finally submitted to a total hip arthroplasty with an uncemented revision femoral stem. at day 15, the patient initiated the rehabilitation protocol with hospital discharge at day 21 with a hemoglobin of 10.2 g/dl. comments: proximal femur fractures arise as one of the major problems of present traumatology. comorbidities frequently prevent surgical treatment within the golden hour (first 48 h) and thus limiting the postoperative results. in this particular case, a timely surgical approach would have made it possible to try a more conservative procedure with femoral osteosynthesis. the surgical delayed due to low hemoglobin values limited the surgical options and forced a more aggressive procedure. routine versus on demand removal of the syndesmotic screw; a multicenter randomized controlled trial on functional outcome introduction: syndesmotic injuries are common, being present in approximately 15-20% of surgically treated ankle fractures 1 . one of the most commonly used ways of fixation is the syndesmotic screw (ss). traditionally, this screw is removed after 8-12 weeks as it is thought to hamper ankle function and cause pain. however, a recent study showed that implant removal does not always result in improvement of functional outcome 2 . with the relatively high complication rate of implant removal in mind, retaining sss could be beneficial. we therefore aimed to investigate the effect of retaining the ss on functional outcome. material and methods: in this multicenter rct, patients were randomized between routine and on demand removal (upon patients request). the primary outcome was functional outcome at 12 months after ss placement, measured by the olerud-molander score (omas) with a non-inferiority limit of 10 points (90% power, a = 0.025). secondary outcomes include quality of life, range of motion, complications and costs of ss removal. results: a total of 197 patients were randomized, of which 93 for routine removal and 104 for on demand removal. the mean age was 45 years old and 63% was male. follow up of all participants will be completed in march 2020. results of the primary outcome analysis are therefore not yet available, but will be at the conference. conclusions: if on demand removal of the ss is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. this means that patients will not have to undergo a secondary procedure, resulting in fewer complications and subsequent lower costs. introduction: treatment options for pertrochanteric fractures of the hip are extra-or intramedullary fixation. the aim of this study is to identify risk factors for the development of complications: varus deformity, neck shortening, revision and cut-out. material and methods: retrospective cohort study in which radiographs of patients with pertrochanteric fractures, treated at the uz brussel between 2008 and 2016, were reviewed. fracture type, type of the device, cut-out and revision where noted. measurements for the centrum-collum-diaphyseal angle (ccd) of the two hips, impaction, tip apex distance (tad), parker''s ratio were realized. statistical analyzes were made with logistic and multiple linear regression analyzes. results: 248 patients were included. bmi (p = 0,043), type of osteosynthesis (p = 0,024), dhs ? plate (p = 0,006), short nail (p = 0,011) and the tad (p = 0,000) are independent risk factors for the development of varus deformity after consolidation. for impaction are bmi (p = 0,005), short nail (p = 0,000), long nail (p = 0,000) and fracture type a1 (p = 0,001) independent risk factors. we identified a marginal statistical significant risk factor for cut-out: tad (p = 0,051). conclusions: 31,4% of the patients had varus deformity after consolidation. the risk of varus deformity rises with a higher bmi and a higher tad. the risk for this complication was higher when using a nail. neck impaction was shown more together with a high bmi and less in fracture type a1 and with the use of a short or long nail. in the prevention of cut-out, it is important to keep the tad low. case history: 85-year old female with previous distal femoral plating (17 years ago) and ipsilateral proximal femoral nailing (2 months ago) presented with a diaphyseal femur fracture. clinical findings: extremity was swollen, painful, neurocirculatory intact, no shortening or external rotation was seen. she was unable to lift her leg. scars showed no sign of infection. investigation: x-ray revealed a spiral fracture including distal pfna locking screw, unhealed proximal femur fracture without loss of reduction, protruding pfna blade and a healed distal femoral fracture. diagnosis: peri-implant fracture classification proposed by the singapore group presented a discrepancy between nail type 1 subtype b and plate type 2 subtype. by simplification, we disregarded the distal (healed) fracture to choose the first option. therapy: firstly, the distal femoral plate was removed as the preoperative simplification dictated. secondly, pfna distal locking screw was removed and the pfna blade shortened. after open reduction 2 cerclage wires were applied. a long lcp plate was initially fixed through the plate and pfna locking hole, adjusted in line, fixed proximally with 8 screws through a locking attachment plate and 1 cerclage, distally 5 locking screws were used. comments: distal femoral callus prevented the use of a long nail. as the proximal fracture was not yet healed, we avoided full implant removal. as the pfna was unstable, fixation through the plate and pfna distal locking hole enabled implant coupling to strengthen the construct. the plate covered the entire bone to bridge the possible loci minori left by the plate removal and minimize stress risers. background: we have been reported the usefulness of intra-medullary antibiotics perfusion (imap) and intra-soft tissue antibiotics perfusion (isap) for suppressing open fracture and bone infection. imap and isap was a method of antibiotics delivery with the continuous administration of high-dose aminoglycosides. however, the best dose was not obviously. the purpose of this study was to evaluate translation of aminoglycosides from imap or isap. as follows: 11 males and 8 females, average age was 54.9 years old, 10 intramedullary nails and 9 plates. one dialysis patient was including. we measured concentration of gentamicin from imap, isap and in blood, outflow. results: average administration concentration of all cases was 1236.67 lg/ml. average blood concentration of all cases was 1 lg/ml and outflow concentration were 1107.77 lg/ml. average blood and outflow concentration of each dosage were shown as follows: 600 lg/ ml: 0.6 lg/ml, 868 lg/ml, 1200 lg/ml: 0.83 lg/ml, 1135.1 lg/ml, 1600 lg/ml: 1.9 lg/ml, 4800 lg/ml, 2400 lg/ml: 1.03 lg/ml, 547.5 lg/ml. in dialysis patient case, 1200 lg/ml administration lead concentration of blood as 2.46 lg/ml, outflow as 822 lg/ml. side effect were not observed. discussion: local antibiotic administration using imap and isap showed increasing blood concentration depend on administration dose. under 2400 lg/ml administration dose showed safe blood concentration(\ 2 lg/ml). on the other hand, 2400 lg/ml administration dose achieve trough concentrations over 100-1000 times of minimum inhibitory concentration. furthermore, we need to pay attention for administration dose in dialysis patient case. conclusion: 2400 lg/ml administration dose achieved safe and effective local concentration. introduction: distal radius fractures and supracondylar humerus fractures are two of the most common fractures seen in children. most can be treated with non-operative treatment but a small number require operative reduction and surgical stabilisation, often with percutaneous kirschner wires. this study aims to identify whether an early review is required before planned removal of the wires. materials and methods: retrospective review of paediatric patients undergoing surgical reduction and stabilisation with percutaneous kirschner wires for upper limb injuries. data collected over threemonth period (june-august 2019). number and type of outpatient reviews, imaging episodes and clinical interventions recorded. results: 45 consecutive patients with mean age 9 years (range 4-15). 35 distal radius fractures and 10 supracondylar humerus fractures. 3 patients transferred to another unit. 41/42 patients received a 2 week check and then a second review where the wires were removed. mean time to first outpatient review 10.5 days (sd 7.6). at initial appointment all patients had a change of cast and a satisfactory radiograph. mean time to second outpatient review was 26.9 days (sd 7.9). at the second appointment 33/41 patients had the wires and cast removed and subsequent satisfactory radiograph. 8/41 required a further period of casting. 19/41 had a third appointment. 4/41 required formal physiotherapy after cast removal. there was one transient anterior interosseous nerve palsy after supracondylar fracture stabilisation. clinical union of the fracture and good functional outcome was seen in all cases. conclusion: the initial outpatient review at 1-2 weeks allows a lighter weight cast to be applied but in this series the radiograph taken after the cast was changed did not alter management. our findings support a cast change alone at 2 weeks and then clinician review with radiographs at the time of wire removal. introduction: the aim of this study was to describe surgical technique, report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. methods: the study comprised 14 patients who were treated with open reduction and internal fixation (orif) of a scapular fractures between september 2010 and july 2018. surgical indications were as follows: medial/lateral displacement greater than 20 mm; shortening greater than 25 mm; angular deformity greater than 40°; intraarticular step-off greater than 4 mm and double shoulder suspensory injuries (including fracture of clavicle, coracoid or acromion with displacement greater than 10 mm). all patients underwent x-ray examination (true ap, y scapular view) and computed tomography (ct) scans. fractures were classified according to the revised (ao/ota) classification system. functional outcome were measured using the constant-murley score. results: seven patients had glenoid fossa fracture, six patients had scapular body fracture and one patient had acromion process fracture. all glenoid fossa and scapular body fractures were exposed via the judet approach. eleven of 14 patients were reviewed with constant-murley score at the final follow-up examination, three patients were lost for follow-up. the mean follow-up after injury was 44 months (6-92 months). we found in four patients infraspinatus muscle hypotrophy. mean constant-murley score was 93.45 (± 8.93) for injured arm and 98.36 (± 2.91) for uninjured arm. mean score between injured and uninjured arm was 4.91(± 6.49) which is excellent functional outcome according to grading the constant-murley score. conclusions: open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in reliable union rate and good to excellent functional outcome. introduction: the aim of this study was to evaluate clinical and radiological results of intramedullary radius and ulna nails in treatment of adult forearm fractures. methods: the retrospective study included 21 patients who were treated with intramedullary nailing of forearm fractures between january 2010 and september 2017. the medical records and radiographic images of all patients, taken preoperatively and postoperatively, were reviewed. fractures were classified according to the ao/ota classification system by reviewing the radiographs. we analayzed time to union, union rate, clinical outcome and complications. results: primary intramedullary osteosynthesis were performed in 17 patients with forearm diaphyseal fractures. the average time to union was 2 months (range, 2-4 months) in primary osteosynthesis cohort. secondary intramedullary osteosynthesis were performed in four patients following removal of plates and screws due to pseudoarthrosis. the average time to union was 4 months (range, 2-6 months) in secondary osteosynthesis cohort. overall union rate was 95,24% in 21 forearms with fractures or pseudoarthrosis of the radius, ulna, or both bones, which were treated with intramedullary nail with compression screw. overall complications were one nonunion, one postoperative rupture of the extensor pollicis longus tendon and one postoperative transitory radial nerve palsy. conclusions: intramedullary nailing of adult forearm fractures is a safe and effective treatment option that results in reliable union rate and good to excellent clinical outcome. key words: forearm fractures, intramedullary nailing, biological fixation, union rate results: transverse or short oblique fractures of the middle third of the humeral shaft were treated using a retrograde approach. spiral fractures of the middle third of the humeral shaft were treated through the antegrade approach. comminuted fractures of the proximal third of the humeral shaft were treated mostly through the antegrade approach. comminuted fractures of the distal third of the humeral shaft were usually treated using the retrograde approach. whenever possible, we prefer retrograde insertion because the approach through the shoulder joint is avoided. reduction with retrograde nailingnis easier because upper arm was placed on the radiolucent operating table extension. interlocking screw insertion by freehand techique is also easier to perform because there is no danger of radial nerve injury. nonunion was found in eight patients (1,8%). there were five patients (1,1%) with postoperative transitory radial nerve palsy that fully recovered within 6 months. conclusions: the choice of approach to the medullary canal depends on the fracture type and the fracture site. therefore, antegrade nailing should be performed for proximal third humeral shaft fractures and complex middle third humeral shaft fractures, while retrograde nailing should be perforemd for distal third humeral shaft fractures and simple transvese or short oblique middle third humeral shaft fractures. keywords: humeral shaft fractures, intramedullary nailing, radial nerve palsy, nonunion the diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail i. kostic 1 , m. m. mitkovic 2 1 clinical center nis, university hospital, orthopaedics and traumatology, nis, serbia, 2 university of nis, serbia, orthopaedics and traumatology, nis, serbia introduction: in this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. material and methods: between 2014 and 2016, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. all patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. results: the time that elapsed from injury to intramedullary nailing ranged from 9 to 48 months (mean 17 months).open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). all patients were followed up in average period of 2 years postoperative (range 1-4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. conclusions: in conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. percutaneous figure of 8 suture as a novel technique for treating closed tendinous mallet injuries following failed splinting therapy. t. eltantawy 1 , a. yousif 1 , k. maheshwari 1 , a. hartpinto 1 1 bedford hospital, plastic surgery, bedford, united kingdom introduction: mallet injuries are common injuries affecting the hand. majority of them are managed using conservative method, however a small percentage of patients that do not do well on conservative treatment need an operative intervention. we wish to evaluate the efficacy of percutaneous figure of 8 suture as a new technique for treating closed tendinous mallet injuries resistant to splinting therapy, as a minimally invasive treatment option. material and methods: we present a case series of 5 patients who had persistence of more than 30 degree extensor lag, despite splinting minimally for 9 weeks. all of these were treated with a percutaneous figure of 8 suture placed across the dorsum of dipj, which provided splinting for further 4 weeks. this technique provides fixation for the dipj in hyperextension position by going through the periosteum on both sides and was done under local anaesthesia. results: the mean age of our patients was 40 years, with a single digit involved in all patients. all the five cases had nearly fully straight dipj with less than 10°extensor lag following 4 weeks of percutaneous stitch placement. there was no further recurrence with mobilisation or overlying skin necrosis. conclusions: percutaneous figure of 8 suturing technique can be an effective, minimally invasive and safe technique to treat closed tendinous mallet injuries not responding well for conservative splinting. introduction: osteosynthesis of pertrochanteric fractures (pf) is a frequently performed procedure in orthopaedic trauma care. dynamization of the osteosynthesis during fracture healing can lead to dynamization of the lag screw. which can cause debilitating complaints. a spontaneous femoral neck fracture (sfnf) after implant removal was seen in 5 patients over a 6 month period. based on these 5 cases we evaluate the different aspects of the pathophysiological and mechanical mechanisms of lag screw dynamization, complaints and complications in pf healing. material and methods: pubmed search on incidence of chronic pain, gait impairment associated with dynamization of osteosynthesis, risk factors for dynamization and complications after implant removal. based on research data preventive recommendations are suggested. results: literature describes complaints as reduced mobility, gait impairment and chronic pain in association with lag screw dynamization. an important risk factor is the ao-classification of pf, a2 type fractures are significantly associated with more dynamization and the onset of trochanteric pain and gait disturbances. partial implant removal can reduce complaints in the majority of symptomatic patients, and induce symptoms in 20% of asymptomatic patients. literature study shows a sfnf after lag screw removal with an incidence of 15%, affecting mostly vulnerable elderly patient resulting in a high mortality rate. risk factors associated with an increased risk of this complication are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant. most importantly the removal itself, a sfnf with the implant in situ is very uncommon. conclusions: the clinical indications for implant removal in healed pf are not well established, and should be restricted to specific cases. after removal, partial weight bearing and good patient counselling is extremely important. replacement with shorter lag screw should be considered. metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with a spray on their surface of hydroxyapatite and 1% silver v. protsenko 1 , a. abudayeh 2 , v. chornyi 2 , y. solonitsyn 1 1 institute of traumatology and orthopedics of nams of ukraine, onco-orthopedics, kiev, ukraine, 2 bogomolets national medical university, kiev, ukraine introduction: surgical intervention in the case of pathological bone fracture against the background of metastatic lesion involves performing osteosynthesis. for more effective integration of the metal plate with the bone, a material based on bioactive glass was sprayed on their surface. bioactive glass-based material is an osteoinductive and osteoconductive biomaterial that integrates quickly with bone, forms a bone-ceramic complex, and is transformed into bone over time. material and methods: metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with spraying on their surface of hydroxyapatite and 1% silver was performed in 12 patients. the functional result of the operated limb was calculated on the msts scale. evaluation of pain was performed on the scale of r.g. watkins. the quality of life of patients was evaluated using the eortc qlq-c30 system. the evaluation of the integration of the plate with the bone was performed by radiological examination and by osteoscintigraphy. results: postoperative complications were found in 1 (8,3%) patient, recurrence of metastatic tumor was noted in 2 (16,7%) patients. the functional result of the operated limb after metal osteosynthesis was 76,8%. the degree of pain decreased from 92,2% to 24,6%. the quality of life of patients after metal osteosynthesis improved from 38 to 74 points. x-ray examination revealed the formation of callus within a shorter timeframe, as evidenced by the more intense accumulation of radioisotope during osteoscintigraphy. introduction:the aim of this study was to evaluate the results in patients who had heal intertrochanteric fracture but did not receive adequate mobilization and rehabilitation support. material and methods:sixty patients over 70 years old age were included in our study. the rehabilitation emphasized pain relief, muscle strength, range of motion, endurance, balance challenges, and proprioceptive enhancement for all patients. it started postoperative first day and was delivered twice a day by the physical therapist until discharge. patients were discharged on average 7.4 days (2-20 days) after surgery. the mobilization of patients was evaluated with the parker and palmer mobility scoring system, the clinical evaluation was performed with the haris hip scoring and daily living activities were evaluated with the barthel life index before and at the end of the fracture. results:34 female 26 male patients were included in our study. the mean age was 75,2 (70-84) years and the mean follow-up period was 25,5 (10-40) months. 35 patients had a1 type, 25 patients had a2 type intertrochanteric femur fracture. in the last follow-up, all patients had fracture union. patients' mobility, daily life activity and clinical evaluations were found to be statistically significantly worse in the last control than before surgery. conclusions:the success of the surgical treatment and the union of the fracture after fixation are not sufficient for the successful mobility,daily life activity,and clinical results.the success in the functional results are significantly related with the ambulatory ability.although early mobilization and rehabilitation support are important in intertrochanteric femur fractures after surgery,the continuity of mabilization and rehabilitation support after hospital discharge is more important.the rehabilitation which administered by the patient''s ralations after hospital discharge is not sufficient.therefore,the importance of home-based rehabilitation is increased. the prognostic value of the hip screw position in trochanteric fractures i. gárgyán 1 , î csonka 1 , t. ecseri 1 1 university of szeged, department of traumatology, szeged, hungary introduction: in our study, we analyzed one of the hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. according to the classification of the swiss association for ostheosynthesis (ao), we focused on 31-a1 and 31-a2 fractures, the incidence of which increases by ageing. material and methods: between 2010 and 2016, we analyzed the data of 1179 patients. all of the fractures were stabilized with intramedullary nails. 992 patients received stryker gamma3 ò , whereas 187 patients' fractures were solved with synthesis pfna ò nail. in all cases, closed reduction method was used with fluoroscopy on an extension table. the surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. data were collected using gepacs software and statistical analysis was done with ms excel. results: cut-out occurred in 33 cases (2,79%): out of that 21 (1.78%) were left sided and 12 were (1,01%) right sided. 29 (87.87%) patients were treated with gamma3 nail, and in 4 (12,12%) cases pfna nail was used. the average tad-index was 18 mm. conclusions: according to recommendations of the tad-index value, when using dynamic hip screw, it should be 20 mm or lower. the average index value was 18 mm which was equal in the complicated and non-complicated groups. our study shows that the cutout is independent from the tad-index value, thus this recommendation cannot be applied for intramedullary nails. oita university hospital, acute trauma, emergency, and critical care center, yufu, japan, 2 oita university, orthopaedic surgery, yufu-city, oita, japan introduction: dome impaction fragments (difs) in acetabular fractures are typically accompanied with anterior column fragments and recognized as the gull sign on plain radiographs. meanwhile there are some difs which do not fit into typical difs. the aims of this study were to define atypical dif and describe tips for diagnosis and intraoperative visualization. material and methods: this study was a retrospective case review. we defined atypical difs as the fragments which were independent of anterior column fragments and did not show the gull sign on plain radiographs. from jan 2012 to july 2019, there were 68 patients of acetabular fractures, and 15 patients (22.1%) had difs. among them, 3 patients (4.4%) were identified as the cases with atypical difs. all of them were male. the ages were from 55 to 68. results: the atypical difs were not obvious on x-rays (fig. 1) . all three atypical difs were located at posteromedial weight bearing zones of the acetabulum. case 1 and 2 were displaced in accordance with posterior column fragments, and were visualized clearly on the sagittal view of ct images (fig. 2) . case 3 was impacted posteriorly into a posterior part of the ilium as a free fragment, and well visualized on ct sagittal and coronal views. anterior intrapelvic approach was chosen in all patients to treat atypical difs. the iliac oblique view was useful to visualize the atypical difs intraoperatively in case 1 and 2. in both cases, the reverse gull sign appeared after reduction of posterior column fragments (fig. 3) . in case 3, the inlet view was useful to visualized the atypical dif intraoperatively.the fragments were reduced and fixed with supra-acetabular screws (fig. 4) . results: we found prospective two to 10 years after acetabular osteosynthesis 64,04% complications. avn of the femoral head was present in 5,55% of the hips reduced within 24 h and 27,77% of the hips reduced more than 24 h after the injury [p = 0,013; 9 2=4,94; or = 25 (95% ci = 1,29-1121,5) ]. post-traumatic oa of the hip we found in 23,07% (fig. 1 ) infections we found in 5,1% (1 deep, 1 superficial), iatrogenic nerve palsy in 1 (2,56%), traumatic nerve palsy in 15,38% (6), dvt in 5,12% (2) , and ho in 10,25% (4) cases. in one case (2,56%) revision surgery was done. conclusions: acetabular fractures are followed with complications. some complications depend on surgery, meanwhile others cannot be affected on (type of fracture, impaction of acetabulum, injury of the femoral head, dislocation of femoral head). good knowledge of acetabular anatomy, surgical technique, experienced surgical team, early surgery, anatomical reduction and stable orif, early mobilization, can significantly influence excellent/good functional outcomes and reduce possibility for complications. introduction: reduction is one of the important factors in surgical treatment of femoral trochanteric fractures. in this study, postoperative reduction status was examined and the relationship between this reduction status and unsatisfactory cases was investigated. material and methods: 135 cases of femoral trochanteric fractures over 65 years treated with pfna-ii were investigated. postoperative reduction status was evaluated in ap and lateral view of x-ray and ct. anatomical reduction means medial or anterior cortex is reduced anatomically (abbreviation am and aa). intramedullary reduction means medial or anterior cortex of proximal fragment is inside the shaft (im, ia). extramedullary reduction is medial or anterior cortex of proximal fragment is overlapped to cortex of shaft (em, ea). unsatisfactory cases were ununited cases until 6 months and excessive sliding cases over 10 mm. reduction status of these cases was evaluated. results: postoperative status was classified with combination of medial and anterior reduction status. so there are nine groups and number of each group are as follows; im-ia:6 case, im-aa:5 cases, im-ea:0 case, am-ia:14 cases, am-aa: 46 case, am-ea:4 cases, em-ia:17 cases, em-aa:32 cases, em-ea:12 cases. non-united cases until 6 months were 29cases. reduction status of non-united cases were; im-ia:2 cases, im-ea:3 cases, am-ia:4 cases, am-aa:6 cases, em-ia:8 cases, em-aa:6 cases. there was no case in extramedullary reduction of anterior cortex. excessive sliding of blade over 10 mm was 11cases. there was also no case of extramedullary reduction of anterior cortex in these 11 cases (2 cases were cut out). conclusions: our results show there are no ununited cases and excessive sliding cases in extramedullary reduction of anterior cortex. this means extramedullary reduction of anterior cortex is important to reduce unsatisfactory results in surgical treatment of femoral trochanteric fractures. male injured open lateral condyle fracture of femur by to be bitten by a pig. after 5 months from initial debridement, i confirmed the size of bone defect was 3 cm(2) 9 3 cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after 7 months from bone transplantation, i confirmed bone union and two 6.5 mm diameter osteochondral grafts and 4.5 mm diameter osteochondral graft were transplanted for the chondral defect lesion. case 2; seventy year old male injured open lateral condyle fracture of femur by traffic accident. after 3 months from first debridement, i confirmed the bone defect (size 7 cm(2) 9 3 cm in depth) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. and simultaneously two 10 mm diameter osteochondral grafts were transplanted for the chondral defect lesion. case 3; 37 year old male injured open lateral condyle fracture of femur by traffic accident. i confirmed the size of bone defect was 6 cm(2) 9 3 cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after 1 month from bone transplantation, he had undergone autologous chondrocyte implantation. investigation/results: at last follow-up, average flexion angle of knee was 147 degrees. in all cases, lysholm knee scoring scale was good. diagnosis: large traumatic osteochondral defect of the weightbearing articular surface of the knee comments: treatment of large traumatic osteochondral defect of the weight-bearing articular surface of the knee is a difficult condition to treat. combination of bone transplantation and osteochondral autograft transfer or autologous chondrocyte implantation is useful strategy for the injury. references: tegner y., lysholm j., clin orthop relat res., 198, 43-108, 1985 pr 264 treatment of double tension band wiring method with ai wiring system for transcondylar distal humeral fractures m. uchino 1 1 hakujikai memorial general hospital, orthopaedic surgery, tokyo, japan introduction: as ai wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. we review the treatment of transcondylar distal humeral fractures with ai wiring system in geriatric patients. patients and methods: 6 were identified as receiving this surgery. all patients were female and their mean age was 68 years. they were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for japanese orthopedic score. results: union rate was 100%. the mean arch of motion was 95°at latest follow-up. the complications were detected 3 cases which were temporary ulnar palsy for 2 cases and hardware failure for 1 case. the average of functional outcome was 73 points (73/100). conclusion: tension band wiring of transcondylar distal humeral fractures with ai wiring system provides stable fixation for osteoporotic bone and tiny fragment. introduction: the purpose of this study was a comparative evaluation of the complications related to the treatment of trochanteric fractures using 2-screw proximal femoral nail (pfn) versus proximal femoral anti-rotational blade nail (pfna). material and methods: a retrospective review was conducted between march 2013 and march 2019. the study included 519 patients treated surgically for trochanteric fractures. the mean age was 79,8 ± 12,0 (24-100) years. patients were treated by pfn (393 patients, 75, 7%) or by pfna (126 patients, 24,3%). implant related complications were the primary objectives. infection and revision surgery were also recorded. results: complications were observed in 38 (9.7%) patients in pfn group and 7 (5,6%) patients in pfna group (p = 0.15). screw backout (n = 11) and cut-out (n = 11) occurred in 5,6% patients treated with pfn. in the pfna group, cut-out occurred in 1,6% (n = 2) of cases. infection (n = 3) represented 2,4% in pfna patients and 2,3% (n = 9) in pfn group. there were no statistically significant differences in both groups considering implant-related complications (p = 0,14) and infections (p = 1.0). revision surgery was performed in 7 (1,3%) patients. soft tissue problems are more likely in fractures due to high energy impact than low energy type fractures. high energy type present with horizontal fractures of tibia and fibula (i.e. on the same level), whereas in low energy type tibia fractures they present with spiral or oblique fracture patterns often associated with concomitant fractures of the posterior rim of the distal tibia (i.e. volkmann's triangle). posterior malleolus fractures occur regularly but are often missed and seen only on ct scans obtained either for preoperative planning or to verify postoperative rotation. in literature these mostly undisplaced fractures are treated with screw fixation mostly from anterior. but is this really necessary? material and methods: we retrospectively analysed 21 consecutive tibia shaft fractures operatively treated over the past 2 years at our regional hospital analysing the fracture pattern. results: out of 21 patients with tibia shaft fractures 9 patients presented with a posterior rim fracture of the tibia. no routine stabilisation of the volkmann fragment was performed, in all cases the posterior rim fragments healed uneventful. angles of 60°and above seem to present themselves with a concomitant fracture of the posterior malleolus. they are mostly undisplaced and the trauma mechanisms is low energy and torsion. none out of the 9 patients had known osteoporosis. conclusions: low energy and torsion-type tibia fractures with an angle of [ 60°seem to have an accompanying undisplaced fracture of the posterior malleolus. these fractures are usually undisplaced and do not need to be addressed. as a consequence there seems to be no need to actively rule them out with ct scans prior to surgery. concomitant ankle fractures including posterior rim fractures should be addressed like isolated ankle fractures. the dangers of bouncing: a prospecive cohort study of injuries associated with trampolines and bouncy castles over a 3 month period in a paediatric population. introduction: within the orthopaedic paediatric population, there is an increasing incidence of presentation of fractures associated with both trampolines & bouncy castles. whilst this phenomenon has been depicted frequently within the media in recent years given the dramatic upsurge in trampoline and bouncy castle usage, there have been few studies documenting either the incidence of fractures associated with either. materials and methods: this was a prospective cohort study conducted within our institution over a 3 month period june to august inclusive 2019. all paediatric patients who sustain a fracture and present to the national childrens'' hospital are referred to the orthopaedic department either whilst as an inpatient or as an outpatient depending on the assessment of the severity of injury. a standardised mixed questionnaire was given to all parents''/guardians which recorded the type of injury, type of trampoline/bouncy castle, inherent awareness of safety precautions governing the usage of either and application of same was recorded. the type of fracture was corroborated via examination of x-ray in addition to the recording of any complications via examination of clinical chart records. results: there were 88 patients who sustained a fracture directly related to the usage of either a trampoline or bouncy castle for which the majority required operative intervention. there was wide variability in the nature of injuries recorded; supracondylar/radial fractures were the most common whilst more complex injuries such as an open fracture of the femur was rarer. conclusions: awareness and application of necessary safety precautions was low (38%) amongst parents'' supervising parents''/guardians highlighting the need for greater public awareness of same. furthermore, the incidence of severe injury relating to usage of trampolines/bouncy castles is not uncommon highlighting the high risk activity that trampolining is. introduction: conventional plate fixation (pf) of distal fibular fractures in elderly patients is associated with a high risk of wound and implant related complications. intramedullary fixation (imf) using a fibular nail is a minimally invasive alternative to pf that provides superior biomechanical strength and allows immediate full weight-bearing postoperatively. aim: to compare the postoperative complications of minimally invasive intramedullary nail fixation to conventional pf for lauge-hansen supination external rotation type 4 fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the netherlands. methods: a retrospective cohort study was performed including unstable ankle fractures in patients aged 65 years or older treated with either imf or pf between 1 january 2017 to 1 january 2019. the primary outcome measure was the total number of wound related complications. results: a total number of 58 patients were included with a mean age of 73.9 years (range 65 to 95). the imf-cohort (n = 13) had a significantly higher mean age (82.5 versus 71.4 years, p = 0.002) and charlson co-morbidity index (4.7 versus 3.6, p = 0.005) compared to the pf-cohort (n = 45). the total number of postoperative complications was lower after imf (31%) compared to pf (53%), although this relative difference was not statistically significant (p = 0.152). all 4 complications observed in the imf-cohort were wound related but demanded no debridement or implant removal. wound related complications did not differ significantly from pf (31% versus 44%, p = 0.378). no implant related complications, hospital-acquired complications or mortality were observed after imf. conclusion: despite the higher mean age and co-morbidity status of patients treated with a minimally invasive intramedullary nail, the total number of postoperative complications was lower after imf compared to pf. this technique might be a promising alternative in a selected group of patients. the authors declare that they have no commercial associations that might pose a conflict of interest. no funding or other compensation was received for the research, authorship or publication of this article. gustilo type ii and 4 gustilo type iii fractures. the treatment protocol was external fixation at admission and definitive osteosynthesis with plate at 15 ± 7 days. a single approach to the tibia was performed in 32 patients, and a combined anterior and posterior approach was used in 9. the incidence of complications was 50%: 15 cases of poor soft tissue evolution, of which 7 were infections. 9 patients evolved to nonunion. osteoarthritis appeared in 100% of patients (70.73% grade 3), and only one patient needed arthrodesis. 15.91% had a valgus ldta (\ 86°) and 38.64% a varus deformity ([ 92°). we found a significant relationship between the history of open fracture and the development of complications (p \ 0.05). we found no relationship between the incidence of complications and the approach. conclusions: tibia ao43c fractures have a high percentage of complications and evolve to well-tolerated osteoarthritis. open fracture seems to significantly influence the poor postoperative outcomes of these patients. clinical findings: a 24-year-old male, who suffers a closed chest trauma with pneumothorax, right pulmonary contusion and poor pneumoperitoneum. also a grade iiia open fracture of the right femur, with a 10 cm bone defect. investigation/results: upon arrival at the hospital, he needs orotracheal intubation, as well as blood transfusion with 9 red blood cell concentrates. external fixator is placed on the right femur. diagnosis: a iiia grade diaphyseal open fracture of the right femur with 10 cm bone defect, bearing external fixator with one broken proximal pin and positive culture for s maltophila in the distal pin. therapy and progressions: antibiotic treatment and medical optimization are performed, cemented intramedullary nailing (t2-stryker) with antibiotic (vancomycin-tobramycin), as well as cement spacer with antibiotic (masquelet's first stage) in the defect area. in second time, withdrawal of spacer and contribution of ria autograft of contralateral femur and allograft respecting membrane. the patient begins the protected weight bearing with two crutches immediately, without using them 3 months after the surgery. bone consolidation without pain or limitation after 1 year. comments: the induced membrane technique is a simple and effective technique for the reconstruction of segmental bone defects and can be used as a first time technique together with the initial stabilization, leaving the defect ready for graft delivery in the second time. introduction: carpal metacarpal dislocation is a rare entity that accounts for less than 1% of all carpal injuries. dorsal dislocations are the most common and occur most frequently after violent trauma in young individuals and are easily overlooked and may lead to longterm sequelae. material and methods: we present the case of a carpal metacarpal dislocation from d2 to d4. male, 40 years old, no relevant personal history. brought to the emergency service after a motorcycle accident with projection. he had a symphysis pubis diastasis, a distal radius fracture on the right wrist and a fracture of the left forearm bones. no other apparent injuries associated. at week 4, he presented edema and dorsal deformity of the left hand associated with limited finger movements. neurovascular assessment was normal. the radiological evaluation showed a carpal metacarpal dislocation from m2 to m4. it was an unstable reduction so open reduction was performed, with debridement of fibrous material, until exposure of the articular surfaces, and reduction and fixation with k wires of the three metacarpals (from d2 to d4). similarly, m5 was stabilized with a k-wire due to clinical instability observed intraoperatively. results: it is necessary to reduce and stabilize these lesions to avoid vasculonervous compression and skin distress. open reduction is indicated in irreducible cases allowing debridement and excision or os of small osteochondral fragments and fixation of associated fractures. conclusions: combined dislocation of multiple metacarpals is a rare lesion that compromises the functional prognosis of the hand in the absence of adequate treatment. instability and post traumatic arthrosis are among the sequelae of this lesion. identify the lesion to allow the appropriate treatment usually leads to good results. case history: 16-year-old suffered direct trauma to his right hand after falling off his bicycle. clinical findings: on physical examination showed edema and bruising from the base of the thumb and thenar eminence, tenderness over the cmc joint and functional disability speacialy in pincer grasp. no neurovascular injuries investigation/results: the x-ray revealed a comminuted fracture of the base of the thumb metacarpal. diagnosis: we identifed a rolando fracture. therapy and progressions: on the day after the trauma, he was submited to open reduction and osteosinthesis with lateral-palmar plate and screws, through radiopalmar aproach of the thumb base. intra operatively no dorsal fragments werefound to be left undisplaced. two months after surgery, the patient went back to the hospital for sudden pain and inability to extend the thumb. clinically with rupture of the long extensor of the thumb. on the x-ray, the fracture was aligned. the latero-lateral tenorrhaphy with kessler suture was preformed and intraoperatively a bony spicule was identified in the proximal stump of the tendon, which was removed. 6 months after the initial trauma, the patient has a consolidated neck and no limitation of the mobility of the thumb. comments: rollando fracture is relatively rare in adolescents. the aim of treatment should be exact reduction usually with open technics. the main complications are stifness and early arthrosis. there are also records of conflicts with the plates and even rupture of the extensor tendon, so the radiopalmar placement of the plate was chosen. nevertheless, the rupture occurred due to conflict with an unidentified bone fragment during surgery causing an unexpected complication in this case. the immobilization necessary after tenorrhaphy could have caused joint stiffness, but in this case the teenager fully recovered after physical therapy case history: periprosthetic and periimplant femoral fractures are an increasingly frequent pathology. in many cases they are a challenge with limited or too aggressive therapeutic options. it is important to investigate new approaches that increase the arsenal of the orthopedic surgeon. the recently described mipo (minimally invasive plate osteosynthesis) approach for the medial aspect of the femur may seem like a dangerous procedure because of the anatomical structures that run along the medial aspect of the thigh, but it is a viable and useful option in selected cases. clinical findings: we present the case of a 54-year-old patient with a total hip replacement who presented a first periprosthetic vancouver b1 fracture of the femur that was treated with a lateral blocked plate. subsequently the patient presented a second supracondylar femur fracture below the first plate (vancouver c). investigation/results: after thinking over the possible therapeutic options, we decided to treat our patient by means of the medial femoral mipo approach with a long medially placed blocked plate, managing to stabilize the fracture and superimpose the plate on the previous implants without the necessity of removing the previous lateral plate. diagnosis: periprosthetic and periimplant supracondylar left femoral fracture. therapy and progressions: we used the surgical technique of the medial femoral mipo approach as described by apivatthakakul 1 . comments: we consider that the medial femoral mipo approach is a useful therapeutic tool to consider. it seems a safe and low-invasive option for the resolution of cases in which the lateral mipo approach is not a feasible option. references: 1 c. jiamton y t. apivatthakakul, « the safety and feasibility of minimally invasive plate osteosynthesis (mipo) on the medial side of the femur: a cadaveric injection study » , injury, vol. 46, n.o 11, pp. 2170 » , injury, vol. 46, n.o 11, pp. -2176 » , injury, vol. 46, n.o 11, pp. , nov. 2015 . posterior knee dislocation with neurovascular injury associated-a case report case history, investigation and diagnosis: a 58-year-old male was brought in after 4 h following a heavy straw bale fall. he presented with a posterior knee dislocation that had already been reduced and an open wound in the popliteal fossa. the limb was flushed and pale on the extremity, with absence of the pedis and posterior tibial pulses. stability tests revealed unstable knee in all axes. an anterior shoulder dislocation was diagnosed and reduced. therapy and progressions: an emergent surgery was performed, involving a transarticular external knee fixation and a femoro-popliteal bypass above the knee (angiogram revealed a stop sign at the level of the interarticular popliteal artery). he developed circulatory shock and was admitted to the intensive care unit. on the 1stpostoperative day(po) was diagnosed a compartment syndrome that was treated with fasciotomies. these incisions showed a slow but progressive evolution, that required vacuum dressings and underwent autologous skin graft on the 34thpo day. the external fixator was removed on the 41stpo day and rehabilitation was started. on a 5-month follow-up, the patient had a good evolution of the wounds, but a knee with valgus and anteroposterior laxity and severe complete peroneal, tibial and sural neurological injury, confirmed with electromyography, and neuropathic pain. introduction: isolated iliac wing fractures represent only a small part of all pelvic fractures. these fractures are associated with severe injuries, but are considered benign. the literature lack information about the function and quality of life of these patients. our objective was to evaluate the long-term effects of isolated iliac wing fractures. material and methods: patients with pelvic fractures treated at oslo university hospital, ullevaal, in the time period 2006-2016, were extracted from the local fracture registry. 403 patients were registered in this period. a search was also made in the hospital''s administrative electronic database for patients registered with diagnose code s32.3 in icd-10 in the same period. 37 patients were identified. in total, 13 patients had an isolated iliac wing fracture, and these were invited to a follow-up examination, including proms (eq-5d-3l and majeed score), clinical examination, and pelvic x-ray. results: nine patients agreed to participate in the study, median 7 years after the fracture (range 4-13). all of them were injured from high energy trauma, with mean niss 18, 3 (range 5-66) . four of the fractures were open, and seven of the patients had associated injuries. five were treated with internal fixation. the mean eq-5d vas was 84 (range 75-99). five patients reported pain, one of them related to the pelvic fracture. the mean majeed score was 87 (range 64-100). seven patients had sensory deficit in the lateral thigh. one patient had difference in range of motion between the two hips. the x-rays showed healed fractures in all the patients. eight of them showed ectopic ossification. conclusions: our study confirms previous studies that isolated iliac wing fractures are results of high energy trauma with severe associated injuries. however, the majority of this group of patients seem to have a good general state of health, which is in accordance with the general assumption of the injury as a benign one. fenton's syndrome-a case report of a common underdiagnosed entity case history: a right handed 54-year-old male, construction worker, was admitted in our emergency department, after a 3 meters fall. the authors report a case of fenton's syndrome in a politrauma scenarium. clinical findings: both right elbow and left wrist were painful, swollen and with a remarkable restriction of the range of motion (rom). patient also reported lower back pain. no neurovascular injuries were detected. investigation/results: x-ray and ct scan confirmed a fracture of a lumbar vertebra, fracture of the right olecranon and, on is left wrist, a carpal fracture-luxation mayfield 4 of both scaphoid and capitate associated with rotation of the last one proximal pole-fenton''s syndrome. diagnosis: this syndrome is an atypical presentation of perilunate fracture dislocation and, therefore, difficult to diagnose. few reports were found in literature. after an open reduction of the fractures, a definitive fixation with headless herbert screws was achieved. percutaneous kw and immobilization of the wrist were performed to further stabilization of the lunotriquetral joint. 12 weeks later consolidation was noted. a decrease of 15°in extension and flexion were detected when compared with the contralateral wrist. grip strength test was similar on both hands. osteosynthesis of the right olecranon was also realized. comments: a careful neurovascular assessment is important. although it is rare, injuries of median nerve were already reported associated to this complex fractures. open reduction and osteosynthesis are necessary due to the great instability and the risk of nonunion and osteonecrosis of the rotated proximal segment. introduction: intramedullary nailing has been popularly applied for the femoral shaft fractures. the current study aimed to analyze the femur geometry for development of implant design with 3 dimensional skeletonization. material and methods: we acquired computed tomography (ct) images of both femur reviewed in a single center from 2015 to 2017. the total 1400 participants were enrolled and they were divided into subgroups according to age (decades) and gender. each subgroup included 100 persons, respectively. these images are used to produce 3d samplings. with the skeletonization, we obtained the geometry parameter; (1) femur shaft length from the tip of the greater trochanter to the bicondylar line, (2) the minimum diameter of the medullary canal and its location, (3) anteroposterior (ap) diameter and lateral diameter of the entire femur, (4) radius of curvature (roc) of the femur (bowing). we compared all parameters according to sex and age. results: the average age of the participants were 54.0 years (range 20-89 years) and the number of each gender was exactly same. the femur length was 425.5 ± 37.6 mm (range, 337.4-516.0 mm) and the femur shaft length was 383.0 ± 35.6 mm (range 301.3-466.5 mm), both of them were longer in male (p = 0.002, \ 0.001). the minimum diameter of the medullary canal was 9.4 ± 1.9 mm (range 5.0-18.1 mm). the roc was 810.7 ± 202.5 mm (range 338. 3-1491.8 mm) . the rate of the minimum diameter less than 8 mm and 7 mm was 26.0% and 9.4%, respectively. the rate of roc with less than 750 mm and 700 mm was 28.5% and 21.3%, respectively. conclusions: this geometry analysis showed that there are mismatch problem between the current nail and the medullary canal in 9.4% and the roc of the femur was smaller than that of the current nail systems (1000-1500 mm). the result indicates potential mismatch problem in clinical cases and the problem can be resolved with newly designed nail system. the study was funded by national reserach foundation of korea (nrf-2018r1d1a1b07050224). safe zone of the infracacetabular screw: virtual mapping of 362 three-dimensional hemipelvises for quantitative anatomic analysis introduction: an infra-acetabular screw can provide increased stability in fixating acetabular fracture. we conducted this study to define the incidence of the safe corridor for infra-acetabular screw and to determine the correlation between the safe corridor and other demographic factors such as age, sex and height. material & methods: pelvis computed tomography (ct) of 182 participants was extracted with evenly age-and sex-allotted. 362 virtual three-dimensional (3d) model was generated. a search was performed to find the maximum-with corridor connecting two points. the entry and exit point was displaced in the template. the maximum diameter of each corridor was measured in automatic procedure. a minimum 5 mm corridor diameter, sate corridor, was defined as a cutoff for placing a 3.5 mm cortical screw in clinical setting. all data were presented as mean and range or mean and standard deviation. two-sample t test and regression analysis were used to compare difference between groups based on sex, age, and height. results: among 354 hemipelvis, 250 hemipelves (70.6%) satisfied a minimum safe corridor diameter of 5 mm. when divided into a subgroup by the patient's gender, the incidence of the safe corridor of a male group was statistically higher than a female group (82.0% vs 59.1%), with the mean corridor diameter of 6.24 mm (95% ci, 0.2) and 5.44 mm (95% ci, 0.2), respectively (p \ 0.001). in correlation analysis, only the height showed a positive correlation with the diameter of the safe corridor of a total population (r = 0.25; p \ 0.001). conclusions: the study provided the safe corridor was found in 81% of male and 69% of female, and the taller had the higher incidence of the safe corridor. the patient''s height was correlated with the corridor diameter of the infra-acetabular screw, whereas the patient''s age did not correlate with the corridor diameter. introduction: femoral neck fractures in middle-aged and older patients represent one of the most common orthopedic conditions. osteosynthesis, as a primary treatment option for femoral neck fractures has shown to have successful outcomes. however, this is not the case for old fractures. the purpose of this study was to evaluate the outcomes of treatment of femoral neck fractures in which cementless total hip arthroplasty was indicated. the aim of our study was to analyze the prosthetic failure, i.e., the reasons for unsuccessful outcome, in order to suggest the indications for primary osteosynthesis which could guide the femoral neck fracture management. material and methods: a total of 120 patients were analyzed in this study, with femoral neck fracture treated with osteosynthesis. reviewing the radiological findings, as well as the course of the treatment, we set up the criteria, on the basis of which we could advice the immediate implantation of total hip prosthesis for the femoral neck fracture. results: old fractures, varus deformity of the femoral head and neck, dislocation, as well as the comminuted fractures, are all factors affecting the surgical outcomes of osteosynthesis. additionally, medical and technical equipment of medical institution, personnel competence, and minutious surgical technique affect the treatment outcomes. introduction:proximal ulnar fractures are usually osteosynthesized by means of angle stable plate osteosynthesis. despite good functional results of this procedure, complications such as high access morbidity and disruptive osteosynthesis material with a high rate of material removal are described. the aim of our study was the development of a new locking nail and test setup for comparison with a plate osteosynthesis on artificial bones. material and methods: in our biomechanical laboratory, a jupiter 2b fracture of the proximal ulna was standardized on 20 sawbones and stabilized by means of the newly developed nail or anglestable posterior plate osteosynthesis. a servopneumatic testing machine, the specimens were flexed under a cyclic load (30-300 n) in the physiological range of movement of the elbow from 0°to 90°.the maximum elastic deformation of the specimens and the loosening of the implants were evaluated after 608 test cycles. results: the primary stability of the constructs at the anterior cortical bone after nail osteosynthesis was significantly greater (0.29 ± 0.13 mm) than in the angle-stable plate osteosynthesis (0.97 ± 0.30 mm, p \ 0.001).after passing through the test cycles, both implants showed a low loosening rate. in the area of the anterior cortex, the locking nail showed a significantly lower rate of loosening (nail 0.08 ± 0.06 mm, plate 0.24 ± 0.13 mm, p \ 0.001). at the dorsal cortex, there were no differences between plate and nail in both series of measurements. conclusions: intramedullary implants provide biomechanical benefits in fracture stabilization. good biomechanical results have already been shown in the literature after nailing olecranon fractures2. nevertheless, due to the complex anatomy and the resulting difficult implantation technique, ulnar nails could not prevail in practice. the presented nail allows a safe stability with simple surgical technique. introduction: adequate treatment of tibial plateau fractures is crucial to minimize patient disability, development of posttraumatic arthritis and subsequent need for a total knee arthroplasty (tka). however, due to the complexity of the fracture, adequate reduction cannot always be achieved which could result in the early conversion to a tka. in this study we introduce a quantitative 3d fracture assessment method and investigate whether it could help to identify patients that are at risk of conversion to a tka. material and methods: we retrospectively included 135 patients, who were treated for a tibial plateau fracture between 2003 and 2017. 16 patients developed severe posttraumatic arthritis and underwent conversion to a tka. from all patients, 3d models were created using the pre-operative ct-scans. for each patient, the 3d gap area between the fracture lines, representing an innovative combined gap and step-off measurement in 3d, was determined in order to quantify the displacement (figure 1 ). roc curve analysis was performed to determine a critical cut-off value for the 3d gap area. kaplan-meier survival curves were created to assess the association between 3d fracture anatomy and risk on a tka at follow up. results: a critical cut-off value of 700 mm 2 was found to give highest combined sensitivity and specificity for 3d gap area and the risk of tka at follow-up. kaplan-meier survival curves showed 98.9% knee survival (no tka) at 2 year follow up in the group with a gap area of \ 700 mm 2 , whereas in the group with a gap area of c 700 mm 2 a knee survival of 82.5% was found. at 10 year follow up knee survival was 97.9% and 63.8%, respectively, for the two groups (\ 700 mm 2 and c 700 mm 2 ). conclusions: we developed an innovative method to quantify the amount of displacement in 3d. pre-operative 3d fracture assessment could be used as an addition to the current fracture classification methods to help identify patients who have a high risk on conversion to tka at follow-up. introduction: soft tissue sarcomas (sts) in the anterior compartment of the thigh are frequent. the extent of quadriceps resection is controversial. the aim of the present study is to communicate our results in complete quadricectomies due to high-grade sts. material and methods: we present 8 sts, in stage iiib of the ajcc, with a mean craniocaudal diameter of 15 cm (9-25). there were 4 women and 4 men, with a mean age of 58 years (35-79). six were undifferentiated pleomorphic sarcomas, 1 myxofibrosarcoma and 1 clear cell sarcoma. in every case, total quadricectomy was performed with wide margins. posterior reconstruction with local muscle transfers was performed, expect for the younger patient, who received a vascularized contralateral vastus lateralis transplant. in all cases, complementary radiotherapy was indicated, and in 4 patients adjuvant chemotherapy. results: three patients required friedrich due to necrosis of the edges of the surgical wound. one patient died 50 months after the intervention as a result of multiple metastasis, and two due to medical complications after 1 week and 4 months, respectively. the average follow-up time for the rest was 28 months , with no local recurrence. as for functional outcomes, mean msts score was 20 (14-30), with deficit of active knee extension in most of them. the functional result of the patient with the vascularized muscle transplantation was excellent. all of them were satisfied with the results of the treatment. conclusions: quadricectomy provides good functional and acceptable cancer results, although it is not exempt from complications in frail patients. vascularized muscle transplantation, though complex, can improve functional results, especially in younger patients. introduction: operative treatment is a valuable option in displaced proximal and/or middle one-third diaphyseal humeral fractures. although plate osteosynthesis is preferred to intramedullary nailing, surgery can be complicated by radial nerve palsy. a helical plate could avoid this high-impact complication. to date there is however a lack of published evidence in literature, although recent asian case reports show promising results. material and methods: we retrospectively reviewed 16 patients who were treated with open reduction and internal fixation with a helical plate consecutively from october 2016 until august 2018 at az groeninge, kortrijk. a deltopectoral approach was used in combination with a distal anterolateral incision, whether or not in continuity. a self-molded long philos plate was used in the first 9 patients, while in our last 7 patients the a.l.p.s plate (zimmer ò ) was used. standard radiographs were obtained pre-and postoperatively. we retrospectively searched for complications, e.g. radial nerve palsy, infection and/or loosening. in autumn 2019, 12 patients were reassessed. patient''s general health status was evaluated using the eq-5d-5l score. constant-murley scores and dash scores were used for evaluating shoulder function and disability measures consecutively. results: all humeral fractures consolidated at 3 months. there were no radial nerve palsies due to surgery. one plate was removed after 1 year due to a late infection. with a minimum follow up of 1 year, the mean dash score was 22 (0-93) and the mean constant-murley score was 68 (33-95). the dash score was inversely proportional with the constant-murley score and patient''s general health status. conclusion: a helical plate avoids neurological complications with similar healing rates and good to excellent shoulder function at 1 year follow up in the treatment for proximal and/or middle one-third diaphyseal humeral fractures. the use of antibiotic-impregnated cancellous bone grafts in onestage surgery for chronic orthopaedic infection: preliminary clinical results k. dendoncker 1 , g. putzeys 1,2 1 az groeninge, tissue bank, kortrijk, belgium, 2 az groeninge, orthopaedic center, kortrijk, belgium introduction: the use of cancellous bone allografts is an established technique in reconstructive orthopaedic surgery. unfortunately, its use is generally avoided in the presence of a local infection. antibiotic impregnated cancellous bone grafts has shown its effectiveness as an local antibiotic delivery system [1] [2] [3] . in this clinical study, we report our first personal experience with the use of vancomycin-impregnated cancellous bone grafts in one-stage surgery for periprosthetic joint infections (pji) and fracture-related infections (fri). material and methods: between december 2015 and march 2019 nine patients were treated during a one-stage surgery with vancomycinimpregnated cancellous bone grafts, containing 1 g vancomycin per 10 cc bone. regular clinical, laboratory and radiographic follow-ups were performed for at least 6 months after surgery. results: the procedures included revision of 5 pjis (hip and humerus) and 4 fris (tibia, femur and clavicula). one tibia required further revision because of recurrent infection and one hip has an uncertain infection state, however the remaining 7 patients stayed free from infection during a follow-up of at least 6 months. interestingly, in one patient the vancomycin concentration could be determined in the drainage fluid from the wound. radiographic examination revealed no signs of osteolysis or loosening, good incorporation of the bone graft and progressive consolidation. conclusions: within the limits of the study, the use of vancomycinimpregnated cancellous bone grafts in one-stage surgery to treat pji and fri yielded positive outcomes in terms of clinical, laboratory and radiographic follow-up. this technique might offer new treatment strategies in often devastating injuries. references: 1. putzeys g., et al. orthopaedic proceedings. 2015; 97-b:supp_16, 145-145. 2 with the modified arthroscopic approach (group b). the prospective follow-up included the lysholm score, the subjective questionnaire of the ikdc score and the specifically extended oak score for clinical evaluation. the rolimeter ò was used to test the translational mobility of the knee joint. the statistical significance level was set at 5%. results: the follow-up was 28.5 ± 19.60 months and 30.6 ± 26.26 months postoperatively in group a and b, respectively. the subjective scores were tested. group a and b achieved a mean lysholm score of 70.3 ± 5.32 and 69.6 ± 19.82 points respectively. in the subjective ikdc assessment, group a achieved 67.3 ± 7.76 points and group b 65.9 ± 12.35 points. the clinical oak score was 77.5 ± 6.10 points in group a and 75.3 ± 11.31 points in group b. the following values could be recorded for the stability of the posterior cruciate ligament: the side difference in the rear drawer test was 1.75 ± 1,192 mm in group a and 2.50 ± 2.160 mm in group b. in the reversed lachman test, a difference of 2.37 ± 2.175 mm and 3.22 ± 2.059 mm was measured in group a and b, respectively. all values mentioned were comparable between the two evaluated groups. conclusions: the results of the two surgical techniques were comparable. therefore the arthroscopic approach is the preferred method in our institute. simple correction technique of femoral malrotation after pfn-a osteosynthesis of trochanteric fracture k. pavotbawan 1 , p. stillhard 1 , c. sommer 1 1 kantonsspital graubünden, department of trauma surgery, chur, switzerland introduction: malrotation after intramedullary nailing in femoral shaft fractures are well known. but malrotation after nailing of trochanteric fractures is an underestimated problem. during surgery the axial alignment can easily be evaluated by fluoroscopy in both planes. but the torsional alignment is difficult to assess especially with the patient placed on the traction table. in literature a malrotation after pfna is described in up to 25% of the cases. a revision with replacement of the blade, especially in patients with poor bone quality, may result in a reduced stability. to our knowledge there is no publication till to date to give a treatment pathway for this problem. we developed a rather easy technique to derotate a malrotated femur after pfna fixation. material and methods: the basic idea is to leave the usually well placed blade insitu in the femoral head, just rotating the distal main fragment around the nail. therefore, a small u-shaped osteotomy with a chisel is performed in the femoral cortex just anterior of the entry site of the blade. the length (l) of this osteotomy can be calculated, following the formula: l = d x p x a/360 (d = diameter of femur, a = angle of malrotation). then the distal locking bolt is removed, the leg derotated and finally locked again. the procedure is controlled by two schanz''screws separately inserted in both main fragments angulated to each other in the angle ''a''. results: since 2014 3 patients were detected with a clinically relevant femoral malrotation. all patients had an internal malrotation from 30 to 40 degrees confirmed and measured by ct scan. all of them were successfully revised in the above described technique 5-9 days after initial fixation. conclusions: first, we believe that malrotation after trochanteric fracture fixation is an underestimated problem. and second our method is a simple salvage procedure for malrotated trochanteric fractures after pfna, leaving the blade in situ in the femoral head. optimal intramedullary nailing for trochanteric fractures: the importance of distal locking screw and reduction position t. waki 1 , t. yano 1 , k. ito 1 , s. matsushima 1 1 akashi medical center, orthopaedic surgery, akashi, japan introduction: distal locking issue for trochanteric fractures is still controversial. therefore, the purpose of this study was to investigate the complications between distal unlocked group and distal locked group. further, the relationships were evaluated between these complications rates and their reduction positions after operation. material and methods: 365 operations were performed for trochanteric fracture (ao 31a1 ?a2) from 2012 to 2018. of these, patients with f/u periods [ 3 month were 218. gamma3 im nailing system (stryker) was used for all patients. 146 patients (unlocked group) from 2012 to 2016 operated without distal locking screw. 72 patients (locked group) from 2016 to 2018 operated with distal locking screw. we retrospectively analyzed those patients who suffered complications such as delayed healing and postoperative periimplant fractures and cut-out of the lag screw. further, in lateral view of their radiographs, we evaluated the position of the proximal fragment compared with distal fragment. the reduction positions were divided into 3 groups: anterior (subtype-a), neutral (subtype-n), and posterior (subtype-p). results: in unlocked group, complication was shown in 94 patients (complication group). delayed healing was shown in 94/146 (64.4%) in unlocked group and 12/72 (16.7%) in locked group. peri-implant fracture was shown in 3/146 (2.1%) in unlocked group and 0/72 (0%) in locked group. cut-out of the lag screw was shown in 4/146 (2.7%) in unlocked group and 1/72 (1.3%) in locked group. in complication group, subtype-p was more than non-complication group. conclusion: in the current study, higher number of complications was seen in the distal unlocked group. and, our study showed the reduction position might be associated with post-operative complications. we concluded that nailing without distal locking screw might be dangerous and subtype-p should be avoided. introduction: heterotopic ossification (ho) after acetabular fracture surgery has been one of the common complications and often limits function with the range of motion severely. surgical resection is challenging and only effective treatment for established ho. we herein report four cases who underwent surgical resection and mobilization for ho after acetabular fractures surgery. material and methods: four cases with severe ho after acetabular fracture surgery were included in this study. the mean age at operation was 45 years old, and all patients were males. in judet-letournel classification, there were three cases classified as posterior wall fracture, and one case as transverse and posterior wall fracture. two of four cases were combined with posterior dislocation of the hip. in all cases, the first operation was performed using with the kocher-langenbeck (kl) approach. results: surgical resection of ho was performed using with the kl approach at 8.4 months (range 5-12 months) after the first operation. the median operating time and intraoperative bleeding were respectively 4.5 h and 3130 ml. intraoperative 3d navigation was used in one case. as postoperative complications, one case developed sciatic nerve palsy and another case sustained the iatrogenic femoral neck fracture. all cases have no recurrence with a follow-up of 4.9 years after the surgical resection. conclusions: surgical resection is the only treatment for symptomatic ho. but that requires preoperative planning and must be performed carefully because the extent of resection is still controversial and that may develop severe complications such as nerve palsy and iatrogenic fractures. by using navigation, we can determine the extent of resection easily and operated safely. case history: 18-year-old male, previously healthy, turned to the hospital after a motorbike crash, resulting in high energy direct trauma of the right wrist. clinical findings: upon admission, cranial, thoracic, abdominal and other traumatic injuries were excluded. the patient presented with pain, swelling and visible deformity of the right wrist and hand, hypoesthesia of the 5th finger, and no perfusion deficits. investigation/results: x-rays showed volar perilunate carpal dislocation with associated comminuted scaphoid fracture, radial styloid avulsion, and metacarpal phalangeal dislocation of the 5th digit. under sedation, closed reduction of the metacarpal phalangeal joint was accomplished, and reduction of the carpal dislocation was attempted unsuccessfully. the wrist was temporarily immobilized in a cast and taken to the or. diagnosis: transcaphoid-transradial-styloid-perilunate volar dislocation therapy and progressions: surgical treatment comprised loose bodies removal, reduction of the perilunate dislocation, orif of the scaphoid using a herbert screw, and stabilization of the carpal rows using two percutaneous kirschner wires. after surgery, a thumb spica cast was applied. post-operatively, neurovascular status was normal. at 6 weeks, x-rays showed signs of bone healing, the cast and k wires were removed, and physical therapy was initiated. at 6 months, scaphoid fracture consolidation was achieved. the patient remained with a mild deficit in wrist extension but reported no pain nor important limitation in daily living activities. comments: perilunate injuries with displacement or dislocation usually require surgery. persistent instability is a described complication, often progressing to secondary post-traumatic arthritis of the wrist and carpus, termed scapholunate advanced collapse. introduction: this study was conducted to study the patient characteristics, classification, treatment, complications and functional outcome of operatively treated displaced intra-articular calcaneal fractures (diacf) in a level 1 trauma center in the netherlands material and methods: patients with an diacf, classified as sanders c 2 and operatively treated with percutaneous screw fixation (psf) or open reduction and internal fixation (orif) between january 1998 and december 2017 were identified. pre-and postoperative radiological assessment was performed. functional outcome, range of motion and change in footwear were evaluated with the use of the american orthopaedic foot & ankle society (aofas) score and the maryland footscore. general health and patient satisfaction was assessed using the short form-36 (sf-36) and the visual analogue scale results: in total, 116 patients with an operatively treated diacf were identified. 67 patient with 76 diacf completed the questionnaires. there were 52 males and 15 females, mean age at trauma was 45 years. average follow up was 11 years. 17 were classified as sanders type 2, 31 and 19 as respectively type 3 and 4. 36 were joint depression and 38 were tongue-type fractures. there were no differences in sanders classification between the group treated with orif and psf. for orif and psf there were (25-25%), (52-42%) and (22-33%) for respectively sanders type 2, 3 and 4 fractures. mean aofas, mfs, sf-36 and vas was (75-74), (79-78), (59-66) and (7-9) for respectively orif and psf. mean pre-and post-bohler angle was (11-24) and (15-22) for respectively psf and orif. 7 underwent an ankle arthrodesis. surgical site infection and deep infection occurred in (12,5-25%) and (12,5-8%) in respectively psf and orif conclusions: long-term comparison shows no significant differences between orif and psf in treatment of sanders fracture type, bohler angle reduction, on functional outcome or complication rates introduction: the prevalence of hand injury in the pediatric population is attributed to their curiosity, limited fear of pain and diminuted motor coordination. the seymour fracture, which was first reported by seymour in 1966, represents a transverse extra-articular open fracture of the distal phalanges associated with nail bed injuries. the fracture includes salter-harris type i and ii fractures as well as juxta-epiphyseal injuries. material and methods: the aim of this report is to present a case of a seymour fracture in a young boy and describe the injury mechanism associated with misuse of the newly emerging vehicle, the hoverboard. results: our patient was treated promptly and provided with appropriate management following the standard of care in our hospital for such injuries: disimpaction and repair of the nail bed, reduction of the fracture, and k-wire fixation across the distal interphalangeal joint. the patient was discharged with a volar slab and was prescribed an oral antibiotic. the patient recovered well with no major deficits. conclusions: the timely recognition and management of seymour fractures is crucial. the surgical treatment has good results however, conservative management can be an option in some specific cases. antibiotics are always required. we report a case of a fracture pattern resulting from the improper use of an hoverboard. although improper use was a factor, design fault also plays a role in causing the injury. hoverboards are a new transport technology that has been introduced in recent years. because of the number of injuries that have resulted from hoverboards, they should be used in the most controlled way possible to prevent any unnecessary injuries. case history: we report the case of a 32 years old male from bangladesh, with 6 months of progressively increasing pain, limited range of motion and swelling on his left knee, with 6 kg of weight loss and inguinal lymph nodes. clinical findings: knee radiography and mri of the knee demonstrated a voluminous soft tissue mass surrounding the distal femur with intraarticular and posterior extension. a toracic-abdominal-pelvic ct showed supra and infradiaphragmatic lymph nodes. c-reactive protein level was 5,72 mg/dl. investigation/results: the clinical picture suggested a lymphoproliferative syndrome. a biopsy was performed, revealing 100 cm 3 of purulent material. synovial fluid had 548 leucocytes/ul, 70% of polymorphonuclear cells, 30% of mononuclear cells and undetectable glucose. acid-alcohol resistant bacilli test and pcr test for mycobacterium tuberculosis were positive. diagnosis: mycobacterium tuberculosis knee arthritis therapy and progressions: the patient was treated with polytherapy consisting on rifampin, isoniazid, pyrazinamide and ethambutol. 6 months later, the patient reports no pain, and tumor size has decreased. comments: mycobacterium tuberculosis infection is not a common disease in developed countries. however, the incidence in europe is increasing due to immigration. even though the lung is the most affected organ, osteoarticular tuberculosis represents around 10% of extra-pulmonary cases. tuberculosis simulates several diseases. because of non-specific symptoms and radiological signs, it can be difficult to diagnose. in a patient with chronic knee pain and limited range of motion, tuberculosis infection should be kept in mind, among other differential diagnoses, such as fibromatosis, pigmented villonodular synovitis or soft tissue sarcomas. clinical findings: the patient presented with a valgus deformity of the knee, the medial femoral condyle protuding on the medial side of the knee. neurovascular status was intact. investigation/results: xray revealed lateral dislocation of the knee. mri revealed mcl, pcl and acl rupture. diagnosis: knee dislocation (kd) grade iii (schenck). therapy and progressions: the patient underwent emergent closed reduction. neurovascular status was intact after resuction. due to important oedema and blisters, the lower limb was immobilized with a brace to allow for skin surveillance. after 3 weeks, the brace was replaced by a long leg cast for 2 more weeks. after 6 months, the patient maintained residual pain, rom -5/855 and minor instability. comments: kd are unusual injuries, associated with high energy trauma, therefore they often result in disruption of at least 3 major ligaments and associated injuries, from soft tissue to vascular structures. emergent reduction is mandatory, and definitive treatment can be conservative, or early/late surgical repair/reconstruction of the ruptured ligaments. there is a lack of large prospective clinical studies comparing the different types of treatment. even so, data tend to associate early surgical treatment with better functional outcomes, though there is no statistic evidence supporting its improvement of the range of motion or stability. long term complications most frequently include residual pain, instability or rigidity. rarely the knee returns to its pre-injured state, independently of the treatment used. references: dwyer, t., et al. (2012) . outcomes of treatment of multiple ligament knee injuries. the journal of knee surgery, 25(04), 317-326. advising a reduction after a fracture of the distal radius, reliability with and without use of expert based criteria introduction: distal radius fractures (drf) are common, however many aspects of its management remain subject of debate 1 . this study assessed the interobserver reliability of surgeons concerning the recommendation for a reduction and the improvement of expert based criteria for reduction. material and methods: we sent out 2 surveys to members of the science of variation group. the first survey divided participants in 4 groups, each rated 23-24 radiographs of drf. resulting in 95 rated fractures by 80 participants. each observer indicated whether they would advise a reduction or not. the second survey randomized participants (68 surgeons) to either receive or not receive criteria for reduction and participants indicated if they would recommend reduction. results: the reliability for advising a reduction was poor, kappa 0.31 (95% ci 0.23-0.39). multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the change of recommending a reduction by 3% (beta 0.03, 95% ci 0.02-0.03 p \ 0.001). criteria for reduction did not increase interobserver reliability for recommending reduction (no criteria kappa 0.43 95% ci 0.26-0.59 vs. criteria 0.47 95% ci 0.33-0.61). the likelihood of recommending a reduction was higher in the group using the criteria (0.61 vs 0.68, p = 0.009). conclusions: poor interobserver reliability is associated with greater practice variation. dorsal angulation is the main drive for recommending a reduction. the liberal use of the criteria in combination with a specific focus on dorsal angulation leads in our opinion to less variation in treatment recommendation for distal radius fractures. this is something future study could assess for distal radius fractures in actual practice introduction: the number of pertrochanteric hip fractures increases proportionally to the increase in life expectancy. currently, the most used treatment in these fractures is the antegrade nailing. suffering a second fracture in the same femur around an antegrade nail is an uncommon complication, but it has a great impact on the patient. the aim of this study is to describe the type of perinail femoral fractures observed in our center, the treatment performed and the medium-term results. material and methods: between 2013 and 2018, 14 patients presented a perinail femoral fracture. 13 were women and one was male, with an average age of 83. initial fractures were classified according to the ao classification: 6 were 31a1, 5 were 31a2 and 3 were 31a3. 8 of them were synthesized by short pfn-a (synthes), 3 with short pfn (synthes) and 3 with gamma3 (stryker). the average time since osteosynthesis of the proximal femur fracture and the perinail fracture was 3.5 years (1 month-12 years). results: 11 of the peri-implant fractures occurred at the level of the nail tip or the distal locking screw. the remaining 3 fractures occurred in the distal femur. these 3 supracondylar fractures and 2 of the fractures at the level of the nail tip were synthesized with a va condylar plate (synthes), overlapped with the nail. in the rest of the fractures around the tip of the nail, the short nail was removed and replaced by a long pfn-a nail. one of the patients died in the immediate postoperative period. two patients died during the first year. in the rest of the patients, a complete consolidation of the fracture was observed, and their previous baseline situation was recovered. conclusions: peri-implant femur fracture is a rare but very severe condition, which requires good surgical planning, and is not without complications. gamagori city hospital, department of orthopedics, gamagori, japan, 3 nagoya daini redcross hospital, department of orthopedics, nagoya, japan introduction: hip fracture is a leading worldwide health problem for the elderly. a missed diagnosis of hip fracture on radiography leads to a dismal prognosis. the application of a computer-aided diagnosis (cad) system using artificial intelligence (ai) to detect hip fracture can potentially improve the accuracy and efficiency of hip fracture diagnosis. material and methods: cad system using ai was trained using 4851 cases, 5242 plain frontal pelvic radiographs (pxrs) between 2009 and 2019 from each institution. the accuracy, sensitivity, falsenegative rate, and area under the receiver operating characteristic curve (auc) were evaluated on 500 independent pxrs. the authors mixed resnext as classification algorithm and ssd as object detection algorithm to train cad system. results: the algorithm achieved an accuracy of 94.1%, a sensitivity of 96.2%, a false-negative rate of 1%, and an auc of 0.94 for identifying hip fractures. the visualization algorithm showed an accuracy of 97.9% for lesion identification. conclusions: our cad system using ai not only detected hip fractures on pxrs with a low false-negative rate but also had high accuracy for localizing fracture lesions. the cad system using ai might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. medical faculty university of nis, orthopaedic surgery, nis, serbia, 2 clinical center nis, orthopaedic and traumatology clinic, nis, serbia, 3 orthopaedic word of medical center, cuprija, serbia introduction: bone reconstruction and limb lengthening usually refers to application of ilizarov or other ring external fixation devi-ces1. we present here series of posttraumatic reconstruction and limb lengthening, by the use of new concept of 3d unilateral external fixation device. material and methods: as a clinical material, we present series of 59 patients with different posttraumatic deformities (28) and limbs discrepancy (31) as a result of severe traffic accidents and wars. all patients have been treated by specially designed unilateral 3d external fixation system. that system is not bulky and it is more comfortable in comparison to ring fixators. procedure is relatively simple, so patients handle the device by themselves. during biomechanical testing, it was found that stability of this device is similar to ring systems. the last version of the device includes computer program and two sensors. results: all deformity corrections have been achieved successfully. sliding graft procedure has successfully been performed in all 9 patients with bone defect reconstruction from 5 to 11 cm. in one patient with complex deformity and shortening, correction couldn''t be achieved during one procedure, so additional operations, by the use of the same system have been performed and correction completed. superficial pin tract infection rate was 11.1% and we didn''t have deep infection. there were no other complications including dvt, joint stiffness, neurovascular injuries. conclusion: unilateral external fixation device with balanced 3d stability provides the same success of bone reconstruction and limb lengthening as ring fixators, but it is more comfortable and more easy for handling. references: treatment principles in bone reconstruction and limb lengthening of the lower extremity. olesen uk, nygaard t, kold sv, hede a. ugeskr laeger. 2017 nov 20; 179(47) at this moment author has licence agreement with the producer of external fixation devices. all patients were classified into the isolated hip fracture and the concomitant fracture. we analyzed these patients'' characteristics such as age, gender, bone mineral density (bmd), body mass index (bmi), korean version of mini-mental state examination (mmse-k), injury mechanism, and length of hospital stay. results: the most common site of upper extremity fracture was distal radius fracture of 15 patients (42.8%), followed by proximal humeral fracture of 8 (22.8%). concomitant fractures occurred on the same side in 30 patients (85.7%). the mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p \ 0.05). mean preinjury mmse-k was 22.7 in isolated hip fracture and 25.6 in concomitant fracture patients (p \ 0.05). mean length of hospital stay was statistically significant different between two groups (p \ 0.05). according to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture. conclusions: we found a 3.4% prevalence of concomitant hip and upper extremity fractures. it was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. in addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation. on the other hand, the amount of bleeding was 658 ml in group e and 792 ml in group l, and there was no significant difference between the two groups. poor cases on postoperative images were 30% in group e and 11% in group l, and the joa hip score was 68.4 (groupe) and 91.2(group l). in clinical results is significantly improved in group l. conclusions: the treatment results improved significantly in group l. as the number of experienced cases increased from these results, the reduction accuracy and treatment results improved, so experience was considered important for improving the treatment results of acetabular fractures. the additional value of the weight-bearing and gravity stress radiograph in determining stability of isolated type b ankle fractures introduction: the goal of the current study is to investigate whether the weight-bearing and gravity stress radiographs have additional value in determining stability in isolated type b fibular fractures. this in order to make the important distinction between fractures that need surgical treatment and fractures that can be safely treated conservatively. material and methods: 90 patients with an isolated type b ankle fracture, without medial or posterior fracture, and a medial clear space (mcs) \ 6 mm on the regular mortise radiograph were included. in the emergency room, a gravity radiograph was performed (in accordance with out protocol). within 1 week, an additional mri scan was made. at this moment, in 51 patients a weight-bearing radiograph was performed too. the mcs measurements of these regular mortise, gravity and weight-bearing radiograph were compared with the mri findings. the mri scan was set as reference standard to detect injury of the deltoid ligament in order to determine (in)stability. results: mean mcs on mortise radiograph was 3.3 mm (range 1.7-5.9); in 12 (13.3%) patients the mcs was [ 4 mm and in 15 patients (18.3%) the superior clear space (scs) was [ mcs ? 1 mm. in 2 (2.4%) patients, the scs [ mcs ? 2 mm. on the gravity stress radiograph, 14.4% of the patients had a mcs [ 6 mm. the weight-bearing radiograph showed a mcs [ 4 mm in 3 (5.9%) patients. in 4 (4.4%) patients, the mri showed a complete rupture of the deltoid ligament. in 21 (23.3%) patients a partial rupture was seen. 10 patients (11.1%) received surgical treatment. in all conservatively treated patients, no secondary dislocation occurred and there was no need for postponed surgical treatment. conclusions: the gravity stress view has a tendency to overestimate the mcs. thus, potentially too many stable fractures are incorrectly diagnosed instable and receive unnecessarily surgical treatment (with additional costs and risks). the weight-bearing radiograph, on the contrary, does not overrate the medial injury and can safely be used in the decision making process of treating conservatively and weightbearing (for example by using a brace) introduction: the purpose of this study was to identify the effect of the intravenous iron supplementation on demand of perioperative blood transfusion and post-operative hemoglobin recovery in geriatric hip fractures. material and methods: a retrospective cohort study was performed on patients who underwent surgery with proximal femoral nail for hip fracture and age 60 years old or older between jan 2018 and may 2019 in a single center. the participants were divided into 2 groups according to preoperative intravenous iron supplementation (iron isomaltoside, monofer ò , pharmacosmos, holbaek, denmark); group 1 (n = 25) with monofer 400 mg before surgery and group 2 (n = 33) without monofer. transfusion was preformed when the hgb was less than 8 mg/dl). primary endpoint was incidence of perioperative transfusion. secondary endpoints were various hemoglobin (hgb) levels. results: the average age of the participants were 77.4 years old, and average body mass index (bmi) was 22.8. demographic data including age, sex, bmi, comorbidity (charlson comorbidity index) of each group showed no difference. the complications from intravenous iron administration were not occurred. the preoperative hgb was 11.4 mg/dl (group 1 11.9 ± 2.1 vs, group 2 10.9 ± 1.9, p = 0.591). the hgb at the postoperative day 2 was 10.2 mg/dl (group 1 10.5 ± 2.1 vs group 2 9.9 ± 1.8, p = 0.273). the average hgb at the postoperative 1 month was 11.6 mg/dl (group 1 11.7 ± 1.7 vs group 2 11.5 ± 1.5, p = 0.431). transfusion rate was 51.7% (30/58) and the rate showed no difference between 2 groups (40.0% vs 60.6%, p = 0.120. the recovery of hgb between postoperative 1 month and preoperative state showed statistically difference (group 1 0.166 vs group 2 -.0579, p = 0.049), and iron supplementation group had more recovery. conclusions: intravenous iron supplement before the hip fracture surgery in elderly helped to recover hgb at postoperative 1 month. comminuted subtrochanteric femur fractures-our experiences introduction: subtrochanteric femoral fractures account for approximately 25% of all the hip fractures and their treatment represents a challenge because of the short proximal fragment and highenergy forces. material and methods: a total of 17 patients with subtrochanteric, highly comminuted fractures, were included in this study, with age range from 30 to 60 years. the mechanism of injury in all patients was high-energy trauma. in each case we applied a long gamma nail (limma lto) without focus opening. results: in all patients, good clinical and radiologic results were accomplished, in addition to early weight-bearing, without shortening of the legs, or consequences on the state of the hip and morbidity in general. conclusions: although the comminuted subtrochanteric femur fractures represent a challenge for the orthopedic surgeons, osteosynthesis using long gamma nail without the focus opening provides outstanding results. introduction: this study analyzed the association between the postoperative reduced position obtained on using short femoral nails (sfns) and the amount of sliding after fixation in unstable trochanteric fractures. material and methods: this retrospective study included 12 patients with unstable trochanteric fractures with posterolateral support deficiency who underwent osteosynthesis with sfns and were followedup for 3 months or longer. the study included 6 men and 6 women with a mean age of 76.3 years at the time of fracture. closed or open reduction was performed to achieve anatomical to medial type position on frontal view and anatomical to extramedullary type position on lateral view, followed by fixation with sfns. immediately and extramedullary type in 4 patients immediately after surgery. three months after surgery, the reduced position worsened from the anatomical to intramedullary type in 2 patients. according to the reduced positions at 3 months after surgery, the mean amount of sliding was 8.7 mm in patients with intramedullary type, 3.3 mm in those with anatomical type, and 3.7 mm in those with extramedullary type. the amount was larger in those with intramedullary type than in those with anatomical and extramedullary types. moreover, excessive sliding was observed in 1 patient with intramedullary type. conclusions:to prevent excessive sliding by ensuring anteromedial bony support in unstable trochanteric fractures with posterolateral support deficiency, open reduction should be aggressively performed to overcorrect to the extramedullary type when reduction performed on a traction table results in either anatomical or intramedullary type positioning. in this paper, we report 31 patient previously studied for osteomyelitis caused by high-energy missile trauma, in 1996. that study involved a total of 120 patients with osteomyelits, divided into two groups, according to the treatment protocol applied. the group 1 included patients treated using classic surgical methods, including debridement, curretage, forage, perfusion drainage and sequestration. the group 2 included patients treated using recommended surgical methods and used pmma antibiotic beads. 25 years after, we tried to contact all of the 120 patients, for the purpose of follow-up. however, only 31 patient was available for analysis. among 31 patients we followed-up, 11 were treated using recommended surgical protocol, while the remaining 20 patients were treated using classic surgical methods. we present the patients' general status, as well as the local surgical status and radiographic analysis, 25 years after. we obtained long-term results of both treatment protocols applied. from the group 1, 9 patients developed chronic recurrent osteomyelitis, while only one patient from the group 2 developed such condition. introduction: the aim of this study was to evaluate the treatment results using anterior subcutaneous internal fixation(infix) for the pelvic fractures and to consider an improvement strategy for the complications. material and methods: from 2013 to 2019, 31 pelvic fractures were enrolled. there were two males and 29 females. the average age was 80 years. there were 26 fragility fractures and five high energy fractures. our operative procedure was as below: the connection between screws and rod was just above the fascia of the sartorius muscle. the connection bar was pre-bended before the operation using the initial axial ct scan. we assessed bone union, additional fixation, the distance between the femoral artery and connection rod (dar), the distance of protruded bar lateral to the connection (dpb), and complications. results: bone union achieved in 27 out of 31 cases. there was one nonunion and three early deaths because of medical complications. seventeen out of 31 cases required additional posterior fixations. the average dar was 17.1 (3.2-49.2 mm) , and the dpb was 10.1 (0-24) mm. thirteen out of 31 cases (41.9%) had complications. there were seven lateral femoral cutaneous nerve (lfcn) symptoms (3 required implant removal (ir)), two infections (1 required ir), one hematoma (ir), one irritation (ir), one heterotopic ossification, one loosening (re-operation). there were no femoral vessels and nerve-related symptoms. to release lfcn and surrounding soft tissues decreased the nerve symptoms. conclusions: to connect the screws, and the rod just above the sartorius fascia could avoid major vessels and nerve complications, and also irritations. although this study found a high complication rate of infix, to release the lfcn and around soft tissue could decrease the complications. introduction: several studies have reported that posterior or anterior tilt increases the risk of reoperation in undisplaced femoral neck fractures (garden i/ii) after internal fixation performed using nonangular stable devices such as pins and multiple screws. however, to the best of our knowledge, there is limited research involving angular stable devices. the present study aimed to investigate the clinical outcomes in undisplaced femoral neck fractures after internal fixation using angular stable devices. material and methods: this retrospective study included 35 patients (mean age, 79.2 [range, 65-95] years) who underwent internal fixation using angular stable devices between january 2011 and january 2019. undisplaced femoral neck fractures with garden alignment index (gai) b 170°(posterior tilt angle c 10°) or gai b 190°( anterior tilt angle c 10°) were included (posterior: 34, anterior: 1) in this study. patients were followed up for at least 3 months (mean, 16.3 months). we analyzed the preoperative and last-followed gai on lateral radiographs, non-union, and late segmental collapse (lsc). results: among the 35 patients, non-union was identified in 2 (5.7%) and lsc was observed in 4 (11.4%). the mean preoperative gai was 159.8°(range, 125°-203°), and the mean last-followed gai was 164.5°(158°-182°). the overall complication (non-union and lsc) rate was 17.1% (6/35 patients). among 16 patients with gai c 20°, lsc occurred in 3 (18.8%). conclusions: in undisplaced femoral neck fractures, preoperative posterior c 10°is a risk factor for postoperative complications even when internal fixation is performed using angular stable devices; thus, primary arthroplasty may be considered. case history: the patient is a 77-year-old female who had undergone lumpectomy at the age of 53 when she was diagnosed with breast cancer. she had antiresorptive drug therapy for bone metastasis, since 10 years after the lumpectomy. she fell down from standing height and was diagnosed as right femoral subtrochanteric fracture. her femur was fixed with short femoral nail. she complained left hip pain at age 77.she complained left hip pain from july 2018. clinical findings: she could walk with crutch.rom of left hip was normal. investigation/results: breast surgeon took mri and there was metastasis in the proximal part of femur. he thought the cause of pain was this metastasis. however, there was fracture line at the height of lesser trochanter when she visited our department. diagnosis: atypical fracture was strongly suspected, however, fracture line was little higher as normal atypical fracture. therapy and progressions: osteosynthesis with long femoral nail was performed 4 months after first visit to our department because of increasing pain. pathological findings were metastasis and fracture. after surgery, radiation to femur was performed. she can walk without pain by crutch and fracture line is almost disappeared on 11 months after surgery. comments: atypical femoral fractures (affs) are recently observed as a complication of antiresorptive drugs for bone metastasis. however, there were metastasis and atypical fracture in this case. introduction: in the present study we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (ct), in complex tibial plateau fractures, treated with an illizarov frame. materials and methods: this retrospective case series covers the period from 03-2010 to 10-2018. forty-four patients with a mean age of 39 years (range 19-65 years), with a complex intrarticular proximal tibia fracture were included. fracture types iii to vi according to schatzker's classification were included. the majority were closed injuries, apart from 2 cases (a gustilo anderson type 3a and a type 2). all patients were placed on a fracture table. a mini-open reduction of the articular surface was followed by application of a knee spanning illizarov frame. post-operatively all patients were subject to ct of the injured knee. outcomes were measured using the american knee society score. results: mean outpatient follow up was of at least 12 months (range of 12-21 months). mean time for fracture consolidation 15.5 weeks (ranging from 13 to 19 weeks). according to the degree of postoperative articular surface depression patients were grouped as follows: 8 had under 2 mm, 19 had 2-4 mm and 17 over 4 mm of depression. those with less than 3.5 mm of collapse had 95% chances of an excellent result according to akss. on the contrary, those with more than 4.5 mm of articular surface collapse had 100% chances for low scores and functional results. the achievement of a mechanical axis within 5°of the contralateral limb was positively correlated with good functional results but did not have a correlation with the akss. conclusions: complex tibial plateau fractures may be treated successfully with mini open reduction and the application of an illizarov frame. post-operative ct denotes the exact degree of displacement of the articular surface, which is prognostic regarding outcome. postoperative x-rays may be misleading, since they can underestimate articular surface collapse. introduction: a new trauma center building was constructed in march 2016, and the process from the trauma bay to the operation room is faster. we hypothesized that this process improved the survival rate of trauma patients in need of trauma laparotomy. material and methods: the new trauma center separates the trauma bay from the emergency room, and the trauma team exam patients initially. it also has a separate operation room that is always available for emergency surgery. therefore, the decision to perform laparotomy and time to operation has been shortened. from january 2011 to december 2018, trauma patients who underwent emergency laparotomy were included. those younger than 18 years, who had delayed operation, underwent surgical observation, delayed admission by patient, or underwent angiography first were excluded. patients were dichotomized to the before-trauma-center (bc) and after-traumacenter (ac) groups, and their characteristics and clinical outcomes were compared. results: of 644 patients, 349 were included in the bc group and 295 were included in the ac group. the times from admission to operation introduction: acute care is a growing worldwide burden with increasing visits to the emergency department (ed). the acute care system in the netherlands is almost overloaded and costs are increasing. almost 50% of ed visits have surgical disease. there is no nationwide acute care surgery (acs) model implemented yet, and resources and infrastructure are organized differently in almost every hospital. this study provides an overview of the existing systems nationwide, and basis for a national uniform model. material and methods: an online survey was distributed through the dutch surgical society and sent to all dutch hospitals. after sending a reminder, the survey was closed and results were analyzed. results: thirty-two hospitals (41%) participated in the survey. in 78% a surgeon (trauma, vascular or gastro-intestinal) was assigned as consultant and responsible for ed admissions, emergencies in-house, and in some cases also emergency surgeries. 59% of hospitals have an ed observation unit (edou). a dedicated emergency surgery operating room (esor) is available in 69% (24/7 available in 73%), and used efficiently in 55% primarily due to the following challenges: elective surgery scheduled at esor (59%), necessary stop of esor when elective programs are delayed (64%). in hospitals without an esor, the emergency surgeries are scheduled in between elective surgeries resulting in extending programs into the evening. finally, 90% of respondents was familiar with acs, with 62% being positive about exploring options of implementing such a model in our country, and 77% of the respondents opts for more focus on acs in surgical residency. conclusions: in the netherlands the organization of acute care varies. the main common bottleneck is the logistics around the or. implementation of a dedicated esor and unconditional availability 24/7 of this or seem to be the most important factors for optimal efficiency. although there needs to be more focus on acs in general, implementing a uniform model nationwide seems challenging at this moment. trauma team activations (tta) at an european trauma center: 1029 cases analyzed s. saar 1,2 , e. lipping 1 , h. vospert 1 , r. volmer 2 , h. k. laas 2 , j. lepp 1 , k. g. isand 1 , p. talving 2,3 1 north estonia medical centre, division of acute care surgery, tallinn, estonia, 2 university of tartu, tartu, estonia, 3 north estonia medical centre, tallinn, estonia introduction: the north estonia medical centre (nemc) is the largest trauma center in estonia with evolving capabilities. however, studies scrutinizing trauma team activations (tta) are currently lacking. thus, we initiated an investigation to document tta profile and outcomes. material and methods: all tta patients admitted to the nemc between 1/2016 and 12/2018 were retrospectively identified. data collected included demographics, injury severity score (iss), management, hospital length of stay (hlos), and in-hospital outcomes. primary outcome was 30-day mortality. results: overall, 1029 patients were included. mean age was 39.3 ± 20.4 years and 74.2% were male. penetrating and blunt trauma accounted for 11.5% and 88.5% of the cases, respectively. non-ground level falls were the predominant mechanism of injury constituting 32.1% of the admissions. mean iss was 10.3 ± 11.5 and 24.7% of the patients were severely injured (iss [ 15). blood alcohol level (bal) was positive at 31.1%. a total of 21.1% of the patients had an emergent operation. mean hlos was 8.0 ± 15.2 days.overall 30-day mortality and mortality of severely injured patients was 5.1% and 19.3%, respectively. conclusions: the current investigation documents comparable outcomes with established european trauma facilities [1, 2] . blunt injury patterns predominate, however, high penetrating trauma incidence for european settings was noted. high rate of positive bal in tta patients warrants national preventive measures. introduction: the acute care surgery (acs) model was initially developed as a dedicated service for the provision of high quality 24/7 non-trauma emergency surgical care. after implementation in the united states (us), the model has been adopted in several variations around the world.in this systemic review we investigated which components are essential for a potential uniform acs model, by giving an overview of the current available acs models worldwide and their state of implementation. material and methods: a literature search (2000-2018) was conducted using pubmed, medline, embase, cochrane library and web of science databases following the prisma guidelines. all relevant data of acs models were extracted from included articles. results: sixty-five articles describing acs models in 12 different countries were included in this review. the majority consist of a dedicated surgical service, providing non-trauma emergency surgical coverage, with daytime on-site attending coverage by an attending surgeon who is cleared from elective duties, and 24/7 in-house resident coverage. emergency department coverage and access to an acute care operating room varied widely across countries. critical care is fully embedded in the original us model as part of the acute care chain (acc), while in most other countries it is still a separate unit. while in most european countries acs is not a recognised specialty yet, there is a tendency towards more structured acute care, with training and separation from elective practice. conclusions: acs is gradually implemented worldwide. however, large national and international heterogeneity exists in the structure and components of the model. critical care is still a separate unit and specialty in most systems while it is essential to be part of the acc in order to provide the best peri-operative care of the physiologically deranged patient. universal acceptance of one global acs model seems challenging, however a global consensus on essential components would benefit any healthcare system. introduction: the recent financial crisis in greece is coped mainly with reformations towards cost effectiveness and rationality in the management of public expenses. the goal of the study is to evaluate the cost and time effectiveness in the management of the surgical patients admitted in emergency department (ed). methods: for a period of 8 h/day in 8 consecutive days, surgical cases presented in the ed of a tertiary university hospital of athens were followed. inclusion criteria were need for laboratory tests or imaging examinations or an immediate resuscitative intervention. data recorded regarding demographics, vitals, critical time points, disease and management. physician related data and cost of examinations were also collected. case severity was calculated by early warning score [1] . results: she average waiting time for each patient was 51 min and the average total time until final decision was 3:02 h. blood tests costs reached an average of 17,59€ per case and imaging an average of 77,88€. the striking finding was that only one out of 60 patients was of medium clinical risk, while all the others were of low. thus, substantial symptoms and clinical findings were lacking and as the ''tertiary care'' character of the hospital was mandating conclusive diagnosis, exams were ordered. this approach absorbs time and funds putting at risk the very few severe cases which are the target population for the magnitude of the facility. the current study indicates that the use of a tertiary hospital as a primary health care center by the public, is disorganizing the system, and increase the cost in time, funds, and preventable morbidity and mortality. a pre-hospital triage and management of the low severity cases system is pending to be established in our environment and becomes top priority in an era of prolonged financial crash. for years, surgical emergencies in ecuador have been managed without significant standardization. scarce numbers of specialists, lack of a constant presence of full-time teaching faculty versed in emergency surgery and lack of continuity with surgical trainees led to variability in clinical and surgical decision-making. to address these issues, the regional hospital vicente corral moscoso (hvcm) adapted and implemented a model of ''trauma and acute care surgery'' (tacs) to the reality of cuenca, ecuador. a cohort study was carried out, comparing trauma and acute care surgery patients exposed to the ''traditional care model'' before the implementation of the tacs model. variables assessed included: surgical wait times, number of hospital visits, number of surgical interventions, number of surgeries performed per surgeon and inhospital mortality. higher mortality was found in the traditional care model (rr of 1.29, p b 0.05) compared to the tacs model. we observed a statistically significant decrease in surgical wait time (10.6-3.2 h for emergency general surgery, 6.3-1.6 h for trauma, p b 0.05). lengthof-stay decreased in trauma patients (9-6 days p b 0.05). the total number of surgical interventions increased (3,919.6-57,445.8, p b 0.05) ; by extension, the total number of surgeries performed per surgeon also increased (5.37-223.68, p b 0.05) . the implementation of tacs model in a typical resource-restrained, tertiary care hospital in latin america had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients, and length-of-stay in trauma patients. we also noted a statistically significant decrease in mortality. while cost could not be objectively evaluated with the available data, savings to the overall system and patients can be inferred by decreased mortality, length-ofstay and surgical wait times. to our knowledge, this is the first implementation of an tacs model that has been described in latin america. introduction: traumatic injuries constitute one of our major public health challenges. the most effective means to reduce the impact trauma has on individuals and society is primary injury prevention, reducing the incidence of traumatic events, which relies on detailed knowledge of risk factors. the aim of this study is to facilitate targeted injury prevention through improved data collection and analysis on impairing substances as risk factors for traumatic injuries. material and methods: idart is a national prospective observational study including analyses of the toxicological profile of all patients c 16 year of age admitted via trauma team activation to any norwegian trauma hospital (n38) during a 12 month study period. residual blood from routinely drawn blood samples at trauma admission is analyzed for alcohol, illegal and psychoactive drugs. toxicological data will be linked to clinical data from the national trauma registry. results: the study period started march 1st, 2019, and during the first 6 months 2689 patients were included from 34 trauma hospitals. more than 30% of the included patients tested positive for psychoactive substances according to preliminary data. data on the prevalence of different psychoactive substances disaggregated by mechanism of injury, demography and geography from the 12 month study period will be presented. conclusions: the idart study will provide a detailed descriptive analysis on the prevalence of alcohol, illicit and medicinal drug use among all patients admitted to a norwegian hospital with suspected severe injury. subgroup analyses will include prevalence of alcohol and other substances in subgroups analyses on patient and injury characteristics and geographical variations. analyses will aim to identify high risk groups according age, gender, circumstances of the injury, geographical location and type of psychoactive substance. the dutch nationwide trauma registry: the value of capturing all acute trauma admissions m. driessen 1 , l. sturms 1 , l. leenen 1 1 lnaz/umcu, trauma surgery, nijmegen, netherlands introduction: twenty years ago the dutch government decided to reform the trauma care system and designated 11 level 1 regional trauma centers (rtcs). these centers, in collaboration with ambulance services and regional hospitals, have managed to set up regionalized inclusive trauma systems. moreover, they set up the dutch national trauma registry (dntr) as a quality evaluation and epidemiology resource. in this resource all acute hospital admissions were included, in order to measure the hospital and prehospital processes and outcomes. in the current study we demonstrate its current status and compare it with national trauma registries from the uk and germany. material and methods: the dntr includes all injured patients treated at the ed of 98% of all hospitals in the netherlands within 48 h after the trauma followed by direct admission, transfer to another hospital or death at the ed. a representative descriptive analysis of extracted data from 2018 is demonstrated. results: between 2007 and 2018 a total of 865,460 trauma cases have been registered in the dntr. hospital participation has increased from 64% up to 98%. in 2018 alone, a total of 77.529 patient were included, 50% concerned males, the median age was 64 years. 6% of all admissions had an iss c 16, of which 70% was treated at a rtc. from this cohort, in comparison, only 5% and 32% of the dntr patients met tr-dgu or tarn inclusion criteria. particularly children, elderly and patients admitted at non rtcs are not captured in the tr-dgu or tarn. also, part of iss c 16 and fatal cases do not meet tr-dgu or tarn inclusion criteria. conclusions: the dntr has evolved into a comprehensive wellstructured nationwide population-based trauma register, with an annual number of 80,000 cases being entered in the database the dtr has grown to be one of the largest trauma databases in europe. the registry enables studies on the injury burden and quality and efficiency of the entire trauma care system encompassing all traumareceiving hospitals. introduction: trauma mortality is not distributed evenly. rural areas have higher incidence rates of trauma mortality than urban areas. the rural northern part of the nordic countries have common challenges with sparsely populated areas, long distances, and an arctic climate. the aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the nordic countries over a fiveyear period. material and methods: in this retrospective cohort we used the cause of death registries and collated all deaths from 2007 to 2011 with an external cause of death (icd-10, v01-y98, except y40-84 and t80-88). the study area was the three northernmost counties in norway, the four northernmost counties in finland and sweden and the whole of iceland. we used 95% confidence intervals (ci 95) to test for differences between the countries. results: there were 4308 deaths in the study area during the 5-year period. low energy (le) trauma constituted 24% and high energy (he) trauma 76% of deaths. northern finland had the highest incidence for both high energy trauma and low energy trauma. iceland had the lowest incidence for high-, and low energy trauma. iceland had the lowest prehospital share of deaths at 74% and the lowest incidence of injuries occurring in a rural location. the incidence rates for he trauma death was 36,1/100.000/year in northern finland, 15,6/100.000/year in iceland, 27,0/100.000/year in northern norway and 23,0/100.000/year in northern sweden. conclusions: there were significant and unexpected differences in the epidemiology of trauma death between the countries. the differences suggest that a comparison of the trauma care systems and preventive strategies in the countries is required. the diurnal and seasonal relationships of pedestrian injuries secondary to motor vehicles in young people introduction: there remains a significant morbidity and mortality in young pedestrians that are hit by motor vehicles, even in the era of pedestrian crossings and speed limits. the aim of this study was to compare incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. we hypothesised that injuries in young people would be more prevalent during dusk and dawn and during autumn and winter. material and methods: data was reviewed from patients in the 10-25 year old age group in the trauma audit and research network (tarn) national database, who had been involved as a pedestrian in a motor vehicle accident between 2015 and 2018. the incidence of injuries, their severity (using the injury severity score [iss]), hospital transfer time and mortality were analysed according to the hours of daylight, darkness and seasons. results: 64.5% of injuries occurred during time of darkness post sunset, while 35.5% occurred during daylight. the incidence of injuries in motor vehicle accidents, in absolute terms, was highest during 1630-2400, with a second peak at 1500-1630. the greatest injury rate (number of injuries/hour) occurred during 0730-0900 and 1500-1630 with respective rates of 5.3 and 8. injuries scoring an iss over 15 occurred 21.7% at 1500-16300 and a further 42.9% until 2400. mortality was greatest during 1500-1630 involving 4 out of the total 7 deaths. autumn was the predominant season and lead to 40.3% of injuries, with a further 22.6% in winter. this demonstrated a clear difference to 19.4% and 17.7% in spring and summer. conclusions: we have identified a relationship between reduced daylight and the frequency and severity of pedestrian trauma in young people suggesting that reduced visibility may play a significant role which could be addressed through a targeted public health approach to implement change. enhancing cost effectiveness in a system in crisis: a 7,581 patient study a. tsolakidis 1 , c. christou 1 , p. smyrnis 1 , a. prionas 1 , a. tooulias 1 , g. tsoulfas 1 , v. n. papadopoulos 1 1 aristotle university of thessaloniki, 1st department of surgery, papageorgiou general hospital, thessaloniki, thessaloniki, greece introduction: to date, there is no national trauma database in greece. the goal of our study is to record and evaluate trauma management at our university hospital as well as to measure the associated healthcare cost, while laying out the foundations for a national database. material and methods: retrospective study of trauma patients (n = 7,581) between 2014 and 2019. demographic information, injury patterns and severity, outcomes and cost were recorded. results: the proportion of patients that were transferred to the hospital by the national emergency medical services was 28,6%, whereas 3873 (51%) of our trauma patients did not meet the us trauma field triage algorithm criteria. over-triage of trauma patients to our facility ranged from 90.7 to 96.7%, depending on the criteria used. 299 (3.9%) of our patients received operative management and 22% (65) of them had postoperative complications. an iss [ 15 was seen in 228(3%) of our patients and their mortality was 19,3%. the overall non-salary cost for trauma management was 3.118.625 euros. the cost resulting from the observed over-triage ranged from 419.501 to 1.742.748 euros. furthermore 1108 (14.6%) of our patients underwent at least one ct scan that did not show any significant traumatic lesion. the cost of hospitalization of these patients was 592.508 euros. conclusions: the prehospital triage of trauma patients in the greek national health system is ineffective, with significant over triaging, leading to excessive costs. appropriate use of criteria for diagnostic procedures and algorithms may lead to a, much-needed, reduction of these costs. introduction: in japan, there are 290 emergency and critical care centers nationwide (one center for approximately every 500,000 people), and a system is in place to accept local critically ill patients 24 h a day, irrespective of whether their conditions are intrinsic or extrinsic. however, manpower and medical care systems differ depending on the emergency and critical care center, and the establishment of a system for consolidating severe trauma patients has been particularly problematic. material and methods: this study examined 518 cases where the patient had some sign of life when encountered by ambulance teams of the 1278 cases of traffic accident deaths that occurred in chiba prefecture between 2009 and 2015. thirteen emergency and critical care center representatives in chiba prefecture met to verify each case based on data from the police, fire department, and medical institutions. the cases were classified into (1) preventable trauma death (ptd) cases, (2) suspected ptd cases, and (3) non-life-saving cases; the problems (causes of ptd) in each case were examined. result: there were 115 cases (22%) of ptd and suspected ptd. sixty-eight of these cases were transported to emergency and critical care centers. the most common cause of death was bleeding, accounting for 78 cases and the locations where the problems that caused ptd occurred were outside of the hospital (n = 11) and in the hospital (n = 67). the problems that occurred in the hospital (including duplications) include circulatory management (n = 42, 54%), the treatment plan (n = 32, 41%), delay of lifesaving surgery (n = 28, 36%), and delay of diagnosis (n = 20, 26%). most of these occurred in the initial emergency care room. conclusion: this study clarified that ptd still occurs in relation to bleeding control in the current trauma care system in chiba prefecture. it is vital to establish a national ''trauma center'' and to thoroughly consolidate trauma cases to eradicate ptd. analysis of the impact of the implementation of a trauma team in a trauma center from an upper-middle-income country introduction: trauma teams (tt) improve the care process and the outcomes. a multidisciplinary tt was conformed in september 2015 to achieve a rapid response by specialists in emergency medicine, trauma surgery, diagnostic imaging services, and blood bank in a level i trauma university hospital in southwestern colombia. objective: to evaluate the impact of a tt implementation in terms of times of attention and mortality. material and methods: retrospective study. all the patients with the highest level of tt activation treated in the 15 months after the tt implementation were included. the subjects triaged to the trauma center in the 15 months pre tt were taken as controls. four hundred sixty-four patients were included, 220 before the implementation of the tt (btt) and 244 after (att). demographic data, trauma characteristics, times to tomography, and trauma surgery and mortality were recorded. the analysis was made on stata 15,1 ò . categorical variables were described as quantities and proportionscontinuous variables as mean and standard deviation or median and interquartile range (iqr). categorical variables were compared by chi2 or fisher's test. continuous variables with student's t or wilcoxon-mann-withney. a multiple logistic regression model was created to evaluate the impact on mortality if being treated att, adjusted by age, trauma severity, and physiologic response on admission. results: the time from admission to the ct scan was 56 min (iqr 39-100) in the btt group and 40 min (iqr 24-76) in the att group, p &lt; 0.001. the time to trauma surgery was 116 min (iqr 63-214) in the btt group and 52 min iqr 24-76) in the att group, p &lt; 0.001. mortality in the btt group was 18.1% and 13.1% in the att group. adjusted or was 0.406 (0.215-0.789) p = 0.006 conclusions: the implementation of a multidisciplinary trauma team associated with a reduction of the times to tomography and surgery and with a decrease in mortality risk. no prediction of an unfavourable outcome after surgical treatment of chronic subdural hematoma patients using machine-learning l. riemann 1 , a. younsi 1 , c. habel 1 , j. fischer 1 , a. unterberg 1 , k. zweckberger 1 1 university hospital heidelberg, neurosurgery, heidelberg, germany introduction: chronic subdural hematomas (csdh) are expected to become the most frequent neurosurgical disease by the year 2030.1 although often perceived as a ''benign'' condition, considerable rates of mortality and poor outcome have been reported. we therefore evaluated factors associated with an unfavorable outcome after surgical treatment of csdh patients by developing a predictive model using machine-learning. material and methods: consecutive patients treated for csdh with surgical evacuation between 2006 and 2018 at a single institution were retrospectively analyzed. potential demographical, clinical, imaging and laboratory predictors were assessed and a decision-tree predicting unfavorable outcome (gos 1-3) was subsequently developed using the classification and regression tree (cart) algorithm. out-of-sample model performance was evaluated using repeated cross-validation (fivefold with 200 repetitions). results: 755 eligible patients were analyzed. median age was 75 (iqr 68-81) years and 69% were males. mortality rate was 1.6% and rate of unfavorable outcome was 14.3%. the developed decision-tree to predict unfavorable outcome had 5 splits and included the following 4 clinical variables (in descending order of calculated importance): gcs, comorbidities, hb, and age. after cross-validation, the following model performance metrics were obtained: a model accuracy of 0.88 (0.85-0.90), sensitivity of 0.35 (0.19-0.51), and specificity of 0.96 (0.94-0.99). conclusions: gcs, comorbidities, hb, and age were identified as the most important clinical predictors for an unfavorable outcome in csdh patients after surgery. the developed model was simple and still displayed a high accuracy and very high specificity, the sensitivity was however rather low. our results might help clinicians to better assess the prognosis in patients with csdh. introduction: in most developing countries access to tertiary care neurosurgical setup is uncommon. majority trauma including neurotrauma & medical conditions requiring emergency neurosurgical interventions present to a general surgeon. this study is an attempt to highlight the importance of emergency neurosurgery as a skill amongst general surgeons & also focus on the challenges in managing such cases in austere environments material and methods: this study was a retrospective analysis of progressively collected data of trauma patients with a specific focus on head injuries & emergency neurosurgical interventions for both traumatic & non traumatic indications in a level 2 trauma centre in a semi urban area over a period of 2 years from august 2016 to september 2018 results: a total of 720 patients of trauma were analysed out of which 392 were head injuries. road traffic accidents accounted for nearly 77% of head injuries. atypical trauma especially in rural setup e.g. train collision, animal related causes were also seen. males accounted for majority (m:f = 2.6:1). mean age was 37 yrs. 104 patients had imaging findings suggestive of severe head injury. acute sdh was the commonest post traumatic finding and mca territory infarct in non traumatic group. 22 patients underwent emergency neurosurgical intervention with a survival of 61%. factors associated with poor outcome were delayed presentation (p \ 0.05), sdh with diffuse axonal injury. alcohol consumption was a significant factor. conclusions: emergency neurosurgery is an essential skill for general surgeons. performing such cases in a low resource environment in absence of modern day facilities for imaging, icp monitoring & powered equipment presents a significant challenge. general surgeons should be able to perform operative interventions with basic handheld instruments. operative management whenever indicated should be done & helps improve outcomes. head trauma in polytraumatized patient. analysis of risk factors and neurological prognosis b. castro 1,2,3 , m. morote gonzález 1,2,4 , l. cebolla 1,2,4 , a. sada 1,2,4 , l. seisdedos 1, 2, 4, 5, 6 , j. gil 6 , c. rey valcárcel 6,7 , f. j. turégano fuentes 6,7 , c. tristan 1 , c. ruiz moreno 1 1 hgugm, surgery, madrid, spain, 2 hospital, madrid, spain, 3 hospital, madrid, spain, 4 hospitall, madrid, spain, 5 hospital, madrid, spain, 6 hospital, madrid, spain, 7 hospital, madrid, sri lanka introduction: severe trauma is one of the most frequent causes of death and disability and traumatic brain injury (tbi) in polytrauma is the main cause of death and disability in survivors. the aim of this study is to analyze mortality associated to tbi in the last 25 years, prognostic factors associated with it and neurological outcomes in survivors with tbi. methods: retrospective observational study that includes risk factors and functional neurologic evaluation in polytrauma patients attended in gregorio marañon hospital between 1993-2018. inclusion criteria were severe trauma patients (iss c 15) with a tbi and abnormal ct of the head. we analyzed mortality trend in two periods : 1993-2005 and 2005-2018 , and neurological evolution and outcome at discharge with functional scores (ramkin scale and gos) in the second one. results: from 1993 to 2018, 2818 severe trauma patients were admitted, 788 (27,9%) with brain or central nervous system injuries visible on head ct. median age was 37'5; 71.4% were men. the global mortality of the cohort has been 34,1%, 27.6% of them for neurological causes. ischemic heart disease, anticoagulation, abnormal pupils or eye opening, the need for surgery, shock, gos, iss, niss, cranial ais are significant associated with higher mortality (p \ 0,05).the mortality rate due to neurological causes decreases in the second period from 19,5 to 14,8%, this descent being statistically significant (p = 0,017). between 2005 and 2018 27,9% patients died from cnsi, and 4,2% of tbi survivors had a vegetative status at discharge, 16,7% had major disability, and 33,9% had a good neurological recovery. conclusions: mortality due to tbi decreased in the last 12 years, but this improvement after tbi was at the expense of a high rate of vegetative status and great disability, showing the need for continuous research in this area. introduction: severe traumatic brain injury (tbi) constitutes one of the most frequent causes of intensive care unit admissions and is a major cause of death and disability among young people. decompressive craniectomy (dc) is a life-saving measure used to relieve intracranial pressure (icp). this procedure is related with low mortality rates and poor functional outcomes. the aim of this study is to analyze the survival rates and prognostic factors related with functional outcomes after dc for severe tbi. material and methods: retrospective, single center study of 60 patients with severe tbi in whom a dc was performed between the years 2006 and 2016. demographic features, clinical parameters, radiological findings and clinical outcomes were included in the study. for the statistical analysis we used anova, chi-square, kaplan meyer, cox regression and logistic regression. a p value of less than 0.05 was considered to indicate statistical significance. results: the mean initial glasgow coma scale was 5,65 ± 1,69 and the mean initial motor response (imr) was 3,20 ± 1,48. the mean icp after dc was 9,75 ± 3,35. the 30-day survival after dc was 65%. twenty percent of the patients improve ate least 1 point in the glasgow outcome scale (gos) between 6 and 24 months after surgery. twelve patients improve from unfavorable gos to favorable gos. at 24-month follow-up, 30% of the patients has gos [ 3. younger age, high irm a post-operative icp were the factors significantly associated with a higher chance of outcome improvement. conclusions: dc is useful for the management of refractory intracranial hypertension related to severe tbi, and in selected patients is associated with good functional outcomes. introduction: antiplatelets and anticoagulation, commonly referred to as antithrombotic therapy, are frequently used in patients c 65 years. the use of antiplatelets and anticoagulation are associated with increased incidence of intracranial bleeding (1, 2) . there are two research questions addressed in this study: (1) does preinjury antithrombotic therapy affect survival in elderly patients with tbi? (2) are direct oral anticoagulants (doacs) associated with better survival than vitamin k antagonists (vka) in tbi patients on anticoagulation? materials andmethods: retrospective cohort study based on data extracted from the oslo tbi registry. included in the study are tbi patients c 65 years admitted to ouh with cerebral-ct showing signs of acute trauma (hemorrhage, fracture, vascular injury) in the time period 2014-2019. the impact of age, comorbidity, antithrombotic medication and antithrombotic reversal protocol for survival will be explored. results: the patient inclusion is ongoing. preliminary data will be presented at the 21 st ectes in april 2020. the estimated number of tbi patients c 65 years with cerebral-ct showing signs of acute trauma in the study period is * 850. in this patients group, the expected preinjury use of antiplatelet and anticoagulation medication is * 33% and * 23%, respectively. conclusions: the knowledge regarding impact of preinjury antithrombotic therapy on survival in elderly tbi patients is clinically relevant, and may improve patient management in the acute phase of injury. references: introduction: traumatic acute subdural hematoma (asdh), especially the large ones in need of surgical evacuation, is associated with high mortality. contemporary population-based series of surgically treated asdh are sparse. the two main aims of this single-center study from oslo university hospital (ous) were to estimate incidence of surgery for asdh in the population of helse sør-øst, and estimate in-hospital and 1-month survival of these patients. treatment of tbi at ous adheres to the brain trauma foundation guidelines, with icp controlled therapy and evacuation of asdh when gcs \ 14 and hematoma volume c 30 cm 3 or midline shift c 5 mm or hematoma width [ 10 mm. the goals of tbi treatment for adults have been to maintain icp \ 22 mmhg and cerebral perfusion pressure (cpp) c 60 mmhg. methods: from 01.01.2015 all patients with traumatic brain injury (tbi) with positive head ct, admitted to ous, living in helse sør-øst (3.0 million inhabitants) and having a norwegian social security number, have been included in our approved tbi-quality register. included in the present study are all patients with asdh undergoing evacuation of the hematoma within 7 days of trauma. the following data were extracted from the register; demographic variables, date of injury and trauma mechanism, severity of head injury according to hiss grade, rotterdam ct score, surgical procedures, multitrauma, glasgow outcome scale at discharge and date of death. results: 116 asdh patients were operated in the 4-year period 2015-2018, 72% males, mean age was 58 years (10-92), the most frequent trauma mechanism was falls (60%), 29% were under influence of ethanol, 58% had severe tbi and 28% had multitrauma. the incidence of surgically treated asdh in helse sør-øst was 1/100.000/year. in-hospital and 1-month mortality was 9.5% and 15%, respectively. conclusion: the presented data for incidence and mortality will be compared with earlier reports. age-related difference in impacts of coagulopathy in patients with isolated traumatic brain injury: an observational cohort study w. takayama 1 , a. endo 1 , y. otomo 1 1 tokyo medical and dental university hospital of medicine, trauma and acute critical care, tokyo, japan background: age and trauma-induced coagulopathy (tic) have been reported to be the predictors of poor outcome following traumatic brain injury (tbi). whether the impact of brain injury induced coagulopathy on outcomes have age related differently is unknown. objectives: we evaluated the age-related difference in the impact of tic on outcomes in patients with isolated tbi. methods: a retrospective observational study was conducted in two tertiary emergency critical care medical centers in japan from 2013 to 2018. the patients with isolated tbi [head abbreviated injury scale (ais) c 3, and other ais \ 3] were included. we evaluated the impact of coagulopathy (international normalized ratio c 1.2, and/or platelet count \ 120 9 109/l, and/or fibrinogen b 150 mg/dl) on the outcomes [glasgow outcome scale-extended (gos-e) scores, inhospital mortality and ventilation free days (vfd)] in both group using univariate and multivariate models. furthermore, we visualized the impact of coagulopathy on gos-e according to age, by using a generalized additive model. results: of the 1036 patients studied, they were divided based on their age: non-elderly group (n = 501, 16-64 years) and elderly group (n = 535, age c 65 years). although, in the multivariate model, age and coagulopathy were significantly associated with lower gos-e, in-hospital mortality and shorter vfd in the non-elderly group, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. the correlation between coagulopathy and lower gos-e decreased with age after round 70 years old. conclusions: in patients with isolated tbi, impact of coagulopathy on functional and survival outcomes was lower in geriatric patients. no difference in mortality between isolated tbi and polytrauma with tbi: it is all about the brain introduction: despite improvements in trauma and critical care mortality caused by traumatic brain injury (tbi) remains high. [1] as polytrauma is naturally associated with increased mortality, this study compared mortality rates in isolated tbi (itbi) patients and polytrauma patients with tbi admitted to icu. material and methods: a 3-year retrospective cohort study included both consecutive trauma patients with itbi with ais head c 3 (ais of other body regions b 2) and polytrauma patients with ais head c 3 admitted to a level-i trauma center icu. patients \ 15 years of age, injury caused by asphyxiation, drowning, burns and transfers from and to other hospitals were excluded. patient demographics, shock and resuscitation parameters, denver multiple organ failure scores and acute respiratory distress syndrome (ards) data were collected. [2] data is shown as medians with interquartile ranges. p-values \ 0.05 were statistically significant. results: a total of 259 patients were included. the median age was 54 (33-67) years, 177 (68%) patients were male, median iss was 26 (20-33). seventy-nine (31%) of all patients died. polytrauma patients developed more often ards (7% vs 1% p = 0.041) but had similar mods rates (18% vs 10% p = 0.066). polytrauma patients stayed longer on the ventilator (7 vs. 3 days p b 0.001), longer in icu (9 vs. 4 days p b 0.001) and longer in hospital (24 vs. 11 days p b 0.001). there was no distinction in in-hospital mortality of itbi and polytrauma patients (35% vs. 24% p = 0.06). tbi contributed to all deaths in itbi patients and all but three deaths (89%) in polytrauma patients. conclusions: tbi was the main cause of death in both groups. there was no difference in mortality rates between polytrauma patients with tbi and itbi patients, even though polytrauma patients were more severely injured. references: [1] dewan mc et al. estimating the global incidence of traumatic brain injury. j neurosurg. 2018;130(4):1080-97. no significant relationships or conflict of interests. how modeling the brain ventricles could help brain trauma understanding (1). in pathological cases as in hydrocephalus, or in brain trauma, it is likely that each patient's ventricle structure has an impact on the way they behave. for instance, a shock wave may turn out differently according to the ventricle's shape. this can explain why for a same shock, the clinical translation is not the same. the aim of the study is to implement a finite element model of the cranio-cerebral system and to analyse the impact of a trauma simulation. material and methods: this is amonocentricretrospective study from 2018. the database contains 33 ct scans of healthy patients. we used itk-snap software to segment the ventricles and matlab to implement the model. results: the mean volume of the 33 total ventricles is 43 ml (sd = 31). the median is 31 ml (table 1) .to identify the correlation between the parameters acquired we performed a pearson test. we found multiple significant correlations and one of the most relevant one is between the ventricular volume and the width of the third ventricle ( table 2 ). showing that the total ventricular volume is statistically correlated to the width of the third ventricle is clinically interesting. we could potentially simplify our analysis of the ventricular system in head trauma by measuring less coordinates and yet come up to an accurate prognosis. the ventricle volumes are used as neuroimaging marker of brain changes in health and brain trauma. to our knowledge, it is the first time they are studied in vivo on ct-scan. this study and the existing correlations are relevant for the configuration of the finite element model on going. it can surely help the comprehension of the interaction between the structural parts of the cranio-cerebral system during brain trauma. (excitatory-glutamate, and inhibitory-c-aminobutyric acid, gaba), is crucial for the normal cerebral functioning. gaba concentrations vary in different cerebral zones [1] responsible for different cerebral tasks. in this study, [gaba] is measured in the posterior cingulate cortex (pcc) of children with acute mtbi. material and methods: 8 acute mtbi patients (\ 70 h since injury, 15.7 ± 1.9 y.o) and 12 healthy controls (19.3 ± 0.7 y.o). mri scanner philips achieva 3t was used. standard mri protocol for tbi revealed no pathological lesions in brain of any subject. magnetic resonance spectroscopy (mega-press [2] ) was applied to obtain gaba signal without macromolecules. spectroscopy voxel is demonstrated on fig. 1 . intensities of gaba, glutamate ? glutamine, creatine and water signals were calculated in gannet program [3] . absolute concentrations were calculated. mann-whitney was used to reveal the statistical significance of between-group differences. results: typical gaba spectrum processing in gannet is demonstrated on fig. 2 . no changes in glx were found. the values of [gaba] in pcc are demonstrated on fig. 3 : the increase in gaba is not statistically significant. conclusions: this is the first study of [gaba] in pcc of children with acute mtbi. the result of current work disagrees with our previous study, where gaba was increased (p \ 0.005) in the anterior cingulate cortex of children with mtbi [4] . this indicates to a necessity of further data collecting in order to reveal any [gaba] alterations in various cerebral loci. this would help to identify the causes of an inhibition/excitation imbalance and to predict possible dysfunctions of cns following mtbi. results: tnaa and naag concentrations along with stable naa concentration were found to be reduced in patient group. reduced asp and elevated mi concentrations were also found. the main finding of the study is that tnaa signal reduction in wm after mild traumatic brain injury is associated with the drop of the naag concentration rather than of naa one, as it was thought previously. this highlights the importance of separation of these signals at least for wm studies to avoid misinterpretations of the results. naag plays an important role in its selective activation of the mglur3 receptors, thus providing neuroprotective and neuroreparative function immediately after mtbi. it might have potential for the development of new therapy strategy for patients with injuries of various severity. introduction: traumatic brain injury (tbi) is globally recognized as a major health and socioeconomic issue. however, reported numbers vary and often represent subgroups. the number of hospital-admitted tbi has an important impact on hospital resources. thus, the monitoring of hospitalized tbi patients is needed. in 2015, oslo neurosurgical tbi registry was established and includes patients admitted to oslo university hospital (ouh) with traumatic intracranial injury identified by neuroimaging. the aim is to introduce the registry; describe the patient group and volume. material and methods: descriptive study from oslo neurosurgical tbi registry. results: 1701 patients from south-east region were included in 2015-2018 (population 3 million). mean age was 52 years (sd 24), 69% were males. most frequent cause of injury was falls (55%), increasing with age. 27% was influenced by alcohol at time of injury. preinjury antithrombotic therapy was common (25%). most of the patients had multiple pathologies on ct caput, e.g. simultaneous cranial fracture, sdh, tsah and brain contusion (four most frequent). accompanying injuries were found in 48%. 37% was transported to ouh directly form accident scene. 27% was classified as severe tbi upon arrival ouh, 35% was intubated, and trauma team was activated in 77%. median annual and monthly numbers of cases were 419 (range 384-480) and 36 (range 17-49), respectively. no clear change in case load between years and months, except a slight decline in march. admission rate peaked during the weekend. patients were continuously admitted throughout day and night, [ 50% between 18:00 and 06:00. conclusions: patients included in the registry were older than those included in previous tbi studies. the numbers of cases admitted were stable across the months and years. however, the majority of patients were admitted during weekends and nights; thus handled by duty staff. relationship between brain-body temperature difference and neurologic outcomes in patients with severe head trauma introduction: brain is one of the most vulnerable organ to temperature. the association between core body temperature(ct) and neurologic outcomes in patients with post-cardiac arrest, severe head trauma and stroke has been reported. there were few reports comparing brain temperature(bt) with ct and peripheral temperature(pt). we investigated the association of differences among bt, ct and pt with neurologic outcomes in patients with severe head trauma. material and methods: we retrospectively reviewed data for patients with severe head trauma who underwent monitoring intracranial cerebral pressure(icp), bt, ct and pt simultaneously between january 2012 and december 2018. results: we evaluated 6 patients with a median age of 32 years (range 20-71 years). glasgow outcome scale(gos) at discharge were as follows: good recovery(gr) 2, severely disabled(sd) 1, vegetative state(vs) 2, death(d) 1. table 1 showed the average values of icp, cerebral perfusion pressure(cpp), bt, ct, pt, differences between each temperature (bt-ct, ct-pt, bt-pt) and gos in each patients. there was remarkable difference between bt and ct in the dead patient, whereas less differences were found in the other alive patients. we found greater difference between bt/ct and pt in the vs patients than gr patients. conclusions: greater differences between bt/ct and pt can be related to poorer neurologic outcomes introduction: minor head traumas are difficult to assess even with guidelines, hence head cts are often requested. as head cts are increasingly accessible, the demand on the radiology department often exceeds its capacity. there has been an increase in head cts at the oslo emergency department (oed), norway. the scandinavian guidelines for initial management of head injuries in adults (sg) is standard practice in the oed when assessing patients with head trauma.the aim of this study is to assess the number of patients with traumatic brain injury, evaluate guideline compliance and false negative initial reports by junior radiologists. material and methods: a consecutive cohort of 2000 patients from jan-june 2016 who received a head ct at oed due to minor head trauma was assessed. data was gathered from the ct request form, radiology report and ct images. the data points analyzed were: type of trauma, gcs, anticoagulants, loss of consciousness, nausea and vomiting, positive traumatic ct findings, and number of head cts within a 5 year period. results: intracranial bleeds were reported in 100 (5%) patients, 5 (0.25%) required neurosurgical intervention. skull fractures were reported in 10 (0.5%) patients, however no intracranial bleeds were present. it was impossible to assess guideline compliance because 40% of the referrals lacked adequate clinical information. ten bleeds were missed, however no further action was needed. 20% received more than 2 head cts in 5 years conclusions: head injury guidelines can improve clinical practice and reduce unnecessary ct scans; thus minimizing radiation exposure. based on the low number of positive findings, we hypothesize that sg compliance can be improved at oed. compliance was not assessable for nearly half of the patients, due to vital clinical factors missing. implementation of a standardized ct referral form based on the sg and educating junior ed doctors may decrease the number of unnecessary head cts. introduction: to date, there is no ideal allograft that provides local antibiotic release. along with this, existing fillers are expensive material, which complicates their application in practice. all this leads to the need to look for new ways to solve this problem. material and methods: gentamicin was used as an antibacterial drug because of its wide spectrum of action and thermal stability. for the study, staphylococcus aureus attc 1518 was used as a microbial strain. the antibiotic release from the studied materials was determined by equilibrium dialysis over the entire observation period. gentamicin antibiotic concentration was determined by hplc. results: an allograft impregnated with an antibiotic, prepared according to the marburg system in the area of the subcortical part of the bone, suppresses the staphylococcus aureus attc 1518 strain twice as much as perossal. when comparing bone allografts impregnated in various ways, the longest release time showed a perforated allograft.a bone graft impregnated with an antibiotic by incubation showed a 9% longer release time compared to perossal granules (p \ 0.05).when in vitro incubation of the antibiotic gentamicin with the drug ''perossal'', the dissociation rate is more than 97% in the first two days. when the antibiotic gentamicin with a bone allograft is incubated in vitro on the second day, dissociation into the extracellular space makes up more than 56% of the drug from the previously bound (p \ 0.05), which also indicates a longer release time from the bone allograft. conclusions: in vitro, a bone allograft impregnated with an antibiotic is able to reversibly bind the antibiotic gentamicin and gradually release it over a period of 7 days. the use of a bone allograft impregnated with an antibiotic suppresses the growth zones of staphylococcus aureus strains. references: rudenko a., impregnation of the bone allograft: comparison of heads coloring. european journal of trauma and emergency surgery 2019 (suppl) p.70 acute appendicitis and pregnancy: from incidence to modern management: literature review and proposal for consensus estes experts guidelines a. l. bubuianu 1 , a. mihailescu 1 , g. pokusevski 1 1 tameside general hospital, general/emergency surgery, ashtonunder-lyne, united kingdom introduction: acute abdominal pathology during pregnancy has historically been a challenging decision for the emergency surgeon, that had to deal with 2 patients at same time. acute appendicitis has probably the highest prevalence of all. early involvement of the gynaecological team was considered paramount and the ongoing debate laparoscopic versus open intervention, has been more recently challenged by case reports where antibiotics alone have been a successful strategy. material and methods: literature review has been conducted by the investigating team, using the following search algorithm: 2 reviewers screened pubmed portal to conduct a thorough search of the 3 most important medical databases, cochrane's library, medline and embase. case reports and low quality case series have been excluded from the literature review. results: there is currently no general consensus in regards to operative strategy in acute appendicitis during pregnancy, but most authors described safety of laparoscopic intervention in the first 2 trimesters and favoured open approach in a mother closer to term. the antibiotic treatment alone can only be considered in presumed early appendicitis, where there are no features of pending perforation, presence of phlebolith or established peritonitis and should be done under the close monitoring of experienced general surgeons. conclusions: an expert consensus is required in first instance, (set of questions submitted to audience at end of presentation for their expert opinion) regarding optimal treatment strategy in acute appendicitis during pregnancy, followed by a multicenter prospective randomised control trial, which we are hopeful to engage with help of numerous european hospitals where estes members activate. introduction: deep tissue pressure injuries (dtpi) are complex and difficult to treat. the higher prevalence is observed in paraplegic and elderly populations. primary closure of large, stage-4 dtpis is rarely feasible and flap closure is customarily applied. presented is a technique using tension relief system (trs; topclosureò tension relief system) and regulated oxygen and irrigation negative pressure wound therapy (roi-npt; vcareaò) to facilitate simple primary wound closure of dtpis. methods: large, stage-4 dtpis were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of trs and roi-npt. results: details of the closure of consecutive 10 large dtpis in 9 patients is presented. immediate primary closure was achieved in 7 cases, while three others were closed over 6-45 days. surgery time ranged between 1.5 and 3 h and hospitalization between 8 and 37 days. following a median follow-up of 19 months (range 1-42 months), all wounds healed with one late recurrence. post-operative wound infection observed in one patient was successfully treated with systemic antibiotics. minor skin damage inflicted by the tension sutures at the anchoring sites healed spontaneously. gradual return to partial loading of the operated area was enabled within 1-4 weeks and full weight-bearing was achieved within 4-6 weeks. introduction: chronic pain is a disabling condition affecting 50-85% of trauma patients. 1 considering the burden of chronic pain, interest in interventions to prevent this disorder after trauma has grown. a descriptive review of literature was undertaken to assess the evidence on these interventions. 1 material and methods: medline, cinahl and cochrane library databases were searched to identify interventional studies published up to august 2019. websites of injury, critical care and pain organizations were also consulted to retrieve relevant guidelines. the literature search used combinations of medical subject headings and keyword under the themes of pain, trauma, surgery and preventive interventions. results: many knowledge syntheses relevant to the population of trauma published between 2016 and 2019 were found. 1 low to moderate level of evidence was reported for pharmacological interventions such as the administration of ketamine, neuropathic pain medication and multimodal analgesia. local or regional nerve block in the presence of factures was associated with a high level of evidence. very low to low evidence was described for nonpharmacological interventions including cryotherapy and early mobilization. finally, psychological interventions were associated with a low to moderate level of evidence and multimodal pain management interventions (pharmacological and non-pharmacological) with a high level of evidence. conclusions: research is still needed to define the role of interventions to prevent chronic pain in trauma patients. thus far, multimodal pain management interventions involving multidisciplinary team management appear to be the most promising. implementing such interventions could reduce the negative consequences associated with chronic pain. introduction: chronic use of opioids has been documented 60% of trauma patients. 1 accordingly, the tapering opioids prescription program in trauma (topp-trauma) was developed. 2 the aim of this study was to assess the feasibility of topp-trauma and explore the efficacy of topp-trauma in reducing opioid use. material and methods: a 2-arm pilot rct was conducted in patients presenting a high risk for chronic opioid use. we aimed to recruit 50 participants to receive either topp-trauma or an educational pamphlet. topp-trauma comprised educational and counseling sessions. the feasibility assessment of topp-trauma was based on the ability to provide its components. the morphine equivalent dose (med) per day as well as pain intensity and pain interference with activities were measured at 6 and 12 weeks following discharge. results: preliminary findings based on data collected in 30 participants showed that 4 counseling sessions were most frequently needed to completely taper opioids. sessions attendance reached 70%. nearly 70% of eligible patients accepted to participate and an attrition rate of 23% was found. even though the experimental group consumed a higher med 24 h prior to hospital discharge compared to the control group (77.1 vs 54.8), its med/day intake was lower at 6 weeks (1.0 vs 9.20) and 12 weeks (0 vs 3.8). these self-reported data were validated by the total med delivered by participants'' pharmacy at both time points (500.6 vs 561.3 at 6 weeks; 500.6 vs 949.3 at 12 weeks). minimal mean score differences were observed in both groups with regard to pain intensity and interference with activities. conclusions: data collected until now provided evidence on the feasibility of topp-trauma and on the program potential efficacy. challenges that will require to be addressed in future rct include the acceptance to take part in the study and participants' drop out. introduction: head preserving surgical treatment for ao-type 31b fractures with little to no dislocation consists of three canullated screws or a dynamic hip screw (dhs). there is a new alternative: the femoral neck system (fns). the fns has some advantages over dhs. the anti-rotation screw provides extra rotational stability because of the diverging design. furthermore, the incision is smaller in fns and only one locking screw is necessary for plate fixation. we present the first results of this new surgical fixation of femoral neck fractures with fns. material and methods: during the period of november 2018 until october 2019, all patients with femoral neck fractures treated with fns, were included in this prospective single center cohort study. patient characteristics, fracture classification (ao, garden, pauwel), perioperative parameters and postoperative complications were registered. patients were allowed to mobilize based on the principle of permissive weightbearing. follow up was planned after 6 weeks and 12 weeks. primary outcome measure was cut-out rate within 3 months. results: twenty-four patients with a femoral neck fracture (ao-type 31b) were surgically treated with fns. median age was 58, (range 47-75). median operation time was 33 mins (range 16-49). mean duration of in hospital stay was 4 days (range 1-12 days). twentytwo (91,67%) patients completed the regular follow up of 12 weeks. one patient (4%) had a reoperation due to a cut-out. during follow up one patient developed a wound-infection (4%) which was treated with intravenous antibiotics conclusions: femoral neck system as surgical treatment for femoral neck fractures shows promising first results. low cut-out rate, limited operation time, low mortality and short duration of in-hospital stay make this device a possible alternative for dhs of canullated screws. definitive conclusions should be made after studying long term results in larger cohorts. references: none. new personalized approach to enteroatmospheric fistulas using 3d bioprinting device introduction: enteroatmospheric fistula is a challenge for surgeons. it presents a great clinical variability. this diversity means that, despite having tried multiple devices and techniques to achieve local control of the intestinal effluvium over the rest of the wound, there is currently no technique that can solve this problem in all patients. 3d printing is a novel therapy that allows the customization of the devices according to the needs of each patient. the aim of this study is to describe the technique of manufacturing a custom device designed by bioscanner imaging and manufactured using a 3d printer for use in the management of enteroatmospheric fistula. we describe our initial results. materials and methods: we present four patients with enteroatmospheric fistula. the intestinal segment involved, the dimensions of the wound, the intestinal debit and the size of the exposed intestinal surface are substantially. all require an average of 4-5 daily cures by the nurse. after obtaining images of each fistula with a bioscanner, a personalized device was designed and made by a 3d printer. the polycaprolactone device was placed including inside the fistulous orifices and surrounding it with npwt in order to accelerate the healing of the wound to ostomize the fistula or achieve its definitive closure. results: four devices with different designs have been manufactured. the wound remained isolated from the intestinal contents after placement, favouring the granulation of the surrounding tissue with npwt and thus avoiding contamination of the wound. the system remained without leaks for an average of 48 h, reducing the need for daily cures, improving patient comfort and avoiding complications. conclusions: the use of a manufacturing model using 3d bioprosthesis printing in order to create a personalized device that fits the characteristics of the patient's wound is feasible and offers promising results in the management of enteroatmospheric fistulas. new approaches in bone tissue engineering: innovative scaffold design for principle unlimited size bone substitutes introduction: in bone tissue engineering (bte), autologous boneregenerative cells are combined with a scaffold for large bone defect treatment. microporous, polylactic acid scaffolds showed good healing results in bone defects in small animals. transfer to large animal models, however, is challenging and not easily achieved simply by upscaling the design. increasing diffusion distances has a negative impact on cell survival and nutrition supply. this can lead to cell death and ultimately implant failure.this approach focuses on scaffold architectures, that meet all the requirements for a modern bone substitute. biological-functional, porous subunits in a loadbearing, compression-resistant frame structure characterise the innovative design. an open, macro-and microporous internal architecture provides optimal conditions for oxygen and nutrient supply in the inner areas of the implant by diffusion. material and methods: during the design process, 3 prototypes (temple (figure a) , grid (figure b) , onion (figure c)) were 3dprinted (fused filament fabrication) using polylactic acid (pla). -after incubation with saos-2 (sarcoma osteogenic) cells for 14 days (measurements on days 1, 7, 14 and 21), cell morphology, distribution and survival (fluorescence microscopy, ldh-based cytotoxicity assay), metabolic activity (mtt test) and osteogenic gene expression were determined. results: all designs not only showed cell colonization, but cells also sustained their ability to differentiate (already after 14 days) and to divide. the open, hierarchical-structured design, with its innovative porous structure, provides a good basis for cell settlement and proliferation. the modular design allows easy upscaling and offers potential solutions to previous limitations scaffold developement in bone tissue engineering. references: the value of 3d reconstructions in determining post-operative reduction in acetabular fractures: a pilot study introduction: in patients with acetabular fractures, the reconstructed three-dimensional (3d) model of the contralateral acetabulum could be used as a mirrored template for the anatomic configuration of the affected joint. this has not been validated. material and methods: computer tomography (ct)-scans of twenty patients with unaffected acetabula were used. the symmetry of the generated 3d models was evaluated through; (1) mirroring of the acetabulum; (2) initial rough matching; (3) automatic optimisation of the matching via surface-based matching; (4) calculation of distances between surfaces by evaluating the euclidean (straight-line) error distance between the closest points between left and right. the percentages of surface-points of the left and right acetabulum with a distance smaller than 0.5, 1.0, 1.5 and 2.0 mm were calculated and evaluated, in relation to matta's criteria, for acetabular fracture reductions. the analysis was performed using the mirrored left acetabulum matched onto the right original structure (left mirrored to right original; ''lm2ro'') and the right mirrored to left original (rm2lo). to determine the inter-observer agreement the procedure was repeated by a second assessor for the first ten patients. results: patients had a mean ± sd age of 39.6 ± 15.6 years, 56% was male. the mean distance deviation was less than 0.75 mm in all 40 comparisons. the calculated distances in 90.7% of the surface points of the left and right acetabulum were below the tolerance threshold of 1.0 mm, based on matta's anatomical reduction critera (table 2). absolute differences between assessors were\ 0.5 mm per patient with an overall moderate agreement of 70%. conclusions: 3d reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. the next step will be to investigate these results in patients with reduced acetabular fractures. : matta, j. (1996 ).j bone joint sur am. 1996 78:1632-45 pr 202 minimally invasive plate osteosynthesis technique for distal humeral fracture: a cadaveric study v. hofmann 1 , c. deininger 1 , t. freude 1 , f. wichlas 1 1 university hospital salzburg, orthopedics and traumatology, salzburg, austria introduction: in our study we want to evaluate the feasibility of minimally invasive plate osteosynthesis (mipo) technique for distal humeral fracture using anatomically precontoured double plate osteosynthesis. material and methods: eight elbows from four thiel fixed cadavers were included. on unfractued cadavers we tested the minimally invasive approach with two separate incisions, one at the lateral and one at the medial epicondylus. the preformed plates were inserted directly into the bone on sides and fixed with percutaneous screws. then we created an ao type a3 and c3 fracture. the reduction was performed under x-ray control and stabilized with k-wires. then we also inserted the plates in mipo technique. in the case of an intraarticular fracture, an olecranon osteotomy was additional performed in a minimal invasive way to control the distal humeral joint surface. after finishing reduction and fixation the approach were extended to control the fracture alignement, position of the plates and to expose the ulnar nerve. results: the plate position was satisfactory and we could not detect any major soft tissue damage or ulnar nerve injury by using the minimally invasive plate osteosynthesis technique. in the extraarticular fractures, reduction was achieved with k-wires and was acceptable in all cases. the intra-articular fractures were controlled by an additional olecranon osteotomy using the mipo technique with a good view on the joint surface of the distal humerus. conclusions: the findings of the present study show that mipo technique in distal humerus fracture is feasible and save especially for ao type a fractures. in ao type c fractures the olecranon osteotomy provided enough visibility to evaluate the distal humeral joint surface. the surgical technique is demanding, and care must be taken not to injure the ulnar nerve. never the less it is an effective surgical treatment method and an alternative option to open techniques. correlation between pelvic incidence and acetabular orientation in anteversion and inclination-an analysis based on a 3d statistical model of the pelvic ring introduction: the pelvic ring is a complex bony structure with a central role for the human''s mobility building the connecting part between the upper body and the lower extremities. pelvic incidence and acetabular orientation are two important parameters used in the description of pelvic anatomy and are of central importance for understanding the biomechanical interaction of spine, pelvis and hip joints. the objective of the study was the analysis of a potential correlation between pelvic incidence and acetabular orientation. material and methods: a 3d statistical model of the pelvic ring consisting of 100 individual ct scans of european adults without bony pathologies was used to analyse pelvic incidence and acetabular orientation in anteversion and inclination. an additional analysis on the correlation between those parameters was performed using the software spss. results: a slight positive correlation between pelvic incidence and acetabular anteversion could be shown (r = 0.223; p = 0.019) as well as a strong positive correlation between anteversion and inclination (r = 0.570; p \ 0.001). pelvic incidence and acetabular inclination showed none statistically significant correlation (r = 0.102; p = 0.311). conclusions: the results of the study might contribute to a better understanding of the biomechanical interaction between the axial skeleton and the lower extremities and deliver valuable information concerning preoperative planning in orthopaedic and trauma surgery of the lumbar spine, the pelvis and the hip joints like for example reconstructive surgery after trauma, operative treatment of congenital or acquired deformities or total joint arthroplasty. references: boulay et al., ''pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminarystudy. '' anat res int. 2014; :594650. doi: 10.1155 /594650. epub 2014 . introduction: the majority of distal clavicle fractures (dcfs) are displaced fractures and are prone to delayed-or non-union. 1 there are several options for surgical reconstruction, open reduction and fixation or hook plate, but in patients with a comminuted or small fracture they are known to have a high complication and failure rate, and secondary surgery for removal is often necessary. we hypothesize that resection of the distal fracture fragment and subsequent stabilization with the lockdown device, is an alternative for selected patients with dcfs. methods: eleven patients with a comminuted dcf were treated with a lockdown device. data on pain and range of motion were documented and the constant shoulder score (css), oxford shoulder score (oss) and nottingham clavicle score (ncs) were assessed at one year follow-up. results: eight patients underwent surgery within 2 weeks, compared to 3 patients where the surgery was delayed ([ 2 weeks) due to persisting pain and delayed-union. none of the patients had postoperative complications. in 3 months after treatment, 10 patients were complaint-free. one patient had hardware removal due to pain at the site of the screw head. four patients were assessed after one year follow-up. the mean pain score was 3.2. the mean flexion 142,5°, abduction 120,5°, exorotation 56°and extension 54°. the css had a mean of 21.75, oss 43.75 and the ncs a mean of 70. conclusions: all 11 patients had a good short-term clinical outcome and hardware complications did not occur. we are the first to describe the use of the lockdown device in dcfs. this device is not dependent on fracture healing and secondary surgery is not necessary, therefore it can be an alternative in the treatment of dcfs. a larger series and longer follow-up is necessary to confirm this conclusion. in this ongoing study, the remainder seven patients will be included and presented at the estes. moore type i tibial head fractures are one of the most challenging fractures to treat. material and methods: we performed the following approaches on eight thiel fixed cadavers: the anterolateral (with an osteotomy of the tuberculum gerdyi, a subcapital fibula-osteotomy and an osteotomy of the tuberositas tibia), the medial approach (with submeniscal arthrotomy and a dissection of the medial collateral ligament) and the posterior approach with a submeniscal athrotomy. the reachable borders of the articular joint surface have been marked by a k-wire. the visual joint surface has also been radiographically documented by inserting k-wires into the tibia head. finally the results have been photo documented on the exarticulated joints. results: the reachable areas of the articular surface have been defined and documented. the combination of the subcapital fibulaosteotomy and the submeniscal arthrotomy showed the most increase in accessibility to the articular surface in the dorsal part. an additional osteotomy of the tuberculum gerdyi increased the vision on the entire lateral and anterior articular surface. the submeniscal arthrotomy, at the medial approach, has not a good view on the surface. the posterior approach showed only a limited view on the lateral and medial articular surface at the dorsal part. none of the surgical approaches sufficiently visualizes the intercondylar region. conclusions: a fracture-specific approach strategy is critical for the preoperative planning of complex tibia-head fractures. subcapital fibula osteotomy is the most efficient surgical approach to reach the posterior and lateral articular surface. for the anterior articular surface, the best overview was achieved by an osteotomy of the tuberculum gerdyi. it was not possible to see and control the intercondylar region with any approach. introduction: osteosarcoma (os) is the most common bone carcinoma in humans. at the time of the first diagnosis are already in about 20% metastases present. the current treatment strategies include above all radical surgical resection and chemotherapy. in the search for alternative therapy methods. treatment with cold atmospheric plasma (cap) shows promising prospects. at the cellular level, this leads to various cellular mechanisms and finally to induction of anticancerogenic effects such as growth inhibition, apoptosis, and changes in the cell-cell interactions. the impact of cap on the integrity of the cell membrane of os cells, however, is unknown. material and methods: suspended cells from two human osteosarcoma cell lines (u2-os, mnng) were treated for 10 s, 30 s, and 60 s with cap. cell proliferation was determined after 4 h, 24, 48, 72, 96 and 120 h using casy cell counter. dye loss assay was performed by using fluorescein diacetate (fda). this was followed by indirect treatment with cap for 60 s. in the cell-free supernatant was determined by tecan multireader the dye emission. flow cytometry assay was used after cap treatments and incubation with fda. the mean fda fluorescence intensity of individual cells in the flow cytometer was measured. results: cell kinetics showed significant inhibition of cell proliferation in both cell lines after cap treatment. the assays for determination of the dye level showed a significantly increased membrane permeability of both cell lines after cap treatment. the significant effect on the membrane integrity correlated with treatment duration. conclusions: this confirms a modulating influence of cap on the functionality of the cell membrane and may support the anti-proliferative effect of the cap treatment. thus, cap is a promising therapy option, especially for chemotherapy-resistant entities introduction: osteosarcoma (os) is the most common bone cancer in humans. standard therapy includes radical surgical resection and chemotherapy, but due to strong toxic effects, new treatment options are urgently needed. currently, there is a discussion about expanding the oncological therapy spectrum and treat with cold atmospheric plasma (cap). it is a reactive ionized gas rich in radicals, photons, and electromagnetic rays. its biological effects are primarily mediated by reactive oxygen and nitrogen species (rons). due to its low temperature, cap is suited for medical applications. in vitro studies have shown the antitumoral effect of cap also for pancreatic cancer, melanoma, ovarian, breast, and colon cancer. material and methods: human os cell lines u2-os and mnng/ hos were used. proliferation assay. the growth of cap-treated cells was examined using a casy cell counter. caspase 3/7 assay. following cap treatment, the activities of caspase-3 and caspase-7 were measured using a specific substrate peptide coupled with a fluorescent dye (cellevent tm ). single-cell gel electrophoresis comet assay. dna damage after cap treatment was identified using alkaline microgel electrophoresis. dna migration was measured using comet score software. the percentage of tail dna was used to indicate the relative fluorescence intensity of the head and tail. tunel assay. after cap treatment tunel analysis was performed. results: the results revealed that the cap treatment of os cell lines leads to significant inhibition of cell growth. subsequently, the activation of caspases and the induction of apoptotic dna fragmentation was demonstrated. the treatment of os cells with cap leads to an induction of apoptosis and a reduction of cell growth. introduction: extra peritoneal packing (epp) is a quick and highly effective method to control pelvic hemorrhage. we hypothesized that this procedure may be as safely and efficiently performed in the emergency room (er) as in the operating room (or). methods: retrospective study of 29 patients who underwent epp in the er or or in two trauma centers in israel between 2008-2018. material and methods: retrospective study of 29 patients who underwent epp in the er or or in two trauma centers in israel between 2008-2018. results: 29 patients were included in our study, 13 in the er-epp group and 16 in the or-epp group. the mean injury severity score (iss) was 34.9 ± 11.8. following epp, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). a raise in the mean arterial pressure (map) with a median of 25 mmhg (mean 30.0 ± 27.5, p = 0.000009) was documented. all patients who did not achieve hemodynamic stability after epp had multiple sources of bleeding or fatal head injury and eventually succumbed. the overall mortality rate was 27.5% (8/29) with no difference between the or and er-epp groups. patients who underwent epp in the er showed higher change in map (p = 0.0458). no differences were found between er and or epp in the amount of transfused blood products, surgical site infections and length of stay in the hospital. however, patients who underwent er epp were more prone to develop deep vein thrombosis (dvt): 50% (5/10) vs 9% (1/11) in er and or-epp groups respectively (p = 0.038). conclusions: epp is equally effective when performed in the er or or with similar surgical site infection rates but higher incidence of dvt. level of evidence: retrospective cohort study, level iv. introduction: application of supraacetabular schanz screws is usually performed under image intensifier guidance. the aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre-and intraoperative fluoroscopy can be avoided. material and methods: insertion of the supra-acetabular schanz screws was performed in 14 human adult cadavers. with cadavers placed in supine position, the anterior superior iliac spine (asis) was palpated. starting from this landmark, 2 cm were measured in a distal and 2 cm in the medial direction. at this point, a 2 cm long oblique skin incision was performed. through this approach, 150 mm schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of 20°to distal as well as 20°to medial. combined obturator oblique-outlet views (cooo) were taken bilaterally to prove the screw position. six of the specimens underwent a 3d-ctscan. images were evaluated concerning correct screw positioning. skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (lfcn) or to the joint capsule were evaluated. results: during radiographic evaluation of the cooo-scans (14 specimens) and the 3d-scans (6 specimens), the schanz screws were placed inside the supra-acetabular corridor in all specimens (14/14). during dissections, no intracapsular screw placements or lfcn lesions were found. conclusions: using our technique, all schanz screws could be sufficiently inserted without intraprocedural x-ray imaging. references: 1. karaharju, e. and p. slätis, external fixation of double vertical pelvic fractures with a trapezoid compression frame. inhury, 1978. 10: p. 142-145. 2. mears, d. and f. fu, external fixation in pelvic fractures. orthop clin north am, 1980. 11: p. 465-479. 3. mears, d. and f. fu, modern concepts of external skeletal fixation of the pelvis. clin orthop, 1980. 151: p. 65-72. pr 210 epidemiology of self-inflicted major trauma r. stoner 1 , n. misra 1 , l. mason 1 1 aintree university hospital, liverpool, united kingdom introduction: in the united kingdom, severely injured patients are taken directly to a major trauma centre (mtc). whilst deliberate self harm (dsh) is a known mechanism for this, there is limited prior research. 1-9% of major trauma is thought to be self inflicted 1,2 . our aim was to describe the epidemiology of presentation to our mtc resulting from dsh. material and methods: retrospective review of patient records in our mtc for adult trauma team activations between 01/07/2016 and 30/06/2018. data was collected on patient demographics, location type, injury severity score (iss), mechanism of injury and mortality. results: 194 episodes of dsh made up 6.4% of all trauma cases, involving 180 patients; 2.6% re-attended. z-scores show no change in incidence over time, but significant variability month by month, with 6/24 months [ 1sd from mean. mean patient age 37 years (range 16-78). 67.8% were male. 64.9% came from residential location and 8.2% from prison. most common mechanism was penetrating trauma (51.5%). in-hospital mortality was 10% (13.4% in males vs 3.4% in females, chi 2 p = 0.04). conclusions: this is the largest review of self inflicted trauma cases in a uk mtc, with a similar incidence to prior studies. there was no observed correlation with season or trend over time. mortality was higher in male patients, in keeping with national statistics on suicide, whilst dsh in females was linked to less severe injury; severity is related to mechanism of injury. injury from self stabbing/cutting was most common in patients from residential locations, whilst hanging was more common in prisoners. this study identifies preventable risk factors for major self inflicted injury. introduction: the distribution of trauma deaths was classically described following a trimodal pattern. during the last decade improvements in trauma care as damage control resuscitation (dcr) have minimized resuscitation injury. we hypothesized that the implementation of dcr in severely injured trauma patients is associated with less mortality and modifies mortality pattern. material and methods: we performed a 25-year (1993-2018) retrospective cohort analysis of all severely injured trauma patients (niss c 35) who underwent surgery at our level 1 trauma center. since 2005, dcr was implemented including damage control surgery, minimizing crystalloids and increasing the use of blood products. our patients were stratified into two phases: pre-dcr ( -2004 ( ) and post-dcr (2005 . results: a total of 308 patients were identified. there were 172 patients (55.84%) in the pre-dcr group and 136 patients (44.16%) in the post-dcr group. mean age (35.17 vs 39.49, non significant (ns)), mechanism of injury (blunt trauma: 89.53% vs 86.76%, ns) and shock on admission (35.46% vs 36.02%, ns) were similar between groups. there is a significant reduction in the rate of overall mortality (44.18% vs 33.82%, p \ 0.05). while early deaths from traumatic brain injury (47.36% vs 47.82%, ns) and hemorrhage (39.47% vs 41.62%, ns) are alike, mortality secondary to multisystem organ failure (msof) is lessened (13.15 vs 6.52%, p \ 0.05). conclusions: dcr has helped in reducing overall mortality and mortality due to msof in our severely injured trauma patients. introduction: the mangled extremity severity score (mess) was constructed as an objective quantification criterion for limb trauma. a mess of or greater than 7 was proposed as a cut-off point for primary limb amputation. opinions concerning the predictive value of the mess vary broadly in the literature. the aim of this study was to evaluate the applicability of the mess in a contemporary civilian central european cohort. material and methods: all patients treated for extremity injuries with arterial reconstruction at two centres between january 2005 and december 2014 were assessed. the mangled extremity severity score (mess) and the amputation rate were determined. results: seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. the mean mess was ). seventy-three percent of all patients (52/71) had a mess b 7 and 27% (19/71) of c 7. eight patients (11%) underwent secondary amputation. patients with a mess c 7 showed a higher, but statistically not significant secondary amputation rate (21.1%; 4/19) than those with a mess b 7 (7.7%; 4/52; p = 0.20). the area under the roc curve was 0.57 (ci 0.41; 0.73). conclusions: based on these results, the mess seems to be an inappropriate predictor for amputation in civilian settings in central europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft tissue traumas. introduction: in polytrauma victims the acute respiratory distress syndrome (ards) is a major cause of morbidity and mortality. it presents a complex pathophysiology that is characterized by pulmonary activated coagulation and reduced fibrinolysis. due to the fact that the pulmonary endothelium is considered a key modulator of ards and that tpa in plasma is predominantly synthesized and secreted by vascular endothelial cells, we hypothesized that the time courses of serum tissue-type plasminogen activator (tpa) and its main inhibitor, the plasminogen activator inhibitor type-1 (pai-1), might indicate a clinical approach to preventing ards in polytrauma victims. material and methods: twenty-eight consecutive polytraumatized patients with concomitant thoracic trauma, age c 18 years, iss c 16, who were directly admitted to our level i trauma center, were evaluated. blood samples were taken initially and on day 1, 3, 5, 7, 10, 14 , and 21 during hospitalization. luminex multi-analyte-technology was used for analysis of tpa and pai-1 antigen levels. results: both levels were particularly high at admission. although they significantly declined within three and seven days, respectively, they remained elevated throughout three weeks. throughout this observation period mean tpa antigen levels were higher in polytrauma victims suffering ards than in those without ards, whereas mean pai-1 levels were higher in polytrauma victims sustaining pneumonia than in those without pneumonia. noteworthy, in each patient, who developed ards, the tpa antigen level raised up to the onset of the syndrome and declined afterwards. conclusions: the development of ards has to be expected in a polytrauma victims if the tpa antigen level continues to rise after admission. potentially, in patients with a low risk of excessive bleeding the onset of the syndrome might be prevented by the timely administration of recombinant profibrinolytic proteins. motocross is a dangerous business: small bowell perforation case report case history: a 19 year-old male, previously healthy, was admitted to the ed after being involved in a motorcross accident. he suffered blunt abdominal trauma. clinical findings: at admission, patient presented pale but haemodinamically stable. physical examination was unremarkable except for an evident abdominal wall hematoma and abdominal guarding over the left quadrants. investigation/results: abdominal ultrasound showed an intestinal loop with decreased peristalsis with a small amount of liquid adjacent (fig 1) . due to the patient's haemodynamic stability, ct scan was performed (fig 2. ) which showed liquid in the left flank and iliac fossa, but without an identifiable intrabdominal lesion. diagnosis: the patient was admitted to the operating theatre with acute abdomen. therapy and progressions: intraoperatively fecal peritonitis was evident from a 3 cm-hole on the antimesenteric border of the jejunum, the enterotomy was closed and profuse lavage was done; the abdominal wall closed without drainage. the patient went through an empirical antibiotic cycle. liquids per os were started on the first postoperative day and the patient progressed without issues. he was discharged at the 5th postoperative day. the remaining follow-up was uneventful. comments: small bowel perforation after blunt abdominal trauma is rare. sbmi has a high morbidity and mortality that increase with delayed diagnosis; however, clinical and radiographic signs of perforation are often absent, like in the case presented. ct is considered the gold-standard. in our specific situation, the small bowel perforation did not produce any pneumoperitoneum in a young patient with very good physiologic status that kept him hemodynamically stable. the prognosis of pelvic injury is closely related to the severity of vascular injury rather than the complexity of bony fracture y. wu 1 , c. hsieh 1 , c. fu 1 1 chang gung memorial hospital, trauma and emergency surgery department, taoyuan city, taiwan introduction: pelvic injuries are among the most dangerous and deadly trauma. although complex pelvic fractures are often associated with vascular injuries, it is still unclear regarding the impact of the severity of vascular injury to the outcome of patients. we hypothesized that, in addition to the complexity of bony fracture, the severity of pelvic vascular injury plays a more decisive role to the patients'' outcome. material and methods:medical records of patients with pelvic fracture in a single trauma center between jan 2016 and dec 2017 were retrospectively reviewed. those who had an abbreviated injury scale (ais) c 3 other than pelvis were excluded. based on ct results, the type of pelvic fracture was classified according to young-burgess classification, and the severity of vascular injury were recorded as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling or extravasation). the patient demographics, clinical parameters, and outcome measures were compared between the groups. results: among the 156 patients, severe vascular injury were noted in 26 patients. patients with severe vascular injuries had significantly increased amount of red blood cell transfusion (rbct) (11.8 vs. 3.8 units, p = 0.002), longer icu stay (is) (3.1 vs. 1.0 days, p = 0.011) and total hospital stay (hs) (15.8 vs. 11.0 days, p = 0.023) compared to minor vascular injuries. on the other hand, those with complicated pelvic fracture (lc type ii/iii, apc type ii/iii, vs and combined type) had similar amount of rbct and is compared to that of simple pelvic fracture (lc type i, apc type i) except a longer hs (13.4 vs. 10.1 days, p = 0.036). conclusions: our results indicated that the severity of vascular injury is more closely correlated to the outcome of patients with pelvic fractures than the type of bony fracture does. in addition to the type of bony fracture, the grade of vascular injury should be considered as an important part of pelvic injury classification. associated abdominal injuries do not influence reduction quality in operatively treated pelvic fractures-a multicenter cohort study from the german pelvic registry results: 16.359 patients with pelvic injuries were treated during this period. 21.6% had a concomitant abdominal trauma. the mean age was 61.5 ± 23.4 years. comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (47.3 ± 22.0 vs. 70.3 ± 20.5 years; p \ 0.001). both, complication rates (21.9% vs. 10.0%; p \ 0.001) and mortality (8.1% vs. 1.9%;p \ 0.001) were significantly higher. in the subgroup of acetabular fractures, the time until definitive surgery of the pelvis was significantly longer in the group with the combined injury (5.7 ± 4.8 vs. 4.7 ± 4.0 days; p \ 0.001) . the grade of successful anatomic reduction did not differ between the two groups. conclusions: patients with a pelvic injury have a concomitant abdominal trauma in about 20% of the cases. the clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. however, the quality of the postoperative results is not influenced by a concomitant abdominal injury. a. martins rangel 1 , r. pozzi 1 , j. alfredo cavalcante padilha 1 , s. sardinha 1 , f. eduardo silva 1 , d. teixeira rangel 1 1 heat, trauma center, são gonçalo, brazil f.f.c., male, 27 years old, was admitted to the trauma center about 12 h after a stabbing wound in the neck. upon examination the patient was mechanically ventilated and hemodynamically stable, with an exposed sectioned trachea, which had a tracheostomy tube applied. the penetrating injury itself was mostly allocated in zone ii. he had a ct angiography and was referred to the or for surgical treatment. the cervicotomy found that both the external and internal right jugular veins had been injured alongside the sternocleidomastoid, sternohyoid and homohyoid muscles, the thyroid cartilage, just above the vocal cords, which had exposed the anterior larynx and the epiglottis the right anterior jugular vein and smaller tributaries of the right internal jugular vein, were ligated; a tracheostomy was performed and the thyroid cartilage and anterior laryngopharyngeal wall were reconstructed with the epiglottis implantation, sternoid, homohyoid and sternocleidomastoid muscle sutures, after which the platysma was closed but not the skin, left to secondary healing. patient was extubated within 48 h, discharged from icu on the fifth postoperative day. thickened oral diet was introduced on the 16th day, and by the 21th day he was discharged without the tracheostomy tube, with a normal diet. comments: the cervical region is an area susceptible to serious injury due to the presence of vital structures, with massive hemorrhage, airway obstruction, cervical spine injuries and cerebral ischemia as the leading causes of death. initial management of penetrating injuries follows the principles of trauma care with airway control initially. references: bhatt nr-penetrating neck injury from a screwdriver: can the no zone approach be applied to zone i injuries? bmj yan wang-penetrating neck trauma caused by a rebar-a case report. medicine (2018) introduction: annually, approximately 3,600 people decease as a result of a fall in the netherlands, according to the statistics netherlands. the aim of this study is to evaluate the demographic parameters, fall characteristics and resulting injury patterns of this group in the region of amsterdam. methods: all patients deceased as a result of injury due to a fall in the period july 1st 2013 until july 1st 2018 in the region of amsterdam were included. data were collected from the database (formatus) of the department of forensic medicine (public health service amsterdam). results: during the study period 1,258 patients deceased after a fall. the mean age was 83 years (0-103 years) and 41% was male. a psychiatric disease was diagnosed or suspected in 44% of the population of which cognitive impairment, including dementia, was encountered in most of the cases (82%). the majority of the falls happened at home (47%) or at nursing facilities. a minority (1.3%) was work related. over 81% of the falls was from standing position, 17.6% was not from standing position of which 80.1% regarded falls from stairs, the majority was male. multitrauma patients accounted for 17.1% of the population. from the remaining 1,040 patients, 61.7% sustained one or more injuries to the pelvis or extremities. central nervous system (cns) injuries were described in 31.3% of the patients. mortality was in 26.8% of the cases due to primary cns injury, 62.3% was due to complications of which clinical deterioration (58.7%) and infection (17.1%) were the most common. conclusions: in the region of amsterdam the majority of deaths due to a fall regards the geriatric population. fall from standing position and mortality due to complications, mainly clinical deterioration, accounted for the majority of deaths. intervention to prevent falls and thereby complications need more awareness to reduce mortality. results from a multidisciplinary blunt splenic injury protocol introduction: the majority of splenic injuries are currently managed non-operatively. failure of non-operative management includes grade iv or v splenic injury or vascular abnormalities that are suitable for embolization. the primary indication for operative management of blunt splenic injury is hemodynamic instability. in our center, the last twenty splenic injuries, admitted during two years, were not managed according to published guidelines. ten patients (50%) underwent splenectomy, being unstable only 2 of them (10% of the whole sample). material and methods: staff from anesthesiology, interventional radiology and trauma surgery came up with a joint protocol. grade iii splenic injury non-operatively management, including fluid responsiveness (achieving shock index (ht/bp) below 0.9 after a bolus of colloids) and, focus placed only on hemodynamic stability instead of on vascular abnormalities are our principal modifications regarding already published protocols. results: seventeen patients with blunt spleen trauma were admitted after starting up our protocol. six (2 grade iii, 2 grade ii and 2 grade i) splenic injuries were successfully managed non-operatively. prophylatic embolization was performed in five patients: 3 were grade iv spleen trauma and 2 were grade iii spleen trauma with vascular abnormalities. one grade iii splenic trauma was embolized due to a pseudoaneurysm detected in ct scan performed 72 h post injury. five grade v spleen trauma required urgent surgery. 4 of them presented with shock index [ 0.9. conclusions: our multidisciplinary protocol has helped in improving outcomes in blunt splenic injuries. we have achieved an almost full compliance to our protocol. case history: 82-year old male experienced severe blunt trauma after a bus accident. clinical findings: he is found alert (gcs = 15), hemodynamically stable and with a patent airway. he presented catastrophic lower left limb where tourniquet was applied. 1 gram of tranexamic acid (txa) and 500 ml of crystalloids were administered. he was intubated in the site of injury and transfered to our center, being always hemodynamically stable. on hospital admission he was normotensive (bp = 140/70 mmhg, sinus rithm 85 ppm), shock index \ 0.9. he suffered uneventfully amputation of the limb with no need for blood products transfusion. his past medical history was only pertinent for hypertension. investigation/results: following urgent damage control surgery, ct scan was performed where acute bilateral pulmonary embolism was diagnosed. diagnosis: asymptomatic acute bilateral pulmonary embolism therapy and progressions: during icu stay, the patient kept hemodynamically stable. endotracheal tube is removed one day later and he is successfully transfered to the ward three days later. comments: hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tpa). in contrast, when shock and hypoperfusion occur, activation of the protein c pathway and endothelial tpa release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. it can be inferred that a patient presenting with severe tissue injury without shock is at high risk of perioperative thrombosis and txa might not be administered. (1) . it signifies high energy force, representative of severe overall trauma. study reported mortality of blunt pelvic trauma to reach 4.8-50% (2) . injury severity score (iss), hypotension, head injury, posterior fracture & haemorrhage have been implicated (3) . however, there is a paucity of data in developing countries. this study identifies the problem burden, management outcomes and factors predicting mortality. material and methods: 568 patients had pelvic trauma, retrospectively from jan 2014 to dec 2017 and prospectively from may 2018 to april 2019. 501 patients was included after excluding less than 18 years and coagulation disorder results: majority were males (78.2%),with a mean age of 34.8. mechanism was rti (72.3%) followed by fall from height (18%), railway accidents (4.8%). mean iss & rts was 17.37 and 7.41 respectively. associated injury were long bone fractures (34.3%), chest injuries (33.53%).head injury (10.4%). lateral compression (63.9%), was the most common followed by anteroposterior compression (17%) & combined (11.17%).majority underwent operative intervention (56.5%) for pelvis or associated injury. the mortality rate was 15.7% secondary to haemorrhagic shock (49.4%) and sepsis (34.2%). the factors were male gender, age, iss, rts, head injury, unstable pelvis. however, no association with haemoglobin, long bone fracture, and massive transfusion protocol was found conclusions: our study showed a mortality of 15.7% which is comparing with previous study introduction: the number of patients admitted to oslo university hospital (ouh) due to bicycle trauma is increasing. we aimed to identify possible predictors of serious and fatal bicycle injury. material and methods: the ouh trauma registry was searched for patients treated for bicycle trauma between 2005 and 2016. data extraction included putative predictors of serious and fatal injuries, defined as iss c 9 and death within 30 days, respectively. univariate analyses were performed and reported as odds ratios (or). p \ 0.05 was regarded as statistically significant. results: 1543 bicyclists were admitted, 72% were males, median age was 40 years (range 3-91). injury mechanisms were single bicycle crash in 68%, collision with a motorized vehicle in 27%, bicycle vs. bicycle in 4% and others in 1%. serious injuries were seen in 63% and 2.3% died. predictors for serious and fatal bicycle trauma are presented in figure 1 . conclusions: we identified age c 50, high comorbidity and loss of consciousness (gcs b 12) as predictors for both serious and fatal injury after bicycle trauma. single bicycle crash was the most common cause of serious bicycle injury in our trauma center. diagnosis, investigation and results: all case reports represent polytrauma patients with clinical worsening and admission to the icu, with subsequent development of acute respiratory distress syndrome (ards) refractory to primary measures. therapy and progressions: different mechanisms led to the development of ards in the different cases. on a primary approach, standard measures such as curarization, recruitment maneuvers, prone positioning and peep increase were applied whenever possible. an absence of improvement led to an almost inevitable need of extracorporeal membrane oxygenation (ecmo) rescue therapy. all patients responded positively to this treatment without major complications and were eventually discharged from the icu. comments: ards is a major cause of respiratory failure in polytrauma patients. among the many therapeutic options, ecmo emerges as a powerful tool as rescue therapy in respiratory failure refractory to all other measures, being the present case reports corroborative examples of its efficiency. introduction: nowadays when cities are improving fast and significantly, including transportation system, even more we encounter with high energy trauma . still the most vulnerable on the roads are pedestrians. material and methods: the analysis of the data collected prospectively from january 2017 to october 2019 was performed including the mechanism and diagnosis of polytrauma, patient demographics and the main outcomes. results: in total, 903 patients were assessed according to the polytrauma protocol. the median age of the cohort was 43 years (iqr 30-55), male patients, 68.2% vs. 31.8% females, p = 0.045. the most frequent mechanism was a pedestrian struck by a vehicle in 33.9% cases, and falling from a height of over 2 m in 29.7%. of those patients who had musculoskeletal injuries, in 31.1% the trauma mechanism was a fall from a height and in 28.2% pedestrians were struck by a vehicle, 36.1% of patients who fell from a height and 29.5% of those struck by a vehicle suffered visceral injuries. the most common cause of neurotrauma was a fall from a height in 33.7%, and pedestrians involved in car accidents in 29.8%. from the whole cohort, 27 patients were not saved, resulting in a 2.9% mortality rate. most patients (25) who died had iss [ 50. the mortality reached 2.3% among pedestrians struck by a vehicle and 5.1% among patients who fell from a height of over 2 m. conclusions: the most common mechanism in the cohort was a pedestrian struck by a vehicle, followed by falling from a height, with a predominant involvement of male patients. similarly, the most frequent cause of musculoskeletal injuries and visceral injuries was falling from a height and pedestrians struck by a vehicle, demonstrating an important direction for polytrauma prevention. introduction: recent reviews of uk trauma data show altering demographics. patients are increasingly older and sustain lower energy injuries, with falls \ 2 m being the most common (1) . material and methods: data collected over 5 years in a major trauma centre was used to calculate injury specific admission rates, case fatality rates and injury specific mortality attribution. data on patient age, footwear, lighting, alcohol intoxication and previous admissions were collected in falls \ 2 m resulting in mortality. results: patients sustaining falls \ 2 m represented 36% of admissions and 37% of mortalities. all falls represented 58% of admissions and 69% of mortalities. case fatality of falls of \ 2 m and [ 2 m was 6.59% and 9.35%. all fall case fatality was 7.62%. this was significantly higher than the case fatality of stabbings (1.0%) and rtas (4.7%). in falls \ 2 m causing fatality, mean patient age was 71.7 years. 50% of patients aged 40-59 were under the influence of alcohol when falling, with 56% aged 60-79, but only 13% patients aged 80-99. 12% aged 40-59 who died when falling were wearing slippers. this increased to 31% in those aged 60-79, and 50% aged 80-99. 69% of falls occurred under daylight/full light. 13% of patients aged 40-59 who died after falling had been admitted to hospital within the last year, although this increased to 19% in those aged 60-79, and 27% aged 80-99. conclusions: falls were the most common cause for hospital admission, had the highest case fatality of injury mechanisms and caused the most patient mortality. alcohol intoxication was associated with falls in younger patients who died after falling, but this was less common in older patients. wearing slippers was less common in the young but significantly associated with fatal falls in older patients. these results offer a range of therapeutic targets when developing fall prevention strategies. introduction: the treatment of splenic lesions is determined by the hemodynamic situation, the degree of injury and the presence of bleeding. arterial embolization has expanded the indications of the conservative treatment. retrospective observational study on splenic traumatism and its therapeutic options. material and methods: a total of 60 patients with splenic injury have been treated at our centre between 2014 and 2018. 43 patients were hemodynamically stable: 11 were embolized and 32 received a conservative treatment. 17 patients were hemodynamically unstable: 6 had a good response to the resuscitation treatment so they were embolized, but there was one patient who deceased because of other causes. from these 17 patients, 10 patients received splenectomy. results: the main objective of this study is to review the management of the trauma patient with splenic injury. of the total of 60 patients with splenic trauma, average iss of 27, 17 underwent splenic embolization, 17 underwent urgent splenectomy and 26 were treated with conservative treatment. the 17 embolized, 6 were hemodynamic unstable at arrival but responded to the fluid therapy, 3 had a splenic lesion grade iv, 1 a grade iii, 1 grade ii and another a grade i. the success rate of embolization was 100% in the 17 embolized patients. 7 patient died, only one of them in the embolization group and was not related to the splenic trauma nor embolization, 4 were in the urgent splenectomy group due to severity of trauma, 1 died before receiving any treatment and 1 in the conservative treatment group due to other complications. conclusions: patients who respond to volume or are hemodinamically with high-grade lesions, arterial embolization would be less aggressive treatment options with excellent results. haukeland university hospital, surgical unit/ regional traumacenter, bergen, norway, 2 norwegian university of science and technology, trondheim, norway, 3 haukeland university hospital, physical and rehabilitation medicine, bergen, norway, 4 university of bergen, bergen, norway, 5 st olavs hospital, physical and rehabilitation medicine, trondheim, norway introduction: during the past decades acute trauma care has improved through the development of highly specialized trauma centres and teams. since patients are considerable young when being affected, trauma may lead to life-long physical, cognitive and emotional constraints interfering with an independent self-determined life (1, 2) . in 2016, a revised national plan for the treatment of trauma patients in norway was published (3) . the plan emphasizes the importance of rehabilitation and the need for early interdisciplinary rehabilitation. this study will examine in which extent patients receive rehabilitation in early phase after trauma as recommended in the norwegian national plan. in addition we will examine what follow-up patients receive after trauma, quality of life, functional level and use of health care and next-of kin resources. material and methods: patients admitted to regional trauma center in mid-or western norway in 2017 with niss c 12 are recruited to participate. data will be collected from national trauma register, the norwegian patient register, the municipal patient and user register, data from statistics norway, the electronic patient record (epj) and the patient/relatives questionnaire. discussion: the results will be useful in the preparation of patient courses that comply with strong recommendations in the national trauma plan, ensuring equal treatment and raising awarness about rehabilitation for trauma patients. introduction: diaphragmatic lesions involve wounds and rupture of the diaphragm, through penetrating wounds or thoraco-abdominal trauma. their incidence is 1-15%. the diagnosis may be late, despite the technical advances made by medical imaging. the choice of surgical approach and technique is still controversial. mortality is usually related to the associated injuries. the present paper analyzes the incidence of diaphragmatic lesions that occur in thoraco-abdominal trauma, their epidemiology, diagnosis and treatment. material and methods: we performed a retrospective study over a 5-year period (2014-2018) , in the surgical units of the emergency county hospital of braila, including all patients diagnosed with diaphragmatic lesions. results: during the study period, 73 patients had thoracic-abdominal trauma. there were 41 cases of blunt trauma and 32 thoracic-abdominal trauma. our study involved 9 cases of diaphragmatic injuries (12.3%), 7 by road accident and 2 by white weapon. the sex ratio was 4:1. the average age was 38 years. chest radiography was a contributory preoperative diagnosis in 4 cases. the diaphragmatic wound was on the left side in 8 cases, and its average size was 5 cm. the surgical procedure involved the reduction in the abdomen of the herniated viscera and the monoplane suture of the diaphragm by nonabsorbable ''x'' points in all cases. chest aspiration was the rule. there was only one death in a complex polytrauma case. case history: we report the one case which performed tae, angioplasty, thoracotomy, laparotomy and preperitoneal pelvic packing (ppp) in the hybrid emergency room (h-er). the patient was male in the 60 s, who was riding on his motorcycle and fell from a 5 m height. clinical findings: he was in shock state. diagnosis: we scanned cect and diagnosed subdural hematoma, traumatic subarachnoid hematoma, lt hemopneumothorax, lung contusion, multiple costal bone fracture, intercostal artery injury, splenic injury (gradeiii), pelvic bone fracture. therapy: we inserted the drainage tube to the hemopneumothorax and did the tae for the pelvic bone fracture and splenic injury. after tae, he was in still shock state. the bleeding volume from the lt drainage tube increased, so trauma surgeons did the emergency thoracotomy and thoracic endovascular aortic repair (tevar) for intercostal artery injury. we suspected he also had abdominal compartment syndrome due to recanalization of tae, and they performed the emergency laparotomy and did ppp for the pelvic bone fracture. comments: we install an ivr-ct system in our trauma resuscitation room in october 2017. we named it h-er, as it enables us to do all examinations (sonography, ct and fluoroscopy) and treatments (ir, operation) required for trauma in a single room. we have to perform prompt diagnosis and treatment, especially in cases of severe polytrauma cases. a retrospective study proved that the h-er had shortened the time of ct initiation and emergency procedure and that lead to improve mortality 1). h-er is a novel trauma resuscitation room to do all treatments required in the only one room for severe traumatic patients introduction: according to the previous advanced trauma life support (atls) guidance, the early assessment of trauma patients with haemorrhage were classified upon the vital signs. recently, national trauma registry analyses suggested to extend the assessment criteria with the base deficit (bd), referring to the metabolic status. our objective was to investigate the relevance of bd and to explore new prognostic factors in the early assessment of the severely injured. material and methods: our study included 162 patients registered between 01.01. 2016 and 11.09 .2019 on our emergency ward for whom the trauma team was activated. they were grouped into severity groups (i-iv) according to either the vital signs (classical) or the extended criteria with bd. the data were extracted from medical documentations of the early phase of treatment. as primary outcome, we compared the 24-h mortality rate of the patient groups. we studied the need for massive transfusion and intensive care unit care as secondary outcomes. results: according to the classical assessment, 50% of the patients were assigned to group i (lowest risk for haemorrhagic shock) and 23% to group ii. the remaining 27% were grouped into groups iii and iv (higher risk). with taking bd into consideration, 58% were reassigned to a higher risk group; however, this change affected only groups i and ii. the 24-h mortality changed only in group i (0.7% vs 7.7%; p = 0.002). bd did not affect the need for massive transfusion. in groups i and ii, 3.5% of the patients, in groups iii-iv 23% needed intensive care unit treatment. conclusions: bd is an effective prognostic factor in the early assessment of trauma patients. however, compared to the vital signbased evaluation, it provides extra informaton only in less severe cases. according to our findings, it may help to assess the need for the administration of blood products. grants: nkfi k120232; ginop-2.3.2-15-2016-00015; efop-3.6.2-16-2017-00006 . complejo hospitalario de jaén, servicio de cirugía general y del aparato digestivo, jaén, spain, 2 complejo hospitalario de jaén, servicio de anestesiología y reanimación, jaén, spain case history: 56 years old male, with history of hypertension and dyslipidemia, suffered a backhoe accident and was admitted in a regional hospital. on initial assesment he presented contusion and two laceration wounds in left chest and in lumbar region. body ct informed subcutaneous emphysema and left rib fractures from 6th to 11th, left hemidiaphragm edema, laminar left pneumothorax and contusive lung. posterior lumbar hematoma and no intra-abdominal free fluid. laceration wounds were partially sutured, with drainages through the wounds clinical findings: he was transferred to our emergency department, presenting dyspnea, tachycardia, sweating, painful luq and left hemithorax worsening with breathing investigation/results: reviewed by our radiologist, tc images showed herniation of abdominal organs into the chest diagnosis: traumatic hernia in left costophrenic recess. multiple rib fractures therapy and progressions: the hernia contents (left colonic flexure and omentum) were reduced and defect closed with primary repair in emergency surgery. rib fractures treated by osteosynthesis.on 4th pod left renal artery dissection and renal infarction were evidence in a new ct. comments: diaphragmatic injuries are caused by blunt or penetrating thoraco-abdominal trauma. potentially life-threatening due to the herniation of abdominal organs and severe associated lesions. clinical suspicion is important as prompt diagnosis and treatment are necessary for good outcomes. in our case, the initial clinical assessment was incorrect and the transfer put the patient in danger as an emergency surgery should have been performed before transfer. this enhances the importance of a correct initial management of polytrauma patients. introduction: the fractures of the calcaneus account for about 1-2% of all fractures of the human skeleton. the majority of these fractures (70%) are intra-articular and surgical intervention is a widely accepted way of treatment material and methods: the aim of this study was to evaluate the results of open reduction and internal fixation for di-afc.in a period of 24 years (1995-2019) 70 patients (9 patients with bilateral fractures) with age range from 19 to 79 years old, were treated surgically using the lateral extensile approach. follow-up was 1-24 years. the results were evaluated based on x-ray parameters (calcaneal morphology, bohler''s and gissane''s angles), active range of motion, footwear problems and time needed to return to work. the sf-36 health survey was used for outcome assessment. results: fracture mean healing time was 15,6 weeks. the outcome was excellent in 32 cases, good in 28 cases and poor in 12 cases. the complications were malposition of fixation in 11 patients, superficial wound slough in 8 patients, reflex sympathetic dystrophy in 6 patients, deep infection in 2 patients who were treated with antibiotics and metalwork removal following union of the fracture. one patient resulted in metal breakage with consequent pseudarthrosis. finally one patient developed chronic osteomyelitis and is under treatment. the treatment with open reduction and internal fixation for di-afc is indicated, provided that the restoration of calcaneal shape, alignment and height is achieved. long term functional results with mild pain, few alterations in activities of daily living or work, and essentially no footwear problems, can be expected from a properly performed open reduction and internal fixation. extraperitoneal rectal injury in emodinamically unstable patient treated after dcs with external traction applied in an endorectal balloon r. somigli 1 1 hospital, general and emergency surgery, pistoia, italy case history: a 46-year-old man was crushed between two vehicles while he was working. he arrived in er hemodynamically unstable, so he underwent to emergency surgery. clinical findings: at rectal examination there was evidence of almost complete antero-lateral anorectal laceration. at abdominal examination there was evidence of anorectal full-thickness laceration and urethra full laceration. investigation/results: no diagnostic was required in preop because of patient instabilty. diagnosis: pelvic fracture with hemodynamic instability, severe rectal injury and complete prostatic urethra transection. therapy and progressions: el, lateral colostomy, pelvic paking, cistostomy and hip external binder. damage control surgery was performed. on 3 pod second look was carried out and an almost complete extraperitoneal rectal injury was found during pelvic depaking. properitoneum was drained and a baloon probe was introduced in the rectum to allow the proximal rectal flap to advance to the distal rectum. stomal washes were performed with no rectal leak and rectal baloon traction mantained for 10 days. radiological and endoscopic check haven't shown any leak and a good mucosal reconstruction. mri no sphincteral anatonical defects. waiting for emg before stoma reversal. comments: the optimal managment for extraperitoneal rectal injuries remains controversial. an approach with lateral colostomy and conservative treatment of rectal lacerations with rectal trac-tion baloon, could represent a safe treatment alternative in those cases with sphincter preservation, with a lower risk of complication. exploring differences between iss and niss scores for 30-day mortality in adult and elderly trauma patients in a norwegian national trauma cohort m. introduction: injury severity score (iss) and new injury severity score (niss) with a threshold over 15 is commonly used to define severe injury and to define the study population in trauma registrybased studies for both adult and elderly trauma patients (1) . for elderly patients (c 65 years) this might be unreasonably high and might lead to exclusion of significantly injured elderly with increased risk of mortality. the aim of this study was to assess whether there were significant differences in 30-days mortality between adults and elderly trauma patients for different frequently used iss and niss thresholds material and methods: the norwegian trauma registry was interrogated to identify all adult (c 16 years) trauma patients included in the registry from january 2015 through december 2018. data were dichotomized to age groups ''adult'' and ''elderly'' (16-64 and c 65 respectively) with 30-days mortality as primary endpoint. mortality rates were assessed for iss and niss thresholds of [ 9, [ 12 and [ 15. we applied descriptive statistics and chi-squared test for comparisons. results: 23768 patients with available information about age, 30-days mortality and iss and niss scores were included in the analysis, of which 16224 patients were 16-64 years old and 4706 patients were c 65 years. 238 adult and 500 elderly patients died, giving overall mortality rates of 1.5% and 10.6% respectively. for iss and niss [ 9 there was a significantly higher 30-days mortality in elderly trauma patients (17.3% and 15.2% respectively) than adult patients (4.7 and 3.8% respectively) (p \ 0,001), as for all other iss and niss thresholds tested. conclusions: this study demonstrates that elderly trauma patients has a significantly higher mortality risk than adult trauma patients at all iss or niss-thresholds analysed. this group has a significant mortality even at iss and niss above 9. introduction: the trauma tertiary survey (tts) is a widely accepted tool in the prevention of missed injury. existing literature on its effectiveness focusses on multitrauma patients. this study investigates the yield of the tertiary survey in trauma who are admitted for tts, without having any significant injury. material and methods: a single center retrospective cohort study was performed in a level ii trauma center. trauma patients without any clinically significant injury at the primary and secondary survey were included. the primary outcome was missed injury found during tts (type 1). secondary outcomes were missed injury found after tts but during admission (type 2), mortality and hospital length of stay [ 2 days. results: from 355 included patients, 11 patients (3.1%) had a type 1 missed injury. alcohol consumption was associated with an increased risk for type 1 missed injuries (odds ratio = 5.49, 95% ci: 1.36-22.16) . a type 2 missed injury was only found once, it concerned the only case of trauma related mortility. out of 335 nonoperated patients, 65 (19.4%) were admitted for more than two days. these patients were significantly older (71 vs. 39 years, p \ 0.001) and had a higher asa classification, 3-4 vs. 1-2 (47.5% vs. 12.7%, p \ 0.001). conclusions: tts showed missed injuries in only 3.1% of trauma patients who had no clinical significant injury found during primary and secondary survey. high costs of admission, together with a low yield found for this study's population the cost benefit of hospitalizing these patients is for discussion. future research should therefore focus on the identification of predictors of a positive tertiary survey. references: 1. advanced trauma life supportò student course manual. 2. keijzers, et al., the effect of tertiary surveys on missed injuries in trauma: a systematic review. 3. enderson et al., the tertiary trauma survey: a prospective study of missed injury. the 4-h rule in the emergency department and its association with surgical mortality in one public hospital in israel: retrospective study i. ashkenazi 1 1 hillel yaffe medical center, hadera, israel introduction: in order to improve patient treatment the 4-h rule in the emergency department (ed) was introduced in many countries as well as in israel. within four h, patients attending the ed must be seen, treated, and a decision must be reached whether these patients are to be admitted or discharged. though a popular performancebased measure, whether the 4-h rule in ed is associated with a decrease in mortality is controversial. the primary objective of this study was to evaluate the association between time in the ed and surgical mortality in one public hospital in israel. material and methods: included in this retrospective study were patients admitted to the ed of hymc during 2017. patients dying on the first day were excluded. . results: included in this study were 106,766 patients. of these, 28,108 (26.3%) patients were hospitalized and the rest were discharged. overall, 825 patients died. general surgery accounted for 18,391 patients of which 73 died (8.8% of hospital deaths; 0.4% of all surgical patients; 1.9% of patients hospitalized in general surgery). internal medicine together with general surgery and orthopedic surgery accounted for 98.5%, 98.6% and 98.5% of the mortalities observed in patients with decisions made within 0-4 h, in patients with decisions made beyond 4 h and in all the patients respectively. forty-five patients with decisions made within 4 h died compared to 28 with decisions made beyond 4 h. these represent 0.3% and 0.6% of all surgical patients in the ed (whether hospitalized or discharged) and 1.9% and 1.9% of those hospitalized. conclusions: general surgery is the second largest contributor to hospital morality. in both absolute terms and relative terms, mortality was not increased by delays in decisions made beyond 4 h. the adoption of this performance-based measure should be questioned. introduction: trauma is an important cause of mortality [1, 2] . researchers are looking for optimal death/survival predictive models in trauma population. one way is to validate traumatic scores for different medical systems [1] . the aim of our study was to validate the new injury severy score (niss) in severe trauma ( introduction: the international classification of diseases-based injury severity score (iciss) has been proposed as a reliable tool to measure trauma system performance especially in countries where a trauma registry has not been yet established. the purpose of this study is to assess the predictive capability for in-hospital mortality of iciss with international and adjusted survival risk ratios (srrs) in greek trauma population. material and methods: this single center, retrospective cohort study was conducted in a greek tertiary care hospital between january 2015 to december 2018. the trauma population was defined as hospitalized patients with a principal hospital discharge diagnosis in the range icd-10 s00-t79. duplicated injury icd codes, readmissions, transfer to another hospital and missing data were excluded. the primary outcome was in-hospital mortality. adjusted srrs was calculated from patients with multiple injuries and the following two iciss scores were evaluated: multiplicative-injury (iciss) and singleworst-injury (swi). the models were assessed in terms of their discrimination, measured by receiver operating curve (roc) analysis and calibration measured using calibration curves. results: a total of 30195 patients were included in the study. median age was 60 ± 22 years and mortality rate was 2,1%. based on international srrs, the area under the curve was 0,839 (95% ci 0.826-0.852) for iciss-multiplicative and 0,839 (95% ci 0.826-0.852) for iciss-worst injury. both modes had statistically significant better performance with adjusted greek srrs (aur = 0,877 95% ci 0.867-0.887 and aur = 0,880 95% ci 0.870-0.890, respectively). conclusions: this analysis has demonstrated the validity iciss model for in-hospital mortality prediction in greek trauma population. further research is warranted to confirm the performance of iciss using a sufficiently sized sample to define national srrs. introduction: the occurrence of intra-abdominal abscesses is the most serious post-operative infective complication after appendectomy. a significant amount of research has been conducted in an attempt to identify those patients at greatest risk. pct is initially described as an early, sensitive and specific marker for sepsis associated with bacterial infection. we hypothesize that pct could serve as a predictor of the development of intraabdominal abscess and postoperative infective complication material and methods: the present study is a prospective, single centre, observational cohort study involving patients undergoing emergency appendectomy. all patients admitted to the acute care surgery ward for appendicitis were screened for study eligibility. pct poc samples will be obtained preoperatively (t0) and post procedure (t1) at 24 h (t2), 48 h (t3), and 5 days (t3) post procedure. the primary objective of this study was to assess the diagnostic accuracy of point-of-care testing for pct in identifying post appendectomy abscess. the secondary objective was to determine the diagnostic accuracy in identifying any infective complication conclusions: we expect the incidence of abscess and infective complication to be increased in the pct elevated group compared with the control group. previous investigations indicate the overall morbidity related to infective complication is approximately 1-10% of patient undergoing laparoscopic appendectomy. our pilot study revealed that the incidence could be as high as 15% in patients with prolonged elevated pct levels. introduction: hand trauma is a common cause for attendance to the accident and emergency (a&e), accounting for nearly 10-30% of all patients 1 . it is essential that accurate treatment and management is done as the implications of mismanagement are long term, which may lead to disability, loss of work and income, livelihood, and even psychological issues 1 . the presence of a specialised hand surgeon is essential for management of these injuries 2 , but in the a&e setting it is not always possible to have such specialised care and there is a need for an efficient triage system. materials and methods: we did an audit in our department and found a delay in the referral of patients from a&e to our trauma clinic, which was quite expected due to a high patient inflow. we devised a trauma pathway for the a&e, known as the d-system which outlines for them till what day from trauma is a particular hand patient safe to be sent to the hand clinic or who needs an urgent referral to a higher trauma centre, based on urgency of need of intervention. the pathway is in the form of a simple flowchart, which is easy to understand even for junior members of the team. we intend to do another audit after implementation of the pathway to assess change in practice. conclusion: it is essential to have simplified pathways for non-specialist areas in order to streamline treatment and offer the best care, in the limited availability of resources, especially at smaller hospitals. our aim is to develop one such system and assess it's effective in delivering better care. introduction: a quantitative method for measuring trauma severity has many potential applications. the intent of this study was to evaluate the accuracy of the mgap score and its components in prediction of in-hospital mortality versus the accuracy of the revised trauma score rts at a trauma center. material and methods: this study included 825 patients with trauma. data regarding age, mechanism of injury, systolic blood pressure, glasgow coma score and respiratory rate were collected at trauma center of alberto torres hospital. mgap and rts scores were calculated, and their accuracy to predict survival/death outcome. results the study included 825 patients, ranging in age from 2 to 89 years, 69% male. from the total sample, 159 patients who suffered from penetrating trauma and 666 patients who suffered from blunt trauma were observed. in the comparison of the scores, rts and mgap, there was no significant superiority in any of them for predicting the outcome -which in our study was hospital discharge or death -even when compared by trauma mechanism. the gcs proved to be a very sensitive criterion in both scores, especially in patients with traumatic brain injury, totaling 62 patients in our statistical analysis, of which 56,4% had a negative outcome. rts was slightly superior than mgap in patients classified by the score as high chance of mortality, with 75% versus 69% of assertiveness. conclusions: up to the moment, there is no evidence to support the superiority of one of the analyzed scores as a predictor of mortality in the patients evaluated. although the rts score is more widely used in trauma centers, the application of the mgap score is more feasible in pre or in-hospital care of polytrauma patients, since it does not use respiratory rate in its parameters. validation of d-dimer for screening for venous thromboembolism in pelvic and lower extremity trauma patients t. uehara 1,2 , t. noda 3 , t. yumoto 4 , n. kobayashi 5 , a. nakao 4 , t. ozaki 2 1 okayama university, emergency healthcare and disaster medicine, okayama, japan, 2 okayama university, orthopaedic surgery, okayama, japan, 3 okayama university, musculoskeletal traumatology, okayama, japan, 4 okayama university, emergency and critical care medicine, okayama, japan, 5 okayama saidaiji hospital, okayama, japan introduction: venous thromboembolism (vte) is a life-threatening complication after major trauma patients. we previously reported that the patients with higher injury severity score (iss) and lower extremity trauma had high risk for vte. additionally, high d-dimer levels (cut-off d-dimer value, 12.45 lg/ml) on day 10 were useful for screening for vte in major trauma patients. we validated d-dimer levels for vte screening for patients with pelvic and lower extremity trauma. material and methods: a retrospective study was undertaken between april and august 2019 at the okayama university hospital. 19 patients with pelvic or lower extremity trauma were included (median iss, 18). we collected following data; age, sex, iss, the number of operation times, value of d-dimer in screening, incidence of vte and use of anticoagulants. results: eleven patients showed high d-dimer levels in screening, furthermore, six patients were diagnosed vte using contrast-enhanced computed tomography. symptomatic pulmonary embolism was not occurred. patients with vte had undergone orthopaedic surgeries two or more times. fourteen patients received therapeutically or prophylactic anticoagulation therapies. conclusions: measurements of d-dimer levels after pelvic or lower extremity trauma patients were useful for screening of incidence of vte. direct oral anticoagulants were convenient for treatment to vte. trauma patients often needed several times of surgeries, heparin was also useful in perioperative period. introduction: early assessment of the clinical status of severely injured patients is crucial for guiding surgical treatment. several scales are available to differentiate between risk categories. we compared four established scoring systems in regard to their predictive abilities for early versus late in-hospital complications. methods: database from a level i trauma center. the following four scales were tested: the clinical grading scale (cgs; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mcgs), the polytrauma grading score (ptgs), and the early appropriate care protocol (eac; covers acid-base changes). admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. results: in total, 3668 severely injured patients were included (mean age, 45.8 ± 20 years; mean iss, 28.2 ± 15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from hem. shock, 4.1%; death from multiple organ failure (mof), 1.9%; mortality rate, 26.8%). istinct differences in the prediction of complications, including mortality, for these scores (or ranging from 0.5 to 9.1). the ptgs demonstrated the highest predictive value for any late complication (or = 2.0), sepsis (or = 2.6, p = 0.05), or pneumonia (or = 2.0, p = 0.2). the eac demonstrated good prediction for hemorrhage-induced early mortality (or = 7.1, p \ 0.0001), but did not predict late complications (sepsis, or = 0.8 and p = 0.52; pneumonia, or = 1.1 and p = 0.7) cgs and mcgs are not comparable and should not be used interchangeably (krippendorff a = 0.045). conclusion: our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid-base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). none of the authors have any conflicts of interest to declare. mortality rate related to trauma mechanisms in trauma center at alberto torres hospital from january 2014 to july 2019 r. p. pereira 1 , r. adriana martins 1 , j. a. c. padilha 1 , f. e. silva 1,2 , d. rangel 1 1 alberto torres hospital, trauma center, são gonçalo, brazil, 2 federal university of rio de janeiro, niterói, brazil introduction: to demonstrate the healthcare services of the trauma center of rio de janeiro based on epidemiological data and on the specificity of the type of initial care delivered to multiple trauma patients, comparing the mortality rate at the second peak of death with the worldwide literature. materials/methods: retrospective study extracted from ''ct heat'' database. polytraumatized patients of both sexes were included and the mortality rate was calculated taking into account the second peak of death from trauma, gender, age and primary mechanisms of injury. discussion: the data collected show 3% mortality in the second peak, with firearm projectiles (40%) followed by traffic accident and fall as the primary causes of death. conclusion: because of the structural and health care profile of this trauma center, it was possible to reach the desirable mortality rate according to the worldwide literature (less than 5%). introduction: trauma patients are sometimes in critical condition upon arrival and need aggressive treatments to survive. despite all efforts many end up dying. it seems necessary to try to identify those patients with a very high risk of death to avoid futile treatments. the aim of our study was to develop a simple clinical tool to predict mortality in trauma patients that can be easily calculated in the ed. material and methods: we analyzed data from all trauma patients arriving at a spanish trauma hospital from june 1993 to june 2018. patient demographics, physiologic trauma scores, vital signs, and glasgow coma scale (gcs) were recorded. our primary outcome was mortality. logistic regression analysis (lra) was performed using three variables (age, shock index (si), and gcs) to determine the appropriate weights for predicting mortality. using them, we constructed a simple score to calculate mortality. results: 2678 patients were studied. the mortality rate was 15.9%. our score was constructed using weights derived from lra for age [ 55y (2 points), si [ 1(3 points) , and gcs conclusions: our score is easy and quick to calculate and could be a useful tool to predict mortality using early available parameters upon arrival in the ed. acknowledging the ethics involved in this topic, this score could sort out patients with a very high risk of death and in whom aggressive therapeutic measures could be limited early or withdrawn in agreement with family members references: haider a, et al (2019) (2015) (2016) states the average cost for an a&e attendance and non-elective inpatient stay is £138 and £1,609 respectively highlighting the importance for schemes to reduce hospital admissions. assess impact of ambulatory care, surgical emergency assessment unit (seau) and ''emergency surgeon of the week'' (esw) on hospital admissions for surgical referrals (gp/ a&e). material and methods: retrospective analysis of prospectively collected data of hospital admissions from the patient centre database before and after implementation of seau (in november 2014) and esw (in november 2017), including the units'' activities. emergency general surgeon followed 1:5 (monday-thursday, 0800-1800) rota based at seau. results: since 2014 (50 months), seau has reviewed 12451 (new 7543; follow ups 4908) patients. surgical admissions (sa) pre and post implementation seau were 766* and 629*/month respectively, a drop by 18%. esw helped a further drop by another 14% to 520*/month. 58% of new referrals were admitted and overall 35% of all patients reviewed were admitted. juniors (st3/st4) and seniors (st5-8/staff grades/consultants) admitted 40% and 34% of the referrals respectively. 2950 uss and 1959 ct were performed in dedicated seau slots. 98% attending seau were likely to recommend the unit to friends or relatives. conclusions: in the face of unprecedented demand for hospital beds (more so in the winter), ''emergency surgeon of the week'' based at seau could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained nhs. surgical emergencies, an educational and medico-economic challenge introduction: surgical emergencies are a frequent reason for consultation in the emergency department and are responsible for significant morbidity and mortality. our study aims to present the number of patients admitted for a surgical emergency in a french level 1 trauma-center and the volume of patients operated in emergency depending on the different specialties. method: we conducted a retrospective, single-center study of the hospital emergency department (uas) of the university hospital center of nice between january 2017 and december 2018. we studied the volume represented by surgical emergencies according to the different specialties. results: the emergency department welcomed 192,004 patients, of which 38,351 surgical emergencies patients accounted for 20% of the total activity; 14397 patients were operated on urgently, which represents 35% of all surgical procedures in our hospital. conclusion: surgical emergencies are an important part of the activity of our hospitals. an academic definition is difficult to achieve. a regional organization is needed for the management and optimal care of these patients. the creation of regional centers, as for the trauma centers, seems indispensable, especially for the most serious patients, allowing both a better medico-economic and educational management of surgical emergencies. introduction: every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last 20 years, however, 20% of patients admitted to an icu will die during their admission (1) . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover (2) . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction (3) . material and methods: a checklist was created to review to score the handover. this was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing 17 handovers on the icu. results: there is a notable discrepancy in the quality of handovers of new patients. this is true of handovers between doctors, nurses and a combination of the two. 41% (n = 7) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight (96%, n = 16), their height (100%, n = 17), whether the patient has previously been admitted to an icu (78%, n = 15) and whether the patient has any allergies (71%, n = 12). conclusions: the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. introduction: bowel resection for acute mesenteric ischaemia (ami) in elderly is associated with significant morbidity and mortality, and increasing age and frailty are associated with increased risk. this study aims to assess the short-term outcomes for elderly patients undergoing surgery for ami, and to assess the accuracy of surgical risk calculators in this population, to determine their utility in preoperative discussions. introduction: intertrochanteric femoral fracture of the super-elderly is often difficult to treat because good surgery does not always lead to good functional prognosis. we investigated the factors affecting the functional prognosis in patients with intertrochanteric fracture over 90 years old. material and methods: 94 cases of intertrochanteric fracture over 90 years old who had undergone surgical treatment at our hospital between december 2010 and september 2018 were examined. nine men and 85 women, age at injury ranged from 90 to 101 years, with a median of 93 years. the average postoperative follow-up period was 3.7 months. for these cases, the mobility was classified into independent walking, assisted walking (cane, walker), wheelchair, bedridden, and the transition of pre-and postoperative mobility was analyzed. the significance test was performed using the mann-whitney u test, and p \ 0.05 was considered significant. results: by fracture type, when jensen classifications i and ii were stable, iii, iv, and v were unstable, mobility of unstable type was significantly reduced (p = 0.024). when the waiting period for surgery is divided by the median of 4 days, there was no difference in mobility reduction between groups of less than 4 days and groups of more than 4 days (p = 0.925). although there was no significant difference in the presence or absence of preoperative rehabilitation intervention (p = 0.08), there was a tendency for less decline in mobility when preoperative rehabilitation intervention was performed. conclusions: in the treatment of this fracture, early surgical treatment after injury is recommended, but in the case of very elderly people, waiting is often required due to existing diseases and poor general condition . this study suggests the importance of preoperative rehabilitation intervention during the waiting period for surgery to prevent disuse disorders. references: 1. kelly-pettersson et al. waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: a cohort study international journal of nursing studies 69 (2017) 91-97. older patients with traumatic shock exhibited lower pulse pressure compared with younger patients; an analysis of nationwide trauma data base in japan introduction: the study purpose was to assess the effect of age on the relationship between pulse pressure (pp) and systolic blood pressure (sbp) in patients with traumatic shock. material and methods: in this retrospective cohort study using nationwide trauma data base in japan from april 2004 to may 2019, trauma patients 18 years of age and older with sbp \ 90 mmhg were selected. patients with severe traumatic brain injury (the abbreviated injury scale on head [ 3) and cardiac arrest (hr = 0 and sbp \ 60 mmhg) were excluded. linear regression analysis assessed association between pp and sbp interacted by age group dichotomized as \ 60 or c 60 years old. results: during the study period, 12444 patients were included. the linear regression analysis indicated the significant association between pp and sbp in overall population (ec, estimated coefficient = 0.37 95%ci [0.33, 0.37], p \ 0.001). association between pp and sbp was significantly interacted by the age group (ec = 0.32 95%ci [0.29, 0.35] introduction: high rates of trauma in south africa (sa) predominantly affect the youth, yet the geriatric population is not exempt. 1 in addition to inherent challenges of age, elderly trauma patients are further compromised by resource constraints. 2 we aimed to assess injuries and outcomes in elderly patients admitted to a tertiary trauma unit in sa. material and methods: a retrospective record review was done of all patients 60 years and older, admitted to the trauma unit over an 8-month period. injury severity score (iss), mechanism of injury (moi), in-hospital complications and length of hospital stay were documented. results: 275 patients (mean age: 72 years; 57% female) were included with mean iss of 8. the most frequent mois included nontraumatic falls (54%), falls from height (10%), motor-vehicle collisions (9%), pedestrian vehicle collisions (7%), and blunt injuries (8%, 87% intentionally inflicted). eighty patients (30%) experienced at least one in-hospital complication. the mortality rate was 7%. the mean length of hospital stay was 7 days. conclusions: despite the known vulnerablities of the elderly, the mortality rate and isss of this cohort were relativley low. however, when compared to first world literature, intentionally inflicted injuries and certain preventable mois (e.g. fall from height and pedestrian vehicle collisions) were common, [3] [4] introduction: the majority of new colorectal cancer is diagnosed in people [ 65 years, yet the elderly are less likely to undergo curative surgery. chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. conversely, frailty is a strong predictor of poor outcomes following surgery and presents an opportunity for patient optimisation. the aim of this systematic review is to assess the available evidence between frailty and outcomes in patients of all ages undergoing surgical resections for colorectal cancer. material and methods: pubmed was searched for articles reporting outcomes for patients deemed frail undergoing elective or emergency colorectal cancer resection up until august 2019. the primary outcome was mortality (30 and 90 day). secondary outcomes; length of stay, readmission, reoperation & post-operative complications. results: 143 studies identified, 17 studies were deemed eligible for inclusion. study types, frailty assessments & outcomes measured were variable. despite this heterogeneity, categorisation of ''frailty'' was associated with higher rates of post-operative mortality, complications, readmission, and length of stay. conclusions: based on current evidence, frailty is a strong predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. standardisation of frailty assessment and measure of outcomes is needed for more robust analysis. accurate risk stratification of patients will allow us to make informed treatment decisions and identify patients who may benefit from prehabilitation and intensive tailored post-operative care. introduction: pneumatosis intestinalis (pi) and hepatic portal venous gas (hpvg) are two radiological findings associated with a broad range of medical conditions. pi can be primary (15% of cases),usually with a benign course, or secondary (85% of cases),which results from obstructive or ischemic gastrointestinal diseases. only a minority of pi is associated to free abdominal air. in literature there is no consensus on radiological and biochemical markers of favourable outcome nor on treatment options-medical or surgical. we tried to identify prognostic markers in a series admitted to a single university hospital. material and methods: the medical records of 36 patients with pi and/or hpvg admitted to ospedale maggiore policlinico (milan, italy) in the period 2012-2019 were collected the ct scan were reviewed by a single radiologist. results: mean age was 76.4 ± 14 years (43-94). pi was primary in 13,9% of the patients (n = 5), and secondary in 86,1% (n = 31). at ct, pi was associated to portal gas in 13 patients (36%) (8 dead, 6 alive) and to free air in 7 patients (20%) (4 dead, 3 alive). linear or rounded gas collections were equally distributed in primary and secondary pi. the colon was involved in 16 patients (44%), followed by the small intestine in 15 (41,6%),and the stomach (n = 2). in 7 patients serum lactate was [ 4, and 6 died. leucocytosis (wbc [ 11,000/mm 3 ) was present in 8 patients (1 alive).four patients had peritonitis and 2 abdominal tenderness. laparotomy was performed in 1 primary (alive) and 16 secondary pi (4 deaths).in two patients it was diagnostic; in 6 and 2 associated to right or left colectomy, in 3 to ileal resection and in 3 to other procedures.surgery was judged futile in 12 patients; all died a few hours after emergency department access. conclusions: we could not found any relationship between clinical, biochemical and radiological findings and outcome of pi. mesenteric and portal gas is a ominous finding, but did not reach significant value. successful transcatheter arterial embolization for a giant pseudoaneurysm of gluteal muscle due to ground level fall in elderly woman with direct oral anticoagulants t. kadoya 1 , r. nakama 1 , k. arakawa 2 , t. ogura 1 , k. kase 1 1 saiseikai utsunomiya hospital, department of emergency medicine and critical care medicine, utsunomiya, japan, 2 saiseikai utsunomiya hospital, department of radiology, utsunomiya, japan case history: a 90's year-old woman using apixaban fell on the ground and was transferred to previous hospital. magnetic resonance imaging was taken and she was diagnosed as gluteal hematoma. she was treated conservatively but hemoglobin (hb) level was gradually decreased. although she was administered red blood cell as needed, anemia progressed. contrast-enhanced ct showed expanding hematoma of gluteal muscle. she transferred our hospital for advanced treatment including surgery on 5th day on hospital. clinical findings: vital signs were stable on arrival at our hospital. extensive subcutaneous hematoma was found in the right thigh and gluteal lesion. investigation/results: laboratory test showed that hb 6.6 g/dl and normal coagulation status. contrast-enhanced ct showed a giant pseudoaneurysm inside the gluteal muscle. therapy and progressions: angiography showed a giant aneurysm of peripheral branch of internal iliac artery. we performed transcatheter arterial embolization (tae) for it by gelatin sponge. after tae, there was no complication and progressive anemia was stopped. she was transferred to another hospital for rehabilitation six days after tae. comments: increase use of direct oral anticoagulants in elderly people could induce severe hemorrhagic trauma by minimal mechanism. tae is minimal invasive and safety procedure for such trauma case. introduction: the number of elderly people will increase during the next few decades. more importantly, the number of people aged 80 or above are projected to increase 100% in developed countries. in spain, people over age 80 were 4.68% of the population in 2009, and this will increase to 6.19% in 2019. that has implications in the health services and in the management of trauma patients. material and methods: we did a retrospective cohort analysis of trauma patients c 80 y.o. admitted to our level i trauma center during the time-period of 2009-2019. demographic data, icu care, and mortality were assessed. results: 109 trauma patients c 80 y.o. were admitted during that period. this is a 200% increase compared with the number of patients admitted during the previous decade (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) . mean age was 84.8 ± 2.4 years, and median new injury severity score (niss) was 17 (interquartile range 13 to 27). 46% were male. the mechanism of injury was 50% falls, and 47% pedestrian runovers. 48 patients were admitted to icu, with median niss of 25 and mortality rate of 38%. among severely injured trauma patients (niss c 35) the hospital mortality rate of those c 80 years was 90%, much higher than in the age group of 65-79 years (40%), with a significant difference (p \ 0.05). no differences mortality rates between 65-79 years and youngers with the same niss. conclusions: the geriatric trauma patient population is on the rise worldwide. this should be taken into account in our trauma centres in order to be able to adapt and try to improve trauma care in these patients. introduction: frailty is a geriatric syndrome which has been considered as a risk factor in the elderly, increasing adverse events in terms of global health, as hospitalization, increase of falls, need of institutionalization, and mortality. the aim of this study is to evaluate relationship between frailty, and the presence of major complications in the postoperative course of patients older than 70 years undergoing emergency surgery. material and methods: prospective, longitudinal, cohort study, using four different scales of frailty as a predictor of risk for short-term adverse events, for patients during the postoperative course of emergency surgery (may 2017-september 2018). the sample is categorized according to four frailty scales (clinical frailty scale, frail score, trst and share-fi) . we analyze the variables regarding diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first 30 days. clavien-dindo classification was used in order to graduate the severity of complications. results: 92 patients were included with a mean age of 78,71 years (sd 6, 26) . 53,3% of the simple are women. frailty prevalence ranges, according to the frailty scales, from 14,13% to 46%. median hospital stay was 6 days ( iqr 3, 65) . all four frailty scales show statistical differences to predict major complication in our simple. trst and frail scales show the strongest measure of association (or 7,69 and 5,92, respectively). the frail phenotype, is also related to an increased of mortality, and frail scale is the frailty scale with largest or (or = 16,071).only frail show association with longer hospital stay ([ 12 days), and reoperation rate. conclusions: frailty represents a predictive marker of major complications and mortality, for patients older than 70 years undergoing emergency surgery. frail score, shows the strongest relationship with mortality and complications. introduction: age has been identified as a predictor of trauma mortality [1] and it is known that even low energy trauma may cause severe injuries in the elderly [2] . the aim of this study was to explore how the elderly trauma patients, and the care thereof, differ from the younger ones in a swedish context. material and methods: the swedish trauma registry (swetrau) was used. consecutive recorded trauma cases that presented at one level ii trauma hospital during december 2019-august 2019 were included (n = 676). patients were stratified into groups; those c 65 and those results: in the c 65 years group, sex distribution was more even (female 49.6 vs 34.9%, p \ 0.05), physical status according to pretrauma asa classification was higher (mean 2.62 vs 1.45, p \ 0.05) and the trauma mechanism was predominantly low-energy (falls from no height) as opposed to the conclusions: the trauma among elderly swedish patients are more often of low energy compared to the younger population. in spite of this, the elderly are more severely injured, require more surgical interventions, and their short term mortality is increased 20-fold. measures aimed at prevention of low energy trauma of the elderly are therefore much needed. introduction: there are intramedullary or extramedullary methods in internal fixation od trochanteric fractures. seldynamisalbe internal fixator with two sliding screws (sif), as an extramedullary method, and gamma nail (gn), as an intramedullary method, are in routine trochanteric fractures treatment at our institution for last two decades. material and methods: health related quality of life and hip function were assesed at least two years after surgery, in the series of 71 patients with a surgically treated ao 31a1 or 31a2 fracture type. there were two groups of patients: group treated by sif and group treated by gn. examination had been performed using sf-12 test, with its physical component score (pcs) and mental component score (mcs), and harris hip score (hhs) tests. results: in sif group, mean pcs was 59,7, mean mcs was 64,9 and mean hhs was 70,7. in gn group mean pcs was 68,2, mean mcs was 70,7 and mean hhs was 76,3. there was no significant difference regarding all these parameters between the groups of patients (p [ 0,05). there was correlation between all evaluated parameters, both in groups of patients particularly and in all patients (p \ 0,05 we identified undertriage in 31,6% (31/98). falls from own height (0-1 m) was found in 54 patients with iss [ 15, 25/54 (46%) of them was found to have been undertiaged (p 0.004). we found an association between gcs \ 15 and undertriage (p = 0.01). 60% (206/341) falls between 0-1 m and 30% (61/ 206) of these without trauma team. falls between 1-5 m 12,5% (15/ 120) without trauma team. all 10 with fall [ 5 m had trauma team. mortality was 12% (41/341), no association between height of fall and mortality (p 0.237). undertriage was not associated with increased mortality (p = 0,104). median age in mortality group was 87 years versus 73 years in surviving group (p \ 0.001). in univariate analysis there was association between prehospital bp \ 90 (p 0.043), gcs \ 15(p \ 0,001), iss 3 16 (p \ 0.001), prehospital rr [ 30, rts \ 12 (p \ 0.001) asa score [ 1 (p \ 0.001) and mortality. conclusions: we found significant undertriage in the geriatric trauma population with fall injuries. gcs \ 15 and low energy falls was associated with undertriage but not with mortality. laparoscopic direct repair of an incarcerated spigelian hernia c. bergamini 1 , v. iacopini 1 , r. de vincenti 1 , a. bottari 1 , g. alemanno 1 , p. prosperi 1 1 aou-careggi, emergency surgery, firenze, italy spigelian hernia occurs through a defect in the anterior abdominal wall adjacent to the semilunar line. it is in itself very rare and more over it is difficult to diagnose clinically. it has been estimated that it constitutes 0.12% of abdominal wall hernias. the majority of patients present with symptomatic incarceration of preperitoneal fat or intraabdominal viscera. radiographic studies are beneficial in confirming the diagnosis. the high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed. the spigelian hernia has been repaired by both conventional and laparoscopic approach. laparoscopic management of spigelian hernia is well established. most of the authors have managed it by transperitoneal approach either by a direct repair or by placing the mesh in intraperitoneal position or raising the peritoneal flap and placing the mesh in extraperitoneal space. there have also been case reports of management of spigelian hernia by total extraperitoneal approach. we present the case of an obese eighty-four y.o patient. complaining for a sudden onset abdominal pain in the right low quadrant, mimicking an appendicitis. the ct scan demonstrated a typical picture of a spigelian hernia containing an intestinal loop. the loop showed classical signs of parietal wall ischemia. the video describes the surgical laparoscopic approach of this case which was able to confirm the diagnosis e to reduce the loop into the abdomen. the loop initially appeared diffusely ischemic, but after the intra-abdominal reduction some signs of vitality started to be noticed. however, they were incomplete; thus the loop was resected. the hernia defect was successively repaired in a direct way because of the small caliber (\ 4 cm of diameter) and the possible contamination coming from the intestinal resection. post-operative course was particularly benign and the patient was discharged on the seventh post-operative day in good health. introduction: trauma audit & research network (tarn) data shows older persons falling from standing height and sustaining significant injury has become the commonest trauma presentation in england and wales 1 . we aimed to assess whether frailty predicts poor outcomes in the elderly. material and methods: retrospective database review of tarn eligible patients [ 65 years old admitted in a 19 week period with documented rockwood clinical frailty score 2 . age, injury severity score (iss), length of stay (los) and mortality were noted. the inhospital mortality group was sub-analysed. logistic regression was performed (stata v15), odds ratios and 95% ci reported. results: older age was associated with higher cfs in the 263 patients studied. increasing cfs was associated with increased overall mortality (cfs6-9 vs cfs1-5 or 2.14; 95% ci 0.88-5.21), decreased likelihood of pre-hospital trauma alert and increased length of stay (cfs6-9 stayed 4 days more than cfs1-5). all 22 deaths had cfs [ 3 and head or chest injury. adjusting for age and cfs those with chest injury were 1.15 times more likely to die (or 1.15 95%ci 0.44-3.04). mortality in those with rib fracture was 5 times higher in cfs6-9 vs cfs1-5 (or 5.53 95%ci 1.21-25.28). conclusions: increasing age and cfs (especially 6-9) are associated with poor outcomes in elderly trauma, thus cfs is a useful prognostic tool in severely injured elderly patients. chest injuries are a major cause of mortality in this group, especially with increasing frailty. major trauma centres must develop practice management guidelines to appropriately manage these patients. introduction: major trauma causes activation of the complement system, which plays a key role in development of systemic inflammatory response syndrome and multiple organ failure. complement is known to be activated early after trauma 1, but the relationship between outcome and the extent of complement activation during the first critical hours after injury is unknown. we hypothesized that complement activation in the first hours after trauma displays a highly dynamic pattern which is associated with outcome. material and methods: complement activation was assessed by plasma terminal c5b-9 complement complex (tcc) using elisa in a prospective cohort of 136 trauma patients. samples were obtained at admission, after 2, 4, 6 and 8 h, and daily in the intensive care unit. the extent of complement activation was assessed as area under the concentration curves 3-6 h after injury (tcc-auc3-6). the relative contribution of complement activation, base excess (be) and new injury severity score (niss) to outcome was analyzed by multivariable analyses. results: niss and be were associated with tcc-auc3-6 in bivariate analyses (spearmans rho (p) was respectively 0,23 (p = 0.01) and -0.33 (p = 0.0003)). in multivariable analyses, niss and initial tcc alone predicted 50% of the variability in ventilatorfree days (vfds), whereas initial tcc and tcc-auc3-6 predicted 66%. tcc auc3-6 alone contributed with 16% to the model. tcc-auc3-6 was also significantly higher in patients deceased at day 30 (4.9; 2.1-17.9 (median; quartiles) vs. 2.4; 1.8-3.8, p = 0.048 introduction: massive transfusion protocols [mtp] have been widely adopted for the care of bleeding trauma patients but their actual effectiveness is unclear. this study aims to conduct an updated meta-analysis to evaluate the effect of implementing an mtp on the mortality of trauma patients. material and methods: medline, pubmed, google scholar and cochrane library databases were systematically searched for relevant articles published from 1 january 2008, to 31 july 2019, using a combination of key words and additional manual searching of reference lists. three reviewers independently screened the articles for potential inclusion. eligible articles were original articles in english, included trauma patients and compared mortality outcomes before and after institutional implementation of a mtp. primary outcomes were 24 h and overall mortality. results: nineteen studies met inclusion criteria, analyzing outcomes from 2,962 trauma patients. there was a wide range of outcome and process indicators utilized by the different authors. mtps significantly reduced over-all mortality, pre-mtp-40.4% and post-mtp 32.6% [or 0.7 (0.56-0.89)] for trauma patients. 24-h mortality was not significantly reduced [or 0.87 (0.60-1.25)]. conclusions: the institution of an mtp has a significant over-all mortality reduction for trauma patients. we encourage that researchers use standard nomenclature and indicators, provide more details regarding protocols and patient populations and incorporate advances in the management of bleeding trauma patients in all future mtp studies. introduction: when resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized with good outcomes for penetrating trauma patients. however, evidence that these concepts apply well to the management of blunt trauma is lacking. this study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. material and methods: in this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival \ 0.6. patient's characteristics, examinations, severity and administrated therapies were compared between survivors and non-survivors. data are described with median (25-75% interquartile range) or number. results: thirty patients were included and median injury severity score in survivors vs non-survivors was 41 (36-51) vs 45 (34-53) (p = 0.49), with no significant difference in probability of survival. despite no significant difference in injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8310 [ conclusions: vasopressor administration and high-dose use for hemorrhagic shock following severe blunt trauma are significantly associated with increased mortality. although the transfused volume of blood products tends to be increased, early termination of vasopressor should be considered. all authors have no significant relationships with regard to this study. early amplitudes of citrated functional fibrinogen in thromboelastography to predict massive transfusion introduction: this study aims to evaluate the role of early amplitudes of the thromboelastography measure of citrated functional fibrinogen (cff) to predict massive transfusion (mtx) defined as transfusion of c 4 of any blood products within an hour of arrival to a major trauma centre. material and methods: trauma patients c 16 years requiring activation of the major haemorrhage protocol with teg performed on a tegò 6 s hemostasis analyser were eligible for inclusion. exclusion criteria were arrival [ 3 h after injury, pregnancy, bleeding disorder or anticoagulant use. patient demographics and transfusion requirements were obtained from medical notes. teg manager was accessed to extract amplitudes at 5 min (a5), 10 min (a10) introduction: hyperfibrinolysis, remains a significant characteristic of acute traumatic coagulopathy induced mortality. s100a10, a cell surface protein, when shed creats an occult hyperfibrinolytic subtype. annexin a2 (a2), a multicompartment protein that co-localizes with s100a10 and contains a tissue plasminogen activator (tpa) binding site has been shown to enhance tpa activity 100-fold and thus behaves as marker of hyperfibrinolysis. we hypothesize that increased concentrations of a2 in blood will enhance tpa fibrinolysis. material and methods: blood was collected from (12) healthy volunteers. recombinant a2 in concentrations 1, 25, 50, 75, 100, 125 lg/ ml was added blood and then combined with tpa 75 ng/ml. samples were assessed using thromboelastography (teg). blood samples were collected from trauma activations from 2014-current at a single, urban, level-1 trauma center. samples were assessed using a combination of rapid, citrated native and tpa challenge teg. a2 levels were established via proteomic analysis. results: a2 50-125 (lg/ml) significantly increased tpa mediated ly30% vs tpa alone (a2 ? tpa [50-125] median 21.5% vs tpa 12.0% p \ 0.01). a2 without tpa had no significant effect on ly30% and was similar to the lysis of control (a2 75 lg/ml 0.7% vs control 1.2% p = 0.36). a2 75-125 (lg/ml) significantly increased r time from control and tpa alone (control normalized to 1 vs a2 median 1.77-fold increase in minutes p \ 0.01 and tpa 0.68-fold decrease vs a2 median 1.77-fold increase p \ 0.001). rapid teg for patient 1 vs patient 2 in our ongoing study was 3.4% vs 4.2% and 1.7% and 51.8% respectively on tpa challenge teg. proteomic analysis of a2 relative activity found a 6.6-fold a2 activity in patient 2 compared to patient 1. conclusions: exogenous cell free a2 significantly increases tpa mediated fibrinolysis measured by teg. preliminary data from our ongoing trauma study evaluating a2 levels and hyperfibrinolysis coincide with our in vitro study. introduction: massive transfusion protocol can be activated to mobilize the blood products resource in a timely and effective manner. blood products, however, are still wasted or overused. we aimed to study what proportion of patients who met the abc criteria for massive transfusion received 4 or more units packed rbc (prbc). material and methods: a retrospective study all level i trauma patients admitted with arrival systolic blood pressure of 90 or less (july 2017 to may 2018) was recruited. transfusion was complied with stts. all clinical and laboratory findings, and management procedures were populated from the data registry. results: 214 of 1200 admitted trauma patients met the inclusion criteria. of 214 patients who where admitted with hypotension, 39 of 95 patients (41.05%), who met the abc criteria for receiving 4 or more prbc were stabilized with 2 or 3 units. in other words, stts enabled us to save 69 units of prbc. arrival data, i.e. blood pressure (cut of point: 83 mmhg and p value:0.01), shock index (cut of point: 0.79 and p value:0.0009) and pulse rate (cut of point:112 beat/min and p value:0.01) were significantly different in patients prescribed 4 or more units prbc. after initial resuscitation, blood pressure (cut of point:98 mmhg and p value:0.0001 shock index cut of point: 0.9 and p value:0.001), pulse rate(cut of poinan95 beat/min and p value:0.001) presence of pelvic fracture, positive fast,and base deficit [ 10 were significantly different in the group received 4 or more units prbc. conclusions: massive transfusion protocol with abc criteria may lead to wasted or overused blood products.consideration of dcr continuation strategy complied with stts along with the findings of this study has resulted in a refined protocol characterized by more effective and efficient blood product resource allocation. references: 1-chang r, holcomb jb. optimal fluid therapy for traumatic hemorrhagic shock. critical care clinics. 2017 jan 1;33 (1) case history: we present the clinical case of a female patient of 77 years old who had been taking aspirin. mechanism of injury: a fall from her own height, resulting in head trauma. clinical findings: dysphonia and stridor, having underwent an immediate orotracheal intubation. investigation/results: she had a head ct done that was normal; and a cervical column and neck ct that showed a large retropharyngeal hematoma, without an associated vertebrae fracture. diagnosis: large retropharyngeal hematoma. therapy and progressions: she was admitted to the intensive care unit for mechanical ventilation. on 2nd day, she underwent a surgical tracheostomy. on 4th day, underwent weaning from mechanical ventilation. on 6 h day, was transferred to the ent ward, had the tracheostomy tube removed and was discharged from hospital. comments: a hematoma in this potential space may constitute an immediately life threatening emergency due to airway compromise. in 1991, thomas et al found only 29 cases described in the literature since 1966. the most common cause is the blunt cervical trauma (in 38% of the cases). other causes are the cervical hyperextension injury, cervical vertebrae fracture, cough, sneeze, strain, blunt head trauma, swallow a foreign body, retropharyngeal infection, carotid artery aneurism, internal jugular vein puncture, metastatic disease, coagulopathy, anticoagulants, etc. in the setting of trauma, the mechanism of injury generally permits explaining the presenting injuries. in this case, the clinical severity expressed by the patient seemed to be disproportional to the resultant injury. however, the presence of haemorrhage contributing factors associated with the existence of fascial spaces in the neck, should warn us of the possibility of formation of deep cervical hematomas that may cause an occult airway obstruction. case history: a 27-year-old male with a personal history of consumption of alcohol, cannabis, smoked cocaine and heroin. he was found in decubitus position and in a situation of cardiac arrest. the last time he was seen in his baseline situation was 48 h before. after performing cpr and administration of naloxone and flumacenyl, sinus rhythm was achieved. clinical findings: 24 h after admission, increased tension was observed in left leg, thigh and gluteal region. absence dorsalis pedis, tibialis posterior and popliteal pulse was observed in a doppler examination. investigation/results: intracompartmental pressure measurement revealed a result of 28 mmhg in the deep posterior compartment and 20 mmhg in the superficial (diastolic bp 40 mmhg). at admission k levels were 10.50 meq/l, creatinine 2.24 mg/dl and ck 113438 u/l. diagnosis: opioid-related compartment syndrome. therapy and progressions: urgent fasciotomies of the leg and thigh were performed 3 h after diagnosis with a posteromedial and anterolateral approach in the first case and with a lateral approach in the latter. herniation and signs of poor viability in all the compartments were observed. after the surgery, he persisted with anuria and a ck peak of 288,000 u/ l, which was next normalized. 7 debridements were performedfor the next 25 days. subsequently, after the isolation of p. stutzeri and mucor in the wound and the absence of signs of vitality, a supracondylar amputation was performed. after, hemodynamic status improved. 2 weeks after the amputation it was possible to withdraw hemodialysis, which he had required since admission. comments: opioid misuse is a topic of growing interest. recent works have reported a worse prognosis in the case of opioid-related compartment syndrome. a high level of suspicion is necessary to make a prompt diagnose in these patients. introduction: the pelvic binder is a mechanical device designed to compress instable pelvic ring fractures and minimize dead space in order to limit blood loss. it is generally recommended to apply a pelvic binder if an unstable injury is suspected and the patient presents with a ''c-problem''. the effectiveness remains questionable though. material and methods: a total of 1207 trauma patients between 2014 and 2018 were retrospectively evaluated regarding instable pelvic injury. 108 patients were admitted with a pelvic binder applied. the correct application was evaluated using ct scout. four groups were generated: group 1 with correct pelvic binder application, group 2 with incorrect placement, group 3 with no pelvic binder at time of admission, group 4 with pelvic binder applied in er. total outcome was determined based upon iss, age, preclinical time, time to ct, shock index, hemoglobin at admission, survival rate, administration of blood products as well as total hospital and icu days. results: 43% of all pelvic binders were applied incorrectly. 30 patients (28%) suffered an instable pelvic fracture. patient survival was not influenced by the preclinical application of a pelvic binder (80% group 1 vs. 81,82% group 3, p = 0,719). no significant statistical difference was found for total icu days 9,08 vs. 11,56, p = 0,399; total hospital days 23,42 vs. 24,76, p = 0,630; rbc transfusion 5, 87 vs. 3, 63, p = 0, 791; iss 23, 8 vs. 24, 5, p = 0, 815. conclusions: the correct application of a pelvic binder seems to pose problems preclinically. while the need to minimize blood loss is crucial, our collective did not benefit from this device. additionally, survival rates of the patients that suffered an instable pelvic fracture were unaffected. the iss remains the strongest predictor of total patient survival in pelvic trauma. trauma resuscitation times in a level 1 trauma center in the netherlands: a prospective overview introduction: in trauma, time is considered to be an important factor influencing patient's outcome. in the first hour after injury, appropriate care has the greatest effect on trauma patient's survival. previous research showed that measuring in-hospital trauma resuscitation times, contributes to insights and improvement of the resuscitation process. however, despite developments of atls guidelines, no recent empirical knowledge regarding resuscitation times exists. the aim of this study is to examine in-hospital trauma resuscitation times in a level 1 trauma center in the netherlands. material and methods: a prospective study was performed in level 1 trauma center amsterdam umc location vumc, between may 2019 and august 2019. trauma patients, aged c 16, presented during daytime at the trauma resuscitation room were included. information regarding patient's characteristics, trauma-and injury type, handover duration, duration till start of diagnostics and intervention, total resuscitation time, patient's disposition and survival were compared. results: in total, 50 patients were analyzed. motorized traffic accident (42%) and blunt injury (92%) were the most common mechanism-and injury types. median prehospital to in-hospital handover time was 3.40 min (iqr 1.20) . median duration till start of diagnostics and intervention were 8.01 (iqr 2.42) and 9.59 min (iqr 9.55) respectively. median total resuscitation time showed to be 40.25 min (iqr 23.01 background: terrorist attacks and civilian mass casualty events are frequent, and some countries have implemented tourniquets for uncontrollable extremity bleeding in civilian settings. we summarized current knowledge on the use of pre-hospital tourniquets in civilian settings to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. methods: using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, we searched medline (ovid), embase (ovid), cochrane library, and epistemonikos in january 2019. all types of studies that examined the topic in a pre-hospital setting published after january 1, 2000, were included. the protocol was registered in prospero (crd42019123172). results: among 3460 screened records, 55 studies were identified as relevant. due to a lack of relevant civilian studies, military studies were also included. the studies were highly heterogeneous, with low quality of evidence. most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. conclusion: the data suggest that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage is probably associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects. the effect of venous infusion by emergency medical service personnel on the prognosis of severe traffic accident patients: a nation-wide study in japan y. katayama 1 , t. kitamura 1,2 , t. hirose 1 , y. nakagawa 1 , t. shimazu 1 1 osaka university graduate school of medicine, department of traumatology and acute critical medicine, suita, japan, 2 osaka university graduate school of medicine, environmental and population science, suita, japan introduction: in japan, the law of paramedic was revised in 2014, and it became possible for paramedic in japan to secure an infusion route before cardiac arrest for severe patients. however, the effect of this treatment on the prognosis of severe trauma patients has not been assessed. we assessed this effect on the prognosis of severe traffic accident patients with using population-based ambulance record and nation-wide hospital-based trauma registry in japan. material and methods: this study was a retrospective observational study and the study periods was 2 years between january 2016 to december 2017. we linked the nation-wide hospital based trauma registry (jtdb) and the population-based ambulance record in japan in case. in this study, we included the traffic accident patients with iss score more than 16 and excluded cardiopulmonary arrest patients on the arrival of ems on the scene and missing data cases. the main outcome was cardiopulmonary arrest on hospital arrival. mcnemar's test and conditional logistic regression analysis were used to assess the association between the securing a infusion route by ems personnel and the primary outcome after one-to-one propensity score matching for securing a infusion route or not. results: 3502 traffic accident patients were eligible for analysis and 142 patients were dripped by ems personnel. after one-to-one propensity score matching, the proportion of cardiopulmonary arrest on hospital arrival were 5.6% (8/142) in patients dripped by ems personnel and 7.7% (11/142) in patients not dripped by ems personnel, respectively (p = 0.648). the adjusted odds ratio for securing a infusion route was 0.727 [95% confidence interval; 0.293-1.808, p = 0.493]. conclusions: in this study, there was no association between the securing a infusion route and outcome of traffic accident patients. the association between trauma patient characteristics and adverse laboratory values: which patient characteristics are most predictive? introduction: in more than 60 countries worldwide, laboratory testing is protocol driven since 1978 when it was included in the practice guideline of the advanced trauma life support course (atls). 1 however, it is not clear yet which patient characteristics are associated with unfortunate laboratory values. the aim was to create an overview of the characteristics that were associated with adverse laboratory values. material and methods: this cohort study was performed at amsterdam umc, location amc (level 1 trauma center), including patients during a period of 2 years. data concerning age, gender, asa scores, injury severity scores (iss), glasgow coma scores (gcs), mechanism of injury, type of injury (blunt or penetrating) and the presence of helicopter emergency medical services (hems) were obtained. the hematology panel included hemoglobin, hematocrit, mcv, leucocyte and thrombocyte values. the coagulation panel included inr, pt, aptt, fibrinogen and d-dimer values. other panels include arterial blood gas, kidney and liver panels. the association between trauma patient characteristics and laboratory values were determined by using binary and multinomial logistic regression. results: a total of 1287 patients were included, consisting of predominantly men (66%) with a mean age of 46 years old. an increase in age and iss was correlated with abnormal laboratory values (p = 0.00). additionally, male gender, iss [ 16, blunt trauma and the absence of hems was associated with a deviation in laboratory values (p \ 0.05). other patient characteristics did not show a significant correlation with adverse laboratory values. case history: a 47-year-old man presented with a classic case of pituitary apoplexy with a history of headache, nausea and vomiting. clinical findings: he was found to have a sellar and suprasellar mass with internal cystic and hemorrhagic component consistent with a pituitary macroadenoma. investigation/results: he underwent transsphenoidal sugery for a pituitary macroadenoma. because the tumor was invaded to left cavernous sinus, we left small portion of the tumor. eighth day after surgery, he underwent gamma-knife surgery (gks) for residual tumor. after two weeks, he complained of left ptosis. we considered the 3rd nerve palsy to be a post-radiation reaction at first. after 3 months, the symptoms had been continuous and mri showed increased size of cystic lesion involving left cavernous sinus. diagnosis: ct angiogram demonstrated a saccular aneurysm at left distal ica. endovascular coil embolization was performed. therapy and progressions: after 3 months of the intervention, the 3rd nerve palsy was partly improving. comments: our case report emphasizes the necessity of cerebrovascular imaging before surgery for pa. mr angiography/ct angiography is not currently obligatory in patients with pituitary adenoma, but in cases with the symptoms of displacement of the neuro-vascular structures it can be of great value. even in patients without such presentations, it may be helpful to evaluate the vascular involvement. case history: a 16-year-old boy during the preparation for a fishing session was pierced to the left orbitary region by a high-speed spearfishing steel. clinical findings: upon arrival the patient was conscious and responsive with a gcs of 15, he followed commands appropriately and there were no motor of sensory deficits. investigation/results: plain skull radiographs showed the spear crossing the skull from the left orbit to the posterior part of the parietal bone. diagnosis: the patient was immediately intubated to prevent involuntary movement of the foreign body. ct scan showed the fracture of the left orbitary roof where a 30 centimetres long metallic object crosses the cerebral parenchyma of the left hemisphere and perforates the left parietal skull. therapy and progressions: under direct visualization via transorbital approach the foreign body was removed together with bone fragments, hemostasis was done and orbitary roof repaired. serial cranial ct scan showed progressive reduction of frontal and parietal hematoma. the movement of the eye improved after a few days, normalizing with the regression of periorbital edema. upon discharge at 11 th postoperative day the patient had a gcs score of 15, no motor deficit and minimal visual loss. comments: penetrating injury of the skull and brain are relatively uncommon events, representing about 0,4% of all head injuries. orbital roof is relatively thinner part of the skull that can provide easy access to projectile objects, which can penetrate into cranial cavity and damaging the brain parenchyma. the principles of treatment are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection though debridement of all contaminated and necrotic tissue and at the same time preservation of as much nervous tissue as possible. multitraumapatients whith severe head injury (ais ‡ 3) are more quickly carried out ct scan on than a patient without severe head injury v. giil-jensen 1 , k. andersen 1 , t. k. helle 2 1 haukeland univercity hospital, sugical department, bergen, norway, 2 haukeland univercity hospital, ambulance service, bergen, norway introduction: trauma patients who are prone to severe head injuries during trauma may profit from obtaining a rapid clarification of the injury magnitude when using ct examination. in the case of a delayed ct examination, the consequence of the head injury could be more extensive. in this study, we wanted to see if those with severe head injury (ais c 3) received a faster ct survey than those who had no severe head injury. material and methods: retrospective registry study of severely injured patients (iss [ 15) which had been hospitalized as a trauma patient at haukeland university hospital in the period 2015-2019. in the study, we have excluded all patients entered as multitrauma but who have iss \ 16 and all patients who have not defined ct time. it turns out that over half of the patients lacked the registration of accurate time for the ct survey in the national trauma register. the number is still considered large enough to find a result. results: 2542 patients were received as multitraumatic at haukeland university hospital during the period. of these, 493 was severely injured. of these, 265 patients had severe head injuries and they again had 52 head injuries as the only serious injury (ais c 3). median time from arrival receipt to start ct, for this group was 27 min. in the control group that was severely injured but without severe head injury is the same time 33 min. there was 102 patients in the control group. conclusions: for the patients in this study who had severe injuries (n:493), the median time from the arrival in the emergency department to the ct starts was 6 min shorter for severe head injuries than for the group without severe head injuries. introduction: the patients with severe traumatic brain injury (stbi) who needs surgical intervention often experience acute traumatic coagulopathy (atc). earlier transfusion with high blood product ratios (plasma, platelets, and red blood cells via 1:1:1 ratio) is recommended for severely injured patients. however, recommended blood product ratio for stbi is still controversial. material and methods: we retrospectively reviewed successive adult stbi who underwent surgical treatment in our hospital between january 2016 and december 2018. we have transfused plasma aggressively to maintain blood fibrinogen above 150-200 mg/dl. we evaluated the total amount of transfusion and mortality. we exclude cases administered fibrinogen concentrate. results: 53 patients were enrolled. the amount of transfusion for 24h is rbc 4.2units, ffp 7.8units, pc 3.8units . stbi with severe other trauma needs higher ratio of plasma. discussion: tissue injury of stbi causes severe coagulopathy and 1:1:1 transfusion was thought to be insufficient for stbi in order to maintain fibrinogen. we agressively transfused plasma but we achieved fibrinogen value above 150 only in 20% of stbi with severe other trauma. agressive plasma transfusion had limitation for hyperfibrinolysis so we expect other product, for example fibrinogen concentrate. introduction: traumatic brain injury (tbi) remains a leading cause of hospital admission and mortality amongst trauma patients. intracranial hemorrhage (ich) can occur with tbi and presents a severe complication. low complication tolerance in developed countries and uncertainty on actual risk cause excessive diagnostics and hospitalization, considered unnecessary and expensive. methods: tbi cases indicated for cranial computer tomography (ct) according to international guidelines, at our level i trauma center between 2008-2018 were retrospectively included. multivariate logistic regression was performed for ich, progression and mortality predictors. results: 2036 tbi patients (m: 57.5; age at trauma: 57.6 ± 22.6), were included. ct was performed in 96.5%, skull fracture diagnosed in 18.6%, ich in 51.9%, ich progression in 28.4%. in patients \ 35a, chronic alcohol consumption (p = 0.004) and neurocranial fracture (p \ 0.001) were significant ich risk factors in a multivariate analysis. in patients between 35-65a, chronic alcohol consumption (p \ 0.001) and skull fracture (p \ 0.001) revealed as significant ich predictors. in patients [ 65a, age (p = 0.009), anticoagulation (p = 0.007) and neurocranial fracture (p \ 0.001) were significant risk factors for ich, age (p = 0.01) was an independent risk factor for mortality. late onset ich only occurred in cases with at least 2 of 3 factors: age [ 65, anticoagulation, neurocranial fracture. overall hospitalization might have been reduced by 15.8% via low risk cases. conclusions: triggered by decreasing error tolerance, international guidelines for mild tbi focus on safety maximization. repeated ct in initially ich negative cases should only be considered in high risk patients. non-ich cases aged \ 65 years do not gain safety from observation or hospitalization. recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics. references: to be added by the authors. evaluation of low-value clinical practices in acute trauma care: a multi-center retrospective study l. moore 1 , k. soltana 2 , j. clément 2 , a. turgeon 2 , î mercier 3 , r. krouchev 2 , p. a. tardif 2 , s. bouderba 3 , a. belcaid 4 1 université laval, social and preventive medicine, québec, canada, 2 chu de québec-université-laval, québec, canada, 3 université-laval, québec, canada, 4 introduction: low-value clinical practices have been identified as one of the most important areas of excess healthcare spending and are associated with adverse health outcomes. the objectives of this study were to estimate the frequency low-value practices in injury care and assess inter-hospital variations. material and methods: we identified low-value clinical practices from internationally recognized clinical guidelines. we conducted a population-based retrospective cohort study using data from an inclusive canadian trauma system (2010-2017) to calculate frequencies and assessed inter-hospital variations with intra-class correlation coefficients (icc). results: we identified 29 low-value practices of which 9 could be measured and validated using trauma registry data. the three lowvalue clinical practices with the highest absolute and relative frequencies were pelvic x-rays in hemodynamically stable patients with a negative physical exam for pelvic injury (42.9%), head ct in adults with minor head injury who were negative on a validated clinical decision rule (24.3%) and chest x-ray in hemodynamically stable patients with a normal physical exam (6.9%). we observed high inter-hospital variation for surgical management of penetrating zone ii neck injury without hard signs (icc = 27%), and moderate variation for head ct in adults with minor head injury who were negative on a validated clinical decision rule (icc = 6.3%). conclusions: we have developed and validated algorithms to evaluate nine potentially low-value clinical practices using trauma registry data. highest frequencies were observed for imaging in the emergency department and the highest inter-hospital variation was observed for inappropriate surgical management. these data can be used to advance the agenda on low-value care for injury admissions. dysfunction of functional connectivity between default mode network and cerebellar structures in patients with mtbi in acute stage. rsfmri and dti study introduction: mild traumatic brain injury (mtbi) occupies one of the first places in children injuries. among all brain networks at the resting state, the default mode network (dmn) is the most widely studied network. the aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mtbi using rsfmri. material and methods: 34 mr negative participants were studied in age from 12 to 17 years (mean age-14.5 years). group of patients consisted of 17 children with mild traumatic brain injury in acute stage. 17 age-matched healthy volunteers comprised control group. all studies were performed at phillips achieva 3.0t mri scanner using 32-channel head coil. fmri data were processed using functional connectivity toolbox conn. seed-based analysis was performed in order to reveal disturbances in functional connectivity. statistical processing was performed using statistica 12. results: dti analysis didn't show any changes in values of apparent diffusion coefficient (adc) and fractional anisotropy (fa) between two groups (see fig. 1 ). no statistically significant differences in correlation strength between dmn parts were observed in two groups (see fig. 2 ). intergroup seed-based analysis revealed statistically significant (p \ 0,05) difference in neural correlations between dmn parts and vermis (cerebellum structural part): positive link in control group and negative link in group of patients. conclusions: one of the most common symptoms of mtbi is dizziness as a result of impaired movements coordination. vermis as an essential cerebellum part plays an important role in the vestibuloocular system which is involved in the learning of basic motor skills in the brain. vermis aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together.our results show that mtbi appears to be a possible reason of connectivity malfunction in normal-appearing vermis. references: predictors of developing post-traumatic endophthalmitis introduction: 1h magnetic resonance spectroscopy (1h mrs) allows to study structural and metabolic brain disorders in various pathological conditions in vivo. non-invasive method determines its advantage for use in children in serious condition with acute cerebral injuries. this determined the purpose of the study: to identify criteria of irreversible brain damage based on the 1h mr spectra analysis in comatose children with acute traumatic brain injury (tbi) or anoxia. material and methods: 8 patients (6 months-16 years) were examined in the acute period of severe cerebral injury (gcs score 3-4): six were in acute and subacute period of severe tbi, one patient was examined on the seventh day after drowning, and one-a day after acute cerebral blood flow (hemorrhage). all patients died in 10-20 days after the study. control group included 10 healthy children aged from 7 to 13 years. single voxel 1h mrs and 2d 1h mrs was performed on 3t scanner. 1h spectroscopic voxel (te/tr = 35/ 2000 ms, voi = 3 cm 3 , nsa = 32) was oriented on mri intact areas: cortex of frontal, parietal and occipital lobes (fig. 1) , thalamic nuclei (fig. 2) , cerebellum, brainstem (fig. 3) . for 2d 1h mrs a spin-echo point-resolved spectroscopy (press) sequence was used (te/tr = 144/2000 ms) with the spectroscopic voi of 150 cm 3 on frontal lobes. results: in all spectra lactate (lac) signal, dominating all other signals, was detected. n-acetylaspartate (naa) was reduced by 60% and creatine/phosphocreatine (cr)-by 35%. conclusions: 1h mrs is a non-invasive prognostic method in patients with acute cerebral brain damage in coma. the cause of patients' death is the shift of cerebral glucose metabolism to an anaerobic type, as evidenced by the accumulation of lac. disturbance of energy metabolism causes a decrease of cr and a decrease in the neuronal marker naa. the combination of these patterns in acute cerebral injury, regardless of etiology indicates irreversible brain tissue damage. introduction: scalds and contact burns are the most common burn injuries both in children and adults. data are conflicting regarding which type of burns are more severe. we compared scalds, contact, and flame/fire burns at our burn center to determine which type were more likely to result in full thickness injuries and prolonged length of stay (los). material and methods: we conducted a structured retrospective medical record review of all patient admissions to a regional burn unit over a 10-year period between 2000 and 2010. data included demographic, clinical, and specific burn characteristics. the association between patient predictor variables and outcomes (full thickness burns, los) was explored using chi-square and stepwise logistic regression. results: there were 1,038 patients with either scald (n = 537, 52%), fire/flame (n = 434, 42%) or contact burns (n = 67, 6%). burn depth was not available for 216 cases (21%). mean (sd) age was 29 (25), 64% were male. mean (sd) total body surface area (tbsa) was 10 (11)%. 24% of burns contained areas of full thickness injury. patients with scalds were younger than those with contact or fire burns (22 ± 24 vs. 32 ± 28 vs. 38 ± 22 years respectively, p \ 0.001). the percentage of burns that were full thickness by etiology were contacts (45%), fire/flame (34%) and scalds (13%); p \ 0.001. after adjusting for age, location, and tbsa, scalds were less likely to result in full thickness injuries than contact burns (odds ratio 0.23, 9%%ci, 0.11-0.48). adjusting for multiple testing, univariate analysis (as well as the multivariate analysis) showed no difference in % 3rd degree burns between fire and contact burns, but scalds were significantly lower than each of those. los for scalds (8 ± 10) and contact burns (8 ± 11) was significantly shorter than for fire/flame (14 ± 25 days, p \ 0.001). conclusions: while less common, contact and flame burns were more likely to result in full thickness injuries than scalds. references: epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (rocket); a multicenter prospective observational case series introduction: the aim of this study is to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from fireworks. material and methods: a multicenter, prospective, observational case series performed in the southwest netherlands trauma region, which reflects 15% of the netherlands and includes a level i trauma center, a burn center, and an eye hospital. all patients with any injury from consumer fireworks, treated at a dutch hospital between december 1, 2017 and january 31, 2018, were eligible for inclusion. exclusion criteria were unknown contact information or insufficient understanding of dutch or english language. the primary outcome measure was injury characteristics. secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma. results: 54 out of 63 patients agreed to participate in this study. the majority was male (n = 50; 93%), 50% were children \ 16 years, and 46% were bystanders. injuries were located to the upper extremity or eyes and were mostly burns (n = 38; 48%) of partial thickness (n = 32; 84%). fifteen (28%) patients were admitted and 11 (20%) patients needed surgery. the mean total costs per patient were €6,320 (95% ci €3,400 to €9,245). patient-reported quality of life and functional outcome was not significantly different during follow-up compared with pre-trauma. conclusion: the most common injuries afflicted by consumer fireworks were burns, mostly located to the upper extremity, and eye injuries. fireworks can result in severe injuries, for which 15 (28%) patients needed hospital admission and 11 (20%) patients needed surgical treatment. although some injuries resulted in permanent disability, 1 year after trauma it in general did not have major or longlasting impact on patients'' self-reported quality of life or functional abilities. persistent inflammation, immunosuppression and catabolism syndrome after polytrauma: a rare syndrome with major consequences. l. hesselink 1 , r. spijkerman 1 , r. hoepelman 1 , l. koenderman 2 , l. leenen 1 , f. hietbrink 1 1 umc utrecht, trauma surgery, utrecht, netherlands, 2 wilhelmina children's hospital, center for translational immunology, utrecht, netherlands introduction: more severely injured patients survive the critical first phase after trauma nowadays. a substantial portion of these patients require long-term critical care support and suffer from recurrent infections. this clinical condition fits in a syndrome referred to as ''persistent inflammation, immunosuppression and catabolism syndrome'' (pics). the aim of this study was to investigate the incidence of pics and clinical outcomes of trauma patients with pics in a level one trauma center. material and methods: all trauma patients c 16 years admitted to the intensive care unit (icu) for c 14 days between 2007 and 2017, were included. patients with isolated neurological injuries were excluded. pics patients were identified by icu stay c 14 days, c 3 infectious complications and increased catabolism. infectious complications included infections during hospitalization and readmissions due to an infection. increased catabolism was defined as weight loss [ 10%, a body mass index. results: of the 3,859 polytrauma patients, 194 patients had an icu stay c 14 days. after exclusion of patients with isolated neurological injuries, 78 patients were included. of these patients, 18 developed pics. pics patients sustained 5 infectious complications on average (compared to 1 in the non-pics group, p \ 0.001) and 72.2% of the pics patients developed sepsis. also, pics patients had a longer hospital stay (mean of 90 days versus 50 days, p \ 0.001) and sustained more surgical procedures (mean of 13 versus 4 per patient, p \ 0.001). infectious readmissions occurred until 5 years after the initial trauma. conclusions: patients who develop pics experience long-term inflammatory complications that lead to frequent readmissions and surgical procedures. therefore, despite its low incidence, this clinical condition forms a burden on patients and a substantial financial burden on society. hyperbilirubinemia as a risk factor of the trauma icu patient introduction: hyperbilirubinemia is common in the intensive care unit (icu). hyperbilirubinemia has been considered as a risk factor of the icu patient. hyperbilirubinemia can have various causes. the hyperbilirubinemia has never been studied for the trauma icu patient. the aim of this study is to elucidate the incidence and effects of the hyperbilirubinemia for the trauma icu patient. material and methods: retrospective review of the trauma icu patients from 2017.01.01 to 2017.06.30. initial bilirubin serum level, 48 h bilirubin level, 7 day bilirubin level, highest bilirubin level, overall morbidity and mortality and other clinical variables were identified and evaluated. the patients who have highest bilirubin level c 3.0 mg/dl were defined as hyperbilirubinemia group. results: a total 78 patients were enrolled in this study. hyperbilirubinemia above serum bilirubin c 3.0 mg/dl were appeared in 26 patients. the mortality of the hyperbilirubinemia group was higher than the other group (71.4% vs 29.6%, p = 0.03). the icu stay of the hyperbilirubinemia group was longer than the other group (12.4 day vs 7.1 day, p = 0.04). the hyperbilirubinemia group had more incidences of pneumonia, acute kidney injury, and sepsis than the other group (42.9% vs 57%, p = 0.01/ 33.3% vs 66.7%, p = 0.001/0% vs 100%, p \ 0.001). conclusions: the hyperbilirubinemia is a risk factor of the trauma icu. if the hyperbilirubinemia is appeared, the cause of the hyperbilirubinemia should be evaluated and make an effort to correct hyperbilirubinemia for the each cause of the hyperbilirubinemia. case history: we present the clinical case of a male patient of 37 years old. injury mechanism: a firework burst on his right forearm. clinical findings: injury: a large area of carbonization of the muscles of the flexor compartment. signs and symptoms: intense pain in the hand and forearm with local oedema and tension. diagnosis: deep burn of the forearm. therapy and progressions: surgical debridement and fasciotomy of this compartment; followed by deferred and progressive primary closure by means of rubber bands that were tightened as the oedema diminuished-shoelace technique. evolution: discharged from hospital on the 8th pos op day; follow-up at 3rd and 6th month without functional impairment, with a good healing evolution. comments: deep burns that reach the subfascial planes of the limbs, increase the pressure in the muscular compartments, and may progress to a compartment syndrome. there is no specific cutoff value of pressure for this diagnosis; consequently, the final decision to proceed with a fasciotomy relies on the clinical experience. surgical debridement and fasciotomy may result in large wounds, sometimes difficult to close. grafts and flaps result in another wounds and carry a risk of pain, infection, scar shrinking and necrosis. the diagnosis of a limb compartment syndrome is almost always a clinical one and requires a high index of suspicion so as to the fasciotomy is done in time. the shoelace technique is a simple, reproducible and cost-effective method of deferred closure of a large wound, preserving functionality and resulting in a good final cosmesis. references: johnson ls et al, management of extremity fasciotomy sites prospective randomized evaluation of two techniques, am j surg. 2018. the use of propranolol in the management of acute thermal burn injury: evaluation of the effect of fixed dosages in african patients c. jac-okereke 1 , i. onah 1,2 1 esut teaching hospital, surgery, enugu, nigeria, 2 national orthopaedic hospital, enugu, nigeria introduction: propranolol has been shown to improve outcomes in burn patients. its effects are achieved at doses that reduce the heart rate by 10-25%. africans have a different propranolol pharmacogenetic profile as compared to other races. there is paucity of literary works on the use of propranolol in africans with burns. in our study, we explored the effectiveness of fixed dosages of propranolol in nigerian patients. material and methods: this was a prospective comparative study of adult burn patients; two test groups received propranolol 40 mg/day and 240 mg/day respectively. the average daily pulse rate prior to and after the administration of propranolol were compared. results: patients in the control group had no effective reduction in their pulse rate. patients who received propranolol at a dose of 240 mg/day had a reduction c 10%. no adverse events were observed. conclusion: it is important to establish the effective dosage of propranolol in burn patients of african-descent and explore its potential benefits in their treatment. although we cannot draw strong case history: the authors present in their paper three cases of blunt abdominal injury caused by seat belt in car accident. in the first two cases there was no diagnostic problem thanks to clear clinical finding. in the third case there was no clinical correlation and even repeated auxiliary examinations did not indicate the need for surgical intervention of the abdominal cavity. clinical findings: case no. 1-male 37 y. old, haemodynamic stability, thoracic an abdominal pain, fast positivity, on ct free fluid in abdominal cavity, small spleen laceration, positivity of peritoneal symptomatology. case no. 2-male 42 y. old, haemodynamic stability, bilateral hypogastric pain without peritoneal symptomatology, fast with small perihepatic fluid, on ct fluido-pneumoperitoneum. case no. 3-female 42 y. old, haemodynamic stability, thoracic pain, massive oedema on the right side of the neck and supraclavicular area, without abdominal symptomatology. fast with small subhepatal fluid collection-4 mm, ct scan with large neck haematoma and fracture of 1st rib, apical pneumothorax-12 mm. intraabdominal only subhepatal fluid stripe-18 mm, suspected of small hepatic laceration. after 3 days the clinical status rapidly changed, during 2 h peritoneal symptomatology occured. on control ct scan fluido-pneumoperitoneum was detected. investigation/results: all patients underwent surgical procedure diagnosis: bowel mesenteric injury therapy and progressions: the first patient underwent ileo-caecal and hartmann resection, by the second patient was small intestine and col. sigmoideum resection needed, and the last one underwent ileal resection and npwt. comments: despite the current diagnostic methods blunt abdominal injuries, unlike the penetrating ones, can present a certain diagnostic problem especially when they are accompanied by other serious conditions such as manifest chest injuries. introduction: patients with hypertension and peritonitis must undergo a laparotomy. in isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. to miss a hollow viscus organ lesion, that would need an operative procedure, is a constant fear. it is the aim of this study to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions. material and methods: data of over 20'000 inpatients of a levelone-trauma centre between 2008 and 2016 were analysed. only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. significant predictors were detected in bi-and multivariant analysis. results: of the 341 patients with an average age of 42 ± 20 years 43% (n = 148) had a splenic-, 49% (n = 168) a liver-and 23% (n = 79) a kidney rupture. the total iss was 30 ± 16 points. in 52 patients (15%) a hollow viscus injury could be found (stomach n = 5, small bowl n = 29, colon n = 22, rectum n = 4). injuries of the thorax (76%), the extremities (70%), the head (70%), the vertebra column (43%) and the pelvis (30%) were diagnosed as concomitant injuries. due to multivariant analysis neither age, gender, heart frequency at admission, gcs, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion. conclusions: clinical parameters taken at admission are not useful to predict hollow viscus injuries. the ct-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first 60 min after trauma. repetitive clinical examination is necessary. in doubt a diagnostic laparoscopy or even laparotomy has to be performed. introduction: a heavy abdominal trauma is associated with a high morbidity and mortality. it is the aim of this study to show injury patterns in the abdomen and concomitant injuries in polytraumatized patients as well as to identify risk factors of the decease. material and methods: data of over 20'000 inpatients of a level-one trauma centre between 2008 and 2016 were retrospectively analysed. only patients with a relevant abdominal trauma (ais abdomen c 3) were included. the ais score was determined either with a contrast enhanced computed tomography or intraoperatively. significant risk factors were detected in bi-and multivariate analysis. results: 315 patients with an averaga age of 43 ± 18 years were included. 48% (n = 155) had an ais abdomen of 3, 40% (n = 127) of 4 and 10% (n = 33) of 5. the overall iss was 31 ± 16 points. the mechanism of injury was mainly blunt (87%). a splenic rupture was present in 40% (n = 128), a liver rupture in 35% (n = 112) and a kidney rupture in 26% (n = 68). hollow viscus injuries were present in 13% (small bowl n = 44, colon n = 33, stomach n = 13, rectum n = 7, bladder n = 14). concomitant injuries were determined in 88% of the patients. of these 70% were diagnosed a thoracic injury, 66% injuries at the extremities, 55% head injuries. 47% spinal injuries and 31% pelvic injuries. the mortality was 16% (n = 51). a liver rupture (p = 0.031, or 4.0), pelvic injuries (p = 0.02, or 4.4), age (p = 0.043, or 1.032), hypotension (systolic blood pressure \ 90 mmhg) (p = 0.003, or 8.2) and a low gcs at admission (p \ 0.001, or 0.67) were determined to be significant risk factors. conclusions: in our trauma department life threatening abdominal traumata are treated about every 10 days. lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. due to our experience we recommend the use of an early ct-scan as thereby the injury severity can be fast and precisely assessed. case history: a 44 yo female was tranferred to our icu on day 2 of a severe acute necrotizing alchoolic pancreatitis with mof. crrt with cytosorb was immediately started. on day 7 after onset (dao7) an acs with a new organ failure (lung) showed up. open abdomen (oa) and tac with mesh-mediated/npwt got a temporary improvement. clinical findings: on dao10 (oa3), reopening of the mesh entailed a sudden fascial retraction of 6 cm. a new larger mesh was positioned. on dao14 (oa7) the fascial defect measured both on ct slices and in or was 26 cm. provision of a longterm oa was done. therapy and progressions: a new fascial traction device (fas-ciotensò, germany)1 was positioned on dao14 (oa7), with a continuous traction weight of 6-8 kg. revision was scheduled any 2-4 days, according to clinical needs, including combined anterior and retroperitoneal necrosectomy. progressive traction allowed to get a 5 cm fascial gap under traction on dao38 (oa31). anterior cst was thus performed and fascia primarily closed. completion of necrosectomy was done through the bilateral lumbar incisions and npwt. comments: early fascial closure is a goal in oa. mesh-mediated traction/npwt is the most effective strategy, but primary fascial closure is sometimes impossible. 2 the duration of oa is a key point. fasciotensò allowed to overcome the failure of mesh-mediated option and avoided fascia retraction in a longterm oa. it was quickly managed by the nurse staff, allowed a easier access to the abdomen and a proper positioning of the protective film. its effectiveness in this demanding case makes it an interesting option for shortening fascial closure in septic oa too. background: small bowel obstruction (sbo) caused by intra-abdominal adhesions is one of the main surgical emergencies. in most of the time, adhesions are created by previous abdominal surgeries. without any severity signs, the medical treatment is first proposed to avoid superfluous surgery. we noticed that the failure of medical treatment is frequently seen in patients previously operated of appendicectomy. the purpose of this study is to determine the eventual relation between a previous appendicectomy and failure of medical treatment in sbo. methods: we conducted a retrospective data collection using a diagnostic code for bowel obstruction in patients who have consulted in emergency from 01.01.2011 to 01.01.2019 at the salengro university hospital in lille. using the administrative database, 1194 patients were identified. we excluded all children, patients with wrong diagnosis and those whose outcome was not known. finally, 324 patients with sbo on intra-abdominal adhesions confirmed on ct-scan were reviewed. the patients were separated in two groups. the group 1 (g1) included patients who required surgical management during hospitalization (107 patients) and group 2 (g2) patients with successful medical treatment (217 patients). we compared the rate of previous appendectomy in these two groups using a pearson's chi-squared test. in a second step, we tried to find out if there were others factor associated with failure of medical management. results: there was significant difference between the two groups with a higher rate of appendectomy in the surgical management group g1 (p = 0.00773). this difference was even more pronounced if appendectomy was the only surgical history. in the subgroup analysis of patients with previous appendicectomy, the laparoscopic approach or laparotomy didn't influence the outcome of the management of the sbo. conclusion: this study shows the difference between the two groups of sbo, with more surgery sanction in the group of patients previously operated of appendicectomy. perhaps because this surgery involves the very distal part of the small bowel and decrease the efficiency of a proximal nasogastric aspiration. these results should not change the initial management of sbo by medical treatment in absence of severity signs. however, knowing this data, we have to consider that a history of appendicectomy is a risk factor of failure of medical treatment in this situation. introduction: diaphragmatic injuries are a rare consequence of closed thoraco-abdominal trauma that could be difficult to detect due to paucity of clinical signs and frequent erroneous interpretation of radiological images. the overall incidence of diaphragmatic injury is 0,8-5,8% in blunt trauma. if the injury is not recognized it could lead to considerable risk of late morbidity and mortality. this study reviews our 10 years experience in the management of this patients. material and methods: a retrospective review of trauma registry of our tertiary referral centre was performed. preoperative, intraoperative and postoperative data were analysed to assess determinants of mortality, morbidity and effect of therapeutic delay by univariate analysis models. penetrating injuries were excluded from the study. results: over 10 years 31 patients with diaphragmatic injury due to blunt trauma were identified: 4 had a simple laceration of the diaphragm without hernia, 21 had acute and 6 chronic diaphragmatic hernia. the mean patient age was 40 years (range 17--78 years). overall mortality was 15%. the site of injury was the left diaphragm in 18 cases, the right diaphragm in 8 cases and bilateral in 1 case.the hernia content was stomach (9), colon (4), spleen (3), liver (3), omentum (2) and multiorgan (6). all acute patients were managed with primary suture repair via laparotomy except for two patients that required additional thoracotomy; chronic patients were treated laparoscopically in 4 cases (66,6%), in which a synthetic or a biosynthetic mesh was used to reinforce the suture. higher morbidity and mortality was seen in multiple associated injuries, head injuries associated, right diaprhagm injury, age [ 65 years and treatment delay [ 24 h. conclusions: delayed treatment of diaphragmatic injuries could be dramatic: it is importnat not to misinterpreter the radiological findings and to reassess the patient mantaining a high level of suspicion of these injuries. trauma opposing vector forces resulting in distal avulsion of internal oblique muscle: a case report p. spada 1 , p. fransvea 1 , g. altieri 1 , m. di grezia 1 , v. cozza 1 , g. pepe 1 , a. la greca 1 , g. sganga 1 1 fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy case history: abdominal muscle injuries after blunt trauma are rare but increasingly recognized. here we report a case of blunt trauma resulting in a complete disinsertion of the distal part of the internal oblique muscle. case report: 46 y.o. male, was involved in a roll over motor vehicle accident. primary survey was carried out according to atlsò approach with good response. he had a seatbelt sign. according to the dynamic of the trauma he underwent a ct. diagnosis: a ce-mdct revealed complete disinsertion of the oblique muscles of the left abdomen from their iliac insertion, with herniation of adipose tissue and hematoma of the soft tissues without active blushing. no other traumatic injuries were identified. therapy progressions: a conservative treatment of the hematoma of the left abdominal wall was adopted. the patients was then ischarged from hospital after 4 days. no late complications were observed. comments: the overall incidence in all traumatic admission is 0.2-0.9%. a deep knowledge of vector force involved in trauma and their influence in the specific anatomical changes of the abdominal wall muscle can lead to suspicious of this rare injuries even if no other lesion are detected. in our opinion this trauma case is useful in reminding us to look for it because the radiologist or a no well experienced trauma surgeon may miss it 1 fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy introduction: the best and correct management of patients with open abdomen (oa) is nowadays still unclear. our algorithm consists of using an intra abdominal negative pressure wound therapy device plus an early medial mesh mediated fascia traction (''step by step'' procedure). the aim of this study was to asses outcomes of this algorithm technique based on patient conditions and open abdomen technique performed. materials and methods: we performed a retrospective analysis of 50 patients treated with open abdomen technique from 01/06/2016 to the 01/06/2019. variables taken into account were: initial diagnosis, open abdomen technique used, number of surgical interventions, abdominal wall closure technique, length of stay in the icu, inhospital morbidity and mortality rates. we collected also data on the post-operative development of incisional hernias and entero-atmospheric fistula. results: 4/50 of open abdomen were done after trauma. in the remaining cases open abdomen was done for non-traumatic disease. 36 patients have been treated following our algorithm (with negative pressure wound therapy abthera device and step by step approach with medial mesh mediated fascia traction). in this group fascial retraction was significant lower and definitive direct abdominal wall closure rate was statistically higher. conclusion: an early fascia traction mediated with a mesh lead to an earlier fascia closure with a lower need of mesh positioning for definitive closure; the rate of post incisional hernia is similar among the two groups references: case history: a 59 year old male presented in the er with malaise, fatigue and loss of appetite. he was recently hospitalised due to a peritonsillar abscess and during investigations he was first-diagnosed with non-hodgkin lymphoma. his medical and surgical history were otherwise unremarkable. clinical findings: on admission the patient was febrile and tachycardic (hr 120 bpm) but remained hemodynamically stable (bp:157/ 99 mmhg). clinical examination revealed abdominal distention and rebound tenderness in the right abdomen. investigation/results: blood tests were significant for leukocytosis (wbc: 48.300/ll-neut:75%), acute kidney injury (urea: 240 mg/dl, cr: 3.0 mg/dl), elevated crp (313 mg/l) and ldh (520 iu/l), hyponatremia (na:126 mmol/l) and hypoalbuminemia. chest and abdominal x-rays were non-diagnostic, while abdominal ultrasound showed increased air presence along the medial line. investigations concluded with an abdominal ct scan that revealed pneumoperitoneum, small bowel distention and multiple enlarged mesenteric lymph nodes. diagnosis: the patient was transferred to the or for an explorative laparotomy. he was diagnosed with ileo-cecal intussusception causing bowel ischemia and perforation at the ileocecal valve. enlarged lymph nodes were observed along the mesentery. therapy and progressions: the affected ileus and colon were removed and a subtotal colectomy with end ileostomy was performed. the pathology report confirmed infiltration of the dissected bowel and lymph nodes by lymphoma cells. the patient continued treatment in the icu. he was discharged on the 14th postoperative day. comments: intussusception is rare in adults and, contrary to children, is highly associated with malignancies. resection without reduction has been advocated-wherever possible-in order to ensure better oncological outcomes. introduction: emergency surgeries are oftenly related to contaminated/infected fields, where the implantation of non reabsorbable meshes for reconstruction of the abdominal wall may not be recomendable. we aim to evaluate the results of polyvinylidenfluoride (pvdf) meshes used for complicated ventral hernia in the acute setting material and methods: retrospective analysis of patients with vh undergoing emergency surgery on which a pvdf mesh was required, in a third level hospital (november 2013-september 2019). we analyzed early and late postoperative complications and 1-year recurrence rates. association between grade of contamination, mesh placement and infectious complications and recurrences was investigated using binary and multiple regression. results: we collected 123 patients with a mean age of 62''3 years, mean bmi of 31''1 kg/m 2 and mean cedar index of 51''6. 96''4% of patients had a grade 2-3 ventral hernia according to rosen''s index. concomitant procedures included al least one organ resection in 48''7% of surgeries and previous contamined mesh explantation in 11''5%. a pvdf mesh was placed using an intraperitoneal onlay mesh (ipom) technique in 56''3% of cases and an interposition location in 39''9%. readmission rate was 15''7%, one-month recurrence 5''7% and recurrence after a year 19''1%. overall mortality rate was 27.6%. risk of recurrence was related with patients with a rosen score over 2 (p \ 0.001) and also with postoperative ssi (p = 0.045). higher recurrence rates were not found regarding the pdvf meshes placement. postoperative seroma and hematoma rates were 21''1% and 10''6%. enteroatmospheric fistula rate was 7''8%. conclusions: pvdf prosthesis seems to be an useful material for complicated ventral hernia repair, specially in the acute setting, showing similar recurrence and infectious complication (fistula, chronic mesh infection, surgical site infection) rates with regard to different prosthesis used in the literature. operative vs non-operative management in liver trauma patients in a uk major trauma centre conclusions: the airs can predict the histologic severity and the intra operative findings in patients with a high clinical suspicion of aa. airs could be useful to reduce negative appendectomy and predict the postoperative stay to evaluate the deformity progression in spine injuries (dorsal, dorsolumbar, lumbar) managed by internal fixation. introduction: there continues to be controversy surrounding the management of thoracolumbar burst fractures. numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. material and methods: 64 patients with spinal injury (dorsal, dorsolumbar, lumbar) were included. all patients had dorsal, dorsolumbar, lumbar spine injuries managed with posterior short segment pedicle screw fixation and were followed up for at least one year after surgery. preoperative, post operative and follow up lateral radiographs were examined for cobb''s angle, anterior wedge compression angle and upper and lower adjacent intervertebral disc heights anteriorly, middle and posteriorly. results: at final follow up, the mean improvement in cobb''s angle post operatively was 10.8°. the mean loss of correction of cobb''s angle was 7.1°with sd of 5.7°compared to post operative. the mean improvement in anterior wedge compression angle was 7.1°post operatively. the mean loss of reduction in anterior wedge compression angle was 2.05°with sd of 2.3°. the increase in cobb''s angle was statically significant (r = 0.684, p = 0.001) with the loss of reduction of anterior wedge compression angle at follow up and loss in intervetebral disc height at upper intervetebral disc anteriorly only(r = 0.545, p = 0.013). the mean period at which sitting and standing was initiated was 1.5 months and 3.12 months respectively and mean periods for which brace was used was 8.6 months. conclusions: pedicle screw fixation is good but related to loss in reduction of anterior wedge compression angle and decrease in upper intervertebral disc height anteriorly. references: p. l. sanderson:short segment fixation of thoracolumbar burst fractures without fusion. introduction: with the newly implemented ao upper cervical spine classification system a modern, pragmatic system has been established. to what extent the simplification is helpful or whether an adjustment of the new ao classification may be discussed, forms the question of this work. material and methods: retrospective analysis of 60 upper cervical spine injuries with ct/mri diagnostics presented to 4 trauma surgeons with several years' experience to do classification and suggest treatment. results: the classification according to the known systems showed a relatively good agreement in the exact classification and therapy. the classification according to the new ao upper cervical spine was simple and consistent but revealed different treatment recommendations for two subtypes (iii type a and iii type b). conclusions: the new ao upper cervical spine classification system leads to a simplification. uncertainties remain with the most frequent fractures on the upper cervical spine, the c2 fractures. these will be managed under iii type a. however, just these injuries require completely different treatment concepts. further adaptation is required for type iii b because there uncertainties regarding the therapy also remain. case history: a 83-year-old woman, on treatment with acenocoumarol due to atrial fibrillation, and interatrial communication, suffered a compression fracture of the vertebrae l2 to l4 after a lowenergy trauma. due to poor pain control, she underwent a percutaneous transpedicular kyphoplasty, with no intraoperative complications. clinical findings: during the immediate postoperative period, she developed dysarthria and claudication of barré in her right upper limb. investigation/results: an angio-ct scan was performed, showing endovascular material in the left middle cerebral artery (mca) and within the lungs, compatible with cement emboli. mri showed cortico-subcortical ischemic areas in mca territory. cement-embolism stroke after percutaneous kyphoplasty therapy and progressions: conservative treatment was chosen due to the high number of emboli and the favorable evolution of the patient, with resolution of the neurologic symptoms in 48 h without sequelae. 15 days later, she suffered a transient ischemic attack, with no changes in the ct-scan compared to the previous images, which also solved with no residual deficits. one month after this episode, the patient died due to a spontaneous cerebellar hemorrhage related to acenocoumarol overdose. comments: kyphoplasty is a safe technique performed to treat vertebral compression fractures in elderly patients, with good clinical results and a low complication rate. its main complications are related to the leakage of cement from the vertebral body, usually well tolerated. other complications are exceptional, such as cerebral strokes, cardiac perforation, or death. the present case, although infrequent, shows us the need to assess the risk-benefit balance when operating fragile patients, as life-threatening complications may happen in these procedures. references: 1. marden fa, putman cm. cement-embolic stroke associated with vertebroplasty. ajnr am j neuroradiol. 2008 nov;29(10):1986-8. survival rate and application number of total hip arthroplasty in patients with femoral neck fracture: an analysis of clinical studies and national arthroplasty registers g. hauer 1 , a. heri 1 , s. klim 1 , p. puchwein 1 , a. leithner 1 , p. sadoghi 1 1 medical university of graz, department of orthopaedics and trauma, graz, austria introduction: total hip arthroplasty (tha) is an increasingly popular treatment option for fractured neck of femur (nof) [1, 2] . the aim of this study was to systematically review all literature on primary tha after fractured nof to calculate an overall revision rate. furthermore, we wanted to compare primary tha implantations after fractured nof between different countries in terms of tha number per inhabitant. material and methods: all clinical studies on tha for femoral neck fractures between 1999 and 2019 were reviewed and evaluated with a special interest on revision rate. revision rate was calculated as ''revision per 100 component years'' [3] . tha registers were compared between different countries with respect to the number of primary implantations per inhabitant. results: twenty-two studies showed a mean revision rate of 11.8% after ten years. we identified eight arthroplasty registers that revealed an annual average incidence of tha for fractured nof of 9.7 per 100,000 inhabitants (table 1) . conclusions: we found similar annual numbers of thas for fractured nof per inhabitant across countries. revision rates in clinical studies are higher compared to registry data [1, 2, 4] . the results of this analysis can be used to rank present and future national tha numbers within an international context. early clinical predictors of pneumonia in patients with acute spinal cord injury without bone injury: a retrospective study t. sakamoto 1 , s. kanezaki 1 , n. notani 1 1 oita university, oita, japan introduction: pneumonia is still significant complication that associates with mortality and duration of hospitalization in patient with acute spinal cord injury without bone injury (sciwobi). the purpose of this retrospective study is to clarify early clinical predictors of pneumonia in patients with sciwobi. material and methods: we reviewed the medical records of patients with sciwobi who admitted between january 2012 and november 2019. spearman's rank-correlation coefficient was used to test the relationship between each parameter. multiple logistic regression analysis was performed to determine the factors that influenced pneumonic morbidity. results: a total of 44 patients with acute sciwobi, who were evaluated for neurological impairment within 24 h after injury, were reviewed. pneumonia occurred in 11 patients (25%), seven patients injured at c4 and four at c5. according to spearman's rank method, asia motor score, beginning period of nutrition, ventilator use, neurological level of injury (nli) ] c5, low prognostic nutritional index (pni) were correlated with onset of pneumonia. logistic regression found ventilator use to be most predictive of pneumonia (odds ratio [or] = 12.7, 95% confidence interval [ci] 1.24-131), followed by nli ] c5 (or 2.3, 95% ci 0.36-14.4), beginning period of nutrition (or 2.1, 95% ci 0.95-4.8), pni (or 1.3, 95% ci 0.94-2.5). conclusions: in addition nli, low pni increases the risk of pneumonia. we consider that improving nutritional status, especially early initiation of enteral nutrition, decrease the incidence of pneumonia. bicycle-related cervical spine fractures e. helseth 1 , j. ramm-pettersen 1 , s. f. eng 1 , i. naess 1 , m. mejlaender-evjensvold 1 , h. linnerud 1 1 oslo university hospital, neurosurgery, oslo, norway introduction: the incidence of traumatic cervical spine fractures (cs-fx) in the norwegian population is 15/100,000/year, and 12% of these injuries are bicycle-related (1, 2) . materials and methods: prospective cohort study of all bicyclerelated cs-fx in the south-east norwegian population (3.0 million) in the time period 2015-2018. the data were retrieved from our quality control database for traumatic cs-fx in south-east norway. in the database all cs-fx patients (c0 (occipital condyle) to c7/th1) are prospectively registered. results: during the four-year study period 209 patients with bicyclerelated cs-fx were registered, 175 (84%) were males, and mean age was 52 years (range 16-87). the cs-fx was located in the upper cervical segment (c0-c2) in 68 (33%) patients, lower cervical segment (c3-th1) in 117 (56%), and at both segments in 24 (11%). the most common fx subtype was c0-fx. spinal cord injury secondary to cs-fx was registered in 26 patients (12%). fracture stabilization was achieved with open surgery in 41 (20%), external immobilization with a stiff collar alone in 147 (70%,) and without treatment in 21 (10%). conclusions: severe bicycle-related cervical spine injuries are not uncommon. the increasing political desire to move commuting from motorized vehicles to bicycles warrants a heightened focus on road safety. introduction: the need for cervical immobilization is predicted by the atls, the standard of care in trauma since 1980, because cervical trauma is a important cause of disability. however, its discontinuation was linked to x-rays, a fact that has been changed thanks to the development of two algorithms that assess the severity of cervical trauma: the canadian c-spine rule (ccr) and the national emergency x-radigraphy utilization study (nexus). material and methods: this study aims to compare the reduction values in the number of ct scans required after the application of both algorithms in a level-1 trauma center and to verify the degree of adherence of residents in the use of each. cohort study with randomized application by residents of the algorithms in all patients suffering from blunt trauma with cervical collars who were admitted from august to october 2019. the conducts had their frequencies analyzed to obtain an inference about the efficacy of each method in the abstention of x-rays and case resolution, in addition to verifying if the indicated conduct was followed by the resident, inferring on the confidence in the algorithm. results: 158 cases were evaluated during this period, of which 76 were by the ccr algorithm and 82 by the nexus. the indication rate for ccr imaging was 39.4% and nexus was 42.6%, showing no statistical difference between them (p = 0,682; ci = 95%). in the evaluation of the effective conduct, which evaluated the reliability of the algorithm, there was no disagreement between them (p [ 0,05; ci = 95%). conclusions: neither method demonstrated superiority to the other in reducing the indication of imaging exams and its uses had equal adherence by resident physicians. panacek case history: a 65 year old lady presented with severe neck pain following a fall and cervical hyper-extension injury. she had previously undergone anterior cervical discectomy and fusion at c6/7 with placement of artificial interbody bone graft. postoperatively, the patient reported an excellent clinical outcome and later imaging confirmed interbody fusion. clinical findings: on examination, the patient was neurologically intact but reported severe mid-cervical neck pain with reduced range of movement. investigation/results: imaging included ct and mri of the whole spine diagnosis: imaging revealed an unstable hyper-extension injury of the cervical spine. a fracture extended through the caudal end of the fused graft-vertebral interface at c6/7 with disruption of the posterior elements. therapy and progressions: given the severity of the injury surgery was recommended. the patient underwent uneventful c6-t1 posterior instrumentation and fusion with excellent outcome (follow up two years). comments: this is the first report of a cervical spine fracture through the site of an anterior cervical discectomy and fusion. it is hypothesised that the fused cervical segment resulted in increased stress at the fused caudal graft-vertebral interface during hyper-extension, this combined with reduced tensile strength at the graft-vertebral interface resulted in this unusual transverse fracture pattern. the clinician should be aware that patients presenting with cervical spine trauma in the context of previous cervical spine surgery are prone to greater mechanical forces. there should be a high index of suspicion for serious injury prompting thorough assessment and investigation. pr 445 s1-screw-fixation: computer aided study prevent unguided missile r. krassnig 1 , w. pichler 2 , e. viertler 3 , a. schwarz 4 , r. wildburger 1 , g. hohenberger 5 1 auva rehabilitation clinic tobelbad, tobelbad, austria, 2 boldin und pichler og, graz, austria, 3 medical university graz, graz, austria, 4 auva unfallkrankenhaus, graz, austria, 5 medical university graz, orthopaedics and trauma, graz, austria introduction: transiliosacral screw fixation of unstable dorsal pelvic ring fractures is not much present neither in literature nor in practice. in cause of the complex anatomy and the varying narrow safe bony corridors its a demanding procedure. limited information is available on optimal placement and the geometry of safe zones for screw insertion in the pelvis. material and methods: 3d-reconstructions of 50 consecutive ct scans of polytraumatic injured patients (15 female, 35 male) were the basis to insert two virtual cad bolts (representing screws) into the first two sacral segments as performing during screw fixation. results: in s1 the narrowest point was reached after a mean of 62.75 mm respectively 63.31 mm, depending on the selected way of measurement. for s2 the mean distance to the tricky constriction area amounted to 50.61 mm, respectively 51.54 mm. the average height in s1 measured 25.88 mm and the average width 25.49 mm. according, the average height for s2 was 17.54 mm and the average width 17.61 mm. the measurement results didn't show a significant difference between male and female pelvis bones for any distance of interest. conclusions: an optimal screw position is very important, because in the areas of bony narrowing are the exit points of the sacral nerves, which exit through the foramina anteriorly and posteriorly. damage to this nerve structures can cause severe long-term consequences such as numbness or paralysis. knowledge of predefined distances may aid in preoperative planning, decrease operative and radiation times and may prevent unguided missiles. clinical findings: there were absent breath sounds on the right side of the thorax, ultrasound showed an extensive pleural effusion. a chest tube was inserted and 2l of bloody-milky fluid was drained. investigation/results: ct scan showed fractured c1-c2 and th1-th3 vertebral bodies, fractured lateral osteophytes of th11-12 and probable injury of the thoracic duct at th11-12 level. pleural effusion analysis showed raised cholesterol and triglyceride levels. diagnosis: traumatic chylothorax; fractures th11-th12, th1-th3, c1-c2 therapy and progressions: patient was kept on ventilatory support for 3 days. primarily she was treated with total parenteral nutrition followed by no fat and hypolipidemic diet. the chest tube was removed after 8 days. she was discharged in stable condition the following day. at the 1 month check-up she was stable and eupnoic. comments: traumatic chylothorax caused by blunt chest trauma is extremely rare. there are hypotheses that injuries to the thoracic duct are caused by hyperextension of the spine or by increased thoracic/ abdominal pressure (seat-belt injuries). in our case, chylothorax probably resulted from fractured lateral osteophytes. patients are usually successfully treated with pleural drainage and total parenteral nutrition. if there is no improvement after 2 weeks or if drainage exceeds 1.5l/day or 1l/day for more than 5 days, thoracic duct ligation should be considered. conservative treatment resulting in t-l or lumbar kyphosis can worsen the quality of life of the patient whereas traditional open surgery may be an overtreatment in some cases, considering blood loss, possible complications, hospital stay and delayed functional recovery. in this setting, a good option can be a percutaneous minimally invasive surgery. the advantages of percutaneous pedicle screw fixation are: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter hospital stay and easier implant removal after bone union. limitations such as inability to achieve direct spinal canal decompression can be dealed by combination with open techniques. the objective of this study was to report the results of ppsf on these fractures and the technical problems we had to overcome. methods: 32 patients are included, treated with percutaneous transpedicular fixation and stabilization with minimally invasive technique from december 2015 to october 2019. 24 patients were males, 8 females; average age was 46,5 years (range from 18 to 82). in all cases, system pathfinder-nxt (zimmer) was used. results: most of the patients presented an early post-operative mobilization with amelioration concerning pain and a low complication rate. limitations in mobilization were mainly due to coexistent injuries, polytrauma or non-reversible neurological deficit. conclusion: ppsf is a reliable and safe procedure which does not replace the open technique but adds to treatment options by restoring a good sagittal alignment similar to those reported for open surgery. removal of hard material is advocated after fracture healing to preserve the lumbar spinal mobility and avoid zygapophyseal joint osteoarthritis. critical surgery within the first hour of presentation: is it a feasible intervention for better trauma care outcomes in low and middle income countries? introduction: in low and middle-income countries (lmic) golden hour care concept is almost nonexistence due to resource constraints. in this study, we analyzed one novel concept of critical surgery within the first hour of admission as a possible intervention which could be applied in the existing scenario in these countries without much resource requirement. material and methods: a retrospective analysis of a prospectively maintained data registry under a project named titco (towards improved trauma care outcome) was done. registry data from a level -1 trauma centre in india were analyzed from october 2013 to september 2015. all patients who admitted and underwent critical surgical interventions within the first hour of presentation were analyzed. these patients were divided into two groups depending upon primary presentation or referred from another facility. statistical analysis was done between these two groups to compare the outcome. results: sixty-one (57.6%) patients were directly admitted from the site of the incident whereas forty-five (42.4%) were transferred from other hospitals for surgical needs. the median time from injury to presentation for primary patients was 50 min with interquartile range (iqr) of 40. in the referred patient median time gap between the injury to our center (not referring center) was 230 min with iqr of 350. this difference was statistically significant. major outcome indicators in the form of median icu and total stay, as well as mortality, were not significantly different conclusions: proposed concept might be a useful hospital-based intervention in existing trauma system in lmic to improve the outcome of injured patients along with improving prehospital services. oslo university hospital, ullevål, orthopedic department, oslo, norway, 2 extrastiftelsen, oslo, norway introduction: it is well-known that physical activity is good for us. although the skeletal muscle is the main organ which is directly affected, exercise affects the whole body. the mechanisms responsible for these beneficial effects are gradually becoming known to us through extensive research. this might make it easier for physicians to prescribe exercise as a therapy equally and even more beneficial than drugs regarding effect and risk profile. the aim of this thesis was to review the current literature on the molecular mechanisms of exercise-induced health benefits. material and methods: a search in medline and embase resulted in 468 articles. they were sorted by title and abstract, then by reading the full text. relevant articles from the reference-lists were included. 18 sources were found outside of the search. results: when we exercise, the skeletal muscle is subjected to several mechanical and chemical stimuli, which in turn activate a set of kinases and phosphatases. these are molecules that regulate transcription-factors and co-activators, and this leads to adaption of the muscle-cells. i addition, the muscle secretes a number of proteins called myokines, which conduct the effect of exercise to other organs and tissues. some lead to increased cerebral neuroplasticity, hypertrophy and angiogenesis (bdnf, vegf and igf-1). several interleukins have also been identified as myokines, and they mediate an anti-inflammatory effect which is favorable in the prevention and management of conditions like atherosclerosis and type 2 diabetes. lastly, we found that exercise leads to epigenetic changes, altering the genetic expression in several types of tissues. some studies suggest that the epigenome is affected by exercise even before we are born, giving babies born to physically active mothers a favorable epigenetic expression. conclusions: we should use this knowledge to support the implementation of physical activity in treatment and preventive health care. impact on undertriage and mortality after changing from a twotiered to one-tiered trauma team activation protocol costs. prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increase rtw rates. evaluation of long-term follow-up and consequences of gunshot and stab wounds in a french civilian population introduction: the data concerning long-temr follow-up of patients and consequences of gunshot wound (gsw) and stab wound (sw) are almost inexistent in the literature. in finland, a 2014 study showed that 12% of patients with trunk wounds died secondarily from alcohol-related or violent problems [1] , highlighting the secondary importance of long-term care for these patients. the main objective of our study was to analyze the hospital and posthospital follow-up of patients with gsw or sw and to evaluate late complications and the consequences of these traumas. material and methods: from january 2007 to january 2017, 165 patients were hospitalized for gsw or sw management in laveran military hospital. hospital data were collected via informatic patient file and post-hospital data via a telephone questionnaire with the general physician (gp). results: median hospital follow-up was 28 days . seventy-six patients had a follow-up visit with their gp (46%). median follow-up was 47 mois . twenty-four patients were totally lost to follow-up (14.5%). global follow-up identified 54 patients with longterm consequences (32.7%), 20 psychiatrics and 30 organics. seventeen cases of recurrence were found (10.3%). high iss, age, gsw and gp identified in patient medical file were significantly linked to long-term consequences occurrence. conclusion: this study showed a high number of long-term consequences occurrence among patients with gsw or sw. however, the extra-hospital follow-up seems insufficient. it is therefore imperative to strengthen the compliance and adherence to the care network of these patients. awareness and involvement of medical, paramedical teams and gp role seems essential to screening and management of these consequences. introduction: focused assessment with sonography for trauma(-fast) is an effective tool for assessments of severely injured patients, especially in the settings of helicopter emergency medical service(hems) because of limited devices and time. the objective of this study is to investigate accuracy of trauma ultrasound in helicopter emergency service compared with enhanced ct scan. material and methods: we investigated the trauma patients in 3 years which was demonstrated fast and delivered to the advanced critical care center in gifu university by hems. accuracy of the fast was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. results: 108 patients were included in this criteria. there were 57 and 13 patients in which we found fluids in thoracic or abdominal cavity by enhanced ct scans and ultrasounds in hems, respectively. sensitivity and specificity, positive predictive value, negative predictive value, accuracy were 0.24, 0.963, 0.866, 0.559, 0.60. if we limited the data for abdominal fluids, each data were 0.409, 0.988, 0.9, 0.86, 0.87. in the patients of negative fast with positive ct, no patient died due to hemorrhage in thoracic or abdominal cavity. conclusions: it has been reported that sensitivity of fast in hems was lower compared with in er. in the settings of prehospital trauma care, advantages of portable ultrasound could be limited because of peculiar environments. and also, the thoracic or abdominal fluids could increase with time by organ injuries and it causes fast negative in acute phases.in this series, we could not find cases which has possibility of death because of negative fast and might influence the treatment. repeated fast or careful assessment of patients based on the other findings could be beneficial. references: the sensitivity of fast in hems was low and demonstrating fast for several times could be effective to detect the thoracic or abdominal hemorrhage. pre-hospital trauma care in switzerland and germany: do they speak the same language? 1 los angeles county ? usc medical center, department of surgery, divison of acute care surgery and surgical critical care, los angeles, united states introduction: field amputation can be life-saving for entrapped patients requiring surgical extrication. under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. the aim of this study was to determine the optimal saw for a field amputation. material and methods: this was a prospective cadaver-based study. four saws (gigli, hand pruning, electric oscillating and reciprocating) were tested in human cadavers. each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula). the time required for each saw to cut through the bone, the number of attempts, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. univariate analysis (fisher's exact and kruskal-wallis or mann-whitney u-test) was used to compare the outcomes between the different saws. results: the fastest saw was the reciprocating followed by oscillating (2.1 [1.4-3.7 ] sec vs 3.0 [1.6-4.9 ] sec, p = 0.007). the number of attempts required to amputate (5.8 [3.0-8.3] , p = 0.02) and the amount of slippage (3.0 [1.5-3.8 ], p = 0.03) were highest with the pruning saw. the reciprocating saw had the worst proximal bone cut quality (75% poor, p = 0.04) and the largest blood splatter (47.5 [41-63] , p = 0.044). the physical space required to perform an amputation ranged from 3500 cm 3 with the oscillating to 12000 cm 3 with the reciprocating saw. overall, the oscillating saw outperformed the others in number of attempts, slippage and quality of bone cut and physical space requirements, and was the second fastest ( table 1) . conclusions: the speed, precision, safety, space required, as well as the highly adjustable blade in the oscillating saw make it ideal for a field amputation. a gigli saw is an excellent backup for when electrical tools cannot be used or fail. impact of air medical transport on the survival of major trauma patients in thailand e. surakarn 1 , w. siriwanitchaphan 1 1 bangkok hospital headquarters, bangkok trauma center, bangkok, thailand introduction: air medical transport is an alternative mode of interfacility transfer for injured patients who required a higher level of trauma care in thailand. this study assessed the impact of air medical transport on the survival of major trauma patients transferred from local hospitals to a tertiary care hospital. material and methods: trauma registry of 2014-2018 was reviewed. major trauma patients transferred by air ambulance were identified. injury severity score (iss), predicted mortality and actual survival to hospital discharge were studied and compared between two subgroups, the seriously injured patients (iss 15-24) and the severely injured patients (iss [ 24) . the predicted mortality was calculated from the probability of survival (ps) of trauma and injury severity score (triss). results: there were 99 major trauma patients (iss [ 15) transferred by air ambulance in five years period. 62 patients were severely injured (median iss = 33), and 37 patients were seriously injured (median iss = 17). the range of flight time was 20-200 min. the overall survival rate was 88.88%. the predicted mortality in the severely injured group was 21 cases (33.87%), but the actual mortality was nine (14.51%), 19.36% lower than predicted mortality. the predicted mortality in the seriously injured group was one case (2.7%), while the actual number was two (5.4%). the eleven deaths in this study were eight cases of severe traumatic brain injury(tbi) patients, two cases of massive bleeding with subsequent multi-organ failure and one drowning. conclusions: air medical transport significantly improved the survival of severely injured patients who need higher level of trauma care. severe tbi and the presence of multi-organ failure associated with unfavorable outcomes. however, a detailed analysis of the trends and epidemiology of rtis affecting the most vulnerable children in qatar, under 5 years of age, has not been conducted. this study's primary objective of is to describe the epidemiology of rtis and deaths in young pediatric patients in qatar. material and methods: data, for all young pediatric [under 5 years] victims of rti''s and rti deaths from january 1, 2008 , through december 31, 2017 , from the trauma registry of the hamad trauma center [htc], the national level 1 trauma referral center of qatar, was analyzed. this data was correlated and compared with data from the hamad general hospital mortuary and vital statistics data from the qatar ministry of development planning and statistics, the vital statistics annual bulletin, for the years 2008-2017. results: the htc attended to 271 patients, under 5 years, with severe rtis and 15 in-hospital rti deaths were reported during the study period. males made up 83.7% of the injured and 60% of fatalities.the average age of the injured was 3 years and for fatalities was it was 2.8 years. the rti incidence rate per 100,000 for both sexes, under 5 years, has been unchanged (246 in 2007 and 225 in 2017) . the road mortality rate, per 100,000, has decreased significantly, from 46.3 in 2008 to 7.2 in 2017. since 2014, the proportion of pre-hospital deaths has been increasing, 25-100%, and the in-hospital death rates has been reduced to 0%. conclusions: rapid improvements in pre and in-hospital post-crash care in qatar have resulted in marked reductions in in-hospital deaths for young children with rtis. the emergence of pre-hospital road deaths of under 5''s must be made a priority for road safety in qatar. the implementation of proven prevention programsshould be fast tracked in order to directly address this issue. introduction: despite improving survival of patients in prehospital traumatic cardiac arrest (tca), initiation and/or discontinuation of resuscitation of tca patients remains a subject of debate among prehospital emergency medical service providers. the aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with tca. methods: twenty-five semi-structured interviews were conducted with experienced ambulance nurses, hems nurses and hems physicians individually, followed by a focus group discussion. participants had to be currently active in prehospital medicine in the netherlands. interviews were encoded for analysis using atlas.ti. using qualitative analysis, different themes around decision making in tca were identified. results: the causes of bleeding were grouped into several categories.the most frequent cause with 7 cases in a row is attributed to diverticular bleeding,other causes of bleeding were angiodysplasia,post polypectomy bleeding,gist tumor,rectal ulcers and inflammatory disease.no case presented mortal or serious complications,secondary to the procedure. only 2 cases presented a mild complication: focal mucosal ischemia of the embolized intestinal segment that was resolved with conservative treatment.lesions in charge of bleeding in those 5 cases in which the angiographic treatment failed,were:ulcer in 2 cases,a case of bleeding after endoscopic polypectomy, a case of diverticular bleeding and bleeding secondary to a coagulation disorder.among these patients, the definitive treatment was the following: -a second angiographic treatment was effective in the case of bleeding due to coagulation disorder. -a case of self-limited bleeding. -surgical treatment was the definitive treatment in both cases of bleeding in the context of and patient with bleeding after polypectomy. we have not observed a significant relationship neither the type of lesion or its location with the probability of failure of the angiographic treatment. nor do we observe a significant relationship between the type of material used for embolization and the risk of treatment failure. comments: our data show that angioembolization is an effective and safe technique to treatment lgi bleeding. references: clin endosc 2019. endoscopic therapy for acute diverticular bleeding introduction: the use of resuscitative endovascular balloon occlusion of the aorta (reboa) as adjunct for temporary hemorrhage control in patients with major torso hemorrhage is increasing. specifications and characteristics of available aortic occlusion balloons (aob) are diverse. in order to minimize the risk of failure and complications it is important to choose a device that fits the requirements per medical situation. the aim of this study is to provide guidance in the choice of an aob in a specific situation. material and methods: 29 aob were assessed for characteristics and different properties of each are outlined. the bending stiffness was measured with a three-point bending device. results: although all aob tested are small caliber devices ranging from 6 (er-reboa tm ) to 10 french (codaò 46), some need large bore access sheaths up to 22 french (fogarty ò 45 and lemaitre tm 45) or even insertion via surgical cut-down (equalizer tm 40). the bending stiffness of the aob varied from 0.08 n/mm (± 0.008 sd) with the codaò 32 to 0.72 n/mm (± 0.024 sd) with the russian prototype. guidewire-free devices are generally stiffer than over-thewire catheters. the tokai rescue balloon tm showed kinking of the shaft at low bending pressures. the er-reboa tm , fogarty ò , lemaitre tm , reboa balloon ò , and rescue balloon tm are the only catheters with external length marks to assist blind positioning. the only aob using a non-compliant balloon is the reboa balloon ò . conclusions: specifications of available aob are diverse. in resource-limited settings, reboa should be performed with a rather stiff device that can be placed without wire and fluoroscopy, such as the er-reboa tm , fogarty ò , and lemaitre tm . of these aob, the er-reboa tm is the only catheter compatible with a small 7 french sheath. use of non-compliant balloons without real-time fluoroscopy is not advised given the potential risk of aortic rupture. when fluoroscopy is available, a guidewire can be considered. case history: 89 year old male patient presenting with an initially uncomplicated pertrochanteric fracture, treated by an intramedullary nailing system (figs. 1 and 2) . days after the operation and mobilization without any adverse events the patient was readmitted. clinical findings: massive swelling, hematoma and pain. investigation/results: sudden fall of hb values down to 4,4 g/dl, ct scans showed the lesser trochanter located directly to the deeper femoral artery after mobilization (fig. 3) . diagnosis: perforation of the deep femoral artery and several veins by the dislocated lesser trochanter therapy and progressions: blood transfusion, intraoperative cardiopulmonary resuscitation, several revision surgeries to stop the bleeding by oversewing the deep femoral artery and ligation of the veins, removal of the lesser trochanter fragment (fig. 4) . admission to intensive care unit. subsequent plastic coverage. comments: according to literature, bleeding complications and injuries of the deep femoral artery can occur even several days after an initially uncomplicated pertrochanteric hip fracture. besides acute life-threatening bleeding, false aneurysm can occur (1) (2) (3) . even if those late complications are very rare, the consequence for the patient can be devastating. these rare cases show the clear obligation to a thorough follow up treatment and regularly dressing changes. investigation/results: arterial colour doppler of the popliteal artery showed hypoechoeic contents and narrowed lumen. biphasic flow was seen in both popliteal and posterior tibial arteries. diagnosis: popliteal artery injury with delayed repair therapy and progressions: two incision and four compartment fasciotomy was done under regional block the next day which revealed a non contractile posterior compartment. superficial and deep muscles of the posterior compartment had doubtful viability. left distal sfa to infragenicular popliteal artery bypass graft was placed on day 4 post injury. blood flow was established upto the ankle and foot, confirmed on check angio. however, foot drop of the patient persisted. after appearance of a healthy granulation tissue at the wound site (7 days), a split thickness skin graft was placed to give coverage with 100% uptake of the graft. comments: blunt popliteal artery injury has been reported to result in amputation rates of nearly 30-60%.the importance of a detailed vascular examination of a blunt trauma patient is emphasized as a limb can be salvaged if timely intervention is done. in this case even with an unfavourable mess score. case history: a healthy 27-year-old male, with no history of interest, suffers a high-energy trauma as a water bottle rushes over his left knee. clinical findings: go to the emergency room with pain and functional impotence in the left knee, with its anatomical deformity. knee x-ray pa and l are performed and the distal pulses that are present are taken. ankle-brachial index [ 0.9. closed reduction is performed in emergencies under sedation and control x-ray is requested, aiming at correct reduction. it was decided to keep under observation for 24-48 h before discharge from hospital to schedule regulated ligament reconstruction surgery after studying with mri. therapy and progressions: at 12 h of evolution after the accident and after having reduced the dislocation, the patient who has the leg with a temperature equal to the contralateral is reassessed, however, there is no palpable dorsal pedis pulse or posterior tibial palpation in the affected leg. it is decided to urgently request an angiotc and it is objective thrombosis of popliteal artery. vascular surgeon is contacted and emergency surgery is decided. a by-pass is performed with vena safena. diagnosis: traumatic knee dislocation and popliteal artery injury comments: in the 21st century, complementary tests in diagnosis are becoming increasingly important. however, in this case we want to management of aseptic tibial nonunion anastasios g. c. reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. can we expect an optimum result? results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion management of tibial non-union using reamed interlocking intramedullary nailing the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre pelvic trauma: wses classification and guidelines damage control orthopaedics in unstable pelvic ring injuries references: beuran, m. trauma scores: a review of the literature glasgow coma scale, age, and arterial pressure (mgap): a new simple prehospital triage score to predict mortality in trauma patients. critical care medicine. champion hr. a revision of the trauma score proximal femoral nail antirotation versus gamma3 nail for intramedullary nailing of unstable trochanteric fractures. a randomised comparative study results of the femur fractures treated with the new selfdynamisable internal fixator (sif) dhs helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures the hypermetabolic response to burn injury and interventions to modify this response racial differences in propranolol enantiomer kinetics following simultaneous i.v. and oral administration propranolol dosing practices in adult burn patients the hypermetabolic response to burn injury and modulation of this response: an overview. wound heal south africa management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience blunt traumatic abdominal wall hernias: a surgeon's dilemma blunt traumatic abdominal wall hernias: associated injuries and optimal timing and method of repair traumatic abdominal wall herniation: case series review and discussion trauma patients with open abdomen: do they differ from others? a single center experience h. fagertun 1 , a. seternes department of circulation and medical imaging, trondheim, norway introduction: treatment with open abdomen is demanding for patients, staff and hospital. a multidisciplinary approach is mandatory. the aim of this study was to compare trauma patients with open abdomen (oa) and patients treated with oa for other reasons, regarding outcome and resources spent. material and methods: retrospective study of patients treated with oa in a tertiary hospital in norway. ten were trauma patients vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy-a systematic review prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique thoracic-abdominal trauma with diaphragm lesions n. vlad 1 , i. streanga 1 , a. morar 1 , i st. spiridon'' hospital iasi. we have analyzed clinical data, trauma mechanism, pathology of the lesion, time trauma-diagnostic, associated lesions, treatment, and follow-up. results: there have been 18 patients (12 men, 6 women), mean age 42. location of diaphragmatic tears has been on the left hemidiaphragm (12 cases), on the right hemidiaphragm (3 cases), or bilateral (3 cases). the trauma mechanism has been blunt (10 cases) or penetrant (8 cases). all patients had associated visceral lesions and had been operated right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literaturereview traumatic diaphrag-matic ruptures: clinical presentation, diagnosis and surgicalapproach in adults traumatic rupture of the diaphragm: experiencewith 65 patients 9% (82/393) were aast grade 4 or 5. in the total group, median age was 32 years, 66.1% were male and 79.6% were blunt injuries. median iss in the nom group was 22 and 25 in the om group. median iss for those with grade 4 or 5 injury was 26. 64.6% (254/393) underwent nom, compared to 59.8% (49/82) of those with aast grade 4 or 5. for each 1 mmhg increase in systolic blood pressure, patients with grade 4 or 5 injury were 3% less likely to have an operation (or 0.97, p = 0.003) and for each 1 beat increase in heart rate intra-operative grade i was revealed in 57 patients (49,8%), grade ii in 24 (20,8%), grade iii in 8 (6,7%) grade iv in 21 (18,2%) and grade v in 5 (4,5%). histologic finding of catarral appendicitis was found in 32 (27,8%) patients, 39 (34%) had phlegmonous appendicitis and 44 (38,2%) had gangrenous appendicitis. the airs difference was statistically significant with histological findings quality of publications regarding the outcome of revision rate after arthroplasty swedish hip arthroplasty register annual report joon yung lee: risk factors for failure of nonoperative treatment for unilateral cervical facet fractures in 2018, 501patients were included in the trauma registry. median iss was 9 and 103 patients had an iss [ 15. of these patients 31/103 (30%) were undertriaged with a mortality of 5/31(16%). the total mortality in 2018 was 4,8% (24/501). i 2017, median age was 62 years for the patients with no tta vs 36 years for those patients who did receive a tta (p \ 0.001) prognostic factors for medical and productivity costs, and return to work after trauma: a prospective cohort study l results: a total of 3785 trauma patients (39% of total study population) responded to at least one follow-up questionnaire. mean medical costs per patient (€9,710) and mean productivity costs per patient (€9,000) varied widely. prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the icu. prognostic factors for rtw were high educational level, male gender, low injury severity swiss and german (pre-)hospital systems, distribution and organisation of trauma centres differ from each other [1,2]. it is unclear if outcome in trauma patients differs as well. therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both german-speaking countries. material and methods: the traumaregister dguò (tr-dgu) was between 01-2009 and 12-2017 were included if they required icu care or died. trauma pattern trauma care in germany trauma systems in europe practical assessment of different saw types for field amputation: a cadaver-based test study these themes were: factual information (e.g., electrocardiography rhythm)educational programs and future guidelines. references: rosemurgy as, prehospital traumatic cardiac arrest: the cost of futility blunt vertebral vascular injury in trauma patients: atlsò recommendations and review of current evidence treatment-relater outcomes fron blunt cerebrovascular injuries. importance of routine follow-up arteriography provided the catheters used for this study. no other support was provided diagnosis: the probe had perforated the ivc wall. therapy and progressions: open repair was performed through a xifopubic laparotomy and the cattel-braasch maneuver to expose the ivc (fig. 3). a retroperitoneal hematoma was observed anteriorly to the infrarenal ivc, without active bleeding. the ivc was dissected out sufficiently to permit proximal and distal vascular control (fig. 4), the probe was then removed and the laceration on the infrarenal ivc closed with a running suture. the postoperative course was uneventful. comments: to our knowledge this is the first reported case of symptomatic ivc laceration by an ice probe during ca. references: enriquez a. use of intracardiac echocardiography in interventional cardiology complications of catheter ablation for atrial fibrilla iatrogenic percutaneous vascular injuries: clinical, presentation, imaging, and management vascular complications during catheter ablation of cardiac arrhythmias: a comparison between vascular ultrasound guided access and conventional vascular access false aneurysm of the profunda artery resulting from intertrochanteric fracture. a case report profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments. a case report with major thoraco-abdominal vascular injuries (aorta, inferior vena cava and main branches). data on demographic, clinical status and imaging was recorded. descriptive and kaplan meir survival analysis was performed. results: 87 patients were included. median age was 33 years (iqr 45-25), 70 (80.5%) were male. aorta was the most frequently damaged vessel (40,2%) the median iss was 29 (iqr 38-25)interventional procedure. overall mortality was 46%, with 45% of deaths during the first hour, 37.5% in the first 24 h and 17.5% afterwards. median survival was 54 days (ic19-88). we compared survival curves in periods abdominal vascular trauma. trauma surg acute care open history: popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. a thirty one year old pathologies. references: natsuhara, k.m. et al, what is the frequency of vascular injury after knee dislocation knee dislocation and vascular injury: 4-year experience at a uk major trauma centre and vascular hub can vascular injury be appropriately assessed with physical examination after knee dislocation? introduction: this retrospective cohort study investigated the prevalence of and risk factors for preoperative venous thromboembolism (vte) in patients with a hip fracture and a delay of [ 24 h from injury to surgery. material and methods: this observational study included 208 patients with a hip fracture surgically treated at 1 university hospital. patients underwent indirect multidetector computed tomographic (mdct) venography for preoperative vte detection after admission. overall vte risk and median time from injury to ct scan were calculated. age, sex, fracture type, time from injury to ct scan, body mass index, preinjury mobility score, previous anticoagulation treatment, previous hospitalization for vte, varicose veins, and medical comorbidities were considered potential risk factors. results: the prevalence of preoperative vte was 11.1% (23 of 208 patients). the mean time from injury to ct scan was 4.9 days. the delay from the time of injury to ct scan averaged 7.6 days for patients who developed preoperative vte, compared with 4.2 days for patients who had not developed vte. in the adjusted models, female sex, subtrochanteric fracture, pulmonary disease, cancer, previous hospitalization for vte, and varicose veins were risk factors for vte. the final multivariate logistic regression analysis introduction: vertebral compression fractures constitute a large percentage of traumatic injuries of spine. the initial management plays an important role in the final outcomes. the present study aims to study the profile of vertebral injuries in rural & semi urban population & to analyse the role of level two hospitals in initial management of vertebral injuries. material and methods: this study was a retrospective analysis of progressively collected data of patients presenting with vertebral injuries in a level two hospital catering to semi urban & rural population in india. the initial presentation along with the age & sex profile was noted. etiological factors leading to compression fractures were noted. any neurological deficit either at the time of admission or transfer to a tertiary care neurocentre was noted as per asia scale. initial management was carried out in accordance with the atls guidelines. results: a total of 44 out 3000 patients admitted with complaints of back pain were diagnosed to have compression fractures of the spine. the mean age was 49.4 years. male: female ratio was approx 5:1. the lumbo sacral spine region was the most comply affected region. two patients were incidentally detected to have vertebral fractures as a result of metastatic malignancy. a due note was made regarding patients who had deteriorated during the transfer in terms of neurological deficit & evidence of spinal shock. conclusions: road traffic accidents contribute a significant portion of vertebral trauma . smaller hospitals & general surgeons have an important role to play in terms of initial stabilisation of such patients particularly the ones presenting with neurogenic shock. a good initial management has sigificant bearing on outcomes. analysis of risk factors for tracheostomy in cervical spinal cord injury without bone injury n. notani 1 , s. kanezaki 1 , t. sakamoto 1 , h. tsumura 1 1 oita university, orthopaedic surgery, yuhu, oita, japan introduction: there are many cases that require tracheostomy in the acute phase of cervical spinal cord injury, and various risk factors have been reported so far. however, there has been no report on cervical spinal cord injury without bone injury. the aim of this study is to evaluate risk factors for tracheostomy in patients with cervical spinal cord injury without bone injury. material and methods: we conducted a retrospective observational study. patients who were treated for cervical spinal cord injury without bone injury in our hospital were divided into 2 groups: tracheostomy (tc) group and no tracheostomy (no tc) group. we compared variables, including age, sex, asia impairment scale (ais), neurological level of injury (nli), injury severity score (iss), vital signs, blood gas analysis, tracheal intubation, chest complication, smoking history between two groups. results: there were 8 patients in tc group, and 46 patients in no tc group. on univariate analysis, there were significant differences in age, ais a, tracheal intubation, nli ] c4. on multivariate analysis, nli ] c4 was an independent predictor of tracheostomy. conclusions: in this study, we demonstrated that nli ] tc4 could be useful to predict tracheostomy in patients with cervical spinal cord injury without bone injury. case history: many fractures of the articular processes of the cervical spine are associated with displacement and instability, approximately 5% of all traumatic cervical spine injuries involve isolated fracture of the articular processes non-displaced or minimally displaced. [1] this case demonstrates a isolated facet fracture of the cervical spine with c7 radiculapathy treated with minimally invasive spine surgery techniques clinical findings: a 47-year-old male was admitted to the neurosurgery department due to severe neck pain (vas 9/10). the pain radiating to the right upper extermity along dermatome c7. neck and trunk rotation worsened the pain. investigation/results: furthermore, physical examination revealed hyperaesthesia in the right index finger without muscle weakness. ailments suddenly appeared 4 weeks earlier after getting up in the morning. imaging demonstrated isolated, unilateral fracture of the right superior articular process of c7 diagnosis: imaging demonstrated isolated, unilateral fracture of the right superior articular process of c7 therapy and progressions: the patient was treated by microsurgical c7 decompression and fusion of c6-7 under navigation guidance. intraoperative ct scans were performed to evaluate sufficient bone removal.after the surgery, the neck and upper extremity pain subsided. the patient had returned to his usual job and sport activities. comments: this case illustrates the value of the navigation and intraoperative ct in the evaluation of bony decompression, anatomy and location of implants. navigation minimized iatrogenic injury resulting in reducing postoperative complications like chronic pain, kyphotic deformity and muscular atrophy.introduction: resuscitative endovascular balloon occlusion of aorta (reboa) is a technique initially developed in the military for trauma patients injured in combat 1 . recently, there has been much debate on its role in civilian trauma cases in controlling non-compressible torso haemorrhage (ncth) 2 . this review aims to provide an update on current literature on the outcomes and concerns of this procedure. material and methods: a systematic literature search according to prisma guidelines was performed over the period of january 2005 to august 2019 across embase, medline and cochrane databases. patient characteristics, mechanism and severity of injury, survival rates and post-reboa complications between survivors and non-survivors were compared. results: a total of 32 studies were included in this review. 8% and 92% of the 4042 reboa cases were penetrative and blunt cases respectively. the survival rates ranged from 6 to 100% across the studies. systolic blood pressure (sbp) was significantly elevated post-procedure, from 75.6 to 119.0 mmhg in the survivor group (p \ 0.001) and 61.4 to 96.8 mmhg in the non-survivor group (p = 0.001). the injury severity score (iss) was lower in the survivor group (31.9 vs 41.7; p \ 0.001) whereas their glasgow coma scale (gcs) was higher (12.3 vs 5.6; p = 0.008). the survivors also had a shorter duration of aortic occlusion (48.2 vs 93.3 min; p = 0.001). common complications noted following the procedure include renal injury, lower limb ischaemia and thrombosis. conclusions: pre-reboa sbp, iss, gcs and duration of aortic occlusion were found to be associated with survival. complications directly due to the procedure were difficult to ascertain. a prospective study in a multiple trauma centre is needed for further evaluation of the indications, feasibility and complications involved in reboa. references: introduction: traumatic vertebral artery injury (vai) is a wellknown complication of cervical spine injury and often causes posterior circulation stroke. we report preventive effect of acute phase endovascular intervention for traumatic vai. material and methods: all patients with cervical spine injury were surveyed with post-contrast computed tomography for vai. when vai was diagnosed, the affected vertebral artery (va) was occluded with endovascular intervention before spine reduction and fixation. brain ischemic lesion was evaluated before and after the treatment. results: forty-one patients with vai associated with cervical spine injury underwent endovascular intervention. the affected va was occluded with endovascular coils before cervical spine reduction and fixation in 38 patients, and after treatment in one patient. va stenting was done for another two. six presented new brain infarctions after spine surgery. of these, two had endovascular intervention after spine reduction. out of 38 patients who had endovascular embolization before spine reduction, four had newly developed infarctions after spine surgery, of which two were symptomatic. there were no complications related to the endovascular procedure. conclusions: in conclusion, endovascular embolization for traumatic vai before spine reduction and fixation was found to be effective to prevent symptomatic brain infarction. introduction: the use of drug coating balloons (dcb) in primary or secondary angioplasty for peripheral vascular disease is a new tendency. the use of paclitaxel decelerates the growth and hyperplasia of neo-intima tissue which can cause re-stenosis and total occlusion in the spot of pta is a very promising technique in long lasting results of balloon ptas. purpose: to demonstrate our experience and results of the technique of dcb pta with the use of drag coating balloons. material and method: in the period between march 2013 and september 2019, 65 patients with sfa lessions were treated with pta with dcb for acute limb ischemia. 41 were males and 24 females. mean age was 69,2 y.o (± 6.39). patients were examined pro operationally and immediate post operationally in abi difference and their post operational follow up included measurement of abi and u/s triplex scan on the 1st, 3rd, 6th and 12th month(where chronically available) after pta. results: the mean immediate post operative increase of abi was 0,32 (± 0,13). were chronically available the increase of abi remained to 0,26 in the 3 months follow up, 0,23 in the 6 months and 0,21 in the 12th month follow up while patency of the artery treated remained in all patients. 2 of the patients suffered from acute complications during or short after the pta (1 with peripheral embolization and 1 with retroperitoneal hematoma) which were treated immediately and left no consequences. conclusions: the use of dcb for pta in acute ischemia is a quite new, promising technique for maintaining patency of treated arteries for long time post operative period. the medium time results from its use in our clinic seem to be satisfactory. jichi medical university hospital, tochigi, japancase history: a 38-year-old male hit his neck hard against the fence. thereafter, he experienced difficulty in breathing and severe neck pain. he was brought to the emergency center by ambulance. clinical findings: his vital signs on arrival were gcs: e4v5m6, hr: 70, bp: 157/101, rr: 20, spo 2 : 100 (3lo 2 ). significant neck edema and tracheal deviation were noted. inspiratory stridor was not heard with no signs of retracted breathing or subcutaneous emphysema. investigation/results: an enhanced ct scan of the neck revealed tracheal deviation and compression with ruptures of the left thyroid lobe. a large hematoma and arterial extravasation from a branch of the inferior thyroid artery were noted. diagnosis: rupture of the left thyroid lobe and injury around the distal portion of the left inferior thyroid artery. therapy and progressions: after securing the airway by intubation, angiography of the neck was performed; extravasation from a branch of the left inferior thyroid artery was suspected. angioembolization was continued for hemostasis using gelatin sponge. neck edema improved in the intensive care unit. following extubation on the hospital day 6, the patient was discharged on the 8 th day with no complication. comments: thyroid injury due to blunt neck trauma is rare and surgical intervention such as hemithyroidectomy is generally prescribed. the patient''s condition, in this case, improved by angioembolization without any invasive surgical procedures. catheter procedure may, thus, be effective for hemostasis on thyroid injury after the confirmation of airway placement. introduction: the indication for resuscitative endovascular balloon occlusion of the aorta (reboa) is hemodynamically unstable patients in life-threatening hemorrhage below diaphragm. it was unclear that the difference of indications for reboa affects mortality in trauma.material and methods: this study used data from the japan trauma data bank (jtdb) (2004-2019), a nationwide trauma registry, to describe the epidemiology of reboa. adult trauma patients used reboa were included. patients were excluded if they had cardiac arrest at the scene or dead on arrival, or had an unsurvivable injury of any region of the body as defined by the abbreviated injury scale. patients were classified by whether patients had indications for reboa. the indications for reboa were defined by indications for hemostasis to intraabdominal, retroperitoneal, pelvic or extremity hemorrhage. the indications were decided by the delphi method with the cooperation of experts in trauma for this study. the contraindications were defined by brain injury needed intervention and hemorrhage above diaphragm. the logistic regression was used to assess the mortality after adjustment for injury severity score. as a sensitivity analysis, a generalized linear mixed model with random effects of a facility was performed. results: of 361,706 patients registered in the jtdb, 993 patients underwent reboa. 669 had indications for reboa and 294 underwent reboa without indications. the physiological variables were similar, but the consciousness was worse in the no-indications group. injury severity of brain and chest were higher in the no-indications group. the indications group had 6.7% and the no-indications group had 13.6% contraindications for reboa. the mortality was similar (43.6% versus 46.5%, or 0.80, 95%ci 0.58-1.10). a sensitivity analysis showed the same result as the primary analysis (or 0.82, 95%ci 0.60-1.12). introduction: most incident first responders have a primary nonmedical role, but are frequently the only professionals initially at the scene. early hemorrhage control via advanced techniques such as resuscitative endovascular balloon occlusion of the aorta (reboa) can save lives. training first responders these techniques has therefore the potential to improve outcomes. this study evaluates the ability to train quick response team fire fighters (qrt-ff) to gain percutaneous femoral artery access and place a reboa catheter, using a comprehensive theoretical and practical training program. material and methods: six qrt-ff participated in the training. sof medics from a previous training served as control group. a formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and reboa catheter placement. key skills were: (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model and (3) placement and positioning of the reboa catheter. results: qrt-ff had significantly better baseline knowledge of surgical anatomy (p = 0.048) compared to medics. they also scored significantly better on using endovascular materials (p = 0.003), performing the procedure without unnecessary attempts (p = 0.032) and overall technical skills (p = 0.030). the median time from start to reboa inflation was 3:23 min for qrt-ff and 5:05 min for medics. procedure times improved in all qrt-ff and 4 of the 5 medics in a second attempt of gaining vascular access and reboa placement. conclusions: our comprehensive theoretical and practical training program proves suitable for percutaneous femoral access and reboa placement training of qrt-ff without prior ultrasound or endovascular experience. repetition reduces procedure times. training in the use of advanced hemorrhage control techniques such as reboa, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in out-of-hospital settings. prytime medical tm devices, inc. provided the reboa access task trainer (ratt) and the catheters used for this study. no other support was provided.the authors declare that there are no conflicts of interest that could inappropriately influence (bias) their work. introduction: angioembolization (ae) has become an important component in the management of bleeding from severe pelvic fractures. timely availablity of ae is required for both, level 1 and 2 trauma centers. the aim of this study was to assess the utilization of this procedure in level 1 and 2 trauma centers and effect on oucomes. material and methods: retrospective, 3-year (2013-2016) study using the the american college of surgeons tqip database, including adult patients with isolated severe pelvic facture (ais [3] [4] [5] . patients who underwent laparotomy or preperitoneal packing within 4 h from admission were excluded, operative management for bleeding control between 4 and 24 h was considered as failure. univariate analysis was used to compare patients in level 1 vs 2 centers, multivariate regression analysis was performed to determine factors predictive for mortality and overall complications.results: 10102 patients (6960 in level 1; 3142 in level 2 centers) met the criteria for inclusion. overall, 610 (6.0%) underwent ae, with a trend toward higher ae rate in level 1 centers (6.3% vs 5.4%, p = 0.061). no significant differences were observed in timing and failure rate of ae between the 2 levels. particulary in the ae subgroup there was a significantly lower blood product utilization in the first 24 h in level i centers (prbc 5.6 vs 6.9 units, p = 0.015; plasma 3.8 vs 5.5 units, p = 0.003). mortality and overall complication rates were similar. table 1 the level of trauma center was not a predictive factor for mortality (or 1.306, p = 0.284) and overall complications (or 1.046, p = 0.591). conclusions: in isolated severe pelvic fractures, there was a trend toward higher ae rate and significantly lower utilization of blood products in level 1 centers. there were no significant differences in mortality or complications. the ae subgroup in level 2 centers had a higher blood products use without outcome benefit, suggesting more restrictive transfusion policy may be considered. portal vein thrombosis after distal splenopancreatectomy: successful recanalization using fogarty balloon catheter case history: intraoperative lesion of smv during distal splenopancreatectomy is repaired using peritoneal patch harvested from anterior abdominal wall clinical findings: postoperative increase in serum lactate and d-dimer without signs of peritonitis prompts bedside doppler us showing no blood flood within portal vein (pv) investigation/results: ct angiography is performed suspecting acute mesenteric ischemia, but no abnormal bowel enhancement/ thickness is seen despite complete pv thrombosis. anticoagulation with unfractioned heparin is started, but clinical conditions deteriorate diagnosis: at reintervention, bowel is viable, so the surgeon performs fogarty balloon catheter thrombectomy successfully reestablishing blood flow within pv. no intestinal resection is required therapy and progressions: pv patency is regularly evaluated with us. anticoagulation with low molecular weight heparin is prosecuted for 3 months and then suspended since no recurrence is recorded meanwhile comments: pv thrombosis is uncommon but can follow injury to portal venous axis during surgery. anticoagulation with heparin should be started as soon as the diagnosis is made and maintained for at least 3-6 months postoperatively to prevent recurrence. patients with persisting/worsening symptoms 48-72 h after initiation of anticoagulation, or those with peritonitis who are poor surgical candidates may be considered for interventional radiological treatment. otherwise, surgical intervention is required and may encompass resection of necrotic bowel. thrombectomy and/or balloon dilation/vascular stent placement may be helpful in recently developed pv thrombosis since risk of recurrence seems to be decreased references: acute mesenteric ischemia: guidelines of the world society of emergency surgery (world j emerg surg 2017); mesenteric venous thrombosis (j clin exp hepatol 2014); contemporary management of acute mesenteric ischemia in the endovascular era (vasc endovascular surg 2019) key: cord-006854-o2e5na78 authors: nan title: scientific session of the 16th world congress of endoscopic surgery, jointly hosted by society of american gastrointestinal and endoscopic surgeons (sages) & canadian association of general surgeons (cags), seattle, washington, usa, 11–14 april 2018: poster abstracts date: 2018-04-20 journal: surg endosc doi: 10.1007/s00464-018-6121-4 sha: doc_id: 6854 cord_uid: o2e5na78 nan purpose: to evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (sils-tep) of incarcerated inguinal hernia. patients and methods: clinical setting a retrospective analysis of 14 patients undergoing sils-tep for incarcerated hernia from may 2016 to august 2017 at kinki central hospital was performed. exclusion criteria sils-tep was contraindicated for the following conditions in our hospital: a history of radical prostatectomy; a small indirect inguinal hernia in a young patient; and unsuitable for general anesthesia. surgical procedure laparoscopic abdominal exploration through a single, 2.5-cm, intraumbilical incision was performed. the incarcerated hernia content was gently retracted from the hernia sac into the abdominal cavity. in some cases, simultaneous manual compression on the incarcerated hernia from the body surface was required. if no bowel resection was needed, a standard sils-tep using mesh was performed following laparoscopic abdominal exploration and incarcerated hernia reduction. if bowel resection was required, inguinal hernia repair using mesh was not performed to avoid postoperative mesh infection, and two-stage sils-tep was performed 2-3 months after the bowel resection. results: fourteen patients (11 men, 3 women) with irreducible inguinal hernias, including 11 with unilateral hernias and 3 with bilateral hernias, underwent surgery. the patients' median age was 74 years (range, 38-83 years), and median bmi was 23.5 kg/m 2 (range, 18.8-30.5 kg/m 2 ). of the 14 patients, 7 had acute incarceration, and 7 had a chronic irreducible hernia. seven patients with acute incarcerated hernias underwent emergency surgery, and two of the seven patients needed singleincision laparoscopic partial resection of the ileum, followed by two-stage sils-tep. twelve patients, excluding two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by sils-tep. one case of chronic incarceration out of the twelve patients who underwent sils-tep after hernia reduction required conversion to kugel patch repair. the median operative times were 102 min (range 52-204 min) for unilateral hernias and 165 min (range 83-173 min) for bilateral hernias. the median blood loss was minimal (range 0-177 ml). the median postoperative hospital stay was 1 day (range 1-3 days). the median follow-up period was 7 months (range 1-15 months). a seroma developed in 25% (3/12) of patients and was managed conservatively. no other major complications or hernia recurrence were noted during the follow-up period. conclusions: sils-tep, which offers good cosmetic results, could be safely performed for incarcerated inguinal hernia. objective: introduction of mis in pediatric age group has been proved feasible and safe. there is considerable evolution with introduction of a number of invovation in mis pediatric inguinal hernia repair. high ligation of sac is the basic premise of surgical repair in pediatric inguinal hernias. there are different mis techniques broadly grouped into intracorporeal or intracorporeal with extracorporeal component namely the suturing. every techniques has its own complications. the main objective of our study was to focus on different anatomical pointers which can lead inadverent complications mainly bleeding and recurrence. methods and procedures: prospective review of 37 hernias (29 male and 2 female) (8 months-13 years) performed laparoscopically between september 2015 and june 2016. under laparoscopic guidance, the internal ring was encircled extraperitoneally using a 2-0 non-absorbable suture and knotted extraperitoneally. data analyzed included operating time, ease of procedure, occult patent processus vaginalis (ppv), contralateral inguinal hernia, complications, cosmesis and recurrence. results: sixteen right (52%), 14 left (45%) and 1 bilateral hernia (3%) were repaired. five unilateral hernias (16.66%), all left, had a contralateral ppv that was repaired (p=0.033). mean operative time for a unilateral and bilateral repair were 13.20 (8-25) and 20.66 min (17-27 min) respectively. one hernia repair still recurred (2.7%) even with all precautions and another had a post operative hydrocoele (2.7%). one case (2.7%) needed an additional port placement due to inability to reduce the contents of hernia completely. because of our techinique we could not find any adverent peroperative bleeding. there were no stitch abscess/granulomas, obvious spermatic cord injuries, testicular atrophy, or nerve injuries. conclusion: the results confirm safety, efficacy and cost effectiveness of laparoscopic inguinal hernia repair. during our per-operative analysis we focus to address the anatomical landmark to minimize future recurrence and peroperative surgical complications. we identified and named a point as j. point at the tip of triangle of "doom". that is most important point to address peroperatively. there is high chance of recurrence if that point is not encircled well or inadequately circled because of fear of iliac vessels injury. we aslo concluded that 'water dissection technique' is effective techniques in un-experienced hand and in early stages of laparoscopic hernia repair to prevent inadvertent iliac vessels injury. 1 medstar georgetown university hospital, 2 georgetown university school of medicine, 3 introduction: incisional hernias following abdominal surgery can be associated with significant morbidity leading to decreased quality of life, increase in health care spending and need for repeat operations. patients undergoing gastrointestinal and hepatobiliary surgery for malignant disease may be at higher risk for developing incisional hernias. identifying these risk factors for incisional hernia development can help decrease occurrence. this will be the largest multi-institutional study looking at incidence of symptomatic hernia rates for major abdominal operations including colectomy, hepatectomy, pancreatectomy, and gastrectomy. methods and procedures: an irb-approved retrospective study within the medstar hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures performed across 11 hospitals between the years of 2002 to 2016. all patients were identified using icd-9 and icd-10 codes for relevant procedures and then subdivided into either having benign or malignant disease. exclusion criteria comprised of patients who had concomitant organ resection, or those undergoing organ transplant. data validation was performed to verify the accuracy of the data set. the rate of symptomatic incisional hernia rates (ihrs) were determined for each cohort based on subsequent hernia procedural codes identified and repairs performed. descriptive statistics and chi squared test were used to report ihrs in each group. results: during this 15-year span, a total of 7,583 major abdominal operations were performed at all 11 institutions, comprising of 4,970 colectomies, 1,122 hepatectomies, 1,165 pancreatectomies, and 326 gastrectomies. malignancy was the indication for surgery in 2,178 (43.8%) colectomies, 747 (66.6%) hepatectomies, 763 (65.5%) pancreatectomies, and 207 (63.5%) gastrectomies. ihr in each cohort for benign vs malignant etiologies, respectively, are as follows: 193 (6.9%) vs 104 (4.8%) in colectomy (p=0.002), 12 (3.2%) vs 16 (2.1%) in hepatectomy (p=0.385), 17 (4.2%) vs 24 (3.1%) in pancreatectomy (p=0.431), and 4 (3.4%) vs 5 (2.4%) in gastrectomy (p=0.88) patients. conclusion: symptomatic incisional hernia rates following major gastrointestinal and hepatobiliary surgery ranges from 2.1 to 6.9%. there was no significant increase in hernia rates in patients undergoing surgery for malignancy. patients undergoing colectomy for benign disease had a high incidence of symptomatic ihrs. introduction: prosthetic infections, although relatively uncommon, are a major source of cost and morbidity. the study aimed to evaluate the influence of mesh structure including the polymer type and mean pore size on bacterial adherence in a mouse model. methods: three commercially available hernia meshes were included in the study. for each mesh type, a 1 cm square was surgically placed intraabdominally in 6 mice. one mouse served as a control while an enterotomy was made in the subsequent mice to introduce a bacterial load onto the mesh. after 24 hours the meshes were harvested. the inoculated meshes were then plated on agar plates and bacterial counts were counted after 24 hours. the bacterial counts were compared between the various mesh types. results: the mean bacterial adherence was increased in the large pore mesh was 695 colonies, for the small pore mesh was 892 colonies, and in the biologic mesh group it was 504 colonies. conclusions: through the use of a mouse model, the influence of mesh type and pore size on bacterial adherence was evaluated. meshes that have larger pores with a lower prosthetic load and the biologic mesh interestingly had lower early bacterial colonization after 24 hours following an enterotomy. further evaluation with a longer incubation time could be helpful to determine the effect of bacterial colonization of mesh. hrishikesh salgaonkar, raquel maia, lynette loo, wee boon tan, sujith wijerathne, davide lomanto; national university hospital, singapore laparoscopic repair of groin hernias is widely accepted approach over open due to lesser pain, faster recovery, better cosmesis and decreased morbidity. however, there is still debate on its use in large inguino-scrotal hernias, recurrent hernias and history of lower abdominal surgery anticipating adhesions and difficulty in dissecting extensive hernia sac. retrospective analysis of prospectively collected data was done of patients undergoing laparoscopic repair of large inguino-scrotal, incarcerated groin hernia, recurrent cases after open or laparoscopic repair and history of previous lower abdominal surgery. between january 2013 to july 2015, 89 patients with large inguino-scrotal hernias, recurrent hernia, history of lower abdominal surgery, incarcerated femoral hernia underwent laparoscopic inguinal hernia repair. patient characteristics, operating time, surgical technique, conversion rate, complications and recurrence up to 18 months recorded. 51 patients had large inguino-scrotal hernia, 22 recurrent hernia (17 previous open, 5 previous lap) , 14 history of lower abdominal surgery (4 lscs, 6 appendectomy, 2 prostatectomy, 2 midline laparotomy), 1 incarcerated femoral hernia, 1 meshoma removal. 75 patients underwent total extraperitoneal (tep) repair, 9 transabdominal pre-peritoneal (tapp), 5 needed conversion to open. mean operation time was 74 min for unilateral and 118 min for bilateral hernia. seroma formation seen in 19 patients, 2 minor wound infections treated conservatively. we conclude that the laparoscopic approach can be safely employed for the treatment of complex groin hernias; surgical experience in laparoscopic hernia repair is mandatory with tailored technique in order to minimize morbidity and achieve good clinical outcomes with acceptable recurrence rates. mesh fixation in ventral incisional hernia is a topic of ongoing debate. permanent and absorbable tacks are acceptable and widely used methods for mesh fixation. the purpose of this study was to compare outcomes of permanent tack fixation versus absorbable when used alone or with suture fixation in laparoscopic incisional hernia repairs. a retrospective review of all patients undergoing laparoscopic ventral hernia using tack fixation (absorbable/permanent) alone or in conjunction with suture fixation was queried from the ahsqc database. outcome measures included hernia recurrence rate, pain, quality of life, wound related issues, and hospital length of stay. propensity match scoring was performed to compare patients undergoing tack only fixation versus tack and suture fixation with a p-value of .05 considered significant. a total of 804 patients were identified after propensity match scoring with 402 who underwent repair with permanent tacks alone or with sutures and 402 who underwent repair with absorbable tacks alone or with sutures. following matching there were no differences in bmi, age, hernia width/length, or baseline pain/ quality of life. there were no significant differences found in outcome measures including recurrence rates, pain and quality of life outcomes at 30 days, 6 months, and 1 year, surgical site infection (ssi), and postoperative length of stay (p[0.05). there was a significant increase in any post op complication in the permanent tack fixation group compared to the absorbable tack fixation group (21% vs 14%, p.0003) which is likely due to the increase in surgical site occurrences noted in the permanent tack fixation group (14% vs. 10%, p.005). based on this large data set, there are no significant differences in postoperative outcomes in permanent versus absorbable fixation in laparoscopic hernia repair except in surgical site occurrences. further study is needed to evaluate but at the present time, there is no convincing evidence that one type of fixation is superior to another in laparoscopic ventral hernia repair. introduction: inguinal hernia repair is the most common procedure in general and visceral surgery worldwide. laparoscopic transabdominal preperitoneal mesh hernioplasty (tapp) has been also popular surgical method in japan. single incision laparoscopic surgery is one of the newest branches of advanced laparoscopy, and its indication has been spread to not only simple surgery such as cholecystectomy, but also complex surgery. we report our experience with single incision laparoscopic tapp (s-tapp) for japanese patients with inguinal hernia. case description: a consecutive series of 290 patients (247 male, 43 female) who underwent s-tapp during june 2010 to september 2017 in a single institution. twenty eight of the patients had bilateral inguinal hernia. the mean follow-up was 1192 days. the average age of the patients was 61.2±16.5 years. establishment of the ports: a 25-mm vertical intra-umbilical incision is made for port access. one 5-mm optical port and two 5-mm ports were placed side-by-side through the umbilical scar. surgical procedure: the procedure was carried out in the conventional fashion with a wide incision in the peritoneum to achieve broad and clear access to the preperitoneal space, and an appropriate placement of polypropylene mesh (3dmaxtm light, bard) with fixation using the tacking device (absorbatack®, covidien). the hernia sac is usually reduced by blunt dissection, or is ligated and transected with ultrasound activated device. the peritoneal flap is closed by one suture with 4-0 pds and the 6-7 tacks using absorbatack®. discussion: in one patient, we encountered a large sliding hernia on the right side having sigmoid colon as content of the sac, which required conversion to the conventional laparoscopic procedure. there were nine recurrence cases after surgery of laparoscopic or anterior approach, and two cases after prostatectomy. there was no intra-operative complication. the mean operative time was 87.4 ±31.1 min, and blood loss was minimum in all cases. the average postoperative stay was 5.4±2.7 days. there was one recurrence case (0.3%) 16 months after the surgery. there was no severe complication after the surgery, but there were 15 seromas (4.7%) and one hematoma (0.3%). two patients had blunt tactile sense in the area of the lateral femoral cutaneous nerve (0.9%), which improved in two months. conclusion: our results suggest that s-tapp is a safe and feasible method without additional risk. moreover, cosmetic benefit is clear. however, further evaluation for postoperative pain and longterm complications compared to standard laparoscopic tapp mesh hernioplasty should be required. manuel garcia, md, daniel srikureja, md, marcos j michelotti, md, facs; loma linda university health introduction: prosthetic mesh use has become standard practice during ventral hernia repair to reduce the risk of recurrence. the ideal mesh is macro-porous which favors rapid cellular ingrowth and tissue integration, has limited tissue reactivity, low profile and weight, and has high tensile strength to add resilience to the repair. additionally, the material is expected to have good handling characteristics. currently, there is a wide variety of options for mesh. biosynthetic material (poliglycolic acid/trimethylene carbonate -pga/tmc) has been shown to behave well in terms of early vascularization and ingrowth as well as adequate long term tissue generation. gore® synecor® biomaterial is a composite mesh including two layers of absorbable biosynthetic material (pga/tmc) with one tridimensional non-absorbable macro-porous knit of dense ptfe mesh. it has shown good vascularization and ingrowth at 30 days in animal examination. however, there is still no evidence of long term behavior of this mesh in human tissue. we present the first histologic analysis of this mesh 1 year after placement in a human. objective: to perform a histologic analysis of the gore® synecor® biomaterial one year after placement in the human body. methods: after incidentally finding incorporated gore® synecor® mesh in a patient with prior ventral hernia repair 1 year ago, during open bilateral inguinal hernia repair, a sample of mesh was taken and sent to pathology lab for analysis. tissue healing, vascularization, and ingrowth of the composite mesh were analyzed. results: histologic findings significant for a biomaterial consistent with a knitted ptfe material surrounded by mature fibrovascular tissue and foreign body inflammation consistent with expected healing response for this time frame. no evidence of any other biomaterial (pga/tmc) or evidence of infection. conclusion: gore® synecor® biomaterial has shown to be well integrated into appropriately healed tissue, with pronounced vascularization and ingrowth. the pga/tmc layers have been seen to be completely absorbed and replaced by collagen. these findings, in a human 12 months sample, replicate what had been shown in animal specimens. method: from 2014 to 2017, 6 patients came to hospital with renal paratransplant hernia. they were evaluated for this study. the following data were collected from their records: age, gender, weight, age at graft rejection, surgical complications, treatment method and the treatment results with composite ptfe mesh. results: for laparoscopic repair of incisional hernia after renal transplant, the median interval between kidney transplantation and developing of incisional hernia was 64 (range 12 to 425) days. predisposing factors were obesity, age over fifty years, and female gender. in six patients, hernia was large, and the repair was performed with using composite ptfe mesh. one patient had developed serous collection in surgical site, which was managed successfully with multiple punctures. hernia recurrence or infection was not noted in these patients during 3 to 36 months follow-up periods. conclusion: incisional hernia is not a rare entity after kidney transplantation. predisposing factors, such as obesity, age over 50 years, and female gender have a role in its development. repeated surgeries in kidney recipients can increase the risk of incisional hernia. managing this complication by laparoscopic approach is a safe and effective method. sujith wijerathne, raquel maia, hrishikesh salgaonkar, wee boon tan, lynette loo, davide lomanto; national university hospital, singapore introduction: a femoral hernia is a less common type of hernia. it is estimated to account for less than 5% of all abdominal wall hernias. only about 1 in every 20 groin hernias are femoral hernias. they are found more commonly in females due to wider shape of pelvis. laparoscopy by offering magnification and better vision provides us the opportunity for clear visualization of the myopectineal orifice. laparoscopy seems to be a safe and feasible approach for femoral hernia repair in an asian population. case description: between 2013 and 2016, 70 consecutive patients with femoral hernia who underwent laparoscopic hernia repair were prospectively studied. patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured. discussion: total of 83 femoral hernias were repaired, 45 on right and 38 on left groin. this included 52 patients with bilateral and 18 unilateral hernia. 19 concomitant obturator hernia were found. there were 65 male and 5 female patient. no conversion was reported. one patient had injury to bowel at the 10 mm port entry site, without contamination, identified and managed immediately. 10 patients developed seroma, all were managed conservatively except one who needed aspiration. peri-port bruising was noticed in 3 patients and 2 patients had hematoma. one patient with hematoma underwent excision of the organised hematoma.1 of the hematoma patient was on aspirin pre-operatively. no wound infection, chronic groin pain or recurrence was documented during follow up till date. conclusion: laparoscopic repair offers accurate diagnosis and simultaneous treatment of both inguinal and femoral hernia with minimum morbidity and good clinical outcomes. better visualisation and magnification gives us an opportunity to identify occult hernias which can be repaired during the same setting, thereby reducing the chance of recurrence and possible need for second surgery. laparoscopic repair has become the procedure of choice for the treatment of the majority of groin hernia at our institution. introduction: totally extraperitoneal (tep) repair that does not require peritoneal incisions is a good procedure that involves minimal visceral damage. however, balloon-or camera-assisted blunt dissections that are performed in a haphazard manner do not follow precise dissection of the fascia layer. furthermore, they have a disadvantage in that they are difficult to understand anatomically. we therefore developed a novel preperitoneal approach to resolve this issue. methods: a 12-mm trocar is inserted into the rectus abdominis sheath cavity after a small incision is made below the umbilicus and the posterior rectus sheath is exposed. a 5-mm trocar is inserted 5 cm towards the pubic bone from the umbilicus. using forceps from this position, narrow branches that enter the posterior rectus sheath from the inferior epigastric vessels are dissected, thereby broadly exposing the anterior surface of the posterior rectus sheath. the third 5 mm-trocar is inserted near the lateral margin of the rectus abdominis. on the outside, local anesthetic is injected beneath the posterior rectus sheath and the preperitoneal cavity is separated in fluid so that the peritoneum is not injured during posterior rectus sheath incision. a small incision is made to the posterior rectus sheath or attenuated posterior rectus sheath at one finger width higher than the expected upper margin of the prosthetic mesh. due to the effects of local injection, a sharp incision to the fascia can be made with an electric scalpel. utilizing this mechanism, the posterior rectus sheath aponeurosis and the lining transverse fascia and superficial preperitoneal layer are individually identified. once the preperitoneal cavity is reached, the peritoneal margin is determined in the lateral direction, and the peritoneum that is pulled due to pneumoperitoneum is separated from the preperitoneal fascia on the outside from the cranial side towards the deep inguinal ring. on the inside, the pneumoperitoneum pressure pushes the peritoneum inferiorly, leading to enlargement and increased visibility of the posterior rectus sheath deep fascia, which is dissected one layer at a time from the outside. the umbilical prevesical fascia is dropped inferiorly, and the dissection of the preperitoneal cavity necessary for mesh deployment is performed. results: by individually dissecting each fascia using emphysema through pneumoperitoneum and enlargement through local injection, the method for reaching the preperitoneal cavity could be successfully completed by following the dissection of the fascia layer without proceeding with the operation blindly, thereby resulting in the elimination of intraoperative bleeding and postoperative hematoma. introduction: in the field of abdominal wall reconstruction, the utility of drain placement is of debatable value. we present outcomes evaluating drain placement vs no drain placement at the time of robotic transversus abdominis release (rtar) technique with placement of mesh in the retromuscular position, a currently understudied subject. methods: retrospective review of a prospectively maintained hernia patient database was conducted identifying individuals who received either drain placement or no drain placement during abdominal wall reconstruction via the rtar technique from august 2015 to june 2017 at a single high volume hernia center. perioperative data and postoperative outcomes between the two groups are presented with statistical analysis for comparison and quality of life (qol) measures assessed using the carolina comfort scale. results: thirty-five patients were identified for this study, of which 9 had drains placed intraoperatively in the retromuscular position at the conclusion of rtar (drn) and 25 underwent rtar without the placement of draining devices (nd). the drn cohort had a mean bmi, defect area, mesh area, and operative time of 37.1, 247 cm 2 , 940 cm 2 and 248 minutes, respectively, compared to 31.8, 157 cm 2 , 822 cm 2 , and 305 minutes in the nd group. all cases utilized medium weight macroporous polypropylene synthetic implantable mesh materials in both the drn and nd subgroups. there were no reported postoperative complications, including no development of hematoma, seroma, or surgical site infections in either group. hernia recurrence was not identified in either the drn or nd cohorts through a mean follow up of 200 days (6.7 months). there were no statistically significant differences in postoperative qol outcomes. conclusion: our series review suggests that the use of intraoperative drains may not afford any benefits with the rtar technique when mesh is placed in the retromuscular position. additional postoperative management associated with drain care may be unnecessary. surg endosc (2018) 32:s130-s359 background: appendectomy is one of the most common operations performed during emergency surgery. although laparoscopic appendectomy (la) has become the treatment of choice, there is still a debate regarding the use of la for treating complicated appendicitis. in this retrospective analysis, we aimed to clinically compare la and open appendectomy (oa) for treating complicated appendicitis. methods: we retrospectively identified 339 patients who underwent an operation for complicated appendicitis at our hospital; these patients were operated on between 2011 and july 2017. [editor1] in total, 222 patients underwent conventional appendectomy and 117 patients were laparoscopically treated. outcomes included operation time, blood loss, length of hospital stay, and postoperative complications. logistic regression analysis was performed to analyze the concurrent effects of various factors on the rate of postoperative complications. objective: small bowel perforation has conventionally been dealt with open exploration, which frequently leads to many wound-related complications. wound infection is the major reason for increasing morbidity in these patients and delay recovery. laparoscopic surgery has various benefits over open surgery like, smaller wound, lesser pain and faster recovery. the aim of this study was to relay the advantages of minimally invasive surgery (mis) to patients with small bowel perforation to decrease postoperative wound complications and duration of hospital stay. methods: it is a retrospective study, including 136 patients with small bowel perforation from 2013 to 2016. of these 136, 43 had traumatic etiology, 28 had typhoid-related perforation and the remaining 65 had a duodenal perforation. 84 of them were male, and the average age was 30.4 years. only patients who presented within 96 hours of perforation were included in the study. laparoscopic exploration was done on introducing camera from 10-mm infraumbilical port after intraperitoneal carbon dioxide insufflation. the remaining two 5-mm working ports were then introduced depending on the site of perforation once identified. the perforations were then repaired using intracorporeal single-layer suturing using polydioxanone 3-0 suture. the peritoneal cavity was given thorough lavage and abdominal drain placed in the pouch of douglas. fecal contamination was found in all the patients. a total of 6 patients underwent conversion to open surgery due to inability to find the site of perforation laparoscopically. of the 136 operated patients, 7 patients developed port-site infection, and there were no major postoperative complications in the 4-week follow up period. conclusion: we conclude from our study that laparoscopic intervention in early small bowel perforation is a safe approach with favorable outcomes, especially with regards to wound complications, that are a major factor in increasing the morbidity in such patients postoperatively. laparoscopic approach leads to early discharge and recovery postoperatively. with the emerging era of laparoscopic surgery, leading to its easy accessibility, more patients can advantage from this technique when they arrive in emergency with intestinal perforation. s144 surg endosc (2018) 32:s130-s359 introduction: pneumatosis intestinalis (pi), or gas in the bowel wall, can be seen on various imaging modalities. the pathophysiology behind pi is unclear. one theory proposes a mechanical cause (e.g. small bowel obstruction) while another proposes a bacterial etiology. management of pi in adults is difficult as often there is a benign clinical course. however, when paired with specific clinical features such as hepatic portal venous gas (hpvg) on imaging, the course of management changes as the suspicion of bowel ischemia increases. hpvg alone has been associated with a high mortality rate and a poor prognosis. management in this case becomes surgical. case presentation: we present a case of 59-year-old latino male who presented to the emergency room with abdominal pain and altered mental status. focused physical examination revealed a non-rigid abdomen, no rebound tenderness, no guarding, and diffuse tenderness only to deep palpation. ct scan of the abdomen and pelvis demonstrated moderate portal venous gas in the right and left hepatic lobes, an upper midline dilated small bowel loop with pneumatosis intestinalis, and a moderately distended stomach with gas and fluid. laboratory studies revealed metabolic acidosis and a lactic acid level of 2.9 mmol/l. due to these findings, bowel ischemia was suspected, and the patient was taken to the operating room for a diagnostic laparoscopy. the laparoscopy was converted to an exploratory laparotomy due to extensive adhesions. intraoperatively, there was no small bowel compromise and no identifiable transition point. extensive lysis of adhesions and repair of iatrogenic enterotomy were performed. patient tolerated the procedure well, clinically improved, and was discharged from the hospital. discussion: this case illustrates the difficulty in management of a patient with pneumatosis intestinalis and, specifically, hepatic portal vein gas seen on ct imaging. hpvg has traditionally been a harbinger of morbidity and mortality, but exploratory laparotomy revealed only diffuse abdominal adhesions and the absence of bowel ischemia despite high clinical suspicion. background: ventral hernia repair is one of the most common surgical procedures facing the general surgeon. there is little consensus as to the best surgical technique for complex scenarios. often these patients have complicating co-morbid conditions such as radiation therapy, that has an inevitable effect in the abdominal wall structures, which can lead to non-traditional repairs. case report: we present a case of a 62 year-old female who underwent a tah/bso and right hemicolectomy which was complicated by wound dehiscence. she underwent primary repair and adjuvant whole pelvis radiation for her squamous cell carcinoma. subsequently, the patient developed acute obstructive symptoms do to a stricture within her small bowel and a large ventral hernia measuring 14913 cm with non-reducible abdominal contents below the level of the fascia more prominent in the suprapubic area. the patient's bmi was 15.3. various considerations are important in planning a surgical repair in a previously irradiated field with loss of domain which include, minimal dissection, and the use of an atraumatic surgical techniqueque with either external oblique release or transversus abdominis muscle release (tar). we chose a a tar, as it provides wider myofascial release and dissection below the arcuate line towards the space of retzius and bogros allowing for a larger sublay mesh placement. also it avoids the need of skin flaps reducing the risk for wound complications in under-perfused tissue. the tar was performed successfully and there were no intraoperative and postoperative complications. her follow-up at 6 months revealed no wound complications or hernia recurrence. conclusion: for patients with compromised tissue and loss of domain a tar technique may be useful when reconstructing complex abdominal wall hernias. it provides the core principals of hernia repair such as primary fascial closure, wide mesh overlap, and finally it provides a reliable approach for the under-perfused tissue without need of skin and soft tissue flap creation. outcomes in the management of cholecystectomy patients in the setting of a new acute care surgery service model: impact on hospital course larsa al-omaishi, bs, william s richardson, md; ochsner medical clinic foundation introduction: the acute care surgery (acs) model, defined as a dedicated team of surgeons to address all emergency department, inpatient, and transfer consultations, is quickly evolving within hospitals across the united states due to demonstrated improved patient outcomes in the non-trauma setting. the traditional model of call scheduling consisted of one senior attending and one senior resident on call per 24-hour shift. attendings were responsible for consults, previously scheduled operations, as well as clinic time. multiple recent studies have shown statistically significant improvements in several parameters of patient care by using acs including but not limited to 1. time from emergency department to surgical evaluation 2. time from surgical evaluation to operating room 3. operative time 4. percent laparoscopic 5. length of hospital stay 6. intra-operative complications (blood loss, perforation rates) 7. post-operative complications (fever, infection, redo) 8. cost. one study demonstrated a statistically significant cost savings for the acute care surgery model with respect to appendectomies, but not cholecystectomies. study design: a retrospective analysis of patients who underwent cholecystectomy in the setting of non-traumatic emergent cholecystitis was performed to compare data from two cohorts: the traditional model and the acs between january 1, 2013 and dec 1, 2016 at ochsner medical center, a 600-bed acute care center in new orleans. parameters gathered included 1. time from emergency department to surgical evaluation 2. time from surgical evaluation to operating room 3. operative time 4. percent laparoscopic 5. length of hospital stay 6. intra-operative complications (blood loss, perforation rates, conversion to open) 7. post-operative complications (fever, infection, redo). demographics were also collected including age, weight, height, ethnicity, asa, etc. inclusion criteria included: age[18 and having undergone cholecystectomy between jan 1, 2013 and december 1, 2016. exclusion criteria included choledocholithiasis, gallstone pancreatitis, ascending cholangitis, gangrenous cholecystitis, septic complications precipitating further procedures and delays, or researcher discretion. results: 699 patients were initially identified as having undergone cholecystectomy within the allotted time period [2013 -178, 2014 -166, 2015 -157, 2016 -198] . 470 were excluded due to one of the reasons above. median patient age was 53 years old and the average patient encounter was 3.9 days. conclusion: the acs model is better suited to manage emergent non-traumatic cholecystectomies than the traditional call service at our institution, as evidenced by several parameters. s146 surg endosc (2018) 32:s130-s359 he nailed it background: nail guns are powerful tools and are widely used. injuries with these devices may be devastating due to the significant force they can deploy. patients and methods: we herein report a first case of a self inflicted abdominal injury with a nail gun. results: a 55 year old male with history of coronary artery disease, type 2 dm and early signs of dementia attempted to refill a nail gun. he lodged the device against his right abdomen while the air hose was still attached and then accidently fired 2 nails into his abdomen. after he unsuccessfully tried to pull the nails out he drove himself 25 minutes to our emergency room. he was hemodynamically stable on arrival; pain control was achieved, antibiotics were given and he received tetanus immunization. ct-scan showed the two foreign bodies penetrating from the ruq with one reaching the transverse colon. on emergency laparoscopy, the nails were found to have penetrated the thick omentum and the puncture site of one nail into the colon was identified. the omentum was resected off the colon and the right colon was completely mobilized. no additional injuries were found. the entrance area of the nails was then used to create a loop colostomy. the postoperative course was initially uneventful but the patient developed a severe posttraumatic inflammatory reaction of the fat tissue in the right upper quadrant and had to be readmitted for pain control and antibiotics were again administered. he recovered and was discharged with a plan for laparoscopically assisted colostomy closure after 6 weeks. discussion: to the best of our knowledge this is the first reported isolated colonic injury by a nail gun. given the tremendous force of the device with unknown collateral damage to the surrounding tissue it was decided to manage the accident with a laparoscopic assisted colostomy using the entrance point of the nails for fecal diversion. introduction: it is difficult to diagnose obturator hernias by routine physical examination. obturator hernias are frequently complicated by ileus and the diagnosis is often first made from abdominal ct. obturator hernias are difficult to reduce, and often necessitate emergency surgery. they are common in elderly people, and they often had bad general condition. so it was high in the death rate. at our hospital, we first attempt to reduce the hernia from the body surface under ultrasonographic guidance. after relieving the strangulation, we perform radical operation electively in patients who are for possible for surgery under the general anesthesia. we perform laparoscopic repair for obturator hernias. obturator hernias are often complicated by other types of hernia. in these cases, we perform total repair. herein, we present a review of the patients who underwent surgery for obturator hernia at our hospital. methods: we review the data of 9 cases of obturator hernia encountered by us from february 2012 to december 2014. we performed total repair in three of the cases. however, it is difficult to procure a mesh that would be adequate for all the defects (inner inguinal ring, femoral ring, obturator). no single mesh can fit, because the inguinal and pelvic curves present opposing curves near the obturator. therefore, we placed two pieces of mesh available at our hospital (3d max [bard] and onlay sheet of kugel patch [bard] ) together in the patientswe could successfully cover all the defects using these two pieces of mesh and could fit the mesh to the pelvic shape by devising an appropriate connection between the meshes. results: we reviewed a total of 9 operated cases for obturator hernia. the hernia was bilateral in 7 cases, and complicated by other hernias in 6 cases. we first determined the appropriate approach for the repair. we performed total repair in 3 cases. they were no complications and no cases of recurrence. conclusion: our approach to the repair of obturator hernias was very useful. we can use the exact area and shape of the mesh needed in individual patients by this method. we show the method of shaping the mesh to fit the pelvic form. demin aleksandr, do, ajit singh, do, noman khan, do; flushing hospital introduction: internal hernias are known complications that are well documented to involve peterson's defect. in bariatric patient's post gastric bypass there is a high index of suspicion for internal hernias as well as a low threshold to operate. there have been some debates around the closure of the potential peterson's space with several studies advocating closure versus some which show that there is no difference in the rate of symptomatic internal hernias. we present a case of an unusual cause of small bowel obstruction due to internal hernia caused by a cecal volvulus. it is an atypical presentation however the patient was triaged and brought to the or within 5 hours of admission. although it is rare there have been reports of internal hernias caused by other structures like congenital bands or natural potential spaces. there have been reports of unusual presentations of the cecum herniating through the foramen of winslow. the anatomical rearrangements after bypass create potential areas where an internal hernia can occur. in this case a bowel resection was undertaken due to the anatomical variation of the cecal bascule and cecal volvulus due to high rate of recurrence of this cecal pathology. majority of internal hernias do not require bowel resection especially when detected earlier and prompt surgical exploration is undertaken. mortality as direct consequence internal hernia is extremely rare. however late diagnosis of internal hernias can lead to catastrophic gut loss and may require lifelong tpn and/or visceral transplantation or autologous reconstruction. conclusion: careful history and physical of our bariatric patient can elicit the signs and symptoms of internal hernias and prevent the morbidity and mortality that can come with the complications of this condition. unusual presentations and causes are reason for prompt diagnosis and complete exploration. shingo ishida 1 , naotsugu yamashiro 1 , satoshi taga 2 , koichi yano 2; 1 shinkomonji hospital, 2 shinmizumaki hospital symptomatic cholelithiasis is common disease performed with laparoscopic cholecystectomy (lc). we will hesitate to operate if the patient is pregnant in the third trimester. pregnant patients undergoing laparoscopic surgery have been reported increasingly. however, most case reports are confined to patients in the first and second trimester. we report a patient who underwent lc in the third trimester and review the relevant literature. a 26 -year-old woman in the third trimester (34w2d) of pregnancy was seen in the emergency department of our hospital with a history of upper abdominal pain. there was no problem in the course of pregnancy. the result of the examination proved to be attack of gallstone colic. she was hospitalized the same day and underwent lc the next day. the base of pregnancy uterus was 20 cm above the navel. we needed to consider the surgical approach, for example inserting the first trocar under left hypochondrium. operative duration was 63 minutes. she complained abdominal distension at postoperative day (pod) 1 and 2 but there was no abnormality in the fetus. she was discharged on pod 4. after that she gave birth to a healthy baby. lc in third trimester of pregnancy was safely performed with obstetrics back up. weekday or weekend hospital discharge: does it matter for acute care surgery? ibrahim albabtain 1 , roaa alsuhaibani 2 , sami almalki 2 , hassan arishi 1 , hatim alsulaim 1; 1 kamc, 2 background: hospitals usually reduce staffing levels over weekend. this raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk for adverse events post-discharge. the aim of this study was to assess the outcomes of common acute care surgery procedures for patients discharged over weekend, and identify the key predictors of early readmission. methods: this retrospective cohort study was conducted at a tertiary care hospital between january and december 2016. surgical procedures included were cholecystectomy, appendectomy, and hernia repairs. patients' demographic, co-morbidities, complications, readmission and follow-up details were collected from the electronic medical records. predictors and post-operative outcomes associated with weekend discharge were identified by multivariable analysis using univariable and multivariable logistic regression models controlling for potential confounders. results: a total of 743 patients were included. overall median age was 35 years (iqr: 22, 58). the majority of patients were female (n=397, 53.4%). 361 patients (48.6%) underwent a cholecystectomy, 288 (38.8%) an appendectomy, and 94 (12.6%) hernia repairs. weekend discharge was 16.8% vs. 83.2% of weekday discharge. patients discharged during weekend were younger (34.2 vs. 41, p-value.001, mean) . post-discharge 14-day follow-up visits were significantly lower in the weekend discharge subgroup (83.1% vs. 91.2%, p-value 0.006). overall, 30-day readmission rate was 3.2% (n=24), and did not differ between those of weekend and weekday discharge (or=0.28, 95% ci 0.52-9.70). conclusions: patients discharged on weekends tended to be younger in age and less likely to have chronic diseases. patients discharged over the weekend were less likely to follow up compared to weekday discharge patients. however, the readmissions rate did not differ between the two groups. intrauterine device (iud) migration out of the uterine cavity is a serious complication. its incidence in the us has been reported to be about 0.001% annually. previously published systematic review supports the use of laparoscopic surgery for elective removal of migrated iucds from the peritoneal cavity. we present the safety and efficacy of the laparoscopic approach to this complication in the acute care setting. depicted is an otherwise healthy 40 year old female with no previous surgical history who presented to the ed with worsening abdominal pain for one week with no associated symptoms. on physical exam, patient was non toxic. abdomen was moderately distended with guarding and rebound tenderness to palpation, no rigid. patient had been seen shorlty prior to ed admission by her obgyn and recent work up with abdominal/pelvic x-ray and ultrasound has revealed a misplaced iud in the transverse position (side ways). pregnancy test was negative. based on patient clinical presentation and recent radiologic findings, we decided to proceed with diagnostic laparoscopy. after systematic review of cavity, the foreign body was found to be incorporated within the greater omentum. we procceded, laparoscopically with omentectomy+foreign body removal. there were no perioperative complications, patiet was discharged on the following day. the use of laparoscopy in elective iud retrieval within in the abdominal cavity has been considered standard of care in surgical management to date. this poster demonstrates its use as an effective approach for safe removal of intra-abdominal foreign bodies also in the acute setting. symptomatic inguinal and umbilical hernias in the emergency department: opportunity lost? andrew t bates, md, jie yang, phd, maria altieri, chencan zhu, bs, salvatore docimo, jr., do, konstantinos spaniolas, md, aurora pryor, md; stony brook university hospital introduction: patients with symptomatic inguinal and umbilical hernias often present to the emergency department (ed) when their symptoms change or increase, usually not requiring emergent surgery. however, little is known about how often these patients present prior to eventual repair and whether they undergo surgery at the initial presenting institution. the aim of this study was to assess the clinical flow of patients presenting in the ed for inguinal and umbilical hernia. methods: all patients presenting to eds in new york state from 2005 to 2014 with symptomatic inguinal and umbilical hernias were identified using the new york state longitudinal hospital claims database (sparcs). patients were followed for records of hernia repair and subsequent inpatient and outpatient visits up to 2014. results: 42,950 patients presenting to the ed for symptomatic inguinal hernia were identified. 5.3% (2, 297) of ed presentations resulted in inpatient admissions. 14,491 (33.7%) had repair later and their average time from ed presentation to inguinal hernia repair was 158 (±351) days. 90.1% of patients who did not have subsequent surgery had only one ed visit. of those that underwent interval repair, 79.7% had only one ed visit prior to surgery. for those patients with only one ed visit before repair, 29.3% had repair at a different hospital, as opposed to 48.6% if multiple ed visits were made. 15,297 umbilical hernia patients presenting to the ed were identified. 7.2% (1, 109) resulted in inpatient admission. 3,507 (22.9%) had interval repair, with the average time from ed presentation to umbilical hernia repair being 175 (±369.82) days. 92% of patients who did not record of later repair presented to the ed once. of those patients who underwent repair, 78.5% did so after one ed visit. for those patients with only one ed visit before repair, 32.9% had repair at a different hospital, as opposed to 48.6% if multiple ed visits were made. conclusion: a majority of patients with symptomatic inguinal and umbilical hernias that present to the ed do so once with no subsequent follow-up or repair. for those patients that undergo interval repair, a significant portion willnopt for surgery at other hospitals. a significant proportion of patients with acutely symptomatic inguinal/umbilical hernias who undergo interval repair after a previous ed visit, will opt for definitive surgery at another hospital facility. this represents a missed opportunity for continuity of care for providers and healthcare systems. nikhil gupta, dr, himanshu agrawal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: peritonitis is the inflammation of the serous membrane that lines the abdominal cavity and the organ contained therein and is one of the most common infections, and an important problem that a surgeon has to face. reproducible scoring system that allows a surgeon to determine the severity of intra-abdominal infections are essential to prognosticate the patient. this study was done to compare apache ii scoring and mpi score to assess prognosis in perforation peritonitis. methods: all patients admitted with hollow viscus perforation from 1st november 2015 till 31st march 2017 was included in the study. it was a cross sectional observational study. apache ii and mannheim peritonitis index (mpi) scoring systems were calculated in all the patients in order to assess their individual risk of morbidity and mortality. the outcome variables were studied postoperatively -post-operative wound infection, wound dehiscence, anastomotic leak, respiratory complications, duration of hospital stay, need of ventilator support and mortality. the inferences were drawn with the use of appropriate tests of significance. results: the study comprised of 63 patients. neither apache ii nor mpi could predict postoperative wound infection. the mean apache ii score of 63 subjects included in the study was 11.2±8.1 with range of 0 to 35 and the mean mpi score of 63 subjects included in the study was 26.9±7.2 with range of 6 to 39. apache ii was able to predict postoperative respiratory complications, post-operative need for ventilatory support, hospital stay duration and mortality while mpi was able to predict post-operative wound dehiscence, post-operative respiratory complications, post-operative need for ventilatory support and mortality. neither apache ii nor mpi could predict postoperative anastomotic leak and postoperative wound infection. conclusion: mannheim peritonitis index is a useful and simple method to determine outcome in patients with peritonitis. mpi is comparable to apache ii in assessing the prognosis in perforation peritonitis and can well be used in emergency setting in place of apache ii scoring when time is a definite constraint. microrna-17 and the prognosis of human carcinomas: a systematic review and meta-analysis chengzhi huang, mengya yu; guangdong general hospital (guangdong academy of medical science) muhammad nadeem 1 , julian ambrus, md 1 , steven schwaitzberg, md 1 , john butsch, md 2; 1 university at buffalo, 2 introduction: mitochondria is a small energy producing structure of a cell. mitochondrial myopathy (mm) is mixed disorder clinically, which can affect various systems besides skeletal muscle. mm starts with muscle weakness or exercise weakness. mm patients have decreased skeletal muscle mitochondrial function than the healthy person, because of weakened intrinsic mitochondrial function and decreased mitochondrial volume density. no one has studied the mm role in gerd and constipation so far. this study is aimed to see effects of mm on the gastrointestinal system specifically gastroesophageal reflux disease (gerd), gall bladder issues, and constipation. methods: between may 2011 and june 2016, 101 mm diagnosed patients at buffalo general hospital were included in this retrospective study. we assessed their demeester score for gerd and wexner's constipation questionnaire for constipation. demeester score[14 and constipation score[15 were set points for gerd and constipation respectively. data was analyzed by using spss version 24. mitochondrial enzymes were assessed by using their muscle biopsy report. results: out of 101 (85.1% female, 14.9% male) mitochondrial myopathy patients, 38.6% and 13.9% were suffering from gerd and constipation respectively. 35.1%, 43.4% and 95.9% patients had gall bladder issues, obstructive sleep apnea (osa) and fatigue respectively. mm gerd patients (87.2% female, 12.8 male) had mean demeester score 22.56 (sd: 6.49) more than normal although 76.3% patients were on gerd medications and 29.2% patients had nadh cytochrome c reductase, cytochrome c oxidase and citrate synthase abnormal mitochondrial enzyme in mm associated gerd but 26.1% mm patients had abnormal cytochrome c oxidase enzyme only. mm along with constipation had mean wexner's constipation score 19.14 (sd: 2.568) more than the normal although 94.9% were taking enema, medications or digital assistance. 50% patients had cytochrome c oxidase and nadh cytochrome c reductase enzymes were abnormal in those patients. 29.4% mm associated gall bladder issues patients had cytochrome c oxidase abnormal. 63.6% mm associated gerd and constipation patients had gall bladder issues. conclusion: in this present study, we found that mm had effects on gastrointestinal system causing gerd, constipation and gall bladder issues. gerd, constipation and gall bladder problems are common in mm patients even patients are taking medications for gerd and constipation. cytochrome c oxidase, citrate synthase and nadh cytochrome c reductase are the most commonly impaired mitochondrial enzyme in mm patients and mm associated gerd, constipation and gall bladder issues patients. objectives: gulf war illness (gwi) is a chronic, multisymptom illness marked by cognitive and mood dysfunction and disrupted neuroendocrine-immune homeostasis affecting 30% of gw veterans. after 25+ years, useful treatments are lacking and its cause is poorly understood, although exposures to pyridostigmine bromide and pesticides are consistently identified among the strongest risk factors. previous work in our laboratory using an established rat model of gwi identified persistent elevation of microrna-124 (mir-124) levels in the hippocampus whose gene targets are involved in cognition-associated pathways and neuroendocrine function, suggesting that mir-124 inhibition is a promising therapeutic approach to improve the complex symptoms exhibited by gwi. the purpose of this study was to identify broad effects of mir-124 inhibition in the brain by profiling the expression of genes known to play a critical role in synaptic plasticity, glucocorticoid signaling, and neurogenesis in gwi rats administered a mir-124 antisense oligonucleotide (mir-124 inhibitor). methods and procedures: nine months after completion of a 28-day exposure regimen involving gw-relevant chemicals and stress, rats underwent intracerebroventricular infusion of mir-124 inhibitor (n=9) or scrambled negative control oligonucleotide (n=8) and were implanted with 28-day osmotic pumps delivering 0.1 nmol/day. intranasal delivery of oligonucleotides was performed on additional rats (n=4 per group; daily for 10 days) to determine whether mir-124 inhibition is achievable using a noninvasive procedure. hippocampi were harvested and quantitative pcr arrays were used to profile the expression of focused panels of genes important for 1) synaptic alterations during learning and memory, 2) signaling initiated by the glucocorticoid receptor (known mir-124 target), and 3) neurogenesis. hippocampi were also analyzed by quantitative pcr to examine expression levels of endogenous mir-124. results: upregulation ([2.5 fold change, p.05) of 8 synaptic plasticity genes, 11 glucocorticoid signaling genes, and 4 neurogenesis genes was observed in the hippocampus of gwi rats infused with mir-124 inhibitor compared to scrambled control, consistent with a significant reduction (p\ 0.001) in mir-124 levels detected in rats receiving mir-124 inhibitor. altered gene expression and a reduction in mir-124 levels were not observed in rats after intranasal delivery. conclusion: mir-124 antagonism in the hippocampus upregulates the expression of several downstream targets involved in synaptic plasticity, glucocorticoid signaling, and neurogenesis and is a promising therapeutic approach to improve cognition, emotion regulation, and neuroendocrine dysfunction in gwi. further testing is being pursued to discover the optimal dose for intranasal administration to test viability of this option for ill gw veterans. nikhil gupta, dr, ananya deori, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi background: the ultrasonic dissector, commonly known as the harmonic scalpel, has been in use for achieving haemostasis in surgery for almost 20 yrs. its advantages in breast surgery, especially in the dissection of axilla, have been a matter of debate as previous studies have shown inconsistent results. this study compares the outcomes of the ultrasonic dissector in axillary dissection with that of the conventional electrocautery. methods: patients who were undergoing mrm and bcs with axillary dissection from november 2014 till march 2016 were included in the study. patients were randomized into two groups, group a undergoing axillary dissection with ultrasonic dissector and group b with electrocautery. the operative time, intra-op bleeding, post-op pain, post op drain volume, hospital stay and any other complications were noted in the two groups. results: the numbers of patients in both groups were 35 each. group a had a significantly shorter operative time, both for axillary dissection (30.86 min vs. 40.63 min, p.001) and the total duration (77.20 vs. 90.20 min, p=0.001). the blood loss was significantly less in group a, as measured by the mop count. there was significant reduction in the total post-op drainage volume, which resulted in fewer days of drain in-situ and the total number days stayed in the hospital. there was no significant change in the post-op complications such as haematoma, seroma, flap necrosis, oedema, etc. conclusion: with the use of ultrasonic dissector, the operative time, blood loss and the axillary drainage was significantly reduced. the axillary drainage in turn, reduced the hospital stay. there was no significant difference in terms of complications like haematoma formation, seroma formation, skin flap necrosis or oedema. for the statistical analysis, χ2 or fisher's exact tests to compare proportions and the nonparametric mann-whitney u test for analysis of values with abnormal distribution were used. discussion: the study included 579 patients. all preoperative laboratory indicators were elevated. the laboratory tests do not demonstrate any statistical significance between these two groups. the group of the patients without stones in the cbd diagnosed by ioc was also divided in patients with diameters.8?mm and with diameters≥0.8?mm of the cbd. also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significant difference. all patients underwent ioc. ioc showed stones in 84/113 patients (74. 3%) . a comparison of patients with and without stones at ioc showed similar mean times from hospitalization to surgery (5.9 background: housed in a high volume tertiary referral center, our division receives a large amount of transfers and referrals from outside institutions for patients who require completion cholecystectomies. in this study "completion cholecystectomy" refers to patients that meet one of three criteria: 1. previous subtotal cholecystectomy, 2. previously aborted cholecystectomy, or 3. previous cholecystectomy with incidental finding of cancer on pathology. traditionally, exploration of a reoperative field in the right-upper quadrant mandates an open approach due to dense adhesions and inflammation. over the past few years, we have found that robotic-assisted surgery has allowed us to perform these completion cholecystectomies in a minimally invasive fashion. methods: case logs and operating room billing logs were reviewed from 2010 to 2017 to identify all robotic-assisted cholecystectomies performed at our institution. review of all reports identified 30 completion cholecystectomies. all additional variables including demographics, operative variables, and postoperative outcomes were determined from manual chart review of all consultation notes, operative reports, anesthesia records, progress notes, discharge summaries, and postoperative office visits. results: of the 30 identified robotic-assisted completion cholecystectomies, 16 patients had a previous subtotal cholecystectomy, 11 patients had an aborted cholecystectomy, and 3 patients had an incidental finding of t2 gallbladder carcinoma on pathology. fifteen patients (50%) underwent preoperative ercp either for choledocolithiasis or to determine biliary anatomy. average time from original procedure was 44 months with 30.0% of previous procedures performed in an open approach. average or time was 142.1 minutes, average ebl was 102.1 cc, and average length of stay was 2.1 days. one patient (3.3%) was readmitted within 30 days for nausea that resolved with antiemetics. three patients (10.0%) had minor postoperative complications (clavien-dindo grade 1 or 2) which resolved with pharmacologic therapy. no patients suffered a 90-day mortality. all cases were completed in minimally invasive fashion without a conversion to an open procedure. conclusions: although rare, completion cholecystectomies present a challenging surgical scenario. although traditionally performed in an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion cholecystectomy. we feel that the robotic approach offers certain advantages in a hostile, reoperative field which allows us to perform these procedures in a minimally invasive fashion with no conversions to an open procedure to date. previously limited to case reports, this report of 30 procedures represents the largest case series of robot-assisted completion cholecystectomies to our knowledge. s152 surg endosc (2018) 32:s130-s359 background: percutaneous cholecystostomy tube (pct) has been used as a bridge treatment for grade ii-iii moderate to severe acute cholecystitis (ac) to "cool" the gallbladder down over several weeks and allow the inflammation to resolve prior to performing interval cholecystectomy (ic) and removal of the pct, often laparoscopically. the aim of this study was to assess the impact of timing of ic after pct on operative success and outcomes. methods: a retrospective review of electronic medical records of patients who were treated for ac with a pct, and subsequently underwent ic at our institution between january 2005 to december 2016 was performed. the patients were divided into three groups (n=7 each), based on the duration of the pct prior to ic, and these groups were comparatively analyzed. a comparative sub-analysis of clinical outcomes between patients who underwent surgery within the first week vs. third week or later after pct was also performed. results: a total of 21 patients met the study criteria. each group had 7 patients. there were no statistically significant differences between the 3 groups in regards to age, gender, bmi, imaging findings, and indications for cholecystostomy tube placement. overall, there was no statistically significant difference in outcomes between performing ic within the first 5 weeks, 5-8 weeks and [8 weeks after pct placement. the length of stay, overall morbidity, clavien-dindo grade of complications and mortality were similar between the 3 time intervals. however, a sub-analysis showed that patients who underwent ic within the first week of pct placement had statistically significant higher mortality rate (p=0.048) compared to those who underwent ic[3 weeks of pct placement. the two patients who died in our sample had ic within a week after pct placement. even though there was a statistically significantly higher morbidity rate in those who had ic[3 weeks after pct, the clavien-dindo grade of these complications was lower than. conclusion: delaying ic to [5 weeks after pct placement for ac is not associated with any improvement in patient morbidity, length of stay or rate of conversion from laparoscopic to open cholecystectomy. cholecystectomy within the first week of pct placement is associated with higher mortality rate than after 3 weeks likely due to associated sepsis. introduction: the effect of intraoperative bile spillage during laparoscopic cholecystectomy (lc) on operative time (or time), length of stay (los), postoperative complication rates, and 30 day readmission rates was analyzed. laparoscopic cholecystectomy is the gold standard operation for gallbladder disease in the united states. number of studies have shown that same day discharge in elective laparoscopic cholecystectomy is feasible and safe. bile spillage during this procedure can be a common occurrence in teaching institutions, however, data on the effects of operative outcomes is lacking. methods: this is a retrospective study analyzing all of the laparoscopic cholecystectomies performed at the brooklyn hospital center (tbhc), both emergent and elective, from 2016 to 2017. patient data was collected on demographics, comorbidities, bile spillage, operative findings, complications, los, and 30 day readmission rates. statistical analysis was performed using imb spss statistics v. 19. covaried analysis of variance (ancova) was performed on continues variables and significance levels were calculated. pearson's chi square significance level was calculated for all binomial variables. results: of the 281 patients who underwent lc during this time period, intraoperative bile spillage was encountered in 32 patients. interestingly, bile spillage was significantly more likely to be seen in elective cases over acute cases (11.8% vs 10.8%, p.05). there was a statistically significant increase in or time in cases where intraoperative bile spillage was encountered vs. cases where no bile spillage was encountered (146 vs. 124 min, p=0.007). there was a significant increase in rate of conversion to open procedure when bile spillage was encountered (3.1% vs. 0.4%, p.05 ). drain placement rates increased, not surprisingly, when bile spillage was encountered (34.4% vs. 5.6%, p.05). there was no statistically significant difference in los between cases with bile spillage and cases without (2.47 days vs. 1.75 days). there was no significant increase in complication rate or 30 day readmission rates. conclusions: intraoperative bile spillage significantly increases or time, conversion to open procedure, and drain placement. however, there was no significant effect observed of intraoperative bile spillage on length of stay, complication, and 30 day readmission rates. thus, intraoperative bile spillage appears to have little clinical significance on surgical outcomes. however it may have an impact on overall healthcare costs. larger prospective studies evaluating the effect of intraoperative bile spillage on los, or time, complication rates, and 30 day readmission rates are needed to analyze these effects further. tariq nawaz, md; rawalpindi medical university study design: prospective and observational study. place and duration: from january, 2012 to july 2017. surgical unit ll, holy family hospital, rawalpindi. patients and methods: thousand patients with a diagnosis of cholithiasis were included. exclusion criteria are patient younger than 12 year and older than 80 year. calot's triangle dissection was done meticulously. cystic artery and hepatic artery anomalies and variations were observed and analyzed on spss 21. results: the age varies from 12 to 80 years. on the basis of distributional variation the cystic artery was single in 90% cases, branched in 7% cases and absent in 3% cases. on positional variations the cystic artery was superomedial to the cystic duct in 85% cases, anterior in 7% cases, and posterior in 3% cases and low lying in 5% of the cases. on the basis of length variation results showed that 800 (80%) cases had a normal cystic artery. a short cystic artery was found in 150 (15%) cases and a long cystic artery was present in 50 (5%) cases. other arterial variations are of hepatic artery i.e moynihan's hump (3%) and and right hepatic artery present in calots triangle in 5% conclusions: for the safety of laparoscopic cholecystectomy one should be well aware of the anatomical variations of the cystic and hepatic artery. keywords: cholelithiasis, cholecystitis, laparoscopic cholecystectomy. as small as it gets: micro-invasive laparoscopic cholecystectomy using only two 5 mm trocars and a needle grasper background: the majority of surgeons use four ports including for laparoscopic cholecystectomy (lc). multiple efforts have been made to reduce number and size of ports. left upper quadrant (luq). patients and methods: of 114 lcs performed from 6/2014-4/2017, 109 (96%) were done using three instruments including 55 cases in which 2 trocars and the teleflex needle grasper were used. in 26 cases only two 5 mm trocars were (left upper quadrant (luq) and umbilicus) with the minigrasper being placed between the two. the gallbladder (gb) serosa was incised on both sides and a window was created behind the gb midportion and widened towards fundus and infundibulum. cystic artery (ca) and cystic duct (cd) were dissected out obtaining the critical view and after the last fundus adhesion was cut, ca and cd were secured with clips or endoloop. results: median age of 19 women and 7 men was 42.4 (range 24. 1-77.4) years. lc was done for acute cholecystitis (n=4), chronic cholecystitis (n=8), biliary dyskinesia (n=9), choledocholithiasis (n=5). three patients had an ercp with bile duct clearance prior to the lc. in one case a keith needle was used to suspend the gb fundus for better exposure. twelve patients had additional procedures together with their lc (wedge liver biopsy (4), lysis of adhesions (3) , umbilical hernia repair (1) , mesenteric/lymphnode biopsies (4) . median or time was 51 (range 34-129) minutes. the specimen was removed through the luq port site in 9 patients. there were no vascular or bile duct injuries in this series. 71% of cases were done as outpatient procedures, 25% of patients required 23 hours observation only three patients were hospitalized for medical reasons. conclusion: in selected cases with either small stones or biliary dyskinesia, lc with only two 5 mm ports and a needle grasper is possible. the teleflex minigrasper can completely replace a port based grasper. introduction: the standard treatment for lithiasic acute cholecystitis remains the laparoscopic cholecystectomy despite the timing of surgery is still controversial. the aim of this prospective study is to evaluate the advantages and limitations of early laparoscopic cholecystectomy in a district hospital. methods and procedure: all patients undergoing laparoscopic cholecystectomy at the surgical department of "carlo urbani" hospital in jesi (italy) from may to september 2017 were consecutively enrolled. clinical data such as gender, age, bmi, comorbidity, previous abdominal surgery, previous acute cholecystitis were collected. subsequently, the patients were arranged in two groups according to the timing of intervention (early versus elective surgery). for each group, we compared data concerning surgery, such as operative time, intraoperative and postoperative complications, length of hospital stay and cost analysis. results: this study is a part of an ongoing research. so far, we collected 67 laparoscopic cholecystectomies. ten (15%) of them were admitted with acute cholecystitis and were operated during the hospital stay (group a). group b included patients scheduled for elective surgery (n=57; 85%). the two groups were comparable with respect to clinical data. conversion to open approach was performed in 3 cases, all of them in group b. mean surgical time was 67.5±22.01 minutes in group a and 62.4±19.77 minutes in group b (p=0.494). no significant differences in intraoperative and postoperative complications rates were seen in the two groups, just a few in both of them. mean overall length of hospitalization was 6.4±3.89 days in group a and 2±1.63 days in group b (p= 0.001), whereas the difference in length of postoperative hospitalization was not statistically significant. due to the extended hospitalization for group a, the cost increase as compared to group b was statistically significant, too. conclusions: early laparoscopy is comparable to delayed laparoscopy in terms of postoperative hospitalization and complications in the management of acute cholecystitis. a longer hospital stay among patients scheduled for immediate surgery may be associated with a more time-consuming diagnostic work-up before surgery. however, in future research we expect to enhance our cost analysis with more data regarding the costs incurred in the first hospitalization reserved to nonoperative treatment of group b inpatients with acute cholecystitis. s154 surg endosc (2018) introduction: with improvements in healthcare access and technology, admissions of octogenarian population with acute cholangitis (ac) are increasing. octogenarians are vulnerable to inferior outcomes. there is no study to evaluate factors predicting outcomes of ac in octogenarians. the aim of our study is identify factors predicting outcomes, and to evaluate the quick sequential organ failure assessment (qsofa) score and tokyo guidelines 2013 (tg13) severity grading for octogenarian patients with ac. methods: a retrospective review of octogenarian patients admitted with ac from january 2010 to december 2016 was performed. demographic profile, clinical presentation and discharge outcomes were studied. systemic inflammatory response syndrome (sirs), qsofa and tg13 severity grading scores were calculated. mortality is defined as death within 30 days of admission or in hospital mortality. statistical analysis was performed using spss version 21. results: there were a total of 1875 patients admitted for ac, of which 284 (15%) were octogenarians. majority (n=167, 59%) were female, with a mean age of 83 (range 80-86) years. majority were secondary to gallstones (n=197, 69%), and 53 (19%) were due to malignancies. 140 (49%) and 8 (3%) patients fulfilled sirs and qsofa criteria of severity respectively. 142 (50%) and 93 (33%) of patients had a tg13 severity grading of moderate and severe respectively. nine (3%) patients required inotropic support in the emergency department (ed) and 48 (17%) patients were admitted to critical care unit (ccu). 166 (58%) patients underwent endoscopic retrograde cholangiopancreatography (ercp) and 33 (12%) underwent percutaneous transhepatic biliary drainage (ptbd) for biliary decompression. 8 patients underwent index cholecystectomy. length of stay was 11.5 (range 1-91) days and 30-day mortality of 11%. multivariate analysis performed showed that an abnormal glasgow coma score (p=0.017) and malignancy (p.001) predicted 30-day mortality. the use of ed inotropic support predicted ccu admission (p=0034). a positive blood culture (p=0.005), presence of malignancy (p.001), use of ed inotropes (p=0.001), and index cholecystectomy (p=0.008) predicted a longer length of stay. qsofa (p.001) and tg13 severity grading (p=0.001) were predictive of 30-day mortality. sirs criteria did not predict 30-day mortality. conclusion: reduced consciousness and malignancy predicted 30-day mortality in octogenarian patients with ac. qsofa and tg13 severity grading system is superior to sirs criteria in predicting mortality of octogenerians with ac. our group has performed needlescopic grasper assisted silc (nsilc) to overcome these problems. we evaluate the technical feasibility, safety and benefit of nsilc versus three-port laparoscopic cholecystectomy (tplc). methods and procedures: this prospective randomized control study was conducted to compare the advantages if any between the nsilc and tplc. one hundred and forty eight patient were randomized into two groups, with one group underwent n0slic (74 patients) and a control group underwent tplc (74 patients). basic information about the patient and diagnosis was collected. the surgical outcome that was composed with critical view of safety (cvs) time, major procedure time and total operation time, and the comparison of postoperative complication was made. result: nsilc group was consisted of 20 male (27.0%) and 54 female (73.0%), and tplc group was consisted of 32 male (43.2%) and 42 female (56.8%) (p=0.038). the average age of nsilc group was 44.5±13.2 years old, and tplc group was 52.5±15.2 years old (p=0.003). cvs time of tplc group was shorter than silc group (nsilc: 14.4±8.9 min, tplc: 10.0±7.1 min, p=0.002), major procedure time (skin incision to gb removal from liver bed) of tplc group was shorter than nsilc group (silc group: 21.7±15.3 min, tplc: 10.6±8.4 min, p=0.002). however, there was no significant difference in postoperative complication (nsilc: 3, tlc: 6, p=0.634). conclusion: although cvs time, major procedure time, and operation time of silc were longer than tplc, overall clinical results were similar. nsilc is feasible and safe surgical procedure in patient with benign gallbladder disease. introduction: management of malignant biliary obstruction not amenable to surgery is usually by means of ercp or pthc. however, on occasions, these routes are not accessible and the alternate decompressive technique of percutaneous cholecystostomy (pc) has to be adopted. the aim of this study was to evaluate the efficacy and outcomes of pc in a highly selected series at a tertiary referral center. methods: we retrospectively reviewed all patients that had undergone pc from 2000 to 2014. data collected included baseline demographics, comorbidities, details of pc placement and management, etiology of mbo, and post-procedure outcomes. the charlson comorbidity index (cci) was calculated for all patients at the time of pc. results: four hundred and eight patients underwent pc placement of which 28 patients including 18 (64%) males and 10 (36%) females, with malignant biliary obstruction. the mean age at the time of pc placement was 63.5±11.7 years of age, and the mean cci was 8.03±2.82 for all patients. of mbo in all 28 patients was due to pancreatic malignancies (n=14), cholangiocarcinoma (n=6), primary hepatic malignancies (n=3), secondary hepatic tumors (n=4), and ampullary carcinoma (n=1). pc tube complications were reported in 7 (25%) patients. mean number of tube exchanges was 3.4±2.65. mean duration from pc tube placement to death was 159±159.4 days. 14 total deaths were recorded. conclusion: pc placement appears to be a viable option in mbo in elderly and frail patients. in this cohort, pc may be a potential definitive management to improve quality of life. melanie boyle, daivyd palencia, philip leggett; houston northwest medical center background: there are very few studies assessing the relationship between gastroesophageal reflux and biliary disease. this is surprising as they share presenting symptoms as well as risk factors, particularly obesity. our group previously produced a review of 36 patients in our practice who had undergone some type of reflux procedure. conclusions showed that the prevalence of gallbladder disease in our severe reflux population is much higher compared to that found in the general population. our goal of this study is to expand on that data to include a larger sample size to investigate the incidence of biliary disease in our reflux population and decide if this should influence our pre-operative algorithm for anti-reflux surgery patients. methods: we expanded on our previously performed retrospective review of patients that underwent laparoscopic fundoplication for reflux disease. we previously reviewed data from 2015 to 2017. we are now looking at data from 2012 to 2017. our expected sample size will include approximately 150 patients, 75 of which have currently been reviewed. our previous study included only 36. the surgery preformed was either a toupet or nissen fundoplication, and one underwent a dor. demographic data, imaging studies, and pathology results were reviewed. results: we looked at whether each patient who underwent antireflux surgery had a prior cholecystectomy either remotely or recently, underwent concomitant cholecystectomy, or had no biliary disease in their workup. the groups had similar age and were predominantly women. we once again demonstrated that the prevalence of gallbladder disease in our severe reflux population is much higher than the general population. when approaching a patient with gastroesophageal reflux disease, attention should be paid to gallbladder symptomatology as well. we recommend that it may be beneficial to include gallbladder ultrasound in pre-operative workup for antireflux surgery so that concomitant cholecystectomy can be performed if indicated. steven schulberg, do, jonathan gumer, do, matt goldstein, vadim meytes, do, george ferzli, md; nyu langone hospital -brooklyn introduction: acute cholecystitis is a common surgical disease with roughly 500,000 cholecystectomies performed in the us annually. the current dogma revolves around the "72 hour rule" advocating early cholecystectomy if within the window, and if beyond 72 hours, conservative treatment and interval operation. in patients beyond the 72 hour window, as well as with multiple comorbidities, advanced age, and other complicating factors, cholecystostomy has become an acceptable treatment as a bridge to interval cholecystectomy. while this has become an appropriate treatment modality, it does not come without its own set of complications. we aim to evaluate the rate of complications in our institution. methods: this is a retrospective review of all patients at our institution who underwent cholecystostomy placement between 2013 and 2016. we evaluate the comorbidities, readmission rate, overall rate of complication associated with cholecystostomy tubes, and eventual definitive cholecystectomy. results: our cohort includes 100 patients, 52% of whom were male, with a mean age of 71. we had an overall complication rate of 49.5%, including tube dislodgements, leaking tubes, and misplaced tubes. all cause readmission rate was 56% and only 32% of patients who had cholecystostomy drains underwent interval cholecystectomy. conclusion: there has been much interest in treatment of acute cholecystitis in patients with multiple comorbidities. in review of our data, a surprisingly large number of patients had mechanical complications involving the cholecystostomy drain. in an era focused on decreasing readmission rates and their associated costs, drains carry a high risk of malfunction which will in turn, lead to increases in these two metrics. while there is more work to be done in the evaluation of early cholecystectomy versus cholecystostomy in this subgroup of patients, we suspect that early cholecystectomy in the medically optimized patient will lead to reduced length of stay and hospital costs as well as increased patient satisfaction. does selective use of hepatobiliary scintigraphy (hida) scan for diagnosis of acute cholecystitis, following equivocal nondiagnostic gallbladder ultrasonography, affect outcomes fahad ali, ba, amir aryaie, md, eneko larumbe, phd, mark williams, md, edwin onkendi, md; texas tech university health sciences center introduction: acute cholecystitis (ac) is diagnosed by characteristic gallbladder ultrasonographic findings (high specificity, low sensitivity). hepatobiliary scintigraphy (hida) may be needed to confirm ac (higher sensitivity and specificity). the aim of this study was to assess the impact of the current selective use of hida scan for sonographically equivocal cases of ac on outcomes. methods: a retrospective chart review of patients treated for ac at our institution (1/2015 to 12/2016) was performed. patients were divided into 2 groups: the ultrasound only group (us-only) and the ultrasound-hida group (us-hida). timing of us and hida, and intervention for ac since presentation to emergency room (er), and their impact on outcomes were analyzed. ac severity was graded per the tg3-tokyo guidelines. results: a total of 110 patients were analyzed. the 2 groups were statistically similar with regards to age, body mass index, asa class ii, iii and iv, extent of leukocytosis at presentation and liver functions test levels at presentation. in the us-only group, diagnostic ultrasound was obtained sooner, [median of 3 (interquartile range, iqr 1.3-8.7) hours] from presentation to the er compared to the us-hida group, ) hours], p=0.007. hida was obtained after a median delay of 11.5 (iqr 3.7-25) hours from a nondiagnostic ultrasound. majority of patients (87%) in the us-only group had mild (tg3 grade i) to moderate (tg3 grade ii) ac, while 78% of the us-hida group had moderate (tg3 grade ii) to severe (tg3 grade iii) ac (p=0.003). despite this, more patients in the us-hida group (39%) had a "normal" non-diagnostic ultrasound compared to the us-only group (4.3%), p.001. seven patients in the us-hida group had no intervention due to normal hida scan (2) , ac misdiagnosis due to liver cirrhosis (1) , and severe medical comorbidities (4) . more patients (74%) in the us-only group underwent laparoscopic cholecystectomy, compared to 39% in the us-hida group (p=0.006). between the two groups, there was no significant differences in 90-day morbidity, mortality and reoperations. however, the length of stay was longer by a median of 3.5 days in the us-hida group (p=0.003). conclusion: patients with moderate to severe ac are more likely to need hida scan due to a "normal" non-diagnostic ultrasound, have a delay in diagnosis, not have intervention for ac due to severe medical comorbidities and have lower chance of laparoscopic cholecystectomy. the length of hospital stay is significantly longer for these patient by a median of 3.5 days. introduction: benign gallbladder disease is commonly treated with laparoscopic cholecystectomy (lc). gallbladder cancer (gbc) is a rare malignancy characterized by high invasiveness and poor survival. in our institution, all gallbladder specimens are routinely sent to pathology, to rule out gbc. the purpose of our study was to assess the efficacy for routine histopathology of gallbladder specimens after cholecystectomy (cly) for all gallbladder disease. methods and procedures: after obtaining approval from our institutional review board, a retrospective review was conducted on all patients who underwent cly from june of 2012 to may 2016 were included in the study. the data obtained include gender, age, american society of anesthesiologist score (asa), body mass index (bmi), comorbidities, length of stay (los), radiological imaging and pathology results. independent t and chi-square tests were performed using ibm® spss® 24 software. results: there were 903 cly performed at our institution, of which 842 (93%) were lc. females composed of 675 (75%) patients and the median age was 48.7 (1%) gallbladder specimens were found to be cancerous. 896 (99%) gallbladder specimens were benign. majority 533 (59%) were chronic cholecystitis, 238 (27%) were acute cholecystitis and 22 (2%) were gangrenous cholecystitis. 29 (3%) were found to be acalculus cholecystitis and 5 (1%) were cholelithiasis. 69 (7%) were found to be adenomyositis, and other. conclusion: in our institution, less than 1% (7) of all gallbladder specimens were found to be cancerous. it would decrease cost and work load if gallbladder specimens are selectively sent to pathology. emanuel a shapera, md 1 we sought to determine clinical factors associated with recurrent cholangitis in two las vegas community hospitals to aid providers in management of this disease. methods and procedures: retrospective, multi-center study. over 4000 ercps were analyzed between 2010 and 2017. 24 patients were identified as having multiple (60) admissions for cholangitis per tokyo criteria. univariate and multivariate analysis was conducted. results: patients with a significantly (p.0001) higher albumin level on admission (3.7) were discharged home more often than patients discharged to a facility or hospice (2.7). on multivariate analysis, non-home discharge was associated with lower albumin level at admission (p=0.0055) and greater maximum temperature prior to decompression (p=0.0354). increased hospital stay was associated with lower albumin level at admission (p=0.0019). a majority (31/60) of recurrent episodes involved stent placement, exchange or removal. 14 patients (58%) had either biliary malignancy, gallbladder or both. blood cultures were drawn in 52% of all episodes and positive in 45%, e coli being the most common pathogen isolated. all patients had low hdl levels (6-36, mean 22) . conclusions: high fevers and poor nutritional status was associated with increased length of hospital stay and fewer home discharges. tumors, gallbladders and malfunctioning stents contribute substantially to morbidity. close follow up for indicated gallbladder removal, stent management and nutritional optimization is critical to reduce the burden of this disease. we compared the surgical method in neonate choledochal cyst between oec and lec. the perioperative and surgical outcomes that were reviewed included age, operative time, postoperative hospital stay, time to diet, and surgical complications. the patients were followed up for 42 months (range, 9-146 months) . results: there was no difference in range of bile duct excision and manner of roux-en-y hepaticojejunostomy between oec and lec groups. there was no intraoperative complication in both groups and no open conversion in the lec group except one case which was ruptured choledochal cyst. the median age of oec and lec groups were 13 days (range, 2-30) and 12.5 days (range, and median body weight at the time of operation were 3.50 kg (range, 2.64-4.22 ) and 3.32 kg (range, 2.73-4.22) , respectively. the median operative time was 163 minutes (range, 126-336) in oec and 237.5 minutes (range, in lec groups and there was no significant difference between oec and lec groups (p=0.116). intraoperative bleeding was minimal in both groups. the postoperative hospital-stay, time to start diet, and time to return to full feeding had no significant differences in both groups. after discharge, 5 of 19 (26%) oec patients experienced readmission due to cholangitis and ileus, while there were none in the lec group. conclusions: this study revealed that lec had better prognosis compared to oec. lec provided an excellent cosmetic result. so we suggest lec could be the treatment of choice for neonatal choledochal cyst. this is a small series, therefore future studies will have to include a larger number of patients and evaluate long-term follow-up. keywords: choledochal cyst, laparoscopy, neonate. laparoscopic narrow band imaging for intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma: a preliminary study yukio iwashita, hiroki uchida, teijiro hirashita, yuichi endo, kazuhiro tada, kunihiro saga, hiroomi takayama, masayuki ohta, masafumi inomata; oita university faculty of medicine introduction: determining tumor invasiveness before operation is one of the most important unsolved issues in the management of gallbladder cancer. we hypothesized that the assessment of irregular vessels on the gallbladder wall may be useful for detecting subserosal infiltration. we present an initial report on the clinical usefulness of laparoscopic narrow band imaging (nbi) for the intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma. methods: thirteen patients with gallbladder cancer were included in this study. patients with tumors located in the liver bed and those with definitive invasion observed on computed tomography findings were excluded from this study. gallbladders were observed using nbi and the microvasculature was evaluated. according to previous reports of endoscopic nbi, we defined four findings as positive: vessel dilatation, tortuousness, interruption, and heterogeneity. the nbi findings were compared with postoperative pathological findings. the study protocol was approved by the institutional review board of the oita university. results: the serosal surface of the tumor site and its microvasculature were successfully observed in all 13 patients. laparoscopic nbi detected at least one abnormal finding in seven patients, and postoperative pathology showed subserosal infiltration accompanied by vessel invasion. on the contrary, six patients with no positive nbi findings showed mild or no subserosal infiltration and no vessel invasion. conclusions: our study indicated that laparoscopic nbi may be useful for diagnosing subserosal infiltration accompanied by a vessel invasion. shuichi iwahashi, mitsuo shimada, satoru imura, yuji morine, tetsuya ikemoto, yu saito, hiroki teraoku; department of surgery, tokushima university introduction: laparoscopic cholecystectomy (lap-c) is the standard operation for the benign diseases. we have reported reduced port lap-c (rpl-c) was safely and comparable method to sils-c and conventional lap-c (sages 2017) . in this time, we examined the utility of rpl-c containing the post-operative adverse event. procedures: the adjustment is the benign illness including the cholecystolithiasis, and advanced obesity and the cases of the inflammation remaining have been excluded. the incision is put and cut open the abdomen to the umbilical region, and camera port was inserted. we used 5 mm flexible scope. 3 mm forceps for holding of the gallbladder bottom and left hand of operator were inserted directly with no port. methods: rpl-c has been introduced in this department since july, 2009. we performed 224 cases of lap-c, containing sils-c and american style conventional lap-c, and we performed rpl-c has been performed already 156 cases. we compared the patient background and the operation factor between rpl-c, sils-c, conventional lap-c. operators were young surgeons, they were not specialists of gastroenterological surgery or endoscopic surgery. results: the difference was not admitted in the age, gender, the physique, and the disease, and the difference was not admitted in hospital stay after the operation (rpl-c:sils-c:conventional lap-c=5.3±0.2 days:5.5±0.2 days:6.7±1.0 days) and the amount of blood loss (rpl-c:sils-c:conventional lap-c=4.7±0.9 ml:9.0±1.9 ml:9.6±4.2 ml) and operation time (rpl-c:sils-c:conventional lap-c=129±3 min:118±6 min:136± 3 min). and surgical wound after rpl-c was cosmetically acceptable. regarding as the post-operative adverse event, there were no patients of bile duct injury. conclusion: in the patients on reduced port lap-c, there were no bile duct injuries of postoperative adverse event. reduced port lap-c is safely for young surgeons and comparable method. introduction: acute cholangitis is an ascending infection of the biliary tree secondary to obstruction and can be severe if proper intervention and treatment are not performed in a timely fashion. the most common management of cholangitis with ductal obstruction due to choledocholithiasis is intravenous hydration, empiric antibiotic therapy, endoscopic retrograde cholangiopancreatogram (ercp) with sphincterotomy and stone extraction with or without stent placement, followed by a delayed laparoscopic cholecystectomy. we present the case of a patient with blood clot obstruction of a common bile duct (cbd) stent after ercp with sphincterotomy and stone extraction. case presentation: a 58 year old male presented to the emergency department with jaundice, right upper quadrant abdominal pain, truncal pruritis, nausea, vomiting, and fever. biochemical analyses and liver profile demonstrated an elevated white blood cell count, hyperbilirubinemia, and elevated liver enzymes consistent with cholestasis. biliary ultrasound demonstrated multiple gallstones and dilation of the cbd with a distal obstructing calculus. he proceeded to ercp where biliary cannulation was achieved, sphincterotomy performed, and a large amount of sludge and pus was drained. an 8 mm stone was removed from the cbd by balloon sweep with completion cholangiogram demonstrating no filling defects. a stent was then placed in the cbd with adequate flow. following the procedure, the patient continued to have increasing hyperbilirubinemia. a repeat ercp revealed a large blood clot and continued bleeding at the previous sphincterotomy that resolved with epinephrine injection. the former stent was visualized in the proper position, removed with a snare, and found to be fully occluded with blood clots. after retrieval of additional clots, a new stent was placed with adequate return of bile. the patient recovered with resolution of his symptoms and hyperbilirubinemia with laparoscopic cholecystectomy. discussion: cholangitis is characterized by charcot's triad of right upper quadrant abdominal pain, fever, and jaundice due to an ascending bacterial infection of the biliary tree coinciding with obstruction of biliary flow most commonly from gallstones. cholangiography via ercp with associated sphincterotomy, stone extraction, and stenting is both diagnostic and therapeutic. while debated by endoscopists, stent placement has shown to reduce recurrent biliary complications, decrease length of hospital stay, and lessen morbidity. although pancreatitis is the most common cause of hyperbilirubinemia post-ercp, stent occlusion secondary to stones or blood clots should be considered to effectively treat patients. proper hemostasis is important in any procedure and close patient follow-up should be performed to prevent further complications. sarrath sutthipong, md, panot yimcharoen, md, poschong suesat, md; bhumibol adulyadej hospital background: choledochal cyst (cc) is a rare disease, characterized by dilatations of the extra-or/ and intrahepatic bile ducts. ccs occur most frequently in asian and female populations. cc is associated with biliary lithiasis and considered at risk of malignant transformation. todani's classification dividing cc into 5 types is the most useful in clinical practice. the current standard treatment is complete cyst excision with roux-en-y hepaticojejunostomy and cholecystectomy for the extrahepatic disease (todani type i and iv). in this report we present our experience using a total laparoscopic technique to treat adult patients with cc in 5-year period. methods: a retrospective review of the records of the patients above 15 years who underwent laparoscopic cyst excision and roux-en-y hepaticojejunostomy in our hospital between january 2013 and may 2017 was carried out. the data included the clinical presentation, investigation, perioperative details and complication. the type of cc was classified according to todani's classification. results: seven cases of cc were reviewed, 6 females and 1 male with mean age 33 years (range 20-65 years). these included 5 cases of todani type ib and 2 cases of type 4a. the predominant symptoms were chronic abdominal pain and jaundice. a case of both pancreatitis and cholangitis were also seen. investigations included ultrasound with mrcp in 6 cases and ercp in 1 case. the mean operative time was 4 hours and 20 minutes (3 hours 30 minutes to 5 hours range) with mean intraoperative blood loss 85 ml (range 20-200 ml). all the resected specimens showed chronic inflammation. malignancy was not seen in any patients. the early postoperative complications included bile leakage with intra-abdominal collection in 2 patients, which were managed conservatively (evidenced by clinical status and imaging study), re-operation was not required. the median duration of hospital stay was 8 days (range 6-23 days). there was no perioperative mortality. all patients were followed up at 1, 6, and 12 months postoperatively, late complication were not detected during each visit. conclusion: in our opinion, laparoscopic cyst excision and hepaticojejunostomy could offer more feasible and safe methods of treatment for ccs in adult patients with potentially less postoperative morbidity, a shortened length of stay and a lower blood loss when compared to the preferred open approach. however, we would need to study this on a larger sample of patients to report the efficacy and safety of laparoscopic approach. endoscopic trans-papillary gallbladder drainage (etgbd) in acute cholecystitis: a single center experience arun kritsanasakul, chotirot angkurawaranon, jerasak wannapraset, thawee rattanachu-ek, kannikar laohavichitra; rajavithi hospital background: surgery is the mainstay of treatment for cholecystitis, however, it may not be safe or feasible in some circumstances such as severe cholecystitis or cholecystitis in extremely high-risk patients. gallbladder drainage may be an appropriate alternative or a bridging option prior to cholecystectomy. endoscopic trans-papillary gallbladder drainage (etgbd) has been proposed as a modality that is feasible and effective in cholecystitis. objective: the primary outcome of this study is to evaluate the effectiveness of etgbd. the secondary outcome is to evaluate the safety, early experience outcomes, and complications of this procedure. methods: retrospective medical records review between january 2014-december 2016 from a single tertiary referral hospital center, rajavithi hospital, bangkok, thailand. a total of 6 patients who was diagnosed with cholecystitis and underwent etgbd. the procedure was performed at the endoscopic suite under light sedation via total intravenous anesthesia. the patient demographic data and procedures were collected. the technical success of etgbd was defined as decompression of the gallbladder by successful cystic duct stent placement. the clinical success was defined as resolution of symptoms and/or improved laboratory data or ultra-sonographic findings. results: a total of 6 patients underwent etgbd. among these patients, 4 were high risk for surgery due to age or comorbidity, 1 had concomitant jaundice and 1 was failure of medical treatment. both technical and clinical success of etgbd was achieved in 4 of 6 cases (67%). the two patients that did not achieve technical success were due to failure to cannulate guidewire through cystic duct and the other had trans-cystic guidewire perforation that needed surgical intervention. there were two intra-operative complications (33%). one was the patient who had trans-cystic guidewire perforation and another had anesthesia-related complication (hypoventilation requiring endotracheal intubation). there were no 30-day mortality. conclusion: endoscopic trans-papillary gallbladder drainage is an alternative treatment modality for patients with cholecystitis who are at high-risk for surgery and or those who are unsuitable for percutaneous gallbladder drainage. the technique is feasible, however, careful case selection and high endoscopic skill is needed. julia f kohn, bs 1 , alexander trenk, md 2 , woody denham, md 2 , john linn, md 2 , stephen haggerty, md 2 , ray joehl, md 2 , michael ujiki, md 2; 1 university of illinois at chicago; northshore university healthsystem, 2 northshore university healthsystem introduction: subtotal cholecystectomy, where the infundibulum of the gallbladder is transected to avoid dissecting within a heavily inflamed triangle of calot, has been suggested as a method to conclude laparoscopic cholecystectomy while avoiding common bile duct injury. however, some case reports have suggested the possibility of recurrent symptoms from the remnant gallbladder. this retrospective case series reports a minimum of two-year follow-up on patients who underwent subtotal cholecystectomy within one four-hospital system. methods: a retrospective chart review database containing 900 randomly selected cholecystectomies, all of which occurred between 2009 and 2015, was reviewed to identify all instances of subtotal cholecystectomy. charts for these patients were reviewed through 09/2017, including any documentation from other providers, including primary care. results: six patients who underwent subtotal cholecystectomy with a remnant of infundibulum left following surgery were identified. surgical approach and the choice to perform subtotal cholecystectomy were dependent on the attending surgeon; all decisions were made intraoperatively. there was an average of 70 months of follow-up for these patients within our institution. discussion: this case series adds six cases to the literature surrounding long-term outcomes in patients who underwent subtotal cholecystectomy. although one patient was lost to follow-up, no patient had recurrent biliary colic or other complications arising from the remnant gallbladder. this may be encouraging to surgeons who feel that subtotal cholecystectomy with an infundibular remnant is the safest way to proceed with cholecystectomy in patients with severe inflammation. objective: this study aims to evaluate the utility and efficiency of icg as an alternative to routine intraoperative cholangiogram in patients undergoing cholecystectomy. introduction: common bile duct injury is an uncommon, but serious complication associated with laparoscopic cholecystectomy. current guidelines state that when used routinely intraoperative cholangiogram (ioc) can decrease biliary injury, however it is not routinely used due to increased time of operation, and inaccessibility of equipment. indocyanine green (icg) has been found to be effective for identification of biliary anatomy during cholecystectomy, however has not yet been widely adopted. we aim to assess if icg is able to overcome the obstacles of ioc, while still effectively assessing biliary anatomy. methods: we performed a retrospective analysis of laparoscopic cholecystectomies performed in a single institution from january 2014 to september 2017. elective and emergent cases were included. we stratified patients into icg and non-icg groups. patients who had concomitant procedures performed were excluded. we analyzed patient demographic information, as well as bmi, asa classification and comorbidities in both groups. our primary outcome was operation time (skin to skin), and laparotomy conversion rate. secondary outcomes were effectiveness of icg in visualizing biliary anatomy, and cost. results: 145 patients were included in our study, 59 in the non-icg arm and 86 in the icg arm. both groups were similar in background. there were no statistical differences in patient demographics, asa classification, bmi, or comorbidities. there was no statistical difference in operation time (58.0 vs 54.5 minutes; p.202) or conversion rate (1.6 vs 0%; p.226). icg was able to delineate biliary anatomy in 100% of the patients. the cost of a 25 mg/vial kit of icg is approximately $70. conclusion: the use of icg does not increase operating time during laparoscopic cholecystectomy. icg is an inexpensive and effective tool used to delineate biliary anatomy without the inherent burden and limitations of ioc. benefsha mohammad, md 1 , michele richard, md 1 , steve brandwein, md 2 , keith zuccala, md 3; 1 danbury hospital, 2 danbury hospital department of gastroenterology, 3 introduction: obesity is a prevalent issue in today's society, which has increased the number of gastric weight loss surgeries. this presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ercp). in gastric bypass patients, traditional ercp via the mouth in these patients is technically more challenging, requiring a longer endoscope with a reported success rate of less than 70%. a solution is laparoscopic assisted ercp (la-ercp) via gastrostomy. this minimally invasive technique has become increasingly more prevalent and safe. we present our experience with la-ercp at our teaching community hospital in a large cohort of patients. methods and procedures: retrospective chart review was performed on all patients with a history of prior laparoscopic gastric bypass surgery who underwent la-ercp from april 2008 to april 2016. the procedure was performed by two different general surgeons and one gastroenterologist. a pursestring suture and transfacial stay sutures were used to bring the gastric remnant to the abdominal wall. a gastrostomy was then created and accessed by the duodenoscope to perform the ercp. biliary sphincterotomy, papillary or biliary dilation, lithotripsy, stent placement, and/or stone removal were performed as indicated. we observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital re-admission and bile leak. results: thirty-two patients met inclusion criteria. six patients were male and twenty-six were female, with mean ages of 59 (std dev 7) and 53 years (std dev 15), respectively. indications for la-ercp included suspected choledocholithiasis (25/32), cholangitis with choledocholithiasis (2/ 32), acute pancreatitis (2/32), abdominal pain with abnormal lft (1/32), cholangitis with cholecystitis (1/32), and bile leak (1/32). la-ercp was successfully performed in all thirty-two patients. biliary cannulation, sphincterotomy and stone extraction were performed on 31/32 patients, and one patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. one patient developed acute pancreatitis with elevated pancreatic enzymes which resolved after conservative treatment. one patient required a second la-ercp for stent replacement due to a persistent bile leak. the median length of stay was 2 days (range 1-10 days). conclusions: la-ercp is a safe and feasible alternative to open surgery, and can be safely implemented at community hospitals with adequately trained providers. obesity is a growing burden on society, increasing the incidence of weight loss surgery. our large study proves that in this minimally invasive era, la-ercp provides gastric bypass patients a safe alternative with less pain and increased satisfaction. ahmed elgeidie, elsayed adel; gastrointestinal surgery center background: endoscopic sphincterotomy (es) is an effective therapeutic procedure for common bile duct (cbd) stone clearance but it carries a substantial risk of recurrent stones at long-term outcome. aim of the study: to evaluate the rate of cbd stones recurrence after primary complete endoscopic clearance, and to identify the risk factors of recurrence. methods: between january 2002 and december 2016, 2255 patients with cbd stones who underwent successful es and complete stone clearance were studied retrospectively. recurrent cbd stone, was defined by the confirmation of the presence of cbd stone at least 6 months after previous complete cbd stone clearance by es. the risk factors for recurrent cbd stones and mean time interval between initial es and stone recurrence were analyzed. results: in total, 2255 patients we included. the median follow up period was 89 months. recurrent cbd stones appeared in 159/2255 (7.05%) patients after a median time interval of 22 (6-216) months following es. stone recurrences were observed on multiple occasions in 20 patients (0.88%). on the univariate analysis, the significant risk factors related to recurrent cbd stone were male sex (p=0.001), previous history of cholecystectomy (p=0.001) multiple cbd stones (p= 0.001), large cbd stone (p=0.001) the presence of periampulary diverticulum (p=0.001) and stone crushing using mechanical lithotripsy (p=0.001) conclusion: recurrence of cbd stones is an identified long-term risk after es and stone clearance. background: laparoscopic cholecystectomy during advanced pregnancy is challenging due to the limited intraabdominal space. patients may be at increased risk for developing trocar site hernia. case report: a 35 year old hispanic female in her 22th week of pregnancy came to the er with acute right upper quadrant pain. due to lack of accessibility she had poor prenatal care. she had mildly elevated amylase but normal lfts and ultrasound showed some gallbladder wall thickening suggestive for acute cholecystitis and no dilated biliary duct. fetal ultrasound was normal. she was admitted to the hospital and started on antibiotics, obstetrics was consulted. her amylase peaked at [600 u/l but then normalized and indication for laparoscopic cholecystectomy was made. mrcp and ercp were not performed as it was assumed that the patient had passed a stone. five mm trocars were placed in the luq and the umbilicus and a teleflex minigrasper between the tow. the uterus was found at the umbilical level. the gb was pulled out and the serosa was incised on both sides and a window was created behind the gb midportion and widened towards infundibulum and fundus. there was gb wall thickening and edema. the critical view was obtained and the cystic artery and duct were clipped and divided. the common bile duct appeared normal and no ioc was done. the specimen was retrieved through the luq port site using a 5 mm endobag after dilatation to 1.5 cm due to the presence of two large stones. the port site fascia was closed using a suture passer. the postoperative course was uneventful and both mother and baby were well at the two weeks follow up. discussion: in case of biliary pancreatitis during pregnancy, lc should be performed and if ultrasound shows a normal biliary system and amylase/lipase normalize, mrcp/ercp and ioc may be avoidable to protect the baby. lc with two ports is feasible during pregnancy. removal of the specimen through a lateral abdominal wall site may help prevent an umbilical port site hernia in this patient population. s160 surg endosc (2018) 32:s130-s359 introduction: splenic abscess is a rare, potentially lethal condition, with autopsy studies showing incidence rates between 0.14-0.7%. mortality rates ranging from 47 to 100% making early diagnosis and prompt intervention vital. several case reports have documented post surgical splenic abscess, most notably after laparoscopic sleeve gastrectomy. to the best of our knowledge, there has not been any reported cases of splenic abscess arising after laparoscopic cholecystectomy. it is important to remember this disease process for expeditious targeted treatment in future cases. case presentation: a 69 year-old female with past medical history significant for cholilithiasis, hypertension, and hyperlipidemia presented to the emergency department (ed) with a chief complaint of abdominal pain for two days. labs and imaging were obtained which confirmed the diagnosis of choledocholithiasis and pancreatitis. ercp was performed which showed a 1.5 cm stone causing obstruction, with several other smaller filling defects. the stones were removed after sphincterotomy. post procedurally, the patient underwent an uncomplicated laparoscopic cholecystectomy on hospital day (hd) #5. post operatively, the patient had persistent leukocytosis peaking at 16.8 thousand on postoperative day (pod) #6. a ct scan was performed which showed a rim-enhancing splenic collection measuring 6.692.2 cm suggestive of an abscess. interventional radiology was consulted and aspirated 50 ml of purulent fluid. cultures grew out klebsiella pneumoniae and enterobacter cloacae complex, and the patient was discharged home on zosyn. discussion: laparoscopic cholecystectomy has become the cornerstone in treatment of symptomatic biliary colic and acute cholecystitis. of the many recognized complications of laparoscopic cholecystectomy, splenic abscess has not yet been reported in current literature. the nonspecific signs and symptoms of splenic abscess make clinical diagnosis difficult. the classic triad of fever, palpable spleen and left upper quadrant pain are only seen in about two-thirds of patients. ct scan has been shown to be the most sensitive imaging modality for diagnosis of splenic abscess. current treatment options for splenic abscess are broken down into two subsets: percutaneous and surgical intervention. percutaneous treatment includes image guided aspiration with or without placement of drainage catheter. surgical intervention can be either laparoscopic or open and includes drainage of abscess with splenectomy or splenic conservation. the best treatment option remains unclear, and there is lacking prospective data demonstrating which modality is superior. introduction: laparoscopic subtotal cholecystectomy is widely accepted as a safe alternative to the conventional laparoscopic cholecystectomy in case of acute cholecystitis with frozen calot's triangle. the remnant stump of the gallbladder may be either sutured or looped. however, there are limited studies comparing the outcomes of the two techniques. the present study is aimed at comparing loop and suture closure of the gall bladder stump. methods: a retrospective analysis of our prospectively maintained database revealed that between january 2013 and december 2016. 81 patients underwent laparoscopic subtotal cholecystectomy for acute cholecystitis, chronic cholecystitis or empyema gallbladder with frozen calot's triangle. the decision to use endoloop or sutures for stump closure was made intra-operatively after dividing the gallbladder through the infundibulum. a no.20 sized drain was kept in all the cases. the patients were discharged with drain in situ, and were reviewed on post-operative day 7 during which an ultrasound was done and drain removed if the progress was satisfactory. the intra-operative and post-operative data between the two groups were recorded and analyzed. results: endoloop closure was performed in 45 patients and suture closure using 2.0 ethibond was done in 36 patients. three patients from the sutured group had post operative bile leak among which one patient underwent endobiliary stenting. the other 2 were managed conservatively while the drain had to be retained for 2 weeks. two patients in the endoloop group were detected to have retained stone in the remnant gallbladder cuff among which one had recurrent cholecystitis requiring laparoscopic completion cholecystectomy. none of the patients had bile duct injury or surgical site infection. mean post operative stay was 2.5+1.2 days, did not significantly vary between the groups. suturing needed more surgical expertise and had prolonged operative time than endoloop (68+22 min versus 84+18 min, p=0.04). conclusion: suture or loop closure of the remnant gallbladder after subtotal cholecystectomy are equally effective. suturing the stump may be associated with increased incidence of biliary leak while endoloop may have higher incidence of retained gallstones. the choice between the two may be made intra-operatively based on the surgeon's expertise and preference. background and aim: in recent years, due to the spread of laparoscopic cholecystectomy, bile duct injury as its complication has been reported at a certain frequency. current surgical treatments include 1) suturing and closing the injured part laparoscopically during surgery, 2) transitioning to laparotomy and closing the suture, 3) inserting a tube such as t-tube under the laparotomy, 4) bile duct-intestinal anastomosis under the laparotomy, etc. are taken into consideration. regardless of which treatment method, it is not a definite ideal treatment. we have developed a bioabsorbable material (caprolactone: lactic acid (50: 50) polymer reinforced with polyglycolic acid fiber and designed to be absorbed in about 8 weeks). at this conference, we would like to talk about the current state and problems of development of minimally invasive therapy for biliary damaged area using bioabsorbable materials we developed. method: in order to overcome the problem of the current bile duct injury cure method, we have been developed, a) a method of closing a perforation part endoscopically from the luminal side of a bile duct (a covered stent using a bioabsorbable material in the damaged part), b) develop a method of closing the biliary duct injury under the laparoscope from the outside of the bile duct (adhering the bioabsorbable sheet to the bile duct perforation using a biocompatible adhesive). results: experimental results of suturing the bioabsorbable material in the biliary duct in surgery of laparotomy were able to regenerate the bile duct without stenosis in the damaged area. however, various adhesives were tried to bond the sheet of this bioabsorbable material and the native bile duct under the endoscope, but at the moment, there is no glue that will allow the sheet to be adhered readily and reliably where there is moisture to a certain extent. a tool for delivering the sheet from the bile duct into the injured part is under development and good results are obtained at present. conclusion: it is possible to regenerate the bile duct without constriction using a bioabsorbable material. it is difficult to laparoscopically adhere to the injured part of the bile duct, but we hope that it will be possible in the near future to develop further adhesives. s162 surg endosc (2018) , 30-35 kg/m 2 (c) and more than 35 kg/m 2 (d). we made a 2.5-cm longitudinal skin incision within the umbilicus. a wound retractor and a surgical glove were applied at that incision. we used the three 5-mm ports technique. after retracting the gallbladder upward, the cystic duct and artery were divided and identified using pre-bending forceps through the flexible port and laparoscopic coagulating shears (lcs). the cystic artery was dissected using the lcs and the cystic duct was also dissected after clipping. the gallbladder was freed from the liver bed using the lcs, and the specimen was retrieved from the umbilical wound. results: there were conversions to open laparotomy in 4 cases (1.3%) and requirement of additional ports in 23 (7.7%). the mean age (years), operation time (min), blood loss (ml) and postoperative hospital stay (days) in group a, b, c and d were 60.0, 55.5, 51.2 and 41.2 (p=0.05[), 89.5, 101.7, 98.4 and 85.3 (p=0.206), 19.7, 18.5, 15.6 and 3.4 (p=0.935) , and 3.5, 3.6, 3.2, and 3.0 (p=0.882), respectively. there was a significant difference in age only. the complications were bile duct injury in one case (0.3%) and pneumothorax in two (0.6%). conclusion: obesity had no influence of surgical outcomes for performing silc. introduction: recent studies have reported mixed outcomes when comparing surgeon case volume and laparoscopic cholecystectomy (lc) outcomes. formal minimally invasive surgical training (mist) has been shown to be associated with shorter post-operative length of stay (los), but no difference in major adverse events such as bile leak, bile duct injury, intra-abdominal abscess formation, and death. we aim to determine 30-day rates of major adverse events after lc in a university hospital setting, to identify significant associated risk factors, and to determine if mist or surgeon volume are associated with differences in los and major adverse events. methods: we conducted a single-center retrospective review of 2,764 cholecystectomies performed over a seven-year period (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) . characteristics and outcomes were compared using chi squared or rank sum tests. multivariable regression modeling was used to determine independent associations with the two main outcomes, major adverse events and los. results: we identified 2,764 adults who underwent lc during the study period, with a median age of 50, and 70% women. about 19% (n=531) of patients had a los[1 day and 4.3% (n=120) were re-admitted within the first 30 days after surgery for any reason. within 30 days of lc, 2.2% (n= 60) of patients suffered from one or more major adverse events. this includes 0.18% (n=5) of patients with bile duct injury, 1.3% (n=35) of patients with bile leak, 0.3% (n=7) of patients with intra-abdominal abscess, and 0.3% (n=9) of patients died for reasons related to their procedure or post-operative recovery. table 1 shows the characteristics of the patients and procedures with a comparison of the patients with an adverse event versus those without one. in univariate analysis, high annual surgical volume (40+ cases/year) and procedure urgency were found to be significant predictors of adverse events and los, however, mist was not. in multivariable analysis, controlling for significant univariate predictors, urgent or emergent cases were associated with a 3-fold increase in odds of an adverse event (or=3. introduction: laparoscopic cholecystectomy is an extremely common procedure in the united states, with over 700,000 cases performed annually. despite the procedure's overall safety, there has been some evidence that tobacco use is associated with increased risk of wound infection after lc. this retrospective chart review sought to examine whether tobacco use is associated with increased complications following laparoscopic cholecystectomy within a high-volume healthcare system. methods: after irb approval, 900 of approximately 3,000 cholecystectomies performed within one four-hospital system between 2009 and 2015 were randomly selected, and patient charts were retrospectively reviewed. pre-, intra-, and postoperative data were collected, including all complications within 90 days. tobacco use cohorts were defined as follows: never, former (any historical tobacco use), and current (active tobacco use within 1 year of surgery) per the acs nsqip surgical risk guidelines. following preliminary data analysis, multivariable logistic regression models were generated to identify whether tobacco use was predictive of outcomes of interest. of the 900 cases analyzed, 535 patients (59.4%) were never smokers; 31.3% were former smokers, and 9.2% were current tobacco users or had quit less than 12 months prior to surgery. there were 17 surgical site infections, one wound dehiscence, one port site hernia, three common bile duct injuries, and 44 medical complications requiring prolonged hospitalization or readmission within 90 days. current tobacco users were significantly more likely to undergo urgent surgery (following emergency admission or direct admission to the hospital) than former or nonsmokers. however, there was no difference between cohorts for prolonged duration of surgery, conversion to an open procedure, surgical site infection, wound dehiscence or hernia, common bile duct injury, or other medical complication. there was no significant difference between cohorts when all postoperative complications were pooled. conclusions: there does not appear to be a significant difference in 90-day surgical outcomes or complications in active tobacco users vs. former or non-users. although studies in other surgical settings have indicated a possible reduction in complications if patients abstained from smoking prior to surgery, this may not be beneficial in laparoscopic cholecystectomy. moreover, as current tobacco use appears to be associated with higher rates of urgent surgery, these patients may not be able to stop smoking prior to an elective procedure. prospective studies to further clarify whether there is any benefit towards tobacco cessation prior to lc may be valuable. 9, [150, [ 150 respectively (0-20) , cyfra 211 were 8.11, 9.22, 6.36 respectively (0-3.5) . afp and cea were negative. as for this patient, he is of high risk of hepatobiliary system diseases. introduction: thymoma is one of the rare tumor entity benign or malignant arsisng from the epithelial cells of thymus gland, frequently associated with neuromuscular disorder myasthenia gravis. so, we are presenting this rare case of thymoma with myasthenia gravis in our institute. methods: we operated a single patient of thymoma in a case of myasthenia gravis by video assissted thoracoscopic approach. results: operative time-78 min, intraoperative blood loss −20 ml, post operative analgesia requirement in form of nsaids is for 2 days, no ventilatory support required post operatively, with follow up reduction in achr ab from 99 nmol/l to 15 nmol/l and reduction in symptoms in form of reduced ptosis. conclusion: thoracoscopic thymectomy is feasible and safe in terms less operative time, less post operative pain and analgesia requirement and no post operative ventilatory support requirement. carter c lebares, md, stanley j rogers, md; ucsf background: duodenal fistulas are uncommon but morbid complications of acute necrotizing pancreatitis. if percutaneous drainage fails, surgical correction via roux-en-y diversion or pancreaticoduodenectomy can be required. while self-expanding metal stents have been tried, complications like migration and perforation have limited such use. endoscopic transmural stents have successfully treated fistulas of the stomach, particularly post-sleeve gastrectomy. here we present a case of endoscopic transmural stents used to treat a non-resolving duodenal fistula following acute necrotizing pancreatitis. methods: under general anesthesia, using a standard adult gastroscope, the fistula was identified in the second portion of the duodenum (fig. 1) . a flexible-tipped guide wire was used to identify the fistula tract and two 7 fr 5 cm double pigtail biliary stents were deployed ( fig. 2 ) with positioning verified under fluoroscopy. two weeks later these were removed and a single stent deployed into the visibly smaller tract (fig. 3 ). two weeks after that, the single stent was removed and contrast medium was injected under fluoroscopic visualization, demonstrating resolution of the fistula (fig. 4) . case: this patient is a 72 year old woman with hypertension and congenital hearing loss who underwent a cholecystectomy for biliary colic and subsequent ercp with sphincterotomy for retained stone. this was complicated by acute pancreatitis which progressed to severe necrotizing pancreatitis with infected retroperitoneal necrosis. percutaneous drainage yielded initial improvement but a persistent moderate collection (300 cc per day) lead to the identification of a fistula in the second part of the duodenum. repositioning and exchange of percutaneous drains over 8 weeks did not hasten resolution. endoscopic transmural pigtail stents were tried after visualization of a large (8-10 mm diameter) fistula tract. stents were utilized as described in methods, with a total of three endoscopic interventions, at 2 week intervals, resulting in resolution of the fistula as evidenced by contrast injection into the duodenum under fluoroscopy and subsequent ct scan with oral contrast. the patient's symptoms resolved and she was tolerating a normal diet. she remained thus at 1 month follow-up. conclusion: this case demonstrates the benefit of endoscopic transmural stents for the resolution of duodenal fistulas, expanding the utility of this technique to address leaks and fistulas of the upper gastrointestinal tract. further study is warranted to clarify the timing and adjuncts to optimize the use of this promising approach. totally laparoscopic alpps combined with the microwave ablation for a patient with a huge hcc hua zhang; department of hepatopancreatobiliary surgery, west china hospital, sichuan university introduction: associating liver partition and portal vein ligation for staged hepatectomy (alpps) is a novel technique for resecting hepatic tumors that were previously considered unresectable due to the insufficient future liver remnant (flr) which may result in postoperative liver failure (plf). the procedure has been accepted and modified in many medical centers worldwide. but reports about the laparoscopic alpps were rare. this study aimed to report a totally alpps combined with microwave ablation for a patient with huge hcc and confirm the feasibility of laparoscopic alpps. methods: a 51-year-old man had complained of 1-year history of right upper abdominal pain, and the syndrome was worsened in recent month. abdominal enhanced computed tomography (ct) imaging revealed a 15911 cm solid mass in right lobe of liver with non-uniform and unclear boundary, the right posterior branch of the portal vein was invaded. in addition, a small lesion was simultaneous found in left lateral lobe of liver. the tumor was evaluated as unresectable due to the flr was only 355 ml (25%). we decided to perform the laparoscopic alpps procedure. first stage including microwave ablation of the lesion in left lobe, cholecystectomy, ligation of the portal vein and transection of liver parenchyma. the second stage was done 11 days later and consisted of laparoscopic right hemihepatectomy. results: the two stages were underwent by laparoscopy successfully. the operation duration was 300 and 200 minutes, respectively. estimated blood loss was 550 and 250 ml. the hospitalization time in intensive care unit was 1 and 3 days. there was no need for transfusion in both stages. the patient was discharged 22 days after the second stage and the total hospitalization time was 38 days. recovery of the patient was uneventful in addition to the incision infection after the second stage which recovered with conservative management. the patient did not show any signs of liver failure. the ct scan before the second stage showed an enlargement of left lobe, the flr was 533 ml (37.5%). there was no signs of residual liver disease in the ct scan 10 days after the operation. the patient showed no signs of recurrence or liver failure in the following up period of six months. conclusion: totally laparoscopic alpps combined with microwave ablation is safe and feasible for the multiple hcc which was not resectable. the hypertrophy of remaining liver was fast and can achieve an adequate volume in a short time. introduction: chronic pancreatitis is a benign, irreversible inflammatory disorder characterized by the conversion of the pancreatic parenchyma into fibrous tissue. initial management should be conservative, surgery is applied in case of failure of medical treatment. the development of minimally invasive techniques has made it possible to perform these highly technical procedures in a laparoscopic manner. materials and method: we have the history of 2 patients with 19 and 42 years with chronic pancreatitis and pancreatic lithiasis of difficult handling but intractable pain to those who decided to surgical management. we performed the procedure under general anesthesia, epidural analgesia catheter was placed. neumoperitoneum technique of cali, at 14 mmhg and approach using a 12 mm umbilical port, 2 working ports of 12 and a 1 of 5 mm port,. the pancreas was exposed by a section of the gastrocolic ligament with a 5 mm ultrasonic scalpel, with cephalic retraction of the stomach, opening of a smaller sac and approaching the transpavity of omentum. the ventral surface of the pancreas was exposed from the neck. an incision was made in a pancreas body with a monopolar hook. primary pancreatic duct lumen was identified and the incision was extended longitudinally from the neck to the tail of the pancreas (8 cm). roux's y loop was prepared 50 cm from the treitz ligament, with a jejunum section with a 60 mm stapler, roux's loop was transmecoscopically retrocollic, closing the gap of the mesocolon with monocryl. a 60-cm jejunum-jejunal anastomosis was performed with endo-gia stapler and closure of enterotomy with 2-0 polypropylene intracorporeal suture. jejunal (roux) isoperistaltic loop was placed longitudinally at the opening of the main pancreatic duct, and enterotomy was performed with monopolar in antimesenteric segment. the intracorporeal pancreatico and jejunum anastomosis was performed using a lower and an upper plane, with single points of total thickness with ethnobond 2-0. 1 closed drains were placed towards each anastomosis. this procedure was performed in the 2 patients reported. operative time 180-300 min complications none operative time 4-7 days minimal bleeding drains no1 retired in both cases at 7 days 1 year follow-up of patients improved pain\ conclusions: minimally invasive surgery is a fundamental tool for the approach and management of patients with biliopancreatic pathologies. the establishment of multidisciplinary groups, offer an excellent alteranativa in the integral management of the patients. surg endosc (2018) gallbladder anatomy is highly variable, and surgeons must be prepared to identify anomalies of form, number, and position. variants include gallbladder agenesis, diverticulum, duplication, bilobed, multiseptate, phrygian cap, ectopic, and hourglass gallbladder. the hourglass gallbladder has been described from the earliest days of cholecystectomy, as morton described a congenital case in 1908, and else thoroughly described the acquired and congenital strictures leading to the hourglass deformity in 1914. we describe a case of an hourglass gallbladder found during one-step endoscopic retrograde cholangiopancreatography (ercp) and laparoscopic cholecystectomy. this 71 year old male presented to an outside hospital with one day of nausea, and constant, severe, epigastric pain that radiated to his back. he endorsed a history of similar pain several times in the past. his abdomen was soft, nontender, and without murphy sign. laboratory evaluation revealed total bilirubin 2.0 mg/dl, alkaline phosphatase 195 u/l, ast 835 u/l, alt 800 u/l, and no leukocytosis. ct abdomen and pelvis revealed cholelithiasis, distal choledocholithiasis, intra-and extra-hepatic ductal dilation, and a 3.8 centimeter left liver hemangioma. he was transferred for management of choledocholithiasis, and an abdominal ultrasound revealed cholelithiasis, without gallbladder wall thickening or pericholecystic fluid, and a 7.7 millimeter common bile duct without choledocholithiasis. he was taken to the operating room for a one-step ercp and laparoscopic cholecystectomy. upon laparoscopy, dense adhesions to the gallbladder were found. after initially attempting to obtain the critical view of safety, we then embarked on the retrograde "top down" dissection. this isolated a spherical structure measuring 2.492.2 centimeters. two very thin tubular structures were identified, clipped, and transected after we found they were too small to place a cholangiocatheter. the common bile duct appeared to be pulled anteriorly by surrounding inflammation, though this was later found to be the proximal segment of gallbladder. the intra-operative ercp identified a remnant gallbladder with cholelithiasis and no extravasation of contrast. given the unusual anatomy, we completed the operation, ordered a post-operative ct liver and mrcp, and consulted a hepatopancreatobiliary surgeon. a small remnant gallbladder was identified on ct liver, though not on mrcp. completion laparoscopic cholecystectomy with intraoperative cholangiogram and ultrasound was performed on hospital day 4. this hourglass gallbladder variant likely occurred secondary to chronic fibrosis from cholecystitis, leading to a proximal and distal gallbladder lumen. in anatomic uncertainty, the "top down" dissection, intraoperative cholangiography, ct liver, and expert consultation are safe methods to avoid iatrogenic injury. introduction: endoscopic entero-enteral bypass could change our approach to small bowel obstruction in patients with prohibitively high operative risk. magnetic compression anastomoses have been well-vetted in animal studies, but remain infrequent in humans. isolated cases of successful use in humans include treatment of biliary strictures and esophageal atresia. while endoscopic gastro-enteric magnetic anastomoses have been described, the associated multicenter cohort study was terminated due to serious adverse events. since then, the technology has evolved and recently our own institution reported results of the first in-human trial of magnetic compression anastomosis (magnamosis), deployed through an open approach. here we present the first case of endoscopic delivery of the magnamosis device and the successful creation of an enteroenteral anastomosis for chronic small bowel obstruction in a patient with prohibitively high operative risk. methods: the magnamosis device has previously been approved by the food and drug administration (fda) for use in clinical trial. our institutional review board approved emergency compassionate endoscopic use of the device in this patient due to a non-resolving small bowel resection and prohibitively high operative risk. case: this is a 59 year old man with advanced liver disease, chronic obstructive pulmonary disease, and history of emergent right colectomy with end ileostomy for cecal perforation. he presented with multiple acute on chronic episodes of small bowel obstruction with a stable transition point in the distal ileum, radiographically estimated at 15 centimeters proximal to the ileostomy. endoscopic evaluation through the ileostomy revealed a traversable obstruction with proximally dilated small bowel. the magnets were delivered via endoscopic snare under fluoroscopic guidance and positioned in adjacent loops of bowel on either side of the obstruction (image 1). by 7 days post-procedure, healthy villi were visible through the central portion of the mated magnetic rings (image 2). by 10 days the magnetic rings were mobile and the anastomosis was widely patent allowing easy passage of the gastroscope (image 3), and the patient's symptoms were completely resolved. the rings passed through the ileostomy 11 days post-procedure. at 1 month follow up, the anastomosis was unchanged (image 4). conclusion: this case demonstrates the benefit of an endoscopically created magnetic compression anastomosis in a patient with small bowel obstruction and high operative risk. further studies are indicated to evaluate the use of this technique in similar patients or those with malignant obstruct, ion. desiree raygor, md, ruchir puri, md; university of florida health jacksonville cholecystectomy is one of the commonest operations in general surgery [1] . occasionally chronic cholecystitis can lead to a small contracted gallbladder. this diagnosis can be misleading as it may represent congenital agenesis of the gallbladder [2] . a 28-year-old female with a past history of pancreatitis presented with a three day history of right upper quadrant pain associated with nausea and vomiting. upon exam she exhibited tenderness in the right upper quadrant. her leukocyte count and liver function tests were within normal limits. ultrasound revealed a poorly visualized, contracted gallbladder without stones and a dilated common bile duct (cbd). cholescintigraphy revealed non visualization of the gallbladder after two hours, which was suggestive of acute cholecystitis. decision was made to proceed with a laparoscopic cholecystectomy. the abdomen was entered by an open hasson technique and standard trocar placement for a cholecystectomy was performed. on initial inspection, the gallbladder was not readily visible. a structure appearing to be the cbd was present and was mobilized circumferentially (fig. 1) . a 19 gauge butterfly cannula was utilized and multiple cholangiographic images were obtained (fig. 2 ). no cystic duct or gallbladder was identified which was suggestive of congenital agenesis of the gallbladder. the patient did well postoperatively, and was discharged home on postoperative day two. the patient's symptoms resolved and she continues to be pain free one month postoperatively. congenital agenesis of the gall bladder is a rare disorder. a high index of suspicion is required especially in the setting of a small contracted gall bladder. if preoperative imaging is inconclusive then diagnostic laparoscopy should be the next step. cholangiogram should be performed routinely to confirm the diagnosis and to rule out an ectopic gall bladder. conversion to open does not offer any distinct advantage, and laparotomy should be avoided if possible given its associated morbidity. there are many reports upper abdominal major arterial aneurysms. however, an aneurysm of left inferior phrenic artery had never been reported. a 48-year-old woman with liver cirrhosis associated with hepatitis b viral infection was referred to department of surgery for treatment of aneurysm of left inferior phrenic artery. she underwent trans-arterial chemoembolization (tace) for treatment of hepatocellular carcinoma three times, previously. on 20 months after last tace, 7 mm sized highly enhancing nodular lesion of gastric fundus was found on follow-up abdomenpelvis computed tomography (a-p ct). one year later, the size of this lesion increased to 18 mm, and an aneurysm was diagnosed. she underwent angiography and attempted embolization with an aneurysm of the left inferior phrenic artery, but access failed. we performed a laparoscopic vessel ligation. she recovered with no complication and discharged on the 3th postoperative day. s170 surg endosc (2018) 32:s130-s359 yousef almuhanna, vatsal trivedi, fady balaa; university of ottawa a 34 years old female, g7 and 10 weeks pregnant, was brought to the hospital by ems, after being found on the floor in her toilette surrounded by vomitus and urine. mother-inlaw, who happens to be at the house that time, have heard severe retching followed by a loud bang sound. firefighters have found no pulse and therefore started cpr. return of spontaneous circulation was achieved, yet unfortunately, she had arrested again 5 minutes prior to arrival to er. pocus assessment showed large rvot, and therefore tpa was started on the assumption of pulmonary embolism. upon arrival of blood work, it was found that her hemoglobin had dropped from 110 to 54. fast was repeated showing moderate to severe amount of free fluid in the morrison's pouch and pelvis. she was then taken to the operating theatre, had undergone laparotomy showing liver segment ii injury. pringle's maneuver and aortic clamping did not control the bleed, therefore finger fracture and venous clips were used to temporary minimize the bleed, and head to interventional radiology suite. after multiple attempts to control the bleed, and the massive transfusion, she vital signs were not maintained, and had arrested afterwards. sarrath sutthipong, md, chumpunut chuthanan, md, chinnavat sutthivana, md, petch kasetsuwan, md; bhumibol adulyadej hospital, bangkok, thailand background: mesenteric panniculitis (mp) is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small bowel and colon. the specific etiology is unknown and no clear information about the incidence. the diagnosis is suggested by ct and is usually confirmed by surgical biopsy. treatment is based on some selected drugs. surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. we reported a case of the mp diagnosed with ct and surgical biopsy by laparoscopic approach. case report: 50-year-old woman with 5 months history of chronic abdominal pain, mainly localized in the sub-epigastrium, intermittent and mild. she had anorexia but no weight loss or change in bowel habits. no history of medical illness or surgery. the physical examination was unremarkable, except for palpation of ill-defined mass about 5 cm at mid-abdomen, firm, smooth surface with mild tenderness. the laboratory profile and tumor marker were normal. ct of the abdomen, which showed focal heterogeneous enhancement of the mesenteric fat with stranding (8.794.8910 cm) with multiple internal subcentimeter lns in the supraumbilical area, which was probably inflammatory in origin and suggestive of mp. 18f-fdg pet/ct showed faint fdg uptake in multiple mesenteric lns. the patient was subsequently underwent diagnostic laparoscopy with biopsy. intra-operative finding showed a fat-like surface of yellowish mass at mesentery of jejunal segment, incisional biopsy was performed laparoscopically. the histology showed adipose tissue with areas of fat necrosis, fibrosis, foamy macrophages infiltration and predominant chronic inflammation, no evidence of malignancy. ihc studies (including cd68, s-100, cd3 and cd20) were performed and the result was compatible with reactive process. treatment was started with 40 mg prednisone once daily and planned for follow-up with repeated ct scan. discussion: mp involves the small bowel mesentery in over 90% of cases. the diagnosis is made by 3 pathologic findings: fibrosis, chronic inflammation and fatty infiltration. the differential diagnosis is broad and has been associated with malignancies such as lymphoma, well-differentiated liposarcoma and melanoma. the imaging appearance varies depending on the predominant tissue component. a definitive diagnosis is biopsy but open biopsy is not always necessary. no data of laparoscopic biopsy, which has been reported previously. treatment has been reserved for symptomatic cases with a variety of drugs. our case was started on oral corticosteroid treatment and waited for responsive evaluation. background: laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. stapled closure of the appendiceal stump is often performed and has been shown to have several advantages. few prior cases have been reported demonstrating complications from free staples left within the abdominal cavity after the laparoscopic stapler has been fired. case report: a previously healthy 29 year old female initially underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (gia) staplers. her initial postoperative recovery was uncomplicated and she was discharged home the same day. the patient returned to the emergency department on postoperative day 17 with one day of sharp mid-abdominal pain, obstipation, and emesis. her abdomen was distended and mildly tender but not peritoneal. she was afebrile but was found to have a leukocytosis of 13.2. ct demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction. diagnostic laparoscopy was performed through the three prior appendectomy incisions. an adhesion was noted between the veil of treves and the mesentery of a more proximal loop of ileum caused by a solitary free closed staple, remote from the staple lines, resulting in an internal hernia containing several loops of ileum ( fig. 1 ). the hernia was reduced, and the small bowel was noted to have early ischemic discoloration. the adhesion was lysed by removing the staple from both structures to prevent recurrence. through the remainder of the procedure, the compromised loops of bowel began to peristalse and the color normalized. the procedure was concluded without resection. the patient recovered on a surgical floor and was discharged home on postoperative day one. conclusion: gastrointestinal staplers are commonly used secondary to ease of use and low complication rate. it is not uncommon to leave free staples in the abdomen during laparoscopy as retrieval can often be more difficult and time consuming. our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staple. choosing the most appropriate size staple load, to reduce the number of extra staples after the fire, and removing as many free staples as possible can prevent potentially devastating complications. video-assisted thoracoscopic pulmonary wedge resection in a patient with hemopytsis and intralobar sequestration: a case report mary k lindemuth, md, subrato j deb, md; the university of oklahoma health science center case report: a 19-year-old male with history of noonan's syndrome, bronchitis, and asthma presented with acute hemoptysis. while chest x-ray was unremarkable, a computed tomography angiogram of his chest was significant for intralobar pulmonary sequestration in the right lower lobe. the aberrant pulmonary artery originated from the abdominal aorta, immediately proximal to the celiac axis, and coursed through the hiatus in the retroperitoneum. flexible, fiberoptic bronchoscopy revealed blood within the right lower lobe bronchus with no appreciable source. a right video-assisted thoracoscopic approach was taken for wedge resection of the sequestration. twoportal technique was utilized with the patient on single lung ventilation. the sequestration was easily identified; the anomalous pulmonary artery coursed directly to a large, focal area of hemorrhage noted within the lower lobe pulmonary parenchyma, as seen in image [rectangle marking the aberrant artery and oval marking the sequestration]. pathologically, the specimen was noted to be benign lung parenchyma with bronchiectasis and abundant, acute hemorrhage. discussion: pulmonary sequestration (ps) is a rare, congenital bronchopulmonary foregut malformation. literature describes the incidence of ps to be only 0.15-6.4% of all pulmonary malformations. as ps is most frequently diagnosed during childhood, the occurrence of diagnosis during adulthood is estimated to be less than 3 per 10,000 adults. two types (intra-and extralobar) are described, with intralobar sequestration most common and contained within the normal visceral pleura. both types have aberrant systemic arterial blood supply, most frequently from the thoracic aorta. likewise, both types are nonfunctioning lung tissue, as there is no direct communication with the bronchopulmonary tree. the most common presentation is pneumonia, and often patients will have had recurrent symptoms before diagnosis. it is rare to present with hemoptysis, which is understood to be secondary to elevated capillary pressure within the sequestration and then communication through the pores of kohn. while endovascular embolization of the aberrant pulmonary artery has been described as a safe alterative for surgical intervention, the subjects of these studies have primarily been children and long-term outcomes are unknown. the definitive treatment of ps continues to be surgical intervention. the surgeon should strive to leave as much normal lung parenchyma as possible. video-assisted thoracoscopic resection is well tolerated by patients when compared to thoracotomy. however, it is vital for the surgeon to be aware of the potential risk of life-threatening hemorrhage secondary to the sequestration having systemic blood supply that must be controlled and ligated. case report: a 51 years-old female patient with history of an increased mass and weight loss of 7 kilograms in 15 months, associated with vomiting and nausea for eight months. abdominal ultrasound showed an irregular cyst, without solid projections and without signs of flow in doppler, measuring 20911920 cm. investigation continued with ct scan that showed a large homogeneous cystic lesion with no septum in the abdominopelvic region, possibly mesenteric, measuring 20.5910.5924 cm. a laparoscopic approach for resection of the cyst was then performed. the surgery was performed with a patient in the dorsal decubitus, using three trocars: one in the umbilical region (11-mm) for the camera, and where the pneumoperitoneum was created by the hasson open technique under direct vision; and another two located in the epigastrium (5-mm) and in the right upper quadrant (3-mm) . in addition to the mesenteric cyst, a simple cyst in the right ovary and a solid nodule with a lipomatous characteristic of approximately 3 cm in the abdominal cavity were visualized. total resection of the mesenteric cyst with periprancreatic fibrous tissue was performed. the cyst was punctured and its contents fully aspirated. resection of the right ovarian cyst was also performed. at the end of the procedure the mesenteric and ovarian cysts, the nodule, part of the omentum, and the peripancreatic tissue were removed through the 11-mm trocar at the umbilicus. patient had no further complications, being discharged four days after the procedure. histopathologic result showed a serous cyst in the right ovary, serous cyst in peripancreatic mesentery with chronic inflammatory process and signs of calcification; no signs of malignancy were observed in any specimen. we aimed to present the succesul therapeutic approach utilizing laparoscopy for safely removing a gastrointestinal stromal tumor. depicted is a 66 year old jehova's witness female who presented to the emergency department for evaluation of bitemporal headache and dizziness and found with profound anemia with hemoglobin 5.4 and hematocrit 16.6 upon arrival to ed. the patient refused blood transfusion as her religious beliefs, jehovah's witness, preclude her from taking blood products. as part of her work up, endoscopy was performed and revealed a large, approximatelly 494 cm, prolapsed, ulcerated, nodular lesion with active bleeding in the cardia of the stomach. this was temporized but the friable tissue, with no single identifiable lesion for clip placement, left the patient at high risk for re-bleeding. she was taken to the operating room and laparoscopic partial gastrectomy with intraoperative esophagogastroduodenoscopy were succefully perfomed, with minimall blood loss and no intra operative complications. patient was discharged on post op day 3. we present the case of a 46-year-old male with a history of morbid obesity with an initial bmi of 44.7, who underwent an elective laparoscopic single anastomosis duodenal-ileal bypass with sleeve gastrectomy (sadi-s). postoperatively he developed an anastomotic leak at the duodeno-ileal anastomosis that would not resolve despite reoperation. he was then converted to a roux-en-y gastric bypass (rygb). postoperative imaging failed to reveal any signs of anastomotic leak and the patient was discharged tolerating an oral diet. he returned to the emergency department 11 days later with a 69392 cm sub-hepatic collection arising from the duodenal stump from the surgical conversion. interventional radiology percutaneously drained the collection and found a connection between the cavity and the duodenum. using this connection, a percutaneous decompressive duodenostomy drain was successfully inserted into the duodenum using a guidewire through the abscess cavity along with an extra-enteric drain placed within this cavity. the collection was obliterated and the duodenal leak was controlled successfully with percutaneous drainage, bowel rest with parenteral nutrition and broad-spectrum intravenous (iv) antibiotics. the patient was reintroduced to a bariatric clear diet after a week of bowel rest and the abscess drain was then discontinued during the same hospital admission. the patient was discharged with the percutaneous duodenostomy tube which was removed in clinic 34 days later, after the patient tolerated capping trials and imaging failed to reveal any further collections, oral contrast extravasation or distal obstruction. in this article we analyze notable imaging from the case and review current literature on the different management options for a duodenal stump blowout. we also discuss the basics of the sadi-s procedure and conversion of a sadi-s procedure to a rygb. keywords: anastomotic leak, duodenal stump blowout, sadi-s, duodenostomy tube. pancreatopic heterotopia is often an incidental finding on autopsy, but in some cases can lead to abdominal pain, obstruction, or intussusception. we present a case of pancreatic herterotopia mimicking an internal hernia on radiologic imaging. a 47 year old female with seven month history of chronic abdominal pain treated for low back pain and recurrent urinary tract infections. she was found to have a computed tomography (ct) scan concerning for internal hernia and labs consistent with acidosis. she was taken for a laparotomy and did not have an internal hernia, but an exophytic mass in the proximal jejunum. the mass was resected and a stapled side to side jejunojejunostomy was created. on pathologic review, the specimen was found to be pancreatic heterotopia. her post operative course was complicated by an ileus, but was discharged post op day three. at her two week follow up she had minimal incisional pain and at one year follow-up she had resolution of her left upper quadrant abdominal pain. prior to this report, pancreatic heterotopia has never been described as presenting on ct scan as an internal hernia. although uncommon it should remain in the differential when evaluating a patient presenting with abdominal pain and radiologic evidence of obstruction or internal hernia. case report: a 26-year-old male patient who was diagnosed with high blood pressure at 18 years-old and presented tetraparesis and intense asthenia for six months. blood tests showed hypokalemia, hypernatremia, and suppressed renin activity. ultrasound of the urinary tract was normal. ct scan of the abdomen showed a hypodense nodule with regular margins, measuring 1.491.0 cm with a density of 18 hu in the non-contrast phase and heterogeneous uptake after the injection of the contrast in the left adrenal gland. thus, the diagnosis of hyperaldosteronism secondary to the left adrenal nodule was confirmed, and surgical resection was indicated. the procedure was performed with the patient in the right lateral decubitus. two 3-mm and one 5-mm trocars were used on the left flank, as well as the 10-mm portal for the camera in the lower right quadrant under direct vision. the pneumoperitoneum was created by the hasson open technique in the transumbilical incision. the procedure consisted of the dissection, isolation and electrocautery of the left renal capsule and the left adrenal region with ultrasonic device, as well as the periadrenal vessels, adjacent lymph nodes and periadrenal and adrenal fat tissue. the surgery was uneventful and the patient had no further complications, being discharged the next day. histopathologic result showed a completely excised adrenocortical adenoma. conclusions: the hybrid minimally invasive approach proved to be safe and effective for this procedure, and the known advantages of minilaparoscopy such as less trauma, better visualization, better dexterity, better aesthetics, and reduced hospital stay were observed. s174 surg endosc (2018) background: coccidioidomycosis is a fungal infection endemic to the southwestern united states, central america and south america. coccidioides is ubiquitous in many of these endemic regions, with near 100% seroconversion in some communities. two-thirds of these mycotic infections may be asymptomatic. the most common presentation of coccidioidomycosis consists of "flu-like" symptoms or pneumonia. less than five percent of symptomatic cases progress to disseminated coccidioidomycosis which may involve any organ system. very rarely infection may include the peritoneum. we report a case of coccidioidomycosis with peritoneal involvement in an immunocompetent individual. case: a 36-year-old male presented to the emergency department with progressive abdominal pain. he was seen and treated for pneumonia in the emergency department one week prior. the patient worked outdoors in arizona and was otherwise healthy with a family history of malignancy and blood disorders. fever, leukocytosis and ascites on computed tomography scan prompted a diagnostic laparoscopy which revealed peritoneal granulomas positive for coccidioides. the patient was treated outpatient with fluconazole. discussion: since 1939 this is the 38th reported case of peritoneal coccidioidomycosis to our knowledge. the patient described in this case report was an otherwise healthy 36-year-old male; this is incongruent with many of the previously recorded cases which involved disseminated disease in immunocompromised patients. the patient's family history of malignancy and blood disorders suggests a potential underlying genetic predisposition that could account for this abdominal presentation. possible mutations include genes coding for the interleukin-12 β1 receptor and the signal transducer and activator of transcription 1 which have been implicated in increased coccidioidomycosis susceptibility. peritoneal infection presents a unique challenge in diagnosis. in these cases coccidioidomycosis may not be suspected due to nonspecific symptoms and imaging, the infrequency of this extra-pulmonary manifestation and clinical characteristics that mimic the presentation of tuberculosis and malignancy. abdominal infections have been misdiagnosed as appendicular abscesses, iliopsoas abscesses, adnexal abscesses and pancreatic masses. consequently, the diagnosis of peritoneal coccidioidomycosis is often made after laparoscopic exploration of the abdomen and histopathology, as it was in this case report. conclusions: coccidioidomycosis incidence is on the rise in endemic areas and it often falls on the surgeon to make the diagnosis in extra-pulmonary cases. the peritoneal subset of coccidioidomycosis should be considered in endemic areas when a young, otherwise healthy patient presents with abdominal pain. failure to recognize the possibility of coccidioidomycosis may lead to unnecessary treatments and procedures. indocyanine green cholangiography to detect anomalous biliary anatomy steven d schwaitzberg, md, gabrielle yee, ms; university at buffalo jacobs school of medicine introduction: common bile duct injury is the most feared complication of cholecystectomy. imaging with indocyanine green (icg) is a safe and effective technique to detect biliary anatomy in open, laparoscopic and robotic surgery. several studies report detecting aberrant biliary anatomy with the use of icg in laparoscopic cholecystectomy with high success rates. by identifying the cystic duct-common hepatic duct confluence before dissecting calot's triangle, icg allows surgeons to perform "virtual" cholangiography at the start of procedures to identify either normal anatomy or possible anatomic variants. it is clear that icg use is an effective tool to achieve the critical view of safety. however, no reports have suggested icg cholangiography as the last operative step in cholecystectomy to identify hidden biliary anomalies and avoid postoperative bile leak complications. case report: we report a novel use of icg cholangiography in visualizing anomalous biliary anatomy prior to closing, thus avoiding potential bile duct leakage. in our case, icg cholangiography was used to fluoresce the common hepatic duct, common bile duct and cystic duct. the cystic duct was transected, and the gallbladder was removed using electrosurgery. at the completion of the gallbladder removal, the liver was elevated to inspect the clips on the cystic duct and artery. at this point, near infrared imaging was reinitiated, and a small 1 mm structure was noted to fluoresce next to the cystic artery. this structure was identified using white light and subsequently clipped. discussion: the use of icg in this context after the completion of the cholecystectomy facilitated the identification of a small hepatocystic or aberrant duct, which would have likely leaked bile sometime in the postoperative period. based on our experience, we recommend one additional routine near infrared viewing to identify small structures or potential leaks at the completion of cholecystectomy. improved visualization of the extrahepatic biliary anatomy by icg has the potential to translate into improved clinical outcomes. solitary fibrous tumors (sft) are uncommon fibroblastic mesenchymal neoplasms that display a wide range of histologic behaviors. these tumors, which are estimated to account for 2% of all soft tissue neoplasms, typically follow a benign clinical course. however, it is estimated that 10-30% of sfts are malignant and demonstrate aggressive behavior with local recurrence and metastasis up to several years after surgical resection. we report a case of sft arising from the stomach, which is an exceptionally rare finding and has been reported only six times in the literature. additionally, this tumor was associated with dedifferentiation into undifferentiated pleomorphic sarcoma. to our knowledge, there are no documented cases of a malignant sft arising from the stomach to demonstrate dedifferentiation into an undifferentiated pleomorphic sarcoma. a 68-year-old male presented to the emergency department with vague complaints of right-sided flank pain. the patient had a history of nephrolithiasis and underwent a ct abdomen. this scan revealed a large heterogeneous mass in the left upper quadrant. the patient underwent endoscopic ultrasonography with fine needle aspiration of the mass, which stained strongly for cd34. gastrointestinal stromal tumor (gist) was the favored diagnosis as it is by far the most common mesenchymal neoplasm of the stomach, especially cd34 positive spindle cell neoplasm. accordingly, the patient began treatment with imatinib; however, after four weeks of therapy, there was no significant radiologic regression. a second biopsy was performed and the specimen was sent for stat6 immunohistochemistry, which revealed diffuse strong nuclear positivity. a diagnosis of solitary fibrous tumor was provided. surgical resection of the tumor was performed, which measured 17914910.5 cm. the patient was to undergo surveillance imaging every 3 to 6 months post-operatively. surveillance scan showed solitary metastatic disease in the left lateral segment of the liver. he underwent left lateral segmentectomy with an uneventful recovery. our case was complicated by diagnostic dilemma with gist, highlighting the challenges of diagnosing and characterizing sfts. dedifferentiation, or the abrupt transition from a classic sft into a high-grade sarcoma, is a particularly concerning finding in our case, as it is associated with a worse prognosis than classic malignant sft. the stat6 marker by immunohistochemistry is very specific for sft and may have aided in the diagnosis earlier. therefore, it is imperative to keep solitary fibrous tumor, albeit exceedingly rare, in the differential diagnosis of mesenchymal neoplasms of the stomach. appendiceal diverticulitits is an uncommon pathology that can clinically mimic acute appendicitis. some radiographic distinctions have been reported, but final pathologic examination of the surgical specimen is required to confirm the diagnosis. symptoms are often more mild, which can lead to a delayed diagnosis, and increases the risk of severe complications such as perforation. a 48 year old female presented with a three day history of right lower quadrant pain. she described the pain as constant and radiating to the left lower quadrant. associated symptoms included nausea and vomiting, and decreased appetite; she denied fevers or diarrhea. the patient had no significant past medical history, and surgical history was significant for a total nephrectomy for living donor kidney transplant to her mother. on physical exam she was tender in the right lower quadrant with rebound and a positive rosving's sign. all laboratory results were unremarkable, and she was hemodynamically stable. ct scan was performed and demonstrated a dilated fluid filled appendix with surrounding inflammatory change without abscess or free intra-peritoneal air. she was subsequently admitted to the hospital, made npo, started on iv antibiotics, and was taken to the operating room where she underwent an uncomplicated laparoscopic appendectomy. post-operatively, her hospital course was unremarkable. pathology revealed acute suppurative appendicitis secondary to an acutely inflamed appendiceal diverticula, consistent with a final diagnosis of acute appendiceal diverticulitis. appendiceal diverticulitis should be considered in patients presenting with acute right lower quadrant abdominal pain. although some consider appendiceal diverticulitis a variant of acute appendicitis, it is important to distinguish between the two diagnoses. appendiceal diverticulitis has a higher rate of complications, including perforation, and is associated with a higher risk of neoplasm, particularly mucinous adenomas and carcinoid tumors. appendectomy should be performed in all cases in order to obtain appropriate pathological examination and rule out coexistent neoplasms. laparoscopic appendectomy is a safe and appropriate approach to treatment of appendiceal diverticulitis. upper gi endoscopy and biopsy showed a gastrointestinal stromal tumor (gist) in the stomach. a videolaparoscopic partial gastrectomy was then proposed. the surgery was performed with the patient in the right lateral decubitus. two 3-mm minilaparoscopic trocars, a 5-mm conventional trocar for an ultrasonic instrument and a 10-mm trocar in the umbilical region for the camera were used. pneumoperitoneum was created using the hasson open technique under direct vision. trans-operatory endoscopy was perfomed to identify the tumor easily. initially, the ultrasonic device released the large omentum, and, then, the tumor was resected in the body of the stomach. the gastric wall was manually sutured with a 2-0 vicryl, and the tumor was removed in an endobag through the 10-mm incision in the umbilicus. the surgery was uneventful, with a total time of 72 minutes. the patient had no further complications, being discharged two days after the procedure with good clinical conditions. histopathological result showed a free margins gist. conclusion: the minimally invasive approach proved to be safe and effective for this procedure. the known advantages of video-surgery such as less trauma, better visualization, increased dexterity, better esthetics, and less postoperative recovery time were confirmed. the upper gi endoscopy contributed to improve the safety and efficacy of the procedure, allowing a more precise resection of the gist, as well as the intragastric review of the suture line at the end of the surgery. background: portal vein thrombosis (pvt) is a rare post-operative complication, which has been associated with a wide range of precipitating factors. most commonly described associated conditions include; cirrhosis, bacteremia, myeloproliferative disorders and hypercoagulable states. pvt most frequently occurs as a complication after hepatobiliary surgery, and although possible, very few cases have been documented occurring after laparoscopic surgery of the gastrointestinal tract. herein, we describe a case of pvt in a patient who underwent elective laparoscopic right hemicolectomy and was treated successfully at our center. case: a 39 year-old female with past medical history of depression, migraines and endometriosis underwent an uncomplicated laparoscopic right hemicolectomy at our facility, for recurrent rightsided diverticulitis. she had suffered 4 previous episodes of diverticulitis and desired definitive surgical treatment. her hospital course was uneventful and she was discharged to home on postoperative day 2. on post-operative day 9, she presented to the emergency department complaining of severe abdominal pain, back pain and nausea. computed tomography of abdomen and pelvis revealed pvt. she was initiated on therapeutic anticoagulation with heparin. hematology was consulted for hypercoagulable workup. further investigation revealed that she had a family history of a brother who had had a lower extremity deep venous thrombosis, with negative hypercoagulable workup. she had also previously been taking leuprolide and conjugated estrogen and medroxyprogesterone for her endometriosis. she was ultimately found to have a heterozygous prothrombin g20210a gene mutation. her anticoagulation was bridged to coumadin and she was discharged home. she has recovered as expected, without any further complications. discussion: although more common in patients with cirrhosis after hepatobiliary surgery, pvt is a rare complication that can occur after virtually all types laparoscopic surgeries, including elective right hemicolectomy. patients may be completely asymptomatic, or present with a broad spectrum of symptoms including; severe abdominal pain, fever, diarrhea, or gastrointestinal bleeding. physicians should be aware of this possible complication, since early diagnosis and treatment is imperative to prevent life-threatening complications, such as intestinal ischemia and perforation. a detailed medical and family history is imperative, and all patients with post-operative pvt should undergo complete hypercoagulability workup. this is a case of a 37 year old male with a previous history of a redo-hiatal hernia 5 years prior who presented with two episodes of upper gastrointestinal bleeding with no identifiable source noted on both endoscopy and angiography. during his second admission, initial hemoglobin was 5.5 g/dl and endoscopy performed showed massive amount of blood in the stomach. continuous oozing was seen originating in the fundus area but no clear source could be identified. empiric epinephrine was injected to the area but failed to achieve hemostasis. angiography was also negative. repeat endoscopy performed showed no active bleeding, however, distention of the wrap into the gastric cavity was observed. the patient re-bled and was taken to the operating room emergently after failed attempt at endoscopic control. the patient underwent proximal gastrectomy after intra-operative gastrostomy and exploration was unable to identify a bleeding source. the patient was left with an open abdomen and in discontinuity while resuscitation was performed in the surgical intensive care unit. he subsequently underwent a roux-en-y reconstruction and gastrostomy tube placement via the distal gastric remnant. upper gastrointestinal series performed demonstrated absence of leak, and the patient was started on a liquid diet supplemented with tube feeding. his recovery was uneventful and he was discharged home in stable condition. pathology revealed gastric ischemia at the base of the wrap making it impossible to visualize through endoscopy. on reviewing the literature, gastric ulcers and ischemia have been previously described. incidence was up to 3% and their onset of presentation ranged from the early post-operative period up to 5 years. most were located in the lesser curvature. the exact pathophysiology for its occurrence is not completely understood. factors hypothesized include technical aspect of the fundoplication causing inappropriate tension, vessel disruption and ischemia, and injury to the vagus nerve affecting gastric emptying which was thought to increase gastrin secretion. treatment includes medical management with proton pump inhibitors; however, few cases describe antrectomy with inclusion of the bleeding ulcer. our case presents failed medical and endoscopic management. we recommend take down of the fundoplication in hemodynamically stable patients to completely evaluate the gastric mucosa, identify, and address the source of bleeding. otherwise emergent cases will require staged gastrectomy including the wrap followed by roux-en-y reconstruction. acalculous cholecystitis associated with a large periampullary duodenal diverticulum: a case report peng yu, md, phd, austin iovoli, aaron hoffman, md; department of surgery, suny buffalo, kaleida health system, buffalo, ny introduction: periampullary diverticulum (pad) could compress common bile duct (cbd), and consequently cause obstructive jaundice and cholangitis as few publications have documented. here we first report an acalculous cholecystitis associated with a pad-related cbd obstruction. case: the patient was a 60-year-old female with a past surgical history of laparoscopic sleeve gastrectomy who presented at the emergency room with upper abdominal pain and vomiting for one day, associated with leukocytosis and left shift. serum total bilirubin raised up to 6.1 mg/dl on hospital day (hd) 3. ct, ultrasound, and mrcp images confirmed a distended, wall-thickening gallbladder with pericholecystic fluid, and a significantly dilated cbd at 1.2 cm of diameter ( fig. 1) , without cholelithiasis or choledocholithiasis. ercp was unable to be completed due to the post-gastrectomy anatomy and the failure in cannulation into the ampulla which embedded in a large foodimpacted pad (fig. 2 ). on hd5, the patient underwent a diagnostic laparoscopy and an intra-operative cholangiogram which confirmed a mildly inflamed edematous gallbladder, and a 3.893.8 cm 2 large pad with a narrow neck that was distorting the distal cbd (fig. 3 ). since the patient's bilirubin level had been improving, we decided to only do a laparoscopic cholecystectomy. intraoperatively an anatomic variation of the cystic artery encircling the cystic duct ( fig. 4 ) was also identified. postoperatively the patient recovered well during the thereafter inpatient course and at the postoperative 3-week outpatient follow-up. the pathology of the excised gallbladder confirmed cholecystitis without cholelithiasis. discussion: lemmel's syndrome is defined, in the absence of cholelithiasis or other detectable obstacle, by obstructive jaundice due to pad. since lemmel described this duodenal-diverticulum-obstructive jaundice in 1934, there still have been very few cases reported or investigated. to date there is no report describing the association of acalculous cholecystitis with lemmel's syndrome. this patient's mild acalculous cholecystitis probably attributed to the biliary obstruction and consequent gallbladder hydrops. her symptoms could be from either acalculous cholecystitis or intermittently worsening biliary obstruction. in this case, the contribution of the anatomic variation of the cystic artery is unclear. in the future, if this patient's symptoms recur, the treatment plans for her will be sphincterotomy, removal of the impacted food in the pad, or diverticulectomy. accidental fish bone ingestion masquerading as acute abdomen aim: to report a case of fish bone ingestion masquerading as acute abdomen. case report: a 48 years old female patient presented with complaints of severe abdominal pain since 5 days. there was no history of associated nausea or vomiting, fever or altered in bowel habits. on examination patient had tenderness and guarding localized to the right iliac fossa. blood investigations revealed raised inflammatory markers. ultrasound whole abdomen and contrast enhanced computed tomography (cect) were normal. patient was managed conservatively but in view of persistence of symptoms a triple puncture diagnostic laparoscopy was performed on day 3 of admission. omental inflammation with soapy appendix was found and appendicectomy was performed. on further assessment a foreign body was also found in the ileum which was removed and identified as a fish bone. patient had a satisfactory post operative recovery and was discharged in stable condition. discussion: acute abdomen due to fish bone ingestion is not a very common occurrence. unfortunately the history is often non-specific and these people can be misdiagnosed with acute appendicitis & other pathologies. ct scans can be useful to aid diagnostics. it is however not fully sensitive in detecting complications arising from fishbone ingestion. conclusion: any patient with acute abdomen, with non-specific history and normal imaging may still benefit from a diagnostic laparoscopy. discussion: this patient presented with a bowel obstruction, partial cecal necrosis and neuroendocrine carcinoma. literature suggests that cecal necrosis in the majority of cases is caused by a vascular event, occlusive or non-occlusive. the patient had atherosclerosis and an underlying malignancy which can be associated with prothrombotic states and contributes to an overall risk of thrombosis. the cecum can sustain ischemic ischemic injury in the presence of severe or prolonged hypotension. most frequent causes being decompensated heart failure, hemorrhage, arrhythmia or severe dehydration, only 1 of which was present in this patient. the midgut neuroendocrine tumor is generally located in the terminal ileum, as a fibrotic submucosal tumor 1 cm or less. mesenteric metastases are often larger than the primary tumor and associated with fibrosis which may entrap loops of the small intestine and cause bowel obstruction. this may eventually encase the mesenteric vessels with resulting venous stasis and ischemia in segments of the intestine as seen in this patient. conclusion: cecal necrosis is a rare entity, but its incidence increases with age. isolated cecal necrosis may manifest as a ct-negative appendicitis or a small bowel obstruction in the absence of past surgical history. s178 surg endosc (2018) laparoscopic transection of the falciform and triangular ligament successfully released the entrapped loop with successful reperfusion by the end of the surgery. in the absence of any prothrombotic comorbidity, the patients were discharged asymptomatic without further anticoagulation. to date only few similar cases have been reported, and most of them described in neonates and pediatric patients. to our knowledge, this cases reporteds in the elderlys. in this patients laparoscopic approach was both diagnostic and therapeutic with the transection the ligament. roberto javier rueda esteban 1 , andres mauricio garcia sierra 2 , felipe perdomo 2; 1 universidad de los andes, 2 fundacion santa fe this is a patient´s rare case of spontaneous splenic rupture associated to chronic myeloid leukemia as an uncommon complication. the case report and review of the relevant literature on symptomatology and clinical management is presented. emphasis is made about the importance of including splenic rupture as differential diagnosis for acute abdominal pain, especially in a patient with neoplastic hematopathology, since early treatment increases patient survival and prognosis. esophagectomy is a complex operation associated with serious immediate complications and long term chronic complications. gastric ulcers are a common chronic complication after esophagectomy with gastric conduit reconstruction. these are rarely complicated by significant bleeding or perforation. we report a case of delayed diagnosis of a fistula forming between a gastric conduit and right bronchial tree 13 years after esophagectomy. this was successfully treated using multiple therapeutic approaches including endoscopic localization and resection through a right thoractomy. to the best of our knowledge, our patient is the only survivor from a chronic gastric conduit bronchial fistula. a 53 year old male with type 1 diabetes mellitus, dyslipidemia, asthma and smoking history presented 15 years after an ivory-lewis esophagectomy for a gastrointestinal stromal tumor (gist) with a chronic cough starting 13 years after his esophagectomy followed by multiple episodes of hematoptysis over the next 2 years. the patient was known to have ulcers in his gastric conduit with a massive bleed 1 year after his esophagectomy. repeat endoscopy revealed two large chronic ulcers that had increased in size based on comparison of pictures from endoscopies 3 to 6 years after his esophagectomy despite maximal medical management. the patient presented to numerous specialists at tertiary care centers in canada and the united states. ultimately, in a clinic the patient was observed to cough immediately after the ingestion of water, but not solids leading to a provisional diagnosis of a gastrobronchial fistula. a barium swallow failed to show a fistula (fig. 1 ). however at endoscopy, instillation of saline directed at an ulcer immediately induced a cough, but this was not reproduced when the saline was directed away from the ulcer. the fistula was ultimately demonstrated by placing a wire through the ulcer and visualizing it bronchoscopically in the right superior segmental bronchus . in an effort to pursue a minimally invasive approach two attempts were made to close the fistula with over-the-scope clips (otsc). unfortunately, the patient's symptoms persisted. a wire was placed through the fistula and delivered through the patient's mouth and endotracheal tube. a right thoracotomy allowed access to the conduit, which was opened and the fistula localized using the wire. the fistula was resected and the bronchus closed. at twelve month follow up the patient did not have a recurrent cough or hemoptysis while tolerating a full diet. introduction: roux en-y gastric bypass (rygb) is one of the initial and most studied weight reduction procedures and remains the gold standard for comparison in bariatric surgery clinical outcomes. although rygb is an effective procedure for weight loss, it has been less popular over last several years because of increased morbidity compared to the more utilized vertical sleeve gastrectomy (vsg). early complications of rygb include bleeding, perforation, or leakage. late complications include internal hernias, small bowel obstruction, anastomotic stenosis, marginal ulcers, and gastrogastric fistulas. case report: a 50-year old female with a past medical history of morbid obesity, diabetes mellitus type 2, hypertension, gerd, peptic ulcer disease, cholelithiasis, liver dysfunction with ascites, asthma, and a past surgical history of rygb (11 years ago) presented to our institution with acute on chronic abdominal pain associated with nausea, vomiting, dysphagia, inability to eat and maintain hydration, and an additional weight loss of about 100 lbs. over the last year. in addition, the patient was a chronic opioid and nsaid user, had an extensive smoking history, and had not followed with her surgeon for 11 years. at the time of presentation, the patient weighed 82 lbs (bmi: 13.2), had normal vital signs, and appeared cachectic. an upper gastrointestinal study followed by an upper endoscopic examination demonstrated complete obliteration of the gastrojejunal anastomosis and revealed a 2-cm long gastrogastric fistula originating from the distal end of the gastric pouch to the lesser curvature of the excluded stomach. after conservative measures were initiated to hydrate and metabolically stabilize the patient, the decision was made to proceed with diagnostic laparoscopy and surgical placement of a gastrostomy tube to the gastric remnant. the patient was discharged after tolerating a full liquid diet and gastrostomy tube feedings, for plan of future revision of gastrojejunostomy when optimal nutritional status is achieved. conclusions: late complications of rygb occur at a rate of 15-20%. major risk factors for anastomotic complications include non-compliance, smoking, and opiate and nsaid abuse. though abdominal pain, anastomotic stenosis, marginal ulcers, and fistulas are relatively common late complications of rygb, complete obliteration of the gastrojejunal anastomosis has not been well described in the literature. this case demonstrates the importance of long term follow up post rygb for early diagnosis of late complications and brings attention to this rare, but possible sequele that can arise in patients after rygb. contrast radiograms and upper endoscopic photographs will be presented. introduction: retroperitoneal sarcoma represents approximately 12-15% of all sarcomas and less than 0.5% of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. in a patient with a large fibrosarcoma and associated hypoglycemia, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. laparoscopic surgery represents an alternative technique for radical resection of such tumors as a minimally invasive rather than traditional surgery. only few cases were reported in the literature. introduction: roux-en-y gastric bypass (rygb) is a frequently performed bariatric procedure, of which internal hernia (ih) is a known complication. we discuss a rare finding of occult gastric remnant perforation as a result of an obstructed ih in a post bypass patient. methods: we present a case report of a single bariatric surgeon's experience at a tertiary care hospital. literature review of pubmed confirms the unique presentation and operative findings in our patient, as few similar cases have been published. a 59-year-old male s/p rygb 12 years ago presented to the ed with right upper quadrant pain, nausea, vomiting, and a leukocytosis of 24,100. bmi was 31.7; weight was 254 lbs. workup included an abdominal ultrasound showing gallbladder distention without signs of cholecystitis. liver function tests were normal. further imaging included a ct scan, remarkable for a paraesophageal hernia (peh) containing the gastric pouch, and an elevated left hemidiaphragm. the scan showed no evidence of ih or bowel obstruction. an upper gi series was additionally obtained, which was also negative for small bowel obstruction. due to unclear etiology for this patient's symptoms or source of leukocytosis, diagnostic laparoscopy was planned. results: intraoperative findings were significant for ih containing dilated small bowel with twisted and incarcerated omentum through the jejunojenunostomy site, as well as a distended gallbladder without acute inflammation. ih was reduced and closed without bowel resection. cholecystectomy was completed. subsequent inspection of the diaphragmatic hiatus revealed uncomplicated herniation of the gastric pouch. in attempts to dissect the left diaphragmatic crus, a large pocket of purulent material was encountered below the left diaphragm in the region of the remnant stomach fundus. methylene blue test and intraoperative endoscopy did not demonstrate any connection to gastric pouch. the purulence was attributed to an occult remnant stomach perforation related to distal obstructed ih. a drain was left in the abscess and the peh was not surgically addressed. patient was discharged on postoperative day 5. he has not suffered any further complications or recurrent complaints. conclusion: gastric perforation following rygb is an uncommon complication resulting from ih. this diagnosis was missed by preoperative imaging and was only found after thorough laparoscopic investigation. surgeons should maintain a high clinical suspicion of ih in post rygb patients with otherwise unexplained abdominal symptoms, fever, and leukocytosis, even in the absence of confirmatory diagnostic testing. threshold for operative exploration in this clinical setting should remain low. alejandro garza, md, robert alleyn, md, jose almeda, md, ricardo martinez, md; utrgv obesity is an epidemic condition worldwide carrying significant morbidity and mortality. surgical therapy is the only proven effective method to sustain weight loss. among the different surgical procedures gastric bypass is the most effective. during this surgery, most of the stomach is excluded from the upper gastrointestinal tract which makes future evaluation of the same very challenging. this could potentially lead to delay in diagnosis of any pathology in the bypass stomach. gastric cancer is the 14th most common cause of cancer and cause of cancer death in the united states. we present a case report of a patient who underwent a roux-en-y gastric bypass and went on to developed adenocarcinoma in the gastric remnant 28 year after her surgery. she underwent an exploratory laparotomy, extended antrectomy, subtotal gastrectomy including the gastro-colic ligament, and incidental appendectomy. pathology showed grade 4 undifferentiated adenocarcinoma that penetrated the visceral peritoneum with clear margins. there was angiolymphatic invasion and perineural invasion along with metastatic carcinoma in 5 out of 6 lymph nodes. introduction: polyarteritis nodosa (pan) is a systemic transmural inflammatory vasculitis that affects medium-sized arteries. inflammation of the vessel wall and intimal proliferation creates luminal narrowing which can lead to stenosis and insufficiency. the same inflammatory process causes disruption of the elastic lamina leading to aneurysm formation and possible spontaneous rupture with life-threatening bleeding. multifocal segments of stenosis and aneurysm formation are characteristically identified as a "rosary sign" or "beads on a string". unlike other vasculitides, pan does not involve small arteries or veins, and is not associated with anti-neutrophil cytoplasmic antibodies. we present the case of a 66 year old female with a significant intra-abdominal bleed that was explored and repaired primarily. she was subsequently found on angiogram and postmortem pathology to have findings consistent with pan. case presentation: 66 year old female who presented to the emergency department with abdominal pain followed by hemorrhagic shock and found to have a ruptured left hepatic artery aneurysm during exploratory laparotomy. this aneurysm was suture ligated with a successful outcome. a mesenteric arteriogram was performed the following day and demonstrated lesions consistent with pan including aneurysms of the left gastric branches, right and left hepatic arteries, and beaded appearance of the iliac artery. however, 2 days after hospital discharge she developed massive pulmonary embolism from which she did not recover. postmortem examination confirmed rupture of the left hepatic artery aneurysm in addition to gross anatomical and histological findings consistent with pan. discussion: polyarteritis nodosa is a systemic inflammatory vasculitis that causes intimal proliferation and elastic lamina disruption. this multifocal disruption of the vessel results in aneurysm formation alternating with stenosis creating a characteristic "rosary sign" on imaging. spontaneous rupture of these aneurysms is rare and almost always fatal due to life-threatening hemorrhage. with acutely ruptured aneurysms, prompt diagnosis, aggressive resuscitation, and hemostasis through transarterial embolization or surgery is paramount for patient survival. while acute rupture of an aneurysm as the result of pan is exceedingly rare, it must be considered as a differential diagnosis in the setting of acute abdominal pain and hemodynamic instability. in a patient known to have a medical history of pan and aneurysm formation, routine monitoring and disease progression should be followed. introduction: 300,000 surgeries are done annually in the us for small bowel obstruction, which is most commonly caused by intraabdominal adhesions, malignancy, and hernias. 0.2 to 5.8% of small bowel obstructions are due to paraduodenal hernias. paraduodenal hernias carry a 50% lifetime risk of incarceration with a mortality of 20 to 50%. case report: the patient is a 78 year old male who presented with severe upper abdominal pain for one day. he was passing flatus and had had a bowel movement the previous day. on examination, the patient was tender over the upper abdomen. computed tomography (ct) scan with iv contrast showed a mesenteric swirl sign. the decision was made to perform diagnostic laparoscopy with possible small bowel resection. intraoperatively, a mesenteric defect was noted posterior and to the right of the duodenum, through which bowel was herniating. the herniated bowel and its mesentery were edematous. the defect was sutured closed, taking seromuscular and mesenteric bites through the stomach, jejunum, and mesentery. the patient had an uneventful recovery postoperatively and was discharged on postoperative day 2. he returned on postoperative day 28 with periumbilical pain which resolved with conservative management. he was followed up 6 weeks postoperatively and was doing well. discussion: paraduodenal hernias are the most common internal hernias. they are seen more often in males. they are caused by failure of the counterclockwise rotation of the prearterial segment of the embryonic midgut in weeks 2 to 12 of embryonic development. paraduodenal hernias usually present with chronic intermittent abdominal pain, weight loss, nausea, and vomiting. they may present acutely with symptoms of bowel obstruction. peritoneal signs are often not appreciated due to retroperitoneal position of the hernia. ct scan of the abdomen often shows clustering of bowel loops, which cannot be displaced on repositioning the patient. if imaging is equivocal, diagnostic laparoscopy may be undertaken. surgical correction consists of reducing the bowel, resecting nonviable segments, and either closing the defect or opening the sac laterally into the general peritoneal cavity. in summary, paraduodenal hernias are a rare cause of bowel obstruction and as such present a challenge in diagnosis and early intervention. diverticulosis of the appendix is a rare disease found in 0.004-2.1% of appendectomies, first described in 1893. the clinical presentation may be acute inflammatory with or without appendicitis or it may be an incidental finding in an uninflamed appendix. the congenital type is rare and it has all the bowel wall layers. it most frequently represents as pseudo diverticulum which lacks the muscularis layer. the pathogenesis of appendiceal diverticula is not completely elucidated. its symptoms are similar to and often misdiagnosed for that early acute or chronic appendicitis. while appendectomy is curative for both entities, it is important to distinguish diverticulum of the appendix from appendicitis as it is four times more likely to perforate and may be a sign of an underlying neoplasm. we reported a very rare giant pseudo diverticulum of the appendix in a 69-year-old male presenting with chronic abdominal discomfort for months. abdominal x-ray showed abnormal gaseous finding. physical exam was significant for a soft rubbery mass in the periumbilical region. blood work revealed slight elevation of c-reactive protein. preoperative ct and mri showed a 9-centimeter-large cavity composed of thin wall, located at the tip of the appendix with peri appendicular fat stranding. in the concern of pending obstructive symptom and chronic abdominal pain, we decided to perform the resection laparoscopic. the soft mass arose from the tip of the appendix. there were dense adhesions between the appendix, mesentery, and sigmoid colon. after adhesiohedlysis, laparoscopic appendectomy was performed with endogia. the specimen was extracted through a small incision without spillage. hospital course was uneventful and the patient was discharged on post-operative day 4. the pathological finding was consistent with a pseudo diverticulum of the appendix which lacked muscularis layer and the inner wall of the cavity was lined with a scattered cubital epithelial layer in the continuity with the appendiceal mucosal membrane. here we report a successful laparoscopic resection of an extremely rare giant chronic pseudo diverticulum of the appendix. yvette farran, ms, jorge a miranda, ms, benjamin clapp, md, elizabeth de la rosa, md; texas tech university health sciences center introduction: sigmoid colon intussusception is rarely encountered and given its vague symptomatology diagnosis and management can be difficult. the treatment of an intussusception in adults is different than in children. lipomas as the causative etiology for intussusception are encountered up to 0.83% of the times and up to 70%-90% of the patients require surgical resection for treatment. methods: this is a case report about a 62 year old male that presented with two weeks of worsening abdominal pain and distention. physical exam was only pertinent for abdominal pain on light palpation, guarding and moderate distress. ct scan of abdomen and pelvis demonstrated a lipomatous mass causing complete obstruction of the sigmoid colon with intussusception. this was managed with laparoscopic sigmoidectomy. the patient had an uncomplicated post-operative period and was discharged on post-operative day 2. pathology of the lipomatous mass confirmed a benign lipoma. discussion: intussusception is rarely encountered in clinical practice in adults and constitutes 5% of all cases. lipoma induced sigmoid intussusception with complete obstruction is rare. symptoms can be non-specific as in this case. this case report highlights the importance of timely diagnosis and treatment of an intussusception in adult patients. ct scan is the gold standard for diagnosis and often shows a "target sign". other imaging techniques like ultrasound have shown adequate results but remain less effective than ct scan. the treatment in adults is not a reduction by enema like in pediatrics but rather resection of the lead point. this can be appropriately done with a laparoscopic technique in most cases. conclusion: colonic intussusception is rare. surgery is the only treatment for an intussusception in adults since the lead point needs to be removed, and can be attempted safely with a laparoscopic approach. surg endosc (2018) 32:s130-s359 joshua smith, md, kern brittany, md, amie hop, md, amy banks-venegoni, md; spectrum health case report: 60 year-old female with no significant past medical history presents with a 10-year history of nocturnal cough that had worsened over the past 3 months and had associated regurgitation. she underwent esophagogastroduodenoscopy (egd) that showed a tortuous esophagus and tight lower esophageal sphincter that required dilation. she received an upper gastrointestinal (ugi) contrast study that showed a dilated, tortuous esophagus with 'bird's beak' tapering, consistent with achalasia, as well as a large epiphrenic diverticulum measuring 797 cm. esophageal manometry confirmed "pan-esophageal pressurization" consistent with type ii achalasia. given her symptoms in the presence of these findings, she elected to proceed with surgery. she underwent laparoscopic, trans-hiatal epiphrenic diverticulectomy, heller myotomy and dorr fundoplication. extensive dissection allowed for approximately 8 cm of retraction down from the chest and we were able to come across it with a single blue load of a 60 mm linear cutting stapler. post-operatively, she tolerated the procedure well with immediate improvement in her symptoms. her ugi on post-operative day 1 showed no evidence of leak, she tolerated a soft diet and was discharged home. she was seen at 2-week and 1-year follow-up appointments with complete resolution of symptoms. discussion: epiphrenic diverticula in the presence of achalasia has an occurrence rate of 25%. large diverticula ([5 cm), are even more rare with only a handful of case reports in the literature. historically, thoracotomy or, more recently, thoracoscopic approaches are required for resection. however, thoracic approaches are associated with a 20% increase in morbidity, namely due to staple line leak and the resulting pulmonary complications. only a single case report exists on our review of the literature that demonstrates successful trans-hiatal laparoscopic resection without post-operative complications of a diverticulum of this size. the shortest documented length of hospital stay postoperatively for similar cases is 4 days, while the average is 7-10 days or longer for those with complications. our patient was able to go home on post-operative day 1 after a normal ugi and was tolerating a soft diet. not only does this case show that a large epiphrenic diverticulm can be successfully resected via the trans-abdominal laparoscopic approach, this case makes the argument that patients undergoing any minimally-invasive epiphrenic diverticulectomy and myotomy, with or without fundoplication, may be successfully managed with early post-operative contrast studies and dietary advancement, thus decreasing their length of hospitalization and overall cost of treatment. kazuma sato, shunji kinuta, koichi takiguchi, naoyuki hanari, naoki koshiishi; takeda general hospital background: situs inversus totalis (sit) is a rare congenital condition in which the abdominal and thoracic organs are located opposite to their normal positions. few cases of laparoscopic surgery for gastric cancer with sit have been reported. we report a case of laparoscopic distal gastrectomy with d2 lymph node dissection performed for gastric cancer in a patient with sit. case description: an 80-year-old woman was admitted to our hospital for treatment of gastric cancer that was diagnosed by esophagogastroduodenoscopy (egd) at a local clinic after she experienced anemia and nausea. egd identified an irregularly shaped gastric ulcer located at the anterior side of the lesser curvature of the antrum. a biopsy revealed a moderately differentiated adenocarcinoma. she was then diagnosed with sit by chest radiography and abdominal computed tomography (ct). the abdominal ct showed that all organs were inversely positioned and that the wall of the antrum had thickened; it also showed the lymph nodes in the lesser curvature of the stomach, without distant metastasis or an abnormal course of vascularity. the patient was clinically diagnosed with t3n1m0 stage iiia gastric cancer according to the japanese classification of gastric carcinoma. a laparoscopic distal gastrectomy with d2 lymph node dissection in accordance with the japanese gastric cancer treatment guidelines as well as a roux-en-y anastomosis due to an esophageal hiatal hernia were performed. the surgery was safely and successfully performed, although it required more time than usual because the inverted anatomic structures were repeatedly examined during the surgery. the postoperative course was positive, and the patient was discharged on postoperative day 7 without any complications. the final stage of this case was pt1bn0m0 stage ia. currently, the patient is doing well without recurrent gastric cancer. conclusion: gastric cancer with sit is an extremely rare occurrence. we experienced a case of laparoscopic distal gastrectomy with d2 lymph node dissection performed for gastric cancer in a patient with sit. we simulated the operation for sit by viewing left-right reversed ordinary surgical videos. the abdominal ct angiography with a three-dimensional reconstruction helped reveal any variation and confirmed the structures and locations of vessels before the surgery. the operation could safely be performed following the standardized surgical technique by reversing the surgeon standing position and trocar position. sternum or chest wall resection is performed for a variety of conditions such as primary and secondary tumors of the chest wall or the sternum. sternum reconstruction has been a complex problem in the past due to intraoperative technical difficulties, surgical complications, and respiratory failure caused by the chest wall instability and paradoxical respiratory movements. advances in the fields of surgery and anesthesia result in more aggressive resections. nowadays neither the size nor the position of the chest wall defect limits surgical management, because resection and reconstruction are performed in a single operation that provides immediate chest wall stability. chest wall resection involves resection of the ribs, sternum, costal cartilages and the accompanying soft tissues and the reconstruction strategy depends on the site and extent of the resected chest wall defect. here i'll present, the youngest ever case reported, 2 years old girl with rhabdomyosarcoma involving the sternum. i will present the management challenges and the reconstruction options. introduction: neuroendrocrine malignancies constitute 0.5% of all cancers. the gastrointestinal tract is the commonest site, followed by the lung. the last decade has seen a steady increase in their incidence. this is a case series of twenty five such tumours and their clinicopathological characteristics. materials and methods: twenty five patients with neuroendocrine tumours of the gastrointestinal tract were studied with reference to their demographic and clinicopathological characteristics. apart from routine pathological examination, these tumours were also checked for e cadherin expression as an independent marker of aggressive disease. results: the age of our patients ranged from 18 to 67 years. we had 13 female and 12 male patients, contradicting a female preponderance in literature. the vast majority of the tumours we encountered were from the stomach and duodenum, with 5 and 12 patients, respectively. two tumours were at the gastroduodenal junction, two from the appendix, small intestine and pancreas, each, and one each from the rectum and gall bladder. this is in contrast to literature that shows that neuroendocrine tumours of the git most commonly arise from the appendix and small bowel, followed by the rectum, stomach and duodenum. two of these tumours were functional. the diagnosis was confirmed by immunohistochemistry staining for chromogranin a and synaptophysin. grading was done using who criteria that takes into account the mitotic count, ki 67 index and necrosis. 21 of our cases were grade i. further, immunohistochemistry for e cadherin showed that absence of expression correlated with more aggressive clinical behavior. 18 out of twenty five patients were operable at presentation and standard resections depending on the organ of origin with adjuvant therapies were given as required. 5 could only be given palliative care. the 2 functional tumours were treated with radiolabelled somatostatin analogues following uptake studies. conclusion: as neuroendocrine tumours are relatively rare, information about them is not as abundant as with other malignancies. absence of e cadherin expression is associated with more aggressive disease. more studies are required that document the pathological characteristics and clinical behavior in order to offer well rounded treatment protocols that treat not only the primary, but also the generalized effects of the secretions produced by them. targeted chemotherapy is gaining prominence, but more specific drugs directed at the plethora of receptors these tumours express, could potentially revolutionize treatment. (1) . unfortunately there are no publications from denmark. we would like to present first to our knowledge reported case of double gallbladder in denmark. double gallbladder is a rare anomaly with a prevalence of 1:3800 in autopsy studies, described first by boyden in 1926 (2) . there are several classifications of double gallbladder that are based on relation between gallbladder, cystic duct and common bile duct (2, 3) . non-specific symptoms and inadequate imaging are possible causes of lack of awareness of the condition. removal of all gallbladders, preferably laparoscopic with special attention to the biliary anatomy, is recommended (4). method: case report with review of the literature. a 55-year-old female patient of polish origin was hospitalized due to upper right quadrant pain. on admission clinical manifestations and paraclinical abnormalities of pancreatitis were present. ultrasound scanning of the abdomen showed bile stones, ultrasonic manifestations of acute cholecystitis and normal intra-and extrahepatic bile ducts. because of elevated liver enzymes mrcp was performed and showed double gallbladder, double cystic duct and signs of pancreas anulare. scheduled ercp confirmed bile stones in cbd, double gallbladder with double cystic duct, h-type according to harlaftis classification (3) . because of minor retroperitoneal perforation second ercp was needed for removal of all stones. the patient was then scheduled to laparoscopic cholecystectomy with perioperativ cholangiography. conclusion: anatomical variations of the gallbladder such as double gallbladder are rare and often remain unnoticed. they are most often identified because of clinical manifestations symptoms, diverse imaging studies, during surgery or autopsy. as most of them are not expected, they can contribute to complications during surgery. careful preoperative imaging is very important to prevent accidental bile duct injury. looking at the number of case reports, double gallbladder seems to be slightly more common than expected. the interesting question is whether a gallbladder discovered during an unrelated radiological investigation in a patient that previously underwent a cholecystectomy can represent undetected case of double gallbladder. we would like to present a review of the literature as well as images from mrcp, ercp and laparoscopy. michael jaroncyzk, md, courtney e collins, md, ms, vladimir p daoud, md, ms, ibrahim daoud, md; st. francis hospital; hartford ct introduction: several decades ago, surgical training was saturated with procedures to treated peptic ulcer disease. since the introduction of histamine-2 blockers and proton pump inhibitors, these procedures have dwindled significantly. however, there are still instances where patients require surgical intervention for peptic ulcer disease. perforation is one of the indications for surgery. the surgical options to treat a perforated peptic ulcer are numerous. one of the most common options is a graham patch. we are presenting a case of a patient with a perforated ulcer that did not have available omentum for the repair. methods and procedures: recently, a 64-year-old female with a past history of an open total abdominal hysterectomy and bilateral salpingo-oophorectomy presented as an outpatient with chronic lower abdominal pain. she underwent a work-up and imaging that did not reveal any pathology. at diagnostic laparoscopy, she had diffuse lower abdominal adhesions, which were lysed. she was discharged on the same day, but presented to the emergency department two days later with severe abdominal pain and fevers. the work-up revealed tachycardia, diffuse abdominal tenderness with peritoneal signs, leukocytosis and a large amount of free air on imaging. she was emergently brought to the operating room for a diagnostic laparoscopy. during laparoscopic exploration, the lower abdominal cavity appeared normal for a recent lysis of adhesions. attention was turned to the upper cavity to find the pathology. bile-stained free fluid and peri-gastric exudates were identified, but no perforation was visualized. intra-operative endoscopy revealed the site of perforation in the antrum on the lesser curvature. a biopsy was performed and the decision was made to perform a graham patch. however, the omentum was already densely involved with the lower abdominal cavity from the enterolysis. due to the close proximity of the falciform ligament, it was mobilized laparoscopically and the pedicle was used as a graham patch. the patient recovered without any additional issues. the biopsy was reported as a chronic gastric ulcer. conclusion: surgical history has given us many options to treat peptic ulcer disease that are not nearly as common as they were decades ago. perforated ulcers can be managed laparoscopically and graham patches are a common choice for repair. however, the lack of the omentum for a proper pedicle flap can pose a problem in some patients. we have shown in this patient that a falciform pedicle flap can be successfully used as a substitution. laparoscopic management of boerhaave's syndrome after a late presentation: a case report and literature review tahir yunus, hager aref, obadah alhallaq; imc background: boerhaave's syndrome involves an abrupt elevation in the intraluminal pressure of the oesophagus, causing a transmural perforation. it is associated with high morbidity and mortality. having a nonspecific presentation may contribute to a delay in diagnosis and results in poor outcomes. treatment is challenging, yet early surgical intervention is the most important prognostic factor. case presentation: we present a case of a thirty-two-year-old male with a long medical history of dysphagia due to benign oesophagal stricture. he presented with acute onset of epigastric pain after severe emesis. based on computed tomography scan, he was diagnosed with boerhaave's syndrome. presenting with signs of shock, mandated immediate surgical exploration. for which he was taken for laparoscopic primary repair with uneventful postoperative recovery. the golden period of the first 24 hours of insult still applies for cases of oesophagal perforation. the rarity of these cases makes a comparison between the various treatment methods difficult. our data support that the use of laparoscopic operative intervention with primary repair as the mainstay of treatment for the management of oesophageal perforation. lipomas of the gastrointestinal tract are rare benign soft tissue tumors that are often discovered incidentally. these lesions are often asymptomatic, but have occasionally been reported to have clinical significance as will be described in this case report. a 40 year old male initially presented to his primary care physician's office with a three week history of vague intermittent abdominal pain. his pain was located in the mid epigastrium and was associated with mild nausea. past medical history was significant for hyperlipidemia and a right-sided goiter, and he denied any previous surgeries. outpatient work up revealed a microcytic anemia, intermittent melena and hemoccult positive stools. the patient was referred to hematology and gastroenterology. endoscopies revealed gastritis, and small internal and external hemorrhoids. he underwent an outpatient ct scan which demonstrated a 6.092.3 cm mass within the lumen of the jejunum causing long segment non-obstucting intussusception. subsequently, the patient was referred to surgery and underwent a diagnostic laparoscopy. at the time of surgery, an approximately twelve centimeter segment of proximal jejunum was identified intussuscepting into a distal limb. this segment was attempted to be reduced laparoscopically, however there was significant mesentery within in the intussusceptum and the segment could not be safely reduced. therefore, the section of bowel was delivered through a small periumbilical incision. the intussusceptum was then able to be manually reduced from the intussusception. at this point a large mass was palpated inside the lumen of the jejunum. a small bowel side to side, functional end to end resection and anastomosis was preformed. the bowel was returned to the abdomen and the abdomen was re-insufflated. the remainder of the small bowel was run and no additional lesions were identified. final pathology revealed a 5.593.693.5 cm submucosal partially obstructing lipoma with ulceration at the tip. the patient recovered uneventfully and was discharged home on the second post operative day. this case report describes a submucosal jejunal lipoma that was acting as a lead point for intermittent non-obstructing small bowel intussusception, while simultaneously causing a microcytic anemia due to ulceration at the tip of the lipoma. laparoscopic assisted reduction and small bowel resection is a safe and effective treatment for gastrointestinal tract lipomas that are unable to removed endoscopically. percutaneous endoscopic gastrostomy (peg) is an alternative to laparotomy for open gastrostomy tube placement to provide enteral nutrition for those who are unable to pass nutrition orally. despite being less invasive, the procedure is not without its complications, one of which includes the formation of a gastrocolocutaneous fistula. the case describes a 90 year old female who presented with a peg placed 6 months prior with reports of leakage of tube feeds from the gastrostomy site. as there was concern for possible ileus or obstruction, an upper gi series was completed which seemed to indicate dislodgement of the g-tube. the g-tube was replaced and a follow-up gastrograffin study was repeated which now indicated that the g-tube was within the lumen of the colon. soon thereafter fecal matter was noted to be draining around the g-tube site; however, patient was without clinical signs of peritonitis. the patient was managed non-surgically as she was a poor surgical candidate with multiple prohibitive co-morbidities. the g-tube was removed bedside by cutting it flush at the skin level with the anticipation that the remainder of the tube would be excreted with bowel movements. the decision was then made to attempt closure of the gastric fistula endoscopically which was accomplished with hemoclips. a follow up upper gi study 72 hours later showed no extravasation of contrast through the gastric fistula. the colocutaneous fistula had self-resolved over the next couple days as well. placement of the peg tube through the transverse colon can present with varying ill effects including diarrhea, pneumoperitoneum, peritonitis, gram negative pulmonary infection or feculent vomiting with the formation of a gastrocutaneous fistula. treatment historically for a gastrocolocutaneous fistula has been exploration and excision of the fistula tract with resection of the involved colonic segment. however, there currently is no gold standard for the management of, and really ranges from conservative management to surgical and is dependent on the presenting symptoms. if the peg becomes dislodged with resultant spillage from the colon with resultant peritonitis, surgical exploration is needed with removal of the g-tube and repair of the stomach and colon. on the other hand, non-surgical management has been suggested in management of a well-established fistula. fistula closure may be spontaneous; however, can be inhibited due to delayed gastric emptying or leakage of gastric secretions through the fistula. endoscopic clipping of the fistula tract employing the hemoclips is a treatment option. median arcuate ligament syndrome (mals) is a rare etiology of abdominal pain caused by narrowing of the celiac artery at its origin by the median arcuate ligament with relative hypoperfusion downstream. patients suffer from post-prandial abdominal pain, abdominal pain associated with exercise, nausea, and unintentional weight loss. diagnosis is historically made by demonstrating elevated celiac artery velocities and respiratory variation on dynamic vascular studies. standard of care for mals patients is laparoscopic celiac artery dissection with release of the median arcuate ligament. at our institution, we have encountered fourteen patients (eleven female, three male) diagnosed by elevated peak velocity in the celiac artery by duplex ultrasound in conjunction with ct angiogram, mr angiogram, arteriogram, or multiple modalities. all but one patient had multiple diagnostic imaging modalities, with the most common being ct angiogram; eight patients had invasive imaging. the mean age at presentation was 58.7 years in men and 47.8 years in women. on average, male patients presented with a longer duration of symptoms, 17.7 years (range 3-30 years), as compared to women, 3.3 years (range 1-15 years). symptoms were fairly consistent between genders and included nausea, emesis, abnormal bowel habits, early satiety, post-prandial pain, and weight loss. all male patients reported at least two symptoms, most commonly nausea and post-prandial pain. in female patients, 82% reported having three or more symptoms. notably, post-prandial pain was universal among men and women, while weight loss was exclusive to female patients as reported by 73%. pre-operative peak velocities were recorded in all but one patient, with mean values more elevated in female patients as opposed to male patients, 156 cm/s versus 345 cm/s. post-operative duplexes were obtained in seven patients; pooled data show a mean change of negative 210 cm/s for an average of 112 cm/s after decompression. in all cases, the celiac artery trifurcation was visualized and noted to have a distinct change in artery caliber after division of the ligament. in total, 79% of patients reported significant improvement with return to normal diet and healthy weight gain post-operatively. of the three without complete resolution, two were diagnosed with motility disorders and one was lost to follow-up. our experience demonstrates that laparoscopic release of the median arcuate ligament in patients with significant flow limitation of the celiac artery on dynamic and anatomic imaging can be a successful treatment option for patients with recalcitrant pain and gastrointestinal dysfunction with no alternative diagnosis. matthew a goldstein, ma, kirill zakharov, do, sharique nazir, md; nyu langone brooklyn adhesions are fibrotic bands that form between and among abdominal organs. the most common cause of abdominal adhesions is previous surgery in the area as well as radiation, infection and frequently occurring with unknown etiology. these bands occur among abdominal organs, commonly the small bowel, and can lead to obstruction or remain asymptomatic, akin to the patient discussed here. congenital abdominal adhesions are rare and have received little attention in research and field of study. the patient described in this case is a 25-year-old female with a past medical history of morbid obesity, bmi of 45, hypertension and no past abdominal surgical procedures. the patient presented in august 2017 for bariatric surgical consultation and was ultimately taken for an attempted laparoscopic sleeve gastrectomy. upon entering the abdomen, significant adhesions were encountered and an additional attending was called to assist in identifying the stomach. the splenic flexure was found to be plastered to the diaphragm and the descending and transverse colon were adhered to the anterior surface of the stomach. additionally, small bowel adhesions encased the area between the right and left hepatic lobes as well as the caudate lobe. after extensive enterolysis, the pylorus remained the only identifiable portion of the stomach. the patient also demonstrated significant hepatomegaly and a wedge resection was performed. the amount of adhesion and matting of the small and large bowel obscured the view of the stomach and the procedure was deemed too dangerous and terminated. this case represents the uncommon scenario in which an abdomen with no prior surgical history presents with extensive, obscuring adhesions. one such recent study describes the influence of cytokines and proinflammatory states as contributors to obstruction and malrotation in children, but this patient demonstrated no significant history. further investigation is needed to determine potential etiologies of symptomatic and non-symptomatic congenital adhesions among bariatric patients who fail conservative treatment. today the patient is doing well and the surgical team will attempt to complete the procedure in the coming months. laparoscopic spenulectomy: an interesting case report riva das, md 1 , daniel a ringold, md 2 , thai q vu, md 2; 1 orlando health, 2 abington jefferson health introduction: spenules, or accessory spleens, are a rare disease entity. most often, they are asymptomatic, and found incidentally during radiographic workup for an unrelated problem. torsion can cause a splenule to not only become symptomatic, but also confound the results of usual diagnostic studies. case description: a 61-year-old female patient with history of uncomplicated hypertension, hyperlipidemia, hysterectomy, cholecystectomy, spinal surgery, and partial left nephrectomy, presented to the hospital with a two-week history of intermittent left upper quadrant abdominal pain. she denied any similar episodes in the past, or any associated symptoms. further investigation with a ct scan of the abdomen and pelvis showed an acute inflammatory process in the left upper quadrant in same location as some colonic diverticulosis, as well as a 4.5 cm soft tissue mass. this indeterminate soft tissue mass was described as having decreased attenuation compared with the spleen. differential diagnosis for this mass included malignancy, an atypical splenule, or an infectious/inflammatory mass. an mri was recommended for further evaluation, but did not reveal any additional significant findings. nuclear medicine liver/spleen scintigraphy was performed, which showed no focal activity associated with the indeterminate left upper quadrant mass, therefore making it unlikely to reflect a splenule, and making malignancy the diagnosis of exclusion. following a period of observation with analgesia, intravenous antibiotics, and bowel rest, her abdominal pain did not resolve, and the decision was made to proceed with operative exploration. diagnostic laparoscopy revealed an approximately 5 cm spherical mass in the left upper quadrant located just below the inferior aspect of the spleen. the superior aspect of the mass gave rise to a vascular pedicle, which upon tracing, seemed to originate from the splenic hilum. this pedicle was easily ligated, and the mass removed. pathology revealed an extensive infarcted hemorrhagic nodule with organizing thrombus and attached thrombosed artery, consistent with an infarcted splenule due to torsion along its own axis. the patient had an uncomplicated postoperative course. discussion: this case report demonstrates the unusual presentation and workup of a patient that was ultimately diagnosed with an infarcted splenule, despite imaging findings that did not correlate, and may even have confused her diagnosis. scintigraphy, which is normally the gold standard for diagnosing and localizing accessory splenic tissue, was in this case unrevealing, due to inability of the tracer to traverse the torsed vascular pedicle. operative exploration was both diagnostic and therapeutic. patients which was treated with antibiotics suggested by culture and sensitivity report and local wound care. one patient died due to sepsis at presentation. conclusion: chikungunya virus was found circulating in rodents in pakistan as early as 1983. duodenal ulcer perforation which is a common surgical emergency in our part of the world usually presents with pinpoint perforation in ant wall of first part of duodenum unlike in already diagnosed cases of chikungunya disease where a slit like duodenal perforation is noted in the anterior wall of first part of duodenum. literature and consensus relate this perforation with the excessive use of nsaids due to usual presentation of arthritis in chikungunya disease but the unusual presentation is still to be answered. introduction: bouveret's syndrome is a rare form of gallstone ileus in which an impaction of a gallstone in the duodenum results in a gastric outlet obstruction. gallstone ileus accounts for approximately 2-3% of all cases of small bowel obstruction. the terminal ileum is the most common location for a calculus to cause obstruction followed by the proximal ileum, jejunum and duodenum/stomach respectively. open and laparoscopic surgery has previously been the mainstay of treatment for bouveret's syndrome, however with the advent of new endoscopic techniques and instruments there has been increasing success in endoscopic management. this case report looks at a patient with a gastric outlet obstruction from a gallstone, and discusses the current literature regarding diagnosis and management. case: 69 year old male presented with several day history of epigastric abdominal pain and multiple episodes of nonbloody, nonbilious emesis. he had previously been diagnosed with cholelithiasis, however had refused surgery at that time. on admission the patient was found to have a leukocytosis of 13.5. an ultrasound was performed in which the images were limited due to pneumobilia. a subsequent ct scan revealed pneumobilia, and a large 2 cm gallstone impacted in the first portion of the duodenum causing a gastric outlet obstruction. the patient underwent failed endoscopic attempts at removal and ultimately required a laparotomy, enerotomy with stone extraction. discussion: bouveret's syndrome is a rare variant of gallstone ileus. with newer endoscopic techniques and electrohydraulic lithotripsy, there has been increasing success with endoscopic retrieval of the impacted gallstones. there is some controversy in regards to the need for definitive operative management. stone extraction, without cholecystectomy and fistula repair, has been shown to have less postoperative complications as well as lower mortality rates compared to when a cholecystectomy and fistula repair has been performed. total mesorectal excision (tme) with neoadjuvant chemoradiotherapy (nacrt) is standard treatment for rectal cancer, which has resulted in a decrease in local recurrence. however, nacrt has shown no significant overall survival and some adverse effects mainly caused by radiation therapy. recently, the usefulness of neoadjuvant chemotherapy (nac) has been reported. we retrospectively assessed the efficacy and safety of the neoadjuvant mfolfoxiri compared with nacrt followed by laparoscopic surgery. a total of 76 patients undergoing laparoscopic surgery for lower rectal cancer (clinical stage: ii or iii) from july 2014 to february 2017 in our department were retrospectively evaluated. 40 patients underwent nac, and 36 patients underwent nacrt. the following data were collected: pathological complete response (pcr), histological grade, down staging, radial margin (rm) and postoperative complications. histological grade was defined as follows: tumor cell necrosis or degeneration is present in less than one third of the tumor area (grade 1a), between one and two thirds (grade 1b), more than two thirds but viable cells remain (grade 2), and complete response (grade 3). these two groups were demographically comparable. down staging did not differ between the two groups. histological grade (?grade 1b) and pcr were significantly higher in the nacrt than in the nac group (p.05). rm had no significant difference in both groups, but tended to be able to secure negative rm in the nac group (95% vs. 83. 3%, p=0.06 aims: increasing evidence suggest that cme may improve overall and disease free survival in colon cancer. our aims were to investigate the safety and efficacy of single incision laparoscopic cme colectomy (silcc) compared to multiport cme laparoscopic colectomy (mpclc) providing the first meta-analytical evidence. methods: pubmed, scopus and cochrane library were searched. studies comparing the silcc to mpclc in adults with colon adenocarcinoma were included. the studies were critically appraised using the newcastle ottawa scale. statistical heterogeneity was assessed with x2 and i2. the symmetry of funnel plots was examined for publication bias. results: one randomized and four case control trials were included (540 silcc vs 609 sl introduction: obesity has been associated with increased morbidity following total proctocolectomies with ilealpouch anal anastomosis (tpc-ipaa). however, the incremental added risk of increasing obesity class is not known. the aim of this study was to evaluate the additional morbidity of increasing obesity class for tpc-ipaa. methods: after ethics board approval, the acs-nsqip database (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) was accessed to identify patients who underwent elective tpc-ipaa. body mass index (bmi, kg/m 2 ) was classified as normal (18. 5-24.9) , overweight (25.0-29.9), obesity class-i (30-34.9), obesity class-ii (35-39.9) and obesity class-iii (≥40). primary outcomes were overall surgical site infection (ssi) and organ-space infection (osi). secondary outcomes were 30-day major morbidity and length of hospital stay (los aim: in curatively intended resection of sigmoid and rectal cancer, many surgeons prefer to perform ligation of the root of the inferior mesenteric artery (ima), high tie, because of oncological reasons. however, ligation of the ima has been known to decrease blood flow to the anastomosis. there are few reports of patients undergoing the reduced port laparoscopic approach (rps) including single-incision laparoscopic approach (sils) even among those undergoing laparoscopic lymph node dissection around the ima with preservation of the left colic artery (lca). our objective was to evaluate the quality of this procedure regarding application of rps for the treatment of sigmoid and rectal cancer. methods: the feasibility of this procedure was evaluated in 61 consecutive cases of rps for sigmoid and rectal cancer. a lap protector (lp) was inserted through a 2.5 cm transumbilical incision, and an ez-access was mounted to lp and three 5-mm ports were placed. almost all procedures were performed with standard laparoscopic instruments using a flexible scope (sils). a 12 mm port was inserted in right lower quadrant mainly in rectal cancer surgery (sils +1). our method involves peeling off the vascular sheath from the ima and dissection of the ln around the ima together with the sheath. results: lymph nodes around the ima were dissected with preservation of the lca in 26 cases (group a). the ima was ligated at its root in 35 cases (high tie, group b). in group a, 11 patients were treated with sils and 15 patients were treated with sils+1. in group b, 15 patients were treated with sils and 20 patients were treated with sils+1. median operative time was 187.7, and 154.8 min for group a, and b, respectively. the operative time was significantly longer in group a. estimated blood loss was 13.7 and 13.0 g, and mean numbers of harvested ln were 21.7, and 23.8. none of the other operative results of groups a and b were different statistically. in this series, there was only one anastomotic leakage in group b. conclusion: our method allows equivalent laparoscopic lymph node dissection to the high tie technique. the operative time tends to be longer, however this procedure has a possibility to reduce an anastomotic leakage. introduction: the routine mobilization of the left colonic flexure in colorectal surgery is still a matter of debate. we present our surgical approach with data. this technique may increases the surgical expertise/confidence when the surgical maneuver is necessary. up to 40% of all splenectomies are for surgery-related injuries;80% of those splenic injuries are treated by splenectomy. the iatrogenic splenic injury rate during colorectal surgery is 0.96%. iatrogenic splenic injuries create: increased risk of mortality/morbidity, extended operative time/patient in-hospital stay and increased healthcare costs. risk factors for iatrogenic splenic injury are: advanced age, adhesions, underlying pathology. obesity is not a risk factor. it is debated if the left colonic flexure mobilization is a risk factor for splenic injury. the ligament over-traction is the most frequent damage mechanism. the most dangerous surgical manuever is the spleno-colic ligament surgical dissection. moreover, laparoscopy descreases by almost 3,5 times the splenic injury risk. some surgeons are reluctant to routinely take down the splenic flexure. materials and procedures: 129 robotic left colonic/rectal cases with routine splenic flexure mobilization technique have been performed: left colectomy (n=74), rectal surgery (n=45), transverse-colectomy (n=6) and pancolectomy (n =4). conversion rate 1,6%, ebl\100 ml,1 postop-leak (0.8%) and 0% iatrogenic splenic injuries. results: in our approach, there are 4 pathways that need to be mastered for the splenic flexure mobilization:a) medial to lateral dissection (underneath the inferior mesenteric vein); b) lateral to medial (from the lateral peritoneal reflection); c) access to the lesser sac with omental detachment from the transverse colon; d) access to the lesser sac with the gastrocolic opening, following the inferior border of the pancreas. the dissection should be closer to the colon rather than to the spleen. in our experience the routine mobilization of the splenic flexure may have some advantages: a) better (without tension) distal anastomosis formation; b) better perfusion of the proxiaml stump; c) wider oncological dissection; d) no need of going back to the flexure when the proximal stump is too short; e) mastering a surgical manuver useful in other procedures (e.g. distal pancreasectomy). the theoretical drawbacks of routine splenic flexure mobilization can be:a) longer operative time, which is on average increased by 35 minutes; b) risk of splenic injuries, in our experience, no splenic injuries have been registered. conclusions: technical accuracy with cautious dissection/visualization can reduce iatrogenic splenic damages rate. laparoscopy decreases splenic injury rate. robotic surgery may have the potential to further reduce this complications. our data suggest that the routine mobilization of the splenic flexure, has more advantages than drawbacks and it can reduce the iatrogenic splenic injury rate. more trials are needed in order confirm our findings. introduction: the robotic stapler with the endowrist™ technology (intuitive surgical, inc.) includes a larger range of motion and articulation compared to the laparoscopic device, and may provide some benefits in difficult areas like the pelvis. to date, few studies have been published on the application of robotic endowristed stapling. we present our preliminary experience using the robotic stapler in low anterior rectal resection (larr) with total mesorectal excision (tme) for rectal cancer. methods and procedures: between march 2016 and september 2017, 24 patients underwent elective robotic larr with tme and primary colorectal anastomosis within the eras program. patient demographic, intra-operative data and post-operative outcomes were compared between the endowrist™ 45 robotic stapler group (rs group) and the laparoscopic stapler group (ls group). results: the two groups were homogeneous in terms of demographic and clinical characteristics. thirteen (10 males) and 11 patients (8 males) were included in rs and in ls group, respectively. seven patients received preoperative chemoradiation in rs group, 8 in ls group. there was no difference in intra-operative blood loss and total operative time. the median number of stapler fires for patients in rs group and in ls group was 2 (range, 1-3) and 3 (range, 2-4), respectively. loop-ileostomy was fashioned in 8 patients in rs group (61.5%) and 8 patients in ls group (72.7%). the 30 days mortality was nil. two cases of anastomotic leaks have been detected in rs group (15.4%), 2 cases (18.2%), occurred in ls group, all treated conservatively. the mean length of postoperative stay was 6.5±5.7 days in rs group, 6.9±3.9 days in ls group. conclusions: in our preliminary experience the application of robotic stapler during larr with tme has shown to be safe and feasible with acceptable morbidity. even if our case series is pretty small, fewer stapler fires were required in the rsg compared to lsg. we believe that the robotic stapler might lead to a more precise firing during pelvic surgery: it can explain the trend toward a decreased number of fires, that has been well documented in literature to be related to a lower risk of anastomotic leak. further high quality studies are required to confirm these findings. background and objectives: the present study was aimed at investigating the safety and feasibility of laparoscopic ultra-low anterior resection (l-ular) with total mesorectal excision (tme) and transanal specimen extraction for rectal cancer located at lower one-third rectum, and specifically understanding the oncological outcome of the operation. patients and method: a prospective designed database of a consecutive series of patients undergoing laparoscopic ultra-low anterior resection for rectal malignancy with various tumornode-metastasis (tnm) classifications from 1991 to 2012 at the texas endosurgery institute was analyzed. in this study ultra-low anterior resection is defined as low anterior resection for the malignant lesion at distal 1/3 of rectum. results: 51 ultralow anterior resections were completed laparoscopically with tme and transanal specimen extraction. the operating time for the surgery was 169.7 ± 31.1 minutes, and estimated blood loss during the procedure was 104.5 ± 72.1 ml. the length of the lesion from the anal verge measured with intraoperative colonoscopy ranged from 3.5 cm to 6.9 cm, and shortest distance of colorectal anastomosis from the anal verge is 1 cm. since diverting ileostomy was routinely installed after l-ular, none was found to have anastomotic leakage, however 3 patients developed anal stenosis within 6-month follow-up. therefore the overall rate of postoperative complication is 5.9%. moreover 4 patients were reported to have local recurrence in 2-year followup with the rate of 7.8%. conclusions: l-ular is safe and effective procedure for the rectal cancer at distal 1/3 rectum with comparable local recurrence and postoperative complication rates, thereby suggesting l-ular can be considered as a procedure of choice for rectal cancer at very low location in the rectum. for rectal cancer, however, local full-thickness excisions are fraught with high local recurrence rates -even if limited to early and best selected lesions. this corroborated observation is likely caused by a combination of missed nodal disease and direct implantation of tumor cells into the mesorectum, which upstages even early t1 lesions to at least a t3 lesion. the treatment of choice for invasive adenocarcinoma consists of an oncological total mesorectal resection, possibly with other modalities. rectal tumors of uncertain behavior can present a treatment dilemma between over-treatment vs under-treatment. concept: if the nature of a lesion is not certain or if contradictory results have been obtained, we propose a superficial local excision as a mucosal excisional biopsy to establish the diagnosis while avoiding interference with subsequent definitive treatment modalities by preserving the integrity of the external rectal wall and mesorectum. a benign final pathology concludes the treatment, whereas a detection of invasive cancer will be managed with a subsequent oncological resection. methods: this is a case report of a 70-year-old woman found to have a 4.4 cm villous lesion in the mid to distal rectum without proven or disproven invasive cancer. a tems-guided mucosal resection of the rectal mass at 3 cm above the anal verge was performed whereby the lesion was dissected off the underlying muscularis. results: with preoperative discrepant erus and mri staging ut0-1 vs ct3 lesion, a technically successful mucosal resection of the large rectal mass was carried out. pathology revealed a tubulovillous adenoma without high grade dysplasia or malignancy and a complete resection. conclusion: tems mucosal excisional biopsy of rectal tumors of uncertain behavior allows for a less invasive diagnostic approach that may (a) be definitive treatment if the lesion is proven benign, or (b) confirm the need for more aggressive treatment without having burned any treatment bridges or upstaged an early tumor by violating the mesorectal plane. an oncologic resection with appropriate (neo-)adjuvant chemotherapy can be carried out while preventing the potential for tumor seeding at initial operation. background: adequate visualization of the entire lumen of the large bowel is essential in detecting pathology and establishing diagnoses during colonoscopies. patients are provided dietary instructions and medications in order to achieve adequate bowel preparation. given the extensive amount of preparation required, some patients may be unable to adhere to the prescribed routine, resulting in rescheduling or repeat procedures and misallocation of limited resources. a number of previous quality-improvement efforts have been implemented to ensure adequate preparation prior to colonoscopy. objective: the objective of this study was to develop and assess the feasibility of a novel smart phone application in the delivery of bowel preparation instructions. methods: a novel smart phone application was developed to deliver bowel preparation instructions to patients undergoing colonoscopy for the first time. patients were included in the pilot phase of this project if they were undergoing a colonoscopy for the first time. we included patients who had access to a smart phone, had not previously had a bowel preparation for any reason. we excluded patients with a previous diagnosis of inflammatory bowel disease or colorectal cancer. patient surveys were administered at the time of colonoscopy. patients were questioned regarding the completeness of bowel preparation and adherence to bowel preparation instructions. patient questionnaires were completed to ascertain the ease of use of the smart phone application and any concerns that arose. quality of bowel preparation was assessed by the colonoscopist using the validated ottawa bowel preparation score. this is the pilot study results for the "coloprep" trial (nct03225560). results: a total of 20 patients were enrolled in the pilot phase of this study. patient satisfaction, adherence to instructions and ease of use of the smart phone application were ascertained. bowel preparation, as assessed by the colonoscopist, was reported. conclusions: this study assessed the feasibility of using a novel smart phone application for delivery of bowel preparation instruction. this pilot study is the initial phase of a randomized controlled trial to compare smart phone application vs. written instructions in the delivery of bowel preparation instructions. the . median follow-up was 44 months. there were no statistically significant differences found in clinical features and laboratory findings between the two groups. no statistically significant difference was found regarding the overall success rates and the complication rates between the conservative and the surgical arms (success rates: 90.1% and 86.5% (p= 0.48) and complication rates: 8.6% and 12.2% (p=0.472), respectively). however, surgical treatment was better than conservative treatment in preventing recurrent diverticulitis (recurrence rates: 0% and 5.4% (p=0.031), respectively). conclusion: conservative management with bowel rest and antibiotics is a safe and effective treatment for right-sided colonic uncomplicated diverticulitis and may be considered as the initial option. on the other hand, laparoscopic diverticulectomy is also safe, effective and adequate. surgery is advocated to decrease the recurrence rate. introduction: it has been hypothesized that the structural and functional changes that develop in the defunctioned segment of bowel may contribute to the development of postoperative ileus (poi) after loop ileostomy closure (lic). as such, longer intersurgery interval between ileostomy creation and lic may increase poi. methods and procedures: after institutional review board approval, all patients who underwent lic at a single institution between 2007-2017 were identified. the primary endpoint, primary poi, was defined as either a) being kept nil-per-os on or after postoperative day 3 for symptoms of nausea/vomiting, distension, and/or obstipation or b) having a nasogastric tube (ngt) inserted, without postoperative obstruction or sepsis. secondary endpoints included length of hospital stay (los) and non-poi related morbidity. patients who left the operating room with a ngt, had a planned laparotomy with a concomitant procedure at the time of lic, had a total proctocolectomy as their index operation, or had secondary poi, were excluded. patients were then divided into two groups based on timing from the index operation to lic (\6 months vs. objective: fecal incontinence can be a debilitating problem significantly diminishing productivity and quality of life. sacral neuromodulation has emerged as a first line surgical option treatment in patients with fecal incontinence. though its efficacy has been rigorously evaluated in adult populations there is scant data available for its use in the pediatric pateints with fecal incontinence. this case study discusses the management of fecal incontinence in a pediatric patient with a history of hirschsprung's disease utilizing sacral nerve stimulation. methods: our patient is a 15-year-old female with a history of hirshsprung's diagnosed in infancy and treated surgically with coloanal pull through at the age of 1 who presented with complaints of fecal incontinence. the patient was wearing pads daily, noting frequent uncontrolled bowel movements as well as having frequent missed days of school due to these symptoms. despite maximal medical management and pelvic floor physical therapy the patient continued to have 3-10 episodes of fecal incontinence daily. a ct scan with rectal contrast was used to establish her postoperative anatomy. anal manometry showed low rest/squeeze pressures, absent resting anal inhibitory reflex, and abnormal sensation. furthermore, during balloon expulsion testing the patient failed to pass device. the patient was deemed a candidate for stage 1 testing with sacral nerve neuromodulation. during follow-up, the patient was noted to have resolution of her episodes of fecal incontinence and the second stage was completed. the patient continues to note 100% continence and dramatic improvement in her quality of life. conclusion: in this patient with a history of severe fecal incontinence due to hirschsprung's disease, sacral neuromodulation has had a significant impact on her quality of life. post-operatively she continues to have marked improvement in her symptoms with 4-5 bowel movements a day with no recurrence of fecal incontinence. the use of sacral neuromodulation is a promising treatment for fecal incontinence in the pediatric population. future research investigating the longterm efficacy of this treatment modality in the pediatric population is needed. cases of bowel obstruction caused by colorectal cancer recurrence and progression were excluded. 9 surgical cases (0.48%) were considered to be early bowel obstruction and 15 (0.81%) were classified as late bowel obstruction. left hemicolectomy (n=4, 3.03%) was a significantly more frequent procedure in early bowel obstruction, and abdominoperineal resection (n=5, 4.20%) was significantly more common in late bowel obstruction (p.05). both early and late bowel obstruction included adhesive small bowel obstruction (n=19), internal hernia (n=3), and strangulation obstruction (n=2). internal hernia (n=3) and strangulation obstruction (n=2) occurred after left hemicolectomy and abdominoperineal resection, respectively. there is no apparent relationship between surgical procedures and adhesion regions (abdominal wall, intestinal tract, and pelvic cavity). the incidence rate of postoperative small bowel obstruction remained low, and laparoscopic colectomy had been safely performed. however, countermeasures are needed because of the high frequency of both early and late bowel obstruction which occurred after left hemicolectomy and abdominoperineal resection, respectively. improved utilization of resources as an improvement introduction: nowadays, treatment decisions about patients with rectal cancer are increasingly made within the context of a multi-disciplinary team (mdt) meeting. the outcomes of rectal cancer patients before and after the era of multi-disciplinary team was analyzed and compared in this paper. the purpose of the present study is to evaluate the value of discussing rectal cancer patients in a multi-disciplinary team. methods and procedures: in our health institute, weekly mdt conferences were initiated in january 2015. meetings were attended by surgeons, radiologists, radiation and medical oncologists and key nursing personnel. all rectal cancer patients diagnosed and treated in 2014-2015 in the general surgery division of the "carlo urbani" hospital in jesi (an, italy) were included. then, the data from rectal cancer patients in 2014 were evaluated, before the adoption of mdt and in year 2015, after the adoption of meetings. datasets regarding demographics, tumor stage, treatment, and outcomes based on pathology after operation were obtained. during an mdt discussion patient history, clinical and psychological condition, co-morbidity, modes of work-up, clinical staging, and optimal treatment strategies were discussed. a database was created to include each patient's workup, treatments to date and recommendations by each specialty. ''demographic variables'' consisted of age at diagnosis, sex, body mass index, comorbidities, american society of anesthesiologists physical status classification system, clinical stage and pathological stage. other analyzed variables included baseline carcinoembryonic antigen (cea), the type of imaging, use of neoadjuvant chemo-radiation, restaging following neoadjuvant therapy, distance from the anal verge, operation type and use of adjuvant chemo-radiation. ''outcome variables'' consisted in a comparison for each group between clinical and pathological stage. results: sixty-five patients were included in this study: thirty patients in 2014 (pre-mdt) and thirty-five patients in 2015. demographic variables did not differ significantly between groups. preoperative clinical stages with baseline preoperative cea and postoperative pathological stage were analysed, too. thanks to the mdt and the increased use of the neoadjuvant therapy, a statistically significant difference in reduction of the stage between the clinical and pathological stage in the patients of the mdt group was verified. conclusions: the vast majority of rectal mdt decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account prior to the adoption of multi-disciplinary team. analysis of the implementation of team decisions is an informative process in order to monitor the quality of mdt decision-making. purpose: in japan, lateral pelvic node dissection (lpnd) is the standard treatment for locally advanced lower rectal cancer. there are few reports of patients undergoing single-incision plus one port laparoscopic (sils+1) lpnd even among those undergoing laparoscopic lpnd. the aim of this study is to describe our initial experience and assess the feasibility and safety of sils+1 lpnd for patients with advanced lower rectal cancer. methods: a lap protector (lp) was inserted through a 2.5 cm transumbilical incision, and an ezaccess was mounted to lp and three 5-mm ports were placed. a 12 mm port was inserted in right lower quadrant. a single institutional experience of sils+1 lplnd for rectal cancer are presented. inclusion criteria was indications for lld were lower rectal cancer with t3-4, or t1-2 rectal cancer with metastasis of lateral lymph node, as described by the japanese society for cancer of the colon and rectum (jsccr) guidelines for the treatment of colorectal cancer. perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively. introduction: endoscopic stenting with a self-expandable metallic stent (sems) is widely accepted procedure for malignant colorectal obstruction. we assessed the safety and efficacy of insertion of a sems followed by elective surgery as 'bridge to surgery (bts)' in our institute. methods: this study was a retrospective study in our institute. the data was collected from medical charts from january 2014 to june 2017. results: a total of 408 consecutive patients underwent radical surgery for colorectal malignancy during this period. in this series, 16 patients (3.9%) were diagnosed malignant colorectal obstruction and intended to a bts. the stent was successfully placed in 13 patients and all the patients were planned to undergo radical surgery. the failed 3 patients underwent stoma creation (2 patients) and hartmann's procedure. the technical success rate was 81% and the clinical success rate was 100%. the median time from sems to surgery was 11 days (2-31 days) . open and laparoscopic surgery was performed in 4 and 8 patients, respectively, except for one patient refused radical surgery because of a great age. the tumor could be resected in 12 patients (bts patients) with primary anastomosis. however, diverting stoma creation was needed in 3 patients and decompression rectal tube was placed in 1 patient. the entire patient laparoscopically was no conversion to open surgery. there was no anastomotic leakage in bts patients. the median duration of postoperative hospital stay was 10 days (8-54 days). the overall postoperative complication was 23% (3/13) including 2 bowel obstruction and 1 anastomotic stricture. the median follow-up period was 580 days. during the follow-up period, 3 patients were relapsed peritoneal dissemination, ovarian metastasis, and liver and pulmonary metastases, respectively. former 2 patients were diagnosed stage iva at the time of primary surgery. one patient died from sudden death. conclusions: our data suggested that routine use of sems insertion was safe and effective procedure for malignant colorectal obstruction as a bts. moreover, laparoscopic procedure was useful procedure in bts patient. the short-and long-term surgical outcomes were also acceptable. introduction: serpin e1, also known as plasminogen activator inhibitor-1 (pai-1) is an inhibitor of urokinase type plasminogen activator (upa) and tissue-type plasminogen activators (tpa ). pai-1 plays a role in the regulation of angiogenesis, wound healing, and tumor cell invasion; over expression has been noted in breast, esophageal, and colorectal cancer (crc). pai-1 is also a potent regulator of endothelial cell (ec) proliferation and migration in vitro and of angiogenesis and tumor growth in vivo. the plasminogen/plasmin system plays a key role in cancer progression by mediating extracellular matrix degradation and tumor cell migration. surgery's impact on plasma pai-1 levels is unknown. this study's purpose was to measure plasma pai-1 levels before and during the first month after minimally invasive colorectal resection (micr) for crc. objectives: retroflexion in the rectum at the end of a colonoscopy is a requirement for a complete endoscopic evaluation. retroflexion helps to visualize and detect polyps which would be missed otherwise. currently new endoscopes are available which can do retroflexion in the caecum. aim: our study aims to compare the rate of polyp detection rate in cecum and ascending colon with and without retroflexion in cecum. methods: this is a single center, single operator, retrospective study. a total of two hundred patients were involved. a single center irb waiver was obtained. patients were divided into two groups based on the presence/absence of retroflexion in caecum during their colonoscopy. the data was obtained from 2017 records. group a (n=100) had colonoscopy without retroflexion in caecum group b (n=100) had colonoscopy with retroflexion in caecum inclusion criteria: patients undergoing screening colonoscopy between the age of 40 and 85. results: group a: total of 100 patients were screened. a total of 95 polyps were detected in group a. number of cecal polyps were 4 (4.2% of total polyp count). number of ascending colon polyp were 18 (19% of total polyp). on analyzing the pathology 60% of the cecal polyps were tubular adenoma, 20% hyperplastic polyps 20% and 20% lymphoid aggregate. number of ascending colon polyps were 18, of which 72% were tubular adenoma, 22% tubular adenoma and 6% tubulovillous adenoma group b: total of 100 patients were screened. a total of 80 polyps were detected. number of cecal polyps detected were 5 (6.2% of total polyp count). number of ascending of ascending colon polyps were 11 (13%). on analyzing pathology, 80% cecal polyps were tubular adenoma and 20% were sessile serrated. out of the ascending colon polyps 27% were tubular adenoma, 27% sessile serrated,27% tubulovillous and 18% hyperplastic polyp. side events: two mass lesions were noted in both group a and b. there was incomplete colonoscopy in group a and b. conclusion: this retrospective analysis reveals a small increase in polyp detection in the cecum with retroflexion, especially in detecting sessile polyps which have more malignant potential. however, a large multicenter analysis will be required to validate the above observation. background: while uncommon, rectal prolapse is a disabling condition affecting older females. in a small subset of patients, concomitant organ prolapses with or without incarceration can lead to significant morbidity. as the field of laparoscopy has evolved, minimally invasive surgical options for rectal prolapse have led to improved quality and reduced morbidity for patients suffering this debilitating disease. methods: the 2012-2015 acs-nsqip databases was queried for patients undergoing a traditional or minimally invasive rectopexy based on cpt codes (45400,45402,45540,45541 and 45550) . emergent cases and patients with preoperative infections or inflammatory states were excluded. the primary outcome of interest was a 30-day postoperative composite morbidity score. statistical analysis incorporated multivariate analysis and binomial logistic regression with p.05 holding significance. results: these inclusion and exclusion criteria identified 2393 patients undergoing traditional (1113) and minimally invasive (1280) rectopexy for prolapse between 2012 and 2015. patients undergoing traditional rectopexy were older (p.001), had a higher body mass index (p=0.018), more comorbid conditions (diabetes, copd, hypertension) and less functional independence (p= 0.026). patients undergoing a traditional rectopexy had a higher composite morbidity incidence of 13.2% vs. 8% for minimally invasive rectopexy (p.001). specifically, minimally invasive rectopexy patients had a 2.63% reduction in wound complications (p=0.002) and a shorter hospital stay (3.3 days vs. 4.3 days, p .001) compared to a traditional rectopexy. readmission rates were also 2.6% lower in the minimally invasive group (p=0.015). after controlling for the differences in the cohorts, a minimally invasive approach was a significant protective factor against the incidence of 30-day postoperative morbidity (or 0.476, p.001). conclusion: a minimally invasive rectopexy has improved 30-day postoperative morbidity compared to a traditional rectopexy and should be strongly considered for the treatment of rectal prolapse. objectives: the short-term safety and efficacy of a self-expandable metallic stent (sems) placement followed by elective surgery, "bridge to surgery (bts)", for malignant large-bowel obstruction (mlbo) have been well described. the aim of this study was to investigate the risk factors for postoperative complications and optimal interval between sems placement and surgery in patients with mlbo. methods: retrospective examination of patient records revealed that the bts strategy was attempted in 49 patients with mlbo from january 2013 to march 2017 in our institution. two of these patients were excluded because they had undergone emergency surgery for sems migration; thus, 47 patients with mlbo who had undergone sems placement followed by elective surgery were included. of these patients, eight had developed postoperative complications (clavien-dindo grading≥ii) (postoperative complication: poc group) whereas 39 patients had no such complications (no poc group). results: univariate analyses showed that the factors of asa score, number of lymph nodes resected, interval between sems and surgery, and preoperative albumin concentration were associated with postoperative complications. multivariate analysis identified only the interval between sems and surgery as an independent risk factor. furthermore, a cut-off value of 15 days for interval between sems and surgery was identified by roc curve analysis. conclusions: an interval of ≥15 days from sems placement to surgery is an independent predictive factor for postoperative complications in patients undergoing elective surgery in a bts setting. thus, an interval of over 15 days is recommended for minimizing postoperative complications. haseeb kothar, ronan cahill; mater misericordiae university hospital current clinical advances in operative near-infrared visualisation of cells, tissues and structures are predicated on the use of commercial available near-infrared cameras to excite and visualise emission energy from non-selective, approved compounds (predominantly indocyanine green (icg)). it is expected that new generation compounds wholly selective for specific cellular components are now needed for further advance and a variety of molecular targets have been proposed and are being developed primarily for oncological imaging purposes. recent publications have however suggested icg itself is retained within malignant tissue differently to its uptake and clearance from surrounding non-malignant tissue which is important for two reasons. firstly, it exploits and makes visual the increased vascular permeability and disordered clearance associated with carcinogenesis which is a common endpoint of a variety of mediators including but not limited to vegf. this raises the useful option of targeting downstream effects of cancer compounds on a metabolic basis as opposed to tagging individual cell or antigen components. this means that a single agent could be used to target a variety of cancers rather then needing a specific one for each specific sub-type as well as obviating the issue of cancer cells heterogeneity even in a single cancer deposit. second, it is very likely that some or all of the "localisation" effect of proposed selective compounds may well be due to a similar phenomenum rather then cell-specific binding and may make distinction from other areas of similar metabolic behaviour (ie inflammatory regions) difficult. the crucial step-advance for such agent development so may well relate to timing of compound delivery and "visualisation window" at the region of interest rather then highly selective oncocellular-targeting. to illustrate this in more detail, we have been examining the tissue-specific effects and actions of near-infrared excitation in patients (n=7) with localised malignant colorectal primaries receiving an aliquot of icg before such examination at the time of resection. icg can be selectively apparent in the colorectal primary 15 minutes after its systemic administration likely due to altered vascular dynamics. additional dose-related work has shown that early administration (40-180 minutes before examination) does not give useful information related to tumour fluorescence. interestingly none of these patients had fluorescence seen within their regional lymphatics but none also had malignant lymph nodes associated with their large primaries on pathological examination. however, this procedure is not usually performed in laparoscopic apr for its technique difficulty, which may lead to increased rates of complications ( fig. 1) . here, we compared the feasibility and peri-operative outcomes of the laparoscopic apr with and without pelvic peritoneum closure (ppc) for lower rectal cancer. introduction: there are reports of increased operative duration, blood loss and postoperative morbidity, caused by difficulties in obtaining good visualization and in controlling bleeding when laparoscopic resection is performed in obese patients with colon cancer. purpose: the aim of this study was to investigate the impact of obesity on perioperative outcomes after laparoscopic colorectal resection performed by various operative methods in our department. patients and methods: we conducted a retrospective analysis of 435 patients with colorectal cancer who underwent laparoscopic surgery between january 2011 to december 2015. right colectomy was performed in 84 patients, sigmoidectomy in 73 patients, and low anterior resection in 50 patients. the surgical outcomes were compared between non-obese (body mass index [bmi]\25 kg/m 2 ) and obese (bmi ?25 kg/m 2 ) patients. results: right colectomy cases: the amount of blood loss was significantly increased in the obese group compared with the non-obese group, but operation time did not differ significantly between the groups. there were no significant differences between the two groups in the rate of postoperative complications and duration of post-operative hospitalization. sigmoidectomy cases: there were no significant differences between the two groups in operation time and amount of blood loss. even though the preoperative asa score and the rate of postoperative complications were higher in the obese group, the mean postoperative hospital stay did not differ significantly between the two groups. low anterior resection cases: there were no significant differences between the obese group and the non-obese groups in operation time, amount of blood loss, rate of postoperative complications, and duration of post-operative hospitalization. discussion: although there are some reports of increased operative times in obese patients, the operative procedure was not extended in any of the present study patients. the amount of blood loss was significantly increased in the obese group compared with the non-obese group when right colectomy was performed. among the patients undergoing sigmoidectomy, the postoperative rate of complications was higher in the obese group; however, the preoperative asa status was also higher in the obese group than non-obese group, indicating that factors other than obesity may be involved. conclusion: we concluded that laparoscopic colorectal resection appeared to be safe and feasible in both obese patients and non-obese patients. however, bmi may not accurately reflect the amount of visceral fat present. background: for the complete rectal prolapse (basically longer than 3 cm), we thought sling rectopexy was most reasonable to hang up and fix the rectum, which drooped down and prolapsed due to the relaxation of supporting tissue. we considered ripstein method had enough fixed power of rectum to sacrum. however, complications of rectal stenosis, constipation, mesh infection and mesh penetration were reported. therefore, we modified ripstein method to conquer such complications. aim: a prospective study beyond the randomized control trial (rct) between our modified ( introduction: the results of the japan clinical oncology group (jcog) 0212 study suggested that total mesorectal excision (tme) and lateral lymph node dissection (llnd) could become the standard treatment for lower rectal carcinoma. however, llnd must also be performed laparoscopically if surgery for lower rectal carcinoma is to be carried out as a completely laparoscopic procedure. transanal tme (tatme) is expected to provide better results than the conventional tme, both oncologically and in terms of pelvic function, and its use has recently been spreading in japan. we started performing laparoscopic tatme+llnd in our department in july 2016 and here report the short-term outcomes. subjects and methods: we used laparoscopic tatme+llnd to treat 5 men and 3 women with ct3 or deeper rectal carcinoma in whom the inferior margin of the tumor was on the anal side of the peritoneal reflection. this was a retrospective study of short-term postoperative outcomes. surgical procedure: laparoscopic surgery was started simultaneously by two teams, one working transabdominally and the other working transanally. the transabdominal team performed the standard proximal llnd and mobilization of the splenic flexure via five ports. they then dissected the bilateral lateral lymph nodes, mainly in the obturator (#283) and internal iliac (#263) groups. during this time, the transanal team performed laparoscopic tatme. finally, both dissection layers were connected and the cancer was excised. results: six patients had clinical stage ii and two had clinical stage iii lower rectal carcinoma. all the patients underwent preoperative chemotherapy with s-1+l-ohp. five underwent a sphincterpreserving surgery, and three underwent rectal amputation. the mean operating time was 335 minutes (range, 267-382 minutes), and the mean amount of hemorrhage was 136 g (20-440 g). the mean number of lymph nodes dissected was 24, and r0 resection was performed in all the cases. the mean length of hospital stay was 14 days, and a postoperative complication of clavien-dindo grade iii or higher occurred in one patient (anastomotic failure). conclusions: laparoscopic tatme+llnd performed by two teams simultaneously is an extremely useful procedure that not only reduces operating time, but also is less invasive than laparoscopic surgery. it may also be effective for improving curative nature, nerve preservation, and anal function. objective: in laparoscopic appendectomy, the base of the appendix is usually secured by applying a roeders knot. the aim of this study was to compare the advantages of using staplers and hem-olocks for securing the base of the appendix. method: the study included 82 patients between age of 12 to 75 years with acute appendicitis randomly divided into two groups. in the first group, the base of the appendix was secured using roeders knot. in the second group, mesoappendix was not dissected and was included in the endostapler jaws. the primary outcome was overall morbidity. secondary outcomes were total duration of surgery, total length of stay and ease in difficult cases. result: no morbidity was recorded in any group. the time of the operative procedure was significantly longer in the cases with roeders knot than in the stapler group (p.0001) as mesoappendix was not dissected in the later. 2 cases with unhealthy base were progressed to laparoscopic quadricolectomy. apart from the ease of applying a stapler, cases of second group with gangrenous base were easily tackled using endostapler, avoiding the need of a hemicolectomy. conclusion: all forms of closure of the appendix base are acceptable, but endostapler technique apart from providing a secure base, reduces operative time and is an essential tool in cases of gangrenous base. introduction: accurate staging is essential to estimate the prognosis of patients with colorectal cancer (crc) and lymph node evaluation is key to determine it. in non-metastatic crc, the number of harvested lymph nodes is the strongest prognostic factor for outcome and survival. additionally, it is thought that a higher lymph node yield may be representative of a higher quality of surgical care. due to the importance of the association between lymph node evaluation and outcome in crc, it is necessary to evaluate factors which may affect lymph node harvest. introduction: hatmann's procedure is commonly done in treating complicated diverticulitis, negleccted rectal trauma with sepsis and sometimes malignancy. the traditional techniques to restore the intestinal continuity after hartmann's procedure were for many years the standard of care in these operations, but in fact they carry many morbidity and even mortality and failure. laparoscopic techniques is not only carry the advantage of minimal invasive surgery, but also of better visualizationn and magnification. the aim is evaluating the outcome of using the laparoscope in reversal of hartmann's procedure as regard feasibility and safety. patients and method: forty patients were subjected to laparoscopic reversal of hatmann's procedure in tanta university hospital, there ages ranged between 25 to 70 years, the time elapsed after the original operation ranged from 6 months to 5 years, excluding advanced malignany. conversin occurred in 6 cases due to extensive adhesions and bleeding. results: no mortality, or major morbidity in our study and only single leak treated by covering ilestomy. conclusion; laparoscopic hartmann's procedure is feasible, promising tehnique with minimal morbidity. background: minimal invasive surgery has been well established in the elective colorectal surgery and it has been proven better clinical outcome compared with open surgery. in the emergent setting, laparoscope is used mostly in the colecystectomy, appendectomy but laparoscopic emergent colorectal surgery is limited for it's complexity and difficulity. the aim of this study was to envaluate the feasibility of laparoscopic emergent colorectal surgery. methods: this study is prospective collected, observational single center study of patients undergoing laparoscopic emergent colorectal surgery from 2011 to 2016. the patient demographics, surgery indication and detail, complication, clinical outcome and hospital stay were collected and analyzed. results: there are total 130 emergent colorectal operations and 57 patients were managed with minimal invasive method. among these laparoscopic emergent surgery, there are 33 male patients and 24 female patients. mean age of the patients was 63.8 years (range 31-89 years). the main indication for operation: perforation 49.1% (28/57), leakage after elective colorectal surgery 42.1% (24/57), obstruction 3.5% (2/57), ischemia colitis 3.5% (2/57,), bleeding 1.8% (1/57). there are 19 cases in asa 2, 32 cases in asa 3, 6 cases in asa 4. the qsofa score for sepsis:23 cases was 0, 28 cases was 1, 5 cases was 2, 1 case was 3. there are 27 cases undergoing laparoscopic lavage with diverting stomy, 15 cases were hartmann procedure, 5 cases were anterior resection,4 cases were right hemicolectomy, 3 cases were perforation repair, 3 cases were redo anastomosis. there are 6 cases coversion to open method including 3 cases were due to bowel adhesion,2 cases were due to bowel distension,1 case was due to severe shock status. mean operative time is 180.3 minutes. the overall mortality rate was 5.2% and major complication rate (clavien-dindo grade above 2) was 24.5%. re-operation rate was 15.7%. the mean hospital stay was 17.1 days. conclusions: this study presents evidence of an initially clinical outcome in emergent laparoscopic colorectal suregry. in the absence of large case series, the benefits of a laparoscopic approach should befall to at least a minority of these patients. confocal laser endomicroscopy (cle) can provide real-time observation of the cell structure and tissue morphology. in our study, we aim to assess the situation of anastomotic perfusion using cle. method: the experimental rabbits were separated into two groups: group a (good anastomotic perfusion, n=6), group b (poor anastomotic perfusion, n=6). the partial colectomy and anastomosis was performed for group a and b. then detection for anastomotic perfusion using cle was carried out after the surgery. during the continuous scanning, we counted the number of blood cells that cross over the certain point of anastomotic stoma in the same period. results: assistant with fluorescein sodium, the blood vessels are highlighted. we can see significant difference of imaging effect between group a and group b. the average number of blood cells are 34.7/min of group a and 6.0/min of group b (p.001), which has significant difference. conclusion: cle can allow real-time observation of the blood flow of anastomotic stoma in vivo. therefore, it is feasible to assess the anastomotic perfusion using cle in colorectal surgery. cigdem benlice, ahmet rencuzogullari, james church, gokhan ozuner, david liska, scott steele, emre gorgun; cleveland clinic background: intraoperative colonoscopy (ioc) is an adjunct in colorectal surgery (crs) especially in patients with malignancies in order to detect location of the primary or synchronous lesions as well as assessing anastomotic integrity. however, effects of intraoperative colonoscopy on short term outcomes during crs is a concern. this study aims to evaluate safety and feasibility and post-operative outcomes of intraoperative colonoscopy in left-sided colectomy patients for colorectal cancer patients by using the nationwide database. patients and methods: patients undergoing elective left-sided colectomy with low pelvic anastomosis without any proximal diversion for colorectal cancer were reviewed from the american college of surgeons national surgical quality improvement program (acs-nsqip) proceduretargeted database (2013) (2014) (2015) according to their primary procedure current procedural terminology (cpt) code. subsequently, patients who underwent intraoperative colonoscopy were identified from concurrent cpt codes and divided into two groups based on the simultaneous intraoperative colonoscopy. demographics, comorbidities, 30-day postoperative complications were evaluated and compared between the groups. multivariate logistic regression was conducted adjusting for significant factors between the groups. results: a total of 5579 patients were identified and ioc was performed for 651 (11.7%) patients. objective: laparoscopic ileostomy commonly performed for the patients with colorectal obstruction due to cancer, peritonitis with perforation of colon or the other reason. reduced port surgery is a novel technique that may be performed when considering minimally invasive surgery and desiring a cosmetic benefit. the aim of this study was to evaluate safety and feasibility of reduced port laparoscopic ileostomy for the patients with advanced colorectal cancer before chemotherapy. methods: between july 2012 and august 2017, 39 patients who underwent reduced port laparoscopic ileostomy were included (15 male and 14 female, age: 66 years old. the outcomes were evaluated in terms of operation time, intraoperative blood loss and perioperative complications. sugical procedures: the patients were placed in the supine position and the operator stood left side. an access device with the wound-protector (ez access, hakko, nagono, japan) was inserted on the future ileostomy site in the right lower abdomen, inserting two of 5-mm trocars, maintaining pneumoperitoneum at 10 mmhg with carbon dioxide. a 5-mm trocar was inserted in the left lower abdomen. a 5-mm flexible laparoscope was inserted from access device port. after exploring abdominal cavity, ileum end was identified. then the marking using dye was put on the ileum of 25 cm proximal from the ileum end. the ileum marked by dye was grasped, and extracted through the access devise. then a blooke ileostomy was created. results: reduced port laparoscopic ileostomy was performed for 39 patients with colorectal obstruction due to cancer before chemotherapy. the mean operative time was 107 minutes, the mean blood loss was 5.0 ml. three patient received one additional port. there were no intraoperative complications. five patients (12.8%) experienced postoperative complications (two of deep surgical site infection, one of pneumonia, one of outlet obstruction and one of renal dysfunction). there were no other intraoperative or postoperative complications. conclusion: reduced port laparoscopic ileostomy is a safe and feasible procedure for the patients with advanced colorectal cancer before chemotherapy. methods: we performed elective lcr on 354 patients for primary colorectal cancers between june 2008 and june 2015. seventy-two patients were excluded in this study following reasons: 44 patients underwent multiple organ resection, and colorectal cancer was diagnosed with stage iv in 28 patients. accordingly, 282 patients were eligible for comparative analysis, with 70 in group po (post operation) and 212 in group c (control). in group po, past operative procedures were as follows: appendectomy (57%), digestive tract (7%), hepato-billiary-pancreatic (7%), gynecologic (17%), urologic surgery (10%), and others (2%). results: there were no significant differences between two groups in asa (grade≤2: 81 vs. 88%, p=0.14), bmi ( introduction: the treatment of rectal cancer requires highly skilled practice by the entire multidisciplinary team. important aims of treatment are: to reduce the risk of residual disease in the pelvis, with lower morbidity and to preserve good sphincter function. the tata procedure is transanal transabdominal radical proctosigmoidectomy with coloanal anastomosis. this technique was first developed in 1984 by dr. gerald marks to avoid a permanent colostomy for low-lying rectal cancer. this study reports the long-term results of tata procedure for low rectal cancer. methods and procedures: a prospective study was on 38 patients with low rectal cancer between april 2007 and july 2017 in a tertiary referral university-affiliated center specializing in laparoscopic surgery. all resections were carried out by a team of dedicated colorectal surgery and standard protocol was used for all pre-and-post-operative care. all the patients underwent total mesorectal excision. results: 38 consecutive patients (19 male, 19 female, mean age 57) underwent tata procedure, 30 of them (78,9%) after neoadjuvant radiochemotherapy. the mean operation time was 201 min (range 90-360) and the mean estimated blood loss was 73 ml (range 10-500). the overall incidence of morbidity was 15,8% (6/38) and the mean hospital stay was 4,4 days. the mean follow-up period was 36,8 (range, 1-123) months with a recurrence rate of 7,9% (3/38), overall estimated 5-year survival 78,2% and the disease-free survival rate 89,5%. conclusion: laparoscopic total mesorectal excision with tata procedure is safe with excellent local recurrence and disease-free survival rate. jacek piatkowski, md, phd, marek jackowski, prof; clinic of general, gastroenterological and oncological surgery introduction: more than 10 years ago, laparoscopic technique was considered to be a fully accepted surgical method for treatment of rectal cancer. the following years are a further search for a new surgical method that reduces invasiveness and improves treatment outcomes. it seems that such a method is transanal total mesorectal excision. the aim of this study was to evaluate the new method of rectal cancer surgery (tatme) after 2 years of its use. methods: radicality of treatment (r0 resection, local recurrence), outcome of surgical treatment and quality of life of patients after surgery were evaluated. results: in the period from 10.03.2015. -30.06.2017. 33 patients (19 men, 14 women) were operated in the clinic. in 29 cases the indication for surgery was lower and middle rectal cancer and in 4 cases high grade dysplasia. all patients underwent laparoscopic rectal proctectomy with transanal access (tatme). in all cases, complete oncological radicalization (resection r0) was obtained. the average operation time was 156 minutes. we had used two teams approach (cecil approach) with 2 laparoscopic sets -abdominal and perineal starting at the same time. in the postoperative course, 6 patients had signs of anastomosis leak (3 of them required reoperation). the follow-up period is 1-29 months. none of the patients had any recurrence of cancer. conclusions: 1. transanal tme for rectal cancer surgery is an alternative method to conventional laparoscopic surgery. 2. in a large proportion of patients with lower and middle tumors, the rectum can avoid abdomino-perineal resection with permanent colostomy. background: the double stapling technique (dst) has widely spread colorectal anastomosis especially for anastomosis after low anterior resection. as for the colorectal cancer treatment, heald reported total mesorectal excision (tme) in 1982, and has been accepted as the standard technique for rectal resection due to the decreased local recurrence rate and improved functional results. with advent of dst, there is a background that it has become possible to preserve anus, even in the case with the lesion at lower rectum. laparoscopic surgery for colon cancer was introduced in the 1990s, and has had promising results including long-term outcomes. according to the spread of laparoscopic surgery, laparoscopic surgery had been applied to the rectal resection, with technical difficulty. one of the reasons for the difficulty is that the high rate of anastomotic leakage, a critical adverse effect of low anterior resection (lar). thus, risk factors for anastomotic leakage were widely discussed, including technical factors such as pre-compression and number or firing. the decisive difference in conventional lar and laparoscopic lar in dst, is the stapler used for transection of the rectum. the laparoscopic staplers which are currently available are thought to be not ideal, and there is little evidence of specific specifications of stapler for laparoscopic surgery. materials and methods: all method described in this study was approved by the institutional ethical review committee. we reviewed the colon and rectal wall thickness according to histological examination using h&e staining of distal margin of resected specimen of the patients who conclusions: rstc for severe acute uc is at least as safe as the laparoscopic approach. although the robotic cohort had more comorbidities, major postoperative complications, readmissions, and reoperation rates were less when compared to lstc. rstc was also associated with an earlier return of bowel function and shorter length of stay. a prospective study with larger numbers is needed to see if the superiority of robotic versus laparoscopic approaches is reproducible. s198 surg endosc (2018) introduction: complete mesocolic excision (cme) has been advocated based on oncologic superiority, but is not commonly performed in north america. furthermore, many data are limited to case series with few comparative studies. therefore the objective was to systematically review studies comparing the short-and long-term outcomes between cme and non-cme colectomy for colon cancer. methods: a systematic review was performed according to prisma guidelines of medline, embase, healthstar, web of science, and cochrane library. studies were only included if they compared conventional resection (non-cme) to cme for colon cancer. quality was assessed using the methodological index for non-randomized studies (minors). the main outcome measures were short-term morbidity and oncologic outcomes. study eligibility, data extraction and quality assessment was performed by two independent reviewers, and disagreements resolved by consensus. weighted pooled means and proportions with 95%ci were calculated using a randomeffects model when appropriate. results: out of 825 citations, 23 studies underwent full-text review and 14 met the inclusion criteria, of which 10 were unique series. mean minors score was 13.6 (range 11-16). the mean sample size in the cme group was 1075 (range 45-3756) and 785 (range 40-3425) in the non-cme group. in the 10 unique studies, 4 included only right-sided resection, and 44.2% (95% ci 35.8-52.6) of the remaining 6 were right-sided colectomies. of the 5 studies that reported surgical approach, 52.2% (95%ci 31.0-73.3) of cme were performed laparoscopically. there were 4 papers reporting plane of dissection, with cme plane achieved in 87.4% (79.7-95.2). mean or time in cme group was 167 minutes (range 163-171) and in non-cme group 138 minutes (range 135-142). perioperative morbidity was reported in 6 studies, with pooled overall complications of 22.5% (95%ci 18.4-26.6) for cme and 19.6 (95%ci 13.6-25.5) for non-cme resections. anastomotic leak occurred in 6.0% (95%ci 2.2-9.7) of cme versus 6.0% (95%ci 4.1-7.9) in non-cme colectomies. cme surgery consistently resulted in more lymph nodes retrieved, longer distance to high tie, and specimen length. there were 7 studies that compared 3-or 5-year overall or disease-free survival, or local recurrence. only 2 studies reported statistically significant higher disease-free or overall survival in favour of cme. local recurrence was lower after cme in 1 of 4 reported studies. conclusions: the quality of the current evidence is limited and does not consistently support the superiority of cme. more rigorous data are needed before cme can be recommended as the standard of care for colon cancer resections. gilberto lozano dubernard, md, facs, ramon gil-ortiz, md, gustavo cruz-santiago, md, bernardo rueda-torres, md, javier lopez-gutierrez, md, facs; hospital angeles del pedregal introduction: to assess the feasibility of a single-stage colorectal laparoscopic re intervention without ostomy. colonic laparoscopic interventions on patients that previously underwent a minimally invasive procedure, constitutes the current boundary in the management of the acute colorectal pathology. that includes, patients with fecal peritonitis due to diverting procedures already treated surgically. the outcome of our patients could significantly improve if the surgical procedure is performed in one time, with no stoma. method and procedures: from september 1995 to june 2016, one hundred thirty-two patients underwent colorectal laparoscopic surgery. five of these patients developed complications: three perforations due to colonoscopy and two due to dehiscence of the anastomosis. these five patients underwent a second laparoscopic procedure that included resection and anastomosis. no stoma required. results: all five patients underwent a second laparoscopic procedure due to an anastomosis leak. no stoma was required. the procedure consisted on resection of the previous anastomosis, re anastomosis, abdominal lavage, aspiration and drains placement. all of them supported with parenteral nutrition. there were no surgical complications. only one patient developed pneumonic symptoms that were solved. conclusion: the reported results, regarding no conversion rate, nor mortality, on our series of patients, suggest that single stage laparoscopic re intervention is feasible, despite fecal peritonitis. introduction: total mesorectal excision is known to be a gold standard surgical procedure for the rectal cancer. subsequently complete mesocolic excision (cme) is recognized as an essential surgical procedure for the colon cancer. the transverse colon is relatively minor location for colon cancer. variety of vessels and mobilization of splenic flexure and dissection close to pancreas make operations for the transverse colon cancer complicated. laparoscopic transverse mesocolic excision in our hospital is presented. method: laparoscopic surgery is conducted with five trocars under the lithotomy position. inferior mesenteric vein is cut after dissection of the descending colon with medial approach. the lower edge of pancreas is exposed near the inferior mesenteric vein and is dissected along toward the tail of pancreas. the splenic flexure is mobilized with lateral approach and the dissection between transverse mesocolon and the lower edge of pancreas is continued in the direction to the pancreas head. coming to the exposure of superior mesenteric artery and vein, the origin of middle colic artery and vein are cut. the transverse mesocolon is separated from the pancreas head and the duodenum with preserving the gastrocolic trunk of henle and the right gastroepiploic vein. the hepatic flexure is mobilized and cme for the transverse colon is finished. this method, the 'tail to head of pancreas' approach, we called, was performed from september 2015. this method is well performed with one series of surgical view, and seems to be a simple procedure as cme with central vascular ligation for the transverse colonic cancer. there were no intraoperative complications, and one postoperative pancreatitis with grade ? of clavien-dindo classification of surgical complications. conclusion: our method, the 'tail to head of pancreas' approach, with transverse mesocoloc excision is simple, safe and feasible. the introduction: anastomotic complication after stapled anastomosis in colorectal cancer surgery is a considerable problem. there are various types of anastomotic complication and they have different severity. this study was aimed to evaluate the impact of intraoperative colonoscopy on detection of anastomotic complication, and its effectiveness in treatment of anastomotic complications after anterior resection (ar) and low anterior resection (lar) for colorectal cancer intraoperatively. methods: from dec. 2016 to jul. 2017, a total of 72 patients who underwent anastomosis between sigmoid colon and rectum after colorectal resection were reviewed retrospectively. intraoperative colonoscopy was performed routinely since december 2016 in our hospital after anterior resection and low anterior resection. to identify effectiveness of intraoperative colonoscopy, we compared postoperative complications with non-intraoperative colonoscopy group during previous 11 months. intraoperative colonoscopy was performed after anastomosis to visualize the anastomosis line and to perform an air leakage test. if anastomotic defect and moderate bleeding were found in intraoperative colonoscopy, it was managed by means of reinforcement suture or transanal suture repair. we used logistic regression to analyze anastomotic complication between two groups with or without intraoperative colonoscopy. results: of the 72 patients who were performed intraoperative colonoscopy after ar (n=50) and lar (n=22), abnormal findings including bleeding and air leak were found in 14 patients (19.4%). among those, 9 cases were observed without any procedure, additional procedures were performed in 5 patients (6.9%, transanal suture (3), lembert suture (2)). postoperative complication was developed in 12 patients; 6 patients had anastomosis bleeding (8.3%), 2 patients had ileus (2.8%), 1 patient had pneumonia (1.4%), 3 patients had minor complication (4.2%, acute urinary retention, chylous drainage, laparoscopic port site bleeding). among 6 patients who had anastomosis bleeding, 4 patients were treated by endoscopic clipping, 2 patients were cured by conservative treatment. there was no postoperative anastomotic leakage. the cases of ar and lar were 62 and 48 in non-intraoperative colonoscopy group, there was no significant difference between two group (p=0.07). the proportion of laparoscopic surgery was 86.4% and 92.2% on intraoperative colonoscopy and non-intraoperative colonoscopy group, respectively, there was significant difference statistically (p=0.02). however, there was no significant difference in anastomotic complication rate between two groups. (rr=0.27, 95% ci, 0.34-2.585). conclusions: although there was no significant difference in postoperative anastomotic complication rate between two groups, intraoperative colonoscopy may be valuable method for decreasing postoperative complication by visualizing anastomosis line and performing additional procedure. conclusion: it was suggested that lymph node dissection of both middle and left colic regions is necessary for splenic flexure colon cancer, because lymph node metastasis was recognized in both region. surg endosc (2018) 32:s130-s359 the aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many centers. most centers use laparoscopic colectomy with extracorporeal resection and anastomosis (lc). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sc) remains controversial. the aim of the present study is to compare these two techniques using propensity score matching analysis. methods: we analysed the data of 111 patients who underwent laparoscopic right hemicolectomy with lc or sc between december 2015 and december 2016. the propensity score was calculated from age, gender, body mass index, the american society of anesthesiologists score, previous abdominal surgery and d3 lymphnode dissection. short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sc group was significantly shorter than in the lc group: median (range) 3 (3.5-6) cm verses 4 (3-6) cm (p=0.007). the vas score on day 1 and day 2 after surgery was significantly less in the sc group than in the lc group: median (range) 30 (10-50) verses 50 (20-69) on day 1 (p=0.037) and median (range) 10 (0-50) verses 30 (0-70) on day 2 (p= 0.029). significantly fewer the number of requiring analgesia in the sc group on day 1 and day 2 after surgery: median (range) 1 (0-3) times verses 2 (0-4) times on day 1 (p=0.024) and 1 (0-2) times verses 1 (0-4) times on day 2 (p=0.035). there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. conclusions: sc for right colon cancer is safe and technically feasible. sc reduces the length of skin incision and postoperative pain compared with conventional lc. patients were divided into the following groups: cephalo-medial-to-lateral approach group (cml group, n=63) and medial-to-lateral approach group (ml group, n=74 introduction: laparoscopic technique has been widely used in the treatment of colorectal cancer, while playing its minimally invasive advantages, but also achieved a good effect of radical oncology. however, t4 colorectal cancer is not recommended laparoscopic surgery. methods: retrospectively collected pt4 colorectal cancer data from 2006 to 2015 in guangdong general hospital, all cases were undergoing radical surgery. results: a total of 211 cases were enrolled in the pt4 group, including 101 cases of laparoscopic group, 110 cases of open group, conversion rate was 12.9%. there was no difference in baseline data (age, sex, bmi, asa, etc.)(p.05). there was a significant difference between the two groups (p.05) in blood loss, postoperative complications and postoperative recovery index. in the pathologic t4a/b, combined-organ resection, postoperative recurrence, the laparotomy group had more cases, and there was a statistically significant difference between the two groups (p\ 0.05). the 3-and 5-year overall survival rates were 74.9% and 60.5% for the lap group and 62.4% and 46.5% for the open group (p=0.060). meanwhile, the 3-and 5-years disease-(p=0.053). iiic stage, lymph node status, ca19-9 and adjuvant chemotherapy were independent prognostic factors affecting overall survival. the age, pt4a/b, iiic stage, ca19-9 and adjuvant chemotherapy were independent influencing factors of disease-free survival. conclusions: laparoscopic surgery for pt4 colorectal cancer surgery, it is not only in the play of its minimally invasive but also obtained with the similar long-term effect. but we need more multicenter, prospective, and large sample clinical studies to validate our findings. introduction: lymph node (ln) retrieval after surgery is important. in the present study we evaluated the efficacy of the fat dissolution technique using fluid containing collagenase and lipase to avoid staging migration after laparoscopic colorectal surgery. methods: seventeen patients who underwent laparoscopic ln dissection for colorectal cancer were evaluated. first, unfixed lns within the resected mesentery were explored by visual inspection and palpation immediately after the operation by the surgeon, which is the most common practice in japan. subsequently, the fat dissolution technique was used on remnant fat tissue, and the lns were evaluated again. the primary endpoint was whether the second assessment increased the number of lns evaluated. results: the median number of lns identified at the first and second assessments was 14 and 6, respectively, resulting in a significant increase in the total number of lns evaluated (14 vs. 21, p\ 0.01, paired t-test). one positive node was identified among all the additional lns identified (1.0%; 1/96). although staging was not altered in any patient, the second assessment resulted in an increase in the originally insufficient number of lns evaluated (\12 for stage ii) in three patients, whose treatment may be altered. tumor cells detected after the fat dissolution technique were stained with carcinoembryonic antigen and cytokeratin-20. conclusion: using the fat dissolution liquid on remnant fat tissue of the mesentery of the colon and rectum enabled identification of additional lns. this method should be considered when the number of lns identified is not sufficient after conventional ln retrieval, and may avoid stage migration. aim: the aim of this study is to evaluate the pathological resection margin after laparoscopic intersphincteric resection for low rectal cancer. method: from 2010 to 2014, there were eight laparoscopic intersphincteric resection cases for low rectal cancer. we evaluated the clinicopathological findings and the positivity of pathological resection margin. results: the median distance from the anal verge to the tumor was 40 mm (range, 10-45), and the median diameter of the tumor was 27 mm (range, 15-60). there was no case with neoadjuvant therapy. the estimated tumor depth were ct1 in 5 cases (62.5%) and ct2 in 3 cases (37.5%), and the actual tumor depth were ptis in 3 cases (37.5%) and pt1 in 2 cases (25.0%) and pt2 in 3 cases (37.5%). the median distal resection margin was 10 mm (range, 5-25). pathological resection margin, such as the proximal, distal and circumferential margin was negative in all cases (100%). there was no mortality, but morbidity occurred in two cases (one case of anastomotic leakage and one case of small bowel obstruction). no recurrence nor distant metastasis was observed in the follow up period. conclusion: there was no positive resection margin case in the series. our patient selection, indication and the technique were considered to be precise and appropriate. introduction: the fistulas of the intestine to the vagina or the bladder include a highly morbid entity, with several functional limitation and loss of the quality of life, its diagnosis is complex and more than its treatment, which include a wide range of possibilities that go from the simple derivative colostomy in search of the spontaneous closure of the fistula, under the complete correction of the pathology with resections, anastomosis and mini-vasive reconstructions. give to know our experience in the minimally invasive treatment of whole vaginal and whole vesicial fistules by laparoscopic via, for the last 3 years. results: a total of 28 patients were operated in this period, 26 women and 2 men, all those by laparoscopic via, with intestinal resection, in 26 thick intestine cases, in one small intestine and in another case with the commitment of the two, everyone restriction and intestinal anastomosis and in no matter were colostomy, primary closures of the fistula in 7 patients were required, conversion to open surgery in a case and there was no recurrence, 2 patients had prolonged hospitalization for localized infections, a requirement reintervencion for revision. a patient suffried a umbilical eventration for the extraction site, which was corrected one year after laparoscopy. conclusion: minimally invasive surgery in patients with this type of pathology becomes an excellent strategy for the integral management of these patients. group work guarantees good results. robbie sparks, dr, ronan cahill; mater misericordiae university hospital background: precise preoperative localisation of colonic cancer is a prerequisite for correct oncological resection. effective endoscopic lesional tattoo is vital for small, radiologically unseen tumors planned for laparoscopic resection but its practice may be imperfect. methods: retrospective review of consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection identified from our prospectively-maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation. results: 169 patients (95 males, mean age 68 years, median bmi 27.8 kg/m 2 , 77 left sided lesions, 36 screen detected, 21 benign polyps, 23% conversion rate). in 104 operations (60%) tattoo visibility was documented with tattoo absence noted in 9 (8.5%) although tattoo was identifiable in the pathological specimen in four. in those with "missing tattoos", six of the lesions were radiologically occult and in three the tumor was found in a different colonic segment then had been judged at colonoscopy. four patients had on-table colonoscopy and five were converted to laparotomy (55% conversion rate, p.005). mean postoperative length of stay was 15.5 (range 4-38) days. one patient's segmental resection contained only benign pathology requiring a second operation to remove the cancer. on univariate analysis, time between endoscopy and surgery (but not patient age, gender, bmi, endoscopist or surgeon seniority, tumor size or location) was significantly associated with absence of tattoo intraoperatively (p=0.006). conclusion: recording related to tattoo is variable but definite lack of gross tattoo visualisation significantly impacts the procedure. the mechanism of tattoo absence is multifactorial needing careful consideration but solvable. the aim of the present study was to perform a systematic review of the literature to determine the role of antibiotics in the management of acute uncomplicated diverticulitis (aud). diverticular disease is the most common disease of the large bowel and poses a significant burden on healthcare resources. in the united states alone, the cost of diverticular disease has been estimated to be over $3 billion making it the fifth most important gastrointestinal disease economically. the use of antibiotics in the management of aud, however, is primarily based on expert opinion as current high-quality evidence is lacking. recent studies have not only questioned the optimal type and duration of antibiotic regimens, but whether antibiotics provide any benefit in the treatment of aud. conclusions: antibiotic use in patients with acute uncomplicated diverticulitis is not associated with a reduction in major complications, readmissions, treatment failure, progression to complicated diverticulitis, or need for elective and emergent surgery. however, it increases the length of hospital stay. given the risk of selection bias in included studies, further randomized trials are needed to clarify the need for antibiotics in uncomplicated diverticulitis. laparoscopic para-aortic lymph node resection for colorectal cancer aim: we want to highlight the feasibility of a sigmoidectomy using total laparoscopic with a transanal extraction of the specimen. methods: it is a 34-year-old female patient, obese (bmi=34 kg/m 2 ) to the antecedents of laparoscopic cholecystectomy and chronic constipation. she was treated three months ago for a sigmoidal diverticulitis complicated with a pelvic abscess. the evolution has been favorable under antibiotic therapy and percutaneous drainage of the abscess. the colonoscopy showed a multiple diverticula located between 20 and 25 cm from the anal verge. prophylactic sigmoidectomy was performed laparoscopically using 3 trocars (10 mm supra ombilical, 12 mm fid and 5 mm right flank). the specimen was extracted transanally, thus avoiding a pubic incision. the steps of the intervention were: 1-mobilisation of left colon 2-closing of distal left colon stump 3-rectal stump lavage 4-opening on the rectum 5-transanal introduction of the anvil 6-specimen transanal extraction 7-closing og rectal stump 8-colonic positioning of the anvil 9-coloractal anastomosis. results: the intervention was 150 minutes. no perioperative incidents. the liquid regime was authorized on the night of the intervention. the operating procedures were favorable with an exit to j2 post operative. the anapath examination of the surgical specimen confirmed the presence of sigmoidal diverticula. conclusion: laparoscopic sigmoidectomy with transanal extraction of the specimen for benign desease is a seductive technique with satisfactory results. it avoids a pubic incision with its parietal and aesthetic complications. chengzhi huang; guangdong general hospital (guangdong academy of medical science) background: colorectal cancer (crc) is one of the most common malignant diseases over the world. of the causes of the death of crc, metastasis to liver or lung are the major factors. however, there is still lack of precise tumor biomarker that precisely predict the clinical outcome of crc. the salt-inducible kinase 1 (sik1) encodes a serine kinase of amp-activated protein kinase (ampk) family, which may play critical roles in tumorigenesis and tumor progression. this study aimed the study the expression and clinical significance of sik1 and crc patients. methods: the expression of sik1 protein was measured by western-blot and analysis of immunohistochemistry. sik1 mrna expression in cancerous tissue was measured by rt-pcr. results: the expression level of sik1 was correlated with the following factors: tumor invasion (t stages), lymph node metastasis, clinical stages (tnm) and tumor location. the down-regulated sik1 implies poor clinical outcome measured by kaplan-meier analysis (p-value.05), and may act as an independent risk factor of crc patients. background: surgical specimens for resected colon cancer vary in quality and there remains no universally accepted technique to guide resection margins. a minimum of 12 lymph nodes provides some quality assurance, however this remains a crude marker of optimal oncological surgery. a tool to precisely identify lymphatic drainage within the mesentery could improve the oncologic quality of resection and better guide adjuvant treatment through more optimal mesenteric lymphadenectomy. while fluorescence imaging (fi) has been described to identify nodal disease in several other cancers, feasibility and best practices have not been established in colon cancer. we describe a novel technique of fi using indocyanine green (icg) to identify lymphatic spread and potentially guide optimal mesenteric lymphadenectomy in colon cancer. methods: three consecutive patients with colon cancer undergoing a laparoscopic resection had peritumoral subserosal injection of icg for fi after extracorporealization of the mobilized specimen. three concentrations of icg were injected −5 mg/10 ml, 5 mg/5 ml, and 5 mg/3 ml. a total of 4 ml was given for each patient. using a modified laparoscopic camera, the icg was excited by light in the near-infrared (nir) spectrum, for real-time visualization of the lymphatic drainage. the main outcome measure was identification of lymphatic drainage. results: three patients with right-sided primary colon cancer were evaluated. all three patients had successful identification of the lymphatic drainage pattern along the mesentery. the most successful protocol was 1 ml (concentration 5 mg/10 ml) subserosal injection at 4 points within close proximity (1 cm) of the tumor with a 23-gauge needle, then waiting 5 minutes for complete mapping. no intraoperative or injection-related adverse effects occurred with 30-day follow-up. the median lymph node yield was 31. all specimens had tumor-free margins. conclusion: from this small series, fluorescence imaging with icg is a potentially safe and feasible technique for identifying mesocolic lymphatic drainage patterns. this proof of concept and protocol will lead to future studies to examine the utility of fluoresence imaging to guide more precise surgery in colon cancer. introduction: anastomotic leakage in colon/rectal surgery is a dangerous event with an occurance rate ranging from 1 to 30%. the associated mortality rate is between 6-22%. the white-light intraoperative subjective surgical assessment (the most frequently used approach) underestimates the actual anastomotic leakage rate. intraoperative tissue perfusion assessment by indocyanine green (icg)-enhanced fluorescence has been reported in multiple clinical scenarios in laparoscopic/ robotic surgery, as well as for for bowel perfusion assessment. this technology can detect microvascular impairment, potentially preventing anastomotic leakage. we reviewed the literature and present our data to evaluate the feasibility and usefulness of icg-enhanced ?uorescence in the intraoperative assessment of vascular peri-anastomotic tissue perfusion in colorectal surgery. methods and procedures: a pubmed literature narrative review has been performed. moreover, out of a total of 164 robotic colorectal cases, we retrospectively analyzed 28 icg-enhanced fluorescence robotic colorectal resections (15 left colectomies-8 rectal resections-3 right-1 transverse-1 pancolectomy). results: after icg-technology use, the biggest (n[100) case-series showed a rate of 3.7-19% of cases in which they changed the level of resection based on icg. icg technology may variably reduce the anastomotic leak rate from 4 to 12%. however, the threshold values to define the actual sub-optimal perfusion are still under investigation. in our experience, out of 28 icg cases performed: the conversion, intraoperative complication, dye allergic reactionand mortality rates were all 0%. post-op surgical complications: 1 case of leak (3,6%) and 1 sbo for incarcerated hernia (3.6%). in 2 cases, with normal white-light assessment, the level of the anastomosis was changed after icg showed ischemic tissues. despite the application of icg, 1 anastomotic leak has been registered. conclusions: icg-enhanced ?uorescence may intraoperatively change the white-light assessed resection/anastomotic level, potentially decreasing the anastomotic leakage rate. our data shows that this technology is safe, feasibile and may prevent anastomotic leakage. however, the decision making is still too subjective and not data driven. at this stage icg, beside being a promising technique, doesn't have high level of evidence (most of the reports are retrospective). some randomized prospective trials with an adequate statistical power are needed. a precise injection dose and timing standardization is required. the main challange is to develop a method to objectively obtain a real-time intensity assessement. this may provide objective metric tresholds for an intraoperative evidence/data-based surgical decision making. introduction: according to the world health organization, colorectal cancer is the 3rd most commonly diagnosed cancer in the world. one of the main risk factors for the development of colorectal cancer is obesity. obesity is seen to increase the risk of colorectal cancer by 9% in women per 5 kg/m 2 and 24% in men per 5 kg/m 2 . bariatric surgery is one of the treatments that is considered to achieve and sustain a significant amount of intentional weight loss in patients. considering that fact that bariatric surgery decreases obesity, this intentional weight loss would seem to provide a favorable outcome in terms of diagnosis and prognosis of colorectal cancer. a systemic review of the literature was conducted via pubmed to identify relevant studies from january 2008 through may 2017. the main outcome for this study is to assess whether patients who underwent bariatric surgery (restrictive and malabsorptive procedures) had an increased or decreased risk of colorectal cancer. all studies included in this meta-analysis are retrospective cohort studies. results were expressed as standard difference in means with standard error. statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups between bariatric surgery and non-surgery in patients with colorectal cancer. (comprehensive meta-analysis version 3.3.070 software; biostat inc., englewood, nj). results: four out of 86 studies were quantitatively assessed and included for meta-analysis. among the four studies, 22,857 underwent bariatric surgery and 78,536 did not undergo bariatric surgery. there is a significant decrease (0.139±0.057; p=0.016) in the risk in patients developing colorectal cancer in patients who underwent bariatric surgery compared to those who didn't get surgery. conclusion: bariatric surgery patients appear to have a decreased risk of colorectal cancer compared to patients who did not have bariatric surgery. guh jung seo, hyung-suk cho; department of colorectal surgery, dae han surgical clinic, gwangju, south korea introduction: the incidence of rectal carcinoid tumors is increasing due to the widespread use of screening colonoscopy. endoscopic mucosal resection (emr) is a useful method for small rectal carcinoid tumors (≤10 mm) because of its simplicity, quick procedure and low complication rates. we aimed to describe our experience and evaluate the outcomes of emr for rectal carcinoid tumors. the patients enrolled in this study were 13 patients with small rectal carcinoid tumors who underwent emr using a submucosal injection technique of epinephrinesaline mixture between august 2010 and october 2016. all medical records, including characteristics of the patients and tumors, complications, were retrospectively reviewed. results: the patients were 6 men and 7 women, with a mean age of 40.8 years (range, 21-72 years). en block resection was performed by emr in all cases. the endoscopic mean size of tumors was 6.46 mm (range, 5-10 mm). the pathologically measured mean size of the resected specimens was 5.92 mm (range, 4-10 mm). the mean size of resected carcinoid tumors was 4.33 mm (range, 1.8-7 mm). the tumor shape was submucosal tumor in 10 and polyp in 3. histological examination revealed that 5 cases had resection margin positive of tumor and 1 case had undetermined resection margin of tumor. of the 6 patients, 4 patients underwent endoscopic treatment and 2 patients underwent transanal excision. no residual tumor was found in additionally removed tissue. there were 2 cases with emr-related complications: 1 early postprocedural bleeding and 1 postpolypectomy syndrome. there was no significant bleeding requiring blood transfusion or perforations. conclusion: endoscopic mucosal resection is considered to be a relatively safe and useful method for treatment of small rectal carcinoids in selected patients. background: disturbance of sexual function after an operation for rectal cancer has often occurred. the relationship between autonomic nerves and arteries in pelvis was examined. methods: clinical studies of 15 male patients with resected rectal cancer were performed using snap gauge method, penile-brachial index and evoked bulvo-cavernous reflex. in 30 canine experiments, pelvic splanchnic nerve (psn) electric stimulation, arterial flow measurement, corpus cavernosum pressure measurement and muscle strip study using drugs were evaluated. results: in clinical studies of 15 male patients, transection of the hypogastric nerve (hgn) and the sympathetic trunk did not affect the erectile function in the postoperative course. in animal experiments transection of these nerves did not affect the increase in inner pressure of the penis cavernosum. in postoperative cases in which only one side of the lower grade branches of the psn (s4) were preserved, the erectile function was preserved. in animal experiments in which the psn of one side was disturbed, the ipa flow of the same side decreased, while the flow of the other side increased. we have evaluated the role of adrenergic components in the psn on the erectile function in the dog. the effect of norepinephrine hydrochloride on canine vascular smooth muscle was examined in vitro. vascular smooth muscle strips from the ipa relaxed longitudinally. electrical stimulation of the psn increased blood flow in the ipa and also elevated the cavernous pressure. these increases were blocked in part by phentolamine, but not by propranolol or atropine. the effects of cholinergic and adrenergic agonists and antagonists on mechanical responses were also examined in muscle strips obtained from various arteries in the intra-pelvic region including the ipa. norepinephrine induced contraction in the iliac artery and relaxation in the ipa, and both the contraction and relaxation responses were blocked by phentolamine but not by propranolol. these findings suggest that in the dog, α-adrenergic components projected through the psn may contribute to penile erection. conclusion: blood flow in the ipa was controlled significantly by the same side psn, but compensatory by the other side psn. it is also conceivable that the erectile function through the psn is controlled by the sympathetic nerve, not by the parasympathetic nerve. in postoperative cases in which only one side of the lower grade branches of the psn (s4) were preserved, the erectile function was preserved. introduction: currently, neoadjuvant chemo-radiotherapy (ncrt) followed by low anterior resection or abdominoperineal resection are the standard treatments for locally advanced rectal cancer. ncrt can improve resecability, achieve better sphincter preservation and reduce local recurrence. although total mesorectal excision is the standard treatment for advanced rectal cancer, recent trends in minimally invasive treatments led to an increase in local excision or "watch and wait" in patients with an excellent response to ncrt. the purpose of this study, part of an ongoing research, is critically evaluating the feasibility of "non-operative treatment" for rectal cancer in a district hospital. methods and procedures: a total of 29 patients with rectal cancer, who where treated with ncrt from january to august 2017 at "carlo urbani" district hospital in jesi (italy), were retrospectively reviewed. all patients had histologically-confirmed primary adenocarcinoma of the rectum located within 12 cm from the anal verge. the involved patients completed ncrt and had no recurrence disease, distant metastasis, synchronous malignancies. they were classified according to the mandard's tumor regression grade (trg) into two clusters: group a (trg 1-3) and b . results: the average age of people is 67.2 and 17 were male. five patients underwent abdominoperineal resection and 76% fell within group a. six patients had lymph nodes involved. four patients suffered relevant complications, such as wound complication, anastomotic leak, operative reintervention and death. univariate analysis showed that the main predictors of tumor regression were the absence of lymph-nodes involvement from initial imaging (p.05), normal initial carcinoembryonic antigen level (p.05) and tumor downstaging in imaging (p.05). in addition, most relevant complications occurred to elderly patients although they observed a good clinical response. besides, 13% of patients were found to be complete pathologic responders upon examination of the surgical specimen. conclusions: the oncologic feasibility of non-operative management for the patients with complete clinical response after ncrt has been growing, but some studies have suggested lack of oncologic safety in these patients. the patients with a complete clinical response expect good survival, but they may still harbor residual disease. no consensus on "watch and wait" policy in the field of rectal cancer was obtained, yet. our data did not entirely support this policy although it might be the best strategy, based on the predictors of tumor regression, to avoid the complications associated with surgery in elderly patients with significant medical comorbidities and fear of a permanent stoma. introduction: conventional 5 incision laparoscopic surgery procedure for rectal cancer is widely accepted as a successful alternative to laparotomy now, bestowing specific advantages without causing detriment to oncological outcome. evolving from this, single-incision laparoscopic surgery (sils) has been successfully utilized for the removal of colonic tumors, but the literature lacks sufficient data analyzing the suitability of sils for rectal cancer especially for total resection mesorectal excision (tme), particularlyon oncological outcome. we report the short-term clinical and oncological outcomes from a large cases retrospective analysis of observational study of sils for tme procedure of rectal cancer. methods: 95 rectal cancer patients who underwent transumbilical single incision laparoscopic tme surgery were recruited in the current study. short-term perioperative clinical parameters and oncological outcomes were observed and all patients were followed up after surgery. then summarize the preliminary application results. results: 87 operations were accomplished successfully with single incision laparoscopy, 7 patients were converted to multiport approach, and 1 was converted to laparotomy, no diverting ileostomy was performed. the average operative time was (128.5±43.6) min, with an average blood loss of (75.5±121.7) ml, the median postoperative hospital stay was (10.3±2.1) days. all patients received a r0 resection and the surgical margin were conformed negative in all 87 cases, the median number of harvested lymph node is (18.4±8.9), the specimens met the requirement of tme. there were 3 postoperational complications, no operation-related mortality or postoperative anastomotic leakage was observed. no patient appeared recurrent in a median follow up of 14 months. conclusions: total mesorectal excision surgery for rectal cancer can be safely performed using transumbilical single incision laparoscopic technique, with acceptable short-term clinical and oncological outcome. surg endosc (2018) background: any surgical trauma induces an inflammatory response, which is considered as a negative factor in the general immune response, specially in malignant disease. the c-reactive protein (crp) is an acute phase protein often used as a marker of surgical trauma. stent treatment has been used as a treatment option for colonic obstruction in palliative cases for many years, and also as a bridge to surgery in selected cases. in a pilot study we compared the inflammatory response after acute stent treatment or surgery for malignant colonic obstruction. method: we compared two consecutive series of treatment of acute malignant colonic obstruction, stent treatment or emergency surgery during 2011-2012. all patients were admitted with acute colonic obstruction due to colorectal cancer. choice of treatment was based on attending senior colorectal surgeons' preference, patient comorbidities and disseminated disease was considered. patient age, crp, time to first defecation and length of stay was recorded. results: a total of 31 patients were identified in a retrospective analysis. 15 patients had acute stent treatment and 16 had acute surgical treatment for colonic obstruction, all due to colorectal cancer. median age was 77 y (30-95) with no difference between the groups. there was no difference in metastatic disease between the groups. median time until first defecation after treatment was significantly shorter for the stented patients (39 h (4-73)) compared with those operated (96 h (24-168)) (p,001). median hospital stay was also shorter in the stent group, 6 days (2-32), versus 11 days (7-30) in the surgical group (p=0,016). crp did not differ between the groups before treatment. both treatments resulted in increased crp levels at postoperative days 1 and 2, but the crp levels were significantly higher in the surgical group than in the stent group at both time points (pod 1 p=0,017, pod 2 p,001) conclusion: acute stent treatment in colonic malignant obstruction seems to induce a less pronounced inflammatory response compared with surgery, as shown by a significantly reduced increase in postoperative crp resulting in shorter time to first defecation and a shorter hospital stay. introduction: meckel's diverticulum is the most common congenital abnormality in newborns, present in about 2-4% of them. diagnostic of meckel's diverticulum requires a high index of suspicion, and even with the use of modern imaging technologies, they are often diagnosed intraoperatively. what to do when an asymptomatic diverticulum is found incidentally during surgery for other causes is a matter of discussion. objective: the aim of this article is to report 27 symptomatic and asymptomatic incidentally found cases seen in a fourth-level hospital in colombia. the reports of the histopathologic examinations carried out in the hospital in the last 12 years were reviewed searching for those containing meckel's diverticulum in their diagnosis. patients were divided in asymptomatic and symptomatic groups. the asymptomatic group was defined as patients who were operated for a different indication and a meckel's diverticulum was found incidentally. morbidity was divided in early and late complications after the initial surgery. results: from january 2004 to june 2017, a total of 42 pathology reports included the diagnosis meckel's diverticulum. a total of 27 adult patients were retrieved. all of those patients with meckel's diverticulum a total of 22 patients were symptomatic, being sbo the most common complication and required the surgical remove incidentally. conclusion: the correct approach of the patients with diverticular pathology allows the early identification and the appropriate management of the surgical complications that can be presented. robert j czuprynski, md, grace montenegro, md; saint louis university hospital presacral masses are a rare entity, with an incidence of 0.014% and can be classified in several categories, including inflammatory, neurogenic, congenital, osseous and miscellaneous. in this case, a neuroendocrine tumor was identified with concern for iliac chain lymphatic and gluteal metastasis. the patient underwent abdominoperineal resection, excision of presacral mass, lymph node biopsy and omental flap. final pathology returned as a grade ii neuroendocrine tumor arising from a tailgut cyst. a 29 year old female with a ten year history of recurrent perianal, ischiorectal and deep postanal abscesses presents with a presacral mass biopsy proven well-differentiated neuroendocrine tumor. octreotide scan demonstrated avidity for presacral mas as well as left intergluteal lymph node and two internal iliac lymph nodes. chromogranin a, neuron-specific enolase and serotonin markers were all negative. the patient was taken to the operating room and underwent abdominoperineal resection, resection of presacral mass and internal iliac nodes with an omental flap. neuroendocrine tumors arising from tailgut cysts of the presacral space are rare in nature. in a retrospective study from great britain, four of thirty one tailgut cysts had malignant transformation, so it is generally recommended to resect the cysts. in this case, the patient's tumor was a moderately differentiated, grade ii with extensive lymphovascular and perineural invasion. there are no prospective studies showing neoadjuvant therapies in neuroendocrine tumors of the presacral space. according nccn guidelines, patient is currently asymptomatic with low tumor burden. recommended treatment at this time is observation with surveillance tumor markers every 3-12 months or octreotide. anastomotic leakage has been commonly regarded as one of the toughing postoperative complications in laparoscopic mid/low rectal cancer surgery, attenuating the short-term clinical benefits. the left colic artery (lca) has been routinely central-ligated in dissection process to guarantee the oncological effects, which may potentially attribute to the postoperative ischemia-induced anastomotic leakage in the patients with left-colic vessel variation, e.g. bypass or absent of riolan arch. however, no specific study focuses on the surgical benefits of lca preservation compares to conventional ones. herein, we conduct a single center randomized controlled trial, demonstrating that lca-preserving technique shows significant reduction rate of postoperative leakage as well as overall complications comparing to the traditional central-ligation group. no difference in survival rate and recurrence in short term is found between the two groups. the lca-preserving strategy is proven to be repeatedly safe and feasible, potentially reduce the risk of anastomotic leakage with comparable short-term outcomes. further investigation is required for both the oncological safety and long-term prognosis for this innovative technique. background: three-photon imaging (tpi), which was based on the field of nonlinear optics and femtosecond lasers, has been proved to be able to provide the 3-dimensional (3d) morphological feature of living tissues without the administration of exogenous contrast agents. the purpose of this study is to investigate whether tpi could make a real-time histological 3d diagnosis for colorectal cancer compared with the gold standard hematoxylin-eosin (h-e). methods: this study was conducted between january 2017 and august 2017. a total of 30 patients diagnosed as colon or rectum carcinoma by preoperative colonoscopy were included. all patients received radical surgery. the fresh, unfixed and unstained full-thickness cancerous and the corresponding normal specimens in the same patient, were immediately prepared to receive tpi after surgery. for 3d visualization, the z-stacks were reconstructed. all tissue went through routine histological procedures. tpi images were compared with h-e by the same attending pathologist. results: the schematic diagram of tpi is shown in fig. 1a . peak tpi signal intensity excited at 1300 nm was detected in living tissues. the field of view (fov) was 5009500 µm and the imaging deep was 200 µm in each specimen. in normal specimens, glands lined regularly and characterized as a typical foveolar, which was comparable to h-e images ( fig. 1b and 1d ). in cancerous specimens, irregular tissue architecture and shape were identified by tpi, which was also validated by corresponding h-e images ( fig. 1c and 1e ). tpi images can be acquired with a view of 3d visualization. based on rates of correlation with pathological diagnosis, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value were 95%, 90%, 100%, 100%, 90.9%, respectively. conclusions: it is feasible to use tpi to make a real-time 3d optical diagnosis for colorectal cancer. with the miniaturization and integration of colonoscopy, tpi has the potential to make a real-time histological 3d diagnosis for colorectal cancer in the future, especially in low rectal cancer. erica pettke 1 , abhinit shah 1 , vesna cekic 1 , daniel feingold 2 , tracey arnell 2 , nipa gandhi 1 , carl winkler, md 1 , richard whelan 1; 1 mount sinai west, 2 columbia university introduction: alvimopan (alvim) is a peripherally acting µ-opioid receptor antagonist used to accelerate gastrointestinal functional recovery postoperatively (postop) after bowel resection. the purpose of this retrospective study was to compare the time to first flatus and bowel movement (bm) as well as length of stay (los) following elective minimally invasive colorectal resection (crr) in a group of patients (pts) who received alvimopan perioperatively (periop) vs a group that did not get this agent. methods: a data review from 2000 to 2015 from 2 irb approved databases was carried out. operative, hospital and office charts were reviewed. routine use of alvim for elective crr cases was stared in 2013. besides gi data, preoperative comorbidities and 30 day postop complication rates were assessed. the results with periop alvim were compared to a no-alvim group. the students t and chi-square tests were used. results: a total of 902 pts underwent elective crr. alvim was administered periop to 262 pts (29%). the breakdown of indications between groups were similar. alvim pts were younger (60.4 vs. 63.8 years old, p=0.002) and, as regards comorbidities, less likely to have heart disease (cad 4.1% vs 13.9%, other heart disease 13.2% vs 19.5%) but were otherwise similar. the rate of laparoscopic-assisted (alvim, 80.9%; no alvim, 68%) and hand assisted or hybrid operations (alvim, 19.1%; no alvim, 32%) were similar. alvim pts had significantly earlier return of flatus (2.4 vs 2.9 days) and first bm (2.6 vs 3.5, p.001 for both) than the no alvim group. there was also a trend toward a shorter los (6.1 vs 6.7 days, p=0.05) for the alvim group. overall complication rates were similar, however, alvim pts had lower rates of post-operative ileus (5.3% vs 14.1%, p.0002), sssi's (5.8 vs 10%, p=0.04), and blood transfusion (7.1 vs 13.0%, p=0.01) than the no alvim group. conclusion: the two groups compared were largely similar (most co-morbidities, indications, crr type) with the differences in age and cardiac issues noted. the impact of the higher rates of sssi's, blood transfusion, and mi in the no alvim group on gi function is unclear. pts who received alvim periop had an accelerated return of bowel function, decreased postoperative ileus and shorter length of stay. these results suggest that alvim is effective in reducing the postoperative ileus but further study is warranted. background: laparoscopic total proctocolectomy (tpc) is selected for minimally invasive surgical treatment of familial adenomatous polyposis (fap) and ulcerative colitis (uc). our policy of tpc is no diverting ileostomy for fap and creating ileostomy for ibd because most of the patients received steroid therapy. objective: we examined the outcome of laparoscopic tpc according to disease of fap and ibd (uc and crohn's disease). methods: twenty-three consecutive patients who underwent laparoscopic tpc between april 2007 and march 2017 were examined. the patients were divided into fap group and ibd group. results: seven patients of fap and 16 patients of ibd (uc 15, crohn's disease 1) underwent laparoscopic tpc or total colectomy. among them, 12 patients (fap 3, ibd 9) were cancerassociated cases. the procedures of the fap group was tpc with iaca in 6 patients and hals total colectomy with ira in 1 patient. the procedures of ibd group were tpc with iaca in 11 patients, tpc with iaa in 2 patients, total colectomy with ira in 3 patients, of which 5 hals cases. the mean operative time and blood loss were 318 minutes, 32.0 g in the fap group and 382 minutes, 86.8 g in the ibd group, respectively. diverting ileostomy was constructed in 11 patients of only uc group. early complications of fap group were observed in 3 cases (postoperative ileus 2, anastomotic leak with conservative treatment 1), and those of ibd were observed in 8 cases (ileus 4, anastomotic leak with conservative treatment 1, abdominal abscess 1, wound infection 1). the median postoperative hospital stay was 12 days in the fap group and 14 days in the ibd group. complications requiring reoperation were 2 cases (fap 1: intestinal obstruction, ibd 1: inflammation of stoma-closure site). no cancer recurrence and mortality were observed. one case of fap underwent additional transanal mucosal resection due to new lesion of adenoma. conclusions: laparoscopic total proctocolectomy for fap and ibd was performed safely, especially less complications occurred in fap patients without diverting ileostomy. in addition, followup of remaining mucosa is important in iaca and ira patients. treatment of complex anal fistula has always been a nightmare for surgeonsby conventional means. even the lowest and simple looking fistula at times comes out to be a complex one with high incidence of recurrence above 20%. most of the availability diagnostic including mri is nit conclusive and many a times the surgeon remains in a state of confusion as to what is going to come at the operation table. the conventional treatment modalities also usually leave the patient wounded needing almost 6 to 12 weeks to heal with a risk of sphincter damage and a high risk of recurrence. we would be presenting the technical details and results of our series of 210 cases of complex anal fistula treated by video assisted endoscopic therapy. jun higashijima, phd, mitsuo shimada, professor, kozo yoshikawa, phd, takuya tokunaga, phd, masaaki nishi, phd, hideya kashihara, phd, chie takasu, phd, daichi ishikawa, phd; department of surgery, the university of tokushima background: one of the important causes for anastomotic leakage (al) in anterior resection is an insufficient blood flow of the stump. the hems (hyper eye medical system) and spies (laparoscopic icg system) can detect the blood flow of fresh organ intraoperatively by injection of indocyanine green (icg). and thermography also can evaluate the bloodflow less invasively. the aim of this study is to evaluate the usefulness of icg system and thermography in laparoscopic anterior resection. patients and methods: this study retrospectively included 86 patients who underwent laparoscopic anterior resection for colon cancer with double stapling anastomosis procedure. blood flow evaluation of oral stumps was performed with measurement of fluorescence time (ft) using hems and spies. and bloodflow was also evaluated by thermography. result: evaluation by icg system: in all cases, the al rate was 8.1% (7/86 cases). over 60 ft cases, the al rate was 60%, higher than that of under 60 s cases and these patinets need additional management, covering stoma or additional resection. and in border cases, ft 50*60 sec, al rate is 10.0%, higher than under 50 s cases. in these borderline cases, if covering stoma was performed in patinets with more than three well known risk factors, the al rate reduced to 2.6% and false positive was 6.9%. and under 50 s cases, they need no additional management. evaluation by thermography: in residual intestine, the temperature was siginificantly higher than resected intestine (31.5 vs 29.0?, p.01). and the temperature in ft under 50 s cases was significantly higher than over ft over 50 s cases (26.3 vs 30.8?). the temperatue and ft was tended to be oppositely correlated (r 2 =0.36). conclusion: both icg system and thermography may be useful to avoid anastomotic leakage. introduction: some patients who undergo neoadjuvant chemoradiation therapy (crt) for rectal cancer achieve a pathologic complete response (pcr) in which no tumor cells are discovered during pathologic analysis of the resection specimen. achievement of pcr is correlated to improved prognoses relative to non-pcr counterparts. such correlations are not well established in the context of a community-based hospital. the study sought to examine response rates, recurrences, and survivals in locally advanced rectal cancer patients and compare patient outcomes to those achieved at major academic institutions. methods and procedures: a single-center retrospective chart review was performed at a local, community-based hospital. study population consisted of 118 patients with locally advanced rectal cancer treated with neoadjuvant crt followed by surgical resection. patients with a history of metastasis, inflammatory bowel disease (ibd), hereditary cancer syndromes, concurrent or prior malignancy, and emergent surgery were excluded. results: 24 patients (20.3%) achieved pcr in the test population. across both groups, mean age (p =.352), gender (p=.254), and ethnicity (p=.529) were found to be comparable. mean interval between crt and or (p=.116), pre-op stage (p=.736), number of nodes (p=.208), radiation dose (p=.094), tumor location (p=.753), and days of follow-up (p=.497) presented statistically insignificant differences between groups. at 5 years, 26 non-pcr patients (27.7%) had a recurrence with zero recurrences in the pcr group. 5-year mortality presented 25 non-pcr patients (26.6%) compared to 1 pcr patient (4.17%). conclusion: a multidisciplinary approach to rectal cancer consisting of standardized preoperative treatment and surgical resection can achieve patient outcomes and survival similar to those of larger academic institutions, even in the context of a community-based hospital. objective: the aim of this study was to assess safety and feasibility of total mesorectum excision (tme) within the holy plane based on embryology for rectal cancer. methods: prospectively collected data of 36 consecutive patients with rectal cancer who underwent tatme from november 2014 to august 2017 were enrolled. surgical outcomes including tme completeness, operative time for tme completion, blood loss, complications, pathological findings and length of hospital stay were assessed. surgical procedure: after performing ractal lavage, self-retaining anal retractor was set, and anal dilators were used for an atraumatic introduction of the transanal access devise (gelpoint path). three of 10-mm trocars and one of 15-mm trocar were inserted through the gelpoint path in a quadrant shape. then the gelpoint path was introduced through the anal to rectum. after rectosigmoid colon was temporally clamped using an atraumatic endo bulldog clip, pneumoperitoneum was maintained at 15 mmhg with carbon dioxide via an air seal platform. a purse-string suture using a 0 polypropylen with 26-mm rounded needle was performed clock-wise to tightly occlude the rectum with a 3 cm margin distal to the tumor. after irrigation with saline and marking dissection line with tattooing the rectal mucosa distal to the mucosal folds, a mucosal transection of rectum was initiated. then a full-thickness rectal transection was performed circumferentially. after dissection of rectococcygeal muscle at 6 o'clock and rectourethral muscle in the anterior wall, circumferential sharp dissection within the holy plane was performed. dissection proceeded between the endopelvic fascia and the prehypogastric nerve fascia in the posterior plane, between the denonvilliers's fascia and the anterior mesorectum in the anterior plane, and between pelvic nerve and the mesorectum with recognition of the neurovascular bandle in the lateral plane. then the dissection connected to the abdominal plane via laparoscopic team with working together until tme completed. results: tme completion performed in 34 (94.4%) patients. thirty five (97.2%) patients had negative of circumferential resection margin. mean of tme completion time and blood loss were 146 min and 72 g, respectively. one (2.8%) patient had an intraoperative complication and 7 (19.4%) patients had postoperative complications. no other complications occurred. the length of hospital stay was 12 days. conclusions: tatme within the holy plane on based on embryology is a safe and feasible procedure for rectal cancer. abstract: acromegaly is a debilitating condition marked by excessive production of growth hormone. this leads to disfiguration, cardiopulmonary complications, and increased risk for cancer. with up to a two-fold increased risk of developing colon cancer and worse prognosis for diagnosed patients, earlier and more frequent screening has been recommended. we present a case of a 54-year-old hispanic male with acromegaly who presented to our hospital with hematochezia and weight loss. a near-obstructing rectal adenocarcinoma with metastasis to the liver was discovered. after completing neoadjuvant chemoradiotherapy, he underwent laparoscopic low-anterior colon resection and simultaneous open hepatic trisegmentectomy. in this case report, we review the literature and current guidelines in screening this high-risk group of patients. introduction: in this study, we discovered that in cme for laparoscopic right hemi-colectomy starting at the ileocolic vessel and proceeds along the superior mesenteric artery (sma) achieved a better oncologic outcome compared with the conventional ones proceeding along the superior mesenteric vein (smv). methods and procedures: 46 patients admitted to a shanghai minimally invasive surgical center were included from september 2015 to january 2017 and were randomly divided into two groups: study group (n = 26) and conventional group (n = 20). operation time, blood loss during surgery, liquid intake time, postoperative hospital stay, postoperative complications within 30 days after surgery, specimen length, and number of lymph nodes harvested as well as the positive lymph node rate were observed and studied. results: there was no statistical difference between the two groups with the exception of number of lymph node dissected and the positive lymph node rate for stage iii colon cancer. the study group had more lymph node retrieved and also a higher positive rate compared with the conventional group. the mean number of lymph node retrieved of study group was 21.8 ± 2.47, while the conventional group was 19.9 ± 2.24 (p.05). and the positive lymph node rate for study group was 41.6%, the conventional group was 34.4%. conclusion: when performing the laparoscopic right hemi-colectomy, dissecting the lymph node along with the left side of sma could be achievable and there were no differences of surgical outcomes compared with the conventional ways, while there was a higher number of lymph nodes dissected and positive rate probably leading to a better oncologic outcome. aims: we describe laparoscopic surgery for rectal cancer using needlescopic instruments performed at our department. methods: from 2012 to 2016, 19 cases of rectal cancer underwent surgery using needlescopic instruments: 3 cases at rectosigmoid colon, 5 at upper rectum, and 11 at lower rectum. an umbilical camera port (12-mm) and two needlescopic instruments (endorelieftm) were directly punctured into the assistant surgical site. we started with 5 port sites. in low rectum cancer cases, we kept the good pelvic visualization to lifting the peritoneum of the bladder onto the ventral side using the lone star retractor staystm. results: the median age was 70 years (56-91 years), with 9 males and 10 females, and body mass index was 21.1 kg/ m 2 (16-25 kg/m 2 ). anterior resection was performed in 2 cases, low anterior resection in 7 cases, intersphincteric resection in 4 cases, abdominoperineal resection in 4 cases, hartmann's procedure in 2 cases, and lateral lymph node dissection in 1 case. in addition, one case of t4b (bladder) was converted from laparoscopic to open surgery. however, there were no cases in which needlescopic instruments were replaced with conventional forceps. moreover, intraoperative complications related to the forceps were not observed. conclusions: in rectum cancer surgery, needlescopic instruments leave a small postoperative wound; healing is rapid and the cosmetic result is excellent. surgical safety is comparable to that using conventional forceps. there is no problem with the rigidity of needlescopic instruments. however, where the shaft is curved, operative control requires attention to mobility and directionality. in low rectum surgery, use of needlescopic instruments is limited due to the curvature of the shaft during the dissection of the anterior rectum wall, but it is possible to maintain a good field of view by using auxiliary equipment. therefore, more cases could be considered for surgeries using needlescopic instruments with the help of auxiliary equipment. introduction: anastomotic leaks are devastating complications of colorectal operations that lead to significant morbidity and potential mortality. inadequate tissue perfusion is considered a key contributor to anastomotic failure following colorectal operations. currently, clinical judgment is the most commonly used method for evaluating adequate blood supply to an anastomosis. more recently intraoperative laser angiography using indocyanine green (icg) has been utilized to assess tissue viability, particularly in reconstructive plastic surgery. this technology provides a real-time evaluation of tissue perfusion and is a helpful tool for intra-operative decisions, particularly in deciding to revise an intended colorectal anastomosis. our study aimed to determine if there is a statistical significance in colorectal anastomotic leak or abscess rate using icg compared to common clinical practice. methods and procedures: 126 patients undergoing left-sided colorectal operations, between march 2012 and february 2015, were retrospectively reviewed. 55 patients' colorectal anastomoses were evaluated using icg angiography (icga) to qualitatively assess tissue perfusion (icg group). peri-operative and post-operative outcomes, including anastomotic leak and abscess rates, were compared to 65 patients who had colorectal operations without icga (control group). the primary outcomes of intra-abdominal leak rate and intra-abdominal abscess rate were compared using exact chi-square tests. the secondary outcomes of 30-days or return, mortality, and readmission rate were compared using chi-square tests. all statistical analyses were performed using sas software. results: two leading indications for surgery included malignancy (n = 57) and diverticulitis (n = 48). the majority of patients either had a low anterior resection (n = 75) or sigmoidectomy (n = 42). all operations were primarily minimally invasive. no statistically significant difference was seen between the two groups in regards to patient demographics, rate of proximal diversion (p = 0.112), and splenic flexure mobilization (p = 0.200). patients in the icga group were more likely to have high ima ligation than in the control group (70.9% vs. 24.4%, p-value.001). of the icga group, 16 of the 55 patients underwent additional colonic resection while 39 of the 55 did not undergo additional colonic resection. there was no statistically significant difference in primary or secondary outcomes between the two groups. conclusion: icg angiography has become a helpful adjunct in determining adequate perfusion to an intended colorectal anastomosis. this data is unable to support any difference in patient outcome utilizing this technology over surgeons' visual and clinical assessment. our results may contribute to larger studies to determine if there is a true difference in anastomotic leak or abscess rate using this technology. objective: to investigate the feasibility and surgical strategy of complete mesocolic excision (cme) with completely medial access by "page-turning" approach (cmapa) for the laparoscopic right hemi-colectomy. the cmapa is a modified medial approach of cme, which focus on the exploration of surgical plane instead of the recognition of vessels. surgical procedures: (1) start point: the anatomy projection of ileocolic vessel; (2) expose the whole trunk of smv to the level of inferior edge of pancreas before ligating any branches, for the purpose of high tie and verifying their location; (3) enter the intermesenteric space (ims) and right retrocolic space (rrcs) with cranial and right extension through transverse retrocolic space (trcs); (4) complete mobilize the mesocolon and remove the tumor en-bloc. see figure 1 ?2. clinical outcome: from september 2011 to march 2017, there were 72 patients underwent cmapa in shanghai ruijin hospital. the average operation time was 135.9 ± 28.3 minutes, average blood loss was 63.2 ± 32.2 ml, number of lymph node was 20.6 ± 7.7, average specimen length was 23.9 ± 4.7 cm, flatus time was 2.5 ± 0.8 days, fluid intake time was 3.2 ± 0.8 days and average hospital stay was 8.9 ± 4.7 days. the overall complications rate was 6.94% (5/72 ). compared to traditional medial approach of cme performed in our center, the blood loss, operation time and hospital stay were significantly reduced by performing cmapa for laparoscopic right hemi-colectomy. conclusion: the advantage of the cmapa (1) to avoid the laparoscopic "leverage effect" and "tunnel effect". (2) to make the branches of superior mesenteric vessels more easily recognized. (3) to offer surgeons an alternative route entering the trcs, ims and rrcs. (4) to avoid repetitive flipping of the colon complying with the "no touch" principle, and to lower the requirements of assistants. figure 1 : anatomy and surgical planes concerning cmapa. aim: we have reported a possibility of "one-stop shop" simulation for liver surgery by mri using gadoliniumethoxybenzyl-diethylenetriamine pentaacetic acid (eob-mri) (emerging technology, sages 2017)., which is characterized by (1) one-time examination, (2) no-radiation exposure, (3) demonstration of liver vasculatures including biliary tract, (4) diagnosis of tumors, (5) volumetry and (6) estimation of liver functional reserve in each segment. the aim of this study is to investigate usefulness of "one-stop shop" simulation for liver surgery using eob-mri. methods: accuracy of liver vasculatures: 3d-reconstruction of dynamic eob-mri imaging was done by synapse vincent software (fujifilm medical co., ltd., japan), using a manual tracing method. visualization of hepatic vessels in eob-mri was compared with that in dynamic ct in 10 patients. assessment of liver functional reserve: the standardized signal intensity (si) of each segment was calculated by si of each segment divided by si of the right erector spine muscle. the standardized total liver functional volume (tlfv) was calculated by ∑ [k=1 to 8] (standardized si of segment (k)9volume of segment (k)) divided by body surface area. the following formula of resection limit was established using 28 normal liver cases (70% of the liver is resectable) and 5 unresectable cirrhotic patients such as recipients of liver transplantation (0% of the liver is resectable). the estimated resection limit (%)=70% 9 (the standardized tlfv of the patient -962)/1,076. this formula was validated using other 30 patients who underwent hepatectomy. results: accuracy of liver vasculatures: the liver simulation by eob-mri succeeded in demonstrating hepatic vasculatures including biliary tract, diagnosis of hepatic tumors, and volumetry without any radiation exposure. regarding the vessel anatomy at hilar area, biliary tract was more clearly visualized in eob-mri. regarding the hepatic artery, right and left hepatic arteries were well visualized in all cases, however, small-sized middle hepatic artery was visualized in only one out of 10 patients. assessment of liver functional reserve: as a result of validation of the 30 patients, one patient having resection volume with over the resection limit died of liver failure, however, the other 29 cases within their resection limits did not suffer from liver failure. conclusion: "one-stop shop" liver surgery simulation could contribute to safety of liver surgery such as laparoscopic hepatectomy, because of no radiation exposure, accurate assessment of anatomical variations especially biliary tract, and helping decision making of resection volume. showing key steps of the procedure to be viewed. the in-studio program was hosted by an education specialist from the science center and a surgical resident from our institution, with laparoscopic instruments available for manipulation by participants. participants then viewed a video highlighting the roles of all healthcare providers involved in the specialty to be featured, including nurses, physicians, dietitians, psychologists, technologists, etc. live questions and answers were then encouraged between students and surgeons during the surgery broadcast. the program also expanded from high schools to vocational-technical colleges and nursing schools. results: during the 2008-2009 academic year there were 6 sessions presented to 11 schools, with 421 student participants. by the 2016-2017 year this increased to 19 sessions presented to 55 schools, with 1721 participants. in sum, throughout the first 9 years of the program, there were 395 schools attending, with a total of 11,351 participants. of polled high school participants, 63% of responders acknowledged considering a career in healthcare after this experience. conclusion: over 10 years, our program has grown steadily in popularity such that schools from several counties attend and regularly return, and we have been asked to expand the program to create a surgical summer camp for students interested in science and technology. live broadcast surgery in an elective, minimally invasive format provides unique visibility and access to surgical procedures for student audiences and promotes future interest in healthcare careers. surg endosc (2018) 32:s130-s359 p296 improving trainees' self-assessment through gaze guidance introduction: effective learning to become competent in surgery depends on a trainee's ability to accurately recognize their strengths and weaknesses. however, a surgical trainee's self-assessment is poorly correlated with expert assessment. this study aimed to improve self-assessment by the visual gaze guidance provided through telestration in laparoscopic training. we hypothesized that visual conveyance of where to look or perform actions on the laparoscopic video enhances the trainees' awareness of the gaps in their skills and knowledge. methods and procedures: a lab-developed telestration system that enables the trainer to point or draw a free hand sketch over a laparoscopic video was used in the study (fig. 1 ). seven surgical trainees (1 surgical fellow, 1 research fellow, 2 pyg-2 and 3 pyg-1) participated in a counterbalanced, within subjects controlled experiment, comparing standard guidance with telestration-supplemented guidance. the trainees performed four laparoscopic cholecystectomy tasks -mobilizing cystic duct and artery, clipping the duct, clipping the artery, and cutting the duct and artery, on a laparoscopic simulation. performance assessment, adapted from the global rating scale (grs) instrument, was completed by the trainers and trainees at the end of each task. the mean self-assessment scores were compared with the trainers' scores by the linear mixed model, where the trainees' performance indicated by the trainers' scores was control. the assessment alignment was evaluated by spearman's rho. results: the trainers' scores were significantly lower than the self-assessment scores in the standard guidance, while the scores of the trainers and trainees were much more similar (fig. 2) . the correlation between the trainers' and trainees' assessment in telestration guidance was high (r= 0.852, p.001), compared to the standard guidance (r=0.569, p=0.03). the correlation comparison for each grs criterion shows a significant increase (p=0.005) in the assessment alignment for depth perception in telestration guidance (r=0.90, p.001), compared to the standard guidance (r=0.30, p=0.31) (fig. 3) . the visual gaze guidance improved the alignment of assessment between the trainer and trainees, especially for the assessment alignment in depth perception. for visual gaze guidance to become an integrated part of the training, further work needs to be conducted to understand how gaze guidance change the nature of the training process. applying to surgical residency: what makes the best candidates? yann beaulieu, beng, louis guertin, md, frcsc, ariane p smith, md, margeret henri, md, frcsc, facs; university of montreal objective: while quotas for canadian surgical residency programs are at their lowest point in ten years, the number of canadian graduating medical students is at an apogee. this year, only 288 spots in surgical residency programs were available for 2893 students applying to carms. undergraduate medical students individually collect anecdotal information regarding what influences admission to their surgical subspecialties of interest, as scarce literature covers the topic. we thus surveyed surgeons and residents to analyze the relative importance of modifiable factors and innate attributes in the selection of new surgical residents. methods: an electronic survey was sent to all surgeons and surgical residents affiliated with the university of montreal. participants were asked to specify their surgical subspecialty, their status, their level of experience and whether they were an active member of a residency selection committee. the subjective importance of predefined application elements and candidate qualities was assessed using 5-point likert-type items. results: of the 510 surgeons and 207 residents to whom the survey was sent, 136 (26.9%) and 91 (44.0%) completed the survey. evaluations of elective rotations and evaluations of core rotations were considered very important by 79.7% and 62.9% of responders respectively. regarding letters of recommendation, the content was rated very important (58.8%) more often than the notoriety of the author (25.6%). networking with key surgeons was considered the least important element to prioritize with 23% of negative assessments. with regards to the fundamental qualities of surgical candidates, the extremes were "clinical judgement" with 90.1% and "innate technical ability" with 26.4% of responders rating them very important. no significant differences in responses were observed between staffs and residents, between members and non-members of selection committees, between different levels of surgical experience and between surgical subspecialties. conclusion: clinical judgement and performance in core and elective rotations along with strong personalized letters of recommendation should be prioritized by medical students aiming for a surgical career. kazuhiko shinohara, phd, md; school of health science, tokyo university of technology background and objective: many types of training devices had been proposed since the early days of endoscopic surgery. however, they are too expensive for daily training of novices. we developed a simple and economical training device made of frozen fruit and agar. material and methods: to make this device, 6 g of agar powder was added to 300 ml of boiling water and boiled for 2 min. the solution was then poured into a stainless steel tray containing frozen blueberries and lychees and refrigerated for 2 h. basic maneuvers required during endoscopic dissection and resection of a tumor with laparoscopic forceps and electrosurgical devices were then performed using this agar model in a conventional laparoscopic training box. results: using this model, endoscopic dissection and enucleation of a tumor with an electrosurgical device could be practiced repeatedly with minimal expense and preparation. background: situs inversus totalis (sit) is a rare congenital anatomy and a challenging condition for laparoscopic surgeries because standardized strategy to overcome such anatomical difficulties. mirror-reversed video images of laparoscopic surgeries for patients with normal anatomy could help to develop surgical strategies for patients with sit. we had a chance to evaluate this idea with a treatment of a patient of early gastric cancer, and describe the surgical results of the case. patient and methods: seventy-two-year-old women with a history of sit was referred to our department for the treatment of early gastric cancer, and laparoscopic distal gastrectomy with d1+ lymphadenectomy was scheduled. a video record of the same surgery for a patient with similar physical attribute performed before then was retrieved, and was edited with a computer into full length, totally mirror-reversed images of the surgery. designated operator and assistant simulated the operation using the video several times before surgery. results: laparoscopic distal gastrectomy was performed with d1+ lymphadenectomy while the operator was on the left side of the patient and the assistant on the other side, being opposite positions as usual. laparoscopic b-1 reconstruction was followed using "delta anastomosis" technique reported by kanaya et al. total laparoscopic procedures were completed with the operation time of 250 minutes and the blood loss below measurable limits. no appreciable complications were observed after surgery and the patient was discharged on postoperative day 12. no recurrence of the disease was detected until 5 years after surgery, conclusion: although further validation is unlikely because of a rare incidence of this anatomy, the same technique would be recommended for one of the preoperative preparations for similar cases. background: surgical simulation is thought to provide a basis for improvement of resident surgical skill training, in the safety of a simulation setting. it is unclear whether surgical skills learned in a simulation curriculum actually contribute to the improvement of surgical skills when transferred to the or. methods: a ten question online survey was sent to attending surgeons and residents. the questionnaire focused on 5 domains: confidence, independence, transferable skills, improvement of skills/knowledge and time spent on the simulation curriculum. evaluation data was collected and anonymously analyzed. background: minimally invasive surgery poses a unique learning curve due to the requirement for non-intuitive psychomotor skills. programmes such as the fundamentals of laparoscopic surgery (fls) provide mandatory training and certification for many residents. however, predictors of fls performance and retention remain to be described. this single-centre observational study aimed to assess for factors predicting the acquisition and retention of fls performance amongst a surgically naïve cohort. methods: laparoscopically naïve individuals were recruited consecutively from preclinical years of a medical university. participants completed five visuospatial and psychomotor tests followed by a questionnaire surveying demographics, extracurricular experiences and personality traits. individuals completed a baseline assessment of the five fls tasks evaluated by fls standards. subsequently, participants attended a 270-minute training-course over week one and two on inanimate box trainers. a post-training assessment was performed in week three to evaluate skill acquisition. participants were withdrawn from laparoscopic exposure and retested at four onemonth intervals to assess skill retention. introduction: bipolar energy can cause thermal injury to adjacent organs when used improperly. sages fuse curriculum provides didactic knowledge on principles and best practices for safety, but there is no hands-on component to practice these skills. the objective of this study is to compare the effectiveness of the vest™ bipolar training module in addition to the fuse curriculum. methods and procedures: the study was a mixed design with two groups, control and simulation. after a pre-test that assessed their baseline knowledge, the subjects were randomized to two groups. both groups were given a 10 min presentation, reading materials from the fuse manual and an online didactic module on bipolar energy. the simulation group also practiced on the simulator for one session that consisted of five trials on the effect of activation time on thermal damage and the importance of providing a margin of safety by sealing short gastric vessels. after one week the performance of both groups was assessed using a post-questionnaire. one week after the post-test both groups performed sealing of 10 vessels on an explanted porcine mesentery with vessels perfused. their performance was videotaped and their activation times were recorded. a total safety score was calculated by assessing the proximity of the location of activation to the intestine by two independent raters. wilcoxon -signed rank and mann-whitney u tests were used to assess difference within and between groups. results: a total of 16 residents (8 in each group) participated in this irb approved study. median test scores for both groups increased (simulation, p=0.041 and control, p=0.027). no difference was found between the two groups in their pre-test (p=1.0) and post-test (p=0.955) scores indicating learning. the median total activation time for control group was higher (42.55 s) compared to simulation (30.6 s) but was not statistically significant (p=0.336). there was a moderate agreement between two raters for margin of safety (kappa=0.58, p.001). total safety scores showed no difference between the two groups (p=0.573). conclusions: subjects with simulation training had lower activation time compared to control. training for margin of safety requires more simulation refinement. small sample size and variations in the explanted models contributed to variability in data but even with small sample size, simulation training along with the fuse curriculum trended towards being more beneficial than the fuse curriculum alone. the general, that aims to build educational infrastructure and standardize training and education in laparoscopy throughout mexico. ilap participants engage in didactic and hands-on modules in educational theory, laparoscopic techniques, and simulation based education (sbe), and then develop and implement a 1-day sbe course for local trainees. the purposes of this study were to understand the existing educational environment at a single institution in mexico and measure the changes in perceptions, attitudes, and engagement in surgical education after an intensive training course. methods and procedures: all 13 faculty and 13 of 25 general surgery resident participants completed a survey that contained 7 items designed to assess the existing educational environment at a large, public hospital in mexico. using a 5-point likert scale, residents self-rated the quality of faculty feedback and the learning environment within their institution (1=strongly disagree, 3= neutral, 5=strongly agree). faculty rated their perceptions of the same educational themes. upon completion of a faculty-lead simulation course, residents rated the educational environment during the course. faculty provided additional qualitative feedback. descriptive analyses were performed. irb-exemption was obtained through lurie children's hospital. results: discordance existed in perceptions of the existing educational environment. the greatest disparity between resident and faculty perceptions included "faculty provide sufficient feedback in the operating room" (31% vs. 100%), "faculty promote an active learning environment" (38% vs. 85%), and "residents may ask questions without fear of negative evaluation" (46% vs. 100%). faculty and residents agreed with "residents are sometimes afraid to speak up in the operating room for fear of retaliation" (46% each). post-course evaluations (n=19) revealed universal improvement in all educational themes during the simulation course. qualitative feedback revealed most faculty plan to incorporate open communication and safe learning into their practice. residents were equally positive, with 100% optimistic that they will see changes within the educational environment. conclusions: significant discordance exists in resident and faculty perceptions of the educational environment at a large teaching hospital in guadalajara, mexico. after participation in the ilap course, residents noted demonstrable change in the faculty approach to education and feedback, and both faculty and residents expressed optimism for increased engagement in education. the immediate successes of the ilap initiative should be followed over time, as the ultimate measure of success is sustainability and scalability throughout mexico. background: laparoscopic anterior resection is technically challenging and the learning curve is long. well-designed formative assessments can provide trainees effective and constructive feedback, an important element in efficient learning. previously reported assessments for laparoscopic colorectal procedures were developed for summative assessment. we aimed to develop a formative assessment tool to evaluate competence and provide trainees with effective feedback in laparoscopic anterior resection. methods: the assessment tool was developed by an expert panel from mcgill university affiliated hospitals. the procedure was deconstructed into a series of sequential steps including general domains, surgical principles, injury prevention and technical skills specific to laparoscopic anterior resection. the tool contains 12 discrete items with global rating scales for each step of the operation; each domain was scored using a 5-point likert scale, with anchors for scores of 1, 3 and 5. each operation was assessed through direct observation in the operating-room by the attending, a trained observer, and trainees themselves. intraclass correlation coefficients (iccs) were calculated to estimate interrater reliability for (1) attending surgeon and trained observer, (2) attending surgeon and self-assessment, and (3) trained observer and self-assessment. internal consistency was measured using cronbach's alpha. comparison between training levels was done using mann-whitney u-test. the global operative assessment of laparoscopic skills (goals) was also used to assess trainees' general laproscopic skills. spearman's correlation was used to determine association between goals and this procedure-specific tool. overall usefulness of this tool was evaluated using a 10 cm visual analog scale. results: in this pilot study, fourteen operations, performed by 5 experienced surgeons and 5 trainees were assessed. the icc between (1) attending surgeon and observer was 0.77 (95% ci 0.26 to 0.93) (2) observer and self-assessment was 0.74 (95% ci 0.30 to 0.92), and (3) attending surgeon and self-assessment was 0.43 (95% ci -0.11 to 0.79). the internal consistency of the items was excellent (cronbach's α=0.93). there was a significant difference in median total score between experienced surgeons and trainees (87.2±9.4 vs. 68.8± 9.3; p=0.016). there was strong correlation (r=0.884) between goals and this procedure-specific score. overall usefulness of this assessment tool was rated as 7.4±1.7. all assessments were completed in about 5 minutes. conclusions: we present a new procedure-specific formative assessment tool for laparoscopic anterior resection and provide preliminary evidence of its reliability and validity. this formative assessment tool could be used for constructive feedback and tracking performance in competencybased surgical training. cullen introduction: one of the key challenges to the proliferation of endoscopic submucosal dissection (esd) in the west has been a lack of training platforms. therefore, the virtual endoluminal surgery simulator (vess) is being developed as a training tool for esd. the aim of our study is to inform the design of vess using cognitive task analysis (cta), which is a human factors engineering framework to describe practitioners' mental models and cognitive processes and incorporate insights into the simulator's design. methods and procedures: cta-based interview questions were developed to probe the cognitive challenges and strategies employed at each stage of the esd procedure. six esd practitioners were interviewed for varying lengths of time. two of these interviews were conducted simultaneously during an observation of a training workshop where the cta participants were instructors (total observation time was five hours, and interview time was *60 minutes). another interview was conducted during observation of esd procedures (total observation time was 22 hours, and interview time was *110 minutes). participants had varying levels of experience in esd, with 4 of them being 'super-experts' (exclusively esd exponents), 1 an 'expert' and 1 a fellow. a cta of the data is currently being conducted to systematically inform design of functionalities in the simulator. results: analysis of our data highlights a few prominent themes at each stage of esd: goals, challenges (e.g., avoiding perforation of muscularis); points of decision-making (e.g., partial or full incision for boundary demarcation); skills involved (e.g., dissection); and ambiguity (e.g., unclear lesion boundaries). participants also described risks associated with each stage of esd and strategies to prevent or overcome the same. conclusions: qualitative data for a cta were collected through observations and interviews of esd practitioners. preliminary analysis has indicated prominent themes to consider in the design of the training simulator. the next step in the study is to conduct a full-scale cta of esd based on the current data. the ultimate benefit of the cta would be to incorporate the results into informing the design of vess in a way that is compatible with the mental models of esd trainees, thus enhancing the fidelity and effectiveness of the simulator. background: colonoscopy is an important diagnostic and therapeutic procedure in the management of colonic disease; achieving competence during residency is an integral part of performing high-quality colonoscopy in-practice, regardless of specialty. there is debate and controversy however, regarding what, if any, number of procedures achieves said proficiency. furthermore, there is significant heterogeneity in the current guidelines and studies published to-date on the definition of competence in colonoscopy. objective: to determine individualized learning curves as an alternative to 'number of procedures' for assessing colonoscopy competence. methods and procedures: this is a multi-institutional prospective cohort study involving eleven surgical trainees (novice endoscopists). the main outcome, colonoscopy competence, was assessed by determining the independent colonoscopy completion rate (iccr), the number of procedures required to reach 90% independent colonoscopy completion and polyp detection rate. individual and overall iccr were calculated using moving average analysis. conclusions: while a benchmark for a minimum number of procedures may be necessary to allow supervisors to adequately assess performance, it is difficult to determine what number is optimal. there appears to be significant heterogeneity in both overall number of colonoscopies completed by each resident, as well as the mean iccr and the number of procedures required to reach the current benchmark for competency. the use of learning curves allows real-time tracking of progress and training tailored to the individual, as we move forward in the era of competency-based medical education. background: with the growing popularity of robotic-assisted surgery, new methods for evaluation of technical skill are necessary to determine when a surgeon is qualified to perform an operation independently. current evaluation methods are limited to 5 point likert scales which require a degree of subjective scoring. surgeons in training need an objective method of evaluation to view progress and target areas for improvement. one method of objectively evaluating surgical performance is a cumulative sum control chart (cusum). by plotting consecutive operative outcomes on a cusum chart, surgeons can view their learning curve for a given task. another method of objective evaluation is the dv logger®, or "black box," which records objective measurements directly from the da vinci® system. methods: we followed two hpb fellows during dry lab simulation of 40 robotic-assisted hepaticojejunostomy reconstructions using biotissues to model a portion of a whipple procedure. we simultaneously recorded objective measurements of dexterity from the da vinci® system and performed cusum analyses for each procedural step. we modeled each variable using machine learning (a self-correcting and autoregressive modeling tool) to reflect the fellows' learning curves for each task. statistically significant objective variables were then combined into a single formula to create an operative robotic index (ori). results: variables that significantly improved over the course of the simulation included completion time (p=0.017), economy of motion in arm 1 (p=0.001), number of times head was removed from the console (p=0.001), total time left master manipulator was active (p=0.005), total time right master manipulator was active (p.001), and total time that any arm was active (p\ 0.001). the inflection points of our cusum charts and plots of objective variables both showed improvement in technical performance beginning between trials 14 and 16 [ fig. 1 and fig. 2 ]. the operative robotic index showed a strong fit to our observed data and improved with additional trials (r 2 =0.796). [ figure 3 ]. conclusions: in this study we identified objective variables recorded by the da vinci® system which correlated with the technical dexterity of fellows during a robotics dry lab. we broke a complex procedure down in stepwise fashion with cusum analyses to determine targets for improvement. using variables which correlated with the improved performance of the fellows, we effectively modeled the learning curve with the creation of an operative robotics index (ori). this study successfully models the learning curve of novice robotic surgeons using a novel combination of objective measures. georg wiese, md, paula veldhuis, steve eubanks, md, facs, scott w bloom, md, frcsc, facs; florida hospital institute for surgical advancement introduction: robotic surgery is a specialized skill which requires time and resources to master. in a general surgery residency program that seeks to train competent surgeons in both open, laparoscopic and endoscopic techniques it is difficult to see where adding robotic training will be of benefit and at what cost this will be to the remaining surgical skills. we therefore sought to ascertain robotic surgery's current role in the training of new general surgeons by soliciting the opinions of current general surgery program directors on the role of robotic surgery at their respective institutions. methods: an irb approved survey was created and sent to general surgery program directors across the country to assess how robotic surgery training is being integrated into current surgical training. the survey was sent via email to publicly available email addresses from the acgme website of program directors. it was voluntary in nature and consisted of questions regarding current status of robotic training in residency as well as future goals. results: overall response from our pd survey were at 12% of the 266 surgical programs with addresses available via acgme, though responses continue to be submitted at the time of this abstract. approximately 48% of all respondents are from independent, university based programs. 85% felt that robotics was an emerging skillset important for residents to master versus 15% feeling that it was more appropriate for fellowship. all respondents noted that robotic surgeons were present at their institution, 90% within the core faculty, and 50% indicated that they were actively recruiting robotically trained surgeons. additionally, 95% of programs indicated that residents were exposed to robotic surgery, 81% of these on core general surgery rotations. 62% of respondents indicated that they had a formal robotic training curriculum with 81% of programs taking measures to integrate robotics into the future curriculum though 71% lacked specific milestones for such training. finally, opinion was evenly divided among respondents as to whether one could sign off on residents to perform robotic assisted cases upon completion of pgy5 year with 45% agreeing with that statement and the remainder indicating some additional training would be necessary. conclusions: our study highlights the emerging field of robotic assisted mis surgery and its increasing role in residency training. it is evident from the data, that robotic surgery is a growing part of residency experience. importantly, however, milestones were significantly lacking for determining resident progress in robotic training. introduction: in chile, medical students have the opportunity to undertake a month-long medicine elective (me) in a community hospital, primary care center or emergency department within the country at the end of their first clinical year. due to the lack of opportunities to practice suturing in the first years, students usually do not have an optimal performance in this type of medical procedure during the me. simulation training programs in suturing improve technical skills, selfconfidence and patient safety in the medical internship. the objective of this study is to evaluate the impact of implementing a simulated suture training program earlier in the medical curriculum, before the me. methods: we conducted a prospective, randomized controlled trial with 50 medical students at the end of their first clinical year. they were randomized into two equal groups. the intervention group received an intensive suture training program consisting in one theory class, four practical sessions and effective feedback from an expert surgeon. the control group did not receive training, remaining with the classic opportunistic learning approach during the me. after the me, all students undertook an electronic survey. statistical analysis was performed on the answers of both groups. per protocol analysis was applied. results: there were no statistical differences between groups in terms of age and sex. four students did not complete the training program. one student in the control group did not reply to the survey. higher self-confidence with regards to suturing was reported in the intervention group in comparison with the control group [10/21 (48%) vs 4/29 (14%), p,001]. also, a greater student desire to carry out suture-related procedures was reported in the intervention group than the control group [16/21 (76%) vs 11/29 (38%), p,001]. in addition, a lower rate of overseeing physician intervention was reported in the intervention group [3/21 (14%) vs 14/29 (48%), p,001] ( table 1) . a greater number of patients requiring sutures were treated by the intervention group than the control group, with a median of 4 patients (3-7) against 2 (1) (2) (3) (4) . the intervention group performed a higher number of sutures with a median of 17 (6-31) vs 7 (2-16), with a statistically significant difference (p,05) in both cases (fig. 1) . conclusion: a simulated suture training program prior to the me generates a positive impact on medical students by improving self-confidence and desire to attend patients that require sutures. this leads to a higher rate of both exposure to suture techniques and suture execution. introduction: measuring performance in the operating room (or) is challenging. performance is a multifaceted construct a complex interaction of many behaviors and actions that reflect an individual's knowledge and skill. no assessment tool to date provides an expertise-based, comprehensive evaluation of the various aptitudes necessary to excel in the or, especially with respect to advanced cognitive skills. using qualitative methodologies, we previously defined behavioral themes that guide surgeons' behaviors, decisions, and actions, within a universal framework of 5 domains that reflect intra-operative performance. the purpose of this pilot study was to use this framework to derive a comprehensive assessment tool and to obtain evidence for its validity as a measure of intra-operative performance. methods: an assessment tool was developed by a panel of 9 surgeons and 5 surgical trainees based on the five-domain model of intra-operative performance: 1) psychomotor skills; 2) declarative knowledge; 3) interpersonal skills (two items); 4) personal resourcefulness, and 5) advanced cognitive skills (ten items). all items were rated on an ordinal scale of 1 (inadequate) to 5 (expert) and equally weighted. surgical residents and surgeons from a single academic center were evaluated on their performance during standard general surgery operations, for example, open inguinal hernia repair and laparoscopic cholecystectomy. for residents, there were 2 evaluators -the attending surgeon and an observing surgeon. attending surgeons evaluated their own performances and were also assessed by 2 observing surgeons. internal consistency, inter-rater reliability, and correlation of total scores with training level (junior residents, senior residents, staff surgeons) were calculated. likert scale questionnaires were administered to evaluate the tool's usability, feasibility, and educational value. results: fifteen subjects (5 junior residents, 5 senior residents, 5 surgeons) participated. the total score on the assessment demonstrated significant differences between training levels ( figure) . inter-rater reliability was high (interclass correlation coefficient=0.87), as were internal consistency between each domain score (cronbach's alpha=0.95), internal consistency amongst items in the advanced cognitive skill domain (cronbach's alpha=0.99), and internal consistency amongst items in the interpersonal skills domain (cronbach's alpha=0.99). all assessments required less than five minutes to complete. overall, evaluators agreed that the assessment tool was easy to use, was comprehensive, and should be used routinely throughout training to track performance and provide formative feedback. conclusion: in this pilot study, we developed a comprehensive assessment tool for intra-operative performance and provide preliminary validity evidence for the score. surg endosc (2018) introduction: the purpose of this study was to evaluate the validity of our developed system for assessing suturing skills in laparoscopic surgery (fig. 1) . we have updated numbers of participants and a comparison method compared with the last year report. methods and procedures: fig. 1 shows our developed computerized system for objective assessment of suturing skills by using a laparoscopic intestinal suturing model, e-lap. the system includes a new artificial intestinal model that mimics living tissue and pressure-measuring and image-processing devices. each examinee performs a specific skill using the artificial model, which is linked to a suture simulator instruction evaluation unit. the model uses internal air pressure measurements and image processing to evaluate suturing skills. five criteria, scored on a five-grade scale, were used to evaluate participants' skills ( fig. 2) . the volume of air pressure leak was determined by the volume of air inside the sutured artificial intestine. for example, for the criterion "air pressure leakage", the approximate midpoint of the acceptable range was grade 3. values lower than the minimum acceptable value received lower grades and those above the midpoint of the acceptable range higher grades. we enrolled 277 surgeons who participated a simulator competition event at the 29th annual meeting of the japan society for endoscopic surgery (jses 2016 houston methodist hosptial, 3 baylor college of medicine introduction: the sages flexible endoscopy course for minimally-invasive surgery (mis) fellows has been shown to improve confidence and skills in performing gi endoscopy. this study evaluated the long-term retention of these confidence levels and investigated how fellows have changed practices within their fellowships as a result of the course. methods: participating mis fellows completed surveys six months after the course. respondents rated their confidence to independently perform sixteen endoscopic procedures (1=not at all; 5=very). while the pre-and post-course surveys identified anticipated endoscopy uses and barriers to use, the 6-month follow-up survey evaluated actual usage and barriers to use in each fellow's practice. respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (fes) certification. comparison of responses from the immediate postcourse survey to the 6-month follow-up survey were examined. mcnemar and paired t-tests were used for analyses. results: twenty-three of 57 (40%) course participants returned the 6-month survey. 26% had passed the fes skills examination and 17% had attended another flexible endoscopy course. no major barriers to endoscopy use were identified. in fact, fellows reported less competition with gi providers as a barrier to practice compared to their original post-course expectations (50% versus 86%, p.01). in addition, confidence was maintained in performing the majority of the 16 endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (− 26%; p.05), control of variceal bleeding (− 39%; p.05), colonic stenting (− 48%; p.01), barrx (− 40%; p.05), and tif (− 31%; p.05). fewer fellows used the gi suite to manage surgical problems than was anticipated post course (26% versus 74%, p.01). fellows without fes certification reported loss in confidence to independently perform barrx (− 54%; p.05) and colonic stenting (− 63%; p.01), and also a 58% decrease in the use of gi suite to manage surgical problems (p.05) fellows who passed fes noted no significant loss of independence, changes in use, or barriers to use. 18% of fellows made additional partnerships with industry after the course. 41% stated flexible endoscopy has influenced their post-fellowship job choice. 100% would recommend the course to other fellows. the sages flexible endoscopy course for mis fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures six months later, and over 40% reporting that flexible endoscopy influenced their career choice. additionally, fellows experienced no major barriers to implementing endoscopy into practice. the materials and methods: at our center, we formulated a laparoscopic mentorship program where a senior consultant was paired with a particular trainee resident for a period of 6 weeks. 12 consultants & 12 residents were a part of the study. the or schedules were rearranged to accommodate these pairs. an evaluation of the residents' views was performed prior to the study and once at its completion, using a simple questionnaire with each parameter scored between 1 & 10. results and discussion: continuous, consistent evaluation by a consultant over an extended period of time allowed them to assess their assigned resident's laparoscopic skill set. all pairs observed an increased frequency of errors being noticed & improved upon. the consultants stressed upon shedding undesirable operative habits. there was a significant improvement in residents' scores at the end of the short study. conclusion: we found that the short-term mentorship program was easy to incorporate within our or schedule and was well received by the participants. continuous short rotations under senior consultants appear to allow residents to not only fully observe and imbibe correct operative techniques, but also helps shed unfavorable habits. we are currently amid the second cycle of our study & looking forward to the results at the end of this academic year. introduction: colorectal cancer is one of the most common cancers in the united states. endoscopic submucosal dissection (esd) is an emerging minimally invasive technique that allows complete en-bloc resection and a much lower recurrence rate at long-term follow-ups. however, performing colorectal esd is technically demanding since the colorectal wall is thin and constantly moving, and potentially higher rates of complications (e.g., bleeding and perforations). hence, an adequate training for colorectal esd is needed to acquire basic proficiency with minimum complications. objectives: a virtual reality (vr)-based simulator with visual and haptic feedback for training in colorectal esd is being developed, which the aim to allow trainees to attain competence in a controlled environment with no risk to patients. in this work, a newly developed application of the virtual simulator that promotes the endoscopists to perform and assess technical skills in esd is developed. training tasks are built based on physics-based computational models of human anatomy with tumors. methods: the main modules of the vr-based simulator for colorectal esd involve: (1) rendering; (2) haptic interface; (3) physics-based simulation; and (4) performance recording and assessment metrics. the rendering engine allows surgical tasks to be performed in the three-dimensional virtual environment. haptic feedback mechanisms allow users to physically feel the interaction forces. physics-based simulation technologies are employed to enable the complicated simulation for performing virtual surgical tool-tissue interactions. the simulator can also collect learners' performance data to offer feedback based on the built-in metrics. results: four training tasks involving marking, injection solution, circumferential cutting, and submucosal dissection are designed to practice skills with different surgical tools. the marking task aims to identify the lesion. the injection solution task minimizes the risk of bleeding and perforation to protect the muscularis. in the circumferential cutting task, the objective is initial incision of the lesion with the surgical tools. the objective of the dissection task is to remove the tumor from the connective tissue of the submucosa under the lesion. conclusions: the vr-based simulator enables realistic esd tasks to provide a possibility for developing, validating and objectively evaluating the performance metrics in colorectal esd training, and offers an opportunity to rise up the learning curve before application to patients. background: the virtual translumenal endoscopic surgery trainer (vtest) simulator is a virtual reality system that was designed to train the hybrid-notes technique. transfer of skill acquired while training on the vtest was measured in a near-real cholecystectomy procedure staged in the easie-r model. methods: sixteen medical students were divided randomly and evenly into 2 groups: control, training. all subjects performed the cholecystectomy procedure on the vtest simulator to establish a baseline (pre-test). the training group received 15 training sessions, over a period of 3 consecutive weeks, consisting of 5 trials per session or as many trials as can be accomplished in one hour, whichever was achieved first. at the end of the training period, all subjects performed one trial on the vtest simulator (post-test), and again 2 to 3 weeks later (retention test). two months after that, subjects performed the hybrid-notes cholecystectomy procedure on an easie-r model. performance with the easie-r simulator was video-recorded, and three tasks within the cholecystectomy procedure were isolated for evaluation: clipping, cutting, and dissecting the gallbladder. objective performance measures, such as time and error, were extracted from the videos by two independent reviewers, while subjective performance was scored by four expert surgeons who were blinded to the training conditions. expert reviewers used a modified version of the operative performance rating system by the american board of surgery and the objective structured assessment of technical skills (osats) tool. results: there was no difference in task completion time between the control and training groups, (t(10)=1.045, p =.161) in the cutting and clipping tasks. however, there was a significant difference in the number of errors, t(10)=-1.847, p=.047. there was no difference in subjective performance between the training groups for the clipping and cutting tasks. in the gallbladder dissection task, however, there was a statistical significance in "instrument handling" based on one of the surgeons' ratings (t(14)=1.919, p=.03), and a statistical significance in "time and motion" based on another surgeon's rating (t(14)=2.118, p=.03). conclusions: results indicate that 3 weeks of training on the vtest simulator did not allow the subjects to transfer their learned skills equally to the near-real environment, even though they retained the skills when tested for retention. this new insight suggests that modification of the training method for different types of surgical skills may be warranted to optimize their transfer to the real environment. examining conclusions: this study provides evidence to suggest that for bariatric surgeons, experience and skills acquired in performing non-bariatric surgery may not translate to improved outcomes in bariatric surgery. as seen in this study, improvement in bariatric surgical outcomes is likely more dependent on experience specifically performing bariatric procedures. as there may be no benefit acquired from performing surrogate procedures, this may have implications in the design of subspecialty training programs and for accreditation purposes. . a universally adjustable cellphone holder was used where smartphones could be placed inside the fls box in order to capture the task from a similar angle as the onboard camera. residents were able to use their own smartphones to record their performance on each of the five fls tasks in high definition (hd) quality. after each practicing session, they would upload their videos to a designated folder on a password-protected computer in the simulation lab. this folder was linked to a cloud-based storage system that fls instructor had exclusive access. the faculty was able to review each video in the next 24 hours and provide immediate feedback to the residents via email, over the phone or in-person. the video library of performance also allowed the instructor to track the progress of the residents and whether they reached proficiency level in all five tasks to take the fls examination. this program was offered to all surgical trainees. results: utilization of simulation lab to practice fls tasks increased significantly across all postgraduate years after implementation of this model. six residents took the fls examination. the passing rate of the residents remained the same (100% before and after) but their scores in fls manual skills improved significantly compared to the group prior to implementation. the residents evaluated this change positively and reported that the use of videos and immediate feedback by faculty was a valuable intervention in their learning experience. conclusions: the smartphone cameras are readily available and can be used for telementoring. incorporation of telementoring in standard proficiency based fls training can promote self-directed learning and improve the access to experts for immediate feedback as a crucial element of effective training in acquisition of laparoscopic skills. background: it is important that making individual procedures a language, and an objective qualitative evaluation for the laproscopic training. recently, task training and the sham operation using the virtual simulator are carried out for medical students as the basic laparoscopic maneuver training, but there are few reports of objective qualitative evaluation for the training. in this study, we investigated rubric evaluation as the qualitative evaluation for laparoscopic training. materials and methods: one hundred and six students in 5th grade of tokushima univ. were participated. basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator were performed. task execution time and rubric evaluation which includes the evaluation standard that became a language for each maneuver were performed before and after basic task training and sham operation. the group who are bad at laparoscopic maneuver was decided by time exceeded in tasks more than two from before practice. relationship between the group who are bad at laparoscopic maneuver and the group which self-evaluation was higher in a rubric evaluation was investigated. results: in basic task training, average task execution time in all students was shortened after practice compared with before practice, but investigated individual, 6 students exceeded in more than two tasks. rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, all students and tutor showed high score by rubric evaluation after practice compared with before practice. some students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. students who showed high score by self-evaluation in many maneuver of sham laparoscopic cholecystectomy also exceeded in more than two basic tasks. conclusions: as rubric evaluation showed the point of the maneuver is made a language definitely, it was useful for an objective qualitative evaluation for laparoscopic training. pre introduction: bariatric surgery candidates have the opportunity to research bariatric surgeons and hospitals prior to scheduling their elective surgery. pre-operative information sessions are important tools for bariatric surgeons to provide patient education while increasing their patient population. online education is becoming increasingly popular, but its utility over in-person education is uncertain. our objective was to compare patients attending the two most commonly used educational formats: online (webinars) and in-person (seminars) and determine which were more likely to undergo bariatric surgery. methods: we conducted a retrospective cohort study of 2,700 patients who attended pre-operative information sessions from january 2014 to december 2016 by reviewing data maintained by the obesity, prevention, policy and management (oppm) database from our institution. the patients were divided into two groups: those who attended an in-person session (n=785) and those who attended an online session (n=1,915). the proportion of patients who went on to have bariatric surgery was compared between the two groups. to categorize the study sample, patient demographics, surgeon providing the information session, and procedure performed were compared between groups. multivariate logistic regression model was applied to compare the effectiveness of in-person session and online session. results: of 2,700 patients analyzed, 71% attended online information sessions (77% female, mean age 42). the remaining 29% attended in-person information sessions (73% female, mean age 46). analysis found that 21.1% of patients who attended online information sessions went on to have a bariatric surgical procedure, while 32.6% of patients who attended in-person sessions went on to have a bariatric surgical procedure. after controlling for differences in age and gender, results of multivariate logistic regression analysis indicate that patients who attended inperson sessions were 71% more likely to have a bariatric surgical procedure than patients who attended an online session ( introduction: knot security is the ability of knots to resist slippage as force is applied, and the optimal number of throws to ensure a secure knot improves efficiency and outcome. the literature on the accepted number of throws per type of suture material has been largely anecdotal, often referring to 3 throws for silk, 4 for polyglactin 910 (vicryl), five for polydioxanone (pds), and six for polyproprolene (prolene). we report a pilot knot-tying study of four suture types to determine optimal numbers of throws. materials and methods: four senior general surgery residents (pgy-5 and above) and four attending surgeons participated. participants viewed a standardized instructional video and a one-handed knot-tying tutorial. they were instructed to tie one-handed knots, beginning each knot with two throws in the same direction, and square the third and subsequent throws in the opposite direction. each surgeon tied 64 knots, using differenttypes of 2-0 suture material: silk, polyglactin, polydioxanone, and polyproprolene. suture types were evaluated using 3, 4, 5, or 6 throws. the participants were randomized to both suture type and order of throw numbers. the knots were then tested on the f.a.s. t knot tester (sawbones, vashon island, wa) for slippage (insecure knot) or breakage (secure knot). generalized estimating equation (gee) analysis was used to determine optimal throw number. results: 512 knots were individually tested on the knot tester for slippage and recorded as % slipped (see table) . the percentage of slipped knots varied by participant and ranged from 5 to 67%. generalized estimating equation analysis suggested that the only significant variable when determining knot security was number of throws (p=0.02), not suture type or participant training level. the optimal number of throws for 2-0 silk, polydioxanone, and polypropylene was five, whereas six throws was optimal for polyglactin. conclusion: knot security is dependent on the number of throws placed, and these optimal numbers were higher in our study than the commonly accepted number of throws. evaluation of take introduction: laparoscopic skills can be learned using portable simulators and these skills are transferrable to the operating room. several training regions within the uk have therefore developed and delivered home-based laparoscopic training programmes for junior surgical trainees. although performance improved in some, overall engagement has been poor. similar results have been observed in north america. the aim of our study was to uncover the reasons for poor engagement with home-based simulation with a view to developing a future, more successful, programme. methods: this was a qualitative study utilising focus groups. interviews were undertaken with key stakeholders involved in various laparoscopic home-based simulation programmes through the uk. training equipment comprised the eosim portable simulator paired with online training tasks. the tasks were similar to those used in the fundamentals of laparoscopic surgery programme (fls). basic metric feedback was provided (eg time to complete task). a total of 45 individuals were interviewed, including surgical trainees, consultant trainers, training directors and programme faculty. this generated approximately 7 hours of data which was coded using nvivo software. a basic thematic analysis was performed. results: trainees cited multiple competing professional commitments as a barrier to engaging with home-based simulation. they tended to focus on scoring 'points' which contributed toward career progression rather than tasks which were interesting, or associated with personal development. this approach is perpetuated by the surgical training system, which rewards trainees with points for publications and exams, but not for operative skill. this leads to conflict between trainers and trainees, the former expecting trainees to instead focus upon developing their technical abilities. trainees were unsatisfied with metric feedback and wanted individual feedback from consultant trainers (attending equivalent). trainees generally perceived consultants as lacking interest toward the programmes and training in general. however, some consultants were in fact unaware of the programmes being delivered and others felt lacking in confidence to deliver necessary training to trainees. conclusions: our findings are widely generalizable and have implications for any institution delivering a similar programme. as a means of improving engagement, the the inception of scheduled simulation study days, providing trainees with the opportunity for personalised feedback from consultants, has been suggested. equipping trainers with the necessary competencies to deliver training can be achieved by ensuring attendance at the necessary professional development courses. tackling the 'box ticking' culture is more challenging and may involve a move toward restructuring the current surgical training scheme. introduction: to provide evidence for the face and content validity of a hybrid active-shooter team training simulation and the impact of a hybrid curricular model on learner's engagement and performance. the following study was conducted because hospitals are increasingly threatened by active-shooter incidents, and no active and noticeable training is currently available to train hospital staff members. methods: thirty-five volunteers (medical students, residents and other allied health providers) from the university of minnesota affiliated medical centers were randomly selected and divided into control and experimental groups. the control group (n=14) was given a traditional lecture-style presentation. the experimental group (n=21) participated in the hybrid curriculum which included augmented reality, kinesthetic simulation, and debriefing components. following both curriculum styles, nasa task load index (tlx) surveys were completed by each group member. a final active shooter simulation experience was presented and evaluated by active-shooter trained raters using a checklist of critical actions from the department of defense. a post-simulation nasa tlx survey and post-test were provided. to assess face and content validation of a hybrid team-training simulation exercise to prepare healthcare personnel in the event of a hospital-related active-shooter crisis, a 5-point likert-scale survey determined the realism, utility, and applicability of this type of training while engagement and performance during the simulation were measured using a nasa-tlx survey and contrasted with the rater's evaluation. our study provided evidence to support the face and content validation of an active-shooter simulation team training curriculum as a useful adjunct to health care institutional safety planning. we demonstrated that this type of training requires an optimal level of cognitive activation to increases learner's engagement and performance. we concluded that the hybrid design of our curriculum was successful in delivering these optimal levels of cognitive stimuli by producing engaging team training simulation experience capable of motivating our learners to acquire the tactical skills and life-preserving behaviors consistent with better survival opportunities during a hospital related active-shooter crisis. the introduction: the virtual electrosurgical skill trainer (vest) provides surgeons and trainees with a hands-on approach to learning the best practices in electrosurgery. it is comprised of five modules covering tissue effects, stray currents, bipolar tools, monopolar tools and or fire safety. the module in this study teaches the origins of stray currents and shows the learner how they can cause damage to non-target tissues via direct and capacitive coupling. the aim of this study was to assess learning using the vest system. methods: the irb approved study followed a single group pretest-posttest design and was conducted at the sages 2017 learning center. thirty-eight subjects participated and out of these, 42% were attending surgeons while the rest were medical students, residents and fellows. 37% of subjects had prior fuse exposure, while the remaining had none. subjects were asked to complete a five-question multiple choice questionnaire before and after using the simulator. it assessed their knowledge in topics such as direct coupling, capacitive coupling and insulation failure. participants then used the simulator to complete three tasks. first, the subject used direct coupling to seal a vessel and observed the desired effects and potential pitfalls. in the second task the subject was immersed inside the peritoneal cavity and was directed to use the active electrode to observe how the activation of energy can cause capacitive coupling. in the third task the subject practiced evaluating the insulation of electrosurgical tools for defects. wilcoxon's signed rank test was used to differentiate between pre-and post-test scores, and the mann-whitney u test was used to differentiate between the groups of subjects as a function of fuse experience. results: the median score on the pre-simulator assessment was 60% and the post-simulator median score was 80% (p =0.035). there was no statistically significant difference in pre-assessment scores between attending surgeons and the others (p=0.148). subjects with prior fuse exposure scored significantly higher on the pre-module assessment compared to those that had no prior fuse exposure (80% vs 40%, p=0.024). in the post-assessment their median scores were 80% and 60%, respectively (p=0.019). conclusions: the vest simulator module successfully increased the overall participants' knowledge of coupling in electrosurgery regardless of level of surgical experience. participants with prior exposure to the fuse curriculum had increased knowledge on this topic at baseline as compared to participants without any fuse exposure. introduction: the objective of this study was to assess the reliability of a modified notechs rating scale for the evaluation of medical students' non-technical (nt) skills. the importance of physician nt skills for the safe care of patients is receiving increasing attention in the literature. tools to assess nt skills such as notechs that addresses communication, situation awareness, cooperation, leadership, and decision-making have been shown to be valid and reliable. despite its importance, the assessment of nt skills of medical students, our future physicians, has received little attention. methods and procedures: twenty-seven medical students participated in 1 of 6 acute care simulated scenarios, each approximately 10 minutes long. video recordings of student performance were reviewed and assessed using a modified notechs rating tool adapted for these scenarios with input from a team of clinicians, nurses, and human factors specialists. the rating scale ranged from 0 to 6, 0 representing very problematic behavior (e.g., not vocalizing concerns or decision process) and 6 representing model behavior (e.g., identifies future problems and remains calm to unexpected events). two reviewers rated all videos independently on the 5 notechs domains and specific subscales. student scores in each nt skill domain and interrater reliability were assessed. results: a summary of the scores of each notechs domain is shown in table 1 . the highest overall average score of a participant was 4.9 while the lowest was 1.5. the intra-class correlation (icc; two-way random model) was 0.66, and the cronbach's α coefficient was [0.62. the lowest icc agreement was in the situation awareness domain (0.59) while the highest agreement was in leadership (0.73). conclusion: medical student nt skills during acute care simulated scenarios vary significantly using a modified notechs assessment. this newly developed tool provides a framework for educators to evaluate medical students' nt skills during simulation training. it further identified domains where students scored lower, such as situation awareness, and could be targeted for education. the moderate icc, between the 0.5-0.75 range, shows that further refinement of the tool is needed to reliably assess the constructs. future steps to obtain validity evidence include additional raters and applying the tool in non-simulated settings. introduction: a general misperception of the real concept of robotic surgery seems to be revealed in our clinical practice. despite its introduction almost years ago, robotic surgery is still related to many myths and beliefs. before designing a trial to see if these false awareness could impact on outcome, we measured this misperception by a survey. moreover we tested if medical school is able today to give to the future doctors a necessary knowledge about robotic surgery. with the same survey we explore the feelings about the introduction of the artificial intelligence in medicine and the perception of the consequences of a larger use of technology in medicine. methods and procedures: a multiple choice survey was designed and anonymously administered via the platform surveymonkey (http://www.surveymonkey.com). a total of 55 questions were selected from the research team and included in the survey. the questionnaire was divided in three parts: the first was to get information on participants' population; the second asked specific questions about robotic surgery; the third focused on technology use in medical education. results: we received and analyzed 81 questionnaires, 70 of which totally filled. many undergraduates consider robotic surgery as "experimental", will prefer open surgery on themselves and see a risk for robotic surgery in damaging the patient-surgeon relationship. this situation is better for medical students, but still a great diffidence were encountered. 25% of ug consider robotic surgery as "experimental" vs only 2.7% of ms (q22). most thought robotic surgery had been used for only 10 years or less (q23). 12.12% of ug and 32.43% of ms gave the right answer (p=.03). almost 66% of ug see robotic surgery as a risk in damaging the patient-surgeon relationship. this is not seen among ms (q29) (p=.007). 40% of ug are fearful of robots used to operate them. this fear is significantly reduced among medical students (p=.05). ug were less familiar with the indications and uses for robotics. ms gave a correct response more frequently (q31, 15.15% vs 37.84%, p=0.04). conclusions: our results indicates that nowadays, the robotic surgery is related a lot of misperceptions and a generally low level of information. this general picture is partially mitigated during the medical school, but the level of knowledge is still low. a big effort seems mandatory in clarify every technical aspect and an ethic debate about robotics, technology and ai as part of medical curriculum is advisable. background: learning theory states that a certain level of physiological stress or cognitive activation is required to achieve optimal task engagement and performance by the learners. our study will seek to determine if a hybrid team training curriculum inclusive of a task-oriented interactive virtual environment could help achieve the optimal level of cognitive activation required to result in a higher task engagement and performance. methods: a total of thirty-five medical professionals from the university of minnesota participated in several team training simulations. participants were randomly selected to an experimental and control groups. the experimental group (n=21) was exposed to a hybrid team training module, consisting of a task-oriented augmented reality phase followed by a second and third phase consisting of a kinesthetic simulation scenario and debriefing, respectively. the augmented reality phase presented the trainees to an interactive 360-degree image of the same clinical room where the simulation would take place allowing for ''situated-learning'' to take place. during the learning phase, trainees were encouraged to interact and communicate with each other while completing the tasks allowing for ''social-learning'' to effect. the control group (n=14), educational component consisted of a traditional audiovisual lecture-style introductory presentation, a simulation, and debriefing. after completing their respective educational components, each group completed a nasa task load index survey to assess the cognitive load experience of the individual educational models. subjects were then exposed to a final simulation (test simulation) similar in content and structure to the initial simulation. this was followed by a second nasa tlx survey. raters evaluated both group level of engagement and performance using a validated checklist of critical actions. results: the experimental groups showed higher weighted overall nasa cognitive load index scores than the control group (p=0.0029) prior to the test simulation. the weighted nasa score remained elevated in the experimental participant groups following the test simulation, whereas in the control group the post-simulation nasa assessment revealed a decrease in cognitive load (p=0.0079). expert raters using a validated checklist determined that 93.75± 6.250% of the experimental (hybrid curriculum) group and 37.50±7.217% of the control group appeared to be more engaged and performed better during the simulation. conclusions: pre-simulation task-oriented augmented reality learning environments designed to incorporate situated, and social learning virtual experiences can provide the optimal level of cognitive boost that can result in a higher participant engagement and performance during team training simulation scenarios. introduction: despite the huge importance of laparoscopy, medical students have a brief contact with this surgical specialty during medical school in brazil. usually, they get in touch with this specialty during the surgery clerkship in the last years of medical school. therefore, few students perform clinical research or develop interest for this area during graduation. objective: to awaken the interest in laparoscopy of medical students early in medical school, improving the development of clinical research projects, and to prepare new generations of minimally invasive surgeons. discussion: the academic league of videolaparoscopy was created in 2010 under the guidance of dr. gustavo carvalho from the university of pernambuco, brazil. an academic league is a group of medical students who are guided by a tutor to develop three areas: research, teaching, and clinical practice. every year new students join the league after being selected with a multiple question test and an analysis of the curriculum vitae. the students are stimulated to participate in laparoscopic procedures as observers, learning about the techniques and instruments. moreover, there are minimally invasive surgery lectures and courses during the year. general surgery residents can also be part of the program as tutors. they are encouraged to present lectures, and to assist with research projects. 50 medical students participated of this program in 7 years. 50% pursued a surgical specialty after graduation. 30% did minimally invasive surgery as a fellowship. conclusions: the students who participate in several activities provided by the league have an increased interest in pursuing the path to become a laparoscopic surgeon. background: surgical education is an active and adaptive process of developing knowledge, technical and non-technical skills. the rise of social media has created a paradigm shift in surgical education, with online learning platforms offering exposure to real-time content, expert instruction, and global collaboration. while these disruptive technologies evolve, their influence on surgical education has not been investigated. our goal was to evaluate the growth and impact of an online surgical education model-the advances in surgery (ais) channel. our hypothesis was that utilization and engagement with the platform continues to grow, providing novel methods of measuring successful education. methods: assessment of the platform's membership demographic, user activity, and engagement was performed from inception in 2013 to quarter 2 2017. the ais channel uniquely provides free, high quality, innovative content from elite surgeons in scheduled and continuously available formats across colorectal, bariatric and endocrine surgery service lines. users login to access content, with demographics, time spent, and content accessed recorded as measures of active account utilization and engagement. the main outcome measures were overall membership trends, utilization patterns by region, content type, and surgical specialty for the platform. results: users were predominately male (81.2%), surgeons (92.9%), and ranged in age from 47 to 56 years (24.6%). the main surgical subspecialty represented was colorectal (52.6%). active account usage/weekly recurrence was 60.1% (10% industry benchmark), with users engaged for a mean 32 minutes/session (excluding live events). since inception, steady exponential growth was seen across several dimensions. registered users and unique ip addresses increased from over 3,000 and 190,128 in 2013 to over 43,000 and 2.1 million in 2017, respectively. the number of countries represented increased to reach 183 across 6 continents. at present, over 76 live surgeries and 16 live congresses have been broadcast from 26 countries, with over 2,000 surgical videos available on demand to facilitate surgical education. the greatest engagement is seen with live surgical broadcasts. conclusion: our analysis demonstrated proof of concept for a unique, online surgical education model to provide effective surgical education. success was validated through the increase in overall users, sustained active account usage, and global penetration. user preferences for live surgical broadcasts were seen. knowing the utilization and preference patterns, the platform can continue to evolve and enhance the learners' experience. with this growth and penetrance, there is the potential to globally improve patient outcomes and the quality of care provided. background: a realistic simulator for transabdominal preperitoneal (tapp) inguinal hernia repair would enhance the surgeons' training experience before they enter the operating theater. the purpose of this study was to evaluate the efficacy of 3d-printed tapp simulator in evaluating preoperative skill before entering operative theater. methods: 15 surgeons in our institution were enrolled in this study. they performed simulation tapp and the performance score was measured using tapp check list. the tapp simulator allows for the performance of all procedures required in tapp. the correlation between post -graduate years (pgys), age, experienced a number of laparoscopic surgery (more than 100, less than 100), experienced number of tapp and the performance score was evaluated. results: strong correlation between experienced member of tapp inguinal hernia repair and the performance score was evaluated in this study (r=0.705). however, the correlation between pgy, age and score was weak ( introduction: as the field of laparoscopic surgery grows, the need for standard measures of complex laparoscopic surgical skills is apparent. fundamentals of laparoscopic skills (fls) testing is required to complete general surgery residency, but there is no standard metric to convey expertise in advanced laparoscopic procedures. in an effort to develop a standardized assessment of laparoscopic suturing expertise, a group of experts was surveyed using delphi methodology to reach consensus on observed laparoscopic suturing skills reflective of performing at an expert level. methods: expert laparoscopic surgeons participated in serial surveys via redcap (research electronic data capture). experts included surgeons who perform[25/year laparoscopic procedures that involve intra-corporeal suturing, obtained from the authors' personal and professions networks. using a 5 point likert scale, participants were asked to agree/disagree if 30 different observed laparoscopic suturing skills indicate performing at an expert level. these skills were chosen from prior assessment instruments in the literature and the authors' previously published work. tasks were considered to meet criteria for consensus and eliminated from the next round of the survey after reaching 80% consensus as "strongly agree." results of the previous round of surveys were shared with participants at the start of the next round. the predefined endpoint for the delphi was set as maximum of 4 rounds, reaching 80% consensus on each skill, or if[50% of initial respondents fail to return for subsequent surveys. results: after the first round of the delphi survey, 17 respondents met inclusion criteria. preliminary data demonstrated 4 skills that reached consensus ([80% of respondents chose "strongly agree"): forehand suturing, avoiding tissue trauma, having a technically acceptable final product (ie. tight closure), and tying a secure knot at the end of suturing. 4 items did not approach consensus (\80% of respondents chose "strongly agree" or "agree"): alternating hands for each throw while tying, never missing a target when grabbing needle/suture, alternating direction of throws when tying, and backhand suturing. data from all four rounds of surveys as well as the final draft of the assessment instrument will be available at time of presentation. conclusion: preliminary data of this delphi study allowed us to reach consensus amongst a group of expert laparoscopic surgeons on the characteristics of expert laparoscopic suturing, which will allow creation of a comprehensive assessment tool for this domain. validation of such a tool will help advance the surgical field towards true competency-based credentialing and promotion. the study was designed to assess the knowledge of scp among european surgeons (specialists and residents). additionally, surgeons' opinion on usefulness of each of the rules of scp was gathered. the data were analyzed in terms of differences between residents and specialists. this is to set ground for and an educational program and increase the safety of elective laparoscopic cholecystectomy by minimizing the occurrence of cbdi. methods: the data on the knowledge of scp and opinion on usefulness of its rules were gathered in form of an anonymous questionnaire distributed among participants of several surgical conferences in poland. the questionnaire then asked about the surgeon's experience in terms of cholecystectomies performed and the number of complications in form of cbdi. it then listed the scp rules and asked the surgeon about their opinion on usefulness of each of the rules on a 10-point scale. gathered data were subject to statistical analysis and a comparison between specialists and residents was performed. the study has been registered in the clinicaltrials.gov-nct03155321. , although these numbers are still low. significant differences in the mean usefulness score between residents and specialists were observed in regard to two rules: rule 2 was found more useful by residents (mean score 7,07 vs.6,01, p=0.008), whereas rule 3 was found more useful by specialists (mean 8.74 vs.8.36, p=0.009). the awareness of the sages safe cholecystectomy program in poland is still low and needs to be promoted. both surgical residents and specialists consider the rules of scp to be useful during surgery, although there are slight differences in the usefulness scores between the groups. an educational program to promote and further implement the scp should be established. introduction: transanal total mesorectal excision (tatme) has attracted substantial interest amongst colorectal surgeons throughout the world. technical challenges of the technique however have been acknowledged by early adopters and this may underpin the early reports of visceral injuries which occurred during the perineal phase. evidence from previous surgical training programs suggest that a structured proctorship programme can shorten the learning curve, operative time and most importantly reduce major complications. the aim of this study was to report on the first national pilot training initiative which was developed in the uk to ensure safe introduction of this technique. methods: a pilot training programme for the uk has been established in partnership with the healthcare industry, and supported by the association of coloproctology of great britain and ireland. the programme consists of three phases: (i) development of a consensus process on the optimum training curriculum of tatme from all relevant stakeholders, including experts, early adopters, and potential learners, to guide the training of this technique (ii) piloting of this training curriculum and (iii) assessment and quality assurance mechanisms to monitor training and measure outcomes. results: a cohesive multi-modal training curriculum has been developed providing clear guidance on case selection, supporting multi-disciplinary and multimodal training including online modules, dry-lab, purse-string simulators, cadaveric training and formal clinical proctoring programme. the uk pilot programme opened for applications in may 2017 and, after a rigorous selection process, the initiative was launched in september 2017 with 10 trainers mentoring 10 consultant colorectal surgeons from five centres. the selection of learners was based on suitable case volume and prior experience in laparoscopic rectal surgery. objective assessment tools were applied to an unedited video of a laparoscopic rectal surgery case for each applicant. for the selected centres, access to the ilapp tatme app was provided to access educational content including operative video footage, prior to attending a bespoke cadaveric workshop. each learner will then benefit from a structured, centrally organised and funded proctorship programme at their own institutions. a global assessment score form has been specifically designed to monitor training and a formal accreditation process will be used to sign off each learner using competency assessment tool. data on the cadaveric workshop and initial outcomes of the clinical mentorship will be presented at the conference. conclusion: a competency-based pilot training programme for transanal total mesorectal excision has been launched in the uk to support safe introduction of this technique. practicing on a fls trainer box is effective but requires large amount of consumables and is scored subjectively. the purpose of this study is to evaluate the face validity of the intracorporeal suturing task on a virtual fundamentals of laparoscopic surgery simulator (virtual fls). we hypothesize that the virtual fls will demonstrate face validity. methods and procedures: after a video demonstration and a practice period, twenty-three medical students and residents completed an evaluation of the simulator. the participants were asked to perform the standard intracorporeal suturing task on each of the virtual fls and the traditional fls box trainer. the presentation order of the devices was balanced. the performance scores on each device were calculated based on time (seconds), deviations to the black dots (mm), and incision gap (mm). the participants were then asked to finish a 13-question questionnaire regarding the face validity of the simulator. participants answered questions with ratings from 1 (not realistic/useful) to 5 (very realistic/ useful). a wilcoxon signed ranks test was performed to identify differences in performance on the virtual fls compared to the traditional fls box trainer. results: responses to 10 of the 13 questions (76.9%) averaged above a 3.0 out of 5. those questions that rated the highest were the degree of realism of the target objects in the virtual fls compared to the fls (3.87) presently, most training methods for thoracoscopic esophagectomy use live porcines; this presents several problems including cost, long preparation times, and ethical issues. these problems further prevent frequent training. currently, no alternative models for thoracocopic esophagectomy training. we report, for the first time, the development and use of a non-biomaterial training model for thoracoscopic esophagectomy. methods: we collaborated with sunarrow co., ltd. (tokyo, japan) to develop the training model. we created organ models for esophagus, trachea, bronchus, aorta, vagus nerve, recurrent nerve, bronchial artery, lymph node, vertebrae, azygos vein, and thoracic duct, and filled the models with a polyvinyl alcohol hydrogel. the gaps between organs were filled with a filler material mimicking connective tissue. we chose a synthetic resin that closely mimics the characteristics (rigidity or elasticity) of each organ. after each organ was fixed, the model was covered with a filler to create a pleural membrane to allow training in peeling operations. in addition, because a patient plate was attached to the rear of the training model, excision with an energy device was possible and more closely simulated surgical conditions. results: using the training model resulted in a highly satisfactory level of experience in three trainees. the trainees were able to learn anatomical positions and sequence of surgical procedures, including endoscope handling. 3 centre for rural health, aberdeen university introduction: as doctors become expert in a complex procedure, they develop automatic nuances of performance that are difficult to explain to a peer or a trainee (so called 'unconscious competence'). traditional methods which aim to allow sharing of expertise have limitations: concurrent reporting alters the flow of the task at hand while retrospective reporting is subject to bias and often incomplete. iview expert is a technique validated in the aerospace domain which externalises an expert's cognitive processes, without disrupting the task at hand. the aim of this project is to assess the feasibility of adapting the technique to medical training. methods: this was an observational case study in which an expert endoscopist wore a head mounted camera to capture a complex procedure (colonoscopy). captured video was reviewed during a facilitated debrief which externalised the expert's cognitive processes. the debrief was recorded and formed an audio commentary. the video and accompanying audio commentary formed a learning package which was watched by a specialty trainee. the technique differs from standard procedural videos in that it provides a more detailed insight into cognitive processes of the expert. this is achieved through the debrief, which encourages reflection upon kinaesthetic (head movement) as well as auditory and visual cues, resulting in a higher level of experiential immersion. questionnaires examined acceptability and educational value of the technique using likert scales and free text answers. quantitative data were presented using basic descriptions in terms of agreement with statements. qualitative data from free text responses were coded in order to identify key themes. results: the expert agreed that wearing the camera was acceptable and did not interfere with the procedure, nor usual decision making processes. qualitative analysis revealed the debrief process to be associated with a high level of experiential immersion: "as if they were there". both the expert and the trainee strongly agreed that the process was educationally valuable and that they learned something new. qualitative analysis demonstrated that the technique revealed useful and unique nuances of the procedure. the intervention could represent a powerful adjunct to existing training methods, especially amongst more experienced practitioners. we are currently undertaking a larger study involving a greater range of procedures with more learners. introduction: endoscopy is an important skill for general surgeons to possess. however, there is lack of training within surgery residency programs. we implemented a one-day endoscopic surgery course with the aim of improving the confidence of surgical residents in performing endoscopic procedures. we also aimed to examine the effect of the exposure to this course on self-reported confidence in performing endoscopic procedures. methods and procedures: the fundamental of endoscopic surgery course at texas tech university health science center is a one-day course consisting of both didactic training and lab training. the didactic part of the course is taught by attending physicians and focuses on the basics of endoscopy, management of upper and lower gastrointestinal (gi) bleed, and techniques to perform a variety of gi endoscopic procedures on swine esophagus and stomach explant. the lab portion of the course allows residents to perform different endoscopic surgical procedures with the attending physicians providing guidance. residents from pgy-1 to pgy-5 participated in the course. a 14-item questionnaire that measured the self-reported confidence in performing several endoscopic procedures on a 1-5 likert scale was administered before and after the course. results: twenty-two participants successfully completed the training and the questionnaires. a significant improvement was observed in the overall confidence in performing a variety of endoscopic procedures (1.231±0.384, p.001). the improvements remained significant even after controlling for the years of postgraduate surgical training (p.001). conclusion: the one-day fundamental of endoscopic surgery course enabled residents to be more confident with endoscopic procedures. overall, the residents felt that the course was helpful and would like to attend more than one session per year. this course should be held, at least, annually to allow the general surgery residents to become even more confident with this important skill. by being more confident in their surgical endoscopy skills, they will ultimately be able to provide better care for patients. introduction: a course evaluation study on the effectiveness of improving laparoscopic skills of surgical residents using swine models was evaluated through a self-report questionnaire administered before and after course completion. the purpose of the training is to provide surgical residents opportunities to practice and advance their laparoscopic proficiencies. methods and procedures: participating residents in all post-graduate year levels (pgy1 through pgy5, n=17) were provided anesthetized pigs with which to perform a variety of simple to complex laparoscopic cases. prior to training, residents were given a questionnaire composed of eleven questions requiring the subjects to rate their confidence in performing various laparoscopic procedures on a 1-5 likert scale. after completion of the course, an identical questionnaire was distributed with two additional questions relating to the overall impact of the course. all statistical analyses were conducted using r statistical software (version 3. conclusion: overall, one-day hands-on training using swine models improved resident's skills, confidence, and understanding of laparoscopic surgery. the information acquired through the questionnaire emphasized the importance of providing a laparoscopic training course as a standard requirement at all medical institutions. allowing opportunities for surgical residents to practice their laparoscopic skillset will not only help in their individual academic advancements, it will allow them to provide optimum care for their patients. background: learning laparoscopy is difficult and many educational tools including simulation training are required. feedback plays a crucial role for motor skill training but require expert tutors and its time consuming. e-learning increases knowledge acquisition through a more interacting multimedia experience and reduces de costs of learning. in the last decade multiple applications (apps) have been developed for mobile medical training. a new ios app was developed using specially designed educational videos that explain the main technical aspects in advanced laparoscopy through simulation training. the aim of this study is to present the first results of its incorporation in a surgical simulation lab as a complement of effective feedback. methods: twenty-five consecutive residents were trained in our simulation lab through a 15 session validated training program for the acquisition of advanced laparoscopic skills needed for the performance of a laparoscopic hand-sewn jejuno-jejunostomy. every session had written instructions and a basic tutorial video. the app consist two main sections, the first one explains the essential techniques needed for intracorporeal suturing and the second is a complete walkthrough of the validated training program. the trainees were divided in two groups, the first was trained without using the app (napp) and the second group was trained using the app (yapp). both groups of trainees could ask for feedback anytime they needed. trainees were assessed before and after the training program using validated rating scales and the number of necessary tutor-feedback sessions were registered. finally the yapp group answered a survey about the strengths and weaknesses of the app for learning advanced laparoscopic skills. results: twenty-five residents completed the training program; 15 yapp and 10 napp. both groups finalized their training with no statistical significant differences in their scores (p:0.32). the number of tutor-feedback needed to complete the training in the yapp vs napp was of [4 (3-6) vs 13 (10-14) (p.001)] respectively. in the questionnaire all participants considered that the app was effective for learning advanced laparoscopy. over 4000 downloads have been registered since the app was published in the apple app store in 2013. we present a novel smartphone app that guides laparoscopic training using simulation-based educational videos with very good results. the use of app guided learning reduces de need of expert tutor feedback reducing the costs of simulated training. jemin choi, young-il choi; kosin university gospel hospital purpose: laparoscopic appendectomy (la) has been widely performed for acute appendicitis. in addition, minimally invasive surgery such as la is common surgical technique to the surgical residents. however, single incision laparoscopic surgery (sils) is a challenge to inexperienced surgical residents. we described our initial experience in teaching sils procedure for appendectomy in our medical center. methods: twenty nine cases of single incision laparoscopic appendectomy (sila) were performed by single surgical resident and 110 cases of la were performed by 4 surgical residents and 5 boardcertified surgeons. a study was reviewed retrospectively. (4) clinical stressors (i.e., vitals of patient coding). we developed a stress simulator testbed by integrating an fls box trainer with a linux computer, running custom c++ code. the code generated various stressor conditions, while recording sensor data from the trainer and human operator. we tested 3 groups of participants in an irb approved trial including: novices (non-medical students), intermediates (medical students), and experts (pgy4 residents and fellows). the study consisted of subjects performing the peg transfer and the pattern cut six times (baseline, four randomized stressors, posttest). after each task, the nasa-tlx survey was administered to determine the overall workload of that stressor condition. an analysis of variance was conducted to identify significant trends in terms of stressor type. results: when compared to baseline nasa-tlx scores, the intermediate group had the greatest changes in overall workload than novices and experts (p=0.0005). additionally, the change between baseline and post-test workload was significantly lower than for the environmental, negative evaluative, and clinical stressors (p=0.0006). for pattern cutting, subjects reported a significantly lower perception of failure (p=0.0479) in both the positive evaluative (mean=8.5556) and post-test conditions (mean=8.222), yet, though not statistically significant (p=0.0564), the measured accuracy in the task during the positive evaluative condition was actually worse (33.3%), second only to the pre-test accuracy (31.1%). the best accuracy for pattern cutting across all expertise levels was 62% for the post-test followed by 54.4% in the negative evaluative condition. these results are interesting as they show that despite perceived improvements in performance with a positive feedback condition, performance actually degrades and is better in the negative feedback condition, which is perceived to be more difficult. these results were not found in the peg transfer task, which is arguably an easier task. conclusion: from the evidence gathered in the study, it is clear that there is a correlation between distractors and performance. further analysis is needed to identify the relationship between the type of stressor, and inherent difficulty of the tasks, in terms of which type of stressor best improves learning and outcomes. surg endosc (2018) each received credentials to perform diagnostic and therapeutic ercp from their respective hospitals in nevada, minnesota, and idaho. one continues to teach ercp to general surgery residents, and another taught the skill to fellows in an advanced endoscopy fellowship. all three continue to use ercp in their practice (2 to 5 times per month), as they each specialized in a field that utilizes ercp routinely. choledocholothiaisis is the most frequent indication, though ercp is also performed for iatrogenic biliary duct leaks, traumatic biliary or pancreatic duct leaks, chronic pancreatitis, and malignancy. conclusions: training in esophagogastroduodenoscopy and colonoscopy is required for general surgery residents, but the addition of ercp to select residents' training enables them to completely manage their patients' surgical disease. the training of select general surgery residents in this skill has been successful, evidenced by the continued use of ercp in the practices of three residents who completed this training program at our institution. the decision to train residents in this skill should be left to individual program directors and department chairs. we recommend that residents selected for this additional training should plan to practice in specialties where ercp can be implemented. conclusion: same-day discharge after nissen fundoplication and hiatal hernia repair is feasible for select patients. one major challenge for same day discharge is the current insurance provisions required for hospital reimbursement. within the parameters of this study, bmi and asa score did not differ between discharged and admitted patients, while older age and increased procedure duration were associated with need for admission. premkumar anandan, ms, facs; bangalore medical college and research institute introduction: minimal access surgery is an imperative element of enhanced recovery program and has significantly improved the outcomes. enhanced recovery program (erp) synonym "fast track" surgery "was first conceived by dr henrich kelhet. largely described for colorectal surgery and reported to be feasible and useful for maintaining physiological function and smooth the progress of recovery. most of the patients who present for surgical emergency are not adequately prepared and many are not in normal physiological state. the feasibility of enhanced recovery programs protocol in such emergency minimal access surgery remains indistinct. this study was designed to validate an enhanced recovery program in patients who undergo emergency minimal access surgery. introduction: pathways for enhanced recovery after surgery (eras) have been shown to improve length of stay and postoperative complication rates across various surgical fields, however there is a relative lack of evidence-based studies in bariatric surgery. the objective of the current study was to determine if starting a bariatric full liquid diet on postoperative day (pod) zero was associated with shorter length of stay (los) for patients who underwent laparoscopic sleeve gastrectomy (lsg) or roux-en-y gastric bypass (rygb). methods: retrospective review of a prospectively collected dataset was conducted at a single institution before and after implementation of a new diet protocol for lsg and rygb. postoperative diet orders were changed from full liquid diet on pod 1 to pod 0. length of stay and 30-day readmissions were reviewed from june 2016 to august 2017. independent samples t-tests were used to compare continuous variables and chi-squared tests for categorical variables before and after diet change was implemented. patients were excluded if they were undergoing revision surgery, were discharged directly from pacu, or had significant intraoperative complications or required reoperation within the same admission. introduction: data suggests value in using tap (transversus abdominis plane) neural blockade in abdominal surgical procedures. we deploy tap blockade using liposomal bupivacaine via ultrasound (us) as part of a narcotic sparing pain management pathway for patients undergoing abdominal surgery in our rural community setting. our goal was to evaluate adequacy of postoperative discomfort and the success in avoiding narcotic usage. methods and procedures: records of patients undergoing abdominal surgical procedures performed by one surgeon over an 18 month period were reviewed under irb approval. patients taking narcotics prior to the procedure (except for discomfort due to the condition being surgically treated) were excluded from analysis, as were those admitted to the hospital for postoperative treatment. us guided lateral tap blocks were performed by the surgeon using 266 mg of liposomal bupivacaine and 50 mg of bupivacaine in the or prior to the incision. unilateral block was performed for unilateral procedures (e.g. inguinal hernia) and bilateral for laparoscopic or midline procedures. incisional sites were treated with a field block of 50 mg of bupivacaine. prescriptions for medications included 1,000 mg of acetaminophen qid and 220 mg of naproxen sodium tid for 7 days. a prescription for tramadol (50 to 100 mg prn up to 4 times daily; 40 tablets with no refill) was given. patients were seen in followup two weeks postoperatively. data (following standard scales/metrics) for patient-reported-outcomes e.g. pain, nausea-vomiting, & fatigue will be analyzed with the above data and the analysis with conclusions will be presented & discussed. federico sertic, md, ashwin gojanur, dr, ahmed hammad, md; guy's and st thomas' hospital introduction: the aim of this project is to assess the quality of post-operative pain relief in colorectal surgery and identify patients in whom pain management has not been effective, in order to improve the quality of post-operative care. effective management of post-operative pain has long been recognised as important in improving the post-operative experience, reducing complications and promoting early discharge from hospital. standards: all patients should be pain free at rest, 100% of elective patients should be told about what analgesia they will have post-operatively, 100% of patients should be satisfied with their pain management and 100% of patients should feel staff did everything they could to control their pain. methods and procedures: questionnaires were given to 20 patients on the day prior to discharge. 13 questions about pre-operative and post-operative pain experience were asked. data regarding post-operative analgesia were collected from medication charts and medical notes. data were collected over a period of two months (august/september 2017). range of procedures: 4 elective laparoscopic abdomino-perineal-excision-of-rectum with igap flaps, 1 elective laparoscopic right hemicholectomy, 7 laparotomy+bowel resection/stoma formation (5 elective, 2 emergency), 1 elective repair of parastomal hernia, 5 appendicectomy (2 laparoscopic elective, 2 laparoscopic emergency, 1 laparotomy emergency) and 2 elective reversal of ileosomy. pain scores (1-10): immediately post-operative pain, day 1 post-operative pain, post-operative pain after day 1 and pain on moving/coughing/straining. results: mean immediate post-operative pain score was 4.0 (10% of patients with score 8+), mean day 1 post-operative pain score was 4.8, mean post-operative pain score after day 1 was 4.25, mean pain score on moving was 6.2 (30% of patients with score 8+), mean pain score on coughing/ straining was 6.8 (30% of patients with score 8+). 90% of patients were satisfied with their post-operative pain management and felt that the staff had done everything they could to manage their pain. 25% of patients were not aware of their post-operative analgesia regimen and 50% did not know how regularly they could request analgesia. conclusions: effective management of post-operative pain is a key part of post-operative care and an important component of enhanced recovery programmes. patient satisfaction with pain management has been found to correlate with received pre-operative information. increasing ward nurses' and acute pain teams' knowledge is important in improving patients' pain experiences. interestingly, those patients who had a background of long-term opioid requirements reported that they were satisfied with their pain management. methods and procedures: a patient undergoing a standard ultrasound guided ql3 block by an anesthesiologist established the baseline anticipated response, and procedure time. the procedure, performed under sedation preoperatively, required over 60 minutes. for this study, patients undergoing laparoscopic colorectal surgery were administered a lateral ql block (modified ql 1) under ultrasound guidance by the operating surgeon. 40 ml of a mixture (10 ml injectable liposomal bupivacaine suspension, 15 ml 0.25% bupivacaine hydrochloride and 15 ml normal saline) was injected bilaterally, after induction, skin preparation, draping, and prior to the operation. postoperative narcotic use and pain vas scores were documented. results: six patients were administered a bi-lateral ql block intraoperatively. procedures were: 3 laparoscopic sigmoid colectomies, one end ileostomy reversal, laparoscopic completion proctectomy with ileal pouch anal anastomosis, and a laparoscopic descending colectomy. of the narcotic naïve patients, mean pain vas on post op days 0, 1 and 2 were 4.5, 3.2 and 2.3 respectively within a multimodality pain management/enhanced recovery program, where standing orders prompting narcotic administration by nursing staff is pain vas 5. all were discharged on pod 2 or 3 without narcotic prescriptions. two of the 6 patients were chronic narcotic users, and they were discharged on their baseline narcotics, i.e. without additional narcotics. all intraoperative blocks were performed in less than 20 minutes. conclusion: a novel, surgeon-administered lateral ql block under ultrasound guidance, is feasible and provides post-operative pain control. patients are discharged home on no/baseline narcotics. a randomized controlled trial is being constructed based on these striking findings. keywords: lc-laparoscopic cholecystectomy, ga-general anaesthesia, sa-spinal anaesthesia. nikhil gupta, rachan kathpal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: cholecystectomy have shown some advantages when done under spinal anaesthesia (sa) and associated with less intra operative and post -operative morbidity and mortality. laparoscopic cholecystectomy (lc) under regional anaesthesia alone included patients with coexisting pulmonary disease, who are deemed high risk for ga. the aim of the present study is to assess the efficacy and safety of laparoscopic cholecystectomy under sa. materials: this prospective, interventional study was conducted on 60 patients with chronic calculous cholecystitis attending general surgery out-patient department of our institution. results: in our study, intraoperative complications recorded were hypotension, bradycardia, intra op shoulder tip pain, bleeding from the liver bed, bile spillage, post-op pain and vomiting. 10% patients had intraoperative pain, 5% had shoulder tip pain, 3.3% had bradycardia, 3.3% had hypotension, 1.7% had bile spillage and 1.7% had bleeding. laparoscopic cholecystectomy under spinal anaesthesia should be promoted more even in developing countries but we need to establish well evaluated safety guidelines that could be followed faithfully for minimizing the risk of complication. background: the "opioid crisis" has taken over headlines with increasing public attention brought to the drastically increasing rates of addiction to prescription narcotics. in 2015, the american society of addiction medicine reported 2 million americans with an addiction to prescription pain relievers and a four-fold increase in overdose related deaths. in a medical setting, increased opiate use is associated with increased rates of delirium, ileus, urinary retention, and respiratory depression. these risks are increased in the obese/bariatric population. transversus abdominis plane (tap) block is a safe and effective approach to achieve optimum pain control. it reduces the use of opiates in patients undergoing major abdominal surgery. however, there is currently no data in the literature examining its use in the bariatric population. our study examines the use of liposomal bupivacaine for tap block in patients undergoing laparoscopic sleeve gastrectomy (lsg). methods: sixteen patients undergoing lsg with tap block were compared with historical cohort of sixteen patients undergoing lsg without tap block (standard group). the primary outcome measured was post-operative in-hospital opiate use (morphine equivalents). statistical analysis was performed using student's t test for continuous variables and fisher's exact test for categorical variables. results: both groups were well matched in regards to bmi, age, and asa class. there was a significant decrease in the post-operative use of opiates with the use of the tap block (11.4 mg in the tap block group vs. 43 mg in the standard group; p 0.00002). there was no difference in the mean length of stay between the two groups. there was an increase in the mean operative time with use of the tap block (76 minutes in the tap block group vs. 58 minutes in the standard group; p.05) conclusions: the use liposomal bupivacaine for tap block provides substantial analgesia, allowing for significant reduction in post-operative opiate use in our bariatric patients. this can be an important adjunct in pain control for the bariatric population and aid in post-operative complication risk reduction. introduction: the objective of this study was to identify variation in weight and demographics in the distribution of pre-operative clinical characteristics between super obese females compared with males who were about to undergo bpd/ds surgery. as the american obesity epidemic increases, morbidly obese patients have become integral to every surgical practice; they are no longer limited to bariatric surgeons. every clinical insight helps the surgeon to optimize outcomes when operating on and managing these medically fragile individuals. in this context, however, clinically and statistically significant differences in demographics, body mass, and in the distribution of weight-related medical problems between super-obese women and men are unknown. introduction: a transversus abdominis plane (tap) block is an ultrasound-guided injection of local anesthetic in the plane between the internal oblique and transversus abdominis muscles to interrupt innervation to the abdominal skin, muscles, and parietal peritoneum. currently there are incongruent findings on the benefit of this regional anesthetic to surgical patients, particularly the obese population. we hypothesized the addition of a tap block in an enhanced recovery pathway (eras) for bariatric patients would decrease opioid use and shorten hospital length of stay. methods: a retrospective review of all patients who underwent bariatric surgery at a single institution from january to december 2016 was performed. patients were identified as: no tap block (no tap), tap blocks that were performed after induction either pre-surgery (pre-tap) or post-surgery (post-tap). the primary outcome was time to first opioid (min) and total morphine (mg) equivalents in pacu. objective: prolonged postoperative ileus increases hospital length of stay and therefore impacts healthcare costs. although many surgeons recommend ambulation in the postoperative period to hasten return of bowel function, little evidence exists to support this practice. our hypothesis is that early ambulation does reduce the time to return of bowel function after intestinal surgery. methods: a subset of 16 patients undergoing intestinal surgery from an ongoing, prospective trial evaluating perioperative physical activity was analyzed. preoperatively, patients wore an activity tracker for a minimum of three days to establish a baseline activity level, measured by daily steps. postoperatively, steps were recorded for 30 days. patients were included in this study if they underwent an operation on the small bowel, colon, or rectum. resolution of postoperative ileus was defined as the postoperative day when patients were noted to meet all of the following criteria on review of nursing documentation: passing flatus, stooling or having ostomy output, and tolerating a regular diet without intravenous fluids. "early" postoperative activity was defined as the average number of daily steps during the first two postoperative days. discussion: these results suggest the patients who received an intraoperative block laparoscopically were more likely to be able to spend less time in the post anesthesia care unit and be discharged home the same day. based on these results, additional process improvement ideas will be implemented in an attempt to improve outcomes. riley d stewart, md, msc, frcsc, james ellsmere, md, msc, frcsc; dalhousie university division of general surgery introduction: oropharyngeal and gastrointestinal (gi) perforations from bbq brush bristles are being reported in the literature with increasing frequency. media attention to this problem has increased awareness by the public. most commonly, bbq bristles lodged in the gi tract can be removed endoscopically or pass without complication. rarely, surgical intervention is required for removal of the bristle or drainage of an associated abscess. we report a case of gastric perforation by a bbq bristle leading to a pancreatic abscess. case report: a 41-year-old male presented to a regional center with epigastric pain and malaise. his medical history included: hypertension, dyslipidemia, gerd, and smoking. his surgical history included: a tonsillectomy, excision of bronchial cleft cyst, and an umbilical hernia repair. on presentation, his laboratory investigations where unremarkable aside from an elevated white blood cell count. investigations including an abdominal x-rays and an abdominal ultrasound were unremarkable. he was initially treated with a proton pump inhibitor for presumed peptic ulcer disease. he returned to the local emergency room, no better than before. a ct scan was arranged which demonstrated a foreign body at the pylorus consistent with a bbq bristle and a peripancreatic fluid collection (figs. 1 & 2) . a gastroscopy failed to identify the bristle. he was admitted, placed on iv antibiotics and referred to our center. despite several days of antibiotics prior to arrival, the collection size on repeat ct scan had increased and the patient had ongoing pain. we repeated the endoscopy with a side viewing endoscope. the perforation was identified posteriorly at the pylorus. the bristle had migrated into the peripancreatic space. the perforation was cannulated with a jagtome. fluoroscopy was used to confirm the position of a wire in the fluid collection (figs. 3 & 4) . pus was drained from the collection into the stomach by placement of a 5 french pigtail catheter (fig. 5) . the patient was discharged pain free the following day. the patient was asymptomatic at 6 weeks' follow-up. a repeat ct scan showed resolution of the abscess and safe migration of the bristle and stent out of the gi tract (fig. 6) conclusion: to our knowledge, this is the first reported transgastric endoscopic drainage of a peripancreatic abscess caused by a bbq bristle gastric perforation. this case is a demonstration of the ever-expanding role of therapeutic endoscopy in a surgical practice. andrew w white, md, carl westcott, md; wake forest baptist medical center introduction: endoscopic balloon dilation of the gastroesophageal junction (gej) is generally limited to 20 mm in diameter. in many stenotic or spastic disorders of the gej 20 mm is just not big enough. larger balloon sizes are available (30 and 40 mm), although these are deployed under fluoroscopy without endoscopy. thus, these larger dilations are often not feasible at the time of the diagnostic endoscopy because different facilities and/or equipment are needed. also, fluoroscopic 30 mm balloon dilations are associated with a 5 percent perforation rate. to address these shortcomings we present an experience with a retroflexed "against the scope" balloon dilation of the gej. in detail, the gej is visualized while retroflexed and a balloon is then placed through the scope. the gej is cannulated next to the scope and deployed. please see the attached image for example. methods and procedures: a retrospective chart review was performed for a single surgeon during the past five years. we identified those who had retrograde dilations and evaluated the indications, repeat dilations, complications and symptomatic response. results: a total of 24 retrograde dilations were performed on 15 patients with gej related dysphagia. the average age was 54.2 years. 17 of 24 dilations were with a 20 mm balloon while other dilations used as small as a 14 mm balloon. 19 dilations were performed for persistent dysphagia after cardiomyotomy between 57 and 5971 days after surgery. other indications for dilation were dysphagia after fundoplication (3/24), dysphagia after paraesophageal hernia repair (1/24) and achalasia during pregnancy (1/24). 5 patients required a total of 9 repeat retrograde dilations at an average time of 488 days after previous dilation. there were 2 instances reported where the dilation did not improve symptoms. there was mucosal breakdown noted in 7 instances although there were no perforations. bleeding was noted in 5 instances although this was always minimal and selfresolving. conclusions: retrograde endoscopic dilation is safe and effective in this small series. the 20 mm balloon against a 10 mm scope gives a 30 mm diameter, but a different shape and a decreased total circumference. there is a possible added safety advantage given that the balloon is inflated under visualization. it can be inflated in steps or stopped if it appears too aggressive. in addition these larger dilations were provided at the time of the initial diagnostic egd without extra equipment. more studies are needed to compare retrograde endoscopic dilation to other methods of management of gej stenosis. introduction: robot-assisted surgery allows surgeons to perform many types of complex laparoscopic surgical procedures. more and more patients are treated with this sophisticated system. however, all the instruments used in the currently available surgical robot system is rigid. therefore, there exists a limitation in the extent of reach to the deeper surgical fields. in order to overcome this difficulty, we are developing a novel flexible endoscopic surgery system (fess) which has flexible single port platform of 3 cm in diameter, independently controlled endoscope and instruments, open architecture that is compatible with existing flexible devices and a magnified 3d hd camera that has sensors of both rgb and infrared. furthermore, the system is smaller and would be more cost-effective than existing robotic surgical system. a preliminary experiment was performed in surgical procedures using porcine model to evaluate effectiveness and feasibility of fess. methods and procedures: experimental protocols were approved by the animal research committees of our institution. we used a female swine of 25 kg. an assistant forcep lifted up the fundus of gallbladder to create good visualization of surgical field. the cystic duct was ligated by laparoscopic clip device from assistant port. blunt dissection was performed by pushing the forceps and sharp dissection by monopolar electrocoagulation. results: the fess accomplished the dissection of the gallbladder from the liver bed successfully. two 5 mm forceps had enough grasping and dissecting force and dexterity. the gallbladder was removed from single port site easily. conclusions: this experiment showed that it is feasible to intuitively operate single-site cholecystectomy with fess. in order to realize a pure fess procedure, an additional novel device to create good visualization of the surgical field is necessary for the fess platform. a prototype has already been developed for evaluation in securing the surgical field. the optimal working range, or "sweet spot" of fess is not relatively large. in addressing this issue, the feature of easy setup is being improved to enable more efficient positioning and shifting of the sweet spot for the surgical field. this mechanism could enhance the expansion of procedures suitable for fess. the target procedures of fess are those specifically suitable for single port surgery, such as transanal surgeries and transcervical mediastinoscopic surgeries. intraluminal procedures and natural orifice translumenal surgery (notes), which are not considered suitable for rigid surgical robot, are also good applications of fess. regression of anal and scrotal squamous cell carcinoma (hpv related) with imiquimod index patient is a 48 year old hiv positive homosexual man with anal-scrotal condylomas (ain) initially resected in 2012, then treated with radiation in 2014 for recurrence. recurred in 2016 with changes severe enough to ''…consider diagnosis of invasive squamous cell carcinoma…''. patient elected trial of imiquimod 5% cream three times per week to defer recommendation of abdominoperineal resection. imiquimod has no antiviral effect but stimulates interferon and cytokines to suppress hpv subtypes 6 and 11, among other immune effects. no data exists as to systemic effects of imiquimod. after three months of therapy, lesions had largely regressed with only one specimen showing ''…concern for squamous cell carcinoma in situ…''. patient has elected to continue treatment pending further biopsy. this report is typical of a number of other reports of small numbers of cases of neoplasia regression with imiquimod 5% cream to include melanoma-in-situ, basal cell cancer of skin and other cutaneous malignancies as well as vin. a second female patient, 38 years old, hiv+ with hpv lesions (ain3) including urethral lesions, is being treated with vulvar application of imiquimod to determine if urethral lesions will regress. there is no fda-approved indication for mucosal application of imiquimod. biopsies are pending at completion of six month trial of imiquiimod. surg endosc (2018) introduction: training in flexible endoscopy remains a critical skill for surgeons, as therapeutic endoscopy procedures continue to evolve and to supplant standard surgical operations. the role of endoscopy across surgical subspecialties is shifting, as endolumenal procedures (like per-oral endoscopic myotomy and endolumenal bariatric interventions) have become commonplace. while surgical residency minimum case volumes are mandated, little is known about the volume of endoscopic procedures surgical fellows participate in. we aimed to characterize the volume of flexible endoscopy cases logged by surgical subspecialty fellows as a measure of endoscopic platform use by surgeons. methods: operative case logs for fellows enrolled in post-graduate training programs participating in the fellowship council were de-identified (no patient or program specific information) and provided for analysis. the case log is an online, mandatory, self-reported collection of all surgeries, procedures and endoscopies performed during fellowship year. all cases listed within the category of "gi endoscopy" in which the fellow designated their role as "primary" surgeon for the procedure were further sorted based on subcategory and linked to the year of fellowship graduation. rigid endoscopy, trans-anal endoscopic procedures, and those in which the fellows roll was "first assistant" were excluded. introduction: complex pancreatic and duodenal injuries due to trauma continue to present a formidable challenge to the trauma surgeon with a described mortality of 5-30% and morbidity of 22-27%. duodenal fistula formation subsequent to failure of attempted primary repair is associated with significant morbidity and mortality. we present the first reported series of four patients with complex trauma-related duodenal injuries who had failure of primary repair which were managed with duodenal stenting. we compared outcomes to a matched case control cohort of patients with trauma related duodenal injuries. the aim of this study is to document our experience with enteral stents in patients with complex duodenopancreatic traumatic injuries. methods: a retrospective review at a level i trauma center identified 4 patients who underwent endoscopically placed indwelling covered metal stents after failure of primary duodenal repair in the form of high output duodenal fistulas. a matched case control cohort was identified including 6 patients with duodenal fistulas who were not treated with stents. drainage volumes were collected and classified according to source and phase of intervention (i.e. admission to fistula diagnosis, to stent insertion, after removal, and until discharge). results: there was a decrease in the mean combined drain output of 497 ml/day (p=0.16) after stent placement. when comparing the sum of all output sources, there was a statistically significant difference across phases (p=0.03) and "after removal" was significantly less when compared to the reference phase (p=0.05). there was also a change in the directionality of the slope for the sum of all drain outputs with an increase of 13 ml/day 2 prior to stent placement compared to a decrease of 13 ml/day 2 (p=0.26) after stent placement. the stenting group demonstrated a decrease in mean drain output (1063 ml/day vs 1446 ml/day, p=0.24) and increase in distal gastrointestinal output (700 ml/day vs 223 ml/day, p=0.16). one patient in the stent group required later operative repair. all other patients in the stenting and control group had resolution of their fistulas over time. there were 2 late mortalities in the control group. the stent treated patients demonstrated diversion of approximately 500 ml/day of enteral contents distally. while all patients eventually healed their fistulas, the stent treated patients demonstrated an accelerated abatement of drain outputs when compared to the control cohort, but did not reach statistical significance. indwelling enteral-coated stents appear to be an effective rescue method for an otherwise inaccessible duodenal fistula after failure of primary repair. kevin l chow, md, hassan mashbari, md, mohannad hemdi, md, eduardo smith-singares, md; university of illinois at chicago introduction: esophageal trauma represents an uncommon but potentially catastrophic injury with a reported overall mortality of up to 20%. the management of iatrogenic and spontaneous perforations have been previously described with well-established guidelines which have been mirrored in the trauma setting. esophageal leaks are the most feared complication after primary surgical management and present a challenge to salvage. there has been increasing reports in the literature supporting the use of removable covered metal stents to treat esophageal perforations and leaks in the non-trauma setting. we present the first reported case series of four patients presenting with external penetrating trauma induced esophageal injuries, complicated by failure of initial primary surgical repair and leak development, successfully managed with the use of esophageal stents. materials and methods: a retrospective review was performed at a level i trauma center identifying four patients who underwent endoscopically placed removable covered metal stents, either by a surgical endoscopist or an interventional gastroenterologist, after failure of primary surgical repair of esophageal traumatic injuries. demographic information, hospital stay, additional interventions, complications, imaging studies, iss scores, and outcomes were collected. results: our cohort consisted of 4 patients with penetrating injuries to the chest and neck with esophageal injuries (3 thoracic and 1 cervical esophageal injuries) managed with esophageal stenting after leaks were diagnosed following primary surgical repair. their initial esophageal injuries included grades 1, 3 and 5. leaks were diagnosed on average post-operative day 9. two patients underwent an additional attempted surgical repair and subsequent leak development. esophageal stents were placed under endoscopic and fluoroscopic guidance within 3 days of leak diagnosis. there was resolution of their esophageal fistulas with all patients resuming oral intake (averaging 72 days after stent placement). three patients (75%) required further endoscopic interventions to adjust the stent due to migration or for dilations due to strictures. mortality was 0%, all patients survived to be discharged from the hospital with average icu length of stay of 30 days. conclusion: the use of esophageal stenting has progressed over the last few years, with successful management of both post-operative upper gastrointestinal leaks as well as benign, spontaneous, or iatrogenic esophageal perforations. while the mainstay of external penetrating traumatic esophageal injuries remains surgical exploration, debridement, and repair with perivisceral drainage; our case series illustrates that the use of esophageal stents is an attractive adjunct that can be effective in the management of post-operative leaks in the trauma patient. results of the ovesco-over-overstitch technique for managing bariatric surgical complications introduction: since 1980, the preferred method of enteral access has been the percutaneous endoscopic gastrostomy tube (peg). accidental removal is a common complication associated with excessive cost and possible significant morbidity. removal prior to 14 days is considered ''early removal.'' early removal has more significant risk associated with it, and can necessitate emergent operation to prevent peritonitis and sepsis. some patients, who do not exhibit signs of peritonitis, may be simply observed. for these patients, peg replacement would typically be delayed 5-10 days to ensure closure. this delay results in prolonged npo status and worsened nutritional status. presented below is a case of early accidental removal followed by endoscopic clip closure, and immediate peg replacement. case report: a 43-year-old male presented after a large left middle cerebral artery infarct. a peg placement was completed without complication. eleven hours after the procedure the patient had pulled the peg tube out of the abdominal wall. at this time the patient appeared to have no abdominal pain and no signs of peritonitis. twelve hours following the accidental removal of his peg tube, the patient was taken back to the endoscopy suite, and an egd was performed. the previous peg site was identified and appeared closed and ulcerated. the mucosal defect was closed with two endoscopic metallic clips. a peg tube was then placed at an adjacent site. the following day, the patient was restarted on trickle feeds and advanced to regular tube feeding over a period of 24 hours. since that time, his peg has been functioning well. discussion: we propose that in the case of early accidental peg removal, the patient should be examined first for evidence of peritonitis. if initial physical exam and radiographic investigation do not reveal peritonitis or significant pneumoperitoneum, the patient should undergo urgent repeat endoscopy. at this time, the gastrotomy can be closed endoscopically via metallic clips and peg can be replaced immediately. tube feeds can be initiated after a 12-24 hour period of dependent drainage with serial abdominal exams. introduction: since its inception in 2008, poem has become a viable procedure for the treatment of achalasia and esophageal dysmotility disorders. however many institutions are in the beginning stages of implementing the procedure into their programs. in view of training, we report the successful ability to dissect and identify common landmarks during a poem procedure performed by trainees under supervision in a high volume poem center. methods: 23 posterior poem procedures performed by trainees with experienced proctor guidance during the period between february to july 2017 were evaluated for the frequency of identifying the 2 perforating vessels, the presence of sling fibers, and position on the lesser curvature of stomach evaluated by double scoping method during the creation of the tunnel and myotomy for procedure. results: all 23 poem procedures were successfully completed by trainees (gi and surgery fellows). the average length of procedure was 79 minutes. indication for procedure included 13 patients with type 1 achalasia (56%), 9 with type 2 achalasia (40%) and 1 des (4%). average length of myotomy for all procedures was 10.4 cm. during these procedures 1 or 2 perforator vessels were identified in 11 (48%) of patients, sling muscle was identified in 10 patients (43%) of patients. myotomy extended to anterior lesser curvature of stomach on double scope exam in 100% of patients. no patient had a serious complication requiring intervention. conclusion: trainees performing a posterior poem procedure were able to correctly dissect and identify the sling muscle and/or perforating vessels in approximately 48% and 40% respectively of procedures. however the myotomy position was correctly placed in all procedures. this indicates that while ideally the sling fibers and perforating vessels should be identified, a correctly positioned myotomy can still be successfully performed by trainees without identification of these landmarks. introduction: gastroparesis is a rapidly increasing problem with sometimes devestating patient consequenses. surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity but require general anesthesia, advanced skills and create risk of leaks. peroral pyloromyotomy (pop) is a less invasive alternative but is technically demanding and not widely available. we propose an hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow a endoluminal stapled pyloroplasty as an alternative treatment option for functional gastric outlet obstruction. methods and procedures: under general anesthesia six female pigs (mean weight 33 kg) had endoscopic placement of 2 or 3 5 mm intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a 5 mm laparoscope was used for visualization. endoflip (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the pylorus before intervention, immediately after and at 1 week survival. pyloroplasty was performed using a 5 mm articulating laparoscopic stapler (dextera microcutter). after removing the taggs ports, the gastrotomies were closed by either endoscopic clip, endoscopic suture or suture under laparoscopic vision. the animals were survived for 1 week. after 6-8 days, a second laparo-endoscopic procedure was performed to verify healing of the pyloroplasty as well as intraluminal dimensions. at the end of the protocol, animals were euthanized. results: six endoluminal linear stapled pyloroplasty were performed. the mean operative time was 112 min. in all cases, this technique was effective in achieving optimal pyloric dilatation. median pyloric diameter (d) and median cross-sectional area (csa) pre-pyloroplasty were 8 mm (4.9-11.6 mm) and 58.6 mm 2 (19-107 mm 2 ). after the procedure, these values were increased to 13.41 mm (9.8-17.6 mm) and 147.7 mm 2 (76-244 mm 2 ) respectively (p=0.0152 the quality of endoscopic examination depends on the quality of endoscopic equipment, experience of the endoscopist and preparation of the patient. contemporarily electronic endoscopes make feasible to transfer image directly to external device which is subsequently linked to computer network and can be transferred further. dynamic image viewed in real time is more accurately interpreted by a physician than a static one. the possibility of simultaneous voice contact makes teleconsultation sterling. the aim of this study was to present our own experience regarding endoscopic teleconsultations. materials and methods: analysis enrolled examinations performed in endoscopic centers located in lesser poland district and in denmark. consultations took place in real time, consulting physicians had more than 10 years of experience in endoscopic procedures and over 10000 colonoscopies and therapeutic procedures performed. there were 84 teleconsultations via standard internet connection 10 mb/s. endoscopic centers were equipped with olympus 180 and 190 series linked to video card. each card had its own ip address, and the image was accessible through internet login from anywhere. consulting physicians used computers connected to internet for tracing the image synchronously and giving advice. results: teleconsultations were undertaken in 0.67% of all endoscopic procedures. teleconsultations concerned difficulties in endoscopic image interpretation in 17 cases and decisions regarding further treatment in 67 cases. the consulting physician solved all problems concerning proper endoscopic image interpretation. in 57 cases the elective procedure was rejected. the elective treatment was continued in remaining cases. 3 patients had a complication of polypectomy that was endoscopically treated. conclusions: the opinion of independent consulting physician in difficult clinical cases regarding endoscopic procedures helps to understand the endoscopic image in real time and implicates a decrease in complications after endoscopic procedures. michelle ganyo, md, robert lawson, md; naval medical center san diego introduction: a presacral phlegmon is a contained collection of infected fluid and inflammation within the bony pelvis, posterior to the rectum and anterior to the sacrum, that usually arises as a complication of surgery, malignancy, inflammatory bowel disease, ischemic colitis or perforated viscous. symptoms include low-back pain, pelvic pain and fevers. antibiotics and supportive therapy are the mainstay of treatment. however, if abscess develops, drainage is required usually by trans-gluteal percutaneous and/or surgical methods, both of which are associated with significant morbidity and mortality. endoscopic ultrasound (eus) -guided drainage of perirectal and presacral abscesses is a well described minimally-invasive approach that permits clear definition of anatomy, real-time access to the abscess and creation of an internalized fistula through placement of one or more transluminal stents. however, to date there is no published report describing endoscopic treatment of the more complicated, clinically challenging presacral phlegmon. here we present a case of a symptomatic presacral phlegmon recalcitrant to medical management that was successfully treated with an endoscopically placed retrievable, transmural, lumen-apposing metal stent. case report: this is a case-report of a 21-year-old, post-partum female who presented with fevers and recurrent lower back pain radiating to her rectum and vagina. her spontaneous vaginal delivery was notable for a second-degree laceration that was primarily repaired at the time of delivery 3 months prior to presentation. her past medical history was otherwise unremarkable. radiographic imaging revealed several perirectal and presacral abscesses that were considered too small for percutaneous drainage. iv antibiotics were started and the largest abscess was targeted for eusguided aspiration. unfortunately, her pain became constant and progressed in severity. a follow-up mri a week later revealed a 7-cm presacral phlegmon. results: colonoscopy revealed a luminal bulge in the rectum but was otherwise normal. to permit drainage and multiple sessions of endoscopic necrosectomy, a 15 mm lumen-apposing metal stent (lams) was placed transrectally under eus-guidance into the presacral phlegmon. endoscopic debridement with forceps and copious irrigation was performed. over the following 2 weeks the patient reported purulent rectal drainage and resolution of her fevers and pain. repeat endoscopy revealed a normal rectum and no sign of the stent. a follow up mri showed a 3-cm area of heterogenous tissue in the presacral area. conclusions: although not previously described for management of a presacral phlegmon, lams appears to be a safe and effective, minimally-invasive treatment option. introduction: flexible endoscopy has evolved to include multiple endoluminal procedures such as anti-reflux procedures, pyloromyotomy, and mucosal and submucosal tumor resections. however, these remain technically demanding procedures as they are hindered by the state of flexible technology which has difficult imaging, limited energy devices, no staplers, and cumbersome suturing abilities. an alternative approach is transgastric laparoscopy, which for almost 2 decades has been shown to be a good procedure for pancreatic pseudocyst drainage and full-thickness and mucosal resection of various lesions. we propose to expand the indications of transgastric laparoscopy by using novel endoscopically placed transgastric laparoscopy ports (taggs, kansa, usa) to replicate endoscopic procedures such as endoluminal antireflux surgery. methods and procedures: under general anesthesia 5 female pigs (mean weight 27.6 kg) had endoscopic placement of 3 5 mm-intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a 5 mm laparoscope was used for visualization. endoflip, (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the gastroesophageal junction (gej) before and after intervention. laparoendoscopic-assited suture plication of the gej was performed using 3-0 sutures (polysorb®). once the taggs ports were removed, the gastrotomies were closed by using endoscopic clip. at the end of the protocol, animals were euthanized. results: five laparoendoscopic-assited sewing plication were performed. the mean operative time was 65,6 min (endoscopic evaluation: 3.2 min, tagss insertion: 11 min, endoflip evaluation+ gej plication: 43,25 min, gastric wall closure: 15 min). in all cases, this technique was effective in achieving adequate gej plication. median gej diameter (d) and median cross-sectional area (csa) pre-plication were 11.42 mm (8.6-13.6 mm) and 104.8 mm 2 (58-146 mm 2 ). after the procedure, these values were decreased to 6.14 mm (5.7-6.6 mm) and 29.8 mm 2 (25-34 mm 2 ) respectively (p=0,0079). median distensibility (d) and median compliance (c) pre-plication were 7.87 mm 2 /mmhg (2.4-22 .69 mm 2 /mmhg) and 190.56 mm 3 /mmhg (70,9-502,8 mm 3 /mmhg). after the procedure, these values were decreased to 1,5 mm 2 /mmhg (0.7-2.2 mm 2 /mmhg) and 52.17 mm 3 /mmhg (21.9-98.7 mm 3 /mmhg) respectively (p=0,0317). no intraoperative events were observed. conclusion: a hybrid laparoendoscopic approach is a feasible alternative for performing intragastric procedures with the assistance of conventional laparoscopic instruments; especially in cases where the location of the intervention limits the access of standard endoscopy or where endoscopic technology is inadequate. further evaluation is planned in survival models and clinical trials. introduction: due to previous manipulation or submucosal invasion, colonic lesions referred for endoscopic mucosal resection (emr) frequently have flat areas of visible tissue that cannot be snared. current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. our aim is to describe dissection-enabled scaffold assisted resection (descar): a new technique combining circumferential esd with emr for removal of superficial non-lifting or residual "islands" with suspected submucosal involvement/fibrosis. methods: from 2015 to 2017, lesions referred for emr were retrospectively reviewed. cases were identified where lifting and/or snaring of the lesion was incomplete and the descar technique was undertaken. cases were reviewed for location, prior manipulation, rates of successful hybrid resection and adverse events. results: 29 lesions underwent descar due to non-lifting or residual "islands" of tissue. patients were 52% m, 48% f, and average age 66 (sd ± 9.9 yrs). lesions were located in the cecum (n= 10), right colon (n=12), left colon (n=4) and rectum (n=3). average size was 31 mm (sd ± 20.6 mm). previous manipulation occurred in 28/29 cases (83% biopsy, 34% resection attempt, 52% tattoo). the technical success rate for resection of non-lifting lesions was 100%. there was one delayed bleeding episode but no other adverse events. approximately 22% of patients have been followed up endoscopically to date with no evidence of residual adenoma. conclusions: descar is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual colonic lesions, providing en-bloc resection of tissue for histologic review. further studies are needed to demonstrate long-term eradication and for comparison with other methods. results: 15 patients underwent 21 fully covered stent placement procedures. indications for stent placement were leak in 8 patients (1 sleeve; 7 bypass) and stricture in 7 patients (4 bypass, 3 sleeve). five patients had stent migration. three required surgical removal, one patient endoscopic repositioning and one passed the stent per rectum. all eight patients with enteric leak successfully underwent stent placement in conjunction with diagnostic laparoscopy and drainage. all but one of these patients developed an enteric leak perioperative to index procedure. the average duration of stent treatment in these patients was 21 days (14-47 days). of the 7 patients treated for a stricture, 3 patients (2 sleeve, 1 bypass) failed treatment and required subsequent definitive operative revision. average length of time of stent treatment in these patients was 3 days (range, 1-14 days) and five had severe intolerance. conclusions: endoscopic stent placement of leak may require multiple procedures and carries the risk of migration; however, this therapy seems to be an effective treatment. failure rates are higher with strictures and are not as tolerated by patients. background: colonoscopy is the most commonly performed endoscopic examination worldwide and is considered the gold standard for colorectal cancer screening. the quality of examination and endoscopic treatment is affected by a number of factors that are verified by recognized parameters such as cecal intubation rate and time (cir, cit), withdrawal time, adenoma detection rate (adr) and polyp detection rate (pdr). advanced endoscopic imaging improves accurate recognition of the nature and variety of pathologic lesions, while the endoscope tips, third eye retroscope and wide-angle endoscopy allow detection of lesions located on the proximal side of the intestinal folds. the aim of the study was to assess the suitability of wide-angle colonoscopy for the detection of colorectal lesions and to analyze the functionality of a special endoscope series regarding cir, cit and withdrawal time. introduction: leak is an uncommon but serious complication of gastrointestinal surgery. when identified post-operatively, percutaneous drains are used to manage abscesses and prevent further peritoneal contamination. if drain position is suboptimal, however, the consequences of persistent leak may necessitate a formal surgical intervention in a hostile abdomen. in select situations, we have utilized natural orifice transluminal endoscopic surgery (notes) methods to enter the abdominal cavity and place/reposition drains under direct endoscopic visualization a part of our comprehensive endoscopic management algorithm for leaks. methods and procedures: a prospectively collected database was queried for patients who had undergone transluminal endoscopic drain repositioning (tedr) as part of multimodal endolumenal therapy for leak (including interventions like defect closure, enteral feeding access, or endolumenal stent placement). inadequate drainage was identified pre-procedurally by undrained fluid collections in conjunction with clinical signs of sepsis. translumenal access was obtained via the leak site and carbon dioxide insufflation was used in all cases. the peritoneal cavity was surveilled and cleared of gross debris by irrigation and suction. intraabdominal drains were located endoscopically and fluoroscopically, grasped with an endoscopic snare or grasper and repositioned adjacent to the leak site to ensure better drainage. results: four patients (3 female), average age 50 (range 52-60), average body mass index 34 (range 29-39) were managed with tedr as a component of endoscopic treatment of full-thickness gastrointestinal leak. two patients developed leak following revisional bariatric surgery. one patient had an acutely dislodged gastrostomy tube with intraperitoneal leak after multiple laparotomies recently closed with a granulating vicryl mesh. one patient developed a leak at an esophagojejunostomy following total gastrectomy. three patients had adequate drainage after the initial tedr, while one patient required tedr on two occasions. all patients had improved drainage demonstrated by resolution of clinical signs of sepsis and resolution of fluid collections. drains were removed as clinically indicated. conclusion: intraabdominal drains are an essential element in the management of full-thickness gastrointestinal leaks, but are not always able to be adequately positioned percutaneously. transluminal endoscopic drain repositioning via a gastrointestinal defect is a viable option to avoid surgical intervention in an otherwise hostile field and is a novel practical notes application. background: epiphrenic diverticula (ed) arise from increased intraluminal pressures, often secondary to achalasia or another underlying esophageal motility disorder which causes "pulsion" physiology. ed are traditionally thought to contribute to patients' symptoms of regurgitation and dysphagia, and are frequently resected at time of heller myotomy and fundoplication done for treatment of the primary motility disorder. ed excision carries significant risks (staple line leak, pulmonary complications, mortality), and little is known regarding patients with ed and esophageal motility disorder who undergo surgical myotomy without ed resection. the goal of this study was to compare outcomes of patients with ed and esophageal motility disorder who did and did not undergo diverticulectomy at time of myotomy and fundoplication. methods: retrospective analysis of prospectively collected database from 2004 to 2017 was performed. patients with diagnosis of ed undergoing surgical treatment of symptomatic esophageal motility disorder were included. all patients underwent laparoscopic heller myotomy with toupet fundoplication by a single surgeon at a tertiary referral hospital. patients were stratified according to whether ed was excised or not excised at time of primary surgery. patient-reported symptoms were obtained from pre/post-operative clinic evaluations and mailed surveys during the follow-up period. independent samples t-test and fisher's exact test were used to compare continuous and categorical variables respectively. results: ed was identified in 15 patients prior to surgery. primary diagnoses included achalasia (n =11), nutcracker esophagus (n=3), and diffuse esophageal spasm (n=1). ed was excised in five patients (33.3%) and not excised in ten patients (66.6%), with no significant difference in frequency of preoperative dysphagia (80% vs. 90%, p=1.00) or regurgitation (40% vs. 60%, p=0.61) between groups respectively. reasons for non-resection included ed was too proximal (n=7), patient/surgeon preference (n=2), and small ed size (n=1). the resection group did not experience any leaks and there were no mortalities in either cohort during the follow-up period. at mean clinic follow-up of 198 days, there was no difference in frequency of residual dysphagia in patients who did or did not undergo ed resection (20% vs. 20%, p=1.00) and neither cohort reported residual regurgitation symptoms. conclusions: this study suggests that leaving ed in place during surgical treatment of an esophageal motility disorder may achieve similar rates of postoperative symptom control. while ed excision in this study did not cause significant excess morbidity, ed resection introduces risk of leak and requires more extensive surgery that may not provide significant benefit to patients. introduction: median arcuate ligament syndrome (mals) has been described in the literature as presenting with a constellation of symptoms including nausea, vomiting, weight loss, and post-prandial epigastric pain. while many of these symptoms are consistent with foregut pathology, a cohort of patients with mals presenting with delayed gastric emptying has not been described in the literature. in this study we report on the possible association of mals with delayed gastric emptying. methods: cases of mal release were collected between 2013 and 2017. eight patients were identified who presented with mals and underwent subsequent mal release. all 8 patients underwent laparoscopic or robotic surgery. patients were compiled into a retrospective database and their demographic, symptomatic, imaging, and outcomes data were analyzed. background: laparoscopic fundoplication (lf) is often performed to treat paraesophageal hernia and/or gerd. care is taken to select the right patients for the operation. some patients may not improve, and others experience dysphagia or bloating after surgery. factors associated with patient satisfaction after fundoplication would be helpful during the patient selection process. methods: a retrospective review of a prospectively collected database was performed. queried patients underwent lf from 2009 to 2015. non-elective operations and fundoplications after heller myotomy were excluded. of this cohort, patients were included only if they responded to a two-year postoperative quality of life survey. surveys were distributed preoperatively, at three weeks, at one year, and at two years. the surveys include the reflux severity index, gerd-hrql, and dysphagia score. the gerd-hrql asks about patient satisfaction with their current state (1 = dissatisfied, 2 = somewhat satisfied, 3 = very satisfied). the cohort was divided according to their answer to this question at two years. demographics and preoperative factors were compared between the groups with kruskal-wallis and fisher's exact tests. univariable and multivariable ordinal logistic regression was performed to identify preoperative symptoms associated with satisfaction at two years. scores on the surveys over time were were also analyzed. results: a total of 94 patients were included in the analysis (dissatisfied = 26, somewhat satisfied = 17, very satisfied = 51). the only significant demographic or preoperative difference was a high number of paraesophageal hernias in the 'very satisfied' cohort (p = 0.017). on univariable regression, younger age and paraesophageal hernia predicted satisfaction. several variables negatively predicted satisfaction with an or \1. multivariable regression, controlled for age and hernia type, identified throat clearing, post-nasal drip, and globus sensation as preoperative symptoms less likely to result in patient satisfaction (p = 0.001, 0.001, and 0.02, respectively). subgroup analysis of patients with paraesophageal hernias revealed that patients with bloating preoperatively are less likely to be satisfied at two years. survey scores over time showed all groups improving over three weeks, but while satisfied patients continued to improved, dissatisfied patients symptomatically worsened over time. conclusion: this study confirms previous reports stating atypical symptoms of gerd are less likely to improve after lf. it also shows individuals with paraesophageal hernia tend to do quite well, unless they report bloating preoperatively. patient-centered analysis such as this can be useful when discussing postoperative expectations with patients, and may reveal opportunities to individualize operative approach. objective: the study was performed to assess whether sutured crural closure or mesh reinforcement for hiatal closure yields better results with regards to symptom resolution and recurrence post-operatively. material and methods: a prospective randomized controlled trial was carried out at grant medical college and sir j. j. group of hospitals, mumbai, india. patients were randomized to receive either sutured repair or mesh reinforcement of hiatal closure. outcomes of interest were symptom resolution, quality of life scores and recurrence in the postoperative period. results: 160 patients were recruited for the trial (80-sutured repair, 80-mesh reinforcement). the two groups were comparable in terms of demographic profiles, symptom severity and findings at esophagogastroscopy and manometry in the pre-operative period as well as size of the hiatal defect measured intra-operatively. post-operatively the mesh repair group had significantly better symptom resolution in terms of early satiety, chest pain and regurgitation (p\ 0.05) while with respect to heartburn, dysphagia and post-prandial pain there was no significant difference between the improvements demonstrated. improvement in quality of life scores after either procedure was not significantly different. recurrence was higher in the suture repair group (8 vs 0, p.001). recurrence lead to poorer symptom severity scores as well as quality of life scores and one patient underwent re-operation. the change in the symptom severity score from baseline after the procedure at 6 months in the subgroup population. conclusion: mesh reinforcement results in a reduced rate of recurrence and offers excellent symptom control in the short-term without a rise in complications when compared to sutured repair for the closure of hiatal defects in laparoscopic hiatal hernia repairs. material and methods: in a period from 2005 to 2016, 72 patients underwent laparoscopic resection (67 -gastric resection, 5 -duodenal resection), using different techniques. all patients were investigated with upper gi endoscopy, eus and abdominal contrast-ct, which allows us to get the complete evaluation of tumor, including size, location, type of growth and the gi layer. based on the findings the decision on the type of resection was made. the majority of resections were wedge or partial resections, performed using endoscopic steplers or using ultrasound scissors followed by double-suturing of gatro/duodenotomy. in the cases of tumor location on the posterior gastric wall we mobilized the the greater curvature to get a direct approach to the tumor with extraluminal growth. in the cases with intraluminal growth we used transgastric approach with small 1,5 cm incision on the anterior gastric wall for endoscopic stepler. technically the most complex procedures were in the cases of tumor location close to anatomically narrow places and muscle sphincters (gastroesophageal junction, pylorus, duodenal bulb, duodenal flexure), with high risk of stenosis and dysfunction of anatomical sphincters. in such cases we used «lifting-technique» in which we dissect serous and muscle layers circumferentially around the tumor making partial enucleation of lesion followed by total resection preserving almost all normal tissue with minimal suturing and deformity at the site of surgery. (1:1), mean age was 60.13 years (sd ± 11.9), 59 patients (72%) had mis. the type of reconstruction was predominantly with a "pull-up" technique (n = 43, 51.2%) followed by the kirschner-akiyama procedure (n = 25, 29.8%), stapled gastroplasty was performed in 12 patients. all the anastomosis were performed at the level of the neck and only one of the patients had a stapled anastomosis, mean operative time was 374 min (sd ± 92 min) including resection of the specimen. primary neoplasms were predominantly hypopharynx (n = 34, 40.5%), distal esophagus (n = 21, 25%), cervical esophagus (n = 12, 14.3%) and thoracic esophagus (n = 11, 13.1%). histologic types were mainly squamous cell carcinoma (n = 63, 77.4%) and adenocarcinoma (n = 12, 14.3%). mean of hospitalization days was 14.76 (sd ± 9.374). no complications were observed in 38 patients and major complications (dindo-clavien ≥iiib) were found in 18 patients. anastomotic leak was present in 6 patients (7.1%) and perioperative mortality (30 days) was 2.4%. progressive shift to laparoscopic surgery was evidenced through the years (2006-2009: 35.29%, 2010-2013:70.27% and 2014-2017:96 .43%; p = 0.000) and reduction in major complications (p = 0,021) was observed. anastomotic leaks (p = 0,545) and perioperative mortality (p = 0.373) did not show significant differences in the present study. conclusions: results in our center show that major complications decrease with time after application of minimally-invasive surgery and no differences in anastomotic leaks and mortality were seen. current data has lead us to abandon open total esophagectomy as a first-choice procedure. introduction: minimal invasive three-fields esophagectomy for minimal invasion is the surgical standard for oncological procedures and benign diseases. cervical dissection has a risk of 2 to 59% in some series, of, lesion or paralysis of the rnl, but the standard in mckeon approach is 14%. a high level of suspicion is needed because this type of lesion has an impact on postoperative evolution and the hospital stay. main: to describe three cases of rnl post esophagectomy paralysis in three planes by least invasion. methods: in a period of 3 years, january 2015 to june 2017, 10 esophagectomies for bening disease were performed. three patients (2 males 1 female) with diagnosis of terminal achalasia and 1 stenosis secondary to caustic ingestion consulted at the minimal invasion service fundcacion valle del lili. they were schedualed for minimal invasive three fields esophagectomy, one patient without complications and early discharge (5 postoperative day) but occasional dysphagia, the other two required early reintubation after de surgery with ards, 1 patient requiered tracheostomy, the second patient could be extubated after 2 days but with occasional dysphagia. all three had mild hoarseness after surgery. the patient who required tracheostomy was decannulated at 20 days without complication. results: the three patients underwent endoscopy without complication in the cervical anastomosis stenosis or disorder in the emptying of the gastric tube, swallowing study without alteration and laryngoscopy with paralysis of the left vocal cord. these patients went to speech therapy with total paralysis recovery at 6 months corroborated with laryngoscopy, without dysphagia or hoarseness. conclusion: rnl innervates the larynx and upper esophageal sphincter, therefore lesion or paresis causes symptoms such as hoarseness, dysphagia, difficulty swallowing, aspiration, difficulty in coughing, pneumonia and ards. injury has a predecessor factor in pulmonary complications and prolongation of the hospital stay. 14% of these patients may require some surgical procedure to restore the function of rnl. noninvasive monitoring of the laryngeal nerve decreases the risk of injury. philip case report: multiple esophageal diverticula associated with achalasia introduction: achalasia is well defined disorder of increased lower esophageal sphincter tone (1). epiphrenic esophageal diverticulum are a rare disorder believed to result from increased intraesophageal pressure often in conjunction with a motility disorder causing functional outflow obstruction. they are a pulsion-type pseudo-diverticulum with mucosal bulging most frequently from the right posterior esophageal wall (2) . we present a very rare case of achalasia associated with multiple esophageal diverticula successfully treated with laparoscopic heller myotomy with dor fundoplication. case presentation: a 75 year old woman presented with 4 years of dysphagia, chest discomfort, regurgitation, and weight loss. esophagoscopy showed a patulous esophagus with multiple esophageal diverticula (figure 1 ). barium esophogram demonstrated 5 esophageal diverticula in the distal esophagus and delayed clearance of esophageal contrast (figure 2 ). high resolution monometry revealed a hypertensive mean les, an aperistaltic body on 10 of 10 wet swallows, and panesophageal pressurization in 7 of 10 wet swallows -consistent with type ii achalasia by chicago classification (1). we performed a laparoscopic heller myotomy with dor fundoplication. the myotomy was extended 6 cm above the gasgtroesophageal junction and 3 cm onto the gastric cardia. an anterior diaphragmatic defect with a moderate type 1 hiatal hernia was repaired with two sutures, ensuring to not impinge the esophagus (figure 3 ). at 10 weeks post operatively the patient reports excellent results. her dysphagia and chest discomfort have entirely resolved. her eckhardt score improved from seven preoperatively to one post operatively. discussion: type ii achalasia is successfully treated in the majority of cases with laparoscopic heller myotomy and partial fundoplication (3). however, esophageal diverticula typically require both myotomy as well as diverticulectomy for successful treatment (4) . there is little experience with the surgical management of multiple esophageal diverticula. we propose a two stage surgical approach for these patients. we reason that the risk of esophageal leak or stenosis in the case of multiple esophageal diverticulectomies out weighs the proposed benefit. indeed epidemiologic studies indicate that the majority of esophageal diverticula are asymptomatic (4) . in the event the patient remains symptomatic after myotomy a second stage operation with diverticulectomies would be possible. this single experience suggests that diverticulectomy may not be necessary in the case of multiple diverticula associated with achalasia. instead, treatment may be directed at relieving the functional obstruction responsible for the symptoms by performing laparoscopic heller myotomy with dor fundoplication. takahiro kinoshita, md, facs, masanori tokunaga, md, akio kaito, md, masahiro watanabe, md, shizuki sugita, md; national cancer center hospital east, japan objective: the optimal surgical approach for siwert type ii cancer is still controversial due to the anatomical complexity of the region. potential advantages of laparoscopic transhiatal approach have not been fully investigated. methods and procedures: we retrospectively analyzed 55 consecutive patients with siewert type ii cancer who underwent laparoscopic transhiatal resection. indication of surgery is patients with siewert type ii cancer with less than 3 cm esophageal invasion. regarding the extent of resection, basically proximal gastrectomy with the lower esophageal resection was selected, aiming at preservation of gastric reservoir function. in terms of reconstruction after proximal gastrectomy, double-tract method was performed. intraoperative peroral endoscopy was routinely employed for determination of the appropriate resection level of the stomach. esophagojejunostomy was employed by overlap method using a 45 mm linear stapler. in order to obtain a wider operative field in the lower mediastinum, the diaphragmatic crus was dissected to widen the esophageal hiatus. results: in 55 patients (38 males and 17 females), median operation time was 282 minutes, and estimated blood loss was 18 g. the rate of surgical morbidity was 18%, and that of anastomotic leakage was 4%. there was no mortality. the mean length of proximal margin was 10 mm, and no positive margin was recorded. the 3-and 5-year overall survival rate was 96.1% and 75%, respectively. conclusions: laparoscopic transhiatal resection for siewert type ii cancer is technically challenging, but appears feasible and safe when performed by an experienced surgical team. a largescale prospective study is necessary for final conclusion. introduction: mesh use for reinforcement of primary crural closure is controversial. synthetic mesh use poses a risk of erosion but there is no evidence that non-synthetic mesh is useful to minimize the risk of hernia recurrence. we evaluated a fully bioresorbable mesh made from poly-4-hydroxybutyrate (p4hb) for crural reinforcement after para-esophageal hernia (peh) repair. the aim of this study was to evaluate the safety and efficacy of p4hb mesh at the hiatus in patients undergoing peh repair. this was a review of prospectively collected data on 50 consecutive patients that had repair of a peh with reinforcement of the crural closure with p4hb mesh. to be considered a peh at least 50% of the stomach was herniated into the chest. a collis gastroplasty or crural relaxing incision was added for short esophagus or crural tension when necessary. routine follow-up consisted of esophagogastroduodenoscopy (egd) at 3 months for patients that had a collis gastroplasty and a barium upper gi study (ugi), high resolution manometry (hrm) and ph test in all patients at 12 months. a hernia of any size identified during objective follow-up testing was considered a recurrence. overall, there was a significant difference in mean measured tension between the three subjective suture ratings by the surgeons. however, there was substantial variability and overlap amongst the surgeon's ratings (figure) . the tension necessary to approximate the crura during peh repair can be objectively measured and as expected increases progressively with anterior movement up the hiatus. while there was some correlation between a surgeon's subjective assessment of the tension necessary to bring the crura together and actual measured tension, there was wide variability and imprecision from one stitch to another. objective tension measurement may provide a more reliable assessment of when excessive force is being used to re-approximate the crura and potentially improve peh recurrence rates. ahmed introduction: paraesophageal hernia repairs are increasing in prevalence, and unfortunately carry a high recurrence rate. consequently, reoperation is expected to increase in frequency. published data on the outcomes of recurrent paraesophageal hernia (rpeh) repair is very limited. because of the technical difficulties of revisional surgery, we hypothesize that laparoscopic revisional paraesophageal hernia repairs are associated with high perioperative morbidity and poor patient outcomes. methods: all rpeh repairs performed by the foregut surgical service at our institution from 2012 to 2015 were reviewed. patients were included if their index operation was a true pehr (initial type 1 hiatal hernia repairs were excluded, as well as multiply recurrent hernias). demographics, medical and surgical history, and operative notes from the index surgery were reviewed. details from standardized pre-operative symptom assessment, objective testing and operative details for the revisional surgery were collected. patients were routinely offered 12 month post-operative upper gastrointestinal contrast evaluation. postoperative outcomes included a standardized symptom assessment and results of objective testing at any time after surgery. results: twenty six patients were identified who underwent repair of rpeh. demographic, operative and perioperative data was available for all patients (table 1) . twenty four patients underwent followup symptom evaluation (two were lost to follow-up after the initial hospitalization). sixteen patients underwent follow-up objective testing by radiographic evaluation with contrast, endoscopy or both. these subgroups were used to calculate symptomatic and objective outcomes (table 1) . conclusion: reoperative laparoscopic surgery for recurrent paraesophageal hernias is technically challenging as evidenced by long operative times. despite this, perioperative outcomes at a high volume center are good, with low morbidity and no mortality. importantly, symptomatic outcomes for this difficult problem are excellent. introduction: hypotension of the lower esophageal sphincter (hles) and the presence of hiatal hernia (hh) have both been associated with gastroesophageal reflux disease (gerd). the exact likelihood with which a hles or a hiatal hernia predict gerd continues to be defined. we hypothesize a synergistic interaction in those with hles and hh in predicting gerd as defined by a positive ph study. methods and procedures: between 2012 and 2013, 148 consecutive patients presenting to a surgical practice with symptoms most concerning for gerd, without prior antireflux surgery were evaluated by high resolution manometry (hrm), esophagogastroduodenoscopy (egd), videoesophagography (veg) and an ambulatory ph study. hles was defined as residual les pressure of\15 mmhg, hh was defined as having been noted and measured by the radiologist, these were further categorized into any hh, 1-3 cm, [3-5 cm background: while clinical outcomes have been reported for antireflux surgery, there is limited data on postoperative outpatient encounters and their associated costs. the aim of this study is to evaluate the utilization of healthcare and its associated costs during the 90-day postoperative period following antireflux surgery. methods: we analyzed data from the truven health marketscan® research databases. patients ≥16 years with an icd-9 procedure code or cpt code for antireflux surgery and a primary diagnosis of gerd during 2012-2014 were selected. only patients with continuous enrollment six months prior to the date of surgery and 90-days after surgery were analyzed. patients with a diagnosis of esophageal cancer or achalasia during the six-month period prior to antireflux surgery, a length of stay [ 30 days following index procedure, a capitated plan, or patients who underwent emergency surgery were excluded. outpatient endoscopy was defined using icd-9 and cpt codes, and related readmission was defined by clinical classification software. introduction: the development of postsurgical gastroparesis following nissen fundoplication is poorly understood. in this study, we analyze the development of gastroparesis requiring intervention and other subsequent procedures following fundoplication and paraesophageal hernia (peh) repair procedures in the state of new york. methods: using a comprehensive state-wide administrative database (sparcs), we examined all in-patient and outpatient records for adult patients who underwent fundoplication or peh repair as a primary procedure for the treatment of gerd between the years of 2005-2010. patients with an initial gastroparesis diagnosis were excluded from the analysis. through the use of a unique identifier, each patient was followed until 2015 for the subsequent diagnosis of gastroparesis or reoperation. surgical procedures for the treatment of gastroparesis included pyloroplasty, pyloromyotomy, or gastroenterostomy procedures. multivariable logistic regression models were used to identify independent predictors for having subsequent reoperation. results: a total of 6,438 patients were analyzed. this included 3,961 fundoplication patients (61.52%) and 2,477 (38.48%) with peh repair. in the fundoplication group, 388 (9.80%) patients had a follow-up diagnosis of gastroparesis or secondary procedure. 211 (8.52%) of the patients who underwent a primary peh repair procedure had a follow-up procedure or gastroparesis diagnosis (table 1) . mean time to follow-up procedure or diagnosis was 2.81 years for the fundoplication group and 2.16 years for the peh repair group. the majority of the follow-up procedures in the fundoplication group were revisional procedures (fundoplication or peh repair) (n = 254, 6.41%), while 134 (3.38%) patients were newly diagnosed with gastroparesis and/or underwent a secondary procedure for its treatment. conclusion: fundoplication and peh repair procedures have a relatively low post-operative incidence of gastroparesis following initial procedure for treatment of gerd. secondary fundoplication or peh repair was more commonly performed compared to any of the surgical procedures for gastroparesis for both procedures. further analysis of association with subsequent procedures is needed. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in 87 cases. the mean operation time was 115 min. the outcome was assessed by reflux test performed on 4-5 postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was 38 months (7-95 months). in 13 cases (14.9%) ppi was restarted before 6 months after the anti-reflux surgery. in 25 cases (28.7%) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed "the esophagitis score". in this scoring method, a number from 0-5 was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p.001). discussion: the number of gerd patients who needed anti-reflux surgery seems to be so high. to extract the patients who needed it remarkably is important. the anti-reflux surgery is most effective for the patients who really have the obvious reflux. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good and satisfied by the patients mostly. surg endosc (2018) 32:s130-s359 introduction: fundoplication at the time of giant paraesophageal hernia repair is controversial. the proposed advantages are better reflux control and lower recurrence. disadvantages include fundoplication specific complications, might be unnecessary and may not decrease recurrence. we retrospectively reviewed giant paraesophageal hernia repairs (peh) with two point gastropexy in the fundus and body, and no antireflux procedure. data collected is postoperative gerd symptoms, postoperative proton pump inhibitors (ppis) therapy and recurrence. methods: a retrospective review of patients who underwent repair of giant peh from 2012 to december of 2016. giant was defined as a hernia with 50% or more of the stomach above the diaphragm. follow up consisted of upper gi (ugi) study one year postoperatively and reflux symptom questionnaire. patients were followed every 4 months in the surgery clinic and a ppi wean was initiated at the second postoperative visit. the primary outcome we evaluated was discontinuation of ppis. in addition, we utilized a standardized reflux scale and recurrence rates collected. chi-squared was used for statistical analysis. background: gastroesophageal reflux disease (gerd) is a highly prevalent disorder with a multitude of treatment options ranging from lifestyle modifications and medical management to surgical options. despite the numerous treatments available, there is still debate over which approach is most appropriate and effective for patients. this study aims to examine the effect of robotic hiatal hernia repair (rhhr) with the novel addition of esophagopexy in patients with gerd. methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rhhr with a partial fundoplication and concomitant esophagopexy for gerd from november 2015 to july 2017. patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was resolution of subjective gerd symptoms and discontinuation of proton pump inhibitor (ppi). recurrence of hiatal hernia was a secondary endpoint. results: eleven patients were identified meeting the inclusion criteria (rhhr + esophagopexy) with a mean follow-up of 9.5 weeks ± 19.4 weeks. in regards to the rhhr, 91% underwent a partial fundoplication and the additional 9% underwent a re-do wrap. this patient cohort was 81.8% female with a mean age of 61.5 ± 11.9 years. preoperative esophagogastroduodenoscopy (egd) was performed in 100% of patients with the study showing a hiatal hernia in 91.0%, gastritis in 45.4% and esophagitis in 63.6% of patients. manometry was performed in 54.5% of the patients showing 50% of these patients with esophageal dysmotility. esophagograms and ph studies were performed preoperatively in 36.4% and 45.5% of patients respectively. preoperatively, 100% of patients had a documented diagnosis of gerd and were taking a ppi and/or h2 blocker. after rhhr with esophagopexy, 81.8% of patients had resolution of their gerd symptoms while 18.2% (n = 2) remained symptomatic. however, one of two patients reported a subjective decrease in symptom severity following the procedure. despite resolution of symptoms, 81.1% remained on ppis. another 9% switched to h2 blockers and one patient discontinued all antisecretory therapy. none of the patients experienced recurrence of their hiatal hernia. conclusion: based on our data, rhhr with esophagopexy results in resolution gerd symptoms in over 80% of symptomatic patient. in patients with hiatal hernias and gerd, rhhr with esophagopexy does lead to resolution of symptoms, however, the majority of patients remained on ppis. long-term follow up is needed to investigate whether these patients are able to discontinue ppis and remain symptom free. chaya shwaartz, nadav zilka, mustapha siddiq, yuri goldes, md; sheba medical center, israel background: d2 gastrectomy for gastric carcinoma is a well-established procedure in patients undergoing surgery for gastric cancer and is the standard of care in our institution. reduced pain, early ambulation, and better cosmetics are some of the benefits of minimally invasive surgery for early gastric cancer. we aimed to describe our experience in laparoscopic d2 gastrectomies undertaken by a single surgeon in our institution. methods: this is a single-center retrospective review of prospectively collected d2 gastrectomies performed by a single surgeon. between november 2011 and february 2017, 45 laparoscopic subtotal/total gastrectomies were performed at sheba medical center, a tertiary center for forgut cancer. clinicopathological characteristics of the patients, surgical performance, postoperative outcomes and pathological data were collected. results: forty-five patients underwent laparoscopic gastrectomy. of these, 38 had subtotal gastrectomy and 7 had total gastrectomy. the median age in our series 65 (43-89). most of the patients in our series had early gastric cancer (t1-2) (80%). the mean average of dissected lymph nodes was 25 ± 13. the mean operative time was 249 ± 48. the postoperative complications, classified using the clavien-dindo classification. severe complications ([ cd iiia) rate was 11%. conclusions: laparoscopic d2 gastrectomy for invasive gastric cancer is safe and feasible when carried out in high-volume centers by an experienced surgeon as part of a multidisciplinary team with careful case selection and appropriate high-quality postoperative support. minimally invasive management of diaphragmatic hernias after esophagectomy: a case report introduction: esophagectomy is a common treatment for both benign and malignant pathologies of the foregut. hiatial paraconduit hernias are rare complications following esophagectomy. in this study, we review our experience with these rare diaphragmatic hernias. methods: a retrospective analysis of all patients presenting with hiatial hernia after esophageal resection at the university of oklahoma health science center between 2014 and 2017 was performed. data was abstracted from the medical record for evaluation and included demographics, symptoms, repair techniques and outcomes. no patients were excluded. results: a total of ten patients were identified to have paraconduit hernias. during this time interval, there were a total of 130 esophageal resections performed. all patients had esophagectomy for malignant disease. seven of the 10 patients have undergone surgery. two patients are asymptomatic and are being followed at their request, and one patient is pending elective correction. of the seven patients who underwent surgery, the median age was 58, with 5 males and two females. six of the seven patients underwent minimally invasive ivor lewis esophagectomy and one had an open mckeown procedure. the median time from esophagectomy to hernia repair was 12 months, with range from 1 month to 120 months. the most common presenting complaint was abdominal pain and nausea. one patient was noted to have a paraconduit hernia on postoperative day 5 and taken to surgery for repair during the hospitalization. there was one death in a patient who presented with necrosis of the small bowel. the remaining 6 patients all had laparoscopic approach. one patient required a hand port to reduce incarcerated colon and one patient was noted to have a cecal perforation during port closure requiring repair. all patients had herniated colon, with small intestine or pancreas herniation noted in three. repair was performed by reducing the viscera, a left phrenic relaxing incision, closure of the hiatus around the conduit and then closure of the diaphragmatic defect with mesh. at median follow up of 6 months, there are no recurrences. conclusion: hiatal paraconduit hernias are becoming a frequent finding among survivors of esophageal cancer surgery. our study demonstrates that there is a propensity for patients who undergo minimally invasive esophagectomy to develop these hernias. the vast majority of patients can undergo laparoscopic repair. our recommendation is to perform a diaphragmatic relaxing incision and liberal use of mesh. early results appear to be favorable regarding recurrence. aim: there have been several reports illustrating the safety and efficacy of various surgical techniques in performing laparoscopic esophagojejunostomy (ej). this study aims to compare two established methods of ej anastomosis -circular stapling with purse-string suture ("lap-jack") and linear stapling technique -in laparoscopic total gastrectomy. methods: 314 patients diagnosed with gastric cancer underwent intracorporeal ej anastomosis in laparoscopic total gastrectomy from january, 2013 to october, 2016. 254 cases used the circular stapler with purse-string "lap-jack" method, and 60 patients used the linear stapling method for ej anastomosis. 59 were matched using propensity scores, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed. the two groups showed no significant difference in age, bmi, or other clinicopathological characteristics, and there was no conversion to an open procedure. after propensity score matching analysis, the linear group had significantly shorter operating time (252.6 ± 72.3 vs 200.1 ± 61.7, p≤0.001) and more sufficient proximal margin (3.9 ± 3.5 vs 4.9 ± 3.0, p = 0.022). no significant difference was found in estimated blood loss, retrieved lymph node, hospital stay, and time for first flatus. there was no postoperative mortality. early postoperative complication of the circular and linear group occurred in 11 (18.6%) and 16 (27.1%, p = 0.381) patients respectively. ej leakage occurred in 2 (3.4%) cases from each groups, with 1 (50%) case from both group needing radiologic or surgical intervention. no other significant difference in early complication was found. late complication was observed in 7 (3.3%) cases (circular = 4 linear = 3, p = 1.000) with 1 ej anastomosis stricture in the linear group, but there was no statistical significance. conclusion: both circular stapling and linear stapling techniques are feasible and safe in performing intracorporeal ej anastomosis during laparoscopic total gastrectomy. linear-stapling technique had more sufficient proximal margin and shorter operating time. there was no significant difference in anastomosis related complication between the two groups. masahiro watanabe, masanori tokunaga, akio kaito, shizuki sugita, takahiro kinoshita; national cancer center hospital east, gastric surgery division background: although the current standard treatment for advanced gastric cancer (agc) is open gastrectomy, laparoscopic gastrectomy (lg) is increasingly performed, especially in the east. however, it is a technically demanding procedure, and the feasibility remains unclear. the aim of the present study was to clarify the feasibility of lg for agc. patients and methods: the present study included 266 patients who underwent lg for agc between 2010 and 2017. the indication of lg has gradually expanded in our institute, and is currently any stage gastric cancer except for gastric cancer obviously invading adjacent organs or gastric stump carcinoma. we retrospectively reviewed short-and long-term surgical outcomes of the patients. results: male/female ratio was 2:1, and median age (range) was 68 (23-90) years. distal gastrectomy was most frequently performed (62 %), followed by total gastrectomy (33%). median operation time and intraoperative blood loss was 251 (156-529) minutes and 15 (0-505) g, respectively. clavien-dindo grade iii or more complication rate was 8.6%. with a median followup period of 18 months, the 3-year recurrence free survival rates of pstage ii and iii patients were 98% and 91%, respectively. conclusion: the outcomes of lg for agc are satisfactory, provided that an experienced team performs the surgery. introduction: the present study aims to evaluate the predictive value of indocyanine green (icg) for the detection and prevention of anastomotic leak following esophagectomy. anastomotic leak is a highly morbid and potentially fatal complication of esophagectomy. ensuring adequate perfusion of the gastric conduit can minimize the risk of postoperative leak. intraoperative evaluation with fluorescence angiography using icg offers a dynamic assessment of gastric conduit perfusion, and can guide anastomotic site selection. methods: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using the search terms "indocyanine/fluorescence" and esophagectomy was completed to include all english articles published between 1946 and august 2017. articles were selected by two independent reviewers based on the following major inclusion criteria: (1) esophagectomy with gastric conduit reconstruction; (2) use of fluorescence angiography with indocyanine green to assess perfusion; (3) age ≥18 years; (4) sufficient outcome data for the calculation of leak rates and (5) sample size ≥5. the quality of included studies was assessed using the quality assessment of diagnostic accuracy studies-2. results: our literature search yielded 146 potential studies, of which 14 studies were included for meta-analysis after screening and exclusions. there were eleven prospective and three retrospective studies. the pooled anastomotic leak rate when icg was used was found to be 10%. pooled sensitivity and specificity for leak detection were 0.83 (0.70-0.93) and 0.60 (0.55-0.66), respectively. when studies involving intraoperative modifications were removed, pooled sensitivity and specificity were only marginally changed to 0.75 (0.51-0.91) and 0.67 (0.55-0.77), respectively. the diagnostic odds ratio was found to be 5.68 (2.29-14. 10) across all studies and 5.06 (0.93-27.55) when intraoperative interventions were excluded. only three trials included a control group, giving a sample size of 251. in studies with a comparator group, icg was associated with an 87% reduction in the risk of anastomotic leak [or: 0.13 (0.03-0.50)]. conclusions: in non-randomized trials, the use of icg as an intraoperative tool for visualizing vascular perfusion and conduit site selection, is promising. however, poor data quality and heterogeneity in reported variables limits cross-study comparisons and generalizability of findings. randomized, multi-center trials are needed to account for independent risk factors for leak rates and to better elucidate the impact of icg in predicting and preventing anastomotic leaks. objective: robotic assistance for bariatric surgery represents a novel application of a rapidly emerging technology. its safety and efficacy remains primarily characterized by smaller, singleinstitution studies. in this investigation, the influence of robotic assistance on short-term perioperative outcomes is contrasted with the more established primary multi-port laparoscopic approach for patients undergoing roux-en-y gastric bypass (rygb), using data from a national bariatric database. methods: a retrospective analysis of 2,976 robotic-assist and 38,716 laparoscopic rygb patients from the 2015 metabolic and bariatric surgery accreditation and quality improvement program national database were reviewed for differences in patient characteristics and short-term outcomes. on bivariate analysis, variables associated with primary outcomes of 30-day reoperation, readmission and reintervention were imputed into multivariate analyses to determine independent significance. results: robotic-assist bypass patients were older (p\.001), had a higher prevalence of comorbidities and had concomitant operations more frequently performed during surgery (p\.001). on bivariate analysis, robotic-assist patients had a higher rate of readmission than laparoscopic patients (7.5% vs. 6.4%; p=.03), but no differences in 30-day reoperation ( conclusion: robotic-assistance does not confer an increased rate of morbidity and mortality after rygb, and represents a feasible surgical modality for the surgeon willing to adopt the technology and accept its limitations. alicia m bonanno, md, brandon tieu, md, farah husain, md; oregon health and science university introduction: marginal ulcer is a common complication following roux-en-y gastric bypass with incidence rates between 4 and 16%. most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. revision of the gastrojejunal (gj) anastomosis carries significant morbidity and mortality with complication rates ranging from 10 to 50%. thoracoscopic truncal vagotomy (ttv) may be a safer alternative with decreased operative times. the purpose of this study is to evaluate the safety and effectiveness of ttv in comparison to gj revision for treatment of recalcitrant marginal ulcers. methods and procedures: a retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from 1st september 2012 to 1st september 2017. all underwent medical therapy along with lifestyle changes prior to intervention and had preoperative egd that demonstrated a recalcitrant marginal ulcer. revision of the gj anastomosis or ttv was performed. data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate. statistical analysis was performed using t-test and fischer's exact test. results: a total of fifteen patients were identified who underwent either gj revision (n=8) or ttv (n=7). there were no 30-day mortalities in either group. mean operative time was significantly lower in the ttv group in comparison to gj revision (95.7±16 vs. 197.8±89 minutes respectively, p=0.0141). recurrence of the ulcer was not significant between groups and occurred following 2 gj revisions and 1 ttv. overall complication rate was not significantly different with 88% in the gj revision group and 57% in the ttv group. complications included anastomotic leak (1 gj), anastomotic stricture (2 gj), aspiration (1 ttv), dysphagia (1 gj and 3 ttv), and dumping syndrome (2 gj). conclusions: our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. however, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups. we present a case of a 59-year-old female with a history of thyroid cancer who initially presented to an outside hospital complaining of reflux, abdominal pain, early satiety, and 35-pound unintentional weight loss. endoscopy demonstrated a 2 cm pre-pyloric mass; with initial biopsies of the mass demonstrating only gastric mucosa. endoscopic ultrasound and fna of the lesion also failed to elucidate its pathology. due to the pyloric location of the mass and inability to rule out invasive malignancy, we recommended a robotic-assisted transgastric submucosal resection with possible distal gastrectomy. intraoperatively we found a 270-degree circumferential pre-pyloric exophytic sessile tumor. frozen sections suggested a benign papillary tumor therefore we proceeded with submucosal resection. the resulting mucosal defect and gastrotomy were closed primarily with absorbable suture. final pathology showed the tumor to be a tubulovillous adenoma with high grade dysplasia arising against a background of intestinal metaplasia. the resection margins were negative for dysplasia. the postoperative course was complicated by a minor leak which did not require operative intervention and subsequent gastric outlet narrowing which required endoscopic dilation and feeding tube placement. however, the patient has recovered well and has advanced to diet as tolerated. gastric adenoma has a prevalence of 0.5-3.75% in the western hemisphere. the risk of carcinomatous transformation in gastric adenomas is related to size, degree of dysplasia, and villosity. gastric adenomas are considered precancerous lesions. pre-operative pathologic diagnosis of dysplasia is often elusive as biopsies will often miss or under-grade the lesion. guidelines advocate for complete resection with either endoscopic submucosal dissection or surgical resection depending on surgeon preference and local expertise. endoscopic resection has been shown to be safe and efficacious in the removal of adenomas with good long-term outcomes. in this case the pathology of the lesion was unclear after multiple unsuccessful biopsies and required a surgical diagnosis to rule out invasive malignancy. management of gastric adenomas, while rare, may require a multidisciplinary approach between surgical endoscopy, minimally invasive surgery, and surgical oncology to achieve local control in an oncologically sound manner. we show that transgastric submucosal resection can be achieved in a minimally invasive fashion using robotic assistance. objective: parahiatal hernia is a rare type of diaphragmatic hernia with incidence of 0.2-0.35%. para-hiatal hernias arises lateral to the left crural musculature adjacent to but separate from the oesophageal diaphragmatic hiatus. in view of its rare occurance and little clinical suspicion, it is almost never diagnosed clinically. the current case report is intended to depict the clinical profile of an intraoperatively diagnosed para-hiatal hernia and feasibility of laparoscopic repair of parahiatal hernias. method: laparoscopic fundoplication is frequently performed at grant medical college and sir j. j. group of hospitals, india. during one such case intraoperatively para-hiatal hernia was diagnosed. discussion: primary or true parahiatal hernias occur as a result of a congenital weakness and secondary defects follow hiatal surgery. the primary treatment of para-hiatal hernia is mesh-plasty. this is coupled with fundoplication in cases of large hernia and those symptomatic for gastroesophageal reflux disease. laparoscopic repair of these uncommon hernias is safe, effective and provides all of the benefits of minimally invasive surgery. conclusion: due to its rare occurrence, knowledge about this condition among laparoscopic surgeons is important to avoid diagnostic dilemma. knowledge about its management aids intraoperatvely to avoid performing incomplete procedure. introduction: extended indications of endoscopic resection for early gastric cancer (egc) have been widely accepted. according to current japanese guidelines, additional gastrectomy with lymph node dissection (lnd) is recommended for patients proven to have potential risks of lymph node metastasis (lnm) on histopathological findings. on the other hand, the frequency of lnm in these patients is exteremely low. the aim of this study was to elucidate the accurate risk of lnm based on the number of risk factors (rf) for possible lnm, and to compare the stratified risk of lnm with predicted risk from additional radical resection. methods and procedures: we enrolled 589 egc patients who did not meet absolute or extended indications of endoscopic resection, and investigated the risk stratification of lnm according to the total number of lnm rfs described below; (1) sm2, (2) lymphatic vessels invasion, (3) undifferentiated adenocarinoma and [20 mm in diameter, and (4) [30 mm in diameter and ulcer formation. we compared the stratification risk to the surgical risk that was calculated based on the japanese national clinical database (ncd) risk calculator in 52 patients with additional gastrectomy after esd. results: the total number of lnm rfs and frequency of lnm were significantly correlated (0/ 1rf; 0.85%, 2rfs; 10.88%, 3rfs, 31.40%, 4rfs, 53.57%; p.05, fischer exact test). the estimated frequency of lnm was found to be lower than the predicted value of in-hospital mortality rate based on ncd in 24.3% of 0/1rf-patients who underwent additional gastrectomy with lnd after esd. the present study suggested that some patients must be over-indicated for additional gastrectomy with lnd, and no additional surgical treatment or less invasive surgery, such as local lnd (sentinel node navigation surgery or lymphatic basin resection), might be indicated for some patients with low number (0/1 rf) of lnm risk factors after esd. aims: laparoscopic proximal gastrectomy has been applied for early gastric cancer in upper third. we previously reported outcomes of laparoscopic total gastrectomy in managing this condition. in this study, we applied this modified technique for upper third early gastric cancer with double tract reconstruction. it is expected that our technique could be useful for treating these cases. methods: from april of 2004 to june of 2017, 69 consecutive patients with upper third early gastric cancer were assigned to undergo surgical treatment with proximal gastrectory at our hospital. we had 195 cases of total gastrectory for upper third early gastric cancer in the same study period. background: laparoscopic total gastrectomy for remnant gastric cancer is much more difficult than common laparoscopic total gastrectomy due to severe adhesions to adjacent organs, displacement of anatomical structure. purpose: the aim was to analyze 10 cases of laparoscopic total gastrectomy for remnant gastric cancer at the department of surgery of juntendo university urayasu hospital between november 1999 and april 2017. method: we analyzed outcome and feasibility of laparoscopic total gastrectomy surgery for remnant gastric cancer. and we compared with laparoscopic total remnant gastrectomy (10 cases) versus laparoscopic total gastrectomy (101 cases) in our hospital. results: in the previous laparoscopic surgeries. we performed laparoscopic distal gastrectomy in 5 cases, laparoscopic proximal gastrectomy in 2 pcases, and open distal gastrectomy in 3 cases. all cases were performed laparoscopic total gastrectomy with r-y reconstruction. 1 case of them had been converted to open surgery due to severe adhesions. the mean operative time was 271 min and the mean blood loss was 189 ml. there were no intraoperative complications, and there were 2 postoperative complications as a pancreatic fistula and a bowel obstruction. however, there were no intra-operative complications more than grade 3 according to the clavien-dindo classification. the mean postoperative hospital stay was 22.4 days. all cases were without recurrence. thus, there were no significant differences in operative time, bleeding volumes, intra and postoperative complications and hospital stay compared with laparoscopic total gastrectomy. conclusions: laparoscopic total remnant gastrectomy can be performed with similar short-term outcomes to laparoscopic total gastrectomy, and may be feasible and safe procedure, and can become an option of therapeutic strategy. although this study was not powered to show lower recurrence rates with synthetic absorbable as compared to biologic, the 8.51% recurrence rate is consistent with other series utilizing this mesh. it is interesting to note the difference in time to recurrence. these results suggest that while synthetic absorbable mesh may result in lower recurrence rates, recurrence seems to occur earlier. the results also suggest that deconditioning (lower bmi), and difficult cases and/or recovery may predispose to recurrence. these findings can help inform lf mesh selection and predict which patients are at higher risk of recurrence. introduction: little discussion of gastroparesis (gp) following laparoscopic paraesophageal hernia repair (lphr) has been reported in the literature. we wished to examine the incidence in our institution, and identify potential risk factors for development of gastroparesis following lphr. methods and procedures: a single institution retrospective chart review was preformed using cpt codes corresponding to paraesophageal hernia repair and fundoplication to identify patients undergoing laparoscopic paraesophageal hernia repair over a five year period (1/1/2012-12/31/ 2016) by three surgeons. emergency procedures and reoperations were excluded. in total, 93 patients undergoing non-emergent first time lphrs were identified. size of the hiatal defect was identified when able, via either measurement between the diaphragmatic crura on ct or by medical record documentation. data obtained included sex, age, hernia type, mesh usage, and existence of specific comorbidities associated with gastroparesis. presence of gastroparesis was identified either by documentation of diagnosis via clinical judgment, or by results of gastric emptying nuclear medicine studies, with timing being no longer than 6 months from date of surgery. independent students t-test and fisher exact test were used to determine statistical differences between the groups. results: 93 patients undergoing non-emergent first time lphrs were identified. of these, we were able to obtain the size of the hiatal defect in 72 patients. 10 patients overall were diagnosed with gastroparesis, with an overall incidence of 11.0%. when comparing all patients who developed gastroparesis to those who did not, only females comprised the group which did develop gastroparesis (0 males/10 females with gp, 28 males/55 females without gp, p=0.029). age was also found to be greater in the group which developed gastroparesis. for patients in which the size of the hernia defect was identified, the average age was 9 years older in the group diagnosed with gastroparesis ( step 1 under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. the right crus of the diaphragma has been dissected free from the soft tissue around the stomach and abdominal esophagus. in this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid bleeding. after cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. then the inside margin of the left crus of the diaphragma was recognized from the right side. in this part of the procedure, laparoscope uses trocar (a), the assistant uses trocar (b) to pull the stomach to left lower side and the operator's right hand uses trocar (c). step 2 the branches of left gastroepiploic vessels and the short gastric vessels were divided with ultrasonic coagulation and dissection device. the left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. in this part of the procedure, laparoscope uses trocar (a) at the beginning of dividing left gastroepiploic vessels, trocar (b) when dividing short gastric vessels. step 3 the right and left crus are sutured with interrupted stitches to reduce the hiatus. from the right side, the fundus of the stomach is grasped through the widely opened window behind the abdominal esophagus. then the fundus of the stomach is pulled to obtain a 360 degree ''stomach-wrap'' around the abdominal esophagus (fundoplication). using 2-0 non-absorbable braided suture, stitches are placed between both gastric flaps. purpose: laparoscopic gastrecomy has been widely adopted as the treatment of choice by many countries and institutions. internal hernia is a well-known complication after rouxen-y gastric bypass in the field of bariatric surgery. however, there were only a few reports of internal hernia after gastrectomy in gastric cancer patients. the purpose of this study was to analyze the incidence and clinical features of internal hernia after gastric cancer surgery in a high-volume center. method: 2,931 gastric cancer patients who underwent curative gastrectomy at seoul national university bundang hospital between january 2013 and december 2016 were retrospectively reviewed in this study. internal hernia was classified into two types, mesenteric hernia and petersen's hernia. result: 2201 patients who underwent distal gastrectomy (dg) with reconstruction by billroth ii, rouxen-y gastrojejunostomy and uncut rouxen-y gastrojejunostomy, total gastrectomy (tg) with esophagojejunostomy, and proximal gastrectomy with double tract reconstruction (pg dtr) with esophagojejunostomy and gastrojejunostomy had potential space for internal hernia. among these patients, 31 (1.4%) were determined as internal hernia by computed tomography and 29 patients (1.3%) underwent surgical treatment of internal herniation. two patients were conservatively managed. all patients suffered from abdominal pain and 13/31(42%) patients showed nausea and vomiting. the median interval between the initial gastrectomy and surgery for internal hernia was 450 days. mesenteric hernia was observed in 18 cases and petersen's hernia in 12 cases. since we started closing the mesenteric and petersen's defects from may of 2015, there were only 5 cases (16%) observed afterwards but there were 24 cases (84%) before closure of the defects. conclusion: internal hernia after gastrectomy is likely underreported. although we analyzed 31 patients with internal hernia, there might be more patients with mild symptoms who were managed conservatively by their own. a high degree of suspiciousness for internal hernia should be maintained in patients presenting symptoms like nausea, vomiting and abdominal pain after gastrectomy with potential space for internal hernia. with our experience, closure of the mesenteric and petersen's defect is helpful in reducing internal hernia. however, due to low incidence, a multicenter retrospective study is necessary. introduction: the increased incidence of anemia in patients with a hiatal hernia (hh) has been clearly demonstrated, as has resolution of anemia after hh repair in these patients. despite this, the implications of preoperative anemia on postoperative outcomes have not been well described. in this study, we aimed to identify the incidence of preoperative anemia in patients undergoing hh repair at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing hh repair between january 2011 and april 2017 at our institution. we identified all patients with anemia, defined as serum hemoglobin levels less than 13 mg/dl in men and 12 mg/dl in women, measured within two weeks prior to surgery, and compared this cohort to those that had normal hemoglobin values preoperatively. specific perioperative outcomes analyzed included: estimated blood loss (ebl), operative time, need for blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and 30-day readmission. results: we identified 266 patients undergoing hh repair, of which 233 had preoperative bloodwork available for review. the average age was 64 years and the majority of patients were female (79%, n=208). most were treated electively (75%, n=196) and with a minimally invasive approach (97%, n=255). 70 patients (26.6%) had preoperative anemia. compared to patients without anemia, patients with anemia had increased rates of failed extubation postoperatively (7.1% vs. 1.5%, p=0.033), increased icu admissions (12.9% vs. 5.1%, p=0.034), increased need for perioperative blood transfusions (11.4% vs 0%, p=0.0003), and increased rates of postoperative complications (41.4% vs. 18.1%, p.0001). although mean los (4.3 days vs. 3.2 days, p 0.077), mean operating time (262 mins vs. 252 mins, p=0.10), and ebl (52 ml vs 38 ml, p=0.38) were greater in the anemic group, they did not reach statistical significance, and there was no significant difference in 30-day readmission rate (8.6% vs 8.8%, p=0.95). conclusions: anemia diagnosed on preoperative bloodwork appears to be associated with increased failure to extubate postoperatively, need for icu admissions, need for perioperative blood transfusion, and increased overall complication rate after hh repair. however, we found no significant difference in los or 30-day readmissions between anemic and non-anemic patients. since the majority of patients in this analysis underwent elective repairs, these results would support the preoperative treatment of anemia in patients undergoing hh repair. few studies have compared the procedures' long-term effectiveness with none looking beyond 5 years. this study sought to characterize the efficacy of laparoscopic toupet versus nissen fundoplication for types iii and iv hiatal hernia using a telephone survey. methods and procedures: with irb approval, a review of all laparoscopic hiatal hernia repairs with mesh reinforcement performed over seven years at a single center by one surgeon was conducted. patient demographics and perioperative characteristics were recorded. hiatal hernia was classified per published sages guidelines as type iii or iv using operative reports and preoperative imaging. patients with type i or ii or recurrent hiatal hernia and patients receiving concomitant procedures were excluded. the gerd-health related quality of life survey was administered by telephone no earlier than 18 months postoperatively. patients responded to items concerning symptom severity using a 5-point scale (0=no symptoms to 5=symptoms are incapacitating to do daily activities). symptoms surveyed included heartburn (6 items), difficulty swallowing (1 item) and regurgitation (6 items introduction: as the thoracic esophageal carcinoma has a high metastatic rate of upper mediastinal lymph nodes, especially along the recurrent laryngeal nerve (rln), it is crucial to perform complete lymph node dissection along the rln without complications. although intraoperative neural monitoring (ionm) during thyroid and parathyroid surgery has gained widespread acceptance as the useful tool of visual nerve identification, the utilization of ionm during esophageal surgery has not become common. here, we describe our procedures focusing on a lymphadenectomy along the rln utilizing the ionm. methods and procedures: we first dissect ventral and dorsal side of the esophagus preserving the membranous structure (meso-esophagus), which contains tracheoesophageal artery, rln and lymph nodes. we next identify the location of the rln which runs in the meso-esophagus using ionm before visual contact. after that, we perform lymphadenectomy around the rln preserving the nerve. this technique was evaluated in 30 consecutive cases (neural monitoring group; nm) of esophagectomy in prone positioning, and compared with our historical 56 cases (conventional method group; cm background: laparoscopic hiatal hernia repair, particularly large type 1 and type 3 hernias, is associated with high recurrence rates. various use of overlay mesh reinforcement have been described in an attempt to improve outcomes. unfortunately, overlay use of biologic mesh continues to result in high recurrence rates, and more effective repairs employing permanent mesh raise serious erosion concerns and are therefore rarely used. we theorize that employing an interlay technique with permanent mesh (positioned between both crura) will help enhance crural closure and improve rates of hiatal hernia recurrences with minimal risk of erosion. methods: we reviewed all patients who underwent a laparoscopic hiatal hernia repair from april 2015 to august 2017 by a single surgeon from a prospectively maintained database at a tertiary care referral center (n=72). patients who underwent surgery for achalasia with concurrent hiatal repair were excluded. during this time frame, a new interlay technique of polypropylene mesh was employed upon suture closure of the crura. outcomes of repair were retrospectively reviewed. recurrence of hernia was identified by positive work up of patient's symptoms (new onset dysphagia, gerd, pain). results: a total of 72 consecutive laparoscopic hiatal hernia repair were reported in a period of 28 months. interlay polypropylene mesh was utilized in all repairs. patients were majority females (74.0%), had a median age of 61 and had a mean bmi of 31.3. eleven (15.0%) patients were redo repairs. majority of patients received a nissen fundoplication (n=54, 75.0%) followed by a toupet fundoplication (n=14, 19.4%). median length of stay after surgery was 1 day. median follow up was 43 days (range: 11-659 days). there were zero reported recurrences. conclusion: laparoscopic hiatal hernia repair with interlay polypropylene mesh appears in the short term to be a safe and durable technique to reduce the incidence of hiatal hernia recurrences. further studies are needed to assess more long term outcomes of this novel technique. zia kanani 1 , melissa helm 1 , max schumm 2 , jon c gould, md 1; introduction: laparoscopic fundoplication remains the current gold standard surgical intervention for medically refractory gastroesophageal reflux disease. studies suggest that on average 5-10% of patients undergo reoperative surgery due to recurrent, persistent, or new symptoms. the primary objective of this study was to characterize the long-term symptomatic outcomes of primary and reoperative fundoplications in a clinical series of patients who have undergone one or more fundoplications. methods: patients who underwent laparoscopic primary or reoperative fundoplication between 2011 and 2017 by a single surgeon were retrospectively identified using a prospectively maintained database. patients undergoing takedown of a failed fundoplication and conversion to roux-en y gastric bypass (for morbid obesity, severe gastroparesis, or 3 or more prior failed attempts) were excluded from the current analysis. all procedures were performed laparoscopically. patients were asked to complete the validated gerd-health related quality of life (gerd-hrql) survey prior to surgery and postoperatively at standard intervals to assess long-term symptomatic outcomes and quality of life. gerd-hrql composite scores range from 0 (highest disease-related quality of life) to 50 (lowest diseaserelated quality of life, most severe symptoms conclusions: patients who need to undergo reoperative fundoplication have more severe gerd-related symptoms at 2 years post-op compared to patients undergoing primary fundoplication. however, good outcomes and morbidity rates of laparoscopic reoperation that approximate that of a primary fundoplication are possible in the hands of an experienced surgeon. adenocarcinoma of duodenum: surgical or endoscopic treatment? introduction: it is well known that the adenocarcinoma of the duodenum (adc) is a quite rare lesion infact represents 40% of cancer of the small bowel and 30% of these are localized in the periampullary area: 7% affect the sub-papillary tract and only 3% the supra-papillary segment of the duodenum. the adc may arise from duodenal polyps (familial polyposis, or gardner's syndrom or be associated with coeliac disease). until now the treatment was the pancreatoduodenectomy (for anatomo-surgical reasons and for the possibility of regional lymphonode resection). infact in my series of 476 of such procedures, 102 where performed for duodenal cancer. in this last 4 years 18 patients with adc of supra-papillary segment of the duodenum underwent endoscopic submucosal dissection (esd). the purpose of this study were to check the feasibility of the esd in treating such cases. in our experience this kind of endoscopic operation was feasible with high complication rate; perforation in 3 cases (0.54%); and bleeding occurred in 1 case (0.18%). all the complications were successfully treated endoscopically and the long-term outcomes was favorable. consitering the high rate of complications, the difficult and long procedure, the compliance of patients (c02), the general anesthesia, a very very skilled endoscopist is needed. conclusions: the esd represent a new endoscopic approach enstablished in clinical practice: end is performed following the intraluminal path (3rd space) wich, unlike the others, remain virtual and has to be created by dissecting and expanding the tissues layer between the mucosa and the muscolaris propria allowing the endoscope to gain access. the benefit of esd for treating the adc of the supra-papillary segment of the duodenum, according to our experience, must be validate in the future; a pre-operative pet-tac scan examination must be performed in order to demostred the lesion of the duodenum and if there is any limphatic involvement and no infiltration of the head of the pancreas. yoontaek lee, md, sa-hong min, md, young suk park, md, sang-hoon ahn, md, do joong park, md, phd; seoul national university bundang hospital purpose: this study summarizes the single institution experience of laparoscopic gastrectomy in advanced gastric cancer and evaluates the postoperative morbidities and long-term oncologic outcomes. methods: a total of 1,597 laparoscopic gastrectomy for advanced gastric cancer were performed at seoul national university bundang hospital between may 2003 and may 2017. the characteristics of patients, surgical techniques, postoperative morbidities, and long-term oncologic outcomes were retrospectively reviewed using electronic medical records. results: 109 patients required conversion to open surgery. the reasons of conversion to open surgery were advanced stage (n=59), intraoperative bleeding (n=19), adhesion due to previous abdominal operation (n=10), small abdominal cavity (n=4), associated disease (n=4), and intraoperative pleural injury (n=2). the mean hospital stay was 7.0 days for distal gastrectomy, 9.6 days for total gastrectomy, 8.3 days for proximal gastrectomy, and 6.5 days for pylorus preserving gastrectomy. the mean number of collected lymph nodes was 58.7 for distal gastrectomy, 70.1 for total gastrectomy, 43.0 for proximal gastrectomy, and 46.5 for pylorus preserving gastrectomy. the rates of postoperative complications of grade ii or more were 9.4 %. there was one case of postoperative mortality due to delayed bleeding after discharge. old age was the only independent predictor of surgical morbidities. background: intrathoracic gastric volvulus is a life-threatening condition of paraesophageal hernia. the therapeutic is a challenge because in acute volvulus it may lead to gastric strangulation and necrosis. most patients are elderly and with a significant associated medical illness which has higher morbidity and mortality of major surgery. we present a laparoscopic surgery is safe in paraesophageal hernia with acute intrathoracic gastric volvulus in a high-risk patient. case presentation: an 80-year-old woman with underlying of diabetes mellitus and hypertension was transferred from an outlying hospital with anemia, dysphagia, urinary tract infection and aspiration pneumonia. she had severe recurrent emesis after admission. ct scan of the chest and abdomen revealed a large esophageal hiatal hernia, and most of the stomach was in the inferior mediastinum with organoaxial gastric volvulus. endoscopy revealed flat pigmented spot gastric ulcer which compatible with cameron lesion and twisting of gastric folds without evidence of ischemia. the endoscopic reduction was unsuccessful. a laparoscopic surgery was performed and the herniated stomach was successfully reduced. the hernial sac was excised. the crura were approximated and reinforced with composite mesh. nissen fundoplication was performed along with gastropexy of the greater curve of the stomach to the abdominal wall. there was no perioperative complication. she tolerated enteral diet on a postoperative day 3. she had an uneventful recovery and discharged in 2 weeks after treatment of her associated medical illnesses. she had no relapse of previous symptoms at her six-month follow-up assessment. discussion: endoscopic reduction of acute gastric volvulus may be the first option in a patient with severe comorbidities. however, if there is evidence of ischemia or failure of endoscopic reduction, surgical treatment should be considered. laparoscopic reduction and gastropexy may be a lessinvasive and viable alternative to the more aggressive surgical procedure but definitive surgery with repair hiatal hernia can be done in a selected patient. conclusion: minimally invasive treatments of acute gastric volvulus with paraesophageal hernia, either endoscopic or laparoscopic offer the option for reducing morbidity and mortality in elderly with significant comorbidities. the definitive laparoscopic surgery can be accomplished successfully and safely when it is performed with meticulous attention to the surgical technique and perioperative care. reid fletcher, md, mph, emily ramirez, rn, alfonso torquati, md, philip omotosho, md; rush university medical center introduction: the objective of this study was to evaluate the impact of an enhanced recovery after surgery (eras) program on post-operative length of stay following laparoscopic sleeve gastrectomy. eras programs have been demonstrated to improve outcomes and decrease length of stay in multiple surgical disciplines however relatively little has been published regarding the impact of eras programs in bariatric surgery. methods: an eras program for all patients undergoing bariatric surgery was implemented in february 2017 at a single institution. we retrospectively reviewed all patients undergoing laparoscopic sleeve gastrectomy between february 2017 and august 2017. as a pre-eras historical control, we also reviewed all patients undergoing laparoscopic sleeve gastrectomy between january 2016 and december 2016. baseline patient characteristics, additional concomitant operative procedures as well as 30-day readmission and complication rates were reviewed. logistic regression analysis was used in univariate and multivariate models to identify factors that predicted early post-operative discharge. data analysis was completed using stata 12 se software (statacorp lp; college station, tx). results: eighty-five patients underwent laparoscopic sleeve gastrectomy after implementation of the eras program while 169 patients were included in the pre-eras control group. there were no statistically significant differences in the baseline characteristics between the two groups and there were no differences in the rate of concomitant procedures performed. there was a statistically significant decrease in post-operative length of stay following implementation of the eras program from 2. it has been reported that laparoscopic redo surgery is effective for recurrent gerd and/or hiatal hernia after surgery. however, there has been very few reports from japan. we report an initial experience of laparoscopic surgery for japanese patients with recurrent gerd and/or hiatal hernia. among 177 patients who had undergone laparoscopic fundoplication in our hospital from 1997 to 2016, 15 patients with recurrent gerd/hiatal hernia underwent redo surgery. preoperative work-up included upper gi series, endoscopy, ct, 24 h ph-impedance and manometry. the patients consisted of 8 women and 7 men with a mean age of 65.8 years. the interval from the initial surgery was 26.7 months (4 days-60 months). the types of initial fundoplication were nissen: 10, toupet: 4, anterior: 1. the types of recurrence were sliding hernia: 11 and paraesophageal hernia: 4. one patient with recurrent sliding hernia had poor gastric motility. laparoscopic redo surgery was performed on 14 patients. redo surgery included crural repair with mesh reinforcement: 3, refundoplication: 10 (nissen-nissen: 3, nissen-toupet: 5, toupet-toupet: 1, toupet-lateral: 1) and reduction of the incarcerated paraesophageal hernia: 1. additional procedure included mesh reinforcement: 4 and pyloroplasty: 1. open partial gastrectomy was performed for one patient with incarcerated and strangulated hernia. operation time was 226 min. 3 patients was converted to open surgery. oral intake was started on the 1st pod and postoperative stay was 6.5 days. two patients recurred after redo surgery, one of whom underwent re-redo surgery. during the surgery, ivc was injured but rescued by open surgery. eleven patients had good outcome and 4 patients required ppi after redo surgery. our morphological fundoplication score significantly improved after redo surgery. symptom score and acid exposure time were also significantly improved after redo surgery. laparoscopic redo surgery for recurrent gerd and/or hiatal hernia after surgery is safe and effective, although attention should be paid during surgery to avoid injury of the adjacent organs. surg endosc (2018) introduction: cameron ulcers (cu) are linear erosions or ulcerations in the gastric mucosa at the level of the diaphragmatic hiatus in patients with a hiatal hernia (hh) and are frequently associated with anemia. perioperative outcomes of patients with cu undergoing hh repair are not well described. we sought to identify the incidence of cu in patients undergoing hh repair at our institution and determine whether the presence of cu impacted postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing repair between january 2011 and april 2017. we identified all patients with cu found on preoperative esophagogastroduodenoscopy (egd). we compared patients with and without cu to determine if they differed in terms of preoperative anemia (defined as hemoglobin levels less than 13 mg/dl in men and 12 mg/dl in women). lastly, we compared outcomes between the cu group and the non-cu group, focusing on need for perioperative blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and 30-day readmission. conclusions: the presence of cu on preoperative egd is associated with increased rate of preoperative anemia, increased los, and increased icu admission after hh repair. although the cause of anemia in patients with hh is commonly attributed to cu, only 38% of cu patients were anemic, indicating that differences in outcomes may not only be attributed to a higher incidence of anemia in cu patients. the implications of cu in patients undergoing hh repair need to be further elucidated. laparoscopic heller myotomy as treatment for achalasia objective: aim of this stud was to review our experience with laparoscopic heller dor myotomy. disphagia constitutes the main symptom. diagnosis is performed by means of esophageal manometry. materials and method: over a period of 15 years, 180 patients were treated with heller myotomy plus dor fundoplication laparoscopically. all patients had lost weight, and there was a prevalence of females with an average age of 46. twenty five patients had chagas disease. they were all assessed with serial x-rays, endoscopy, esophageal manometry, and their symptoms were assessed with a 0-4 score, 4 being the most severe. results: there was no conversion or mortality. in 3 patients the mucosa was perforated during myotomy. the mucosa was sutured without altering the result of the treatment. average hospital stay was 36 hours. one patient had to be reoperate because of esophageal perforation with peritonitis. sixty patients were followed up with manometric control and ph-probe testing, and only 10% of those had pathologic reflux. conclusions: laparoscopic treatment of achalasia is possible and reproducible, while reducing the morbility of laparotomy with relieve of patients symptoms. introduction: stent treatment in the gastrointestinal tract is emerging as a standard therapy for overcoming strictures and sealing perforations. we have started to treat patients with perforated duodenal ulcers using a partially covered stent and external drainage achieving good clinical results. stent migration is a serious complication that may require surgery. pyloric physiology during stent-treatment has not been studied and mechanisms for migration are unknown. the aims of this study were to investigate the pyloric response to distention mimicking stent-treatment, using the endoflip, investigating changes in motility patterns due to distention at baseline, after a pro-kinetic drug and after food ingestion. methods: a non-survival study in five pigs was carried out, followed by a pilot study in one human volunteer. a gastroscopy was performed in anaesthetized pigs and the endoflip was placed through the scope straddling the pylorus. baseline distensibility readings were performed at stepwise balloon distention to 20 ml, 30 ml, 40 ml and 50 ml, measuring pyloric cross sectional area and pyloric pressure. measurements were repeated after administration of a pro-kinetic drug (neostigmin) and after instillation of a liquid meal. in the human study readings were performed in conscious sedation at baseline and after stimulation with metoclopramide. results: during baseline readings the pylorus was shown to open more with increasing distention, together with higher amplitude motility waves. reaching maximum distention-volume (50 ml), pyloric pressure increased significantly (p=0.016) and motility waves disappeared. after prokinetic stimulation pyloric pressure decreased and motility waves increased in frequency and amplitude at 20, 30 and 40 ml distentions. after food stimulation pyloric pressure stayed low and motility waves showed increase in amplitude at distentions of 20, 30 and 40 ml. during both tests the pylorus showed higher pressure and lack of motility waves at maximum probe distention of 50 ml. similar results were found in the human study. the pylorus seems to acts as a sphincter at low distention but when further dilated starts acting as a peristaltic pump. when fully distended, pyloric motility waves almost disappeared and the pressure remained high, leaving the pylorus open and inactive. stent placement in the pylorus results in pyloric distention, possibly changing motility. this study indicates that a duodenal stent placed over the pylorus should have a high radial force in the pyloric part in order to dilate the pylorus and diminish the contraction waves, this might reduce stent migration. introduction: cutting-edge technology in the field of minimal invasive surgery allows the application of singleincision laparoscopic surgery on gastric cancer. however, single-incision distal gastrectomy (sidg) is still technically difficult due to limited range of motion and unstable field of view-even in the hands of an experienced scopist. solo surgery using a passive scope holder may be the key in allowing sidg to be safer and efficient. we report our initial experience of 100 consecutive cases of solo sidg. methods: prospectively collected database of 100 patients clinically diagnosed as early gastric cancer who underwent solo sidg from october 2013 until july 2016 were analyzed. all the operations were held by a single surgeon and a scrub nurse. a passive laparoscopic scope holder was controlled by the surgeon to fix the field of view. results: the mean operation time (sd) was 122.8 (±34.9) min, and the average estimated blood loss was 30.5± 57.0 ml. average body mass index was 23.4±2.9 kg/m 2 . the median hospital stay (range) was 5 (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) days, and the mean number of retrieved lymph nodes was 56.0±22.8. there was no conversion to multiport or open surgery. early postoperative complication occurred on 7% with three delayed gastric emptying, two postoperative pneumonia, one pancreatitis, and one wound complication. conclusion: solo sidg using a passive scope holder allows sidg to become more feasible by providing a stable field of view. there were no peri-operative deaths in either group. in the elective group, age was not an independent risk factor for complications (or 1.05, 95% ci 0.98-1.12). conclusions: the incidence of major complications and mortality in this series were much lower than those previously reported for elective lpehr, while morbidity after emergency repair remains high. the paradigm of watchful waiting for elderly and/or minimally symptomatic patients with giant peh should be revisited. the impact of vagal nerve integrity testing in the surgical kamthorn yolsuriyanwong, md, eric marcotte, md, mukund venu, bipan chand, md; loyola university chicago, stritch school of medicine background: thoracic and gastric operations can cause vagal nerve injury, either accidentally or intended. the most common procedure, which can lead to such an injury, includes fundoplication, lung or heart transplantation and esophageal or gastric surgery. patients may present with minimal symptoms or some degree of gastroparesis. gastroparetic symptoms of include nausea, vomiting, early satiety, bloating and abdominal pain. if these symptoms occur and persist, the clinician should have a high suspicion of a possible vagal injury. investigative studies include endoscopy, esophageal motility, contrast imaging and often nuclear medicine gastric emptying studies (ges). however, ges in the post-surgical patient have limited sensitivity and specificity. if a vagal nerve injury is encountered, subsequent secondary operations must be planned accordingly. methods: from january 2014 to august 2017, patients who had a previous surgical history of a foregut operation, with the potential risk of a vagal nerve injury, had vagal nerve integrity (vni) test results reviewed. vni test was measured indirectly by the response of plasma pancreatic polypeptide to sham feeding. the data collected and analyzed included age, gender, previous surgical procedures, clinical presentation, results of vni testing and the secondary procedure planned or performed. vni testing was compared to other testing modalities to determine if outcomes would have changed. results: eight patients (5 females) were included. the age ranged from 37 to 73 years. two patients had prior lung transplantation and six patients had prior hiatal hernia repair with fundoplication. seven patients presented with reflux and delayed gastric emptying symptoms. one lung transplantation patient had no symptoms but his lung biopsy pathology showed chronic micro-aspiration with rejection. the vni testing results were compatible with vagal nerve injury in 6 patients. according to these abnormal results, the plans for nissen fundoplication in 2 patients were modified by an additional pyloroplasty and the plans for redo-nissen fundoplication in 4 patients were changed to redo-nissen fundoplication plus pyloroplasty in 1 patient and partial gastrectomy with roux-en-y reconstruction in 3 patients. the operative plans in 2 patients with a normal vni test were not altered. all patients that had secondary surgery had improvement in symptoms and or improvement in objective tests (ie signs of rejection). conclusion: the addition of vni testing in patients with previous potential risks of vagal nerve injury may help the surgeon select the appropriate secondary procedure. . we present a single-center experience with a "myotomy first" approach for all patients, regardless of diverticular size. the hypothesis is that cardiomyotomy alone will provide satisfactory symptom abatement in some patients. and mis cardiomyotomy causes minimal scarring, so a staged mis diverticulectomy is feasible at a later date if diverticular retention/stasis continues. in order to discuss this treatment algorithm we present our experience with cardiomyotomy alone for patients with epiphrenic diverticula. methods: the electronic medical record was queried for patients with esophageal diverticula who were managed with cardiomyotomy and dor fundoplication alone. pre and post-operative reflux/dysphagia questionnaires were gathered; imaging studies, operative data, complications and follow up were reviewed. results: from march of 2016 until the present, 7 patients with esophageal diverticula were treated using the "myotomy first" approach. intraoperative esophagoscopy was done to internally visualize the elimination of the inciting spastic esophageal muscle. preoperatively, all patients complained of regurgitation, followed by dysphagia in 6 (85%) and weight loss 3 (42%). postoperatively, dysphagia and weight loss resolved in all subjects. regurgitation symptoms resolved in 6 (85%) patients. the average size of the diverticula was 22.7 cm 2 , the range was 2-62 cm 2 . post operative esophagream's showed persistent diverticual, however most had decreased in size. there were no perioperative complications, average length of stay was 2.1 days and there were no icu admissions or returns to the or. the average length of follow up for these patients was 116 days where all patients reported being satisfied with their results and none of them have yet desired to pursue diverticulectomy. discussion: a "myotomy first" approach resulted in excellent short term symptomatic control. none of the 7 have retained or re-experienced symptoms of diverticular retention worthy of surgical intervention. in the age of laparoscopic surgery, an esophageal epiphrenic diverteculectomy should be staged. this step wise approach seeks to assure surgical necessity for a morbid endeavor. surg endosc (2018) 32:s130-s359 the background: the two-stage oesophagectomy (ivor-lewis procedure) remains the mainstay of curative surgery for oesophageal cancers in the uk. gastro-oesophageal anastomotic leak is a potentially devastating complication of this procedure affecting perioperative morbidity and mortality. although the leak rates have improved over the years, it still remains widely variable. intraoperative reinforcement of gastro-oesophageal anastomosis with an 'omental wrap' has been proposed as a measure to reduce anastomotic leak rates. there is some data to suggest that this additional technique reduces anastomotic leak. we reviewed our single institution data to assess if the omental wrap indeed had a 'cocoon' effect in maturing the anastomosis and reducing leak rates. methods: data for all cancer oesophagectomies (ilog) performed in our institute since april 2013-17 was retrospectively analysed from a prospectively maintained database. the patients were categorised into two groups. masafumi ohira; department of gastroenterological surgery, hokkaido university graduate school of medicine background: in laparoscopic surgery, both surgical technique and adequate support and traction by an assistant are highly important. this study assessed the impact of the first assistant on shortterm outcomes of laparoscopic distal gastrectomy (ldg) and laparoscope-assisted distal gastrectomy (ladg). methods: patients who underwent ldg or ladg for gastric cancer at our hospital, between november 2013 and august 2017, were included. ldg and ladg cases of billroth i reconstruction, performed by a single surgeon accredited in endoscopic procedures, were analyzed. the cases were categorized into the following 4 groups according to the first assistant's postgraduate years (pgy) of experience: group a, 3-5 years; group b, 6-10 years; group c, 11-15 years; and group d, [16 years. short-term outcomes were compared between the groups. results: we examined 48 cases. operative time was significantly longer in group a than in group b (p=0.029). no significant differences in operative time were found between groups b, c, and d. the cases were recategorized into 2 groups as follows: group a, the young assistant group (group y, n=8), and groups b, c, and d, the senior assistant group (group s, n=40). significant differences in operative time and method of anastomosis (circular stapler or delta anastomosis) were observed between the 2 groups (p=0.0054 and p=0.0028, respectively), but no significant differences in complication rates were found (p=1.0000). the unadjusted analysis revealed that the group, method of anastomosis, and body mass index (bmi) were significant factors associated with longer operative time. multivariate linear regression analysis with stepwise model selection using akaike's information criterion (aic) revealed that bmi and group were significant factors associated with longer operative time (p=0.0075 and p=0.0024, respectively). multivariate analysis using these 2 variables and the method of anastomosis confirmed the significance of bmi and group for longer operative time, but no significance was found in the method of anastomosis (p=0.0088, p=0.021, and p=0.51, respectively). conclusions: our study showed that operative time tended to be longer when the first assistant had experience of less than 6 pgy, but the morbidity did not increase. as with the operator, the first assistant needs adequate training to ensure a smooth operation. steven g leeds, md, marc ward, md, brittany buckmaster, pa, estrellita ontiveros, ms; baylor university medical center at dallas background: gastric contents can reach beyond the esophagus into the larynx and pharynx causing an increasingly prevalent disease called laryngopharyngeal reflux (lpr). magnetic sphincter augmentation (msa) has been used as an alternative treatment for gerd with good success, but there is no data to support its use in lpr. methods: forty-five patients with msa implants for symptomatic relief with both gerd and lpr symptoms were examined. all patients experienced at least one typical gerd symptom as well as at least one extra-esophageal symptom. this was assessed using the gerd-hrql which is 15 questions graded 1-5 on each question, and reflux symptom index (rsi) which is 9 questions graded 1-5 on each question. patients filled out questionnaires preoperatively, one month postoperatively (early follow up), and at 6 months to 1 year postoperatively (late follow up). the responses on the gerd-hrql were clustered into questions inquiring about heartburn (6), dysphagia (2), and regurgitation (6) like all surgical fields there is a push towards standardization of the post operative course while maintaining safe practices. other surgical fields have streamlined recovery processes in an effort to standardize care and minimize costs. laparoscopic hiatal hernia repair is a complex procedure, but with experience and a team approach, this operation can become a streamline process. methods: a retrospective review was done for over 250 laparoscopic hiatal hernia repairs at a single institution. aspects of post operative care such hospital floor, nursing ratio utilized, pain medication, diet advancement, use of foley catheters and length of hospital stay were tracked. statistical analysis was done to compare utilization of resources as years went on along with complications and readmissions. results: a total of 258 hiatal hernias were performed between 2011 and 2017. improvements were noted in nearly every field over time, including faster foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (pcas) and faster advancement of diet. furthermore these patients are now treated on a surgical floor rather than the intensive care unit or step down with a higher nurse to patient ratio, decreasing hospital cost. there were no changes in complications, reoperations or readmissions over the course of the study. conclusions: cost, length of stay and so called "advanced recovery pathways" are all the rage in the surgical literature. anytime a procedure and its post operative course can become less of a "major undertaking" and more routine, the more streamline it becomes. this comes from making a standard protocol that deescalates treatment based on what is actually needed. nearly every aspect of post operative care was simplified; length of stay and cost to the hospital was decreased while no additional complications or readmissions were accrued. the foundation of a formalized advanced recovery pathway will be implemented from these factors which were studied. background: the obesity epidemic continues to worsen. bariatric surgery remains the most effective way to achieve weight loss and resolution of comorbidities. laparoscopic sleeve gastrectomy has become the most common bariatric operation due to excellent efficacy and low morbidity and mortality. the most common complication of sleeve gastrectomy is gastroesophageal reflux disease (gerd), which can adversely impact the quality of life and lead to additional esophageal complications. recently, esophageal magnetic sphincter augmentation (linx®) has become an acceptable alternative to fundoplication for certain patients with gerd. the use of linx® in patients who previously underwent laparoscopic sleeve gastrectomy was described in a case series in 2015. the known complications of these devices include dysphagia, need for endoscopic dilation, and device erosion. the complication profile of linx® in the setting of sleeve gastrectomy has not been reported heretofore. methods: we present a case of a patient with prior sleeve gastrectomy who received a linx® device one year after her bariatric operation due to severe gerd refractory to medical management. initial evaluation demonstrated a hypotensive lower esophageal sphincter and hiatal hernia, but no evidence of stricture or twisting. soon after linx® implantation, the patient developed progressive dysphagia and worsened reflux. repeat evaluation showed esophagitis, a moderate stricture with angulation at the incisura, and a large amount of retained food. discussion: the patient was recommended conversion to roux-en-y gastric bypass, but was deemed to be a poor candidate due to heavy smoking. thus, laparoscopic removal of the linx® device was performed with hiatal hernia repair and gastric stricturoplasty. post-operative fluoroscopic evaluation revealed improvement in the stricture, but persistent gastroesophageal reflux. the patient experienced a significant improvement in her symptoms of dysphagia, nausea, and vomiting. however, once smoking cessation is achieved, she may still need a conversion to roux-en-y gastric bypass in order to address persistent gerd. conclusion: conversion to roux-en-y gastric bypass remains the standard approach to treatment of gerd post sleeve gastrectomy. new approaches to this problem, including placement of linx®, are promising but have not been evaluated for long-term safety and efficacy in the setting of prior bariatric surgery. careful diagnostic evaluation prior to placement of magnetic sphincter augmentation device should be routinely undertaken. postoperatively, close long-term follow up is imperative, particularly in patients with prior sleeve gastrectomy. presence of linx® in a patient with prior bariatric surgery may lead to worsening symptoms if complications of initial operation are present. kazuto tsuboi, md 1 , nobuo omura, md 2 , fumiaki yano, md 3 , masato hoshino, md 3 , se-ryung yamamoto 3 , shunsuke akimoto, md 3 , takahiro masuda 3 , hideyuki kashiwagi, md 1 , norio mitsumori, md 3 , katsuhiko yanaga, md 3; 1 fuji city general hospital, shizuoka, japan, 2 nishisaitama-chuo national hospital, saitama, japan, 3 the jikei university school of medicine, tokyo, japan background: esophageal achalasia is one of the primary esophageal motility disorders, and the patients suffer from dysphagia, vomiting and chest pain. timed barium esophagogram (tbe) is a convenient method to assess esophageal clearance, which we usually performed before and after surgery. meanwhile, laparoscopic heller-dor operation (lhd) has been considered worldwide as a gold standard for the surgical management of esophageal achalasia. the aim of this study is to examine the effect of preoperative clearance rate at the lower part of the esophagus on surgical outcomes in patients with esophageal achalasia. patients and method: between august 1994 and april 2017, patients who underwent lhd at our institution were extracted from the database. out of 557 patients, 398 patients met our inclusion criteria; such as the patients who underwent lhd as an initial operation with complete evaluation with preoperative esophageal clearance by tbe. these patients were divided into three groups by the degree of esophageal clearance (group a: clearance rate \10%, group b: 10%? clearance rate \50%, and group c: 50%? clearance rate). patients' background, pre-and post-operative symptom scores, and surgical results were compared. before and after surgery, the standardized questionnaire was used to assess the degree of frequency and severity of symptoms (dysphagia, vomiting, chest pain and heartburn). moreover, satisfaction with operation was evaluated using the standardized questionnaire. statistical analysis was performed by using krasukal-wallis test or chi-square test, and p-value less than 0.05 was defined as statistically different. results: their mean age was 44.3 years and 204 of them were male (51.3%). one hundred and sixty-eight patients (42.2%) were in group a, 149 (37.4%) in group b, and 81(20.4%) in group c. the maximum width of the esophagus in group c was smaller than that in other groups (p= 0.0258). as to the pre-operative symptom score, the frequency score of dysphagia was significantly lower in group c (p=0.026), whereas the severity score of chest pain was significantly higher in group c (p=0.0465). surgical outcomes including the incidence of mucosal injury were not different among the groups. moreover, the patient satisfaction with lhd was excellent regardless of preoperative esophageal clearance. conclusion: preoperative clearance rate at the lower part of the esophagus in patients with esophageal achalasia did not affect the surgical outcomes of lhd, but the characteristics of preoperative symptoms in patients with poor esophageal clearance was low dysphagia and high chest pain. surg endosc (2018) (3.5 cm92.5 cm) was made by dissecting between submucosal and muscular layers at the anterior remnant gastric wall. after creation of the double flap, the posterior esophageal wall (5 cm from the edge) and the anterior gastric wall (superior edge of the mucosal window) were sutured for fixation, and 1.0 cm from the inferior edge of the mucosal window was opened, and the wall of the esophageal edge and the opening of the remnant gastric mucosa were sutured continuously. the anastomosis was fully covered by the seromuscular flaps with suturing. in latg, roux-en-y reconstruction was performed through a small incision using a circular stapler. introduction: the purpose of this study was to clarify the long-term and short-term outcomes of 330 consecutive patients who underwent thoracoscopic esophagectomy in the prone position using a preceding anterior approach for the resection of esophageal cancer at a single institution. this method was established to make an esophagectomy easier to perform and to achieve better outcomes in terms of safety and curativity. methods and procedures: we retrospectively reviewed a database of 673 patients with thoracic esophageal cancer who had undergone a thoracoscopic esophagectomy (te, 330 patients) or an esophagectomy through thoracotomy (oe, 343 patients) between january 2003 and august 2017. to compare the long-term outcomes of te and oe, we used a propensity score matching analysis and a kaplan-meier survival analysis. to analyze the short-term outcomes of te, patients were chronologically divided into three groups: a first period group (110 patients), a second period group (110 patients), and a third period group (110 patients). as for thoracoscopic procedure, the esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. the lymph nodes around the esophagus were also dissected anteriorly and posteriorly. the intraoperative factors, the number of dissected lymph nodes, and the incidence of adverse events were compared among the three period groups using a one-way anova or chi-square test. results: one hundred and twenty-three patients from each group, for a total of 246 patients, were completely selected and paired. background: it is also difficult to anastomose using circular stapler in the narrow neck field. to overcome the problem we modified circular stapling for anastomosis. gastric juice reflux is frequently observed at the esophagogastric anastomosis. we develop and report trapezoidal tunnel method to reduce the incidence reflux. (1) patients one hundred thirteen cases (27 in left lateral and 93 in prone position), with esophageal carcinomas underwent vats-e, respectively. esophago-gastric anastomosis is performed for 80 cases by modified circular stapling and 3 cases by trapezoidal tunnel method. (2) methods at first the patients are fixed at semi-prone position and esophagectomy is performed in prone position that can be set by rotating and 5 ports are used at the intercostal space (ics). esophagectomy and the l.n. dissection are performed with pneumothorax by maintaining co2 insufflation. esophago-gastric anastomosis is performed as following, i) trapezoidal tunnel method sero-muscular layer of anterior wall in the near top of gastric conduit is peeled from submucosal layer after parallel horizontal incision of sero-muscular layer, and then trapezoidal tunnel of sero-muscular layer is created. the edge of the proximal esophagus is drawn into the tunnel and esophago-gastric submucosa anastomosis is performed. to wrap anastomosis distal side of parallel line is closed. ii) modified circular stapling at first the circular stapler is introduced into the gastric conduit and joined to an anvil, and close a little. and then a joined anvil is placed into the proximal esophagus and secured by means of a pursestring suture. the gastric conduit opening is closed by a linear stapler. purpose: mesh utilization and its impact on postoperative hernia recurrence following paraesophageal hernia repair remains a polarizing topic. this analysis evaluates the recent trends in laparoscopic paraesophageal hernia repairs and analyzes the impact of operative time on postoperative morbidity. methods: the 2013-2015 acs-nsqip database was queried for primary cpt code for laparoscopic paraesophageal hernia repair with and without mesh (43282/43281). only elective cases performed by a general surgeon were included. operative time was grouped into quartiles (80-110, 111-142, 143-185, 186-360 min) and statistical analysis was performed using anova univariate with post-hoc testing and multivariate regression modeling controlling for age, diabetes, renal disease and weight loss. this analysis was powered to detect a greater than 2% difference in outcomes based on mesh utilization. the outcomes of interest were composite morbidity scores and readmission rates within 30 days of surgery. results: the database identified a cohort of 6,234 laparoscopic paraesophageal hernia repairs performed between 2013 and 2015. average patient age was 64 years and average patient body mass index was 31. mesh was utilized in 42% of cases per year and did not change over the study period (p=0.367) however mesh utilization was 37%, 40%, 43%, and 49% within operative time quartiles 1-4 respectively (p.001). postoperative morbidity and readmission rates for each operative time quartile were 2.8%, 4.1%, 5.42%, and 6.13% (p.001) and 4.4%, 5%, 6.2%, and 7.6% (p=0.001), respectively. post-hoc testing indicated statistically significant differences in postoperative morbidity and readmission rates between quartiles 1 and 3/4. multivariate regression analysis documented operative time as a risk factor for postoperative morbidities and readmission, even after controlling for covariates. mesh utilization was only significant for a reduction in the rate of venous thromboembolic complications (or 0.493, p=0.027) but did not impact other morbidities or readmission rates. conclusion: this analysis suggests that patients with higher operative times have increased postoperative morbidity and readmission while mesh utilization does not impact postoperative outcomes, after accounting for the longer operative time of a paraesophageal hernia repair with mesh. introduction: gastroparesis is a chronic gastric motility disorder defined by delayed gastric emptying and symptoms such as nausea, vomiting, bloating and abdominal pain. surgical options for refractory gastroparesis include pyloroplasty, gastric stimulator insertion, and gastrectomy. the palliation from a pyloroplasty and gastric stimulator may be synergistic, however concerns remain regarding the possibility of stimulator infection when performing both procedures simultaneously. we present our initial experience of combined laparoscopic pyloroplasty and insertion of gastric stimulator. methods: gastroparesis patients diagnosed by solid gastric scintigraphy or endoscopic evidence of retained food after prolonged npo status who underwent combined laparoscopic heineke-mikulicz pyloroplasty and gastric stimulator insertion between july 2016 and july 2017 were reviewed. patient demographics, pre-and post-operative symptom scores and outcomes were collected. results were analyzed using statistical tests as appropriate. p value .05 were considered significant. results: seven patients underwent the simultaneous pyloroplasty and gastric stimulator insertion. six patients (86%) were idiopathic and one patient (14%) was diabetic. one patient was male and six patients were female. charleen yeo, enming yong, danson yeo, kaushal sanghvi, aaryan koura, jaideepraj rao, myint oo aung; tan tock seng hospital introduction: gastric cancer is one of the most common cancers in the asian population, with recent literature supporting the laparoscopic approach in early disease. however, the minimally invasive approach in advanced disease is still controversial. the outcomes of laparoscopic gastrectomy in the elderly have also not been extensively studied. we aim to evaluate our institution's short term outcomes of laparoscopic versus open gastrectomy for gastric cancer-with particular focus on advanced disease and elderly patients. methodology: we prospectively collected the data of all patients who underwent gastrectomies for stomach cancer from 2008 to 2015. all patients underwent a partial or total gastrectomy with d2 lymphadenectomy. the decision for open or laparoscopic approach was decided between surgeon and patient. we excluded patients who underwent palliative resection. all patients were followed up for at least one year post-operatively. introduction: it was an eye-opener when the lancet brought the attention about global surgery. it is estimated that the deaths due to lack of access to surgery is far greater than deaths due to malaria, tuberculosis and hiv/aids put together. there is greater need to stress the importance in developing countries. there is a responsibility at the medical schools to enlighten students about this necessity and arouse interest in concept of global surgery. the students or surgical residents in the future are a great resource to solve this major problem. the first step would be to educate surgical residents. we need to assess the existing awareness about global surgery problem among surgical residents. we can plan a program to train the next generation surgeons. methods and procedure: all the surgical residents in our institution (victoria hospital, bangalore, india) were enrolled for this study. a total of 212 residents were enrolled. a multiple-choice questionnaire regarding global surgery was designed. the received questionnaire was analyzed to assess the depth of knowledge about global surgery. there were 20 multiple choice questions (mcq) and an option was provided at the end for feedback and suggestion to improve the global surgery in our country. each question carried one mark. score more than 10 was considered the cutoff for pass and those students were termed 'informed'. results: 91(42.9%) students cleared the cut off score of 10 and were termed 'informed'. among this group 21 (9%) residents scored 20 marks. 121 (57.07%) students did not cross the cut off and were termed 'non-informed'. among these 57 (26.8%) students scored 0 marks and did not know anything on the topic. 43 students provided relevant suggestions and opinions to improve global surgery issue. conclusion: there is a great lacuna in knowledge about global surgery among surgical residents. we need to plan a program integrating global surgery in the syllabus of surgical training. the awareness among residents would arouse interest and participation in the future. introduction: minimally invasive surgical techniques (mists) could have tremendous applications and benefits in resource poor environment. these include but are not limited to short hospital stay, reduced cost of care, and reduced morbidity, especially related to post operative infections. there is growing interest in mists in most low and middle income countries (lmic) but its adoption has remained limited largely due to high cost of initial set-up, lack of technological backup and limited access to training among others. one of the most limiting factors is the maintenance of the vision system. an affordable laparoscopic set-up as an example will therefore go a long way in improving access to mists. methods and procedures: a common zero-degrees 10 mm scope is attached on the camera of a low price smartphone (samsung galaxy j3 2016, samsung®, seoul, south korea). two elastic bands are used to fix the scope right in front of the main camera on the smartphone. the device is covered with sterile transparent drapes (tegaderm®, 3m corporate, st. paul, mn, usa). a light source is connected with a fiber optic cable for endoscopic use. the image can be seen in real time on a common tv screen through an hdmi connection to the smartphone, with a sterile drape. holding the vision system through the scope would guarantee to keep the camera in place without issues. to operate in full screen the vision was digitally zoomed at 91.6, without losing quality (that is more related to the intensity of the light). as a collateral project we built a low cost simulator training box with the same camera to train the surgeon, obtaining a high fidelity and affordable simulation setting. results: we were able to perform the 5 tasks of the fundamentals of laparoscopic surgery curriculum using our vision system with proficiency. in a pig model, we performed a tubal ligation to simulate an appendectomy and we were able to perform basic laparoscopic suturing. no major issue were encountered and small adjustment only were required to have an acceptable, stable and clear view. conclusion: there is growing interest in minimally invasive surgeries among surgeons in lmic, but its adoption has remained limited due to reasons such as high cost of initial set-up, lack of technological backup and limited access to training among others. an affordable laparoscopic camera system will therefore go a long way in improving access to mis in such settings. open. there were no deaths or bile duct injuries in our series. two patients undergoing laparoscopic approach were converted to open (7.1%). complications, los, and gender were similar between the two groups. the laparoscopic group were significantly younger and had a significantly longer operative duration (table) . long term outcomes were not available for analysis. laparoscopic and open cholecystectomy appear safe in the setting of short term surgical missions. neither group suffered major complications. both had similar immediate outcomes. los for both groups was surprisingly similar and shorter than larger series which may possibly due to patient selection. given similar immediate outcomes and large burden of disease, the open approach should be considered. however, this cost may be extracted in terms of greater pain or longer recovery time for patients, which may outweigh the benefits. further data is needed to study pain, long term outcomes, and return to work. introduction: minimally invasive surgery relies on optimal camera control for the successful execution of operations. one disadvantage of laparoscopic surgery is that camera control is dependent on a surgical assistant's interpretation of visual cues and ability to predict the next field of focus in addition to verbal commands from the operating physician to provide the optimal view. robot-assisted minimally invasive surgery provides the operating surgeon the advantage of dictating their field of view. this study aims to utilize a video processing algorithm to determine the incidence of improperly centered field of view in laparoscopic vs. robot-assisted surgery. methods: in this study, 8 recordings of minimally invasive resection of rectal cancer (4 laparoscopic and 4 robot-assisted surgery) were evaluated. recordings were input into matlab® video processing to generate single frames at each second interval. a single reviewer would indicate the pixel which best determined where the camera should be centered based on positioning of instruments, current action (dissection/hemostasis/traction) depicted in the frame, and previous review of recordings. pixel locations were recorded for subsequent analysis. centered views were determined as those with the identified centered position pixel lying within the center quadrant when frames were split into a uniform 393 grid. in addition, distance of each point to the absolute center of the frame was calculated based on the pixel's x and y positions. results: individual operation data was analyzed for percent of centered pixel locations and pixel distance from the center pixel of the frame. robot-assisted surgery demonstrated higher percentage of centered views over laparoscopic surgery (61.5±5.1 vs. 49.7±7.8; p.05). robot-assisted surgery also demonstrated shorter distances to frame center than laparoscopic surgery (123.3±9.8 vs. 144.8±13.9; p.05). conclusion: robot-assisted surgery aims to resolve conflicts of cooperation that occur between surgeon and assistant in laparoscopic surgery by enabling manual visual control of the operative field by the operating surgeon. this study demonstrates that by eliminating such conflicts, optimal surgical view is more frequently obtained. surg endosc (2018) background/objective: valveless laparoscopic insufflator systems are marketed for ability to prevent loss of abdominal collapse and desufflation during laparoscopy. however, community surgeons raised concern for possible entrainment of room air, including oxygen (02), with these systems. this study seeks to quantify o 2 and non-medical air entrainment by a laparoscopic valveless cannula system to understand the risk of intraoperative air embolism. a communityuniversity collaborative was created to design a model and test this hypothesis. methods: an artificial abdomen was developed and calibrated to equivalent compliance and intraoperative volume of an average adult abdomen. it was connected to a flow meter, oxygen concentration sensor, and commercially available laparoscopic valveless cannula system. background: further advance of near-infrared (nir) imaging capability into greater clinical usefulness will be helped by the development of new targetable agents. to avoid issues related to dose timing and contamination, compounds that become fluorescent only at the site being targeted would be a significant advance. here we build on earlier laboratory work to show step-wise advance of the agent towards clinical trialling. methods: a novel agent (nir-aza) was tested in ex vivo colorectal specimens using two commercially available systems to determine characteristics in biological tissue. it was then trialled in a large animal cohort (n=4) to determine its performance for both intestinal perfusion assessment and lymph node mapping (both stomach and colon) using again a commercially available optical imaging system and including a direct comparison with indocyanine green. results: the novel agent was easily detectable in biological tissue in the near infrared wavelength relevant to commercial instrumentation both as a local depot tattoo and as a lymphatic tracing agent. porcine model trialling again showing excellent detection and tracking characteristics both in the circulation and in gastrointestinal tissue with clear tracking to relevant lymph nodes within minutes evident with the latter. while these studies were non-survival, there was no evidence of local tissue or systemic system toxicity in any case. direct qualitative and quantificative comparison between in situ nir-aza and icg at both intestinal and lymph basin regions showed similar levels of fluorescence. conclusion: the trial compound underwent successful testing indicating proof of earlier projected potential. this is encouraging for further work to advance to first in human testing. introduction: enhanced imaging systems have been developed to alter laparoscopic camera output to facilitate visualization during laparoscopic surgery using several novel imaging modes: clara mode reduces overexposure and reflections while brightening darker areas of the image; chroma mode intensifies color contrast to more clearly delineate blood vessels; and a combined chroma-clara mode. the ies also allows the surgeon to change imaging modes throughout the procedure as needed to facilitate different portions of the operation. we hypothesized that this technology would enhance visualization of critical structures during laparoscopic cholecystectomy (lc) compared to standard laparoscopic imaging. methods: videos and still images from an ies (karl storz endoscopy) were assessed in 12 patients undergoing lc using the four imaging modalities. three time points were assessed: 1) after adhesions were taken down but before any other dissection; 2) after partial dissection of the hepatocystic triangle; and 3) after establishment of the critical view of safety (cvs). seven surgeons blinded to the imaging modalities ranked each modality from 1 (best) to 4 (worst) for each of 36 time points (3 dissection points for 12 cases). structures identified on achievement of the cvs were also analyzed. all statistics were performed using spss. rank data was analyzed with the friedman and wilcoxon signed rank tests. results: the median ranks of the chroma and chroma-clara imaging modalities (median [iqr] 2 [1] [2] [3] vs 2 (1-2), p=0.07) were not significantly different from each other, but both ranked significantly higher than the clara and standard modalities (median rank [iqr] 4 [3] [4] and 3 [2] [3] , respectively, p.001). individual surgeon preferences varied; four surgeons preferred chroma-clara, two preferred chroma, one preferred clara, and none preferred the standard mode. in addition, the cystic artery and cystic duct were visible in all cases after achieving the cvs, but the common bile duct was visible in only 13% of cases. conclusion: enhanced imaging system technology provides modalities that were significantly preferred over standard laparoscopic imaging on retrospective review of still and video images during lc. enhanced imaging modalities should be evaluated further to assess their impact on outcomes of lc and other laparoscopic procedures. introduction: cholangiocarcinoma is often diagnosed at an unresectable stage. endoscopic stent placement is generally performed to release the tumor-induced biliary obstruction. however, stents misplacement and migration, tumor tissue ingrowth and cholangitis are relatively frequent complications. energy-based techniques (radiofrequency ablation and photodynamic therapy) have been proposed as alternatives or in addition to the stent placement, showing controversial results. the use of laser sources in the ablation of the biliary wall has not been investigated so far. this study aims at the evaluation of the optimal power and exposure time to achieve a controlled circumferential intraluminal laser ablation of the common bile duct (cbd). methods: through a laparotomy access, the cbd of 4 pigs was exposed and a small choledocotomy was made. a confocal endomicroscopy (ce) scanning (cellvizio) was performed through the choledocotomy, after injection of 5 ml of sodium fluorescein. the 1.2 mm diameter circumferentiallyemitting diode laser probe (940 nm wavelength) was introduced in the cbd. laser ablation was performed at 7 w during 180s (n=2) or 360s (n=2). the power setting was predetermined on preliminary ex-vivo tests on porcine liver specimen. local temperature control was monitored through a fiber bragg grating, embedded in the laser probe. ce scanning was then repeated. the extent of the ablation was measured on hematoxilin-eosin and nadh stained slides. results: the diameter of the probe was too small to enable a single-shot circumferential ablation. there were no full-thickness perforations. after 50s from turning laser on, the temperature at the application site reached a plateau with minimal oscillations, and remained at mean values of 61.5± 6.7°c during both 3 and 6 min. histology revealed that the mucosa ablation, at the contact areas, induced a consistent cellular necrosis (nadh-). ce scanning provided real-time images with a specific aspect of the post-ablation mucosa, including an alteration of the normal glandular structure and a general lack of enhanced imaging. the local application of a circumferential laser source induced a precise and safe mucosa ablation with a long-standing increase in temperature in the cbd, in this experimental trial. however, there is a need of an adapted probe, better fitting the diameter of the cbd to enable a single-shot circumferential treatment. goutaro katsuno, md, phd 1 , yasuhiko nakata, md, phd 1 , nobuyuki kubota, md, phd 1 , teruo kaiga, md, phd 1 , takao mamiya, md 1 , masahiro yan, md 1 , naoaki shimamoto, md 1 , shuichi sakamoto, md, phd 2; 1 department of gastrointestinal and minimally invasive surgery, mitsuwadai general hospital, 2 introduction: recently major developments in video imaging have been achieved for performing complete mesocolic excisions (cme) or total mesorectum excisions (tme). indocyanine green (icg) fluorescence imaging is already contributing greatly to making intraoperative decisions for keeping an intact visceral fascial layer, making suitable mesentery division lines and identifying anastomotic perfusions. the aim of this study is to present our experience with laparoscopic procedures for colo-rectal cancers using icg fluorescence imaging (lap icg-fi). patients and methods: we usually use the near-infrared (nir) laparoscopy (stryker corporation, michigan, usa) for lap icg-fi. [indocyanine green fluorescent imaging] visualization of lymph flow: icg (2.5 mg/1.0 ml) was injected into the submucosal layer around the tumor at 2 points with a 23-gauge localized injection before the lymph node dissection. visualization of blood flow: after complete colorectal mobilization, the mesocolon was completely divided at the planned proximal or distal transection line. indocyanine green was injected intravenously and the transection location(s) and/or distal rectal stump, if applicable, were re-assessed in fluorescent imaging mode. results: we experienced 32 lap icg-fi cases with colo-rectal cancer patients. tumor was located at the rectum in 12 of them, at the sigmoid colon in 10, at the transverse colon in 2, at the descending colon in 2, at the ascending colon in 4, and at the cecum in 2. tnm stage was 0-i in 10 patients, ii in 9, iii in 8, and iv in 5. the median (range) age of the patients was 68 (55-77) years with a median (range) bmi of 24.8 (20-36.4) kg/m 2 . the lymph flow was visualized in 30 patients (94%) intraoperatively. however, a high-quality intraoperative icg lymphangiogram was achieved in 22 patients (73%). in high-quality lymphangiogram, the lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in keeping an intact visceral fascial layer as well as in making a suitable mesentery division line even in the bmi[30 patients. a high-quality intraoperative icg angiogram was achieved in all patients. anastomotic perfusion was satisfactory in all cases. in 2 patients (6.3%), the use of nir+icg resulted in revision of the proximal colonic transection point before formation of the anastomosis. there were no postoperative anastomotic leakages. no injection-related adverse effects were reported. conclusion: lap icg-fi is a simple, safe and useful tool to help us complete lap cme or tme and check real-time anastomotic tissue perfusion. introduction: recently, the spread of laparoscopic surgery as a standard treatment and the development of information & communication technology have yielded abundant video data of laparoscopic procedures. these data have been accumulated and we can access them anytime, anywhere. however, the direction of how to use the abundant video data are still unclear. conventionally, surgical procedures have been performed based on surgeon's subjective decisions and skills, so called "tacit knowledge". for the purpose of objective analysis of laparoscopic procedures in video data, automatic recognition of surgical tools and understanding of surgical workflow must be the first critical step. we used convolutional neural network (cnn) which is the current trend in machine learning and computer vision tasks. methods: using video database of laparoscopic sigmoid colectomy in our institute, we performed annotation of tools and phases in every frame of the operating videos. for the tool detection, we annotated bounding boxes for both left and right tools in the videos. furthermore, phase annotation was performed by watching the videos in consultation with laparoscopic surgeons. the laparoscopic sigmoid colectomy operation passes through 10 phases; 1-placement of ports and preparation, 2-dissection of retrorectal space, 3-medial approach to ima, 4-isolation and division of ima, 5-medial-to-lateral retromesenteric dissection, 6-lateral mobilization of left colon, 7-rectosigmoid mobilization, 8-division of mesorectum, 9-rectosigmoid resection and anastomosis, 10-finishing. we used cnn architecture to perform surgical tool detection and workflow recognition. results: we totally labeled 8 tools used in the procedures of laparoscopic sigmoid colectomy and successfully developed tool detection system by cnn. as for surgical workflow, average times of phase 1-10 were 11. 3, 9.9, 8.7, 5.9, 11.5, 10.2, 8.7, 11.6, 17.8, 2 .7 min, respectively. workflow recognition system using cnn was also successfully developed, while we needed to extract pure operating scenes in advance for efficient recognition outcomes. we've developed tool detection and phase recognition systems using cnn. we need more datasets to improve the detecting ability for future clinical uses. introduction: surgical environments require special aseptic conditions for direct interaction with the preoperative images and surgical equipment, which hampers the use of traditional input devices. we presented the feasibility of using a natural user interface (nui) for gesture control combined with voice control to directly interact in a more intuitive and sterile manner with the preoperative images and the integrated operating room (or) functionalities during laparoscopic surgery. in this study, efficiency and face validity of using this nui for medical image navigation and remote control during the performance of a set of basic tasks in the or will be assessed. methods and procedures: twenty experienced laparoscopic surgeons participated in this study. they performed 25 basic tasks in the or focused on the interaction with a medical image viewer (osirix; pixmeo) and with the functionalities of the integrated or (or1; karl storz). these tasks were carried out by means of traditional manual interaction, using a computer keyboard and mouse and a touching screen, and using a gesture control sensor (myo armband) in combination with voice commands. this nui is controlled by the tedcube system (tedcas medical systems). time required to complete the tasks using each interaction method was recorded. at the end of the tasks, participants completed a questionnaire for face validation and usability assessment. results: the use of the nui required significantly less time than conventional manual control to show preoperative studies and information for surgical support. however, the interaction with the medical image viewer was significantly faster using the traditional input devices. participants evaluated the nui as an intuitive, simple and versatile tool that improves sterility during surgical activity. seventy-five percent of the participants would choose the gesture control system as a method of interaction with the patient's preoperative information during surgery. conclusions: the presented gesture control system allows surgeons to directly interact with preoperative imaging studies and the functionalities of an integrated or during surgery maintaining the aseptic conditions. for the traditional manual interaction, it is necessary to take into account the possible reaction time and displacement time of the technician to execute the surgeon's requests. a more personalized medical image viewer is required and with higher integration with the capabilities of the presented gesture control system. emma k gibson, bs, jacqueline j blank, md, timothy j ridolfi, introduction: following a generous left hemicolectomy an anastomosis between the transverse colon and rectum may be required. extensive mobilization and retroileal routing is sometimes necessary to create a tension-free anastomosis. retroileal routing is a technique in which a window is created in the ilieocolic mesentery. the colon is routed through this window, beneath the ileum, prior to entering the pelvis. retroileal routing is uncommon and there is no data on this technique when performed in using a hand-assisted laparoscopic technique. the aim of this study was to review our experience with hand-assisted laparoscopic left sided colon resections including retroileal routing of the proximal colon to the rectum. methods and procedures: we performed a retrospective review of a single surgeon's experience with hand-assisted laparoscopic left sided resections over a seven-year period from 2008-2015. indication for operation, basic demographics, bmi, procedure time, short-and long-term morbidity, and mortality were recorded. results: a total of 340 patients underwent a hand-assisted laparoscopic left sided resection with a colorectal or coloanal anastomosis. of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon. in each case, operations included a midline hand port incision and two 5 mm ports in the lower abdomen. the indications for operation were diverticular disease and neoplasm in nine and four patients respectively. procedures took an average of 188.6 (128-221) minutes to complete. postoperative morbidity included intubation for co2 retention in one patient and a rll effusion in another patient. there were no anastomotic leaks and there were no 30-day or 90-day mortalities. conclusion: retroileal routing of the colon following left hemicolectomy occurs infrequently. a hand-assisted laparoscopic approach appears to be a safe and efficient in these technically challenging cases. objective: approximation of the diaphragmatic crus pillars is a key step in hiatal hernia repair. the dogma of successful hernia repair requires tension free approximation of tissue. there are no techniques described to measure tension across the crus closure. aim of this study is to describe a novel technique for measuring the tension exerted on crural sutures and report initial findings. methods: data was collected at 2 institutions by the same surgeon. after hiatus dissection was complete the crus defect was measured both anterio-posterior and transverse dimension. the crus closure sutures were placed posterior and then lateral to the esophagus. the initial suture is started posteriorly with a figure of eight fashion (#1). with each subsequent stitch placed anteriorly (#2 and #3) or laterally (l1, l2) till adequate hiatus closure is achieved. we measured tension on each suture placed as follows. conclusions: the autolap system provides improved image stability, staff interactions, and enhanced ergonomic comfort for the surgical team. it also offers cost-savings from decreased staffing requirements for hospitals that routinely use staff camera holders. the system set up of 7-8 min was less variable after 20 cases, representing the learning curve. in addition, our approach identified problems with the system that require improvement by the manufacturer. notably, we identified significant ergonomic problems for human camera holders, which has been previously described and can be addressed by this device. background: gastric leaks continue to be a troubling predicament for physicians and patients alike. they are especially concerning after bariatric surgery. electrolyte abnormalities and dehydration continuously pose a life threatening problem in these patients. methods: this is an irb approved retrospective review of our experience with a biologic tissue mesh plug closure of gastric leaks. our interventional radiology colleagues percutaneously accessed the perigastric collection with a wire and a straight catheter was guided through the gastric wall defect and advanced over the wire until it was intraluminal. the surgeon then placed an endoscope down to the level of the gastric defect. the wire was then retrieved by the endoscope achieving percutaneo-oral wire access. the biologic tissue matrix was then measured and cut to a square and inverted into a cone like structure with a flat straight piece on the open end. the cone patch was then secured to the wire with 0 braided polyglactin suture loop. the wire was then withdrawn back through the gastric defect pulling the plug and patch into position and placement was confirmed by endoscopy. results: we attempted closure of a gastric leak arising after bariatric surgery in six patients. five underwent successful deployment while one had premature disconnection of the plug from the wire and could not be deployed. the five who had successful deployment had immediate success and within days resumed enteral intake of liquids and resolution of the leak. two of the six patients additionally underwent covered stent placement to stent a stenotic area at the incisura angularis from the esophagus to the antrum. this stent was typically removed 1-2 weeks later. there were no complications related to the procedure or the plug. only one patient has undergone repeat endoscopy to evaluate the status of the plug. in that patient an ulcer at the plug site was visualized one month after the procedure. three months later endoscopy showed the clean ulcer had shrunk to half of the original ulcer size. conclusion: this novel minimally invasive technique utilizing ir and endoscopic placement of a biologic mesh plug into gastric leaks after bariatric surgery has been highly successful in treating chronic and subacute gastric leaks. we recommend that these endoscopic techniques be used to close gastric defects prior to operative intervention. introduction: laparoscopic surgery has spread worldwide and become a standard procedure among many abdominal surgical fields. the incidence of postoperative adhesion, which is a typical postoperative complication, is considered low compared with that after laparotomy, but once complications develop, such as adhesion-induced intestinal obstruction and chronic abdominal pain, the low-invasiveness of laparoscopic surgery may decrease markedly. while we have previously used a sheet-type absorbable barrier to prevent adhesion, it requires a technique in many cases when it is applied in the abdominal cavity. in this study, we used a spray-type absorbable barrier, which is considered simple to apply, as an adhesion-preventing absorbable barrier following laparoscopic surgery. subjects and methods: a spray-type absorbable barrier for prevention of adhesion (ad spray type l®) was applied to the dissected surface, port region, and beneath the small incised wound in 5 patients who underwent laparoscopic surgery of the large intestine after february 2017. the nozzle is long (334 mm in length) and the angle of the tip is adjustable to some extent, so that the spray could be applied easily to the target region, even in areas in which it would be difficult to secure a work space, by rotating the shaft and finely adjusting the angle of the tip. in order for the barrier to remain in the target region, this preparation must remain viscous after application. discussion: approaches for the insertion and affixing of a conventional sheet-type absorbable barrier for the prevention of adhesion has been reported previously by various researchers. the adhesion-preventing absorbable barrier used in this study was a spray type with a long nozzle, which may have been useful because it made the laparoscopic application easy. however, its application requires some experience and time for preparation compared with the use of the sheet type, which could be disadvantageous. further accumulation of cases, including evaluation of prevention of adhesion after use of the adhesion-preventing absorbable barrier may be necessary. christopher g yheulon, md, priya rajdev, md, s. scott davis, md; introduction: evidence has demonstrated that biosynthetic glue for laparoscopic inguinal hernia repair results in decreased pain. however, the two glue sub-types (biologic-fibrin based; synthetic -cyanoacrylate based) have never been compared. this study aims to assess the outcomes of those subtypes. method and procedures: a systematic review of the medline database was undertaken. randomized trials assessing the outcomes of laparoscopic inguinal hernia repair with penetrating and glue fixation methods were considered for inclusion and data analysis. thirteen trials involving 1633 patients were identified with eight trials utilizing fibrin and five trials utilizing cyanoacrylate. results: there were no differences in recurrence or wound infection between the glue subtypes when compared individually to penetrating fixation alone or indirectly to each other. there was a significant reduction in urinary retention with fibrin glue when compared to penetrating fixation (or 0.31, 95% c.i. 0.12-0.81). no studies utilizing cyanoacrylate analyzed urinary retention as an outcome. there were non-significant trends in reduction of hematoma and seroma for both glue subtypes when compared to penetrating fixation (or 0.71, 95% confidence interval 0.50-1.01). conclusions: glue fixation in laparoscopic inguinal hernia repair reduces the incidence of urinary retention and may reduce the rate of hematoma or seroma formation. as there are no differences in outcomes when comparing fibrin or cyanoacrylate glue, surgeons should choose the glue that is available at the lowest cost at their respective institution. however, improvement of the optical system is necessary to further utilize this advantage. we are developing an optical lens system covering the range from macroscopic to microscopic. methods: we developed a handheld prototype created by combining the objective lens system of an optical microscope and a telescope lens. a feasibility study using a porcine model was conducted. macroscopic observation was done at a distance followed by microscopic observation in contact with tissue. first, we observed the operative field macroscopically. we then observed the serosa of the small intestine microscopically, and effects of blood flow occlusion were studied. results: ( fig.1 and fig.2 ) the same visual field as ordinary laparoscopy was achieved during macroscopic observation, while using microscopic observation it was possible to observe the complex peristaltic movements of the intestine. the minute blood vessels of the visceral peritoneum and larger, deeper blood vessels were also observed. when the mesenteric vessels were occluded, changes in peristaltic movement were seen directly. congestion in blood vessels in the deep layers of the serosa was observed. improvement in peristalsis and congestion were confirmed by restoring blood flow. this system enables direct visual observations not possible with conventional optics. this system can be utilized in both laparoscopic and open surgery. the microscopic visual information obtained by this system may help with intra-operative decision making and serve to facilitate safe and precise surgery. introduction: accurate, real-time visualization is critical for efficient, effective and safe surgery. although optical imaging using near-infrared (nir) fluorescence has been used for visualization of anatomic structures and physiologic functions in open and minimally invasive surgeries, its efficacy and adoption remain suboptimal due to the lack of specificity and sensitivity. herein, we report a novel class of compounds, which are exclusively metabolized in liver or kidney, rapidly excreted into to biliary or urinary systems, and emitted two different nir fluorescence spectrums. methods: novel, water-soluble heptamethine cyanines; compound x (biliary) and compound y (urinary), unreactive towards gluthathione and the cellular proteome were synthesized, and visualized using real-time, dual-color nir imaging device. sprague-dawley rats (n=12) and yorkshire pigs (n= 9) were used to demonstrate and validate its usefulness, distributed into a control group (icg; rat n=3, irdye800cw rat n=3), a biliary group (compound x; rat n=3, pig n=3), a urinary group (compound y; rat n=3, pig n=3), and dual-labeling group (compound x&y; rat n=3, pig n=3). each rat and pig received one or two of the compounds at optimized dose of 0.09-mg/kg intravenously, fluorescence signals and bio-distributions were monitored and recorded over time. the target to background ratio (tbr) was calculated in each target systems and compared to assess sensitivity and specificity. results: compound x was rapidly cleared from liver within 15 min after intravenous injection while the fluorescence signals in biliary system lasted up to 1 h both in rats and pigs. compound y showed significant renal excretion up to 4 h and the urinary signals remained up to 2 h. they were both highly specific to target organs with tbr values of 4.23 (biliary), 6.32 (urinary) and 1.23 (cf. icg) at peak signals. these new compounds have approximately 2-3 times higher quantum yields than icg and 1.75-2.5 times higher specificity to kidney and liver than irdye800cw. one-way anova showed significant differences between control, biliary, and urinary group (p.0001.) dual-labeling results also showed a complete separation of these two metabolic systems (p=0.008) and a real-time display of these two systems were clearly visualized with pseudo-colored labeling inside the animal body. conclusion: we report a new generation of organ-specific, real-time fluorescent markers for intraoperative visualization, navigation and potential geo-fencing. these new compounds have significantly higher quantum yields and higher specificity to visualize kidney and/or liver than any currently available reagents. background: porcine models have been widely accepted for gastrointestinal surgery studies, due to their similarities to human anatomy, histology and physiology. devices such as laparoscopic staplers have been widely used in bariatrics and are currently the cornerstone of bariatric. there are currently few published articles regarding surgical stapler testing in porcine models by means of a survival design. the purpose of this study is to present a new model for stapler testing in porcines. we present the following study in which we asses a novel stapler's feasibility and safety, and its compatibility to currently used stapler reloads. this novel stapler, the aeon™ endoscopic linear stapler (lexington medical inc., billerica, ma. pending fda approval), has been previously tested in-vitro and in-vivo by the lexington medical engineering department in matters of mechanical function, staple line bursting pressure, staple formation and hemostasis. duffy et al. used this instrument for small bowel anastomoses in a two-week survival study in porcine models. methods and procedures: four porcine animal model was used under iacuc protocol for a 29-day survival study held at the fiu (doral, fl, u.s.a) research facility. all animals underwent sleeve gastrectomy using the novel stapler handle, combined with the endo gia™ (medtronic, mansfield, ma) 4 mm-staple reloads in two of the animals and aeon™ 4 mm-staple reloads in the remaining two. no reinforcements or oversewing of the staple line was done. these procedures were performed by two bariatric surgeons. animals were monitored perioperatively by the facility staff as per protocol. the animals were euthanized at day 29. post-mortem assessments were done blindly. gross evaluation and comparison of the gastric tube and their staple lines was done, as well as patency, strictures, and staple line integrity. results: stapler function was equivalent with both reload brands, no technical issues were encountered. 3-5 firings were used per animal. no intraoperative complications related to stapler function ensued. no postoperative complications were encountered. all animals survived the full length of the study-29 days. all sleeves were patent, no strictures or bowel obstruction were present. conclusions: in an animal survival study, a follow-up period of 4 weeks appears to be a good benchmark for stapler testing. the use of the novel stapler for gastric resections appears feasible and safe. further studies such as microscopic examination of the staple lines, might help confirm equivalence, safety and feasibility of these products for the sleeve gastrectomy procedure. jason m samuels, md 1 , peter einersen, md 1 , krzysztof j wikiel, md 2 , heather carmichael 1 , douglas m overby 1 , john t moore 2 , carlton c barnett 2 , thomas n robinson, md 2 , teresa s jones 2 , edward l jones, md 2; 1 university of colorado denver, 2 denver va medical center introduction: the purpose of our study was to evaluate the impact of smoke evacuation devices on operating room fires caused by surgical skin preps. surgical fires are rare but preventable events that cause devastating injuries. alcohol-based surgical skin prep serves as the fuel for a fire ignited by electrosurgical instruments. we hypothesized that increasing air exchanges near the tip of the active electrode will reduce the concentration of alcohol thus reducing the incidence of surgical fires. methods: a standardized, ex vivo model was created with a 15915 cm section of clipped, porcine skin. surgical skin preparations tested: 70% isopropyl alcohol with 2% chlorhexidine gluconate (chg-ipa) and 74% isopropyl alcohol with 0.7% iodine povacrylex (iodine-ipa). based upon previous studies, a high-risk situation was replicated with immediate energy activation in the presence of pooled alcohol-based prep. the site was draped to simulate a small surgical procedure with approximately 25 square cm exposed. (figure 1 ) a standard and smoke evacuating electrosurgical pencil was activated for 3 s on 30 w coagulation mode in the presence of 21% oxygen. a standard wall suction was also tested with the tip held 5 cm from the tip of the electrosurgical pencil. a chi-square test was used to compare differences between groups. results: surgical fires were created in 80% (16/20) of the tests with the chg-ipa and 95% (19/20; p=0.34) of the tests with iodine-ipa. continuous wall suction did not change the incidence of fire. the smoke evacuation electrosurgical pencil significantly decreased the incidence of fire when compared to the standard pencil and continuous wall suction for both preparations (table 1) . with chg-ipa, the smoke evacuation electrosurgical pencil decreased the frequency of fire by 81% (figure 2 , p.001). similarly, when using iodine-ipa, the electrosurgical pencil with integrated smoke evacuation demonstrated a 73% decrease in fires (figure 2, p.001). conclusion: alcohol-based skin preps fuel surgical fires. the use of a smoke evacuator electrosurgical pencil reduces the occurrence of surgical fires. elimination of alcohol-based preps and the use of smoke evacuation devices decrease the risk of operating room fires. brian bassiri-tehrani, md, netanel alper, md, jeffrey s aronoff, md, yaniv larish, md; lenox hill hospital ureteral stents have historically been used in pelvic surgery when anatomical or clinical considerations warrant urological expertise to aid in identifying the ureters. in the colorectal and gynecologic surgery literature, prophylactic ureteral stents appear to increase the ability to detect ureteral injuries while not being shown to prevent such injuries. with the increasingly widespread use of laparoscopy and the robotic platform in complex colorectal and pelvic surgery, the utility of stents remains unclear. one of the limiting factors regarding the use of ureteral stents in minimally invasive surgery is the lack of tactile feedback; the inability of the surgeon to directly palpate the stents. one proposed method to overcome this deficiency has been the use of lighted ureteral stents. increased operating time, increased cost, and need for specialized equipment are potential drawbacks of lighted stents. an alternative to using lighted stents in minimally-invasive surgery is to directly inject indocyanine green (icg) into the ureters after cystoscopy-guided placement of ureteral stents. intraoperative visualization of the ureters is acheived by using either the pinpoint endoscopic fluorescence imaging system in laparoscopy, or firefly integrated with the robotic platform. it is hoped that the risk of inadvertent ureteral injuries during colorectal and pelvic operations will be minimized using this technique, due to improved visualization of the ureters throughout the procedure. in this case presentation, we describe a novel use of icg in a patient undergoing a laparoscopic surgery for resection of a 6.798.095.1 cm pelvic mass abutting the bladder, sigmoid colon and left ureter. preoperatively, there was concern that the mass would be intimately adherent to, or even invading, the bilateral ureters based on ct scan findings. after ureteral injection of icg, visualization of both ureters was easily achieved at the time of operation, and the procedure proceeded with careful and safe dissection of the mass with visualization of the ureters at all times. though there is a paucity of studies evaluating the use of icg in the laparoscopic modality, this technique was safe, easy to employ, inexpensive and very useful to visualize the ureters intraoperatively. indeed, larger studies with appropriate sample sizes would help to further validate this novel use of icg. university of colorado -denver, 2 va eastern colorado healthcare system introduction: operating room fires are "never events" that expose the patient to the risk of devastating complications. our group has previously demonstrated that alcohol-based surgical skin preparations fuel operating room fires. manufacturer guidelines recommend a three-minute delay after application of alcohol-based preps to decrease the risk of prep pooling and surgical fires. the purpose of this study was to evaluate the efficacy of the three-minute dry time in reducing the incidence of surgical fires. methods and procedures: a standardized, ex vivo model was used with a 15915 cm section of clipped, porcine skin. alcohol-based surgical skin preparations tested were 70% isopropyl alcohol (ipa) with 2% chlorhexidine gluconate (chg) and 74% ipa with 0.7% iodine povacrylex (iodine-ipa). nonalcohol-based solutions included 2% chlorhexidine gluconate and 1% povidone-iodine "paint." an electrosurgical ''bovie'' pencil was activated for 3 seconds on 30 watts coagulation mode in 21% oxygen, both immediately and 3 minutes after skin preparation application, with and without solution pooling. results: no fires occurred with immediate testing of nonalcohol-based preparations (0/40). alcohol-based preps created flames on immediate testing in 83% (33/40) of cases when pooling was present. without pooling, flames occurred in 40% (16/40) of cases on immediate testing. after a 3-minute delay, there was no difference in the incidence of fire when pooling was present (33/40 vs. 33/40, p [1) . similarly, there was no difference when pooling was not present (16/40 vs. 14/40, p=1). (table 1 ) conclusions: alcohol-based surgical skin preparations fuel surgical fires. waiting 3 minutes for drying of the surgical skin prep did not change the incidence of surgical fire (regardless of whether there was pooling of the prep solution). the use of nonalcohol-based skin preps eliminated the risk of fire. introduction: laparoscopic port sites are associated with a significant incidence of long-term hernia formation. in addition, closure with closed loop suture may lead to increased post operative pain thereby limiting patient mobility. the development of novel trocar closure systems could offer a pathway towards quality improvement and warrants investigation. we performed a randomized controlled trial comparing a novel anchor based system (neoclose®) versus standard suture closure. methods: a prospective randomized controlled trial of 70 patients undergoing port site closure following robotic assisted laparoscopic sleeve gastrectomy or gastric bypass was completed (35 with neoclose® device and 35 with standard laparoscopic suture closure). each patient had both the camera port and stapling port closed (70 port sites in each group). primary outcome measures included the incidence of hernia (6 week ultrasound), time for port site closure, and depth of needle penetration. secondary outcome measures were analog pain scoring at post op day 1, week 1 and week 6. results: physical exam as well as ultrasound evaluation showed no hernias in either group at 6 weeks. when compared to suture closure, the neoclose® device was associated with shorter closure times (20.2±1.2 versus 30.0±2.4 s, p.001) and needle depth penetration (3.3±0.1 versus 5.2±0.2 cm, p\ 0.001). the neoclose® device was associated with decreased pain at 1 week after the operation (analog pain score 0.3±0.1 versus 0.9±0.2, p.01). no difference in pain scoring was observed on post operative day 1 or at week 6. conclusions: trocar site closure with the neoclose® device is associated with decreased closure times and needle depth penetration. no difference in the incidence of hernias was identified very early after operation. the neoclose® device led to decreased pain 1 week after trocar closure which is potentially secondary to decreased tension when compared to closure with closed loop suture. long term hernia data (1 year) is pending with patients scheduled for follow up physical exams and ultrasounds. federico gheza, md, mario a masrur, md, simone crivellaro, md; uic introduction: robotic instruments provides a better ergonomics during suturing compared to standard laparoscopy. minimally invasive procedures with limited need of few suture may benefit from an economically affordable device able to overcome some limitations of laparoscopic suturing. flexdex surgical recently obtained the fda approval for human use of its articulated laparoscopic needle driver. the official training provided by the company (available at https://flexdex.com/register-for-training) is a 3 h basic dry lab. the training curriculum as well as the accreditation process is not well structured. no literature is available today on this matter. our goal was building a dedicated training, to allow a safe and predictable early use in humans. methods and procedures: the training module design and implementation was done in our minimally invasive laboratory. in the preliminary phase we define with a small group of residents and research specialists a short list of mandatory concepts to detail showing the instrument. a simple suturing task was then performed by the same group with the new device, laparoscopically and with the robot, available in our lab for training only. a more complex task, based on a dedicated self-designed high-fidelity model of urethral anastomosis was then proposed, exploring different options (one flexdex only vs two flexdex, surgeon vs assistant holding the camera). lastly, we applied the new device in animals to evaluate the usefulness of including simple tasks or entire procedures in the training curriculum. results: we were able to define a multilevel, adaptable training module including a basic information session, a dry lab with inanimate low-and highfidelity models and a pig lab. subjects with different level of expertise (medical student, resident, fellow, expert and very expert surgeon) were involved to have an extensive feedback. however, our main focus was to design a training module for laparoscopic and robotic surgeons, to safely introduce the flexdex in their practice. the only outcome for this preliminary work was collected through a "post exposure" survey. the expert surgeon that did the entire training was able to give feedback after his first application of the device in humans as well. conclusions: flexdex is a promising device, available in the united states in approved facilities only. a minimally invasive lab with high laparoscopic and robotic training experience is the ideal setting to build a curriculum. a first adaptable, multilevel, original, high-fidelity training is proposed to be validated with further studies and could be implementable for accreditation purposes. surg endosc (2018) 32:s130-s359 augmenting spatial awareness in laparoscopic surgery by immersive holographic mixed reality navigation using hololens objectives: endoscopic minimally invasive surgery provides a limited field of view, thus requiring a high degree of spatial awareness and orientation. because of a 2d field of endoscopic view, a surgeon's spatial awareness is diminished. this study aims to evaluate the efficacy of our novel surgical navigation system of immersive holographic mixed reality (mr) using a head-mounted smart glass display hololens to enhance spatial awareness of the operating field in laparoscopic surgery. the authors describe a method of registering and overlaying the preoperative mdct imaging localization of tumors, vessels, and organs onto the real world in the operating theatre through holographic smartglasses in augmented reality (ar). methods: in this study we included 20 laparoscopic gi, hpb, urology, and gynecologic surgeries using this system. we developed a ct-based patient-specific holographic mr surgical navigating application using hololens, that is a pair of see-through monitors built-in head-mounted display. by reconstructing the patient-specific 3d surface polygons of tumors, vessels, and organs out of the patient's mdct, mr anatomy was displayed on the see-through grasses three-dimensionally during actual surgery. the hololens features an inertial measurement unit which includes an accelerometer, gyroscope, and a magnetometer for environment understanding sensors, an energy-efficient depth camera, a photographic video camera, and an ambient light sensor. results: the accurate surgical anatomy of size, position, and depth of the tumors, surrounding organs, and vessels during surgeries could be measured using build-in dual infrared light sensors. the exact location between surgical devices and patient's anatomy could be traced on the pair of mr smart-glasses by satellite tracking. the gesture controlled manipulation by surgeons' hands with surgical groves was useful for intraoperative anatomical references of tumors and vascular position under sterilized environment. it allowed the user to manipulate the spatial attributes of the virtual and real anatomies. this system reduced the length of the operation and discussion time. this could support complex procedures with the help of pre-and intra-operative imaging with better visualization of the surgical anatomy and spatial awareness with visualization of surgical instruments in relation to anatomical landmarks. conclusions: the immersive holographic mr system provides a real-time 3d interactive perspective of the inside of the patient, accurately guiding the surgeon. this helps spatial awareness of the surgeons in the operating field and has illustrative benefits in surgical planning, simulation, education, and navigation. enhancing scene visualization is a feasible strategy for augmenting spatial awareness in laparoscopic surgery. francisco miguel sánchez margallo, phd 1 , juan a. sánchez-margallo, phd 1 , andreas skiadopoulos, phd 2 , konstantinos gianikellis, phd 3; 1 minimally invasive surgery centre, cáceres, spain, 2 university of nebraska at omaha, 3 university of extremadura, spain introduction: new handheld devices have been developed in order to address the technical limitations and ergonomic issues present in laparoscopic surgery. the aim of this study is to analyze the surgeon's performance and ergonomics using the radius r2 drive instruments (tubingen scientific medical, germany) during the execution of laparoscopic cutting and suturing tasks. methods and procedures: three experienced laparoscopic surgeons performed both an intracorporeal suturing task and a cutting task on a box trainer. both tasks were repeated three times. a maryland dissector and a pair of scissors were used for the cutting task. for the suturing task, a maryland dissector and needle holder were used. conventional laparoscopic instruments and their equivalent r2 drive instruments were used. the order in the use of the type of instruments was randomized. execution time and surgeon's ergonomics were assessed. for the latter, surface electromyography (trapezius, deltoid and paravertebral muscles) and the nasa-tlx index were analyzed. for the cutting task, the percentage of the area of deviation from the cutting pattern (% of error) was assessed. the suturing performance was assessed by means of a task-specific validated checklist. results: surgeons required more time to perform both laparoscopic tasks using the r2 drive instruments. the use of both instruments had a similar percentage of deviation from the exterior part of the cutting pattern. however, the deviation from the inner part was significantly higher using the r2 drive instruments (conv: 7.9±1.3% vs r2 drive: 10.8±2.1%; p\.05). needle driving was scored lower using the r2 drive instruments, but quality of knot tying was similar to conventional instruments. the use of r2 drive increased the muscle activity of the trapezius muscles bilaterally for both laparoscopic tasks. this muscle activity also increased for the left deltoid muscle during the cutting task. surgeons stated that the use of r2 drive instruments leads to a higher mental and physical workload when compared to traditional laparoscopic instruments. conclusions: despite the novel and ergonomic design of the r2 drive laparoscopic instruments, the results of this study suggest that an improvement in surgical performance and physical workload is required prior their use in an actual surgical setting. further studies should be done to analyze the use of these instruments during other laparoscopic tasks and procedures. we believe that surgeons need a longer and comprehensive training period with these laparoscopic instruments to reach their full potential in laparoscopic practice. background/objectives: 3d printing has been shown to be a useful tool for preoperative planning in various surgical disciplines. however, there are only several single case reports in the field of liver surgery. this is because of problematic visualization of anatomy, difficulties in methodology and-most importantly-high costs limiting implementation of 3d printing. the goal of this study is to evaluate the utility of personalized 3d-printed liver models as routinely used tools in planning and guidance of laparoscopic liver resections. materials and methods: contrast-enhanced computed tomography images of 6 consecutive patients who underwent laparoscopic liver resections in a single centre were acquired and processed. proper segmentation algorithms were used to obtain virtual models of anatomical structures, including vessels, tumor, gallbladder and liver parenchyma in stl (stereolithography) format. after processing files, models in parts were subsequently printed with desktop ultimaker 2+ (ultimaker, netherlands) 3d printer, using polylactic acid filaments as printing material. all parts were matched together to create a mold, which was later casted with transparent silicone. models were delivered to surgical teams prior to the surgery as well as used in patients' education. results: up to now, six full-sized, transparent, personalized liver models were created before laparoscopic liver resections and used as a tool for preoperative planning and intraoperative guidance. usefulness of these models has been evaluated qualitatively with surgeons. operative data was obtained for each patient and it will be used for quantitative analysis in further study phases. costs of one model varied between $100 and $150 and whole process of development took approximately 5 days in every case. conclusions: 3d-printed models allow precise planning in complex cases of minimally invasive liver surgery by providing high-quality visualization of patient-specific anatomy. implementation of this technology might potentially lead to clinical benefits, such as reduction of operative time or improvement of short-term outcomes. having said that, more data is needed to decisively prove these hypotheses. introduction: modern laparoscopic graspers may risk inadvertent injury to tissues, and have been shown to produce crush and puncture injuries. in addition, the force transmitted to the tissues by grasper handles can be highly variable, dependent on the orientation and amount of tissue engaged by the grasper. we have developed a novel vacuum-based laparoscopic grasper designed to reduce tissue injury from grasping. the aim of this study is to compare the incidence and severity of tissue trauma caused by vacuum-based graspers versus standard compressive graspers while manipulating tissue. we performed an in vivo surgical porcine study to assess gross and histologic tissue injury after grasping trials. grasping trials were divided equally between two adult porcine models; 43 samples of small bowel were grasped with a standard atraumatic laparoscopic grasper (aesculap double-action atraumatic wave grasper) and 85 were grasped with our novel vacuum grasper with varying vacuum head designs (45 for head a, 20 each for heads b and c). following grasping, the porcine model was allowed to dwell for 2 hours prior to harvest. gross injury was graded as follows: 1) no injury, 2) ecchymosis only, 3) serosal injury, 4) seromuscular injury, and 5) perforation. histologic injury was graded as follows: 1) serositis, 2) partial-thickness injury to the muscularis propria (mp), 3) full-thickness mp injury, and 4) full-thickness mp and mucosal injury. mann-whitney u test was performed to compare both gross and histologic injury scores between the groups. results: on gross assessment, no samples were noted to have injury more severe than ecchymoses following grasping. the vacuum grasper was found to cause more ecchymosis (median=2) than the compressive laparoscopic grasper (med.=1, u=2591, p.001). on histologic assessment, the compressive grasper caused significantly more severe injury (med.= 3) compared to the vacuum grasper (med.=2, u=1355, p=0.008). subgroup analysis showed that heads a (med.=2, u=741.5, p=0.04) and b (med.=2, u=558, p=0.047) caused significantly less injury compared to the compressive grasper. head c (med.=2, u=311.5, p=0.065) also showed less injury but did not reach statistical significance. conclusion: this study demonstrates that our novel laparoscopic vacuum grasper produces less tissue trauma than standard compressive graspers. vacuum-based grasping is a viable alterative for reducing inadvertent tissue injury in laparoscopy. minimally invasive surgery centre, cáceres, spain, 2 university of nebraska at omaha, 3 university of extremadura, spain introduction: the aim of this study is to analyze the surgeon's performance, workload and ergonomics using an ergonomically designed handheld robotic needle holder during laparoscopic urethrovesical anastomosis in an animal model, and comparing it with the use of a conventional laparoscopic needle holder. methods and procedures: six experienced surgeons performed an urethrovesical anastomosis in a porcine model using a handheld robotic needle holder and a conventional laparoscopic axialhandled needle holder (karl storz gmbh). the robotic instrument (dex®, dextérité surgical) has an ergonomic handle and a flexible tip with unlimited rotation, providing seven degrees of freedom. the use of the surgical instrument was randomized. for each procedure, an expert surgeon evaluated the surgical performance in a blinded fashion using the global operative assessment of laparoscopic skills rating scale. besides, the quality of the intracorporeal suture was assess by a validated suturing-specific checklist. the surgeon's posture was recorded and analyzed using the xsens mvn biomech system based on inertial measurement units. the surgeon's workload was evaluated by means of the nasa task load index, a subjective, multidimensional assessment tool. the patency of each anastomosis was assessed using methylene blue. results: all urethrovesical anastomoses were completed without complications. only one anastomosis with the robotic device failed the patency test. surgeons showed similar surgical skills with both instruments, although they presented greater autonomy with the conventional instruments (p =.048). for the suturing performance, the use of the robotic device led to an increase in the number of movements during the needle driving and lower tendency to follow its curvature during the withdrawal maneuver (p=.007). the level of workload increased with the robotic device. however, the surgeon's satisfaction with the surgical outcome did not differ using both instruments. the use of the robotic instrument led to similar posture of the shoulder and wrist and better posture of the right elbow (p=.026) when compared to the conventional instrument. conclusions: the use of the robotized needle holder obtained similar results for the surgical performance and surgical outcome of the urethrovesical anastomosis when compared to the conventional instrument. we consider that aspects such as the surgeon's autonomy, dexterity in driving the needle and workload could be improved with a comprehensive training with the new device. inertial sensors can be an alternative for actual and crowded surgical environments. surgeons acquired a better body posture using the novel robotic needle holder. surg endosc (2018) 32:s130-s359 introduction: temporal and spatial tissue temperature profile in electrosurgical devises, such as ultrasonic scissors and bipolar vessel sealing system, was experimentally measured, and the incidence of postoperative complications after thoracoscopic esophagectomy was assessed according to the electrosurgical devises used. methods and procedures: experiment of thermal spread: sonicision (sonic) was used for ultrasonic scissors and ligasure (ls) was used for bipolar vessel sealing system. each device was activated in order to cut porcine muscle at room temperature. temperatures of both the device blade and porcine tissues beside the device were measured using a temperature probe. each experiment was performed at least three times. room temperature was 25 degrees. clinical analysis: the 46 patients who underwent thoracoscopic esophagectomy with 3-field lymph node dissection in the prone position were selected in the study. incidence of postoperative complications after thoracoscopic esophagectomy was compared according to electrosurgical devises. bronchoscopy was used for diagnosis of recurrent laryngeal nerve paralysis (rlnp). sonic and ls was employed in 6 and 40 patients, respectively. material: we compared 50 consecutive cases using 3d laparoscopic surgery versus 50 cases of 2d conventional laparoscopic surgery from january to june 2017. all surgical procedures were performed by experienced laparoscopic surgeons using 3d (einsteinvision system) and hd conventional laparoscopic optic.3d-laparoscopic surgery offers the depth perception of the surgical field that is lost with the conventional (2d) laparoscopic surgery, and in many series is reported to be better in terms of surgical performance. outcome measures was operation time, surgical performance, blood looses, complications and surgeon satisfaction with the procedure. results: cholecystectomy was the most frequent surgery performed with 19 cases (38%); hernia surgery 12 cases (24%); fundoplication 6 cases (12%), appendectomy 4 cases (8%), left colon excison with colo-rectal anastomosis 3 cases(6%), and other 6 cases (12%) wich included ovarian cyst excision, liver biopsy, prostatectomy and pediatric surgery. we compared each 3d procedure with a standard laparoscopy case performed by the same surgeon during the time of the study. 3d vs 2d surgical procedures outcome measures are shown in table 1 . we found better results in operation time, surgical performance and less blood looses in favor of three-dimensional laparoscopy (.05). conclusion: 3d laparoscopy reduces operation time related to better performance during the procedure. depth perception facilitates dissection, intracorporeal knotting, mesh placement and colo-rectal anastomosis. surgeons reported better surgical performance and comfort during 3d laparoscopy; there were any reported side effects such as headache or dizziness. background: social media (some) uniquely allows international collaboration, with immediacy and ease of access and communication. in areas where surgical management is contentious, this could be a valuable tool to frame the current state, propose best practices, and possibly guide management in a rapid, cost-effective, global scale. our goal was to determine the ability to use twitter-a some platform-as an alternative surgical research tool. methods: twitter was used to host an online poll on a pre-selected controversial topic with no current consensus guidelines-pathological complete response in rectal cancer. an influential colorectal surgeon published the survey "t3n1 rectal cancer undergoes a complete response" on two separate occasions. both polls were open for duration of three days. two methodologies were tested to increase exposure and direct towards relevant participants: first, tagging several worldwide experts, then using the well-established hashtag #colorectalsurgery and publishing during an international surgical conference. the main outcome measure was the feasibility, validity, reproducibility, and methods to further participation of a twitter survey. results: the tweet polls were posted three weeks apart. there was no cost and the time required for the process was three minutes, demonstrating the feasibility. providing three closed options to select from facilitated validity. the poll's anonymity limited knowledge of the participant's qualifications, but public comments and "retweets" came from surgeons with experience ranging from trainee to department chair. a robust volume of respondents was observed. the 1st post received 169 votes, 14 "likes", 13 "retweets", and 18 comments from a diverse international group (9 countries). all tagged members participated in the forum. the 2nd received 125 votes, 13 "likes", 14 "retweets", and 3 comments. the results were reproducible, with the majority favoring 1 option on both occasions (69% and 75%, respectively; p=0.4312). treatment recommendations, their rationale, and open questions were identified in the thread. conclusions: some can be used as a research tool, with valid, reproducible, and representative survey results. while exposure was comparable across the two methods, tagging specific members guided experts to provide more opinions than using conference and specialty hashtags. this could expand awareness, education, and possibly affect management in a transparent, cost-effective method. the anonymous nature of respondents limited the ability to make conclusions, but interest and opinion leaders for further study can be easily identified. this demonstrates the potential for some to facilitate international collaborative research. background: despite the technological advancement of a minimally invasive approach to pylorus -preserving pancreaticoduodenectomy (pppd), the morbidity is still high. among the many complications, postoperative pancreatic fistula (popf) is reported in high incidence rate, which varies from researcher to researcher, and a fistula risk score (frs) has been developed to predict the popf. the aim of this study is validate the fistula risk score in minimally invasive approach of pppd and find the other meaningful parameter for prediction of popf. method and materials: from january 2008 to august 2017, laparoscopy attempted right-sided pancreas resection was performed on 142 patients including robotic reconstruction in the division of hepatobiliary and pancreas at yonsei university health system. among them, 43 patients were excluded due to total pancreatectomy (n=15), open conversion (n=12), pancreaticogastrostomy and hybrid manual anastomosis (n=12), non-measurable drain and missing datas (n=4 conclusions: fistula risk score is significant prediction factor of popf including biochemical leaks. in addition to the previously known frs variables, our data showed that bmi is an important predictor of popf with clinical relavancy in a minimally invasive approach of pppd. laparoscopic hemi-hepatectomy for liver tumor satoru imura, hiroki teraoku, yuji saito, shuichi iwahashi, tetsuya ikemoto, yuji morine, mitsuo shimada; tokushima university introduction: with progress of surgical technique and devices, laparoscopic liver resection became a realizable option for patients with liver tumor. major liver resection such as anatomical left or right hemi-hepatectomy has also been introduced in many centers. herein, we evaluate surgical results of laparoscopic hemi-hepatectomy for liver tumor. patients and methods: until march 2017, 27 consecutive patients who underwent laparoscopic or laparoscope-assisted hemi-hepatectomy (left: 18, right: 9) were reviewed and the surgical data such as operation time, blood loss, postoperative complications were analyzed retrospectively. results: of the 18 patients underwent left hemi-hepatectomy, 6 cases were primary liver cancer, 6 cases were metastatic tumor, and 6 cases were benign tumor. pure laparoscopic surgery was performed in 5 cases. the mean blood loss was 203 (30-995) ml, mean operating time was 315 (204-578) minutes and mean postoperative hospital stay was 18 (8-52) days. the rate of postoperative complications was 5.6% (wound infection; n=1). all right hemi-hepatectomy was performed by laparoscope-assisted method. of the 9 patients underwent right hemi-hepatectomy, 3 cases were primary liver cancer, 3 cases were metastatic tumor, and 3 cases were benign tumor. the mean blood loss was 188 (10-600) ml, mean operating time was 382 (290-514) minutes and mean postoperative hospital stay was 19 (8-48) days. the rate of postoperative complications was 22.2% (biliary stenosis; n=2). the patients with hepatocellular carcinoma were followed up for a median of 68 (29-92) months. recurrence occurred in 4 cases and none of them had died at the time of follow-up. conclusion: laparoscopic hemi-hepatectomy is a safe and effective procedure for the treatment of benign and malignant liver tumors. ibrahim a salama, professor; department of hepatobiliary surgery, national liver institute, menoufia university abstract background: iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. better outcome of such injuries have been shown in cases managed in a specialized center. objective: evaluatation of biliary injuries management in major referral hepatobiliary center. patients and methods: four hundred seventy two consecutive patients with post-cholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist and radiologist) at major hepatobiliary center in egypt over 10 years period using endoscopy in 232 patients, percutaneous techniques in 42 patients and surgery in 198 patients. results: endoscopy was very successful initial treatment of 232 patients (49%) with mild/moderate biliary leakage (68%) and biliary stricture (47%) with increased success by addition of percutaneous (rendezvous technique) in 18 patients (3.8%). however, surgery was needed in 198 (42%) for major duct transection, ligation, major leakage and massive stricture. surgery was urgently in 62 patients and electively in 136 patients. hepaticojejunostomy was done in most of cases with transanastomatic stents. one mortality after surgery due to biliary sepsis and postoperative stricture was in 3 cases (1.5%) treated with percutaneous dilation and stenting. conclusion: management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging for early referral to highly specialized hepatobiliary center. introduction: simple liver cyst is the solitary non parasitic cystic lesion of the liver. teatment of symptomatic liver cyst varies from simple aspiration to hepatic resection. each treatment has its own merits and associatied complications. laparoscopic unroofing (fenestration) offers the best balance between efficacy and safety. polycystic liver disese (pcld) treatment by this method are less clear because of high failure rate. liver resection though more effective carries higher risks. treatment of hydatid disease are controversial. materials and method: simple cyst may be asymptomatic and picked up as incidental findings on ultrasound examination for other abdominal complaints. few cyst have symptoms of mass effect or with complication effect due to haemorrage, rupture, infection. on examination liver is palpable. compression over bile duct give rise to jaundice. the commonest symptoms are pain, early satiety, nausea and vomiting. simple cyst are more common in female after 50 years of age. the cyst located antriorly inferiorly and laterally are the ideal case. investigation like ultrasonography is important. it will helps us to detect the cyst nature, will help to differentiate bet ween simple cyst from poly cystic liver disease, from neoplastic liver. in endemic area of hydatid liver disease serological test is mandatory. ct scan is important regarding details information about to localise the cyst, to identify the liver tissue arroud the cyst, relationship of cyst with the nearby vital structures, number of cyst, calcification and carcinomatous changes in its wall. aspiration of cystfluid, biological and cytological examination to rule out the presence of infection, biliary communication and malignancy. recently, ca 19-9 estimation is helpful for the differentiating the simple cyst from the cystadenoma or carcinoma. for jaundice patient ercp is impotant to locate the intraductal polyp causing the biliary obstruction or cyst causes the compression of the biliary tree. for bleeding in cyst mri is helpful. carcinoma at epithelial lining may occur. result: laparoscopic de-roofing (fenestration) less radical procedure ensures adequate drainage of cyst content into the peritoneal cavity. the cyst wall can be removed using harmonic scalpel so smoked produced and fogging of lens can be minimized. the interior surface inspected with care to exclude neoplastic growth and biliary communication. whole operative procedure, duration of postoperative recovery, hospital stay is much shorter in this procedure. large cevron incision can be avoided. no recurrence in two years follow up period. liver resection and total cystectomy theoretically minimizes the recurrence risk but invoke the a real risk of postoperative complications and death. conclusion: careful case selection and meticulous surgical skills are the two major determinants of the outcome. in the llr group, the first port was placed with an alexis® wound retractor (applied medical, usa) and free access® (top corporation, japan) at the abdominal defect made by previous sc. an additional 2 or 3 trocars were placed as needed. results: all patients in the llr group were treated using the laparoscopic approach. there were no other significant differences in patient background and characteristics. operative duration was similar for these groups. blood loss, complication rate, and hospital stay in the llr group were significantly decreased compared with the olr group. conclusion: in concurrent liver resection and sc, the open approach may require multiple large incisions, but the laparoscopic approach can complete procedures with a stoma wound and a few port wounds. additionally, use of a platform on the wound for sc enhances safety and efficacy for dissection of intraabdominal adhesions and a clear operative view. primary hepatic lymphoma: the importance of liver biopsy diego t enjuto 1 , carlos ortiz 2 , laura casanova 2 , jose luis castro 1 , pablo sánchez 1 , jaime vázquez 1 , norberto herrera 1 , benjamín tallon 2 , carmen jimenez 3; 1 hospital severo ochoa, 2 hospital san rafael, 3 hospital henares primary hepatic lymphoma (phl) is a very uncommon lymphoproliferative malignancy. it accounts for only 0.4% of all extranodal non-hodgkin lymphoma and 0.016 % of all cases of non-hodgkin disease. the diagnosis is made when there is only liver involvement or when there is minimal non-liver disease. bone marrow, spleen, or hematologic affection should be excluded to confirm the diagnosis. we present our experience with two phl's that were correctly diagnosed thanks to laparoscopic liver biopsy. 67-year-old male admitted because of a 2-month history of right upper quadrant pain and nonmeasured weight loss. liver function tests and cholestasic enzymes showed normal values. serologic tests showed negative results for both hbv (hepatitis b virus) and hcv (hepatitis c virus). ct (computed tomography) scan showed three intrahepatic lesions in segments v, vi, and vii. ct-guided fine needle did not reach the diagnosis so a laparoscopic hepatic biopsy was performed. the final diagnosis was burkitt-like lymphoma. chemotherapy with r-chop (rutiximab, cyclophosphamide, adriamycin, vincristine, and prednisone) modality was started and completed after 6 cycles. it is currently 2 years since the patient was diagnosed and there are no clinical or radiological signs of recurrence. 54-year-old male who complained of diarrhoea and abdominal pain. chronic hb infection with no viral charge was detected. ultrasound showed heterogeneity of the whole left hepatic lobe and an mri was performed. a ten by segen centimeters lesion occupying the left hepatic lobe enhanced in arterial phase was seen suggesting adenoma. laparoscopic hepatic biopsy was completed to reach a definitive diagnosis. non-hodgkin lymphoma follicular type has just been confirmed with the histology and immuno-histochemistry. chemotherapy with r-chop should be started in the following weeks. phl's diagnosis is hard to achieve. fine needle biopsies are frequently negative because of the large area of necrosis. surgical biopsies are sometimes indispensable to get enough tissue to reach the diagnosis. phls are sometimes misdiagnosed as hepatocellular carcinoma because of its relation to hcv meaning a major hepatic resection. that is the reason why we consider that all diagnostic measures should be undertaken to rule out a different type of tumor. surgical resection is normally not needed in phls; as they are chemosensitive lesions. surgical options usually add unnecessary morbidity and mortality to these patients. chemotherapy standard treatment for phl consists on r-chop combination. pancreatic neoplasm enucleation -when is it safe? case report and review of the literature elaine jayne buckley 1 , k molik 2 , j mellinger 1; 1 siu-som, 2 hshs pediatric surgery introduction: solid pseudopapillary tumors are rare neoplasms accounting for 2-3% of pancreatic malignancies with a low risk of recurrence and metastasis. pancreatic malignancies are less common in pediatric populations, though small case series have identified that pseudopapillary tumors comprise between 20 and 70% of pediatric pancreatic neoplasms. as these tumors have a low risk of metastasis, the mainstay of treatment has remained surgical excision. several surgical approaches have been described from extensive resections such as pancreaticoduodenectomy to local enucleation. we present a case of enucleation of a large pseudopapillary tumor from the pancreatic head complicated by pancreatic fistula. a literature review was performed given the rarity of this tumor to review surgical approaches, to compare complications and long-term outcomes, and to identify specific strategies to decrease the risk of pancreatic fistula. case description: a 13 year-old female presented with 6 months of abdominal pain. computed tomography identified a right upper quadrant mass felt to be consistent with a lipoma. follow up ct at 6 months suggested the mass was more likely a gastrointestinal stromal tumor (gist), and surgical resection was recommended. enucleation of the mass was chosen in view of a wellcircumscribed appearance, clear operative tissue planes, and concern for long-term morbidity of a more extensive resection given the patient's young age. pathology demonstrated an 8.5 cm pseudopapillary tumor with negative margins. her post-operative course was complicated by a grade b pancreatic fistula, managed with nutritional support, external drain maintenance, and endoscopic stenting. the patient achieved healing of the pancreatic fistula after four months. results: our literature review demonstrates no difference in recurrence, mortality or morbidity between types of surgery. pancreatic fistula contributed to the majority of postoperative morbidity in all cases. recommendations for enucleation include small (2-4 cm) tumors with between 2 and 5 mm margin from the main pancreatic duct. techniques identified to minimized post-operative pancreatic fistula include preoperative imaging of the duct anatomy, preoperative pancreatic stent placement, and intraoperative ultrasound to identify the pancreatic duct. some literature supports preservation of pancreatic parenchyma, particularly in younger patients, to reduce endocrine and exocrine dysfunction given the low rates of recurrence and metastasis with this rare neoplasm. conclusion: our case demonstrates complications of enucleation of a large pseudopapillary tumor with successful multidisciplinary post-operative management. with the risk reduction strategies identified, we suggest that enucleation may be considered for pseudopapillary tumors in younger patients to preserve pancreatic parenchyma and long-term pancreatic function. introduction: recent advancements in minimally invasive techniques led to increased effort and interest in laparoscopic pancreatic surgery. laparoscopic distal pancreatectomy is a widely accepted procedure for left-sided pancreatic lesions. in other cases, the adoption of laparoscopic pancreaticoduodenectomy has been hindered by the technical complexity of laparoscopic reconstruction. hybrid laparoscopy-assisted pancreaticoduodenectomy (hlapd) in which pancreaticoduodenal resection is performed laparoscopically, while reconstruction is completed via a small upper midline minilaparotomy, is combines the efficacy of open approach, and the benefits of laparoscopic approach. the purpose of this study is to report our experience of hlapd and to define the learning curves. methods: 90 patients with benign and malignant periampullary lesion underwent hlapd by a single surgeon between july 2007 and may 2017 were retrospectively reviewed. the clinicopathologic variables were prospectively collected and analyzed. the learning curve for hlapd was assessed using cumulative sum (cusum) and risk-adjusted cusum (ra-cusum) methods. results: the most common histopathology was pancreatic ductal adenocarcinoma (n=27, 27.8%), followed by intraductal papillary mucinous neoplasms (n=16, 16.5%), ampulla of vater cancer (n= 16, 16.5%), and common bile duct cancer (n=15, 15.5%). the median operation time was 540 min (range, 300-865 min) and the median estimated blood loss was 550 ml. based on the cusum and the ra-cusum analyses, the learning curve for hlapd was grouped into four phases: phase i was the initial learning period (cases 1-10), phase ii was the technical stabilizing period (cases 11-37), phase iii was the second learning period (cases 38-70) and phase iv represented the second stabilizing period (cases 71-90). there was a statistical difference in terms of surgical indication between phase ii and iii (p=0.002). conclusions: hlapd is a technically feasible and safe procedure in selected patients. this procedure has benefits of both open and minimally invasive procedure, and could be a stepping-stone for transition from open to purely minimally invasive pancreaticoduodenectomy. in silico investigation of the background: wilson's disease is a rare autosomal recessive genetic disorder of copper metabolism, which is characterized by hepatic and neurological disease. the gene atp7b (on chromosome 13) leads to wilson's disease is highly expressed in the liver, kidney, and placenta and encodes a transmembrane protein atpase (atp7b), which functions as a copper-dependent p-type atpase. methods: here, the rare codons of atp7b gene and their location in the structure of atp7b protein was studied with rare codon calculator (racc) (http://nihserver.mbi.ucla.edu/racc/), atgme (http://atgme.org/), latcom (http://structure.biol.ucy.ac.cy/latcom.html) and sherlocc program (http://bcb.med.usherbrooke.ca/sherlocc.php). racc server identified arg, leu, ile, and pro codons as rare codons. results: results showed that cyp152a1 gene have 35 single rare codons of arg. additionally, racc detected two rare codons of leu, 13 single rare codons of ile and 28 rare codon of pro. atp7b gene analysis in minmax and sliding_window algorithm resulted in identification of 16 and 17 rare codon clusters, which shows the difference features of these algorithms in detection of rcc. analyzing the 3d model of atp7b protein show that arg816 residue constitute hydrogen bonds with glu810 and glu816 that with mutation of this residue to ser816 this hydrogen bonds were disrupted and may interfere in the proper folding of this protein. moreover, the side chain of arg1228 don't forms any bond with others residues that with mutation to thr1228 form new hydrogen bond with the side chain of arg1228. these addition and deletion of hydrogen bonds effects on the folding mechanism of atp7b protein and interfere with the proper function of the atp7b position. his1069 forms the hydrogen bonds with the his880 and it seems that this hydrogen bond close together two region of this protein and it seems that has a critical role in the final folding of atp7b protein. conclusions: computational study of diseases such as wilson's disease and involved genes (atp7b) help us in understanding of disease's physiopathology and finding new approaches for detection and treatment. pancreatic stump leak and fistula formation are significant causes of morbidity in patients undergoing distal pancreatectomy (dp), with incidence of 15% to as high as 64% in a large systematic review. we present a case of a 58 year old female, four months status post distal pancreatectomy and splenectomy for pseudopapillary neoplasm of pancreatic tail. patient presented to our institution with 7 day history of left upper quadrant pain and general malaise. differential diagnosis on admission was abdominal wall abscess vs incarcerated incisional hernia. physical exam was positive for severe tenderness to palpation over a *4 cm94 cm non reducible mass in left upper quadrant with surrounding skin erythema. patient underwent a diagnostic laparoscopy and intraoperative findings revealed extensive adhesions to the anterior abdominal wall and a loop of small bowel was found adhered to the previous incision site in left upper quadrant. upon further dissection we entered a large 1098 cm cavity with saponified caseous material. the saponified material and thick tan fluid were evacuated into an endocatch bag and two large bore jackson pratt drains were left within the cavity. further examination showed that the small intestine was normal with no signs of obstruction or ischemia. fluid studies and cultures were sent and showed yeast like organisms and negative for acid fast bacillus. we report an unusual presentation of a distal pancreatectomy stump leak in the formation of an intra-abdominal saponified fluid collection four months after the primary procedure. given the high incidence of pancreatic stump leak and fistula formation after distal pancreatectomy, much effort has been made to identify factors associated with higher incidence of leaks and their usual and unusual presentations, which will be reviewed in this report. initial concerns regarding healthy donor's safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation (ldlt) have delayed the development of laparoscopic donor hepatectomy in adult-to-adult ldlt. however, decreased blood loss, less postoperative pain, shorter length of stay in hospital, and excellent cosmetic outcome have well been validated as the advantage of laparoscopic hepatectomy. hence, the safety and feasibility for laparoscopic donor should be further investigated. we present initial experiences and safety for totally laparoscopic living donor right hepatectomy. in 20 cases who received elective living donor right hepatectomy for adult-to-adult ldlt, totally laparoscopic approach was applied from may 2016 up to august 2017. the anatomical variation of portal vein was not considered as an exclusion criteria, but all donors were with type i portal vein variation. the bile duct anomaly was preoperatively evaluated with magnetic resonance cholangiopancreatography (mrcp) and was never excluded for totally laparoscopic approach. 2d conventional rigid 30º rigid laparoscopic system was used in 2 cases and the remaining 18 cases used 3d flexible laparoscopic system. in about 40%, hepatic duct anomalies (type 2, 3a, 3b) were identified. the operation time was from 6 hours to 7 hours. and the time for the graft removal was within 15 minutes. the hepatic duct transection was performed under operative cholangiography via a cystic duct and the patency of left hepatic duct was also confirmed by operative cholangiography. however, during postoperative period, bile leakage was identified in only 1 case and resolved after the biliary stent insertion by ercp. during operation, there was no transfusion and the inflow control like pringle maneuver was not used at all. v5 or v8 were reconstructed in 19 cases and large right inferior hepatic vein was prepared for anastomosis in 6 cases. all grafts were removed through the suprapubic transverse incision. most donors were discharged at 7 days after hepatectomy. during the short-term follow-up period in the donors except this case, complications were not identified. conclusively, totally laparoscopic right donor hepatectomy in elective adult-to-adult ldlt can be initially attempted after enough experiences of laparoscopic hepatectomy and ldlt. however, the true benefits of totally laparoscopic living donor right hepatectomy should be fully assessed through various experiences from multi-institutes. background: the role of neoadjuvent chemotherapy on the treatment of pancreatic cancer remains widely controversial. studies have evaluated its effect on resectability and survival; however, few have studied the consequence of neoadjuvent therapy on surgical outcomes and complications. methods and procedures: a retrospective analysis was performed utilizing the targeted pancreas module of the national surgical quality improvement project (nsqip) for patients undergoing pancreaticoduodenectomy. neoadjuvent therapy was defined by chemotherapy and/or radiation in the 30-days before surgery. patient demographics, operative characteristics, and 30-day outcomes were compared amongst patients undergoing neoadjuvent chemotherapy, radiation, chemoradiation, and no neoadjuvent therapy. both univariable and multivariable analysis were completed. results: pancreaticoduodenectomy was completed in 3,114 patients. 2,635 patients had no neoadjuvent therapy; 207 underwent both chemotherapy and radiation; 256 underwent chemotherapy alone, and 16 underwent radiation alone. there were no differences in demographics or comorbidities. no difference in 30-day mortality was found; however pancreatic fistula formation was affected by neoadjuvent therapy. neoadjuvant radiation increased fistula formation (or: 2.4, 95% ci: 1.1-5.2) while neoadjuvent chemotherapy (or: 0.5, 95% ci: 0.3-0.99) was protective. conclusion: neoadjuvent therapy significantly impacts surgical outcomes following pancreaticoduodenectomy. given that pancreatic fistula formation can delay post-operative chemotherapy, it may be reasonable to refrain from neoadjuvent radiation therapy for patients with resectable and borderlineresectable disease. the influence of thickest background: the use of stapling devices for distal pancreatectomy remains controversial, due to concerns about the development of postoperative pancreatic ?stula (popf). pancreas thickness might be associated with popf, but suitable thickness of stapler remains also inconclusive in view of reducing popf. methods: we routinely use thickest endo gia™ reloads with tri-staple™ (covidien, north haven, ct) for pancreas closure during laparoscopic left side pancreatectomy (lp) since 2013. we compared short term surgical results of the consecutive ten patients underwent lp using new stapler (ns) and 20 patients with lp using other type of stapler (os) focusing on popf. results: no patients developed clinically relavent (cr)-popf in ns group and two patients (10.0%) with os group experienced cr-popf. however, there was no difference of cr-popf between two groups. pancreas thickness on stapling point were not different between two groups (15.9 mm vs 18.9 mm, p=0.246). in ns group, 3 patients (30.0%) developed a popf, whereas in os group, 12 patients (60.0%) developed a popf. there was also no difference of popf between 2 groups. conclusion: the gia™ reloads with the thickest tri-staple™ allows effective prevention of cr-popf after distal pancreatectomy. however, there was no advantage over thinner stapler for lp. introduction: single-incision laparoscopic hepatectomy (silh) has been showed feasible and safe in experienced hands for selected patients with benign or malignant liver diseases. there were only small series reported and most of the procedures were minor liver resections. we herein present our experience of silh during a period of 13 months. methods and procedures: consecutive 13 patients underwent silh which were performed by two experienced laparoscopic surgeons with straight instruments. patient characteristics and surgical outcomes were analyzed by reviewing the medical charts. results: the patient age was 62.7±9.2 (47-78) years with male predominance (8 patients, 61.5 %). six patients (46.2%) had liver cirrhosis proved by pathologic examinations. nine procedures (69.2%) were indicated for malignancy. four major hepatectomies (over two segments) and nine minor ones were performed including seven anatomical resections. the abdominal incisions were para-or trans-umbilical except one which was along the old operative scar at lower midline, while most of them (n=12, 92.3%) was within 5 cm in length. inflow control was carried out by either individual hilar dissection or extraglissonian approach instead of pringle maneuver. the operations were all accomplished successfully without additional ports or open conversion. the operative time was 436.5±178.4 (163-673) min and the estimated blood loss was 435.0±377.2 (75-1400) ml. five (38.5 %) patients encountered complications and four of them were classified as clavien-dindo grade i. the postoperative length of hospital stay was 6.1±2.2 (4-10) days. there was no mortality. conclusion: silh can be performed safely and efficaciously for selected patients with benign and malignant liver diseases including cirrhosis. not only minor but also major liver resections are feasible. this innovative procedure provides low postoperative pain and fast recovery. before adopting this demanding technique, surgeons should be familiar with both single-incision laparoscopic surgery and laparoscopic hepatectomy. better outcomes after the learning curve could be anticipated. background: laparoscopic distal panreatectomy (ldp) has been replacing the open procedure for benign or malignant diseases of the pancreas. however, it is often difficult to apply ldp for pancreatic ductal adenocarcinoma (pdac) because its aggressive invasion to adjacent organs or major vessels. objectives: the objective of this study was to report our experiences for laparoscopic extended pancreatectomy with en-bloc resection of adjacent organs or major vessels for left-sided pdac. methods: we reviewed data for all consecutive patients undergoing ldp for left-sided pdac at asan medical center (seoul, south korea) between april 2006 and december 2016. the patients who underwent laparoscopic extended panreatectomy with en-bloc resection of adjacent organs or major vessels were included in analyses. results: of total 257 patients, 21 underwent laparoscopic extended pancreatectomy. there were 14 male and 7 female patients with a median age of 64.1 years. resected adjacent organs or vessels were as following: stomach in 6, duodenum in 1, colon in 4, kidney in 2, superior mesenteric vein in 4, and celiac axis in 4. median operative duration was 280 minutes, and median length of hospital stay was 9 days. pathological reports revealed the following: a median tumor size of 3.5 cm, the tumor differentiation (well differentiated in 2, moderately differentiated in 17, and poorly differentiated in 2), t stages (t1 in 1, t3 in 18, and t4 in 2) , and n stages (n0 in 10 and n1 in 11). r0 resection was achieved in 6 patients, and most r1 resection were tangential retroperitoneal margins. postoperatively, clinically relevant postoperative pancreatic fistula was occured in 2 patients, and there was no 90-day mortality. median overall survival was 19.6 months and 1 year survival rate was 71.1%. conclusions: although laparoscopic surgery has limitations in treating extensive diseases, some selected patients can be applicable for laparoscopic extended pancreatectomy with acceptable complication and survival rates. who underwent hepatic resection was included. these patients were divided into llr or olr. demographics, tumor characteristics, recurrence rates and over-all survival were compared between the 2 groups. results: 49 patients were included and grouped into llr (n=28) and olr (n=21). the average tumor number was 2±1 for both groups, while the mean tumor size was 4.1 cm and 4.9 cm for the llr and olr group, respectively. when compared with olr, llr had lower post-operative complication rates (14.3% vs 33.3%, p=0.118) and shorter hospital stay (9 vs 21 days, p=0.103), although the difference was not statistically significant. overall, recurrence-free and disease-free survival was comparable between llr and olr. introduction: single port surgery has been described since 2009 with cholecystectomy, colectomy, gastrectomy, and others. nevertheless, few cases are still reported in field of hbp surgery. herein, we report single port pancreatic surgery developed from our previous experience. we had started single port surgery in 2009, since then we have done more than 850 cases of single port surgery using surgical glove port including cholecystectomy, appendectomy, and colectomy. because we consider this experience should develop to pancreatic surgery, 73 cases of single port staging laparoscopy for potentially resectable and borderline resectable pancreatic cancer and 15 cases of single port plus one port distal pancreatectomy (spop-dp) have been done in our institution. single port staging laparoscopy for pancreatic cancer. resectability was proved in 63 (86%) out of 73 patients while 10 patents had unresectale factor such as small liver and peritoneal metastases that was not able to detect pre-operatively. the length of hospital days were 5.0±4.8 days and the days to chemotherapy were 33.1±2.8 days. single port plus one port distal pancreatectomy (spop-dp) spop-dp starts with 1.5 cm skin incision on umbilicus. subsequently, a wound retractor is installed at umbilical wound. then, a non-powdered surgical glove (5.5 inches) is put on the wound retractor through which three 5-mm slim trocars and one 12-mm trocar are inserted via each finger tips. a semi-flexible laparoscopic camera is inserted via the middle finger port. 12-mm port is used when laparoscopic us, mechanical stapler, endo intestinal clip or retrieval bag were needed. an additional 5-mm port is inserted at left subcostal lesion mainly used for surgeon's right hand instrument. gastric posterior wall is fixed to abdominal wall by suture instead of manual retraction. pre-compression before transection of the pancreas was done using endo intestinal clip before firing. discussion: as we have seen in these two decades, surgery has dramatically been changed by laparoscopic surgery or robotic surgery. nevertheless, because of technical difficulty and relatively high post-operative complication rate, introduction of reduced port surgery to hbp surgery has just started. spop-dp using endo intestinal clip, glove port and gastric wall hanging method is feasible. but its advantage is not clear so far, multicenter rct is highly desired to clear the benefit of reduced port surgery for pancreas. introduction: scoring systems (ss) are an essential pillar of care in acute pancreatitis (ap) management. we compared six ss (acute physiology and chronic health examination (apache-ii), bedside index for severity in ap (bisap), glasgow score, harmless ap score (haps), ranson's score and sequential organ failure assessment (sofa) score) for their utility in predicting severity, intensive care unit (icu) admission and mortality. methods: ap patients treated between july 2009 and september 2016 were studied retrospectively. demographic profile, clinical presentation and discharge outcomes were recorded. predictive accuracy of six ss was assessed using areas under receiver-operative curve (auc) with pairwise comparisons. results: 675 patients were treated for ap. twenty-two (3.3%) patients were excluded for insufficient data. 383/653 (58.7%) were male and mean age was 58.7 (20-98) years. most common aetiology was gallstones (61.9%). mean length of stay was 6.8 (2-92) days. 81 (12.4%) patients had severe ap, 20 (3.1%) required icu admission and 12 (1.8%) died. table below shows positive predictive value (ppv), negative predictive value (npv) and auc of six ss in predicting outcomes. pairwise comparisons revealed ranson's (p.016) and sofa (p.024) scores were superior than other ss in predicting all three outcomes. auc of sofa was greater than ranson's score in predicting severity (p.001), but similar in predicting icu admission (p=0.933) and mortality (p =0.150). conclusion: sofa score is superior to classical ss in predicting severity, icu admission, and mortality in ap. introduction: necrotizing pancreatitis is often a devastating sequelae of acute pancreatitis. historically several approaches have been described with variable outcome. open necrosectomy is associated with higher morbidity (95%) and mortality (25%). endoscopic necrosectomy often is tolerated well but associated with stent migration and multiple procedures. video-assisted retroperitoneal debridement is tolerated well but associated with severe bleeding if adjacent blood vessels are injured during the procedure leading to severe complications. methods: in our series, we perform a step up approach by involvement of a multidisciplinary group consisting of general surgeons, gastroenterologists, infectious disease physicians, critical care internalist, interventional radiologist and nutritional services to formulate a management plan. the necrotized pancreas is initially drained with an ir guided drain, fluid cultures sent for microbiology and treatment with appropriate antibiotics if deemed necessary. the drain is gradually upsized to a 24 fr sized drain to form a well-defined tract for surgical debridement; a preoperative ct scan of the abdomen with iv contrast to access the location and proximity of the vasculature around the necrotized pancreas. a collaboration with the interventional radiologist to discuss possible ir embolization of splenic artery prior to surgical debridement. the patient would then undergo video assisted retroperitoneal pancreatic necrosectomy and a sump drain left in-situ at the pancreatic fossa. post-operative management in the surgical icu would be lead by the critical care internalist. results: three patients were managed by this multidisciplinary approach with excellent outcomes. one patient underwent preoperative ir embolization followed by surgical debridement; second patient underwent embolization immediately following debridement; one patient did not require any embolization but had ir on standby if needed to intervene. post-operatively all three patients recovered well. they all were tolerating good oral intake and were discharged to rehabilitation facilities. conclusion: our preliminary experience demonstrates that an early multidisciplinary plan by various subspecialties can result in a pragmatic and successful approach to this potentially catastrophic condition. introduction: liver resection with preservation of as much liver parenchyma as possible is called parenchymal sparing hepatectomy (psh). psh has been shown to improve overall survival by increasing the re-resection rate in patients with colorectal liver metastases (crlm) and recurrence. the caudal-cranial perspective in laparoscopy makes the cranial segments (2, 4a, 7 , and 8) more difficult to access. the objective of this systematic review is to analyze feasibility, safety, morbidity, and oncologic outcomes of laparoscopic psh. methods: a systematic review of the literature was performed. medline/pubmed, scopus, and cochrane databases were searched. a search strategy was published with the prospero registry. a systematic review was conducted on all cases reported, they were categorized by area of resection and quantitative meta-analysis of operative time, blood loss, length of hospital stay, complications, and r0 resection was performed. results: of the 351 studies screened for relevance, 48 studies were selected. because interventions or endpoints were noncontributory or reporting incomplete, 38 were excluded. only 10 publications remained, reporting data from 579 patients who underwent laparoscopic psh. the highest oxford evidence level was 2b and selective reporting bias was common due to single center and noncontrolled reports. among them, 132 (21.5%) resections were in the cranial segments 2 (1.1%), 4a (5.2%), 7 (6%), and 8 (9.1%), which previously would have required laparoscopic hemi-hepatectomies or sectorectomies. the most common tumor type was crlm (58%) and the second most common tumor type was hepatocellular carcinoma (16%). feasibility of laparoscopic psh was 93%, conversion rate was 7%, and complications were seen in 17% of cases. no perioperative mortality was reported. no standardized reporting format for complications was used across studies. meta-analysis revealed a weighted average operating time of 385 minutes, estimated blood loss of 463 cc, and length of stay of 8 days. r0 resections were achieved in 91% of cases. conclusion: laparoscopic psh of difficult to reach liver tumors are feasible with acceptable conversion and complication rate, but relatively long operating times and relatively high blood loss. in future studies, data on long term survival and specific tumor type recurrence should be reported and bias reduced. yangseok koh 1 , eun-kyu park 2 , hee-joon kim 2 , young-hoe hur 1 , chol-kyoon cho 1; 1 chonnam national university hwasun hospital, 2 chonnam national university hospital purpose: laparoscopic surgery has become the mainstream surgical operation due to its stability and feasibility. even for liver surgery, the laparoscopic approach has become an integral procedure. according to the recent international consensus meeting on laparoscopic liver surgery, laparoscopic left lateral sectionectomy ( conclusion: this study showed that laparoscopic lls is safe and feasible, because it involves less blood loss and a shorter hospital stay. for left lateral lesions, laparoscopic lls might be the first option to be considered. keywords: laparoscopy, left lateral sectionectomy. outcome analysis of pure laparoscopic hepatectomy for hcc and cirrhosis by icg immunofluorescence in.-a propensity score analysis introduction: in laparoscopic hepatectomy, the surgeon cannot use their hand to palpate the liver lesion and estimate margin of resection. the use of icg immunofluorescence technique can show up the liver tumour and has the potential to facilitate a throughout assessment during the operation. method: between 2013 and 2016, there were 182 patients undergone pure laparoscopic liver resection for hcc in our hospital. 162 patients had undergone surgery by the conventional laparoscopic approach. 20 patients had laparoscopic hepatectomy with additional icg immunofluorescence augmented technique. the surgical outcome was compared with propensity score analysis in a ratio of 1:3. result: 20 patients had icg immunofluorescence assisted laparoscopic hepatectomy (group 1). 60 patients using conventional laparoscopic liver resection with propensity-matched were selected for comparison (group 2). the median operation time was 200 minutes vs 164 minutes p=0.679, the median blood loss was 125 ml vs 100 ml (p=0.928). 3 additional tumours were identified by icg technique. 3 patients had suspicious lesion picked up by icg technique but proven to be benign pathology on frozen section examination. the sensitivity of tumour detection by group 1 was 90%. 100% r0 resection was achieved in group 1 and group 2 respectively. hospital stay was 5 days vs 4 days (p=0.824), post-operative complication was 0 (0%) vs 5 (8.3%) (p=0.424) none of the patient developed icg related complication. conclusion: in the current study, the new technique showed equally good short-term outcome when compared with conventional laparoscopic hepatectomy. icg immunofluorescence augmented reality is a promising technique that might facilitate easier identification tumour during laparoscopic hepatectomy. surg endosc (2018) 32:s130-s359 taking the training wheels off: transitioning from robotic assisted to total laparoscopic whipple introduction: there is a substantial learning curve to performing minimally invasive pancreatoduodenectomy (mis-pd) for surgeons who are trained in open pd. the learning curve to transition from robotic assisted pd (rapd) to total laparoscopic pd (tlpd) is not well established. methods: mis-pds performed between january 2014 and june 2017 performed by sc as a surgeon or co-surgeon were included for analysis. mis-pds were performed using a robotic assisted technique prior to august 2016, and tlpds were performed subsequently. rapds performed prior to 2014 were excluded to limit the comparison to rapds after the initial learning curve. demographics, clinical and pathologic outcomes, operative and post-operative outcomes were compared. results: a total of 28 rapds and 12 tlpds were scheduled during the study period. there was no statistically significant difference in age, body mass index, or prior abdominal surgery. median time from initial clinic consultation to surgery was 35 days for the rapd group versus 15 days in the tlpd group (p=0.005). conversion to laparotomy was required in 4 of 28 patients ( there were no operative complications or mortality. the mean hospital stay was 28±17.8 hours. there was no postoperative jaundice, bile leak, intra-abdominal collections or mortality. conclusion: when surgery is indicated for difficult acute calculous cholecystitis, laparoscopic subtotal cholecystectomy with control of the cystic duct is safe with excellent outcomes. however, if the critical view of safety can't be achieved due to obscured anatomy at calot's triangle, conversion to open surgery or cholecystostomy must be performed to prevent bile duct injury. scott revell, md 1 , joshua parreco 1 , rishi rattan, md 2 , alvaro castillo, md 1; 1 u. miami -jfk gme consortium, 2 university of miami, miller school of medicine introduction: over the last two decades the increasing incidence of benign liver tumors has led to the expanded need for clinicians to make therapeutic decisions regarding the utilization of open, minimally invasive and ablative techniques. the purpose of this study was to compare outcomes of the management of benign liver disease based on operative approach and pathology. methods: patients aged 18 years or older who underwent liver surgery for benign liver tumors from 2010 to 2014 were identified in the nationwide readmissions database. patients were compared based on liver pathology, resection versus ablation, and an open versus laparoscopic/robotic approach. the outcomes of interest were in-hospital mortality, prolonged length of stay (los) [7 days, and readmission within 30-days. univariable analysis was performed for these outcomes and multivariable logistic regression was performed using the variables with a p-value .05 on univariable analysis. results were weighted for national estimates. results: there were 6,173 patients undergoing surgery for benign hepatic tumors in the us during the study period. the most common pathology was benign neoplasm (62.1%) followed by hemangioma (28.9%), and congenital cystic disease (9.1%). resection alone was performed in 72.8%, ablation alone in 21.1%, and resection with ablation in 6.1%. a laparoscopic/robotic approach was used in 10.3% of cases. the overall mortality rate was 0.3%, a prolonged los was found in 14.7%, and readmission within 30 days occurred in 8.1%. an increased risk for mortality was found with hemangioma (or 12.34, p=0.03) and congenital cystic disease (or 11.43, p= 0.03). resection with ablation was associated with an increased risk of prolonged los (or 2.22, p.01), while a laparoscopic/robotic approach was a protective factor for prolonged los (or 0.39, p.01). patients treated with ablation alone were at decreased risk for readmission (or 0.59, p.01). omar m ghanem, md 1 , desmond huynh, md 2 , tomasz rogula, md 3; 1 mosaic life care, 2 cedars sinai, 3 introduction: laparoscopic sleeve gastrectomy is the most commonly weight loss procedures performed worldwide. as such, there is great diversity in the techniques utilized. this study aims to identify and categorize the differences in techniques and assess the need for guidelines in this field. case description: surgeons were surveyed on the techniques they employ on biweekly basis using the international bariatric club facebook group. the survey included sleeve staple line reinforcement, preoperative work up, intraoperative hiatal dissection, bougie size, distance from pylorus to distal staple line, and intraoperative leak testing. surveys were conducted between may 2017 and july 2017. each survey was active for 2 weeks after which data was collected. participants were required to select a single answer per question. discussion: when surveyed on staple line reinforcement (n=305), 122 surgeons used no reinforcement, 103 over-sewed, 43 buttressed, 19 clipped as necessary, 10 over-sewed as necessary. for preoperative work up (n=188), 125 utilized routine endoscopy, 9 routinely obtained upper gi series, 2 routinely obtained both endoscopy and upper gi, and 43 employed endoscopy or upper gi series only in patients who were symptomatic. for hiatal dissection (n=168), 14 surgeons dissected the hiatus routinely, 116 dissected only when obvious hernias intraoperatively, 32 dissected only if the hernia was detected on preoperative work up, and 1 dissected in the setting of gerd symptoms. for sleeve caliber sizing (n=275), bougie \32 f was used by 1 surgeon, bougie size 32f, 34f, 36f were utilized by 86, bougie size 38f and 40f were utilized by 171, bougie[40f were used by 4, and gastroscopes (34f) were used by 9. with regards to distance from pylorus to where the sleeve staple line was initiated (n=207), 44 participants started \4 cm away from pylorus, 159 between 4 and 6 cm, and 4 started [6 cm from pylorus. finally, for preferred intraoperative leak test during sleeve (n=268), methylene blue was used by 133 surgeons, air leak test by 50, 4 used both, and 78 opted for none. conclusion: this study characterizes the wide varieties in the techniques used during sleeve gastrectomy. a great number of variations exist in every parameter surveyed; however, there is little evidence comparing the effectiveness and safety of these variations. in this setting, further randomized controlled trials are necessary and should be used to construct guidelines to best optimize outcomes in this extremely common and necessary operation. yen-yi juo, md, mph, yas sanaiha, md, yijun chen, md, erik dutson, md; ucla introduction: bariatric surgeries are commonly performed in accredited centers of excellence, but no consensus exists regarding the optimal readmission destination when complications occurred. our study aims to examine the impact of care fragmentation on post-operative outcome and evaluate its causes and consequences among patients undergoing 30-day readmission after bariatric surgery. methods: the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) 2015 database was used to identify patients who experienced 30-day unplanned readmission following bariatric surgery. non-index readmission was defined as any readmission occurring at a hospital other than the one where initial surgery was performed. primary outcome was 30-day mortality after surgery. logistic regressions were used to identify risk factors for nonindex readmission and to adjust for confounders in the association between non-index readmission and 30-day mortality. results: a total of 5,276 patients were identified as experiencing 30-day unplanned readmission following bariatric surgery, among whom 359 (6.8%) were non-index readmissions. occurrence of postoperative complication during initial hospitalization was the most significant risk factor for non-index readmission (or 1.36, 95% ci 1.06-1.75, p=0.02) in our multivariate logistic regression. the three most common reasons for readmission were similar within the two comparison groups, including nausea/vomit, abdominal pain and anastomotic leakage. similar proportion of patients underwent reoperation among the two comparison groups (22.7 vs 20.6%, p=0.362). even after adjusting for occurrence of complications, being readmitted to a non-index facility was still associated with a 5.2-fold odds of 30-day mortality (95% ci 2.50-10.85, p\.001). conclusion: non-index readmission significantly increases the risk of 30-day mortality following bariatric surgery. patients were more likely to visit a non-index facility if complications occurred during their initial hospitalization. further patient education is required to re-inforce the importance of continuity-of-care during management of bariatric complications and guide patient's decision making in choosing readmission destinations. introduction: sleeve gastrectomy has become the most performed bariatric surgery. removing part of the stomach causes weight loss by restricting food intake and regulating the production of incretins, particularly ghrelin. however, prognostic factors to weight loss after sleeve gastrectomy have been difficult to find. the goal of this research was to study the correlation between the volume of resected stomach and weight loss. methods and procedures: volume of resected stomach of 217 patients undergoing sleeve gastrectomy was measured. a standard laparoscopic technique was used. calibration was performed tightly around a 28 fr bougie, and stapling started 4-6 cm from the pylorus. the standardized technique for measurement involved insufflation with a 14g catheter with saline solution to a pressure of 18 cm h2o immediately after removal of the specimen. resected stomach's volume, gender, age, bmi, height and % of total weight loss (%twl) at 6 months and 1 year were prospectively recorded. correlation between variables was analyzed with pearson's test and linear regression models. conclusion: removed stomach was larger on men than women and its size slightly correlated to height. however, volume of resected stomach did not seem to have an incidence on short termweight loss. gastric size should not be considered as a prognostic factor for weight loss in patients undergoing sleeve gastrectomy. revisional bariatric surgery after initial laparoscopic sleeve gastrectomy: what to choose salman alsabah, eliana al haddad, ahmad almulla, khaled alenezi, shehab akrouf, waleed buhamid, mohannad alhaddad, saud al-subaie; amiri hospital introduction: bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (lsg) being the most performed procedure as of 2014. however, inadequate weight-loss may present the need for a revisional procedure. the aim of this study is to compare the efficacy of laparoscopic re-sleeve gastrectomy (lrsg), laparoscopic roux-en-y gastric bypass (lrygb) and gastric mini-bypass surgery (mgbp) in attaining successful weight loss following initial lsg. methods: a retrospective analysis was performed on all patients who underwent lsg at amiri and royale hayat hospital, kuwait from 2008 to 2017. a list was obtained of those who underwent revisional bariatric surgery after initial lsg, and their demographics were analyzed. introduction: the aim of this study is to identify potential risk factors or early indicators, specifically related to perioperative blood pressure, and its association with perioperative hemorrhage in the bariatric population. laparoscopic bariatric surgery in the united states has been steadily increasing over the past several years. between 2011 and 2015, the annual number of cases has increased by 24%. although rare, hemorrhagic complications (hc) occur at a rate of 1-5% and can lead to significant morbidity and mortality. by identifying factors which may place a patient at higher chance of hc, surgeons can potentially mitigate those risks. these modifications could reduce morbidity and limit the requirement of transfusions or reoperations. methods and procedures: a retrospective case-control series was performed to include all patients who underwent either laparoscopic sleeve gastrectomy (sg) or laparoscopic roux-en-y gastric bypass (gb) in 2016 at a single bariatric center of excellence. a total of 8 patients were identified with perioperative hc. each patient was matched 2:1 for procedure, body mass index, and medical comorbidities. peak systolic, diastolic, and mean arterial pressures were compared between groups at time of admission, intraoperative, and during remainder of initial hospital stay. welch's t-tests were used for comparison between groups. results: a total of 467 procedures were performed with 383 de novo sg, and 84 de novo gb. revisional bariatric cases were excluded from the study. hc occurred in 8 (1.7%) total patients, 5 gs and 3 gb. four patients required operative treatment for hc, 3 were treated laparoscopically and 1 required laparotomy. the mean diastolic pressures at time of arrival on day of surgery was higher in patients who develop hc (p=0.04) and mean peak diastolic pressure intraoperatively was lower in patients who develop hc (p=0.01). there was no statistical difference in peak systolic or mean arterial pressures throughout the hospital stay. conclusions: bariatric surgical patients with elevated preoperative diastolic blood pressures are at an increased risk of postoperative hc. additionally, decreased peak diastolic blood pressures may be an early indication of an hc in bariatric patients. introduction: bariatric surgery in the adult population is recognized as one of the most effective treatments for obesity and its comorbidities. nonetheless, the safety, efficacy, and substantial outcomes of bariatric surgery in young adults are still not well documented. the aim of our study is to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (lsg) in young adults (\ 29 years old) versus older adults (≥30 years old). methods: we retrospectively reviewed all patients who underwent bariatric surgery at our institution from 2010 to. propensity score matching was used in order to balance covariates, matching for common demographics and comorbidities between the younger patient population (\29 years old) and the control group ([30 years old). all tests were two-tailed and performed at a significant level of 0.05. statistical software r, version 3.3.1 (2016-06-21) was used for all analyses. results: of 1330 patients, 40.07% (n=533) met our inclusion criteria after matching. we found 12.63% (n=119) patients under 29 years old and 43.94% (n=414) patients greater or equal to 30 years old (control group). we observed that our younger population distribution was predominantly caucasian and female, 70.58 % (n=84) and 77.31% (n=92) respectively. the mean age was 24.63 ±3.49 years with a preoperative body mass index (bmi) of 45.93±7.3 kg/m 2 in the younger group compared to 50.08±3.49 years and a bmi of 44.88±6.16 kg/m 2 in the control group. diagnosis of diabetes and hypertension were present in 22.68% (n=27) and 10.08% (n=12) of our younger group, respectively. no statistical significance was found when assessing the percentage of bmi loss (% ebmil) at 3 and 6 months follow-up as shown in table 1 . when comparing the % ebmil at 12 months follow-up, the younger group had 10.39% more ebmil than the control group (p=0.0231). when assessing post-operative complications we observed no statistical significance. conclusions: bariatric surgery is equally effective and safe in young adult population demonstrating a significant better %ebmil at 12 months following bariatric surgery. following prospective studies are needed to elucidate the resolution and behavior of comorbidities in a younger bariatric population. minimally invasive conversion of sleeve gastrectomy to rouxen-y gastric bypass for intractable gastroesophageal reflux disease: short term outcome background: surgical management recommendations for intractable gastroesophageal reflux disease (gerd) after sleeve gastrectomy (sg) remain controversial. this case series demonstrates our experience with treatment of post-operative intractable gerd using minimally invasive conversion of sg to roux-en-y gastric bypass (rygb). patients and methods: this is a retrospective review of a prospective data registry (mbsaqip) from jan 2016 through sept 2017. eleven patients, 10 female and 1 male, were evaluated. of the 11 surgeries, 7 were laparoscopic, 3 assisted with xi da vinci robot, and 1 assisted with si da vinci robot. all patients presented with intractable reflux on high dose ppi. three had a history of aspiration pneumonia. 1±14.88%, respectively. one was omitted due to pending results. conclusion: several solutions exist for operative management of intractable gerd after sg including redo-sleeve gastrectomy, combined gastrectomy with fundoplication, conversion to gastric bypass or anti-reflux procedures such as linx. reports remain small in series and require further study to evaluate the consistency of results. we found minimally invasive conversion of sg to rygb is a highly effective and safe option for treatment of intractable gerd. setthasiri pantanakul, chotirot angkurawaranon, ratchamon pinyoteppratarn, poochong timrattana; rajavithi hospital background: obesity is an important health problem affecting more than 500 million people worldwide. esophageal dysmotility is a gastrointestinal pathology associated with obesity; however, its prevalence and characteristics remain unclear. esophageal dysmotilities have a high prevalence among obese patients regardless of gastrointestinal symptoms. objective: to identify the prevalence of esophageal motility disorder in asymptomatic obese patient. materials and methods: prospective study was performed between june 2014 and march 2017. a total of 47 of morbid obese patients who visited the bariatric and metabolic clinic at rajavithi hospital (bangkok, thailand) underwent preoperative evaluation with high resolution esophageal manometric test with manoscantm eso (smith medical). tracings were retrospective analysis and reviewed according to chicago classification criteria for esophageal motility disorders. results: among 47 asymptomatic obese participants, twenty five of them were female. the mean age was 32.94 (16-68) years old. most of the participants were classified as class three obesity or over. the mean bmi was 53.83 kg/m 2 . no hiatal hernia was found and the anatomy of esophagus was normal in all patients. the mean irp was 14.59 mmhg. twenty-one patients (44.68%) demonstrated high irp over normal limit ([15 mmhg) . four patients demonstrated premature contraction (dl\4.5 second). hypercontractile esophagus was identified in 2 patients and ineffective motility disorder was found in 5 patients. two patients were diagnosed as distal esophageal spasm (des). two patients were compatible with type 3 achalasia and 19 patients (40.42%) have esophageal outflow obstruction. none of the patient demonstrate incomplete bolus clearance even high irp or abnormal motility. conclusion: this study reveals a high prevalence of esophageal dysmotility in asymptomatic thai obese patients. the most common abnormality were esophageal outflow obstruction and ineffective motility. the chicago classification of esophageal motility disorder may not suitable among obese population. sitembile lee, ms 1 , chike okolocha 1 , aliu sanni, mdfacs 2; 1 philadelphia college of osteopathic medicine ga campus, 2 eastside bariatric and general surgery introduction: roux-en-y gastric bypass (rygb) is the most popular bariatric procedure performed worldwide, accounting for 45% of all bariatric procedures. however, in patients with a body mass index (bmi) ≥60 kg/m 2 (super-super obese) the rygb procedure can be technically challenging. this has led to the adoption of a single-stage treatment such as one anastomosis (mini) gastric bypass (oagb/mgb) in the super-super obese patients. proponents of the oagb/mgb claim the clinical outcomes are comparable to the rygb. the aim of this study is to compare the outcomes of the two procedures by examining the literature. methods: a systematic review was conducted through pubmed to identify relevant studies from 2001 to 2015 with comparative data on rygb versus oagb/mgb on super-super obese populations. the primary outcome was the percentage excess weight loss (%ewl). other outcomes include operative times, complication rates and length of hospital stay. results were expressed as standard difference in means with standard error. statistical analysis was done using randomeffects meta-analysis to compare the mean value of the two groups (comprehensive meta analysis version 3.3.070 software; biostat inc., englewood, nj introduction: obesity is becoming more prevalent in patients with inflammatory bowel disease (ibd). the obese body habitus increases the complexity of surgeries that are often needed to treat ibd. some surgeons may delay definitive surgical treatment because of obesity. little data exists on bariatric surgery in the obese patient with ibd. methods: we retrospectively identified 17 patients who had known diagnosis of ibd who underwent bariatric surgery from 2006 to 2016. demographics and post-operative outcomes were assessed. results: 17 patients were identified: 8 with ulcerative colitis (uc) and 9 with crohn's disease (cd). of the 8 uc patients, none of the patients had surgery for uc and only one was on a biologic. of the 8 uc patients, 2 had adjustable gastric band (agb), 1 had gastric bypass and 5 had sleeve gastrectomy. one patient with agb had it replaced for slip and subsequently removed for dysphagia. uc preoperative bmi average was 43.5. postoperative bmi was 32.4 with excess weight loss (ewl) of 57%. average follow up was 23 months. of the 9 cd patients, 4 patients had ileocolic resections and one had total proctocolectomy with end ileostomy. one was on remicade and one on 6mp. of the cd patients, 5 had agb, 1 had gastric bypass and 3 had sleeve gastrectomy. one agb patient had conversion to gastric bypass because of dysphagia and poor weight loss. a second abg patient had band removal because of dysphagia. cd patients' preoperative bmi average was 43.1. postoperative bmi was 37.0 with average ewl of 30%. average follow up was 37 months. overall, agb patients had 17% ewl, sleeves 51% and gastric bypass 74%. two uc patients had post-operative flares, one immediately post op and one month post-operative. four of the 7 band patients had dysphagia, with one replacement, two removals and one conversion to bypass. there were no leaks, intraabdominal infections, fistulas or wound infections. conclusions: uc patients appear to have higher excess weight loss compared to crohn's patients; ewl 57% compared to 30% but was not statistically significant. agb had poor results in both uc and cd patients. sleeve gastrectomy and gastric bypass results in effective weight loss for obese patients with ibd. gastric bypass in ibd patient is controversial, but may be appropriate in the right clinical setting. introduction: previous studies suggest that modest preoperative weight loss is associated with improved weight loss following bariatric surgery. however, there remains a need to investigate factors which may successfully predict preoperative weight loss among bariatric patients. methods and procedures: this analysis included patients who underwent laparoscopic roux-en-y gastric bypass (rygb), sleeve gastrectomy, or gastric banding at an academic medical center in california. data were measured at patients' consult and preoperative clinical visits. preoperative weight loss outcomes were categorized as follows: no weight loss, lost weight, or gained weight. associations between categorical sociodemographic and surgical characteristics and preoperative weight loss outcomes were assessed using the chi-square test of association. associations between continuous measures and preoperative weight loss outcomes were assessed using anova. a sub-group analysis was completed among participants who lost weight prior to bariatric surgery. wilcoxon-rank-sum and kruskal-wallis tests were used to evaluate associations between patient characteristics and the number of pounds lost. results: patients (n=2,597) were predominately ages 45-65 (56%), female (80%), white (53%), and privately insured (68%). patient race was significantly associated with weight loss outcomes (p =0.013): whereas 62% of white patients lost weight prior to surgery, only 54% of black patients lost preoperative weight. among privately insured patients, 59% lost weight. in contrast, 64% of patients insured by medi-cal/medicaid lost weight (p=0.049). on average, lower baseline excess body weight was associated with no weight loss. patients who lost preoperative weight (n=1,570) were included in the sub-group analysis. male sex (p\.001), black race (p.001), undergoing laparoscopic rygb (p=0.003), no previous abdominal surgeries (p=0.038), upper tertile baseline weight (p.0001), waist circumference (p\.0001), percent body fat (p\.01), bmi (p.0001), excess body weight (p.0001), and systolic blood pressure (p=0.001) were associated with more pounds lost. conclusions: this study demonstrates various associations between sociodemographic and clinical patient characteristics and preoperative weight loss. given previous literature indicating the positive relationship between preoperative and postoperative weight loss following bariatric surgery, the results of this study suggest an opportunity to improve preoperative weight loss among specific groups. yen-yi juo, md, mph 1 , usah khrucharoen, md 2 , yijun chen, md 1 , yas sanaiha, md 1 , peyman benharash, md 1 , erik dutson, md 1; background: besides rate and extent of weight loss, little is known regarding factors predicting interval cholecystectomy following bariatric surgery, which are important factors in a surgeon's consideration during decision-making regarding whether to perform prophylactic cholecystectomy. in addition, no previous studies have quantified the incremental costs associated with ic. we aim to identify risk factors predicting interval cholecystectomy (ic) following bariatric surgery and quantify its costs. methods: a retrospective cohort study was performed using the national readmission database 2010-2014. cox proportional hazard analyses were used to identify risk factors for ic. linear regression models were constructed to examine associations between cholecystectomy timing and cumulative hospitalization costs. background: patient-reported outcomes after bariatric surgery are important in understanding the longitudinal effects of surgery. the impact of hospital practices and surgical outcomes on followup rates remains unexplored. objective: to assess the effect of hospital-level practices and 30-day complication rates on 1-year follow-up rates of a standardized patient-reported outcomes survey. methods: bariatric surgery program coordinators in a statewide quality improvement collaborative were surveyed in june 2017 about their practices for obtaining patient-reported outcomes data one year after surgery. hospitals were ranked based on their follow-up rates between 2011 and 2015 (accounting for overall performance and improvement). univariate analysis was used to identify hospital practices associated with higher follow-up rates. multivariable regression was used to identify independent associations between 30-day outcomes and follow-up rates after adjusting for patient factors. results: overall, follow-up rates improved from 2011 (33.9%±14.5) to 2015 (51.0%±13.0) though there was wide variability between hospitals (21.1% vs 77. 3% in 2015) . coordinator survey response rate was 100%. sixty-one percent of all surveyed coordinators perceived that surgeons prioritize high follow-up rates. when asked how long were their patients followed for, 78% of coordinators noted their programs provided lifelong follow-up. patient reminders about the 1-year survey were used by 67% of programs, mostly during clinic visits (75%). most programs (83%) had implemented strategies to improve follow-up rates, such as handing out the survey (73%) during clinic visits. follow-up providers included surgeons (86%), nurse practitioners (56%), and/or registered dietitians (47%). patient disinterest (81%), loss to follow-up (44%), survey length (36%), and lack of staff/ resources (33%) were the factors most commonly perceived as barriers to high follow-up rates. when compared to programs in the bottom quartile of follow-up rates, those in the top quartile were more likely to hand out the survey to patients during clinic visits (100% vs 44.44%; p=0.0106) and had lower rates of risk-adjusted severe complications (1.79% vs 2.60%; p=0.0481), readmissions (3.96% vs 5.08%; p=0.0157), and reoperations (0.75% vs 1.50%; p=0.0216). conclusions: hospitals vary considerably in their 1-year follow-up rates when seeking patientreported outcomes data after bariatric surgery. there were also significant differences in programspecific practices for obtaining these data. hospitals with higher 1-year follow-up rates were more likely to physically hand surveys to patients during a clinic visit and had lower 30-day severe complication, readmission, and reoperation rates. improved 1-year patient-reported outcomes follow-up after bariatric surgery may be a proxy for higher quality perioperative care. david merkle 1 , kazim mohommed 1 , danielle r rioux 2 , dilendra weerasinghe, md, facs 3; 1 nova southeastern university, 2 herbert wertheim college of medicine, 3 bariatric surgery is gaining popularity not only for its weight loss benefits, but also for its metabolic effects. we present a 44-year-old female patient with symptoms of neuroglycopenia, occurring 11-years post roux-en-y gastric bypass surgery. during one of her syncopal episodes, her blood sugar was noted to be 21 mg/dl. continuous glucose monitoring demonstrated post prandial hypoglycemia, averaging 4 episodes per day, with a maximum of 6 episodes in one day. upon further evaluation, the lab results of the hba1c, chromogranin a, somatostatin, and urinary sulfonylurea levels were all normal, with the c-peptide level within the upper limit of normal. ct scan of the abdomen and pelvis did not show any obvious masses in the pancreas, and since the chromogranin a level was normal, it lead to the empiric diagnosis of nesidioblastosis by exclusion. we placed the patient initially on medical management which included a carbohydrate restricted diet of 30 g per meal, eating 6-8 small meals per day, and taking 50 mg of acarbose three times per day. overall, symptoms have improved, and she has 1-2 episodes per month, compared with about 4 episodes per day. we will also present the data with regards to other invasive treatment options, which are available when medical treatment options have failed, such as gastric bypass reversal versus distal gastrectomy. vertical banded gastroplasties (vbgs) were a common bariatric procedure in the 1980s but have largely fallen out of favor due to unsatisfactory weight loss and a relatively high incidence of longterm complications such as dysphagia and severe gastroesophageal reflux disease (gerd). one of the ways to address these undesirable effects is to convert to a roux-en-y gastric bypass (rygb). the aim of this study was to assess the safety and efficacy of vbg-to-rygb conversion. outcomes of vbg revisions performed at an academic center between 2008 and 2017 were reviewed. of the 54 vbg revisions, gastrogastrostomies were created in two patients, two underwent a planned 2-stage conversion, and 50 vbgs were converted to rygbs. patients were operated on an average of 24 years after their initial vbg. presenting symptoms were weight regain (n=30, 55.6%), dysphagia (n=29, 53.7%), or severe gerd (n=23, 42.6%). fourteen patients (26%) had a gastric staple line dehiscence. of the 50 vbg to rygb conversions, 39 were laparoscopic, 5 were converted to open, 4 were open, and 2 were robotic-assisted. average operative time and length of hospital stay were 305.4 minutes and 9.2 days, respectively. within the first 3 months post-operatively, twelve (24%) patients required readmission directly related to surgery, while eight (16%) visited the emergency department. eight patients (16%) required at least one unplanned operation due to complication(s) during the entire follow-up: small bowel obstruction (n=3, at 1-week, 12-months, and 14-months), necrosis/leak of remnant stomach requiring remnant gastrectomy (n=3), tracheostomy for prolonged respiratory failure (n=2), bleeding (n=1), anastomotic leak (n=1), and hemothorax requiring vats (n=1). four patients (8%) had a contained perforation that was medically managed and five (10%) developed a gastrojejunal anastomosis stricture requiring endoscopic intervention. one patient (1.8%) developed pulmonary embolism. there was no mortality directly related to surgery. complete resolution or improvement of gerd/dysphagia was appreciated in all patients in the short term follow-up. patients who presented with weight regain had a mean bmi loss of 13.2±8.2 points in the median follow-up time of 8.5 months up to a year after conversion to rygb. in summary, reoperative bariatric surgeries after vbgs are complex, requiring longer operative times and length of stay. our study found 16% risk of severe complications requiring reoperations, compared to the previously cited 38% in short and long-term complications. conversion of vbg to rygb provides excellent relief of severe gerd and dysphagia and is a viable option for significant weight reduction. introduction: bariatric surgery is a safe and effective treatment for severe obesity and its comorbidities. however, concomitant splenectomy is sometimes required due to uncontrolled bleeding during the surgery. limited literature exists regarding the effects of concurrent splenectomy on outcomes of bariatric surgery. this study aimed to determine these outcomes. methods: adult patients with obesity who underwent primary, elective laparoscopic roux-en-y gastric bypass (lrygb) or laparoscopic sleeve gastrectomy (lsg) with concomitant splenectomy were identified from the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip, 2015) and national surgical quality improvement program (nsqip, 2005 (nsqip, -2014 datasets. using propensity scores (based on 14 baseline variables), patients who underwent primary bariatric surgery were matched 1:10 to a control group (primary lrygb/lsg without concomitant splenectomy) and thirty-day postoperative outcomes were compared. continuous variables and categorical variables were categorized as medians with interquartile range (iqr) and counts with percentages, respectively. background: several previous studies have suggested a correlation between weight loss and age after bariatric surgery. objective: the aim of our study is to further address age as a preoperative factor to determine the amount of weight loss after bariatric surgery. materials and methods: we performed a retrospective analysis of outcomes of a prospectively maintained database of 1,244 obese patients who underwent either sleeve gastrectomy (sg) or roux-en-y gastric bypass surgery (rygb) at our hospital between 2011 and 2015. we analyzed the 3-month, 6-month, and 1-year postoperative percent total body weight loss (%tbwl) of obese patients who underwent bariatric surgery based on their preoperative age. results: the average age of patients included in the study was 45 years old with a range of 21-78 years. an inverse relationship between preoperative age and postoperative weight loss was observed. younger patients achieved a higher % tbwl than older patients at the 3-month, 6-month, and 1-year postoperative follow-up. the average %tbwl for all patients at the 3-month, 6-month, and 1-year postoperative follow-up periods were 15.5%, 23.6%, and 28.9%, respectively. at the 1-year follow-up, for every decade increase in age (above the average age of 45), patients lost 4% less tbwl. conclusion: in our study, younger patients tend to lose a greater amount of %tbwl than older patients after bariatric surgery. results: 51 patients participated in the survey. the median age was 45 yo (iqr: 36-51) and 74.5% were females. the following responses were encountered when asked about the importance of surgery-related factors: the study population indicated the following responses regarding expectations from magnetic surgery compared to conventional laparoscopy: there was no significant evidence of different responses by demographic groups. additionally, 90.2% of the population indicated that a surgeon performing magnetic surgery should be more skillful than a surgeon performing conventional laparoscopy. conclusion: this study represents the first report of bariatric patient's perception regarding surgery-related factors. notably, nearly 80% of the cohort indicated that cosmesis after surgery is an important factor, whereas the responses regarding the rest of the factors were indicated as expected. the bariatric population included in this study had a positive perception of magnetic surgery. furthermore, the population perceived that this technique is associated with better outcomes, better cosmetic results, and higher surgeon dexterity. introduction: although much is known regarding medical outcomes of metabolic surgery, less is known regarding quality of life outcomes. we hypothesized that the collection of patient-reported outcomes (pros) could help us understand quality of life in this patient population. we chose to primarily use patient reported outcomes measurement information system (promis) instruments because of their broad applicability, low cost, and ability to use computer-adapted technology to survey. methods: we implemented the routine collection of pros as part of clinical care in december, 2015. patients were offered tablets in clinic, and were asked to complete the surveys at most of their visits. we used computer-adapted technology to decrease the length of time needed to survey. we collected the following promis instruments: depression, pain interference, physical function, and satisfaction with social roles. we also collected the gerd-hrql, a general health question, and a current health visual analog scale (vas). we retrospectively reviewed our results from december 2015 through september 2017. results: our response rate was 70% over the last year of collection. in total, 2166 assessments were completed by 1026 patients. the mean scores in our total patient population were as follows: vas 59, gerd-hrql 8, general health 51, depression 52, pain 56, physical function 43, and social roles 46. for promis instruments, the mean for the national population is 50, with 10 as the standard deviation. for the depression and pain scores a higher score is worse, while a higher score indicates better quality of life for social roles and physical function. conclusions: routine collection of patient reported outcomes can be implemented in a metabolic surgery clinic. health-related quality of life appears to be decreased in this patient population compared to the general public. further work is ongoing to learn about postoperative trends, as well as differential effects of metabolic procedures. the effect of peri-operative antibiotic drug class on the resolution rate of hypertension after roux-en-y gastric bypass and sleeve gastrectomy. results: in total, 123 rygb and 88 sg were included in our analysis. no significant differences were found between cefazolin and clindamycin regarding hypertension resolution rates after sg. there was a significant difference in the resolution of hypertension after rygb with the use of prophylactic clindamycin or cefazolin. as shown in figure 1 , patients who underwent rygb and received clindamycin had a significantly higher rate of hypertension resolution compared to cefazolin. this effect started at 2 weeks post-operatively (52.4% vs 23.5% respectively, p=0.008) and persisted up to the 1-year (57.9% vs 33.3% respectively, p=0.05). we found no significant differences in patient age, sex, number of pre-operative hypertensive medications, pre-operative bmi, or %bmi change after 1 year to account for the significant effect of antibiotic choice on hypertension resolution. conclusion: this study represents the first clinical report to suggest an impact of the type of antibiotic administered at the time of rygb on co-morbidity resolution, specifically hypertension. future studies will be needed to confirm that the mechanism of action for this novel finding is due to the differing modifications of the gastrointestinal microflora population based on the specific peri-operative antibiotic administered. introduction: laparoscopic adjustable gastric band with plication (lagbp) is a novel bariatric procedure which combines the adjustability of the laparoscopic adjustable gastric band (lagb) with the restrictive nature of the vertical sleeve gastrectomy (vsg). the addition of plication of the stomach to lagb should provide better appetite control, more effective weight loss, and greater weight loss potential. objective: the purpose of the study was to analyze the outcomes of lagbp at 18 months. setting: this is a retrospective analysis from one surgeon at a single private institution. methods: data from all patients who underwent a primary laparoscopic lagbp procedure from december 2011 to june 2016 were retrospectively analyzed. data collected from each patient included age, gender, weight, body mass index (bmi), and excess weight loss (ewl). results: sixty-six patients underwent lagbp. the mean age and bmi was 44.6±12.7 years and 42.1±5.1 kg/m, respectively. all 66 patients were beyond the 18-month postoperative mark. no patient was lost to follow-up. the patients lost an average of 49% and 46.8% excess weight loss (ewl) at 12 months (77.2% follow-up) and 18 months (66.1% follow-up), respectively. also, the patients lost a mean bmi of 7.7 kg/m 2 and 7.6 kg/m 2 at 12 months and 18 months, respectively. the total number of fills during the study period was 201, and the mean fill volume was 0.6±1 cc. dysphagia was the most common long-term complication. the mortality rate was 0%. conclusions: lagbp is a relatively safe and effective bariatric procedure. in light of recent studies demonstrating poor outcomes following lagb, lagbp may prove to be the future for patients desiring a bariatric procedure without resection of the stomach. the median interval between (lrygb) and reoperation is 53 months in group a and 26 months in group b. the median percentage of excess weight loss (%ewl) is 61% vs 67%, respectively (p=0.79). 14 patients 70% (5 in group a) were admitted in an emergency with an acute abdomen pain. ct scan was performed in 8 patients 40 % and has shown signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed by laparoscopy in 8 patients 40% and by laparotomy or conversion in 12 patients 60%. in all cases internal hernia was reduced and closed all defects. in only one patient in (group a) small bowel at jja was resected. there was no mortality and one patient had pneumonia with acute respiratory distress which was treated medically. conclusions: the closure of mesenteric defects at (lrygb) by tight non-absorbable continued sutures is recommended because it is associated with a significant reduction in the incidence of internal hernia. introduction: laparoscopic roux-en-y gastric bypass (rygb) is a common and effective form of bariatric weight loss surgery. however, a subset of patients will fail to achieve the expected total body weight loss (tbwl) greater than 20% after 12 months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. although alternative procedural interventions exist for operative revision after suboptimal rygb weight loss, laparoscopic adjustable gastric banding (lagb) provides an option with short operative time, low morbidity, and effective results. we have previously demonstrated that short-term (12-month), and mid-term (24-month) weight loss is achievable with lagb for failed rygb. the objective of this study is to report the long term 5 year outcomes of lagb after rygb failure. methods and procedures: a retrospective review of prospectively collected data before and after rygb when available, and before and after revision with lagb was performed. background: saline filled intragastic balloons have become a common outpatient procedure for the treatment of obesity. acute dilation, ischemia and necrosis of the stomach has been described in the medical literature. gastric necrosis from acute gastric dilation is a rare but life-threatening condition, which requires timely diagnosis and management. we present a case of partial gastric ischemia with necrosis 72 hours following placement of a saline filled intragastric balloon. postoperative complaints of bloating, nausea and vomiting are common complaints following placement of saline filled intragastric balloons and can lead to a delay in diagnosis. early diagnosis and management is essential in avoiding this life threatening complication. case report: a 59 year old woman, bmi 33, comorbid conditions of diabetes mellitus underwent uncomplicated placement of a saline filled intragastric balloon for treatment of obesity. 24 hours after placement the patient complained of cramping and bloating. 48 hours following placement the patient developed vomiting and presented to an emergency room for evaluation. she was found to have blood glucose exceeding 400 and a severely dilated stomach with pneumotosis on ct evaluation. ng tube decompression and icu management of the severe hyperglycemia was initiated. removal of the intragastric balloon was delayed 12-14 hours until an appropriate endoscopic retrieval kit could be obtained. endoscopic retrieval was performed without incident and near complete necrosis of the gastric mucosa was noted. the antrum was the only area spared. 48 hours after retrieval a laparoscopic evaluation of the stomach revealed full thickness necross of the entire fundus and greater curve. indocyanine green (icg) fluorescent dye was used to assess vascular integrity of the remaining stomach and to define lines of resection. resection of the greater curvature was performed using icg florescent dye to ensure that the angle of hiss was viable and well perfused. the patient had a full recovery and subtotal gastrectomy was avoided. conclusions: spontaneous gastric distension exacerbated by gastric outlet obstruction following placement of a saline filled intragastric balloon can occur. unrecognized this condition can lead to ischemia, necrosis and perforation of the stomach. appropriate evaluation of patients following placement of intragastric balloons is essential. recognition of this condition can be delayed due to the complaints of cramping, bloating and vomiting which are typical following placement of saline filled intragastric balloons. untreated, gastric ischemia and necrosis can lead to early perforation which is associated with a high mortality rate. introduction: morbid obesity has become a growing health risk in the united states with up to 40% of americans suffering with obesity. bariatric surgery remains the best treatment for morbid obesity. the recent use of laparoscopic sleeve gastrectomy (lsg) as a single stage procedure has met with great success because of its quick learning curve and minimal postoperative complication rates. however, there are concerns if the lsg is an effective procedure for long-term weight loss. although criticized at first, the mini-gastric bypass (mgb) surgery has become a great option for morbidly obese patients because of the ability to lose weight with minimal post-op complications. the aim of this review is to assess the outcomes of lsg as it compares to mgb for the management of morbid obesity. introduction: we hypothesize that a jejunoileal anastomosis and partial diversion using magnamosis, a novel magnetic compression device, is technically feasible and will improve insulin resistance and metabolic syndrome similarly to patients who underwent bariatric surgery. metabolic surgery has demonstrated improvements in various parameters including insulin resistance, triglyceride levels, and cholesterol. it may be technically feasible to perform a less-invasive operation through partial diversion, and thereby stimulate an increase in incretins from the l-cells of the ileum to glean these benefits. methods and procedures: we performed a laparotomy and jejunoileal partial diversion using magnamosis in five rhesus macaques with induced insulin resistance through dietary modifications. after surgery, weight was monitored and a metabolic laboratory evaluation was performed weekly. timed tests were performed at baseline and again at 3 and 6 weeks postoperatively for triglyceride levels, glp-1, insulin, glucose, and bile acids. the primates were followed for 8 weeks prior to euthanasia. results are represented as mean±sem and all p-values were calculated using a two-sample students' t-test. introduction: many studies concerning individuals seeking bariatric surgery indicate a higher prevalence of psychiatric disorder in this population, both before and after surgery, however results are not conclusive. the aim of this study was to investigate changes in psychiatric health after gastric bypass surgery. methods: patients within the catchment area of the department of psychiatry of the south alvsborg hospital, operated with gastric bypass surgery during 2011-2012 were identified through the scandinavian quality registry (soreg). patients files were examined and psychiatric diagnoses and alcohol/drug abuse were recorded preoperatively and with a follow up time of 5 years. results: a total of 148 operated patients were identified. 48 of these patients had been in contact with the psychiatric department before or after surgery. 7 patients had attempted suicide preoperatively, but no attempts were made postoperatively, all women. 5 patients attempted suicide postoperatively without a previous history of suicidal attempts, 4 men 1 woman. four patients with a preoperative history of alcohol abuse were identified, all women. these individuals did not seem to abuse alcohol/drugs postoperatively. postoperatively 9 patients with an alcohol/drug abuse were identified, 3 men, 6 women. none of them had a former history of abuse. 4 of the patient performing suicidal attempts postoperatively, 3 men 1 woman, had a postoperatively emerging alcohol/drug abuse. conclusion: preoperatively known alcohol/drug abuse or suicidal attempts do not seem to predispose for postoperative abusive problems or suicidal behavior. preoperative identification of individuals prone to alcohol/drug abuse or suicidal attempts seems difficult. introduction: in the past, our group has popularized models for gastric bypass, sleeve and gastric imbrication. there are currently no models to predict weight loss following single anastomosis duodenal switch. surgeons who offer this procedure are left to guess based on their limited experience how their patients will do following surgery we have developed a simple office based algorithm to predict weight loss following this procedure. method: 161 patients met the criteria for this study. these patients underwent surgery at a single institution from june 2013 to december 2016. non-linear regression analysis was performed to interpolate weight loss at one year. a multilinear regression was run to determine the significant variables. a model was then constructed to predict weight loss after single anastomosis duodenal switch. results: bmi, htn, gender, and the interaction between htn and dm were found to affect weight loss. the model achieved a r value of .616 and the average error of prediction in the model was 12.5%ewl. conclusion: today too many surgical practices offer procedures tailored to surgeon instead of the needs of the patient. using our models predicting postoperative weight loss can be a straightforward process using easily gathered data. all surgeons should be doing this currently in their own practice to allow patient to choose targeted healthcare interventions based on patient's personal goals. surg endosc (2018) introduction: there is a long-standing practice of testing anastamosis both in upper and lower gi surgery. post-operative leaks in bariatric surgery are an uncommon but serious compilation increasing morbidity and risk of mortality. the present study looks at the practice of performing an intra-operative leak test during roux-en-y gastric bypass (rygb) and sleeve gastrectomy (sg). methods and procedures: the study was divided in two independent phases of six months and 12 months. data was collected from all patients undergoing sg, rygb or revision rygb within those two periods. to confirm the integrity of the staple line all patients underwent a methylene blue and air test intra-operatively. this was followed by a gastrograffin swallow the morning post procedure. results: total number of patients in the study was 219. there were four positive intraoperative tests. one patient was a primary rygb and three patients were undergoing revision rygb. all were reinforced and subsequent recovery and gastrograffin swallow showed no leak. one revision rygb had an undetected small bowel injury distal to jejuno-jejunostomy that was not identified on intraoperative or next day imaging. we used multivariate statistical analysis to study our population sample and classified the impact of each factor or their combination with the use of principal component analysis. we used systematic clustering to identify subpopulations that have significant differences in statistical distribution. result: the main determinant of total operative time was the surgeon and the level of his assistant. prior surgeries, bmi and smoking history had a statistically significant impact on the laparoscopic time (p value.05). removing the impact of various surgeons, we detected four clusters of patients based on more than 15 patient characteristics. we noticed total or time had two different clusters: one with a standard-deviation of 17-21 min while the other had over 50 min. conclusion: this study may have practical implications on improving scheduling. the different comorbidities of these bariatric patients helped to stratify patients into these 2 main cluster groups. better predictability on length of operative procedure can lead to more efficient use of or time and staff, thus ultimately leading to savings for the hospital. in addition, we used automated noninvasive tracking methods to identify phases of bariatric procedures that will allow more accurate estimated or time to efficiently schedule cases. the smart or, which is equipped with multiple noninvasive sensors, allows for error free tracking and monitoring without human interference. objectives: successful outcomes after bariatric surgery (bs) require a comprehensive educational program (cep) focused on post-surgical dietary and lifestyle changes. at our institution, patients must comply with a 4-week life-after-surgery program prior to surgery. since many patients are not able to participate in-person, an online cep was created to improve accessibility. to evaluate comprehension, a 16-question test is administered at the last preoperative visit to participants of both classes. the primary objective of this study is to evaluate the effectiveness of online versus inperson cep in terms of comprehension and post-operative weight loss. methods: patients who underwent bs from august 2016-may 2017 were retrospectively reviewed at a single institution. all patients who underwent the in-person or online cep, completed the 16-question test, and had post-operative follow-up for at least 6 months were included. baseline demographic, operative, and weight data were obtained using the electronic medical record. background: body weight loss after bariatric surgery is affected by several factors. diabetes status or preoperative body mass index (bmi) would affect the body weight loss after surgery. age and sexuality may also be the predictor. furthermore, the malabsorptive procedure is considered more effective for body weight loss than the restrictive procedure alone. we investigated the contribution of preoperative background data and procedures to the body weight loss after surgery. methods: this was a multicenter, retrospective study to validate the efficacy of bariatric surgery for morbidly obese patients in japan. patients underwent sleeve gastrectomy (lsg) or lsg with duodenal-jejunal bypass (lsg/djb) in each institution from january 2005 to december 2015, and whose bmi was 35kg/m 2 or more at the first visit were included in this study. we investigated the percent excess body weight loss (%ewl) at 12 months after surgery. univariate and multivariate analyses were done to evaluate the predictive factors of body weight loss. we defined that %ewl more than 50% as well response (wr background: despite its known safety and efficacy, bariatric surgery is an underutilized treatment for morbid obesity in the united states. objective: our goal was to identify factors associated with failing to proceed with surgery despite being considered an eligible candidate by a bariatric surgery program. methods: this is a retrospective study that includes all patients (n=486) who attended a bariatric surgery informational session (bis) at a single center academic institution in 2015. eligible candidates were identified after clinical evaluation and multidisciplinary candidacy review (mcr). we compared patients who underwent surgery to those who did not (i.e. dropped out) by evaluating patient-specific, insurance-specific, and bariatric surgery program-specific variables. univariate analysis and multivariable regression were performed to identify risk factors associated with failing to undergo surgery among eligible candidates. introduction: the elderly are a special subset of the population due to their limited physiological reserve with aging. revisional bariatric surgery is becoming more common with increase in primary bariatric procedures. data on safety, weight loss, and metabolic effects of revisional bariatric surgery in elderly is limited. the aim of this study was to assess the safety and efficacy of revisional bariatric surgery in the elderly. methods: clinical data of all elderly patients (65 years and above) who underwent elective revisional bariatric surgery at an academic institute between 2008 and 2014 were reviewed. demographic data, perioperative variables, and postoperative outcomes were studied. results: a total of 52 patients were identified with a female predominance (3:1). mean age was 68 ±2.8 years. mean bmi at the time of revisional surgery was 39.3±10.3 kg/m 2 . the primary indication for revisional surgery included management of postoperative adverse events (n=32, 61.5%) and weight recidivism (n=20, 38.5%). in patients with postoperative complications, the most common indications for revisional surgery were dysphagia (n=8, 15.4%), marginal ulcer (n= 7, 13.5%), gastric outlet obstruction (n=7, 13.5%), and fistula formation (n=5, 9.6%). the most common type of revisions included conversion of vertical banded gastroplasty to roux-en-y gastric bypass (rygb, n=18), revision of rygb (n=13), conversion of adjustable gastric banding to sleeve gastrectomy (sg, n=6), and sg to rygb (n=4). two out of seven (28.6%) patients with 30-day postoperative readmissions had serious complications that required reoperation. one of them underwent small bowel resection for ischemia and the other had thoracotomy for hemothorax evacuation developing secondary to a gastropleural fistula. while there was no mortality over the first 30 days postoperatively, two patients died 6 months after surgery due to infectious complications. in the median follow-up time of 20 (interquartile range, 10-38) months, mean weight and bmi changes of −15.8 kg and −5.6 kg/m 2 were observed. twenty-three (44.2%) patients had diabetes at time of revisional surgery. a mean reduction of 12.6 mg/dl in fasting blood glucose and 1.1% in glycated hemoglobin were noted between baseline and last follow-up. conclusion: revisional bariatric surgery in elderly is associated with high complication rates. our data indicate that revisional bariatric surgery can potentially alleviate symptoms and resolve complications of primary bariatric surgery. elderly patients should have their risk stratified and weighed against the benefits of surgery. anne-marie carpenter, bs, alexander l ayzengart, md, mph; university of florida introduction: bariatric surgery is the most effective treatment for morbid obesity. of all available procedures, laparoscopic sleeve gastrectomy (lsg) is now the most popular worldwide. common complications of lsg include gastroesophageal reflux, stricture, and staple-line leak. although rare, portomesenteric venous thrombosis (pmvt) and liver retractor-induced injuries are increasingly reported. we present a case of isolated left portal vein thrombus after routine lsg that was likely caused by prolonged compression of left liver lobe by the nathanson retractor. case presentation: a 55-year-old female with a bmi of 39 and biliary colic due to cholelithiasis underwent lsg with hiatal hernia repair and cholecystectomy. she tolerated the procedure without complication and was discharged home on the following day. on postoperative day 9, she presented to the emergency department with fever and epigastric pain. contrast ct revealed an isolated filling defect within the proximal left portal vein; abdominal doppler demonstrated an acute thrombus occluding the left portal vein with normal flow in the main and right portal veins. the patient was treated with a 3-month course of therapeutic anticoagulation with lovenox. a complete hematologic workup did not uncover any hypercoagulable conditions. the patient recovered well and remained asymptomatic at her follow-up visit 12 weeks after operation. discussion: pmvt is a rare surgical complication with multifactorial etiology. in bariatric surgery, evidence suggests lsg elicits more frequent pmvt compared with roux-en-y gastric bypass. a 2017 systematic review cited the incidence rate of pmvt as 0.3-1% after lsg. the mechanisms are thought to be due to pneumoperitoneum, procoagulant obese state, manipulation of portomesenteric venous system during division of the gastrocolic ligament, and postoperative dehydration. liver retraction is paramount during laparoscopic bariatric surgery to provide adequate visualization of the upper stomach and diaphragmatic hiatus. most methods of liver retraction produce significant pressure on the liver parenchyma by compressing it against the diaphragm. three types of liver injury have been documented in literature: minor congestion, traumatic parenchymal rupture, and delayed liver necrosis. uniquely, we propose an additional type of injury-left portal vein thrombosis due to compression of left liver lobe with the nathanson retractor. conclusion: the case described herein represents the first documented report of isolated left portal vein thrombosis after lsg. this is a unique presentation of retraction-related liver injury causing pmvt by mechanical compression of liver parenchyma. as surgical procedures increase in duration, intermittent release of liver retraction should be performed at regular intervals. introduction: up to 11% of patients experience internal hernia (ih) after laparoscopic roux-en-y gastric bypass (rygb). studies have shown that antecolic roux limb orientation, and closure of the mesenteric defect reduce, but do not eliminate, the incidence of ih. we hypothesize that despite operative differences, ih occur more frequently in patients who experience significant weight loss. this study aims to determine whether those patients who present with ih following rygb experience greater than 70% excess body weight loss (ebwl). methods: a retrospective chart of all patients who underwent ih repair following rygb at our institution between sept 2014 and sept 2017 was performed. all applicable cpt codes to encompass ih repair were reviewed (n=412). 17 patients with ih repair after rygb were identified. results: of the 17 patients, 16 were female. the mean pre-rygb weight was 279lbs (sd±54.5), bmi 37.8 kg/m 2 (sd±8.7). all procedures but one were performed in an antecolic configuration; the other retrocolic-antegastric. fifteen cases were laparoscopic and two were open; nine had the jejunal mesenteric defect closed, eight did not. the average weight loss from the time of rygbp to ih presentation was 91.82lbs (sd±38.18) and %ebwl from rygb to the nadir weight was 77% (sd±24). when evaluated by t-test, there was no statistical difference in bmi at the time of program initiation, rygb, or ih presentation, as well as number of pounds lost, %ebwl, or time to ih presentation, when comparing patients for whom the mesenteric defect was closed or not. average time from rygb to ih presentation was 4.5 years (range 190-4655 days) . conclusion: in our limited cohort of patients who have presented with internal hernia after rygb, there was an average of 77% ebwl. this is greater than the average expected %ebwl at our institution and others, suggesting that ih may occur in patients with greater weight loss at a higher frequency. mesenteric defect closure did not appear to have any influence in this limited cohort, suggesting that weight loss is a stronger factor in ih development. we plan a more extensive evaluation in a larger cohort of patients to determine if greater %ebwl is a predictor of ih formation in patients undergoing rygb. introduction: introduction of enhanced recovery after surgery (eras) pathways has led to early recovery and shorter hospital stay after laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg). this study aims to assess feasibility and outcomes of postoperative day (pod) 1 discharge after lrygb and lsg from a national database. methods: patients who underwent elective primary lrygb and lsg and were discharged on pod 1 and 2 were extracted from metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) 2015 dataset. a 1:1 propensity score matching was performed between cases with pod1 vs pod2 discharge, and the 30-day outcomes of the propensity-matched cohorts were compared. high risk patients were excluded from the analysis. purpose: the aim of this study was to evaluate a large volume, multi surgeon bariatric surgery center producing the largest sample size to date proving efficacy (% weight loss) and safety of sleeve gastrectomy following band removal in one or two step procedures. methods: all patients undergoing conversion of lagb to lrygb (33) and lsg (291) regardless of one step vs two step conversion from january 2006 to january 2017 were included. a retrospective analysis of our prospectively maintained database was performed to compare outcomes in patients undergoing conversion to lrybg vs lsg after lagb to identify the outcomes. introduction: the purpose of the study was to describe the use of intraoperative indocyanine green (icg) fluorescence angiography to identify the blood supply patterns of the stomach and gastroesophageal junction (gej). we hypothesized that identifying these vascular patterns may help modifying the surgical technique to prevent ischemia-related postoperative leaks. methods: 86 patients underwent laparoscopic sg and were examined intraoperatively with icg fluorescence angiography at an academic center from january 2016 to september 2017. prior to the construction of the sg, 1ml of icg was injected intravenously and pinpoint® technology was used to identify the blood supply of the stomach. afterwards, the sg was created with attention to preserving the identified blood supply to the gej and gastric tube. finally, 3ml of icg were injected and pinpoint® technology was used again to ensure that all the pertinent blood vessels were preserved. results: 86 patients successfully underwent the procedure with no complications. the following blood supply patterns to the gej were found: the incidence of overall accessory blood supply to the right-side dominant pattern was more common than expected. in about half of the cases where an accessory vessel was found in the gastrohepatic ligament, the blood flow was toward the stomach (and not the liver). furthermore, the incidence of accessory blood supply from the left side was found in 34% of the cases. 10% of patients had both the left side accessory and accessory gastric artery pattern. in these particular patients, if a concurrent hiatal hernia repair is performed, these accessory blood supplies are at risk of being injured if care is not taken to preserve them, rendering the gej relatively ischemic. conclusion: icg fluorescence angiography allows determining the major blood supply to the proximal stomach prior to any dissection during sleeve gastrectomy so that an effort can be made to avoid unnecessary injury to these vessels. background: morbid obesity, a common medical concern with significant health risks, has a prevalence of 10.4% among u.s. adults. bariatric surgery provides effective weight loss for morbidly obese patients with improvement in their comorbid conditions. traditionally, routine intraoperative drain placement (idp) and postoperative esophagram (ugis) were thought to identify early postoperative complications. recently, these interventions have been scrutinized for their effectiveness. we hypothesized that idp and postoperative ugis do not alter outcomes in bariatric surgery and only increase hospital length of stay (los). methods: two cohorts, each consisting of 100 patients from either 2015 or 2017 were analyzed from our institution. in the 2015 cohort, all patients had idp and an ugis on postoperative day 1, prior to starting a clear liquid diet. in the 2017 cohort, no patients had idp or ugis, but instead were started on a clear liquid diet on postoperative day 1, in the absence of vomiting. all patients in each cohort underwent either a laparoscopic sleeve gastrectomy or a roux-en-y gastric bypass. a retrospective study was performed to analyze whether there was a significant difference in postoperative complications, length of stay, and operating room time between these two cohorts. those who underwent t2dm remission were less likely to be vdd at all time points. the rates of vdd appear to be slightly higher in rygb at each time points. the rates of macrocytic anemia, microcytic anemia and hypoalbuminemia were low and varied depending on surgical procedure, with no relevant increase following surgery (see figure 1 ). conclusions: vitamin d deficiency is prevalent among diabetic patients with obesity presenting for bariatric surgery. the postoperative management was successful in addressing vdd following surgery; those who experienced t2dm remission after surgery were less likely to be vdd. further prospective studies are needed to explore this relationship. surg endosc (2018) 32:s130-s359 introduction: it is well known that morbid obesity is strongly associated with high blood pressure. cardiovascular risk reduction is a well studied and described result of bariatric surgery. the objective of this study is to quantify hypertension resolution in patients who underwent bariatric surgery at our institution. methods: we retrospectively reviewed all the patients who underwent either laparoscopic sleeve gastrectomy (lsg) or laparoscopic roux en y gastric bypass (lrygb) at our institution between 2010 and 2015. we selected those patients who were on antihypertensive medical treatment and had a 12-month follow-up. hypertension resolution was defined as the interruption of any blood pressure medications within the follow-up period. we compared the patients who had resolution of hypertension (group 1) with patients who did not (group 2), based on demographics, comorbidities, and outcomes. chi-square and student t-test were used for categorical and continuous variables respectively. results: out of 1330 patients, 185 (13.9%) patients met the inclusion criteria, out of which, 73 (39.5%) had a complete resolution of hypertension within 12 months. the patient population included in group 1 was predominantly female n=114 patients (61.8%), diabetic (n=87, 47%), with a mean bmi of 30.31±4.45 kg/m 2 , a mean age of 52.6±10.7 years, and a preoperative systolic blood pressure mean of 131±14.31 mmhg. the most common procedure performed was lsg with n=105 (57%). comparison between group 1 and group 2 based on age, gender, bmi, and diabetes showed no statistically significant difference. estimated bmi loss % at 12 months, type of procedure and % ebmil showed no statistically significant difference between the groups. conclusions: rapid weight loss is associated with a drastic reduction of blood pressure. besides weight loss, we did not identify a clear correlation between risk factors when we compared patients who had resolution of hypertension with patients without resolution. further prospective studies should be done for better understand these findings. the mount sinai hospital, 2 university of chicago introduction: for many patients, hiv has transformed from a life-threatening illness into a manageable chronic disease. reflecting trends in the general population, obesity is increasingly prevalent among hiv-positive patients. surgical intervention has shown the greatest effectiveness in treating obesity. it is unknown, however, whether physician attitudes reflect the changing trends in obesity care for hiv-positive patients. methods and procedures: medical students from the first, second, and fourth years of training were invited to participate in an irb-approved survey, handed out during didactic sessions, which was designed to assess their knowledge and attitudes regarding bariatric surgery in hiv-positive patients. self-reported demographic information of respondents was also collected. the outcome of interest was the proportion of correct responses. univariate and multivariate regression analyses were performed. results: surveys were completed by 127 medical students. demographic covariates included the following: age, sex, race, bmi, and year of training. age, sex, race, and bmi were not statistically significant in the multivariate model. however, in both univariate and multivariate models, each additional year of training was associated with a significant increase in the proportion of correct responses (multivariate model beta coefficient=0.440, p.001). conclusions: obese and hiv-positive patients suffer from well-documented stigma in health care. these findings suggest that medical training corrects common misperceptions of obese and hivpositive patients, and may lead to a better understanding of the appropriateness of bariatric surgery for hiv patients. whether these attitudes are predictive of referral practices remains to be seen. introduction: obesity is a common problem worldwide with numerous associated comorbidities and is associated with an increased risk of developing some cancers. despite bariatric surgery being associated with a risk reduction for cancer development, some will develop cancer after surgery and little is known about complications which might arise during multimodality cancer treatment. here we report the case of a 55 year-old female who developed an unusual giant marginal ulcer (mu) post laparoscopic roux-en-y-gastric bypass (lrygb) while receiving systemic chemotherapy for an early stage breast cancer. case report: in summary, a 55 year-old female with a preoperative bmi of 40kg/m2 had an uncomplicated lrygb one year prior to her presentation. she was a non-smoker, was abstinent of alcohol and did not use nsaids, steroids or other ulcerogenic medications. eight months post procedure with a bmi of 29.1 kg/m 2 she was diagnosed and treated with bcs plus slnb for a pt2n0m0 er/pr +ve her2 −ve breast cancer. one week following her third cycle of docetaxel and cyclophosphamide, she presented with two days of melena, small volume hematemesis and abdominal discomfort. the patient was resuscitated with prbc, started on a ppi infusion and had free air ruled out on a cxr. upper endoscopy was complete showing a giant mu at the gastrojejunal anastomosis, biopsies ruled out malignancy and h. pylori. subsequent ct abdomen/pelvis identified contrast extravasation from the anastomosis confirming a free perforation. broad spectrum antibiotics were started and a diagnostic laparoscopy complete. a graham patch repair utilizing omentum and abdominal washout were complete with placement of surgical drains. the patient was supported with parenteral nutrition while npo. diet was advanced after an upper gi series on post operative day 7 showed no ongoing leak. the patient was discharged on post operative day 13, recovered and although further chemotherapy was discontinued she completed whole breast radiotherapy. conclusion: leaks and hemorrhage are early postoperative complications that are not seen intraoperatively in our experience. furthermore, endoscopy significantly increases mean operative time. routine use should be left to the discretion of the surgeon but should not be considered an essential step of the sleeve gastrectomy. the objective of the study: surgical site infection (ssi) following bariatric surgery contributes to patient morbidity and additional use of health care resources. we investigated whether a ssi quality control initiative in the form of a refined preoperativeantimicrobial protocol affected the rate of ssi following laparoscopic roux-en-y gastric bypass (lrygb). we reviewed all lrygb procedures performed between june 2015 and december 2016 at a single bariatric surgery centre of excellence. two preoperative antimicrobial protocols were compared. patients undergoing surgery prior to february 2016 received 2 g of cefazolin whereas patients undergoing surgery after february 1, 2016 received a new antimicrobial protocol consisting of 2 g cefazolin, 500 mg metronidazole and 30 ml oralchlorhexidine rinse. the primary outcome was 30 day ssi including superficial ssi, deep incisional ssi and organ/space infection as defined by the centre for disease control. clinic charts and provincial electronic medical records were reviewed for emergency department visits, microbiology investigations and physician dictations diagnosing ssi. outcomes were assessed using a students t-test. results: two hundred seventy six patients underwent lrygb of which 167 received the refined antimicrobial protocol and 109 received cefazolin. the refined antimicrobial protocol significantly decreased the rate of deep incisional ssi compared to cefazolin (n=1, 0.6% vs n=5, 4.6%; p\ 0.05). the refined antimicrobial protocol resulted in an insignificant overall reduction in the rate of superficial ssi (n=12, 7.2% vs n=13, 11.9%; p[0.05) and organ/space infection (n=0, 0.0% vs n= 2, 1.8%; p[0.05) respectively. conclusions: a preoperative antimicrobial protocol using cefazolin, metronidazole and chlorhexidine oral rinse appears to reduce the rate of ssi following lrygb. this protocol may be most effective to prevent deep incisional ssi. additional patient cases or alternative study design including a randomized control trial is required to better understand the efficacy of this protocol. background: for many years, the roux-en-y gastric bypass (rygb) was considered a good balance of complications and weight loss. according to a several short-term studies single anastomosis duodenal switch or stomach intestinal pylorus sparing surgery (sips) offers similar to weight loss to rygb with fewer complications and better diabetes resolution. however, no one has substantiated complication and nutritional differences between these two procedures over the midterm. this paper seeks to substantiate previous studies and compare complication and nutritional outcomes between rygb and sips. methods: a retrospective analysis of 798 patients who either had sips or rygb from 2010 to 2016. complications were gathered for each patient. nutritional outcomes were measured for each group at 1, 2, and 3 years. regression analysis was applied to interpolate each patient's weight at 3, 6, 9, 12, 18, 24 , and 36 months. these were then compared with t tests, fisher exact tests, and chi squared tests. results: rygb and sips have statistically similar weight loss at 3, 6, 9, 12 , and 36 months. they statistically differ at 18 and 24 months. at 36 months, there is a trend for weight loss difference. there were only statistical differences in nutritional outcomes between the two procedures with calcium at 1 and 3 years and vitamin d at 1 year. there were statistically significantly more long term major complications, minor complications, reoperations, ulcers, small bowel obstructions, nausea, and vomiting with the rygb than sips. conclusion: with comparable weight loss and nutritional outcomes, sips has fewer short and long-term complications than rygb and better type 2 diabetes resolution rates. introduction: the purpose of this study is to determine the risk factors that contributed to increased postoperative complications, as noted in prior studies within the publicly funded insurance population undergoing bariatric surgery. methods and procedures: data was collected via a retrospective review of the medical records of patients who underwent laparoscopic roux en y gastric bypass or laparoscopic sleeve gastrectomy from 2010 to 2014 at a single institution. for each patient, data was collected in the following categories: baseline demographics, insurance status, medical comorbidities, immediate complications, re-admissions and associated complications, and follow up out to 3 years. results: a total of 553 patient charts were reviewed, 513 patients were categorized as private insurance and 40 patients were categorized as public insurance. there was no statistically significant difference in mean patient age (private 46.6 years vs public 48 years), sex (male:female 22%:78% for both groups), or bmi (48 vs 50). there was a statistical significance in relationship status in the categories of single (21% vs 30%), married (61% vs 35%) or living with a partner (3% vs 10%), as well as employment status (78% vs 12%). when comparing comorbid conditions preoperatively there was no difference except for diabetes which was less common in the private insurance group 32% vs 50%. readmission rates for complications were significantly different as well at 35% vs 55% with public insurance patients having increased complication rates and readmissions. there was no difference in follow up percentages at each time point for the two groups. interestingly postoperative bmi was significantly different in the two groups until 1 year out (32 vs 34) when the difference disappears. conclusions: our current data set confirms prior research that documented higher complication rates in public insurance patient populations without differences in long term results in regards to weight loss. it also shows that the public insurance group is possibly at higher risk for complications and readmissions postoperatively due to the lack of social support at home given that a much higher percentage of them are single or divorced, and lack employment. it is likely that this lack of support at home prompts more frequent readmissions and associated complications. introduction: gastric bypass has been an acceptable treatment for the morbidly obese patient, with proven efficacy on weight loss and remission of co morbidities, especially diabetes (t2dm). laparoscopic sleeve gastrectomy (lsg) is gaining momentum as an alternative procedure for the morbidly obese patient. the aim of this study is to assess the resolution of t2dm by examining hba1c, bmi, fat %, and % excess weight loss in t2dm patients in our lsg patients. methods: we performed a retrospective chart review of 33 t2dm patients before and after lsg, analyzing hga1c, bmi, % weight loss, fat %, and diabetic medications. data was analyzed by using spss version 24. paired t-test was applied to see the significance of bmi, weight, fat % and hba1c before and after the procedure. introduction: gastroesophageal reflux disease (gerd) is a known risk following laparoscopic sleeve gastrectomy (lsg), with up to 50% of patients affected by the disease postoperatively. of these patients, an unknown number progress to medically refractory gerd. due to their postsurgical anatomy, these patients have limited options for intervention. while endoluminal therapies are available, surgical revision to roux-en-y gastric bypass (lrygb) has become an accepted revisional treatment. despite this therapeutic option, many payors deny coverage for this treatment. in this study, we report outcomes of revision of lsg to lrygb and difficulties in obtaining insurance approval for the operation. methods: we conducted a retrospective review of all patients who underwent a revisional bariatric operation at a single institution between january 2015 and august 2017. we analyzed all patients who underwent conversion of lsg to lrygb. we collected data on 30-day mortality and morbidities, pre-and postoperative antacid use, and the insurance approval process. results: within the study period, we identified 164 patients undergoing revisional bariatric surgery. seventeen patients had undergone conversion of lsg to lrygb. all of these patients underwent revision due gerd refractory to maximal medical therapy. the average body mass index was 37 kg/m 2 , and our average operative time was 184 minutes. one patient required laparoscopic cholecystectomy within 30 days due to acute cholecystitis, and another patient required reoperation for control of staple line bleeding. there were otherwise no 30-day morbidities or readmissions. fifty nine percent stopped all antacid medication by six months, and 65% stopped by 24 months. of the 35% percent of patient still on proton pump inhibitor therapy, none of those patients complained of reflux symptoms. of non-medicare patients, 69% were initially denied insurance coverage for revision. only one plan accounted for all initial approvals. twenty five percent of denied patients eventually paid out of pocket, and the remaining 75% ultimately secured coverage after an appeal process. with no significant differences in mortality or hospital stay. significantly shorter operative times were observed in the adolescent group (83.6±46 vs 88.1±51, p.001). in univariate analysis blood transfusions and vte rates were significantly lower in the adolescent group but there was no difference after risk-adjusted logistic regression analysis. analysis of readmission data showed lower rates in adolescents compared to young adults (3.67% vs 4.44% p=0.06). however, adolescents are more frequently readmitted secondary to gallstone disease (6.3% vs 1.9%, p.05). the most common reason for readmissions in both groups was nausea and vomiting with fluid/electrolyte depletion, followed by abdominal pain. conclusion: adolescent bariatric surgery is feasible and safe, with outcomes similar to that of young adults. lsg is currently the most common bariatric procedure performed in adolescents which is reasonable given the relative lack of co-morbid conditions within this group. nausea and vomiting are the most common reason of readmission in both groups, but gallstone disease is significantly higher in adolescents, suggesting that this population should be carefully screened for gallbladder disease preoperatively. further studies regarding long-term results are needed to elucidate long-term outcomes, such as the durability of comorbidity resolutions in adolescent patients. introduction: revision bariatric surgery is always considered to be associated with higher complication rates. there is currently controversy in the literature regarding one stage and two stage revisions. methods: the present study is ongoing longitudinal prospective analysis of data of revision surgery in a single unit. the revision surgery was offered after initial failed or complicated gastric band, sleeve gastrectomy and roux-en-y gastric bypass (rygb). results: there were forty-two individuals who had revision bariatric surgery. the age of the cohort of patients ranged from twenty-six to seventy-five years. thirty-three were females and nine males. all patients who were hypertensive or diabetic at the time of their initial bariatric operation had a relapse of their co-morbidity prior to their revision surgery. the two stage revisions patients had their band removed at another facility, had a compilation from the band itself or did not wish for revision surgery initially. of the two failed bypasses one had a large pouch and very short limbs. the other had a gastro-gastric fistula and ultra short limbs. there were no deaths in this study. one patient who underwent one stage revision of a gastric band to bypass had an iatrogenic small bowel injury that required a second operation. amelioration of diabetes and hypertension was seen in all who had relapsed. weight loss was good in all patients except for the those undergoing revision from short limbed to long limbed bypass. conclusion: there is enough evidence that revision surgery is feasible, and can ameliorate metabolic co-morbidities after failed band and sleeve. two staged surgery is not necessarily safer compared to one stage revision. in the present study an inadvertent iatrogenic injury occurred in one stage revision group but is not true reflection of increased complications. the association between preoperative endoscopic esophagitis and post operative gerd in sleeve gastrectomy patients samer elkassem, md; medicine hat regional hospital introduction: gerd is a common complication after sleeve gastrectomy (sg). the purpose of this study is assess the relationship between pre-operative findings of endoscopic esophagitis and postoperative gerd in sg patients. the hypothesis of this study is that patients with pre-op esophagitis are more likely to have gerd post-op than patients with no esophagitis pre-op. methods: a retrospective review of 103 sg patients who had pre-operative endoscopy and followed prospectively for at least one year was preformed. patients were divided into two groups based on pre-op endoscopic findings: those with no findings of esophagitis (ne), and those with endoscopic esophagitis, including barretts (ee). patients were followed for at least one year, and assessed for usage of a proton pump inhibitor (ppi) usage. the two groups were compared using both student t-test and chi square test. results: a total of 63 patients did not have any findings of esophagitis on pre-op endoscopy (ne group), and 38 patients had findings of endoscopic esophigitis (ee). there was no difference in preoperative demographics and post-op weight loss at one year (table i) . follow-up ranged from one to 4 years post-op. the dependency on ppi usage and de novo reflux are shown in table ii . introduction: patients with "super-super obesity", defined as a bmi≥60, are at higher risk of weight-related health problems and might benefit more than others from metabolic and bariatric surgery. however, these benefits need to be weighed against the potential for increased operative and perioperative risks. accurate data regarding these patients is critical to guide procedure choice and informed, shared decision-making. the metabolic and bariatric surgery accreditation and quality improvement program (mbsa-qip) is a national accreditation and quality improvement program, which captures clinically-rich specialty-specific data for the majority of all bariatric operations in the united states. this is the first analysis of the mbsaqip participant use file (puf) focusing on this at-risk subpopulation. introduction: sleeve gastrectomy represents one of the most common surgical procedure used in bariatric surgery. the most feared complication following laparoscopic sleeve gastrectomy is the leak that occurs at the staple line. one method to reduce the risk of leak is the use of reinforcement material at the suture line. in this study, the efficacy of sutures and fibrin glue in the prevention of staple leak has been compared retrospectively. materials and methods: a total of 250 patients undergoing lsg between october 2011 and august 2015 at the medical faculty of firat university were retrospectively assessed using the hospital database system records. results: there were 77 males (31%) and 173 (69%) females, with a mean age of 34 years (range: 16-65 y), and body mass index of 45 kg/m 2 . while no reinforcement material was used in 61 patients (24%) at the suture line, reinforcement sutures or fibrin glue were used in 54 (22%) and 135 (54%) patients, respectively. postoperative leak occurred in 8 patients (3.2%), and 6 (9.8%) of these had no use of reinforcment material for leak prevention, while additional sutures or fibrin glue had been used in 2 patients, one in each group (0.7%). one patient died due to leak and the consequent development of sepsis (0.4%). discussion: lsg is increasingly more frequently used in bariatric surgery practice. however, an increase also occurs in the rate of complications. a discrepancy exists in the published literature regarding the benefit of reinforcment the suture line on the risk of leak risk. in our patient series, patients without the use of additional material in the staple line had a significantly increased risk of leak. conclusion: despite some controversy, strong evidence exists on the effectiveness of fibrin glue in the prevention of leaks in patients undergoing laparoscopic sleeve gastrectomy. background: laparoscopic bariatric surgery has been performed safely since 1991. in a persistent search for fewer and smaller scars, single port and acuscopic surgery or even notes have been implemented. the goal of this study is to analyze the safety and feasibility of using a low cost incisionless liver retraction compared to a standard laparoscopic retractor for sleeve gastrectomy. methods and procedures: candidates for sleeve gastrectomy that fulfilled 1991 nih criteria for bariatric surgery were selected. those younger than 18 and/or with prior upper-left quadrant surgery were excluded. all patients signed written consent. patients were randomized 1:1 to either a standard 5 port technique with a fan-type liver retractor through a 5 mm port (group a); or a 4 port technique with the liver retracted by a polypropylene 1 suture passed through the right crura and retrieved at the epigastrium with the use of a fascia closure needle (group b). all surgeries were performed by the same surgeon. surgery length from insertion of first port to withdrawal of the last was the primary endpoint. anthropometric data, % of pre-surgical total weight loss (%ptwl), visualization of the surgical field, complications inherent to liver retraction and postoperative morbidity were recorded. background: comprehensive web and hospital based preparative patient education allow the morbidly obese patients to understand weight loss surgery, its benefits, the necessity of follow up and the risk of weight regain. while the inhouse seminars provide a face-to-face interaction with the bariatric program staff, the online seminars are easily accessible and more cost effective. the primary objective of this study is to compare demographics and weight loss surgery outcomes between patients who participated in the online vs in-house preparative seminars. methods: after obtaining institutional review board approval, a retrospective chart review was performed involving patients who underwent bariatric surgery between january 2015 and december 2016 at a tertiary care center. the patients were divided into two groups based on their choice of educational seminar, online or in-house, prior to their initial consult with a surgeon. data was collected on age, type of insurance, length of stay (los), longest follow up and change in bmi to assess weight loss. results: one hundred and eighteen patients were included in this study. eighty patients attended in-house seminar while 38 completed online seminar. the various types of surgery (laparoscopic gastric bypass, sleeve gastrectomy, and band) were similarly represented between the two groups. there was no difference in the type of insurance policy between the groups. patients who elected to take the in-house seminar were on average 5 years older than those who chose the online course, which was statistically significant (p.05). there were no differences in los, longest follow up after surgery, and weight loss at 12 months between the groups. conclusions: based on mbsaqip registry data, patients age 65 or over did not have higher odds of a 30-day readmission compared to younger patients after lsg or lrygb. rates of 30-day readmission, reoperation, and death were similar, but rates of complications (e.g. pneumonias, unplanned intubations) were higher in the older group. bariatric surgery in the elderly should therefore be performed only after careful and patient-centered selection processes. introduction: revisional bariatric surgery has become more common in recent years. it is to address short and long-term complications of primary bariatric surgery as well as the issue of weight regain. the aim of this study was to retrospectively analyze the indications for reoperation and short-term outcomes in our institution. methods and procedures: between 2011 and 2017, patients who underwent bariatric surgery in our center were included in a prospectively collected database. demographic data, primary and revisional bariatric procedures, reasons for revisions and outcomes were recorded and reviewed retrospectively. results: a total of 527 patients underwent bariatric surgery at our institution and 22% of these (n= 119) were revisional bariatric surgery. we identified 4 groups of patients according to their primary procedures: adjustable gastric band (agb), roux-en-y gastric bypass (rygbp), vertical band gastroplasty (vbg), and sleeve gastrectomy (sg). of the 119 patients, 51 (43%) had abg as primary procedure. of those, 55% had their band removed due to food intolerance and severe dysphagia and 37% had a conversion to either rygbp or sleeve gastrectomy (sg) due to weight recidivism. in the rygpbp group (n=38), 53% of the patients presented with late complications. of these, 45% had an acute presentation (small bowel obstruction, internal hernia, or perforated marginal ulcer) requiring emergency surgery. only 8% patients needed gastric bypass takedown due to severe hypoglycemia. weight recidivism was noted in 47% of the patients that necessitated either revising the anastomosis, trimming of the gastric pouch or gastrogastric fistula takedown. in the vbg group (n=14), 79% of the patients experienced weight recidivism that required conversion to rygb and 21% of the patients required the vbg to be taken down due to obstructive symptoms. in the sg group (n=14), 21% of the patients experienced early complications needing a second procedure. weight recidivism was found as the most common reason for conversion (50%) to rygbp. twenty nine percent of the patients in this group underwent conversion to a rygbp due to severe de novo gerd. introduction: our aim was to systematically review the literature to compare weight loss outcomes and safety of secondary surgery after sleeve gastrectomy (sg), particularly between roux-en-y gastric bypass (rygb) and biliopancreatic diversion with duodenal switch (bpd-ds). sg was originally developed as the first part of a two-stage procedure for bpd-ds. however, it is now the most common standalone bariatric surgery performed in the united states. the majority of sg are done as the sole bariatric operation but in 3%, a second operation is necessary, due to insufficient weight loss, weight regain or reflux. the most common second-stage operations are rygb at 46% and bpd-ds at 24%. there are a few small case series comparing rygb to bpd-ds as a secondary surgery after sg. these studies suggest that after failed sg, bpd-ds results in greater weight loss but higher early complication rates than rygb. we had one mortality, related in part to supra-therapeutic anticoagulation perioperatively. one patient underwent successful heart transplantation and 2 additional patients were reactivated on the transplant list. conclusion: laparoscopic sleeve gastrectomy is effective in advanced heart failure patients for meaningful weight loss, reactivation to the transplant wait list, and ultimately cardiac transplantation. however, this complex population carries a high perioperative risk and close multidisciplinary collaboration is required. more data is needed to best optimize perioperative management of these patients. the introduction: bariatric surgery is a highly effective treatment for severe obesity. while its effect on improvement of the metabolic syndrome is well described, its effect on intrinsic bone fragility and fracture propagation is unclear. therefore, the aims of this systematic review of the literature were to examine (1) the incidence of fracture following bariatric surgery, (2) the association of fracture with the specific bariatric surgical procedure (3) conclusion: it appears that the overall risk of sustaining a fracture of any type after undergoing bariatric surgery is approximately 5 percent after an average follow up of 3.6 years. the greatest risk of fractures is associated with the bpd, with the rygb being the most favorable. fractures following bariatric surgeries tend to follow osteoporotic and fragility patterns. post-operative supplementation of vitamin d, calcium and weight bearing exercises need to be optimized, and long term follow-up studies will be needed to confirm that these interventions will indeed reduce fracture risk following bariatric surgery. background: the effect of sleeve gastrectomy on gastroesophageal reflux (gerd) remains controversial. it is currently common practice to perform a hiatal hernia repair (hhr) at the time of the sleeve gastrectomy, however, there are few data on the outcomes of gerd symptoms in these patients. the aim of this study was to evaluate the effect of performing an esophagopexy hiatal hernia repair on gerd symptoms in morbidly obese patients undergoing robotic sleeve gastrectomy (rsg). methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rsg and concomitant esophagopexy for hiatal hernia repair from november 2015 to july 2017. patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was subjective gerd symptoms and recurrence of hiatal hernia. results: thirty-seven patients were identified meeting the inclusion criteria (rsg+hhr+esophagopexy) with a mean follow-up of 28. over the past 4 years there have been several bariatric surgeries cancelled secondarily to abnormal pre-operative test results within eastern health. these surgeries are often cancelled the day before their scheduled surgery, which does not provide sufficient time to book other patients. the end result is that the or gets underutilized and the bariatric surgery waitlist grows. prior to any major surgery patients are often subjected to a routine screening process, which includes a history and physical along with diagnostic screening tests and screening blood work. a preliminary analysis was done of the first 50 patients through the bariatric surgery program at eastern health assessing the coagulation study results and outcomes. analysis showed that out of the first 50 patients 2% were found to have a history of bleeding, 10% were using anticoagulants preoperatively, another 2% were noted to have a family history of bleeding. in the preoperative blood work that was done, 30% were found to have an elevated ptt/ inr for which hematology ended up being consulted in 4% of the patients. overall this did not change the preoperative management of these patients and they went on to have their surgery. intraoperatively 1 patient was noted to have excessive bleeding and this was found not be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. post operatively there was bleeding in 1 patient which required transfusion, however this too was found not to be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. overall this initial analysis showed no difference in operative management or delay in surgery secondarily to abnormal preoperative assessment findings. further analysis of a larger population of the bariatric surgery program patients is needed in order to determine whether any changes should be made to the preoperative assessment protocol. introduction: patients undergoing bariatric surgery frequently present with various obesity-related psychiatric comorbidities, including depression. furthermore, previous literature has demonstrated a positive association between depression and cardiovascular disease, and obesity serves as an independent risk factor for cardiovascular disease. however, the relationship between preoperative depression and cardio-metabolic risk factors following bariatric surgery remains unknown. methods and procedures: this retrospective analysis utilized data obtained from patients (n= 2,420) who underwent bariatric surgery at a single academic medical center in california. patients underwent either laparoscopic roux-en-y gastric bypass or sleeve gastrectomy. using medical record data, patients were preoperatively categorized as follows: not depressed, history of depression but not currently on anti-depressive medication, and history of depression and presently taking anti-depressive medication. patient demographic characteristics were obtained preoperatively. clinical and biochemical risk factors for cardiovascular disease were evaluated preoperatively and 6 and 12 months following bariatric surgery. anova, kruskal-wallis, and chisquare tests were applied where appropriate. results: in this sample, 59% of patients were not depressed, 21% had a history of depression but were not taking anti-depressive medication preoperatively, and 20% had a history of depression and were taking anti-depressive medication preoperatively. at baseline, depressive history was positively associated with female sex (p\.0001), older age (p\.0001), white race (p\.0001), medicare insurance (p\.0001), previous abdominal surgery (p\.0001), length of stay (p\.0001), requiring an inferior vena cava filter (p=.009), total cholesterol (p\.0001), and triglycerides (p =.003). on average, patients with a history of depression taking anti-depressive medication weighed less than patients with a history of depression not on medication and patients without depression preoperatively (p=.002) and 6 (p=.024) and 12 (p=.004) months after surgery. after six months of follow-up, preoperative depressive history was positively associated with total cholesterol (p=.039), triglycerides (p\.0001), hba1c (p=.039), and fasting serum concentrations of insulin (p=.017). after 12 months of follow-up, preoperative depressive history was positively associated with higher levels of total cholesterol (p=.013), ldl cholesterol (p=.021), and triglycerides (p=0.016). conclusion: a history of depression prior to surgery was associated with higher levels of total cholesterol and triglycerides at baseline and 6 and 12 months postoperatively. after 12 months, preoperative depressive history was also associated with higher levels of ldl cholesterol. this study suggests that, on average, bariatric patients with comorbid depression have worse lipid profiles prior to-and up to one year after-bariatric surgery relative to counterparts without depression. yen-yi juo, md, mph, yas sanaiha, md, erik dutson, md, yijun chen, md; ucla introduction: anastomotic leak is one of the most morbid complications of roux-en-y gastric bypass (rygb), yet its risk factors are ill-defined due to the rarity of the complication. we aim to identify both patient-and operative-level risk factors for anastomotic leak after rygb using a national clinical database. methods: a retrospective cohort study was performed using the 2015 metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) database. all adult patients who underwent laparoscopic or open rygb were included. multivariate logistic regression models were used to identify patient-and operative-level variables associated with development of anastomotic leakage. clinically relevant anastomotic leakage is defined as those that required readmission, intervention, or reoperation. introduction: hyperammonemia secondary to ornithine transcarbamylase (otc) deficiency is a rare and potentially lethal disorder. the prevalence of otc deficiency is reported to be 1:14,000 to 1:70,000 in the general population. otc deficiency has been reported in patients presenting with neurological symptoms after roux-en-y gastric bypass (rygb), and less than 30 cases have been reported in the literature. the aims of this study are to examine the apparent incidence of this uncommon disorder in patients after bariatric surgery and to examine potential predictors of mortality. methods and procedures: this is a single center, retrospective study in a large, urban teaching hospital of postbariatric surgery patients who developed hyperammonemia from january 2012 to august 2017. elevated plasma ammonia with an elevated urinary orotic acid level is accepted as consistent with a diagnosis of otc deficiency. all patients in our program are instructed on a post-operative diet containing 60 grams/day of protein. descriptive and correlative statistics are calculated for all variables. results: between january 2012 and august 2017, 1597 bariatric surgical procedures were performed at this single medical center. seven women with neurological symptoms had plasma ammonia levels above the upper limit of normal range. their average bmi is 45 kg/m2. two patients underwent vertical sleeve gastrectomy (vsg), 1 underwent vsg with duodenal switch, and 4 underwent rygb. all patients were hospitalized. the mean peak plasma ammonia level is 142 umol/l (range: 57-235). the mean urinary orotic acid level is 3.3 mmol/mol creatinine (range: 1.6-7.9). there were 2 patients with no orotic acid level checked, secondary to demise. no patient had clinical features or findings of progressive hepatic failure. there are four mortalities (57.1%). serum folate and peak lactic acid levels are predictors of mortality with p-values of 0.048 and 0.006 respectively. the apparent incidence of otc deficiency is 1:319 in post-operative patients. conclusions: in our post-operative population, hyperammonemia results in a high mortality. its apparent incidence, secondary to otc deficiency, amongst bariatric surgery patients is higher than that reported in the general population. since otc deficiency is identified after multiple bariatric surgical procedures, further investigation will be important to examine potential mechanisms for its development which may include a genetic predisposition (possibly triggered by nutritional deficiencies), upper gut bacterial overgrowth (supported by elevated serum folate levels), or preexisting, subclinical hepatic dysfunction. introduction: the use of closed suction drains is associated with poor outcomes in many anastomotic operations and routine use is not recommended. in this context, intraoperative drain placement for primary bariatric surgery remains controversial. recent studies demonstrate that drains confer no benefit to patients; however, data are limited to descriptive single center experiences with low sample size. in order to characterize this practice gap, and implement evidence based recommendations, we sought to evaluate the use of closed suction drain and outcomes following primary bariatric cases using the mbsaqip registry. methods: we used data from the 2015 metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) public use file for patients who underwent a non-revisional laparoscopic roux-en-y gastric bypass (rygb), laparoscopic sleeve gastrectomy (lsg), or laparoscopic adjustable gastric banding (lagb). we excluded patients with asa status greater than 3 or conversion to an open procedure. we analyzed demographics, preoperative comorbidities, procedure type for patients who did and did not undergo drain placement. adjusted rates of postoperative complications and mortality were then compared based on receipt of postoperative drain placement. results: of the 141,404 included patients who underwent laparoscopic bariatric surgery, 33,618 (23.8%) underwent intraoperative drain placement. drains were more often placed in patients who underwent lrygb, were older, had higher preoperative bmi, had higher preoperative asa status, and had more comorbid conditions. after patient level risk adjustment, there was no difference in rates of leaks requiring intervention (0.32% versus 0.26%, p=0.065) or mortality (6.5% versus 5.4%, p=0.206) for patients with and without drains. in patients who underwent drain placement, there were higher rates of transfusion (9.2% versus 5.6%, p.001), reoperations for bleeding (0.30% versus 0.18%, p=0.001), all reoperations (4.8% versus 3.9%, p.001), and surgical site infections (ssi) (1.0% versus 0.6%, p.001). conclusion: our analysis demonstrates that nearly one quarter of all laparoscopic bariatric surgery patients undergo drain placement. we found that drain placement is more common in preoperatively higher risk patients and following higher complexity procedures as suggested by associated increased rates of transfusion and reoperations for bleeding. we found no benefit to drain placement in terms of interventions for clinically significant leaks or mortality. finally, patients who underwent drain placement were more likely to develop ssi suggesting routine placement is not without risk. although further prospective studies are warranted, our analysis demonstrates that drains have the potential for harm with minimal protective benefit for patients after primary bariatric surgery. sleeve gastrectomy (50% n=24) and laparoscopic roux-en-y gastric bypass (50% n=24) were the two types of surgeries done in our population. the risk of developing atrial fibrillation was calculated preoperatively and found a 7-fold higher risk in females and 4-fold greater risk in males when compared with the ideal risk for each category. at 12 months follow-up the preoperative risk was 11.14±15.45% with an absolute risk reduction of 2.03% corresponding to a relative risk reduction of 18.22% with males having a more significant change at 12 months follow-up. these findings and the electrocardiographic changes at 12 months follow-up are better described in background: the sleeve gastrectomy (lsg) is the most popular procedure worldwide to treat obesity. among those that are obese, gerd has a prevalence of 39.8 percent. many surgeons do not perform lsg in these patients because only 34.6 percent of symptomatic patients showed resolution of gerd-like symptoms after concomitant sleeve gastrectomy with hiatal hernia repair. many surgeons perform the gastric bypass on gerd patients with hiatal hernias because they believe its superior for the resolution of gerd. when they do this they overlook the many long term complication associated with gastric bypass. also, many patients do not want the gastric bypass under any circumstances. surgeons need to be open to finding better way to reduce the high recurrent rates of gerd after lsg. materials and methods: this is a single institution, multi-surgeon, retrospective study involving 73 morbidly obese patients in a prospectively kept data base from january of 2015 through july of 2017. these patients all had gerd with preoperatively identified hiatal hernias on egd. all patients were dependent on anti-reflux medications. there were 9 (12.4%) males and 64 (87.6%) females. bmi ranged from 35 to 63. hiatal hernias measured from 2 cm to 8 cm. all lsg patients received a primary crural closure, with or without gore bio a mesh placement, at least 6 weeks prior to the sleeve gastrectomy. post-operatively, patients were interviewed for gerd symptomatology and anti-reflux medication dependency. results: of the 73 patients, 53 (72.60%) patients had resolution of gerd-like symptoms and off all anti-reflux medications after the staged hiatal hernia repair and sleeve gastrectomy. 13 patients (17.80%) had improvement of gerd but still dependent on anti-reflux medication. 7 patients (9.60%) had no resolution or improvement of gerd. there was one post-operative complication of laryngospasm with pulmonary edema status post extubation. there were no mortalities in the series. conclusions: in this study, staged hiatal hernia repair, at least 6 weeks prior to sleeve gastrectomy, doubled the published rate of gerd resolution from 34% to 73%. 90% showed improvement in symptoms at one year. this rate is comparable to gerd resolution after gastric bypass. this may be an alternative approach to hiatal hernias in the morbidly obese patient with gastroesophageal reflux disease who do not want a gastric bypass. background: bariatric surgery is a common procedure in general surgery. gastric bypass has been performed laparoscopically for over two decades and multiple techniques are described. the circular stapled anastomosis, one of the earliest methods for gastrojejunostomy, is performed in two ways: a transoral method to introduce the anvil and a transabdominal approach developed later. the former technique requires passing the anvil of the circular stapler through the mouth, down the esophagus, and into the gastric pouch. in the latter method, a gastrotomy is made, the anvil is introduced, and the gastrotomy is stapled off, creating the gastric pouch. this study aims to objectively compare the two methods of circular stapled gastrojejunostomy in terms of surgical site infection (ssi) rate. methods: a retrospective chart review of patients undergoing laparoscopic roux-en-y gastric bypass with one of two surgeons at a bariatric center of excellence in an academic hospital from january introduction: laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed procedure in the treatment of morbid obesity, but there is significant variability in its performance. from national database analysis, more restrictive sleeve construction, based on smaller bougie size, has not correlated with greater weight loss. we hypothesize that bougie size is not reflective of actual restriction, or that sleeve restriction does not correlate with weight loss. we performed qualitative and volumetric analysis of immediate post-sleeve contrast studies to determine the association of sleeve restriction with post-operative weight loss and complications. methods: between 2010 and 2015, 222 patients underwent immediate post-sleeve contrast studies. based on standardized vertebral body height assessment by preoperative chest radiograph, sleeve diameter at intervals (including the narrowest point) was measured in mm, and the volume above the narrowest point of the sleeve was calculated. sleeve shape was assumed as dual-tiered or simple truncated cone based on morphology. sleeve restriction, morphology and volumetric analysis were associated with clinical outcomes including complications, post-op symptoms, and weight loss at 6 months. background: variability in surgical technique resulting in narrowing at the incisura angularis, twisting along the staple line, and retention of the gastric fundus has been implicated in increased gastroesophageal reflux disease (gerd) following laparoscopic sleeve gastrectomy (lsg). standardizing creation of the sleeve based on anatomic landmarks may help produce more consistent sleeve anatomy and improve outcomes. methods: a retrospective review of all patients undergoing lsg from january 2016 to november 2016 at a single institution specializing in bariatric surgery was performed (n=271). patients underwent either traditional lsg with use of a 40f suction bougie to guide creation of the sleeve (n =156) or anatomy-based sleeve gastrectomy (abs, n=115). abs was performed using a gastric clamp to maintain predetermined distances from key landmarks (1 cm from gastroesophageal junction, 3 cm from incisura angularis, 6 cm from pylorus) during stapling. patient demographics, perioperative characteristics, and post-operative outcomes were compared using chi-square and student's t-tests as required. helicobacter pylori (hp) is prevalent in up to 50% of the population worldwide with increased rates observed in the bariatric population. bariatric surgery has seen a rapid expansion over the last 20 years with the growing rates of severe obesity. higher hp rates are thought to be associated with increased rates of postoperative complications including increased marginal ulceration and leak rates. accordingly, some bariatric centers have adopted routine pre-operative screening and hp eradication programs. yet, while hp correlation with gastritis and malignancy has now been well defined, its impact on patients undergoing bariatric surgery remains unclear. background: the risk of developing a hiatal hernia in the obese population is 4.2 fold compared to patients with a bmi \30. most hiatal hernias after bariatric surgery are asymptomatic and when symptoms are present they may be difficult to differentiate from overeating or maladaptive eating habits. the aim of this study was to define the risk and symptoms associated with a hiatal hernia in the post-bariatric surgery cohort. methods: a retrospective review of prospectively collected data for patients who underwent laparoscopic hiatal hernia repair who previously had primary roux-en-y gastric bypass (rygb) or sleeve gastrectomy (sg). data collection spanned a five-year interval (7/2012-6/2017). preoperative and follow up data were collected from medical records and questionnaires in the clinic or by telephone. variables obtained include age, gender, psychiatric history, pre-index procedure bmi, pre-hiatal hernia repair bmi, post-hernia repair bmi, pre and post operative symptoms, and associated morbidity. all hiatal hernia repairs were done laparoscopically, with posterior cruroplasty after circumferential hiatal dissection. results: we identified 30 patients with a symptomatic hiatal hernia who had previously (range: 1-23 years) underwent bariatric surgery. fourteen rygb patients presented at a mean of 10.7 years compared to 16 sg patients who presented at a mean of 3.4 years after index procedure. diagnosis was by a combination of ugi (67%), ct scan (50%) and egd (27%). mean follow up was 8.6 months (range: 1-32 months). laparoscopic hiatal hernia repair was successfully performed in all 30 patients with 0% mortality. dysphagia and regurgitative symptoms markedly improved in [ 85% of patients however, nausea, vomiting and abdominal pain were not changed in 20-30% of patients ( figure) . conclusion: hiatal hernia following bariatric surgery is a rare but important cause of bloating manifested as nausea and vomiting, abdominal pain, regurgitation or reflux, and food intolerance or dysphagia (barf)-and should be further evaluated with imaging or endoscopy when present. laparoscopic repair of hiatal hernia is warranted and results in resolution of symptoms in the majority of symptomatic patients. mid-term outcomes of sleeve introduction: obese patients suffer from multiple organ comorbidities which contribute to a shortened lifespan. one of the effects of obesity is thought to be pseudotumor cerebri, which is secondary to increase in intracranial pressure (icp) in the absence of an obstruction. over the past two years, we have measured icp after insufflating with a laparoscopy device. we found that icp increases dramatically and it correlates with the amount of insufflation in the abdomen. over the years, there have been studies in obese patients and intra-abdominal pressure. these studies have shown that some obese patients have an intra-abdominal pressure of 15-18 mmhg. increasing intraabdominal pressure is thought to escalate intracranial pressure (icp). the objective of this pilot study was to observed change in icp after the raising intra-abdominal pressure. method: in this retrospective chart review preliminary study, pressure in each of the patients either normal pressure hydrocephalous or high pressure hydrocephalous receiving a ventricle shunt were measured by manometer. once the shunt was placed into the ventricle, we attached a manometer to measure the opening pressure. after we accessed the abdominal cavity using the standardoptiview technique, we created a pneumoperitoneum. after achieving an intraabominal pressure of 15mmhg, were measured the icp using the manometer. spss software version 24 was used for data analysis. paired t-test was applied on icp before and after the procedure. introduction: postoperative bleeding represents an infrequent, yet serious complication after bariatric surgery. differences in the rate of postoperative bleeding reported for the two most common weight loss procedures-laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg)-are ostensibly confounded by patient and surgeon specific preoperative, intraoperative and postoperative factors, in particular, by the utilization of staple line reinforcement or oversewing. with this understanding, we aim to use a large national database to definitively characterize differences in bleeding rates between lsg and lrygb. conclusions: after appropriate risk-matching, lsg patients have a reduced likelihood of a postoperative bleeding event compared to those undergoing lrygb. this difference is likely more pronounced with intraoperative securing of the staple line via oversew, buttress or an alternative method. these findings from a large national database represent an important consideration for surgeons and patients alike when evaluating the appropriate bariatric operation. background: bariatric surgery has shown to be the most effective treatment, with documented improvement in obesity-related comorbidities. the type of health insurance coverage plays an important role in the access to bariatric surgery, but might also affect postoperative outcomes. the objective of this study is to determine whether there is a difference in outcomes based on the type of insurance 12 months after bariatric surgery. methods: we retrospectively reviewed all the patients that underwent bariatric surgery at our institution from 2010 to 2016. we divided the patients into two groups, based on the type of insurance, private (group one), and public (group two). we compared demographics and 12 months outcomes between the groups, using t-test for continuous variables and chi-square for categorical variables. we also compared 12 months estimated bmi loss between 8 different private insurances using anova. introduction: bariatric surgeons are now performing primary and revisional procedures on the extremes of age. there is controversy surrounding the safety and effectiveness of bariatric surgery among older age groups compared to younger age groups. to address this knowledge gap, we designed a study assessing short-term bariatric surgery outcomes among various age groupings across a large national database. methods and procedures: de-identified patient data across 2015 from the mbsaqip registry was used. age groupings were organized into young, middle-aged, and older adults (in years) as follows: \40, 40-60, and [60, respectively. the following 30-day outcomes were evaluated between all possible pairwise age groupings: mortality, surgical site infection (ssi), and readmission; logistic regression was used to compare outcomes between age groupings controlling for primary vs. revisional index operation, patient factors, and procedure factors. a p value of .05 was deemed statistically significant. results: a total of 168,058 patients were identified (age range: 13 to [80); 86% (n=144,507) underwent primary bariatric operations while 14% (n=23,551) underwent revisional cases. older adults had significantly worse outcomes than middle-aged and younger adults, respectively, for over 100 comparisons across all 3 outcomes; in contrast, younger adults had significantly worse outcomes than middle-aged adults for only 14 comparisons across ssi and readmission. for primary bariatric cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the following categories: asa 3, laparoscopic sleeve gastrectomy (lsg), or laparoscopic roux-en-y gastric bypass (lrygb). for revisional cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the setting of female gender, caucasian race, or asa 3. regarding ssi, older adults undergoing primary lrygb had significantly higher organ space infections compared to younger adults. in addition, older adults who had revisional lrygb had significantly higher deep surgical site infections compared to middle-aged adults. following primary bariatric cases, older adults had significantly higher readmission rates compared to younger adults in the presence of male gender, caucasian race, asa 3, copd, or after lsg. following revisional cases, older adults had significantly higher readmission rates than middle-aged and younger adults, respectively, in the setting of pre-operative chronic steroid use. conclusions: overall, older adults had worse short-term outcomes compared to their younger counterparts following primary and revisional cases. further research is required to investigate these findings with the goal of targeting interventions to improve outcomes among bariatric surgical patients. background: the obesity epidemic in the united states has been accompanied by surge in bariatric surgery. nearly 200,000 bariatric procedures were performed in the us in 2015, 23% of which involved roux-en-y gastric bypass (rnygb). while rnygb has proven an effective tool in combating obesity, it also alters a patient's anatomy in a way that makes traditional ercp a difficult, if not impossible option for interrogating the common bile duct. one way to approach the post-rnygb patient with obstructive jaundice is to access the peritoneal cavity via a laparoscopic/ robotic approach followed by direct cannulation of the gastric remnant with a laparoscopic port, allowing passage of an endoscope. the aim of this study was to evaluate our single center experience with minimally-invasive transgastric ercp (tg-ercp) from 2010 to 2017. methods: we compiled a list of all patients who underwent laparoscopically or robotically assisted tg-ercp at our institution from 2010-2017. we then examined patient demographics, procedural details, postoperative outcomes, and success rate, with success defined as cannulation of the ampulla, clearance of obstruction if present (stones/sludge/stenotic ampulla), and completion imaging of the biliary and pancreatic ducts. results: 40 patients were included in the study. 2 cases were performed robotically (5%), and 38 laparoscopically (95%). ercp was successful in 36 cases (90%). all 4 unsuccessful attempts were aborted when the endoscopist was unable to pass the scope through a tight pylorus. median time of operation was 163 minutes (199 minutes if concomitant cholecystectomy was performed, 159 minutes if not). median length of stay after operation was 2 days (range 1-14 days). median estimated blood loss (ebl) was 50 ml. post ercp pancreatitis occurred in 3 patients (8.3%), and was mild and self limited in all cases. 2 patients had postoperative bleeding requiring transfusion. both of these had concomitant cholecystectomy. discussion: in patients with biliary obstruction and anatomy not suitable for traditional ercp, tg-ercp is a viable option. it can be performed with in a minimally invasive fashion (either laparoscopically or robotically) with a high success rate and low morbidity. as the population of patients who have undergone rnygb continues to grow, so does the likelihood of encountering one with obstructive jaundice. tg-ercp, therefore, should be thought of as an essential tool in the armamentarium of the general surgeon. introduction: primary palmar hyperhidrosis (ph) is a pathological condition of over perspiration caused by body produces an excessive amount of sweat. this disorder affects to decrease quality of life of patients. thoracoscopic sympathectomy is minimally invasive and an effective procedure to treat hyperhidrosis. different of level of sympathectomy has been debate for the best outcomes. many researchers studied about short term outcomes but no empirical research evidences long term outcomes of thoracoscopic sympathectomy in thailand. this study purposed to evaluate and compare the long term clinical outcomes between patients who underwent t3 and t4 thoracoscopic sympathectomy for ph with particular attention to patient satisfaction and quality of life. methods and procedures: sixty patients with ph underwent thoracoscopic sympathectomy. patients were divided into two groups by the level of thoracoscopic sympathectomy as t3 group and t4 group. they were investigated the improvement of sweating, compensatory sweating, satisfaction and quality of life. the long-term investigation was designed to examine clinical outcomes at before surgery, six months after surgery, 1 year after surgery, 3 years after surgery, and last follow up days were compared within group and between of t3 and t4 group. they were subjected to telephone interview using multiple questionnaires to investigate surgery outcomes, degree of satisfaction, and quality of life improvement. results: sixty patients responded to the telephone interview. patients demographic data and also recurrence rate of ph between t3 and t4 group was not significant different (p=0.353). both groups improved severity of sweating without any statistical significant. but the t4 thoracoscopic sympathectomy led to significantly lower incidence of compensatory hyperhidrosis when compared with t3 group at back and trunk sites. the t4 group had higher overall satisfaction than t3 group with was not significantly different. long term result are followed after 3 years. conclusions: there was no difference in decreasing severity of sweating between t3 and t4 level of thoracoscopic sympathectomy. both group equally archived patient satisfaction. but the t4 level of thoracoscopic significantly had lower severity of ch and better quality of life in long term period. introduction: acute pancreatitis due trauma is commonest cause of pseudocyst in pediatric age. due to limited literature available and under diagnosis by pediatricians, the true incidence of pseudocyst in 4-12 age group is not known. material and methods: retrospective analysis of 10 pediatric age (4-12 years) patients who underwent laparoscopic cystogastrostomy at distric teaching hospital was done. patients data, presentation, investigations, opetation done and post operative course was studied. result: total of 10 patients (8 males & 2 females) had mean age of 6.5 years, mean weight of 25 kg. etiollogies included blunt abdominal trauma (6), idiopathic (3), gallstones (1) . average cyst diameter was 6.5 cm. laparoscopic cystogastrostomy by transgastric approach was successfully possible in 10 cases with no conversion. cystogastrostomy was performed using sutures in 5 patients and ultrasonic energy device in 5 patients. gastrotomy was closed with sutures in all 10 cases. mean operative time was 98 minutes. post operative imaging at 3 months revealed no persistence or recurrence of cyst. conclusion: minimally invasive laparoscopic approach for chronic pancreatic pseudocyst in pediatric age group is safe and effective strategy and should be adopted as primary modality of treatment. introduction: videoscopic neck surgery is developing despite the fact that only potential spaces exist in the neck. gagner first described the endoscopic subtotal parathyroidectomy with constant co2 gas insufflations for hyperparathyroidism in 1996. the cervical approach utilizes small incisions in the neck thus making it cosmetically unacceptable and cannot be used for lesions greater than 4 cm. the axillary approach makes it difficult to visualize the opposite lobe. the anterior chest wall approach utilizes port access at various positions on the anterior chest wall depending on the surgeon. this technique also allows bilateral neck exploration. hence we have been able to perform total thyroidectomies with central compartment clearance for papillary carcinoma and near-total thyroidectomies for large multinodular goiters, materials and methods: three incisions subplatysmal plane pneumoinsufflation with carbon dioxide (co2) ports creating a subplatysmal palne dissection begins at the inferior pole posterior dissection clipping superior thyroid vessels specimen freed up thyroid lobectomy was performed in the twenty cases. the average blood loss was 40 ml mean operative time was 85 min there were no complications and no cases were converted to open. there were no cases of recurrent laryngeal nerve injury or postoperative tetany. no subcutaneous emphysema, ecchymosis or hypercarbia was observed in any patient. all patients were discharged on the second postoperative day except the first on the fifth day. in conclusion this approach seems to be safe in case of unilateral lobectomy but early to say it is superior to conventional thyroidectomy especially in total thyroidectomy. introduction: laparoscopic sleeve gastrectomy (lsg) is one of the most commonly performed weight loss surgeries. prolonged hospital admissions are associated with both increased morbidity and mortality and increased strain on the health care system; studies are now investigating the safety and feasibility of outpatient lsg. this study examined a single surgeon's postoperative admission trends for patients who underwent lsg. the patients were divided into two cohorts based on the date of surgery, and we hypothesize institutional experience has a significant impact on postoperative stay and hospital readmission rate. methods: this is a retrospective study on lsgs performed by a single surgeon in a tertiary center from 2012-2017. inclusion criteria: patients [18 years old, bmi [35 with comorbidities or bmi [40, and patient approval by the bariatric surgical program in victoria, british columbia. patients with prior weight-loss surgery were excluded. patients were discharged home on a care plan involving: nurse and surgeon telephone follow-ups within one week post-surgery. patients were divided into two cohorts: cohort a (procedures between 2012-2014 inclusive) and cohort b (procedures between 2015-2017 inclusive). results: 323 patients were included in this study: 265 females (82.0%) and 58 males (18.0%). the mean preoperative age was 46.8±10.5 years, and the mean preoperative bmi was 45.4±5.72 kg/m 2 . the average postoperative discharge day for the population was day 1.69±0.85 and the average or time was 53.9±20.6 minutes. one patient in cohort b was re-admitted pod8 with a diagnosis of postoperative edema managed conservatively and is included in the analysis as pod1. a second patient in cohort b returned to hospital (pod21) for abdominal pain and was managed conservatively as outpatient. conclusion: there was a significant difference in the average postoperative discharge day between patients in cohort a and cohort b who underwent lsg with patients in cohort b requiring a shorter average admission time. this study suggests that with increasing institutional experience and a postoperative discharge plan, patients undergoing lsg may be discharged on postoperative day one safely. surg endosc (2018) introduction: minimally invasive techniques have revolutionized the art of the surgical practice. the laparoscopic approach to cholecystectomy has become the gold standard and is the most common laparoscopic general surgery procedure worldwide. in an effort to further enhance the advantages of laparoscopic surgery, even less invasive methods have been attempted, including smaller and fewer incisions. the objective of this study was describing our results of 22 years of needlescopic cholecystectomy. methods: since march 1995 all patients that underwent to needlescopic cholecystectomy micro-laparoscopic procedure with instruments of 3 mm were included in this study in a prospective database and the information was analyzed. results: between march 1995 and september 2017, 638 needlescopic cholecystectomies have been done at texas endosurgery institute in san antonio, texas by a single surgeon. 86% of the patients were female. the average age was 41.9 (range of 14-82 years old). average operating time was 59.3 minutes (range of 30-200 minutes). the 200minute operation required laparoscopic cbd exploration, accounting for the extended time. average estimated blood loss (ebl) was 15 cc (range of 5-50 cc). 2% of cases required conversion to standard 5 mm cholecystectomy and was completed without incidents. all patients were followed up at 2 weeks, 4 weeks, and 6 months after the procedure. only 1 patient presented with a hernia at the umbilical site. otherwise no wound, bile duct, bile leak, bleeding or thermal injury complications were identified. conclusions: micro-laparoscopic procedures with 3 mm instruments in this specific procedure of needlescopic cholecystectomy is safe and feasible, and is a cosmetic alternative to the standard laparoscopic cholecystectomy. there's still less report about thyroid cancer cases in toetva. this study reviews all cases of thyroid cancer which surgery were performed. there were 47 cases of toetva in thyroid cancer and 7 cases of opened thyroidectomy. objective: to review and report in terms of surgical outcome, complication, post-surgical treatment and recurrence in all cases of thyroid cancer surgery, especially in toetva technique. material and methods: from march 2014-july 2017 in police general hospital, a total of 680 patients underwent toetva with 47 cases of toetva in thyroid cancer and 7 cases of opened thyroid surgery in thyroid cancer. all patients were recorded in multiple parameters. results: this study have total of 54 thyroid cancer cases which 7 cases (13%) were male and 47cases (87%) were female, with an average age of 38. most clinical presentation was thyroid mass or nodule which was at 52 cases (96.3%), 1 case (3.7%) was non-toxic goiter and 1 case (3.7%) was grave disease. the clinical presentation mean time was 2.6 years (2 weeks-13 years). there were 36 cases (66.7%) with a mass at right lobe, 15 cases (27.8%) with a mass at left lobe, and 3 cases (5.6%) with mass at both lobes. the size of thyroid mass was 3.5±2.3 centimeters (1-15 centimeters). there were 49 cases (90.7%) had euthyroid, 1 case (1.85%) had subclinical hyperthyroid, 2 cases (3.7%) had subclinical hypothyroid, and 2 cases (3.7%) had hyperthyroid. for type of surgery, there were 47 cases (87.04%) of toetva surgery and 7 cases (12.96%) of opened total thyroidectomy. most patients at 41 cases (75.9%) didn't have any post-operative complication. and there were hypothyroid 5 cases (9.35%), transient hypocalcemia with no symptom 6 cases (11.1%), and transient hoarseness 2 cases (3.7%). after toetva surgery performed, 24 cases (44.4%) were redo completion thyroidectomy, 19 cases (79.2%) were transaxillary completion thyroidectomy, 4 cases (16.7%) were redo toetva, and 1 case (4.2%) deny for reoperation. and 18 cases (75%) didn't have any complication after redo surgery, 3 cases (12.5%) were hypothyroid, 2 cases (8.32%) were hypocalcemia and hypoparathyroid, and 1 case (4.2%) was transient hoarseness. after did thyroidectomy, ultrasound neck shown that 47 cases had no residual or recurrence thyroid mass, 7 cases had residual thyroid tissue. all cases received radioactive iodine ablation. radionuclide total body scan showed no evidence of distant functioning metastasis. conclusion: three-year short-term followed up toetva in thyroid cancer has shown less complication and no recurrence cancer. objective of the study: sentinel node navigation surgery (snns) in gastric cancer has been investigated for almost two decades in an effort to reduce operative morbidity. indocyanine green (icg) with enhanced infrared visualization is one technique with increasing evidence for clinical use. we are the first to systematically review and perform metaanalysis to assess the diagnostic utility of icg and infrared electronic endoscopy (iree) or near infrared fluorescent imaging (nifi) for snns exclusively in gastric cancer. methods and procedures: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using search terms "gastric/stomach" and "tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy" and "indocyanine green" was completed in may 2017. all human, english language randomized control trials, non-randomized studies, and case series were evaluated. articles were selected by two independent reviewers based on the following major inclusion criteria: (1) diagnostic accuracy study design; (2) indocyanine green was injected at tumor site; (3) iree or nifi was used for intraoperative visualization. the primary outcomes of interest were identification rate, sensitivity and specificity. 327 titles or abstracts were screened after removing duplicates. the quality of all included studies was assessed using the quality assessment of diagnostic accuracy studies-2. results: ten full text studies were selected for meta-analysis. a total of 643 patients were identified with the majority of patients possessing t1 tumors (79.8%). pooled identification rate, diagnostic odds ratio, sensitivity and specificity was 0.99 (0.97-1.0), 380.0 (68.71-2101), 0.87 (0.80-0.93) and 1.00 (0.99-1.00) respectively. the summary receiver operator characteristic for icg+iree/nifi demonstrated a test accuracy of 98.3%. subgroup analysis found improved test performance for studies with low risk quadas-2 scores, studies published after 2010 and submucosal icg injection. iree had improved diagnostic odds ratio, sensitivity and identification rate compared to nifi. heterogeneity among studies ranged from low (i2 \25%) to high (i2 [75%). conclusions: the idea of snns in gastric cancer is intriguing because of the potential to limit operative morbidity. we found encouraging results regarding the accuracy, diagnostic odds ratio and specificity of the test. the sensitivity was not optimal but may be improved by a carefully planned and strict protocol to augment the technique. given the limited number and heterogeneity of studies, our results must be viewed with caution. objective: to evaluate the feasibility, cost effectiveness and safety of single incision laparoscopic surgery using routine laparoscopy instruments. method: 64 cases of acute appendicitis and 56 cases of symptomatic gallstone disease were included in study. 120 cases were enrolled in study and prospective observational study was performed. ruptured appendicitis/abscess formation were excluded from study. similarly empyema gallbladder/gallbladder perforation were also excluded. results: total 120 cases included; 64 cases of appendicitis and 56 cases of symptomatic cholelithiasis. mean age of appendectomy group was 28.71±9.69 years and mean age of cholecystectomy group was 36.71±10.48 years. in our study, mean operative time for sil appendectomy was 42.04±5.74 min. post-operative fever was noted in 10 cases (14.25%). mean post-operative pain as per vas score taken after 24 hours, on pod 2 was 2.14. average post op stay in hospital was 2.14 days, port site infection occurred in one case (4.17%). patient satisfaction score obtained on the scale of 1-10 on one month follow up was 7.95, while scar cosmesis score was 7.9. in our study, 56 cases underwent sil cholecystectomy, of which 21 were male (36.8%) and 35 were females (41.2%), and mean age of patients was 36.71yrs. mean operative time in our study was 75.21 min, mean post-operative pain taken on pod 2 as per vas score was 2.91, mean post-operative hospital stay was 2.1 days, port site infections occurred in 2 cases. post-op fever was noted in 6 cases, post-operative patient satisfaction score obtained at 1 month follow up was 7.73 and scar score of 7.84 on the scale of 0-10. no case required drain placement and conversion. conclusion: sils can be performed using conventional laparoscopic instruments especially in a government setup where per capita economic burden to patient will be less. though it has more operative time, it has comparably less post-operative hospital stay, causes less pain, and has significantly more patient satisfaction regarding post-operative scar and cosmesis. since sils has more patient acceptance and satisfaction, it can be offered to all patients undergoing laparoscopic surgery. it is very useful in government setup where lower economic class of patients will also benefit, irrespective of unavailability of special instruments and financial constraints, as it can be performed using routine laparoscopic instruments. in the year 2009 we started to practice the pericardic window by laparoscopy to diagnostic of head injury hidden in precausal trauma, although lucketally for our society, this type of injury has decreased considerably, we have achieved an important number of patients and in the last year we have performed the procedure for another type of pathologies and also diversified the approach route according to the case. objective: sharing accumulated experience in 8 years in the pericardic window practice by laparoscopy or thoracoscopy. material and methods description of cases results: during this period, we have accomplished 65 cases of laparoscopic pericardal window with two unique ports for the diagnosis of head injury in trauma precordial, additionally there were practiced 15 windows through traumatic trauma of which 4 have been derived in treatment of cardiac injury on this way, without performing open approach. in another scenario, we have performed 8 pericardial spill treatments for different causes by minimally invasive via. no complication or mortality associated with the procedure has been presented. conclusions: the pericardic window performed by a minimally invasive surgery is an effective, replicable strategy for the management of diagnosis and the medical and traumatic treatment of this pathology. patient selection is key and work in multidisciplinary groups guarantees good results. introduction: for the transabdominal preperitoneal repair (tapp) for groin hernia, single port surgery (sps) has been reported to reduce the abdominal wall damages. to reduce the length of the umbilical scar and to keep the view of triangulation, we use one needle forceps plus sps. patients and methods: from may 2014 to july 2017, 168 consecutive tapp patients were retrospectively investigated. there were 139 male and 29 female. we use two 5 mm ports (1 for the scope and 1 for the operator's right hand forceps) through an umbilical multi-channel port and additional 3 mm needle instrument is pierced above the pubic bone. a 5 mm flexible scope allowed us to keep the triangular formation easily. we studied the safety and usefulness of this method from the viewpoints of operation time and the complications. results: median operation time of single side hernia (135 cases) was 77 min (38-152) and the bilateral case (33 cases) was 139 min (91-269). five cases needed one or two additional 5 mm ports, and one case with severe preperitoneal adhesion due to the previous prostate cancer surgery was converted to open method because of the venous bleeding. other complications were 2 spermatic cord injury and 3 postoperative seroma that required the percutaneous puncture. umbilical scars and the pierced needle instrument scars became gradually invisible within 1 or 2 months. there were no incisional hernia nor wound infections in our series. these data was comparable to the conventional laparoscopic hernia repairs. conclusions: operation scars of this method had better cosmesis than the conventional tapp or sps tapp, and there were no differences between our sps-tapp with one needle foerceps and conventional method in operation time and the complication rate. our method was demonstrated as a less invasive approach for laparoscopic groin hernia repair. clinical application: fj clip is a stainless steel that can be used to hold organs in the abdominal cavity. it is available in two sizes: 5 mm and 12 mm. the device is short, it has a strong grasp, and it causes no or only negligible organ damage. we have used fj clip in the performance of local gastric excision (n=13), colectomy (n=8), and cholecystectomy (n=50) with no resulting difficulty. f loop plus is a 21g stainless steel loop-like device into which we can insert φ0.1 mm nt alloy thread, which we draw out extracorporeally via simple puncture. laparoscopic total and proximal gastrectomy. we made a small incision at the umbilicus and inserted a 12-mm camera port and 6-mm metal cannula. we placed two (left and right) epigastric ports. retraction of the left hepatic lobe was easy with use of the 12-mm fj clip and a 6-mm penrose drain. for #4 lymph node dissection, we used the fj clip to grasp the upper part of the stomach, inserted the f loop plus from the upper right abdomen. for #6 dissection, we grasped the pyloric vestibule and pulled it leftward. for dissection of the upper edge of the pancreas, we grasped the left gastric arteriovenous pedicle and pulled it toward the abdomen. the fj clip's grasp and traction exerted on the stomach wall were strong and effective, and there was little organ damage. reconstruction (roux-y) or double tract were performed within the abdominal cavity by hand-sewn purse string suture of the esophageal stump, insertion of an anvil, and use of an automated anastomosis device. we have experienced 2 total and 3 proximally cases to date, but there have been no complications, and both intraoperative bleeding and operation time were within normal limits. conclusion: we believe the fj clip and f loop plus will replace conventional forceps for various tasks in reduced port gastrectomy. introduction: pulmonary anatomical resection is considered as standard treatment for early staged lung cancer. uniportal video-assisted thoracoscopic surgery (uvats) has recently showed favorable surgical outcomes, but remains technically demanding, especially in a complex procedure such as anatomic segmentectomy. needlescopic instruments facilitates complex laparoscopic surgeries with nearly painless and scarless postoperative outcomes, however, its utilization of thoracoscopic surgery were mostly for minor procedures such as bullectomy and sympathectomy. we presented our initial experience of lung cancer surgery performed by uniportal vats and additional needlescopic instruments, and we also compare the operative results with conventional uniportal vats. methods: from december 2016 to august 2017, 75 consecutive patients with lung cancer undergoing anatomical lung resections including lobectomies and segmentectomies were reviewed retrospectively. of these 75 patients, 39 patients received conventional uniportal vats (uvats), and 36 patients received needlescopic-assisted uniportal vats (na-uvats). we compared the peri-and post-operative outcomes in these 2 groups. results: there was no significant difference in demographic, anesthetic, or operative characteristics in two groups except for age. the mean operation time was statistically less in the na-uvats group (198.8±86.8 min vs 159.3±55.4 min, p=0.023). the intraoperative blood loss was significantly less in the na-uvats group (143.2±298.1 ml vs 40.9±56.7 ml, p=0.047). there were two major pulmonary arterial bleeding events and one conversion to thoracotomy in the uvats group. the hospital stay, duration of chest tube drainage and post-operative pain scale were comparative in the two groups. conclusion: under the assistance of additional needlescopic instruments, uniportal vats can be performed more efficiently and safely without compromising its benefit in less postoperative pain and early recovery. purpose: we applicated the v-loc 90 into abdominal wall closure in single incision laparoscopic appendectomy (sila) from 2014. the aim of our study is to present our experience of abdominal wall wound closure technique using barbed suture in sila and comparision of perioperative outcomes with conventional method of layer by layer abdominal wall closure after sila. methods: from august 2014 to june 2015, sila was performed on 160 patients with acute appendicitis at the department of surgery, hallym sacred heart hospital. under approval of institutional review board, data concerning demographic characteristics, operative outcomes, postoperative complications were compared between both v-loc closure group and conventional layer by layer closure procedures. in v-loc closure group, after removing the appendix, divided linear alba was closed using unidirectional absorbable barbed suture v-loc 90 2-0 with continous running fashon. begins at the end of incision, and coming back with reinforced running. subcutaneous closure was also done using same thread, and the subcuticular suture along incision line was performed with remaning portion of v-loc. results: the demographic data of patients's characteristics were similar between the two groups. the use of barbed suture significantly reduced the suturing time for abdominal wall closure (p= 0.014) compared with conventional suture. the postoperative incision length was significantly shorter in v-loc group than conventional group (p=0.034). the rate of surgical site infection were similar in both group. no incisional hernia were noted in both group with median follow up periods of 25.2 months. the total costs of the procedure were comparable in both group under korean drg system. the use of barbed suture in abdominal wall closure in single port laparoscopic appendectomy is safe, and feasible method, reduces the suturing time, thereby decreasing the total operation time, and incision length with cosmetic effect. angela m kao, md, michael r arnold, md, julia e marx, paul d colavita, md, b todd heniford; carolinas medical center introduction: morgagni hernia is an anteromedial congenital diaphragmatic hernia seen in approximately 1 in 3000 live births and rarely identified in adulthood. patients may be asymptomatic, have intermittent symptoms, or present acutely with incarceration/obstruction. given this, surgical repair is recommended, but a standardized technique has not yet been described. methods: a prospectively collected hernia-specific database was queried for all adult morgagni hernias performed at a tertiary hernia center. demographics and peri-operative data were compared. (2) repair. the most common (66.7%) method of repair included suturing mesh to the diaphragmatic portion of the defect and securing the anterior-inferior edge to anterior abdominal wall with transfascial sutures and/or tacks. four patients (26.7%) underwent primary repair. average defect and mesh size was 37.2 cm 2 and 226.4 cm 2 , respectively. three patients (20%) underwent a concomitant paraesophageal hernia repair. mean ebl and length of stay was 31 ml (range 10-125 ml) and 2.7 days (range 1-7 days). postoperative morbidity included transient postoperative hypoxemia (2 patients) and pleural effusion (1) . there was no mortality, mesh complications or recurrences with a mean follow-up of 36 months. conclusions: morgagni hernias patients were more often older, obese, and women. these hernias remained unrepaired in 87% of patients despite their having had previous abdominal surgery. a laparoscopic or robotic approach offers an effective hernia repair with minimal complications, short hospital stay, and excellent long-term results for both elective and acute operations. mesh repair, sutured to the diaphragm and sutured/tacked to the abdominal wall, appears to be a very successful means to repair larger defects. introduction: hydatidosis is a zoonotic disease caused by echinococcus granulosus. it is endemic in the mediterranean, south america and middle east. it is a systemic disease wherein lungs are the second most common organ involved, after liver. radio-imaging plays an important role in diagnosing and determining the extent of the disease. surgical enucleation of cyst has been the classical treatment for this disease. bilateral lung involvement has been traditionally treated by median sternotomy or a bilateral thoracotomy. video assisted thoracoscopic surgery (vats) is an effective surgical approach in such settings. materials and methods: at our center, we have operated 67 cases of pulmonary hydatidosis thoracoscopically over the past 3 years. in all cases, area around the cyst was cordoned off with 0.5% cetrimide soaked gauze pieces. a pericystotomy is performed with ultrasonic shears & the germinal membrane is delivered en masse into an endo-bag. an air leak test after saline instillation into the cavity, is a standard part of the procedure. for those cases with cysto-bronchiolar communications, the defect was sealed by either suturing or glue application. traditionally, bilateral cases & cysts larger than 10 cm in size were tackled by an open approach. but, in our experience, cyst size, bilaterality & presence of complications are not contraindications for vats. all cases are administered perioperative albendazole (400 mg twice a day, administered for three cycles of 21 days each, with a gap of 7 days in between) which helps in preventing recurrence and also takes care of any inadvertent intra-operative spillage. introduction: minimally invasive surgery (mis) is the standard approach for most of the surgical procedures performed by general surgeons. traditionally the majority of operations for trauma are performed open due to the complexity of the cases, however, trauma surgeons are expanding their armamentarium to include mis in a variety of acute procedures. we report our experience with the application of laparoscopy in a variety of trauma cases. methods: a retrospective review of trauma cases performed between 1/2012-1/2016. during that time 52 laparoscopic cases were performed after traumatic injury. patient demographics, injury severity (iss), injury mechanisms, the types of procedures and outcomes will be described. means and standard deviations were calculated and t test were performed. a p value of .05 was statistically significant. results: demographics-a total of 52 trauma cases were performed laparoscopically during the study period. the majority were male, n=43 and the age was 29 sd 11. obesity was documented in 30%, hypertension or cad was in 20%, and substance abuse was in 44%. blunt trauma was in 35% and penetrating 65%. the iss was 15 sd 9. surgical procedures-the majority, 85%, of the procedures were completed laparoscopically. non-therapeutic laparoscopy was performed in 36%. repair of diaphragmatic or traumatic abdominal wall hernias were 29%. hematoma evacuation and control of bleeding was 15%. control of solid organ bleeding and repair was performed in 11%. intestinal repair occurred in 9%. for the cases that required open conversion iss was 20 sd 7 vs. laparoscopic cases iss was 12 sd 9, p=0.04. outcomes: the overall length of stay was 5 days sd 6. there was n=1 late death in a poly-trauma patient that required open conversion for complex solid organ and intestinal injuries. there was n= 1 case of a community acquired pneumonia, and n=1 case of a recurrent pneumothorax. conclusions: a descriptive series of trauma operations approached with mis techniques is described. this cohort had high injury severity and a predominance of comorbid conditions. laparoscopy was successfully applied in the majority of cases for a variety of therapeutic procedures and mortality and morbidity was low. mis is safe and is gaining momentum for application in traumatic injury. objectives: laparoscopic distal gastrectomy for early gastric cancer is a standard treatment in japan described in guidelines. the surgical procedure has been shifting from laparoscopic assisted to complete laparoscopic surgery. in this study, we evaluated the outcomes and safety of the laparoscopic assisted distal gastrectomy. methods: for the marking of the oral side transecting line, the clipping at oral side of cancer lesion was performed by gastro-endoscopy before surgery. the lymph node dissection (d1+/d2) is performed laparoscopically. as the dissection of the pancreatic superior region, the assistant hold the left gastric artery and keep the good view by retracting the pancreas. the common hepatic artery and proximal side of splenic artery are exposed. both sides of the left gastric artery and vein are exposed. left gastric vein and left gastric artery are cut after clipping and sealing. lymph node dissention of hepato-duodenal ligament is done and right gastric artery is cut after clipping and sealing. minor curvature of upper gastric wall is exposed (no 1, 3 dissection). billroth i reconstruction by the circular stapler (cdh) is performed. through the upper median incision with 5 cm, operator pulls out the stomach and transects the oral side of stomach with linear stapler after palpating the clips. duodenum is transected after purse string suture. gastroduodenal anastomosis is performed by cdh. results: two hundred cases were analyzed. the operation time, blood loss and the conversion to open surgery rate were 175 minutes, 40 ml, and 1.0%, respectively. as postoperative complications, anastomotic failure, pancreatic fistula and postoperative bleeding were 2%, 1.5% and 1%, respectively. the reoperation rate was 2%. one surgical death due to cerebral infarction was experienced. there were no patients with ppm (pathological proximal margin) positive and too much pm distance. frequency of abdominal wall incisional hernia and ileus were 1% and 0%, respectively. conclusion: although there is the disadvantage that small laparotomy can be made in the upper abdomen, laparoscopic assisted distal gastrectomy with billroth i reconstruction in our procedure is enough good from the viewpoint of the precision of proximal margin, and the incidence of serious complications. introduction: minilaparoscopy (mini) is a modality of minimally invasive surgery that attempts to produce less surgical trauma to the abdominal wall by reducing the diameter of surgical instruments to 3 mm. searching for better outcomes in inguinal hernia repair, surgeons have looked for new and less invasive alternatives such as single-incision surgery, single-port surgery and mini. minilaparoscopic transabdominal preperitoneal hernia repair (mini-tapp) demonstrates some of the known advantages of mini general surgery procedures such as enhanced visualization, improved dexterity and great cosmetic outcome. it is safe and reproducible since it does not differ from standard laparoscopy. introduction: the celiac plexus is a structure located in the retroperitoneum, at the level of the lumbar vertebra, which is located in the prevertebral region and has sympathetic fibers. patients with advanced gastrointestinal cancer and associated pain, one of the management strategies is pain control. neurolysis of the celiac pleural by laparoscopy was first reported in humans in 2006 in patients with advanced pancreatic adenocarcinoma with excellent results. experience will be shown in the simplification of the technique for the procedure. method: neurolysis of the celiac pleura was performed in 89 patients with advanced gastrointestinal cancer, stomach 52%, pancreas 23% liver 14% other 11%, no complications associated with the procedure, pain improvement was achieved in 80% of patients after process. the standardization of the technique by laparoscopy and its simplification, has made this procedure that is replicable and safe. description of the technique: patient in french position, technique of 3 trocars, umbilical trocar 10 mm and 2 trocars of 5 mm paraumbilical, staging laparoscopy is performed and sampling if necessary, is identified in the region of the lowercurvature of the stomach, the celiac trunk and the emergence of the left gastric artery are identified and 20cc of 90% alcohol diluted to the medium in the lateral fatty bearing are instilled through a pericranial 22 under direct vision, verifying the non-arterial instillation of the alcohol. there were no complications related to the procedure. results: we report the experience of one group who underwent celiac pleura neurolysis in 89 patients with advanced gastrointestinal cancer, gastric cancer 52%, pancreatic cancer 23%, liver cancer 14% and another 11%. the most frequent pathology report was adenocarcinoma, 80% of the patients were managed at 24 hours with sustained effects, up to 6 months of follow-up. with a significant decrease in pain medication. only 1 patient required new laparoscopic neurolysis because of difficult-to-manage pain. the operative time of this procedure was 30 minutes. the standardization of the technique, the use of low cost inputs, makes this type of procedure easily replicable with goodresults in pain management in cancerpatients. conclusions: mis is offered as one of the fundamental tools for the management of palliative procedures in gastrointestinal cancer. neurolysis of the celiac pleura with standardization of the technique, use of low cost elements, and the surgeon's skills make this procedure an option of management and control of pain in patients with advanced gastrointestinal cancer, is easily replicable, economical and insurance. background: the non-absorbable polymer clip offers a solution to the disadvantage of traditional metallic clip. due to its metallic property, it is not only expensive but also causes artifacts on imaging studies and often migrates into cbd. this study compares the traditional standard metallic clip with hem-o-lock used in laparoscopic cholecystectomy (lc) in regard of the safety and efficacy?. material and methods: this study includes 40 patients who underwent lc implementing metallic clip (mc) and 40 patients implementing hem-o-lock clips (h0)?. both clips were applied to cystic duct and artery, then the gallbladder was dissected from the liver bed by diathermy. the intraoperative and postoperative parameters were collected including duration of the operation and complications?. results: the median operative time was not statistically different between the mc and the hc group (89.33 vs 86.17 minutes, respectively; p=0.96) with no significantly less incidence of bile spillage (9 vs. 8, p=0.956) . no statistically significant difference was found in the incidence of postoperative complications between both groups (1 vs. 2, p= 0.97). no postoperative bile leakage was encountered in both groups. conclusion: hem-o-lock clip provides a complete hemobiliary stasis and a secure cystic duct and artery control. its cost effectiveness is also attractive while provides efficacy equivalent to that of the standard metallic clip. introduction: most of the blunt thoracoabdominal injury patients always have multiple organ injuries. plan of definite treatment depends on the preoperative diagnosis. in isolating diaphragmatic traumatic injury without others organ injury laparoscopic approach is helpful, decrease a length of hospital stay as well as decrease a wound complication. authors describe the laparoscopic treatment of the patient who had rupture of a diaphragm from blunt trauma in an emergency setting. methods and procedures: a 56 years old man presented with motor vehicle accident and mechanism of injury was blunt thoracoabdominal injury. he complains about chest tightness and tachycardia. complete evaluation and ct scan ware performed. stomach was herniated to the left chest and diaphragmatic ruptured was found neither others great vessels nor solid organs injury. the laparoscopic approach was desired and left diaphragm was repair by non-absorbable sutured without intraoperative complication. results: the patient has been discharged 4 days post-operative with full recovery. chest x-ray was taken before discharge, in out-patient department 2 weeks as well as 6 months after discharge which shown no diaphragmatic herniation. conclusion(s): laparoscopic approach in isolated traumatic ruptured diaphragm patients is safe and should be considered. short-term outcome of laparoscopy-assisted distal gastrectomy with roux-en-y reconstruction through mini-laparotomy for gastric cancer since 1991, we have introduced laparoscopy-assisted distal gastrectomy (ladg) with b-i reconstruction through mini-laparotomy. regarding to reconstruction, roux-en y reconstruction are also one of the choice in ladg, however, the technical feasibility has not been well documented so far. the purpose of this study was to compare the short-term outcome of ladg with roux-en-y reconstruction through mini-laparotomy compared to that of ladg with b-i anastomosis. between 1994 and 2014, 440 patients who underwent ladg for gastric cancer in oita university were enrolled in this retrospective study. since 2005, the roux-en-y reconstruction has been performed as a standard method in our department. these patients were divided two groups based on anatstomosis; roux-en-y (r-y) group (n=246) and billroth i (b-i) group (n=194). baseline characteristics, operative results (including complications) and pathological results were evaluated. there were a considerably greater number of patients with advanced clinical stage and having ≥t3 invasion in the r-y group. estimated blood loss was lower in r-y than in b-i (p.001) and operative time was longer in r-y than in b-i (p.001). there were no significant differences in all grade intra-operative complications (p=0.441). in addition, there were no significant differences in all grade post-operative complications between the two groups except internal hernia. hospital mortality was 0% in each group. ladg with r-y reconstruction through mini-laparotomy was technically feasible as well as ladg with b-i anastomosis. utilization of laparoscopy associated with blunt abdominal trauma: the nationwide inpatient sample 2004-2014 kenneth w bueltmann 1 , marek rudnicki 2; 1 advocate illinois masonic medical center, chicago, il, 2 university of illinois introduction: the incidence of trauma and its heavy burden upon the healthcare system remain strong. paradigm shifts in the management of these cases has, however, improved the mortality in such cases. it can be expected that improvements in management, when combined with the benefits of laparoscopy, will demonstrate positive impacts upon treatment outcomes. methods: the nationwide inpatient sample was referenced for inpatient stays for the years 2004 to 2014. abdominal trauma cases were selected and identified as hollow (ho) or solid organ (so) type, and as blunt or penetrating. the trauma subset was then scanned for the presence of discrete laparoscopic procedures, laparotomy, and converted cases, and flagged accordingly. conclusion: utilization of laparoscopy in treatment of intraabdominal solid and hollow organs injury increases over time. although current analysis based on available hcup nis data include any procedures done during post-traumatic hospitalization, its results can lead to conclusion that minimally invasive technique is being utilized in increased fashion. introduction: single incision laparoscopic (sil) surgery is a laparoscopic procedure which leaves a single small incision in navel, and has been reported to be less invasive than and as safe and efficient as the conventional multiport laparoscopic (mpl) surgery. the long-term rate of incisional hernia after sils colectomy is unknown, and the risk factors of incisional hernia formation is not fully elucidated. methods and procedures: this is a retrospective from a prospectively collected database. the investigation took place in a high-volume multidisciplinary tertiary private hospital in japan. introduction: laparoscopic approach in the acute surgical care setting continues to be underutilized. we aim to report the successful diagnostic and therapeutic use of laparoscopy in the management of a nontoxic patient presenting with acute abdomen and to highlight the benefits of a minimally invasive approach without added morbidity. case report: presented is a 52-year-old male with history of cad s/p cabgx4 two years prior and no abdominal surgical history who presented to the ed with sudden onset severe, diffuse, abdominal pain of six-hour duration with n/v. there was no trauma to the abdomen. he had mildmoderate hypertension, but was otherwise hemodynamically stable. on examination, the patient was in severe distress and writhing in pain. fast exam was unable to be performed secondary to pain. cta of the abdomen revealed mesenteric abnormalities with associated small bowel edema in the rlq suspicious for small bowel ischemia. he was taken to the or for diagnostic laparoscopy. he was found to have an omental adhesive band to the abdominal wall with herniation of the small bowel through the small opening. approximately 70 cm of ischemic, nonviable small bowel was resected and anastomosed intracorporeally. he tolerated the procedure well and was discharged home on post-operative day 3. discussion: primary omental related internal herniation of small bowel is exceedingly rare. there have been only few cases reported in the literature (1, 2, 3, 4) . two were diagnosed on exploratory laparotomy, one on diagnostic laparoscopy and one at autopsy. the one who underwent diagnostic laparoscopy did not require bowel resection. in presenting this case, we hope to illustrate the role of laparoscopy in the management of acute abdominal pain due to bowel compromise. introduction: morgagni hernias are a rare finding in the adult population, and represent 1-3% of all congenital diaphragmatic hernias. multiple approaches to these rare hernias have been described in the literature. here we present a novel technique of laparoscopic trans-abdominal repair using a combination of the endo-close device (medtronic, minneapolis, mn) and the ti-knot (lsi solutions, victor, ny.) methods: in a patient with a large left anterior diaphragmatic defect we performed trans-abdominal suturing utilizing the endo-close to perform primary closure of the defect, using the ti-knot to secure the pledged sutures along the anterior fascia. due to the size of the defect (7910 cm) this primary repair was buttressed with polyester mesh. in a second patient with a smaller (698 cm) classic right-sided anterior diaphragmatic defect we similarly performed laparoscopic trans-abdominal suturing using the endo-close to traverse both the anterior and posterior fascia and the ti-knot to secure the sutures in order to perform a primary repair of the hernia. both patients presented had an uneventful postoperative course and no indication of recurrence at 4 months. conclusions: morgagni hernias present unique technical challenges. in our experience the combined use of trans-abdominal suture with laparoscopic knot replacement device allowed for completion of both cases laparoscopically with minimal tension on the repairs. feasibility of concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis: first case report worldwide ibrahim a salama, md, phd; department of hepatobiliary surgery, national liver institute, menoufia university introduction: situs inversus totalis is a rare anomaly characterized by transposition of organs to the opposite site of the body. combined laparoscopic splenectomy and cholecystectomy in those patients is technically more demanding and needs reorientation of visual-motor skills. presentation of case: herein, we report a 16 year old girl presented with yellowish discoloration and left hypochondrium and epigastric pain diagnosed as hereditary spherocytosis (hs). the patient had not been diagnosed as situs inversus totalis before. the patient exhibit a left sided "murphy's sign" and spleen palpable in right hypochondruim. diagnosis of situs inversus totalis was confirmed with ultrasound, computerized tomography (ct) and magnetic resonant image (mri) with enlarged right sided spleen and presence of multiplegall bladder stones with no intra or extrabiliary duct dilatation. the patient underwent combined laparoscopic splenectomy and cholecystectomy as treatment of hereditary spherocytosis (hs). discussion: feasibility and technical difficulty in diagnosis and treatment of such case pose challenge problem due to the contra lateral disposition of the viscera. difficulty is the laparoscopic technique encountered in skelatonizing the structures in calot's triangle, which consume extra time than normally located gall bladder with right sided standing surgeon and the position changed to left sided standing surgeon during splenectomy. in review up to date medical literature this is the first case reported worldwide. conclusion: provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder disease as in hereditary spherocytosis (hs) as changes in anatomical disposition of organ not only influence the localization of symptoms and signs arising from a diseased organ but also imposes special demands on the diagnosis and surgical skills of the surgeon. objective: to identify the preference among medical students of the following surgical approaches: open surgery, conventional laparoscopy, minilaparoscopy (mini), single incision laparoscopic surgery (sils), natural orifice transluminal endoscopic surgery (notes), and robotic surgery. methods: an online google questionnaire was filled by 111 medical students of different years in medical school. before answering the questionnaire, they watched an online video showing the different techniques, its advantages and disadvantages. the questionnaire consisted of 18 questions about the hypothetical situation where the participants were going to be submitted to an elective cholecystectomy and they could decide which technique they would prefer. all statistical analysis was performed using the r software program, version 3.3.1. the chi-squared test was performed for categorical variables where appropriate. a p value .05 was statistically significant. results: one hundred and eleven medical students answered the survey. 60 (54.05%) were female and 51 men. most of the students were between 19 to 22 years old (54.95%). they were in the first four years of medical school. when asked if they would consider notes or single incision even if they know that they are new procedures and with not completely established security standards, 84.68% (94) answered that they wouldn´t consider with no difference between gender (p=0.920). when asked if only conventional laparoscopy, robotics or mini were offered, which one they would choose: 85% of women and 62.75% men chose mini first (p=0.025). about the factors that they would consider the most important when choosing the surgical technique, they answered safety first (57.66%), followed by the surgeon´s experience with the procedure (29.73%), with no statistically significant result between genders (p=0.529). when asked if they would consider an open technique even with the other techniques available and compared according to their year in medical school, students closer to finishing medical school would not consider it, with a statistically significant result (p=0.036). regarding the most important factors they would consider and compared by year in medical school, safety and experience of the surgeon performed best, with a statistically significant result (p.05). conclusion: among the available surgical approaches, minilaparoscopy tends to be the preference among women medical students who considered safety the most important aspect. the closer they get to the end to medical school, the less they consider the open technique. background: extension of the single incision for the purpose of specimen removal in singleincision plus one additional port laparoscopic surgery (sils+1) can undermine the merits of sils +1, either by increasing wound-related morbidity or by destroying cosmesis. methods: we retrospectively analyzed the clinical outcomes of patients underwent elective sils +1 anterior resection, either with transanal specimen extraction (tase, n=25) or transumbilical specimen extraction (tuse, n=77), for colorectal cancer from january 2014 to june 2017. this study included patients with a tumor diameter less than 5 cm, measured by preoperative computer tomography. results: both groups were similar in patient's basic information and oncologic condition. most surgical data and postoperative clinical variables were comparable between tase and tuse group, except for increasing operative time in tase (210.2+45.7 vs. 167±43.4 min, p=0.032) and reducing wound complications in tase (0% vs 14.6%, p=0.043). dosage requirement of narcotic analgesics was not inferior in tase group compare to tuse group. no significant differences were observed in conversion rate, perioperative and overall morbidity between the two groups. conclusion: although sils+1 with tase prolonged operative time compare to with tuse, implement of tase is expected to provide benefit of reduced wound-related morbidity in patients with a tumor diameter less than 5 cm. medhat ibrahim, md; al-azhar university, naser city, cairo, egypt purpose: morgagni hernia (mh) is a rare condition. mh is less than 6% of surgically treated diaphragmatic hernias in infants. there is no specific symptom for the maorgagni hernia. open surgical repair was the golden stander before the introduction of the laparoscopic surgery in the children and infant. there are many different laparoscopic techniques for mh repair have been reported. i report laparoscopic repair of mh in five infants using primary sutures closure with inrta-corporeal knot tying and ethicon secure strap device. this study is an evaluation of the safety and efficacy of this new laparoscopic technique of mh repair in infants with it is short-term outcomes follow up. patients and methods: five infants with mhs underwent laparoscopic repair by hernia sac excision then two primary sutures, non-absorbable proline through the full thickness of the anterior abdominal wall and the posterior rim of the defect, intra corporeal sutures knot tying, ethicon secure strap device which was used to complete the colures of the defect. there was no insertion of chest tube or drain. results: five infants with mh were operated upon. there were 4 males and 1 female. all cases were left side mh, male-female ratio was 4:1. intraoperative and postoperative analgesia requirement was minimal (paracetamole 100 mg/kg/rectal suppository/12 hours for the first 24 hours). ceftriaxone 50 mg/kg single dose at the anesthesia induction. all operations were completed laparoscopic. all infants started and tolerated oral regular feeding with in 24 hours from surgery. none of the patients developed intraoperative or postoperative complications. the maximum follow-up was 36 months (mean, 17 months). all patients are in good health without recurrence or port site compilation. conclusion: this easy save technique of mh repair is reducing the operative time and postoperative hospital stay. it is minims the need of postoperative analgesia, anti biotic. the early oral feeding is also a good benefit. the introduction: transumbilical single port laparoscopic appendectomy (tspla) is the most popularized single port surgery in the world. it provides more cosmetic benefits than conventional laparoscopic surgery. however, single port appendectomy requires longer operation time and advanced surgical skills. we aimed to investigate the learning curve for tspla. material and methods: data were collected from patients who underwent tspla by single surgeon between march 2013 and february 2016. the learning curve were analyzed using a cumulative sum control chart (cusum) for operation time and complication. results: a total of 109 patients were included in this study. mean operation time is 61.6±20.61 minutes. there was no open or multi-port conversion. based on cusum for operation time, learning curve were 31 cases. conclusions: tspla is a safe and effective alternative procedure. the learning curve could be overcome safely without major complications. our results suggest that the 31 cases are sufficient to achieve surgical skills for tspla. introduction: anastomotic leakage (al) is a life threatening complication after minimally invasive ivor lewis esophagectomy (tmie ile) and has diverse treatment strategies such as conservative treatment, endoscopic treatment and surgery. however, there is no consensus on which treatment strategy is best. the aim of this study was to analyse various therapeutic strategies for al and their outcomes. methods and procedures: this retrospective multicentre study was performed in three highvolume hospitals. all patients that developed al after tmie ile in the period of january 2011-july 2016 were included. the different endoscopic (stenting, clipping and suction-drainage) and surgical treatments and their success-rate were described; success was defined as clinical improvement after primary treatment. primary endpoint was the time until oral feeding was resumed. secondary endpoints were hospital stay and the total amount of surgical, endoscopic and radiologic interventions. results: in total 83 patients that developed al were identified; four patients received antibiotics only. in the remaining 79 patient, endoscopic treatment was performed as primary treatment in 53%; 47% received primary surgical treatment. basic variables were similar in these groups. median postoperative day of diagnosis of al was day 7 in the endoscopic-group and day 5 in the surgical-group (p=0.038). admission to the icu as a result of the leakage was necessary in 52% in the endoscopic-group versus 95% in the surgical-group (p.001). however, median icu-stay was significantly shorter in the endoscopic-group (7 days versus 12 days, p=0.020). success-rate of the primary treatment was similar; 76% and 73% respectively (p=0.743). primary and secondary endpoints were comparable for both the endoscopic-and surgical-group; median time until oral feeding was resumed was 36 days and 31 days respectively (p=0.232), median total hospital stay 36 days and 40 days respectively (p=0.378) and the median number of interventions was 5 in both groups (p=0.378). conclusion: endoscopic treatment appears to be a safe and efficient therapy for al after tmie ile. a patient-tailored approach based on the condition of the patient and the morphology of the leak can be adapted to avoid surgery in a selection of patients. this may prevent surgical reoperations and reduce icu admissions. background: lymph node (ln) dissection around recurrent laryngeal nerve (rln) is one of the most important and difficult procedure in esophageal cancer surgery because of high rate of ln metastasis and risk of rln palsy. especially around left rln, the surgical area is far and narrow by thoracic approach which tends to results in insufficient ln dissection. therefore, we tried to remove this ln by imaging lymphatic chain to dissect sufficient ln. surgical procedure: we perform thoracoscopic esophagectomy by semi-prone position using 6-10 mmhg thoracic air pressure. after dissection of right rln ln, middle and lower esophagus, encircle the esophagus at the level of bifurcation of bronchus and pull toward right side by tape to dissect the dorsal and left side of upper esophagus. dissect the tissue including left rln ln from trachea by pulling esophagus up to dorsal side and try to move this tissue toward dorsal side of left rln so that this rln ln tissue can recognize as the "lymphatic chain". to increase the mobility of esophagus, cut the esophagus at the level of aortic arch and pull further up this upper esophagus to dorsal side. cut the esophageal branch of rln and separate this lymphatic chain from rln. at the end of thoracic procedure, this lymphatic chain is attached to upper esophagus. after the upper esophagus has pulled out from cervical site, lymphatic chain can easily recognize at the esophageal wall. result: we performed this lymphatic chain procedure in 88 cases. to evaluate this procedure, 106 cases of conventional method by same prone positioned esophagectomy was used for control. there was no statistical difference between these two groups in amount of blood loss (lymphatic chain: conventional=45ml:55ml, p=0.524), rate of rln palsy (14.8%:14.2%, p=1.00). although the thoracic operation time was extended in some degree (291 min:270 min, p=0.005), number of dissected ln was increased (2.9:1.9, p=0.004) and recurrence along left rln has been relatively fewer by this method (4.5%:7.5% p=0.552). conclusion: ln dissection around left rln would be easy and sufficient by imaging lymphatic chain. further improvement is needed to secure this procedure and further evaluation should be done to support this data. introduction: to evaluate the role of robotic assisted surgery as part of an appropriate patient work-up and treatment of ipmn and its consistency in terms of perioperative and long term results. few reports described singular minimally invasive procedures for ipmn. this study aims to describe a comprehensive, oncologically adequate treatment of ipmn in a minimally invasive unit with an extremely high robotic penetrance. methods and procedures: we retrospectively analyze our database of resected ipmn between 2008 and 2017. this case series includes consecutive, unselected patients: all candidates with a preoperative diagnosis of ipmn were approached robotically. results: among 142 robot assisted pancreatic resections, we identified 13 patients with ipmn. one was excluded for having less than 6 months follow-up, so 12 patients were included and analyzed. they underwent duodenopancreatectomy in 7 cases, distal pancreatectomy in 4 cases and central pancratectomy in 1. all but one indications followed the most updated available guidelines (sendai from 2008 to 2012 and fukoka from 2012 to 2017; american gastroenterology association guidelines were used for comparison only). one patient was operated even if the guidelines were suggesting to follow up, because of a strong familiar cancer history. the final pathology for this patient was high grade dysplasia. in another patient we were inside fukoka's recommendations, but outside aga guidelines and the final pathology was adenoma in chronic pancreatitis. postoperative morbidity was 16.7 (2 low grade complications, one grade a pancreatic fistula, now considered a biochemical leakage only) and mortality was zero. one conversions to open surgery occurred only: a dp in jehowah's witness with a bulky mass behind the portal vein. the mean follow up was 40 months (range: 10-68), with only one loss to follow up after 12 months for a high grade dysplasia. conclusion: in hepatobiliary pancreatic minimally invasive centers the treatment of ipmn can be grant following the same principles of major cancer centers, with comparable results. large unbiased studies are needed to evaluate if a minimally invasive approach could modify the ratio between operated and surveilled patients. reducing the use of catheters, tubes and imaging after hiatal hernia surgery significantly reduces length of hospital stay sophia s oswald, candice l wilshire, md, brian e louie, md, ralph w aye, md, alexander s farivar, md; swedish medical center introduction: historically, standard post-operative management of patients undergoing laparoscopic hiatal hernia surgery has been placement of a foley catheter and nasogastric tube (ngt) at the time of surgery with removal early on postoperative day (pod) one, at which time an upper-gastrointestinal series study (ugi) would be performed. we initiated a quality improvement project, seeking to assess if we could safely forego placement of foley and ngt along with the ugi, unless clinically indicated. our aim was to determine if this decreased overall length of stay (los), and how often and which demographic of patients needed placement of foley or ngt postoperatively. methods and procedures: we reviewed patients who had undergone laparoscopic hiatal hernia surgery between 2010 and 2016 under a single thoracic surgeon. patients were excluded for poor esophageal motility (peristalsis \70%), previous esophageal surgery, and presence of a paraesophageal hernia (peh) with over 50% of the stomach contained in the chest. eligible patients were further stratified into two groups: fast track and non-fast track. fast track was defined as patients who left the operating room (or) with no foley or ngt, and did not receive a routine ugi on pod one. non-fast track was defined as patients who left the or with a foley and ngt and received a routine ugi on pod one. los was measured in hours from the start of surgery to the time of discharge. results: of the 75 patients included, 42 were categorized as fast track and 33 as non-fast track. the two groups were similar in terms of age, gender, bmi and asa; however, the fast track group had fewer paraesophageal hernias and shorter surgery times [table] . the hospital los, however, was significantly shorter in the fast track group, even though there were more postoperative urinary catheters utilized. no patients in fast track group needed an ngt placed or ugi ordered during initial stay. conclusion: in more straightforward laparoscopic hiatal hernia surgery, surgeons can safely forego ngt and foley placement, as well as ugi evaluation the following morning. these initiatives may translate to a quicker discharge from the ward, and may allow safe transition to performing these cases in 24 hour ambulatory outpatient setting. further evaluation of additional interventions and patient education to decrease los are underway. the conclusion: laparoscopic surgery seems to be a safe and feasible option, with long-term benefit for primary tumor resection with metastatic colorectal cancer, but optimal treatment has yet to be defined. the canadian association of gastroenterology (cag) has implemented the colonoscopy skills improvement (csi) program across canada with a goal of improving colonoscopy quality. the programs' efficacy has not yet been formally assessed. this retrospective cohort study was performed on fourteen endoscopists practicing in a tertiary referral center who have undergone csi training between october 2014 and december 2015. procedural data were collected before and after csi training. data were extracted from the electronic medical record (emr) and entered into spss version 20.0 for analysis. student's t-test was used to compare groups for continuous data; chi-squared tests were used for categorical data. data were collected for a total of 3783 procedures; 2383 were done before csi training and 1400 procedures since csi training. our sample size provided 80% power to detect a mean difference in adr improvement of 5%. the most common indication for colonoscopy was family history of colorectal cancer in 970 (25.6%) patients. while age (58.0 yrs v. 60.1 yrs, p.001) and gender (43.4% male v. 46.9% male, p=0.035) were similar, they were statistically different between groups. groups were comparable in terms of indication, and completion rate (92.6% v. 94.2%). adr improved significantly after completing the course (23.5% v. 35%, p.001). an improvement was also noted in both polyp detection (37.6% v. 52.9%, p.001) and polyp removal (36.1% v. 50.4%, p\ 0.001). we have seen a significant increase in adr at out institution since implementing the csi program. gastric stomach cancer is a rapid major cause of cancer-related death globally, have higher incidence in men and it is noticeable by its heterogeneity. a lot of studies have expressed out the molecular basis of this cancer, include pathogenesis, invasion and metastasis. the invention of new technologies has help to bring out several novel biomarkers that have diagnostic and prognostic value. therefore, this review centers on biomarkers for the early diagnosis, treatment and prognosis of gastric cancer, elaborate the clinical important of serum tumor markers in a patient with this cancer as well as checking the growths, prognosis together with epigenetic changes and genetic polymorphisms. a deep and rigorous search was carried out in pub med/medline using specific words; "gastric cancer", with "tumor marker". our search yielded 4947 important reports about related topic from books and articles that were published before the end of september 2016. conclusively, scientists are utilizing time and resource to salvage this nemesis which is of global burden. classical and novel biomarkers are important for treatment as well as pre-post diagnosis of gc. major causes for this disease are cigarette smoking, infection by helicobacter pylori, atrophic gastritis, male sex, and high salt intake. the treatment of which early diagnoses is of important to the management, after pathological diagnoses by stage prognosis and metastatic setting, although the outcome proved not so good includes chemotherapy, and oral medication are oxaliplatin, capecitabine, cisplatin and 5-fluorouracil (5-fu). introduction: emergent appendectomy is the standard of care in usa based on tradition rooted in theory that delaying surgery allows for progression of disease and poorer outcomes. antibiotic treatment alone has been shown feasible in the treatment of uncomplicated appendicitis. in clinical practice surgical treatment can be delayed due to a multitude of medical and logistical reasons. this study evaluates the relation between timing of surgery to outcomes. methods and procedures: 120 consecutive adult patients undergoing appendectomy in a teaching community hospital were risk stratified using the acs risk calculator. time from imaging to incision defined early and delayed groups. statistical analysis was used to determine association between risk level, timing of surgery and outcomes. results: 79% of patients in this study were considered high risk. average time to incision was 9.7 hours. shorter time to incision was associated with a statistically significant lower length of stay (p.05). for every 12 hours in surgery delay, one day was added to the length of stay. no statistical difference was found between time to incision and other outcome variables of clinical complications, conversion to open appendectomy or frequency of complicated appendicitis. length of stay was longer than predicted by acs risk calculator in both high and low risk groups. a multidisciplinary, obesity-focused approach improves diagnosis of obesity-related illnesses: a new paradigm for the care of patients with obesity roderick olivas, aaron brown, md, racquel s bueno, md, cedric s lorenzo, md; university of hawaii -department of surgery introduction: patients suffering from the burden of obesity are at significant risk for medical problems that lead to premature death and disability. we hypothesize that a multidisciplinary bariatric team will be better equipped to recognize and diagnose these conditions. this study hopes to quantify that a patient focused approach leads to increased recognition of obesity-associated comorbidities, thus improving quality of care and surgical outcomes. methods and procedure: a retrospective medical chart review of patients who underwent bariatric surgery from 12/1/15 to 12/1/16 was performed comparing patient problem lists obtained from their primary care providers upon entry into the bariatric program, and the final problem list generated after evaluation by the program's multidisciplinary team. the total number and specific comorbidities identified before and after multidisciplinary team evaluation was analyzed with a paired t-test and manova, respectively. comparison of the number of comorbidities identified against specific patient demographics was conducted using paired t-test. results: a total of 120 patient charts were selected and 100 met inclusion criteria. the sample consisted of 68% women and 32% men; the mean age was 46.5; the mean bmi was 51.2; 87% were morbidly obese (bmi 40) and 13% were obese . the total number of comorbidities identified after evaluation by a multidisciplinary team was significantly greater (p=.000), with the average number of comorbidities diagnosed before and after being 3.65 and 6.61, respectively. a significant increase (p.05) in the identification of comorbidities before and after evaluation were noted for all demographics, and no disparities regarding gender, age, marital status, employment status, bmi, or ethnicity where identified. conclusion: patients with obesity unknowingly suffer from many obesity-associated comorbidities simply because their health care providers have failed to recognize the existence of these conditions. surprisingly, this include diseases that are highly associated with obesity, such as osa and t2dm, for which obese patients should be screened. although the root of this dereliction is yet to be determined, insufficient obesity-focused education and inherent weight bias among providers must be considered. assessment by a multidisciplinary bariatric team resulted in the identification and treatment of an increased number of comorbidities in this patient population. increased recognition of obesity-related comorbidities improves quality of care, which can translate into improved surgical outcomes. introduction: it is known that surgical residents suffer from sleep deprivation. no recent study evaluated the type and number of calls received at night. lately, burn out, depression and suicide have been the subject of interest in studies and media because of the higher rate among the residents compared to general population. the objective of our study is to evaluate junior resident's level of fatigue and the quantity and quality of calls received during on-call nights in general surgery at chus. methods and procedure: transversal study conducted on 17 junior residents that were on-call in general surgery at the chus between april 25 and august 27, 2017. the participants detailed all the calls received between 11 pm and 6 am on an database created on the application handbase and completed a daily calendar of their on-call night noting all the tasks they did every half hour (surgery/consultation/sleep). the level of fatigue was evaluated at the end of the night at 8 am with a visual analog of sleep scale on a score over 5 points. results: the level of fatigue 4/5 (tired) or 5/5 (exhausted) was reached in closed to 50% of the oncall nights. the median number of calls by night was 3 and the median duration of sleep was only 3.3 hours. the median lenght of uninterrupted sleep was 2.5 hours by night. among the total 110 nights and 384 calls analyzed, 15% were ''not pertinent'' and 10% were ''reportable in the morning''. more than 28% of the nights had at least one call ''not pertinent'' or ''reportable in the morning'' that have interrupted the junior resident's sleep. the level of fatigue was significantly correlated to the number of calls received during the night (spearman's rho=+0.380, p.001) and to the number of uninterrupted hours of sleep (spearman's rho=−0.687, p.001). conclusion: the level of fatigue is very high among the junior residents in general surgery. many of the calls received during the night are not pertinent or could have been delayed to the morning. our results lead us to the conclusion that interventions and recommendations should be made to raise nurses and resident's awareness about the situation to reduce the unnecessary calls and the level of fatigue of the residents. we hope that on-call resident sleep will be better preserved and that will result in fewer health issues for them (burn out, depression, suicide). without interruptions: does twitter level the playing field? heather j logghe, md 1 , laurel milam, ma 2 , natalie tully, bs 3 , arghavan salles, md, phd 2; 1 thomas jefferson university, 2 washington university, 3 introduction: frequent interruption of women in conversation has long been noted anecdotally, and studies confirm that women are interrupted more often than men. such interruptions can diminish perceptions of authority and compromise women's self-confidence. on twitter, users cannot be interrupted in the same way they can be in live conversation. thus the platform may provide a means for women to overcome this obstacle. to determine the degree to which women surgeon leaders utilize twitter compared to their male colleagues, we examined the twitter accounts and activity of the leaders of three national surgical societies. methods and procedures: lists of surgeons holding leadership positions in three surgical societies; the american college of surgeons, the academic association of surgery, and the society of american gastrointestinal and endoscopic surgeons, were obtained and duplicate names were deleted. table 1 details the organizations and leadership positions included. the twitter accounts of these leaders were then identified and confirmed by reviewing the accounts for surgical content. account duration was calculated from the join date. the number of tweets, accounts following, followers, and likes were recorded for each account. outliers were defined as two standard deviations from the mean. results: one hundred sixty-eight men and 64 women surgeon leaders were identified. forty-nine percent of the men and 66% of the women were found to have twitter accounts. mean account durations for men and women were similar, 4.6 years and 4.1 years, respectively. outliers for total tweets (7 men, 1 women), accounts following (5 men), followers (2 men), and likes (3 men) were excluded from analyses. almost all positive outliers were men. there were no negative outliers. overall, excluding the outliers, there were no significant differences between men and women in any metric. conclusion: among leaders in the surgical organizations analyzed, a higher percentage of women than men have twitter accounts. those with the greatest number of tweets, accounts following, followers, and likes, however, are overwhelmingly male. thus, although women in this sample were more likely than the men to have twitter accounts, men were more likely to gain influence through their accounts. increasing women's influence in this public forum may position them as much-needed role models for the current and next generations. surgical societies may help reduce the disparity in women's representation in surgical fields through education of their members on how to use social media. introduction: the aim of this study was to report the perioperative morbidity and short-term outcomes of a case series of robotic-assisted laparoscopic transabdominal preperitoneal (tapp) inguinal hernia repairs. methods and procedures: a retrospective review (january through december 2015) of 104 patients who underwent either unilateral or bilateral robotic-assisted laparoscopic tapp inguinal herniorrhaphy by two attending surgeons was performed. patient demographics, perioperative morbidity, operative time, and follow-up data were analyzed. results: patient demographics are summarized in table 1 . mean operative times for unilateral and bilateral inguinal herniorrhaphy were 87.5±20.8 and 129.0±37.6 minutes, respectively. mean robot console times for unilateral and bilateral inguinal herniorrhaphy were 70.0±25.1 and 113.0±39.8 minutes, respectively. postoperative complications included urinary retention (6.7%), conversion to open repair (1%), and delayed reoperation (1.9%). no major bleeding, surgical site infection (ssi), or mortality was observed. at first follow-up visit (19±6 days), symptoms/signs included groin/scrotal swelling (8%), seroma (7%), groin pain (3%), burning (3%), numbness (1%), and persistent urinary retention (1%). 12% of patients required a second follow-up visit. two patients underwent reoperation for suspected recurrence but instead a cord lipoma was found without a hernia defect. conclusions: robotic-assisted tapp inguinal herniorrhaphy can be performed with operative times and short-term outcomes similar to those published for open technique. the robotic-assisted tapp inguinal herniorrhaphy is a safe and an efficient minimally invasive surgical option with lower ssi risk and better cosmetic results. gunnar nelson, nathan lau, phd; virginia polytechnic institute & state university introduction: the fundamentals of robotic surgery (frs) and fundamentals skills of robotic surgery (fsrs) are universal curriculums covering a range of topics to assure a high level of surgical skills for optimal patient outcomes. this assurance of skills should include management and response to adverse events. thus, we reviewed frs and fsrs to identify any gaps in educational contents pertaining to how surgical teams are trained to handle adverse events in robotic surgery. methods and procedures: we conducted a literature search through google scholar, journal of robotic surgery, and plos one on frs and fsrs from 2010 to 2017. we reviewed 65 articles on preparing medical professionals in handling adverse events during robotic surgeries. besides the two curriculums, we also surveyed the literature on the characteristics of the adverse events and responses of the medical team. this literature survey provided a basis for recommending additional education contents to frs and fsrs. results: in our review, the frs contains 4 modules consisting of an introduction to robotic surgery, with cognitive, psychomotor, and team training/communication skills. meanwhile, the fsrs contains 16 different tasks, half of which on human-machine interaction and another half on operative interaction. both curriculums appear to lack contents on managing adverse events in robotic surgery. according to fda data, 4,798 adverse events were reported per 100,000 surgeries, of which (i) 40% relates to broken pieces of surgical instruments falling into patients, (ii) 19.1% pertains to burning holes in tissue from electric arching, and (iii) 16.9% relates to unexpected operations of the instrument such as power outage and issues with electrosurgical units. thus, medical professionals should be trained to manage common adverse events in robotic surgery. for frs, augmenting the five current scenarios in the communication section with common adverse events (i.e., broken pieces falling into patients) would minimize complications under abnormal circumstances. for fsrs, the most logical method would be augmenting the operative interaction tasks with adverse events to train medical professionals. conclusion: we discovered universal curriculums on robotic surgery lack education contents for training medical professionals to manage adverse events and out of the 4,798 procedures, 4382 (91.3%) pertained to device malfunction. to protect the patient's health, universal curriculums must incorporate contents preparing medical professionals in responding to adverse events, particularly device malfunctions, during robotic surgeries. introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for laparoscopic cholecystectomies. we report the first single-institutional experience utilizing this new robotic platform. methods: approximately 20 robotic cholecystectomies were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node ( figure 1 ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between 18 and 80 years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than 12 month and a bmi\ 40. a retrospective review of a variety of prospectively collected pre-, peri-and postoperative data including but not limited to patient demographics, intraoperative as well as postoperative complications was performed. cholecystectomies were performed by expert level laparoscopic surgeons. results: the standard laparoscopic technique and setup was easily applicable to the senhance robotic system for this particular surgery. operative time and perioperative complications were comparable to reports of standard laparoscopic cholecystectomies. there was no significant learning curve detected in our case series. conclusion: we report the first experience with laparoscopic cholecystectomies using the new senhance robotic system. there were no major perioperative complications and operative time was comparable to standard laparoscopic cholecystectomies well reported in the literature. this case series suggests that the senhance robotic system can be safely and easily used for laparoscopic cholecystectomies by experienced laparoscopic surgeons. background: the ergonomic benefits or robotic surgery for the health of the surgeon are widely touted as benefits of this technique, though concern remains over a perception of increased risk of injury to patients, particularly in the novice robotic surgeon. injury to the bedside surgeon and assistants due to robotic movement can also occur, though not previously reported. we describe a finger fracture to the bedside surgeon due to entrapment between robotic arms and discuss potential risks to the surgeon in robotic procedures. procedure: a distal pancreatectomy and splenectomy was performed utilizing the davinci si system (intuitive surgical, inc., sunnyvale, ca). during the operation, hemorrhage was encountered which required an instrument exchange that was delayed by self-testing failures. after the instrument was validated and advanced into the field by the bedside surgeon, the operator abruptly took control of the device to reposition. the external portion of the active arm was then rapidly and forcefully propelled laterally toward a stationary retracting arm. the bedside surgeon's hand was still engaged on the instrument being inserted and became trapped between the two arms, leading to a right middle finger crush injury. results: the bedside surgeon sustained a fracture to the distal phalanx at the insertion of the flexor tendon with significant hyperextension of the joint. there was temporary paresthesia of the fingertip. while flexor tendon function was preserved and surgery was not required, the surgeon was required to maintain continuous splinting and was unable to return to full duty for a total of 13 weeks. the surgeon has mild residual hyperextension. conclusions: while complications to the patient have previously been attributed to the robotic platform, this case demonstrates that there are other inherent hazards to members of the operative team. as is natural with all indirect visual surgical techniques, the operator becomes intensely focused on the internal view and instruments in the field. this spatial separation is accentuated on the robotic platform as the isolated console provides a complete visual field immersion, no tactile feedback, and a disconnect between the rapid, sizeable outward arm motions need to produce small internal movements. given the need for maximum dexterity internally, the device doesn't have external proximity sensors to prevent arm-arm or arm-operator collisions. while many bedside operators report anecdotes of collisions with the device, this case reveals the forces involved at the human-machine interface can lead to more significant injuries. robtic approach to non-midline abdominal wall hernias: a single institution experience from a high volume center emily benzer, do, j. stephen scott, md, facs; university of missouri introduction: the objective of our study was to evaluate our experience with robotically repaired non-midline abdominal wall hernias at a high-volume robotic surgery program. we also will discuss the technical advantages of the use of robotic technology in repair of these unusual hernias which have typically had higher recurrence rates then midline hernias. laparoscopic approach for lateral ventral abdominal wall hernia (spigelian) and lumbar hernia has been described, however the success of robotic assisted repair for these hernias has yet to be determined. methods: a retrospective case analysis of all robotic abdominal hernia cases between june 2016 and june 2017 at an academic institution with a single high volume robotic surgeon was performed. the operative details of robotic repair of non-midline abdominal hernias, patient demographics, length of stay and smoking status were recorded and analyzed. the technical advantages of the use of robotic technology for example circumferential fixation of the mesh, ease of intracorporeal suturing, and the use of wristed instruments to gain better angles for posterior fascial release were evaluated. results: a total of 11 cases were identified. the average age of the patients was 54.3 years (range 25-74 years) and patients were predominantly female (91%). spigelian hernias represented 73% (n =8) and lumbar hernias 27% (n=3). all patients had primary closure of their defect and 7 patients (64%) had a posterior myofascial release performed. mesh types placed included polypropylene uncoated (n=7), polypropylene coated (n=3), and biologic (n=1). with uncoated polypropylene mesh placed had peritoneum closed over the mesh. the average length of stat was 1.9 days (range 0-6 days). there were no recurrences identified over a mean follow up period of 3.1 months (range 0.5-13.2 months). conclusion: robotic assisted repair of non-midline abdominal wall hernias is a viable option in the elective setting with no recurrences noted in this case series. the technical advantages of using robotic technology were identified and discussed in detail. these advantages theoretically improve outcomes in these patients however further analysis on long-term outcome and costs will have to be determined in future studies. the inguinal hernia repair has seen several critical improvements in recent times due to the implementation of new techniques, including laparoscopic repair, as well as robotic repair. with over 600,000 inguinal hernia repairs performed annually, it is important to identify the safest and most patient-friendly method. for surgeons, robotic assisted laparoscopic surgery is gaining in popularity for its dexterity and 3d visualization. but despite the growing interest in robotic hernia repairs, there is a scarcity of literature to support its superiority over open inguinal hernia repair. this study hypothesizes that patients who undergo robot assisted laparoscopic inguinal hernia repair will have decreased immediate post-operative pain, shorter recovery room stays, decreased narcotic requirement, and overall decreased pain at follow up compared to open inguinal hernia repair. in this study, we performed a retrospective analysis of patients who underwent either an open or robotic assisted laparoscopic inguinal hernia repair at stamford hospital, from july 2015-july 2017. the following characteristics were analyzed for both subsets of patients: gender, bmi, type of repair, operative time, recovery room time, immediate post-operative pain, and post-operative pain at follow up. our study demonstrated longer average operative time for patients undergoing robotic hernia repair compared to open repair, which was statistically significant (p value=.05). patients who underwent robotic inguinal hernia repair spent less time in the recovery room compared to patient who underwent open repair. in addition, patients in the robotic hernia group required less narcotics in the recovery room compared to patients who underwent open repair (p value = .05). there was no statistically significant difference between lengths of hospital stay between the two groups. this study highlights several possible advantages of robotic inguinal hernia repair, including lower post-operative pain scores, less narcotic usage required in the post-operative period, as well as shorter recovery room time. the results from this study should increase interest in investigating the superiority of robotic inguinal hernia repair. future plans for study involve comparing robotic to laparoscopic repair. in addition, we plan to continue to follow the study patients to look at additional qualitative metrics, including time to return to work and time to return to daily activities. introduction: buccal mucosal grafts (bmg) are traditionally used in urethral reconstruction. there may be insufficient bmg for applications requiring large amounts of graft, such as urethral stricture after gender affirming phalloplasty. rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger graft dimension. laparoscopic transanal minimally invasive surgery (tamis) has been described by our group. due to the technical challenges of harvesting a sizable graft within a confined space, we adopted a new approach using the intuitive da vinci xi® system. we demonstrate the feasibility and safety of a novel technique of robotic tamis (r-tamis) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. methods and procedures: irb approval was obtained. three female-to-male transgender adults (age range: 33-53 years) presenting with post-phalloplasty urethral strictures underwent robotic rectal mucosal harvest. the procedure was first rehearsed on an inanimate model using bovine colon. the surgery was performed under general anesthesia with the patient in lithotomy position. the gelpoint path transanal access platform was used. the rectal mucosa was harvested by the robotic instruments after submucosal hydrodissection. specimen size harvested correlated with clinical surface area needed for urethral reconstruction. following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. the rectal mucosa graft was placed as an onlay for urethroplasty. results: there were no intraoperative or postoperative complications. average graft size was 39 12 cm (range: 8-15 cm). every case had excellent graft take for reconstruction. all patients recovered without morbidity or mortality. they reported minimal postoperative pain and all regained bowel function on the first postoperative day. all reported significantly less postoperative pain and greater quality of life in comparison to prior bmg harvests. the procedure has been refined to increase efficiency and decrease operative time by maintaining adequate insufflation, retraction of the mucosal graft, and maintaining graft integrity. conclusions: to our knowledge, this is the first use of r-tamis for harvest of rectal mucosal graft. our preliminary series indicates the robotic approach is feasible and safe. it constitutes a promising minimally-invasive technique to employ in urethral reconstruction. demonstrated feasibility and avoidance of the challenging recovery associated with bmg harvest warrants further application and long-term evaluation of this procedure. prospective studies evaluating graft success, donor site morbidity and long-term outcomes are needed. introduction: the proportion of robotic minimally invasive procedures that are being performed annually is growing rapidly, specifically in the field of general surgery. a robotic approach to minimally invasive procedures potentially confers a number of benefits ranging from a magnified viewing field to greater attenuation and translation of hand movements leading to improved stability and maneuverability. it is paramount that a robust curriculum is designed for training surgical residents in robotic techniques. the aim of this project is to assess the current state of robotic surgery training at the ohio state university, with specific regard to whether it is currently temporally effective in addition to establishing a baseline against which the robotic surgery curriculum can be compared. methods and procedures: data were obtained for 199 cases performed at the ohio state university hospital east, between january and september of 2017. case time, date, type, and attending surgeon were recorded and tracked for review. of the 199 cases, 72 were cholecystectomies, 40 were unilateral inguinal hernia repairs, and 36 were bilateral inguinal hernia repairs-for a total of 148 procedures included in the analysis. chief residents were trained in two-month blocks, beginning in january of 2017. mean console operative times for the first and second months were compared for cholecystectomies as well as unilateral and bilateral inguinal hernia repairs. results: mean console time decreased for cholecystectomies (−9.0%; n=72), bilateral (−16.0%; n=36) and unilateral (−1.5%; n=40) inguinal hernia repairs from month one to month two. there was a large amount of variance across training blocks, but there was a systematic improvement in operative time across the training period. average operation length was shortest for cholecystectomies (m=66.8 min), followed by unilateral inguinal hernia repairs (m=85.3 min), and finally bilateral inguinal hernia repairs (m=111.2 min). discussion: this preliminary data suggests that residents are able to decrease their robotic operation time over the course of the two-month rotation. although sample sizes were relatively small for each block, the consistency of the trend supports this conclusion. further data collection will allow for more precise estimates in the future, and stronger conclusions to be drawn. these results show that rapid improvement is possible and provide motivation to establish robotic surgery curricula for general surgery residents nationally. robotic pancreas-sparing treatment of pancreatic neuroendocrine tumors: three case reports and review of the literature alessandra marano, giorgio giraudo, stefano giaccardi, desiree cianflocca, diego sasia, felice borghi; santa croce e carle hospital introduction: pancreas-sparing resections would be the ideal procedure in case of small pancreatic neuroendocrine tumors (p-nets) reducing the risk of exocrine and endocrine insufficiency. compared to standard resection, this type of surgery is safe and feasible without increasing the risk of postoperative complications except the overall rate of clinical pancreatic fistula (pf), which did not result in higher mortality or overall morbidity. robotic surgery for pnets enucleation has been rarely described but initials experiences have shown that this approach is associated with favorable outcomes. the aim of this study is to describe three cases of dv®si™ pancreatic enucleation for p-nets located in the uncinate process, in the body and in the posterior aspect of the tail of the pancreas, respectively. a brief review of the literature regarding the application of robotics for pnets enucleation is also included. methods and procedures: this study includes patients undergoing dv®si™ enucleation for pnets with a maximum diameter no more than 2 cm and a distance between tumour and main pancreatic duct (mpd) greater than 2 mm. at surgery, exposure of the pancreas was achieved by separation and traction of the gastrocolic and gastropancreatic ligaments. the pancreas was explored: an intraoperative ultrasound was used ensuring negative margins and leaving the mpd intact. thus, a cross-stitch through the tumour was made routinely in order to pull the tumour. enucleoresection was carried out with monopolar scissors and bipolar forceps. the tumour was placed into a specimen bag and removed from the trocar port. a drain was always left. results: median total operative time was 178 min. no conversion neither intraoperative complications occurred. median length of stay was 4.6 days. two patients presented a pf grade a (classification isgpf) while a pf grade b occurred in case of pancreatic tail net enucleation. final pathology revealed two insulinomas and one non-functioning net of the pancreatic body. at a median follow-up of 15 months no pancreatic insufficiency, reoperation or tumour reoccurrence was observed in all cases. the robotic approach for the treatment of p-nets is safe and feasible and, in selected cases, it may extend the indications of minimally invasive pancreatic-sparing surgery. in particular, the robotic approach provides a more precise dissection and may ensure negative margins and the mpd intact. these preliminary results are consistent with literature data about over 100 robotic pancreatic enucleations for p-nets that shows favourable surgical outcomes, especially if compared with those of open surgery. introduction: rectal cancer continues to be a surgical challenge. new technologies must be incorporated into practice and, at the same time, oncologic surgery and overall outcomes must be improved. the use of da vinci robotic surgery systems has spread rapidly in the field of rectal cancer treatment showing several technical advantages and favorable outcome compared to laparoscopy. since the introduction of the robotic platform in our institution in 2013, we have adopted a single-docking robotic technique for rectal resection. the aim of this study is to present our standardized technique and to analyse the clinical outcomes of the first 100 robotic rectal procedures. methods and procedures: prospectively collected data reviewed from 100 consecutive patients who underwent single docking totally robotic (da vinci® si™) dissection for rectal cancer resection between june 2013 and august 2017 under eras program. robotic rectal surgery was performed without changing the position of the robotic cart but only the robotic arms are repositioned between two phases: 1) vascular ligation, and sigmoid colon to splenic flexure mobilization; and 2) pelvic tme. results: there were 66 men (66%) and the median age was 68 years (range-24-92). thirty-five patients had neo-adjuvant chemoradiotherapy whilst 15 patients had bmi [30. procedures performed included anterior resection (n=95) and abdominoperineal resection (n=5). protective ileostomy was performed in 50 patients. the median operating time was 270 min (range-160-604). there was one conversion and two intra-operative complications (one bladder lesion and one ureteral lesion, respectively). median length of stay was 3.5 days (range, , and readmission rate was 7%. thirty-day mortality was zero. anastomotic leak rate was 7%, and all patients except by one were managed conservatively. the mean lymph node harvested was 14 (sd±8.3). radial margin was negative in all patients. at median follow-up of 21 months, there were no local recurrences. the single docking robotic technique is a safe and feasible approach for rectal surgery: in our study it has demonstrated favourable clinical outcomes and the adoption of a standardized stepwise approach was useful especially during the initial learning phase. to the best of our knowledge, this is the largest series from italy to report this standardized approach and the short-term clinical and oncological outcomes. in the complex laparoscopic surgical procedure, there is a problem such as that the laparoscope and the surgical instruments interfere with each other because multiple instruments is concentrated in one place. this problem is significantly appear in the laparoendoscopic single site surgery. therefore we suggested multi degrees of freedom (dof) manipulator with mantle tube for assisting laparoendoscopic surgery, which manipulator has two flexion and one telescopic mechanisms actuated by wire. it is possible to insert any thin surgical instruments such an endoscope the mantle tube of the multi dof manipulator, which the manipulator can let those surgical instruments access the operative field from different axis with other instruments. the use of this manipulator has two advantages, one of which is avoidance of fighting between instruments and laparoscope. the other is that become possible to ensure a satisfactory field of vision in the operative field. in this report, we assumed that this multi-dof manipulator is used as laparoendscope. in order to evaluate the performance of this manipulator, the operation time of the test in the abdominal cavity simulator (fasotec inc.) was measured. the test is a contact test to multiple-targets, which is a test that bring a forceps contact multiple-targets in the abdominal cavity simulator according to the defined pattern. as a general comparison and evaluation target for this measurement result, it is compared with the case using the same access method as the conventional rigid endoscope. in this test, the number of contacts between forceps and laparoendoscope were recorded by using electrical device. subjects (n=10) are adult men who trained the peg transfer in the above simulator. it was compared of total operating times of the test and the field of vision obtaining each device. from these results, using the suggested manipulator device rather than using rigid laparoscope a satisfactory field of vision is obtained, and it is possible to short the operating time approximately 4 seconds, and to small the number of contacts significantly. therefore it was shown that the effectiveness using the suggested manipulator device. for this reason, use of this device is expected to facilitate the complex surgical operation. additionally, it is performed para ablative operation of swine liver tissue in the abdominal cavity simulator, as previous step of clinical test. the operative field in this test was surveyed, the refinements of this manipulator for improvement performance were described in this report. yoshiyuki usui, md, phd, ichiro akiyama, md, phd, hironori kunisue, md, phd, hideaki mori, md, phd, tetsuya ota, md, phd; okayama medical center background and methods: we have performed approximately 200 cases of gasless endoscopic thyroid surgery since 1999 for 17 years. this surgery was performed through a small subclavian incision and using a wire traction and inserting an endoscope. we have modified and improved our surgical techniques by inventing various surgical instruments. here we introduce four newly invented surgical instruments, chronologically. results: we made u-retractor (2000), u-trocar (2005), u-kelly forceps (2008), and u-suction tube retractor (2013). all surgical instruments were modified from conventional surgical instruments. the u-retractor was a piercing retractor, each end of which had a sharp tip and a retractor. this retractor was inserted from the 3-cm working port outside the body and retracted the muscles effectively. the u-trocar was reversely set from inside to outside to make the working space wider. the u-kelly forceps which had a special ratchet were made to dissect loose connective tissue around the thyroid gland avoiding injury of the recurrent laryngeal nerve. the u-suction tube retractor facilitated a wider working port and eliminated the mist created by the ultrasonically activated scalpel effectively. recent data showed no difference of operative time, hoarseness, blood loss and hospital stay between conventional thyroid lobectomy and gasless endoscopic lobectomy. conclusion: gasless endoscopic thyroid surgery has been improved in the last 17 years. this procedure made the excision of not only benign thyroid tumors but also small thyroid carcinomas. this operation is still cost effective, because almost all surgical instruments are reusable and is a satisfactory experience to both the patients and surgeons. objective: to put forward the importance of complete (r0) resection for the treatment of retroperitoneal tumors increasing overall survey. methods: in this study; 30 patients having the diagnosis of retroperitoneal tumors with different histopathological subtypes whom were hospitalized in emergency surgery department of istanbul medical faculty between the years of 2009 and 2017 were evaluated retrospectively. the database of the department was analyzed. operational backgrounds, histopathological results, radiological evaluations, and assesments about relapses, and overall survey were obtained from the medical archieve. results: the average follow-up time was 2, 5 years. all of the patients included into the study were undergone operations. the average time of hospital stay was calculated as 15 days. 4 of the patients were found to have positive surgical margins in their histopathological evaluations. overall mortality rate of the study was 20% (6/30). we have observed a direct correlation between complete (r0) resection and disease-free survival. patients having relapses had worse prognosis in terms of overall survey (44% mortality rate). after having done the statistical evaluation, surgery was found to be the main determining factor for the assesment of overall survey. conclusion: reference to an experienced and multidisciplinary surgical center after an early diagnosis has upmost importance for the treatment of retroperitoneal tumors. surgical approach constitutes the main element in the management. overall survey is directly correlated with complete (r0) resection. novel fluorescent dyes for real-time, intraoperative, organ-specific visualization of biliary and urinary systems using dual-color near-infrared imaging 1; 1 children's national health system, 2 nih/nci p536 multidisciplinary approach for management of necrotizing pancreatitis: a case series prabhu senthil-kumar university of alberta, 2 centre for the advancement of minimally invasive surgery introduction: the objective of this study was to systematically review the bariatric surgery literature to understand how weight loss is reported. the incidence of obesity has increased globally. according to the world health organization more than 600 million were obese in 2014. in the last decade, bariatric surgery has been increasingly utilized as an effective treatment option for severely obese patients. currently, bariatric surgeries are among the most commonly performed operations. the primary outcome of such procedures is weight loss which has been shown to vary according to the type of surgery. however, there are different methods used to report weight loss which makes it difficult to directly compare outcomes between studies. a previous review by dixon et al. in 2004 revealed a wide heterogeneity in weight loss reporting. however, there have been no recent reviews on the reporting of weight loss in bariatric surgery. methods: a search of the medline electronic database was performed for studies published in 2016 using search terms gastric bypass/sleeve gastrectomy, weight, human, and english. articles were selected by two independent reviewers based on the following inclusion criteria: (1) adult participant ≥18 years predictive factors for excess body weight loss after bariatric surgery in japanese obese patients takeshi naitoh hypertension resolution after rapid weight loss: a single institution experience cristian milla matute reoperative bariatric surgery: analysis of indications and outcomes: a single center experience iman ghaderi objective: to observe the effects of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass rat model. method: in order to verify the effect of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass, twenty-two type-2 diabetes sprague-dawley rat model established through high fat diet and low dose streptozotocin (stz) administered intraperitoneally were assigned to one of three groups: gastric bypass with duodenal-jejunal transit (gb-djt n=8), gastric bypass without duodenal-jejunal transit (rygb n=8) and sham (n=6). body weight, food intake, blood glucose, as well as meal-stimulated insulin, and incretin hormones responses were assess to ascertain the effect of surgery in all groups. oral glucose tolerance test (ogtt) and insulin tolerance test (itt) were conducted three and seven weeks after surgery. results: comparing our gb-djt to the rygb group, we saw no differences in the mean decline in bodyweight, food intake, and blood glucose 8-weeks after surgery. gb-djt group exhibited immediate and sustained glucose control throughout the study outcomes with sham operation did not differ from preoperative level. conclusion: preserving duodenal-jejunal transit does not impede glucose tolerance and diabetes remission after gastric bypass in type-2 diabetes sprague-dawley rat model is bariatric surgery effective for comorbidity resolution in super obese patients? methods: a retrospective analysis of outcomes of a prospectively maintained database was done on 723 obese patients with a diagnosis of at least one or more of the following comorbidities-t2dm, htn, osa, or hld-at the time of initial visit who had undergone either a sleeve gastrectomy (sg) or a roux-en-y gastric bypass (rygb) at our hospital between 2011 and 2015. the patients were stratified based on their preoperative body mass index (bmi) class: bmi methods: we retrospectively reviewed all patients that underwent laparoscopic sleeve gastrectomy (lsg) at our institution from 2010-2015. common demographics and comorbidities were collected as well as creatinine, preoperatively and up to 48 hours after surgery. the renal function was calculated using the ckd-epi formula, derived and validated by levey et al. acute kidney injury was defined as an increase in serum creatinine by ≥0.3 mg/dl within 48 hours after surgery. all tests were two-tailed and performed at a significant level of 0.05. statistical software r, version 3.3.1 (2016-06-21) was used for all analyses. results: of the 1330 patients reviewed conclusion: the impact of laparoscopic sleeve gastrectomy in renal function is evident within the first 48 hours after surgery. patients undergoing lsg, especially patients with baseline chronic kidney disease stage ≥2 are at increased risk of developing acute kidney injury in the perioperative setting the body mass index (bmi), fasting plasma glucose (fpg), glycosylated hemoglobin (hba1c), serum triglyceride, serum cholesterol and blood pressure of all patients were measured before and at 6 months after surgery. the results were collected and analyzed. results: 32 patients suffered from metabolic disease undertook lsg surgery successfully (a mean age of 34 years), 12 were male and 20 were female. all of 32 patients suffered from obesity and the mean bmi of them was 40.61±7.66 kg/m 2 before surgery. among them, 19 patients had type 2 diabetes mellitus (t2dm), 23 patients had hypertriglyceridemia (htg), 7 patients had hypercholesterolemia (hc) and 16 patients had hypertension. the mean bmi of 32 patients at 6 months after surgery was 30.78±5.51 kg/m 2 and decreased significantly (p.05). the mean excess weight loss (ewl%) of 32 patients was 68.97%±26.68%(17%*120%) at 6 months after surgery. the average levels fpg, hba1c of 19 t2dm patients at 6 months after surgery were 6.52±2.15 mmol/l, 6.89%±1.34% methods: we retrospectively reviewed all patients who underwent bariatric surgery from 2012 to 2015. we assessed kidney function using the chronic kidney disease epidemiology collaboration (ckd-epi) and cardiovascular risk using framingham risk score (frs) equation pre-operatively and at 3 and 12 months of follow-up. our population was divided into two groups: patients with ckd stage ≥2 (gfr\90 ml/min) and patients with normal gfr. significance. results: of the 1,330 patients reviewed, 22.48% (n=299) met the criteria for ckd-epi glomerular filtration rate (gfr) and framingham risk score (frs) calculations. after matching, 200 patients (15.03%) were left to analyze, 70% (n=140) of which had a laparoscopic sleeve gastrectomy. eighty-six patients (43%) had an impaired kidney function (ckd≥2) (group 1) and 114 patients (57%) had a normal gfr (group 2). common demographics and comorbidities after matching are described in table 1. the mean creatinine in group 1 was 1.25±1.23 mg/dl versus 0.68±0.13mg/ dl in group 2 (p�). glomerular filtration rate was 66.70±20.36ml/min in group 1 and 101 81±9.79 ml/min in group 2. furthermore, when the frs was calculated at 12 months follow-up, patients with impaired kidney function had an absolute risk reduction of 13.05% corresponding to a relative risk reduction (rrr) of 37 group 2. the percentage of estimated bmi loss was found to be similar in both groups (69.05±23.86 and 67.06±64.59 respectively p=0.786). conclusions: bariatric surgery, especially lsg, has a positive impact on kidney function particularly in patients with chronic kidney disease stage 2 or greater. despite these patients having a higher preoperative cardiovascular risk, they showed similar risk reduction when compared to patients with normal kidney function at 12 months of follow-up the impact of socioeconomic factors and indigenous status jerry t dang only 2 (2.3%) patients underwent urgent conversion for management of complications after sg. three patients had intraoperative complications necessitating blood transfusion. fourteen (16.1%) patients required readmission within 30 days postoperatively. six patients (6.9%) required surgical interventions including 2 for gastrointestinal leak, 2 for hemodynamic instability, 1 for a cecal perforation, and 1 for a small bowel obstruction. there were no mortalities within the first year of revisional surgery. in 62 patients with bmi[35 kg/m 2 at the time of revisional surgery, at the median postoperative follow-up of 30 (interquartile range, 14-72) months, a median 6 (interquartile range, 2-9) kg/m 2 reduction in bmi was observed. overall, 19 (21.8%) patients had persistent type 2 diabetes at time of revisional surgery. improvement of diabetes was observed in 15 patients (78.9%) after conversion of sg to rygb. among 14 patients with gerd symptoms, subjective symptomatic relief was reported at the last follow-up. conclusion: weight recidivism is the most common indication for revision of sg objective: to evaluate laparoscopic mini-gastric bypass in the treatment of morbid obesity. method: three hundred patients with a mean bmi of 41.84.5 kg/m 2 underwent a laparoscopic mini-gastric bypass between 2011 to 2016. a laparoscopic approach with five trocar incisions was used to create a long narrow gastric tube; this was then anastomosed ante-colically to a loop of jejunum 200 cm. distal to the ligament of treitz peri-operative and short-term follow-up results up to does age or preoperative bmi influence weight loss after bariatric surgery? one-way anova or the kruskal-wallis test was used to compare continuous data across all groups. subsequent analysis of categorical data was achieved by chi-square or fisher's exact test. statistical significance was accepted as p.05. results: a total of 160 patients (20% male) were analyzed. average age and preoperative bmi were 45.8 (10.9) years and 44.8 (8.2) kg/m 2 , respectively. preoperative comorbidities included: diabetes (20.6%), hypertension (46.3%), hyperlipidemia (29.4%), previous myocardial infarction (1.9%), obstructive sleep apnea (30.0%), chronic obstructive pulmonary disease (2.5%), gastroesophageal reflux (30.0%), tobacco use (8.8%). the asa classes of patients undergoing sg were ii (14.4%), iii (84.4%), and iv (1.3%). the follow up rate at 6, 12 and 24 months was 86.9%, 44.4%, and 18.8%, respectively. the 30-day mortality and readmission rate were 0% and 4.4%, respectively. the %ewl was not different among age groups at 6, 12 or 24 months for the total, male, or female cohorts. among preoperative bmi groups, %ewl was not different in any cohort at 12 or 24 months, but was different at 6 months for the total cohort (p.001) and female cohort (p\ 0.001), and trended toward significance in the male cohort (p=0.051). the highest %ewl was found to be in patients with preoperative bmi of 35-40. there was no difference in 30-day mortality or readmissions among groups a crp≥5 mg/dl had a sensitivity for a complication of 27% and a specificity of 88%. primary bariatric surgery patients with a post-operative complication had higher crp levels compared to those who did not (4.9±4.9 mg/dl vs 2.8±1.9 mg/dl; p=0.008). there was no difference in crp levels for patients with a 30-day reoperation or readmission. there were no mortalities. conclusions: bariatric surgery patients with elevated post-operative crp levels are at increased risk for 30-day complications. the low sensitivity of a crp≥5 mg/dl suggests that a normal crp methods and procedures: the 28 patients, who formed the previously published cohort, were contacted and their charts were reviewed. follow-up visits, symptom severity scores, and any subsequent medical or surgical interventions were collected. symptoms were assessed using the symptom severity score (sss) and the gastroparesis cardinal symptom index (gcsi) questionnaires. success was defined as a sss of 2 or less. results: out of 28 original patients, 15 patients (2 males, 13 females) were available for follow-up (2 patients declined participation, 9 were lost to follow-up, 1 patient was deceased, and 1 was excluded after undergoing esophagectomy for unrelated indication) mbbs 1 ; 1 grant government medical college and sir jj government hospitals methods and procedures: twenty-six nh patients with dm were prospectively randomized to undergo either lrygb or lsg. patients were followed for 2-years with primary end points consisting of total weight loss (twl), percent excess body weight loss (%ebw) and impact on dm as measured by fasting blood glucose (fbs) and hba1c. in addition, baseline, 1 week, and 1, 6, 12, 18, and 24 months post-operative levels of glucagon-like peptide (glp-1), peptide yy (pyy), leptin, and ghrelin were collected. results: a total of 25/26 patients completed follow-up. the %ebw at 1 year for lrygb and lsg were 54% and 49%, respectively. resolution of dm occurred in 22/25 patients, the remaining three subjects were in the lgs arm. pre-operative fbs in lrgyb and lsg groups, were 127 and 131, respectively. pre-operative hba1c in the lrygb and lsg groups, were 7.06 and 7.15, respectively. fbs at 1 year for lrygb and lsg were 93 and 110, while hba1c for lrygb and lsg were 5.89 and 6.54, respectively. a consistent post-operative decrease in fbs was only seen in lrygb. lrygb ghrelin percentages increased at 6, 12, and 18 months, while levels decreased in lsg. leptin percentages decreased in both groups. the ppy levels remained relatively unchanged in both groups. lrygb glp-1 levels increased at 1 week, 6, 12, and 18 months. lsg glp-1 trends were similar except at 18 months where glp-1 levels decreased. conclusion: lrygb and lsg resulted in equivalent post-surgical weight loss and resolution of dm in the nh population video assisted thoracoscopic thymectomy (vats) has emerged as a minimally invasive alternative to the standard transsternal approach. we present herewith the surgical and neurological outcomes after vats their operative time, blood loss, conversion rate and post operative parameters like intensive care unit (icu) stay, inter-costal drainage (icd) indwelling time, hospital stay were recorded. neurological outcomes were assessed based on myasthenia gravis foundation of america (mgfa) post intervention status classification. statistical analysis was done using stata 14 software. results: ninety patients underwent thoracoscopic thymectomy during the study period. vats was done through right approach in 47 (53.4%), left approach in 33 (38%) bilateral approach in 6 patients (7%) and subxiphoid approach in 2 (2.2%). there was conversion to open approach in 2 (2.2%) patients due to dense adhesions at westchina hospital of sichuan university were included. all of the operations were performed by a single skilled surgeon. we divided our patients into two groups based on whether isao was used. of them, 28 patients received isao for lps and 26 patients received lps without isao. surgical skills and safety were evaluated. results: there were no significant differences in preoperative patients characteristics of the two groups. significantly less intraoperative blood loss(78.1±34.0 ml vs 177.5±81.3 ml; t=−6.4, p= 0.001) were observed in group of isao conclusions: isao is technically feasible, safe surgical skills for patients reveived lps, and its represents an effective method to decreased intraoperative blood loss. p686 modular laser-based endoluminal ablation of early cancers: in-vivo dose-effect evaluation and predictive numerical modelling giuseppe endoscopic submucosal dissection enables en-bloc removal of early gastrointestinal neoplasms. however, it is technically demanding and time-consuming. laser-based ablation (la) techniques, are limited by the lack of depth penetration control and thermal damage (td) prediction. our aim was to evaluate a predictive numerical modelling (pnm) of the td to preoperatively select the optimal power and exposure time enabling a controlled ablation down to the submucosa (sm). additionally, the ability of confocal endomicroscopy (ce) to provide information on the td was assessed at the histology, there was an increased damage depth per higher j applications. the r value at 0.5 j was 0.57±0.21, and was significantly lower when compared to energies from 15 j (r=1.2±0.3; p.001) up to 30 j (1.33±0.31; p\ 0.001). safe m and sm ablations were achieved applying lower p settings (0.5 and 1 w), at different t values, leading to an mp impairment only in 5 and 20% of the cases, respectively. ce provided relevant images of the td, consisting in architecture's distortion and disappearance of the gland's contours. the predicted damage depth we also analyzed 10 early gastric cancer patients who received lpg-ip with 8cm jejunal interposition. anastomosis procedure was overlap method for eshophagojejunostomy and gastrojejunostomy, feea for jejuno-jejunostomy. results: the comparison between otg/opg-ip shows no significant difference in perioperative complications and qol scores, significant smaller body weight loss in opg-ip group. lpg-ip group also shows good result in short term outcomes. consideration: as comparison in open surgery implies superiority in jejunal interposition, we have introduced lpg-ip. esophagogastrostomy after proximal gastrectomy is simple but has a risk for sever gerd symptoms, no optimal procedure for reconstruction after proximal gastrectomy has yet been established. although laparoscopic jejunal interposition is relatively complicated in procedure, we can safely perform in combination with common anastomosis techniques. conclusion: body weight loss in otg-ip group is smaller compared to otg group 938 consecutive patients with early gastric cancer underwent solo spdg (n=103) and mldg (n=835) performed by same surgical team. solo spdg can be defined as practice in which a surgeon operates alone using camera holder. mldg usually requires two or three surgical assistants. the inclusion criteria in this study were (i) pathologic proven stage i-ii gastric cancer (ii) no other malignancy (iii) more than d1 lymph node dissection (iv) r0 surgery. one-to-two propensity score matching was performed to compensate for the differences between two groups. results: after the propensity score matching, solo spdg (n=99) and mldg (n=198) patients were selected. mean operation time (120±35.3 vs 178±53.4 mins, p=0.001) and estimated blood loss (ebl) (24.6±47.4 vs 46.7±66.5 ml, p=0.001) were significantly lower in the solo spdg group than in the mldg group. the hospital stay and the use of pain control were similar between the two groups. although the initiation of semi fluid diet was similar, the time to first flatus was earlier in the solo spdg adhesional omental hernia: a case report an unexpected cause of small intestinal obstruction in crohn's disease strangulation inguinal hernia due to an omental band adhesion within the hernia sac: a case report omental adhesion, intestinal herniation, and unexpected death in the elderly small bowel obstruction secondary to greater omental encircling band-unusual case report the median operative time was 281 min. the median postoperative hospital stay was 12.6 d. histological examination of the tumors revealed 27 carcinomas, 12 adenomas, and 1 carcinoid. complications occurred in 8 (23%) patients, viz., ssi (two patients), pancreatic fistula (two patients), bleeding (two patients), passing failure (one patient), and cholangitis (one patient). however, no severe postoperative complications (clavien-dindo classification grade 3 or higher) were reported in these cases. conclusion: our cases showed that duodenal tumor resection using lecs enables curability through a minimally this study aimed to compare the outcomes of tltg with those of latg by using a meta-analysis. methods: we searched pubmed, embase, and cochrane library in may, 2016 to locate prospective or retrospective studies on surgical outcomes of tltg versus latg. the outcome measures were postoperative complications such as anastomosis leakage and anastomosis stenosis, operation time, blood loss, time to flatus, time to first oral intake, and postoperative hospital stay endoscopic thyroid lobectomy: our early experience at tertiary care hospitals of lahore univariate analysis was performed followed by logistic regression to identify independent predictors for the primary outcome. results: forty-six out of 555 (8%) patients referred for gp required jt insertion to treat malnutrition. etiology of gp included: 67% idiopathic, 22% diabetic, 11% post-surgical. thirty-six patients (78%) reported severe daily symptoms. twenty-five patients (55%) had successful return to oral intake while 21 (45%) required prolonged feeding access, reinsertion of a jt or tpn initiation. on multivariate analysis patients who had a pyloroplasty (p=0.003, or 6.6) and those who were married (p=0.043, or 3.8) were found to be independent predictors of successful discontinuation of tube feedings. on subgroup analysis 4-hour gastric emptying time normalized after pyloroplasty (p= 0.008) in patients which had a successful re-initiation of oral intake while persistent gastric emptying refractory to pyloroplasty was associated with failure. the group of patients who underwent pyloroplasty did not differ in terms of demographics, marital status (p=0.192) and preoperative gastric emptying (p=0.492) from those who did not. gp etiology (p=0.585) psychiatric conditions (p=0.277) and substance abuse laparoscopic transabdominal repair of morgagni hernia rebekah macfie average procedure length was 68.6 minutes. average hospital length of stay was 0.99 days, with all patients tolerating a regular diet prior to discharge. our 30-day readmission rate was 1/75 (1.3%). 5/75 (6.7%) patients required repeat egd evaluation for either recurrence of symptoms or impacted food bolus. at 6 week follow-up, 25/75 patients (33%) complained of dysphagia and 65/75 patients (87%) had eliminated ppi from their daily medication regimen. at 6 month follow-up, 13/62 patients (21%) complained of dysphagia and 54/62 patients (87%) had eliminated ppis. at 1 year follow-up, 5/44 patients (11%) complained of dysphagia and 5/44 patients (89%) had eliminated ppis. conclusion: as a recently introduced surgical option, no long-term data exists detailing the linx procedures ultimate success rates and complication profile mini-laparoscopic vs traditional laparoscopic cholecystectomy: preliminary report deniz atasoy since the introduction of minilaparoscopic cholecystectomy (mlc) in 1997, it gained little interest that could be attributed to decreased durability of the reduced size instruments, poorer optical resolution and smaller jaws of the instrument tips. our aim was to compare the outcomes of mlc with traditional laparoscopic cholecystectomy (tlc) one developed choledocholithiasis on postoperative day one and after ercp the course was uneventful. the other patient developed choledocholithiasis and acute pancreatitis on the sixth postoperative day and was treated conservatively. the stone in the ampulla had fallen by itself without a need for ercp single-incision plus one additional port laparoscopic surgery for colorectal cancer with transanal specimen extraction: a comparative study two patients had a previous attempt of hernia repair, one with mesh. one patient did not have any immunosuppression due to hiv infection, whereas the other were on cyclosporine, tacrolimus and/or mycophenolate mofetil. there were two laparoscopic and two open cases, mean operative time was 169.25 minutes (111-311), mean blood loss was 85 ml (20-200). mesh used were biological porcine dermis in one case, polypropylene with absorbable hydrogel barrier in three cases. mean mesh length and width were 27 cm (20-33) and 28.25 cm (25-33) respectively. one patient underwent a component separation, though none of the patients had the fascial defect closed. there were no intra-operative complications. three patients were readmitted for hyperkalemia, abdominal pain, and seroma respectively. neither recurrences nor reoperations were reported. mean follow-up was 75.5 days (17-136) conclusion: post liver transplant incisional hernia repair is feasible either laparoscopic or in an open fashion. because of the size and location of the defect, fascial closure is unlikely achievable. the use of standard techniques and materials give a similar result of the non-transplant population. p722 technique of esophagojejunostomy using orvil after laparoscopy assisted total gastrectomy for gastric cancer shinichi sakuramoto there was a significant difference in mortality between the two time-periods, 10/38 patients died during 2000-2005 and 1/28 died during 2010-2015 (p=0.01). those who died were significantly older (69 years (51-79)) than the survivors (69 y (51-79)) (p=0.01). five of the patients who died in the previous group died without any intervention. 4/5 of those who had an acute open necrosectomy died. surgical necrosectomy correlated significantly with mortality (p=0.002). the only patient who died in the recent group died without any intervention. none of the 11 patients receiving minimal invasive drainage in this group died until now only 94 cases in adults and fewer than 20 cases in children have been reported in world literature, with surgical management being the only option. an innovative, minimally invasive laparoscopic excision of the abdominal sac was performed and the scrotal component was managed by jaboulay's procedure. this is probably the first case report in world literature describing laparoscopic management of hydrocele-en-bissac. case report: a 50 year old male presented with complaints of bilateral hydrocele and swelling in right lower abdomen since one year. computed tomography of the abdomen revealed an encysted hypodense lesion with enhancing walls along the right side of pelvis, anterior to the psoas muscle and extending through the internal ring into the right inguinal region upto the scrotal sac; measuring 14.1 cm93.6 cm suggestive of an encysted hydrocele of cord associated with hydrocele of both scrotal sacs excessive gastric resection may result in postoperative deformity of the stomach, with consequent gastric stasis in food uptake. to minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we have developed laparoscopic wedge resection (lwr) with the serosal and muscular layers incision technique (samit) for gastric gastrointestinal stromal tumors. this samit is simple and does not require special devices. purpose: the purpose of this study was to clarify whether lwr with samit for gastric gists is technically feasible in term of short-term outcome methods: all patients who went through lsg in our department between 4/2014 to 12/2016 have been evaluated for bleeding complications, after implementation of anti-bleeding policy: blood pressure was controlled to 140 mmhg during stomach resection and staple line was reinforced throughout it's length with a running 3-0 absorbable v-lock suture. drains were used selectively. results: out of 308 patients who went through the procedure 9 (2.9%) suffered hemorrhagic complications: 7 patients had? hb[2gr%. 7 patients received 1-3 red blood pc's. no patients were re-operated for bleeding. 2 patients were readmitted for infected hematoma and had ct guided drainage. one patient (0.3%) suffered from leak. conclusion: implementation of anti-bleeding policy in lsg is very effective. there is no need to use expensive buttress material to achieve these results. drains can be used selectively. the impact of this policy on leak rate needs to be fifty procedures immediately prior to, immediately after, and eight months after completion of training were included for each endoscopist. data were extracted from the electronic medical record and entered into spss for analysis. student's t-test was used to compare groups for continuous data, and chi-squared tests were used for categorical data. data were collected for 2533 procedures. patient groups pre, post, and eight months after csi training were comparable in terms of age (60.1 yrs, 60.3 yrs, and 60.1 yrs), sex (56 it's in the bag; can stoma output predict acute kidney injury in new ostomates? robert fearn colostomy output stabilised rapidly, whilst ileostomy output increased progressively throughout the first 7 postoperative days as can be seen in chart 1. twelve patients (18%) developed aki during index admission. length of stay was significantly greater in the aki group at 34 (95% ci 30-38) days vs 15 (11-19) days. highest daily stoma output was non significantly higher in the aki group 1612 ml (95% ci 636-2,588 ml) vs 1,122 (857-1,387 ml) as was mean daily stoma output at 800 ml (337-1,263 ml) vs 549 ml (312-786 ml) (chart 2). seventeen patients (25%) were readmitted for any reason, 7 (9%) specifically for aki. in total 13 patients (19%) developed aki within three months of their stoma surgery only 3 of whom had developed aki during their index admission. all patients who developed aki following their index admission were ileostomy patients. conclusion: acute kidney injury in new stoma patients is associated with prolonged hospital stay and readmissions with associated morbidity and healthcare costs 2315 consecutive laparoscopic bariatric operations were performed, including 706 primary roux-en-y gastric bypasses (lrygb), 429 primary adjustable gastric bands (lagb), 901 primary sleeve gastrectomies (lsg) and 279 secondary bariatric surgeries and revisions. all bariatric procedures were approached laparoscopically (1814 procedures were stapled and 501 were nonstapled). the mean patient age was 38 years (16-73), females represented 85% and mean bmi was 48.2 kg/m 2 (35-73). there were no perioperative mortalities, no conversions to open surgery and no intraoperative blood transfusions. there we two major intraoperative complications (hypopharyngeal perforation-1, malignant hyperthermia-1). mean hospital stay was 1.45 days (1-40 days). eleven patients (0.47%, 10 in gastric bypass group and one in lsg group) required 30-day reoperations for postoperative complications (staple line gastrointestinal bleeding-5, anastomotic leak-1, strangulated port site hernia-1, unexplained severe abdominal pain-1, intestinal obstruction-2, and intraabdominal abscess-1). there were no long term (1-year) mortalities in patients that required reoperation. there was one transfer to another institution. the dynamics of further improving safety was such that there was no complication on the recent consecutive 127 stapled procedures and the mean hospital stay was 1.1 days (1-4 days). detailed subgroup analyses will be provided. conclusions: with well-controlled and structured pre-, intra-, and post-operative care, laparoscopic bariatric surgery can be performed with minimal reoperations and zero mortality in a teaching institution does concomitant placement of a feeding jejunostomy tube during esophagectomy affect quality outcomes? md, facs; icahn school of medicine at mount sinai background: placement of a feeding jejunostomy tube (fj) is often performed during esophagectomy. few studies, however, have sought to determine whether concomitant placement affects postoperative outcomes of esophagectomy of these, ldg was performed 280 patients and odg was performed 159. we compared elderly patients (aged 75 years or more) with younger patients in each operative procedure. (ldg: elderly 71, younger 209; odg: elderly 73, younger 86) preoperative comorbidity and surgical results were analyzed. multivariate analysis was performed to detect predictive factors for postoperative complications. results: in both ldg and odg groups, the operative time and amount of blood loss did not differ, while comorbidity was more common in elderly patients than in the nonelderly, and there were fewer retrieved lymph nodes in elderly patients. the incidence of all postoperative complications did not differ between both groups in each procedure, and there were no significant differences in the time to first flatus or postoperative hospital stay. however, in terms of specific postoperative complications, respiratory complications were more frequently observed in eldery group with odg significantly (p=0.034), while not with ldg group. in multivariable analysis, age was not independent predictor of postoperative complications. conclusion: odg for eldery patients requires attention particularly in postoperative respiratory complications. ldg is a safe and less invasive treatment for gastric cancer in elderly patients who have greater comorbidity. p739 examining the role of preoperative ineffective esophageal motility in laparoscopic fundoplication outcomes tyler hall there were no significant differences in complications or recurrence rates. preoperative quality of life measures did not vary between the cohorts nor did postoperative scores at three weeks or six months. patients with 100% ineffective clearance exhibited worse gerd-hrql scores one and two years postoperatively conclusion: preoperative ineffective esophageal motility was shown to result in comparable short-term quality of life following ars. however, gerd-hrql scores at one and two yearsshowed worse outcomes in patients with preoperative iem robotic surgery as part of oncologically adequate ipmn treatment: indications, short and long term results federico gheza eligible patients who had minimally invasive surgery were stratified in multiport laparoscopic and robotic cohorts, and included if they had poi/sbo after surgery. comparative analysis assessed the demographic, perioperative, and postoperative outcomes. the main outcome measures were the incidence rate, associated variables, and time to ileus/ sbo across the mis platforms. results: during the study period 4161 total patients were reviewed-3856 laparoscopic and 305 robotic. postoperatively, 512 (13.28%) laparoscopic and 49 (16.07%) robotic patients suffered from poi/sbo laparoscopic sbo occur significantly later after the index procedure than robotic sbo (24 conclusions: the rate of poi/ sbo is considerable and comparable across laparoscopic and robotic approaches. however, there are distinct differences in the severity, time to occurrence, and impact on quality measures, such as los and readmissions between laparoscopic and robotics. this information could be an important factor in which approach the surgeon choses laparoscopic surgical procedure was standard with using laparoscopic linear stapler. responses to surgery were evaluated a month after the operation based upon the american society of hematology 2011 evidence-based practice guidelines for itp. results: there was no open conversion in this study. the mean operation time and blood loss were 151 min and 64 g, respectively. there was no case using blood transfusion during and after operation. with regard to complications, one patient (4%) had a postoperative pancreatic fistula that did not require percutaneous drainage. positive responses, including the complete and partial remissions, were achieved in 78% (18/23). the mean follow-up duration was 89 months, and the 5-, 10-, and 15-year relapse-free survival rates were 94% for all three time points. conclusions: the present study demonstrated that ls for itp can provide good long-term outcomes two cases of conversion from sp-c to open surgery were excluded. all procedures were followed postoperatively for a minimum of 6 months, and wound complications such as bleeding, fat lysis, infection, or hernia were recorded. patients were classified as having a wound complication or not. results: pure transumbilical sp-c was completed 94.6%, additional trocars were used in 5.0%, and the rate of conversion to open surgery was 0.4%. after a median follow-up of 32.1 (range, 6-50) months few cases performed with hand assist, notes, or single-incision. utilization of robotics was highest for bpd/ds (227 of 1,051 cases, 21.6%). the greatest number of robotic-assisted cases were sleeve gastrectomy (5,539 of 92,406, 5.99%) and gastric bypass (2,904 of 36,076 cases, 7.18%). relatively few operations were converted to a different approach (see table). operative time was longer when using robotic approaches for both sleeve (74.01 vs 102.39 minutes, p.0001) and bypass (116.62 vs 152.68, p\ 0.0001). postoperative los was no shorter when using robotic-assistance (see table). unadjusted 30-day outcomes revealed slightly higher rates of readmission for both operations when using robotic-assistance (see table), and slightly higher rates of complications after robotic sleeve gastrectomy p756 comparision of perioperative and survival outcomes of laparoscopic versus open gastrectomy after preoperative chemotherapy: a propensity score-matched analysis adjustment for potential selection bias in the surgical approach was made with propensity score-matched (psm) analysis. perioperative and survival outcomes were compared between the lag and og groups. results: in total, 174 patients were identified from the database. after psm analysis, 45 patients who underwent og were one-to-one matched to 45 patients who underwent lag in the setting of nact. these two groups had similar outcomes in terms of intra-and postoperative complications and 3-year overall survival. however, the lag group had a longer operation time (p=0.031) and lower estimated blood loss (p=0.001). moreover, compared with patients in the og group, those in the lag group had fewer days until first ambulation conclusion: the present study indicates that lag performed by well-qualified surgeons for treatment of locally advanced gastric cancer after preoperative chemotherapy is as acceptable as og in terms of oncological outcomes. p757 outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease: effectiveness and economic benefits kyung won seo, phd; kosin university college of medicine purpose: laparoscopic antireflux surgery (ars) is an alternative treatment option for gastroesophageal reflux disease (gerd) in the world. however, the effectiveness and economic feasibility of ars versus medical treatment is unknown. this study was performed to evaluate the effectiveness and economic benefits of ars. methods: nine patients with gerd were treated using laparoscopic ars between 2012 and 2016. surgical results and total cost for surgery were reviewed. results: seven men and 2 women were enrolled. preoperatively, typical symptoms were present in 9 patients, while atypical symptoms were present in 5 patients. one patient underwent partial fundoplication due to absent peristalsis and the other underwent nissen fundoplication. postoperatively, typical symptoms were controlled in 9 of 9 patients, while atypical symptoms were controlled in 4 of 5 patients. overall, at 6 months after surgery, 3 reported partial resolution of gerd symptoms, with 6 achieving complete control. the average cost of ars for nine patients was 5840 usd. conclusion: laparoscopic ars is effective for controlling typical and atypical gerd symptoms. the cost of ars may be more economical over the long term compared to medical treatment since laparoscopic surgery is reported to affect respiration and circulation, we should take indication of lag for elderly patients into consideration carefully. indication of lag for elderly patients, however, is still controversial. the aim of this study is to assess the safety and validity of lag for elderly patients. method: medical records were retrospectively reviewed for 94 patients who underwent lag for gastric cancer between 2009 and 2016. in this study, patients over 75 years of age were defined as elderly patients. patients were divided into two groups according to age; group a (age ≥75, n=28), group b (age \75, n=66). preoperative characteristics and postoperative outcomes were analyzed. two-tailed student's test and/or pearson's chi-square test were used for statistical analysis. results: there were no significant differences in male/female ratio and body mass index between two groups. number of patients whose asa physical status was ≥3, and/or performance status was ≥3 did not differ total gastrectomy (14.3 vs 22.7 %, p=0.351), proximal gastrectomy (0 vs 1.5 %, p=0.246). intra-operative blood loss, operating time, and number of harvested lymph nodes did not differ between the two groups. as for postoperative complications such as intra-abdominal abscess (7.4 vs 6.1%, p=0.844), anastomotic leakage (0 vs 3.0%, p= 0.352), significant difference was not observed between the two groups. in addition, respiratory and cardiovascular complication was not observed in elderly patients. incidence of clavien-dindo classification ≥grade 3 (3.6 vs 3.0 %, p=0.891), and postoperative hospital stay (10.5 vs 10.0 days, p=0.985) did not differ. conclusion: short-term outcomes of lag in elderly patients were not different from those in young patients the essential role of the transcystic duct tube (c-tube) during laparoscopic common bile duct exploration (lcbde) towakai hospital introduction: laparoscopic common bile duct exploration (lcbde) is a standard surgical procedure for the treatment of common bile duct stones (cbds). however, there are some problems associated with cbd drainage after operations even if performing with the primary closure. therefore, we developed a new drainage tube, c-tube, which contributes to shorter drainage periods and reduces perioperative complications. method: c-tube is a type of bile drainage tube which is fixed to the cystic duct with an elastic band. closing the duct with an elastic band as soon as c-tube is removed prevents bile leakage from the stump of the cystic duct. the essential roles of this tube include: 1. assisting suturing during operations, 2. use during intra-and post-operative cholangiograpy, 3. assisting post-operative endoscopic sphincterotomy when necessary we included patients from 2-years prior to our intervention and compared this with patients who had follow-up after implementation. we excluded patients having revisions, gastric banding, and patients whose primary surgeon had left during the data collection period. we analyzed demographics and follow-up rates at 1, 3, 6, 12, and 24 months. chi-square test was used to evaluate for significance, and results were corrected for multiple comparison. results: 435 patients met inclusion criteria in the pre-intervention group, and 836 in the postintervention group. of those, 418 were analyzed for the 2 year follow-up visit. the pre-intervention group had 62 males, 373 females, and an average age of 37. approximately 1/3 of the surgeries performed were sg, 2/3 were rygb. the post-intervention group had 127 males, 709 females, average age of 38. approximately half of the post-intervention cases were sg while the rest were rygb. conclusion: bariatric surgery is a useful tool in aiding weight loss and improving comorbidities. it is essential that patients receive long-term follow-up and monitoring to achieve these goals. our program now uses a system of phone call reminders for scheduled visits, as well as calls and letters for annual visits surgeon's evaluation of an intraoperative microbreaks web-app workload questions were modified nasa task load index (physical demand, mental demand, and complexity) and procedural difficulty on 0-10 (10=maximum impact) scales. primary outcomes were the impact of microbreaks on surgeons' physical performance, mental focus, pain/discomfort and fatigue with checkboxes for improved, no change and diminished. secondary outcomes were microbreaks impact on distraction level and workflow disruption using a 0-10 (10=maximum impact) scale. descriptive statistics were calculated for median and interquartile ranges (iqr) of these responses. results: seven surgeons (3 male, 4 female), with a median (iqr) surgical experience of 8 (5.5, 17) years, completed ten surgical days with a median (iqr) operative duration of 367 (283, 533) minutes/surgical day. the median number of microbreaks/surgical day was 6. the median (iqr) for mental demand, physical demand, surgical complexity and difficulty are shown in table 1. following each surgical day, surgeons reported 10/10 improved physical performance situs inversus totalis (sit) is inherited in an autosomalrecessive fashion with complete abnormal transposition of thoracic & abdominal viscera. its incidence varies from 1 in 1400 to 35000 live births. for those undergoing surgery, laparoscopic approach is preferred as it avoids inappropriate incisions. however, due to mirroring of the viscera, the surgeon faces constant visio-spatial disorientation during laparoscopy. p764 ''how to be a surgeon and not dying trying'' control of basic physiological parameters in perioperative phase second main variable: blood pressure (bp) with manual measurement sleeve. preoperative bp and immediate postoperative bp were measured, we were not able to measure intraoperative bp due to the lack of consent of the surgeons involved for the use of other devices different from the heart rate band. secondary variables: years from graduation, years of practice, age, body mass index (bmi), number of medical co-morbidities, number of jobs, sleeping hours the night before. we took measurements to surgeons during a laparoscopic cholecystectomy. results: the mean preoperative heart rate was 77.8 bpm. the mean minimum intraoperative heart rate was 86 bpm. the mean maximum intraoperative heart rate was 115.2 bpm (86% with tachycardia at the surgery). the mean immediate postoperative heart rate was 89.5 cpm. the mean heart rate 15 minutes after the postoperative phase was 80.1 cpm. at the immediate preoperative phase 53% of surgeons had elevated bp level (usual normotensives) articles were randomly selected and the gender of the first and last authors determined. results: of the bariatric surgery publications reviewed, only 5% of first authors and 7.5% of last authors were female surgeons. even though the proportion of female authors has increased over time, this is not proportional to the increase in the number of female surgeons or surgery residents (figure 1). discussion: female surgeons are under-represented in bariatric surgery research. the number of female surgeons and residents has a continuous up trend over the last few decades our survey also included the validated quick-dash (disabilities of the arm, shoulder, and hand) questionnaire for upper-limb symptoms and the ability to perform certain physical activities. the quickdash is scored into two components: disability/symptom score, and the optional work module, which represent the impact of disability on daily activities and work responsibilities, respectively. both scores range from 0-100, with a higher score indicating greater disability. surgeons were grouped according surgical focus (open, lap, or ra), and comparisons were made between groups. surveys with more than 10% of responses missing were excluded. statistical analysis were done using spss 23.0, with α=0.05. results: 156 completed surveys were evaluated (open: n=23, lap: n=96, ra: n=37). the survey response rate was 50%. 76.9% of respondents were general surgeons, and mean age was 45 ±9.49 years. surgeons reported an average of 30±16.7 cases performed per month ra: 51.4%, p=0.253). likewise, there were no differences in the mean disability similarly, there was a positive correlation between mean work scores and reported pain in the upper-limb for lap and ra, both p.001. conclusions: this nationwide survey revealed a similar prevalence of pain in the upper-limb among surgeons performing open, laparoscopic and robotic-assisted procedures. likewise, similar disability scores were reported between the three surgical groups. older surgeons performing laparoscopic and robotic-assisted approaches reported a higher impact of upper-limb problems interfering with their daily activities, unlike open surgeons. among all surgeons who reported pain in the upper-limb, laparoscopic and robotic surgeons were more likely to report that this pain interferes with their work activities an analysis of subjective and objective fatigue between laparoscopic and robotic surgical skills practice p771 3d laparoscopic versus robotic gastrectomy for gastric cancer: comparisons of short-term surgical outcomes lin chen, xin guo 164 patients who underwent 3d-lag (n=99) or rag (n=65) for gastric cancer were enrolled. the clinicopathological factors and short-term surgical outcomes were compared with retrospectively analysis. results: the clinicopathological factors between the two groups were well matched. postoperative recovery factors including the days of first flatus, days of eating liquid diet and hospital stay were similar. the rate of postoperative complications between the two groups were with no statistical differences in the subgroups of patients with total gastrectomy, 3d-lag had less blood loss and shorter operative time than rag (p=0.006 and p.001), while for distal gastrectomy, blood loss and operative time showed no statistical differences. conclusions: this study suggests that 3d-lag is a novel and acceptable surgical technology in terms of surgical and oncological outcomes. 3d-lag is a promising approach for gastric cancer therapy methods: patients underwent robotic surgery between the beginning of 2013 to first half of 2017 in turkey were included. data were obtained from a prospectively maintained database. patient, surgeon and hospital identifiers were encrypted. parameters were operation type, operation year, robotic system used (s, si, xi), hospital volume and surgeon volume. high volume robotic colorectal hospital and surgeon was defined as the caseload within the forth interquartile (75th-100th) based on the median value. results: there were 799 colorectal procedures. 47 surgeons performed robotic colorectal surgery at 25 hospitals. 341 (42.7%) and 458 (57.3%) procedures were performed with the s-si and xi platforms respectively. 2 hospitals have both of the si and xi platforms. 4 hospitals are the si, 8 hospitals are the xi hospital currently. the number of robotic colorectal operations increased gradually by years (figure 1). the median numbers of colorectal procedures were 13 (range 1-171) and 5 (range 1-151) per hospital and per surgeon respectively among those hvrcs, the numbers of si and xi users were 7 and 5 respectively. the surgeons who performed more than 11 procedures continued to use robot in their practice except one surgeon who stopped at 27. only 2 left colectomies and no right colonic resection were performed before introduction of the xi platform first 100 robotic cases and implementation of a robotics curriculum in a general surgery residency domenech asbun armonk ny) and utilized student's t test and chi-square. we also performed a linear regression analysis to determine the effect of or time, robotic surgery, and diagnosis on operating room costs and postoperative length of stay. results: 37 laparoscopic and 14 robotic cholecystectomies were performed. demographic parameters (age, gender, medical comorbidities, preoperative albumin and bmi, surgical history and smoking) were comparable. primary diagnosis was significantly different (chi-square 0.05), driven by more acute cholecystitis in the laparoscopic group. 0/14 robotic cases and 5/37 (13.5%, p =0.305) laparoscopic cases were converted to open (2 for adhesions, 2 for failure to progress, and 1 for visualization of anatomy after adjusting for or time and diagnosis, robotic surgery was associated with a $980 increase in costs robotic surgery is independently associated with increased or cost, but individual hospital systems must decide if this additional cost outweighs increased robot utilization and training benefits for physicians and staff robotic abdominal wall hernia repairs: technical considerations and lessons learned inguinal hernia repairs (ihrs) comprised the majority (59.3%) of cases (71.9% male, mean age 55.5, mean bmi 26.2). there were 103 unilateral ihrs with an average operative time of 97.2±55.5 min and an average ebl of 19.8 ml. there were 18 bilateral ihrs with an average operative time of 132.4±49.9 min and average ebl of 19.8 ml. thirteen ihrs were combined with umbilical hernias and two with incisional hernias. average operative time for combined procedures was 152.8 min and average ebl was 29.7 ml. fifty-five incisional hernias were repaired robotically (56.3% male, mean age 54.5, mean bmi 28.9), four of which were retrorectus and two of those required transversus abdominis release. median hernia size was 6 cm (2-13 cm). mean operative time was 132.9±57.4 min and average ebl was 31.5 ml. twenty-three ventral/umbilical hernias were repaired robotically (52.2% male, mean age 45.4, mean bmi 28.8, median size 2.5 cm (1-4 cm), mean operative time 89.7±29.5 min, average ebl 13.3 ml). one spigelian hernia (operative time 99 min, ebl 20 ml) and one parastomal hernia (operative time 117 min, ebl 200 ml) were repaired robotically. there were no major complications and only 1 groin seroma requiring percutaneous aspiration. nine patients required conclusion: this study demonstrates improved outcomes of robotic inguinal hernia repair compared to an open or laparoscopic approach. robotic hernia repair showed overall lower 30-day complication and readmission rates, and shortened los. while open approach had the highest rate of opiate use we retrospectively investigated 186 consecutive overweight gc patients (bmi≥24) underwent distal gastrectomy with d2 lymphadenectomy (81 for rag and 105 for lag) performed by two surgeons. the clinicopathological and surgical features were compared between groups. the cutoff point for initial phase (phase i) and stable phase (phase ii) were determined by cumulative sum (cusum) curve of operation time. results: generally, the surgical outcomes including postoperative complication rate, duration of postoperative hospital stay and lymph nodes harvest in the overweight patients have comparable results between rag and lag groups. the cutoff determining phase i and ii according to the cusum figure for rag group was 15 and 10 cases for surgeon a and b, respectively. and comparison analysis showed that the operation time of phase ii rag was significantly shorter robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy: a single-center experience including perioperative morbidity and short-term outcomes patient factors, treatment factors, and outcome measures were collected in an attempt to gain insight and to generate ideas to potentially improve outcomes. results: there were no operative complications. six patients (40%) had failed gastric pacemaker placement prior to intervention. nine patients (60%) reported improvement in their symptoms and overall quality of life. four patients (26%) reported no improvement in symptoms and required additional intervention for symptom control and supportive care (one underwent roux-en-y gastric bypass, three underwent laparoscopic jejunostomy feeding tube placement to maintain nutrition). conclusion: robotic-assisted pyloroplasty is a safe option that improves symptoms and quality of life in 60% of our patients patients were matched into cohorts by procedure type. outcomes were analyzed using unpaired t-test and fisher's exact test. results: cost data was available for 447 patients undergoing ras or la procedures. significant increases in equipment, labor, and overhead costs resulted with ras vs. la. variable-labor and variable-overhead costs were significantly higher in la procedures. higher supply costs and longer procedure time was seen with ras in all cohorts however, total 30-day costs were not significantly different in any group. conclusion: ras led to significant increases in fixed clinical, operative and pathologic factors were reviewed and analyzed. results: seventy patients underwent robotic surgery for rectal cancer during the study period. the locations of tumor were 26 upper rectum, 44 lower rectum. the procedure were as follow, high anterior resection in 6, low anterior resection in 51, isr in 6, apr in 7 patients. eight patients underwent bilateral lymph nodes dissection (llnd). the procedures were performed successfully in all cases. mean age was 66.5 years, and 70% of the patients were men, and the mean body mass index was 22.5 (range, 18.5-29.4) kg/m 2 . median operative duration was 321 (190-666) minutes. median blood loss was 15 (0-270) ml. median postoperative stay was 13 (6-16) days. mean harvest lymph node number was 17.0 (5-37). surgical margins were negative in all cases. there was one conversion due to bleeding during the llnd and anastomotic leakage occurred in two patients. morbidity was 17%. there was no mortality postoperatively in this series. conclusion: in early series of the selected patients, this technique appears to be fesible and safe when performed by surgeons skilled in laparoscopic colorectal surgery the inactive electrode was placed touching small bowel to simulate accidental thermal injury. the bowel tissue at the site of temperature change was immediately resected and examined histologically for tissue injury. student t-tests were used for all comparisons with a p-value less than 0.05 considered statistically significant. results: comparison of the laparoscopic and robotic techniques are displayed in table 1. energy transfer was quantified using energy leak (per ma), which in these tests averaged 1.18 degree celsius change (95% ci 1.05-1.31) at the inactive electrode. surface temperature heated to a maximum of 5.5 degrees celsius, more in the robotic system than laparoscopy but still clinically negligible. pathology results from in vivo testing showed only thermal injury to the serosa without deeper mural injury. conclusions: stray energy transfer occurs in both laparoscopic and robotic surgery in amounts that are measurable but without clinical relevance. the average change in tissue temperature is less than 2 degrees celsius laparoscopically and less than 6 degrees robotically. while the robotic surgery appears to transfer more stray energy, no significant bowel injuries were caused in either group. p789 robot assistance can improve the performance of laparoscopic extensive concomitant adhesiolysis: results from a large observational study federico gheza outcomes compared were operative time, conversion rate, overall complications, gastrointestinal (gi) related complications (wound infection, abdominal abscess, anastomotic leak, ileus and small bowel obstruction), hospital length of stay, and 30-day re-admission rate. two sample t-test was used and p.05 was considered statistically significant. results: fifty-five robotic colectomies were matched with 55 laparoscopic counterparts based on type of operation: right colectomy (n=28), sigmoidectomy (n=46), low anterior resection (n=26), proctocolectomy (n=4), transverse colectomy (n=2), abdominoperineal resection (n=2), and total abdominal colectomy (n=2) we assessed if technical obstacles of laparoscopic suturing were decreased and if laparoscopic skills overall were improved. surgical outcomes were compared relative to our historic values; we assessed procedure time and operating room efficiency, including set up and turn-over times. results: overall, the 3d/flexdex system permitted a greater improvement in working speed, superior optical visualization, and better suture handling compared to standard laparoscopy. all surgeries were completed without any complications. historically, we considered laparoscopic suturing to be complicated and inefficient. we relied on tacking devices for mesh fixation, suturing was previously completed with large cumbersome straight laparascopic devices. however, with flexdex and endoeye flex 3d, tacking devices have been eliminated and suturing technique improved. the mean total procedure times remained comparable for inguinal and hiatal hernia surgeries, and slightly longer for ventral hernias. operating room efficiency, including mean set up and turn-over times also remained unchanged. the acquisition cost for both the olympus endoeye flex 3d laparoscopic imaging system we performed a cost analysis which showed an average total cost of $7,024 for laparoscopic sleeve gastrectomy and an average of $11,680 for robotic assisted. the total reimbursements were $21,587 for laparoscopic sleeve gastrectomy and $18,310 for robot assisted. this translated to an average contribution margin of $14,564 for laparoscopic vs $6,630 for robot assisted. we analyzed these differences for bypasses as well. laparoscopic bypasses averaged 193 minutes laparoscopically vs 330 robotically. we found an average cost of laparoscopic $11,366 vs robot assisted $17,032, with a contribution margin of $13,734 laparoscopic vs $5,701 robot assisted. conclusions: in our study we noted increased operative times with robot assisted operations, especially bypasses which could be explained by increased use of the robotic system for difficult cases such as revisional bypasses. the impact of cost is especially important in this financial climate, and judicious use of resources becomes important when determining surgical approach average or time for rih was 127 minutes compared to lih which was 85 minutes. average intraoperative cost for rih was $1,110 compared to lih which was $890. of note, one lih was converted to open, whereas none of the rih required conversion. average los was 9.16 hours for rih compared to 11.6 hours for lih. postoperative pain at one week follow up was the same between both groups. two postoperative surgical site occurrences (sso) occurred in the lih group (2 groin seromas), whereas no ssos occurred in the rih group. eleven ventral hernia repairs were examined, 7 were robotic (rvh) and 4 were laparoscopic (lvh). average or time for rvh was 132 minutes compared to 65 minutes for lvh. average intraoperative cost for rvh was $1,492 compared to lvh which was $1,264. no procedure from either group required conversion to open. average los was 9.86 hours for rvh, and 13.5 hours for lvh. again, postoperative pain was the same at one week follow up for both groups. there were no postoperative complications noted in either cohort. conclusion: operative time and procedural costs for rvh and rih repairs were shown to be longer and more expensive when compared to their laparoscopic counterparts. however, with increased operative experience using the robotic platform, surgical time did show a decreasing trend does robotic system have advantages over laparoscopic system for distal pancreatectomy? results: a total of 91 consecutive patients underwent minimally invasive distal pancreatectomy (ldp n=61; ra-ldp n=30). most common pathologic finding was pancreatic ductal adenocarcinomas (36 cases). there was no in-hospital mortality or cases of conversion to open surgery in this study. spleen-preserving approach was performed more often in the ra-ldp (95%) than in the ldp (77.8%) groups (p=0.132) both groups showed no significant differences in the total number of lymph nodes, number of positive lymph nodes, tumor differentiation, tumor stage, and resection margins. conclusions: ra-ldp is a safe and feasible approach that has an advantage of performing spleenpreserving distal pancreatectomy, with perioperative and short-term oncologic outcomes comparable to those of ldp. p797 robot-assisted alpps technique mike fruscione right portal vein embolization was not feasible secondary to the proximity and size of the right hemi-liver tumor burden relative to the right portal vein. the pre-operative planned procedure was a right trisectionectomy and microwave ablation of the segment 2 lesion. results: using the da vinci xi surgical system (intuitive surgical, inc.) the right portal vein was dissected, doubly-ligated, and divided. the liver parenchyma was split from the inferior edge to the dome 5 mm medial to the falciform ligament and down to the middle hepatic vein which was preserved to maintain adequate venous outflow. the patient was discharged home on post-operative day two. on post-operative day six, ct volumetrics demonstrated a flr of 47%. on post-operative day seven, a second stage alpps procedure was performed where the right hepatic artery, middle and right hepatic veins and right hepatic duct were ligated and divided. segments 4a/b, 5, 6, 7 and 8 were removed. the patient was discharged home on post-operative day five they were asked to answer demographic questions and rate their comfort level (0=not comfortable, 10=very comfortable) with aspects of robotic surgery. paired t-tests and wilcoxon tests were used to assess whether there were changes in comfort level before and after labs, and chi-square goodness of fit tests were used to assess whether dry lab (using inanimate objects), wet lab (using a porcine model), or simulator modules were thought to be most helpful in obtaining specific robotic skills. results: the survey response rate was 73% (n=32). ninety-one percent of residents felt that robotic surgery is not intuitive. prior to simulation, 94% of residents felt inadequately prepared to safely operate on the robotic console. following simulation, 100% felt better prepared and more confident to participate in robotic surgery for the first 4 patients whom we treated (the first-stage group), we invited a visiting expert from a high-volume center to perform the procedure jointly with our hospital's surgeons by using a dual console. for the subsequent 6 patients (the second-stage group), the procedure was performed by our hospital staff alone. in this report, we describe our experience of introduction of robotassisted colectomy and discuss issues for the future. patients and methods: the operative procedure was sigmoid colectomy, low anterior resection, and intersphincteric resection. the median number of lymph nodes dissected was 15.6. the mean operating time was 337 minutes for the first-stage group and 365 minutes for the second-stage group. the median console time was 206 minutes for the first-stage group and 193 minutes for the second-stage group, with no significant differences between the two groups. the mean operating time other than console time was 127 minutes for the first-stage group and 171 minutes for the second-stage group, significantly longer in the latter group. the mean amount of hemorrhage was 15.5 g in the first-stage group and 31 g in the second-stage group. no significant differences were found between the two groups in the mean length of postoperative hospital stay. none of the patients in either group developed a complication of clavien-dindo grade iii or higher. conclusions: the use of dual console system was particularly useful for the introduction of robotassisted surgery in our hospital. for the patients whom we treated, we found almost no difference in console time between the first-and second-stage groups. the high-quality instruction received via the dual console was considered to have had a beneficial effect on the operators' learning curve. however, the operations that were set up other than console time, such as roll-in and docking, took significantly longer in the second-stage group when the proctor was not present select specimens from each trial were immediately resected and evaluated for histologic thermal injury. experiments were repeated 20 times based to detect an expected difference of five degrees. student t-tests were used for all comparisons with significance set at 0.05. results: stray energy transfer was higher in the single incision setup compared to the traditional setup (figure 1). stray energy in the assistant grasper caused 8.4±1.6°c of temperature change in the standard configuration, and 11.6±3.3°c in the single incision configuration (p=0.015). doubling energy output to 60w amplified the same finding robotic single-site cholecystectomy of 520 cases: surgical outcomes and comparing with laparoscopic single-site procedure jae hoon lee incisional hernia occurred one case in each group. rssc is safe and feasible procedures. with accumulating of experience, rssc had more short operative time than sslc. comparing to sslc, rssc is relatively suitable to acute gallbladder disease and high bmi and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy. p805 initial experience using da vinci xi robot in colorectal surgery anna r spivak, do, john marks, md; lankenau medical center introduction: the xi robot has been developed to facilitate multiquadrant abdominal surgery. this report presents initial experience to evaluate feasibility and safety of xi robot in colorectal surgery. methods: all cases performed on xi robot were prospectively entered into a robotic database that was queried for colorectal cases performed from intraoperative complications were encountered in 2 cases (1.9%), requiring conversion to laparoscopy. none were converted to open. mean length of largest incision 4.7 cm. median ebl 55 ml. there was no mortality. there were 10 (9.6%) immediate postoperative morbidities: postoperative abscess, bowel perforation, two postoperative bleeds, two hernias, two hematomas, smv thrombosis, small bowel obstruction. perioperative blood transfusions were required in 2.8% of cases. there was one anastomotic leak. median time from surgery to low residue diet and discharge was 3 days. conclusion: initial experience shows robotic colorectal resection with da vinci xi learning curve for robotic sleeve gastrectomy and roux-en-y gastric bypass: achieving equivalence to laparoscopy residents and fellows participated in an analogous fashion in both arms of the study, and patients undergoing re-operative bariatric surgery were excluded. results: a total of 109 patients undergoing rsg (n=84) or rrygb (n=25) were included. for the overall robotic cohort, median age was 38 (range 19-69), 36% were american society of anesthesiologists (asa) score 2, 60% were asa score 3, and mean body mass index (bmi) was 46±7 with no differences between procedures. there were no conversions to open. there was one patient with portal vein thrombosis after rsg which occurred in the 84th rsg and one patient who underwent re-operation in the immediate post-operative period for hemorrhage at the gastro-jejunal anastomosis in the rrygb group; this occurred in the 8th rrygb. there were no leaks, strictures, or mortalities in either group. mean length of stay was 2 days±1 for rsg with no difference based on number of procedures performed. in the rrygb group, los decreased after the first five procedures from 3 days±1 to 2 days±(p=0.04). for both procedures, operative time decreased by number of procedures performed (figure). equivalence to lsg in operative time (118 minutes±40) was reached after eight robotic procedures were included. the da-vinci xi® was used for the operations. age, gender, body mass index (bmi), asa score, indication for surgery, urgency of procedure, type of procedure, docking number, operation time, estimated blood loss, complications, short (≤30 days) and long term ([30 days) complications were evaluated. results: 19 patients (7 females) were included. median age was 28. median bmi was 23, median asa score was 2. total and completion rrp-ipaa were performed for 9 and 10 patients respectively. the indications were as follows: medical refractory uc (n=12), cancer/dysplasia (n= 2), fulminant colitis (n=2), toxic megacolon (n=1), medical treatment resulting in growth retardation (n=1), medical treatment refractory bleeding (n=1). 1 patient with toxic megacolon had an emergent operation. the median docking number was 1 and 3 for completion and total rrp-ipaa respectively. median operative time was 330 minutes. median blood loss was 100 ml. all patients had a stapled ileal j pouch anal anastomosis. all patients had a diverting loop ileostomy at the time of ipaa creation. no intraoperative complications were observed. no conversion to open surgery was needed. the median time to flatus was 1 day. the median time to oral intake was 1 day. 1 patient had a laparotomy on postoperative day 12 due to intra-abdominal bleeding. 1 patient had a bleeding from ileostomy which was treated endoscopically. superficial surgical site infection was observed in 3 patients. 1 patient had a pouchitis managed with oral antibiotics. 1 patient had an ileus responded to conservative treatment. 1 patient had a per-anal bleeding stopped spontaneously. 1 patient had a urinary tract infection responded to antibiotics. 2 patients had pouchitis, 1 patient had a perianal fistula requiring a loop ileostomy and a parastomal hernia was developed in another patient in long term follow up ) were significantly different between the two groups. 2,858 pairs undergoing primary and 354 pairs undergoing revisional procedures were successfully matched. robotic gastric bypass was associated with a significantly longer operation length than laparoscopic gastric bypass for both primary (median difference 31 minutes, p.0001) and revisional (median difference 47 minutes, p.0001) procedures overall, there were no significant differences in anastomotic/staple line leak, 30-day readmission, reoperation, re-intervention, total event, and mortality rates between matched cohorts. conclusion: when controlling for patient characteristics, those undergoing primary and revisional lrygb and rrygb had no difference in early morbidity. despite the prolonged operative duration, the robotic approach was not associated with any clinical benefit or increased complications for primary or revisional gastric bypass surgery preoperative risk factors were collected. we focused on perioperative outcomes and in hospital complication rate. results: thirty-three patients underwent robot assisted giant hiatal hernia repair at our institution. 13 patients (40%) were 70 years and older and 15 patients (46%) had a bmi higher then. there were no significant differences in patient characteristics between the groups. no patient underwent conversion to open or standard laparoscopy. no mortality was observed and no transfusions were needed. four patients (12%) had a complication, two of them were older than 70 years old. three of the four patient (75%) that had a complication were obese. there were no statistical differences in mortality 5% and 43.5% of them were with s-si and xi platforms respectively. the median numbers of procedures were 33 (range 3-290) and 7 (range 1-276) cases per hospital and per general surgeon respectively. the high volume surgeons (higher than 75th percentile) performed 1462 (77%) of the cases. the xi platform has been the main tool for colorectal surgery only (figure 1). conclusions: while xi platform significantly increased caseload in general surgery by facilitating performance of colorectal surgery, its preference in other general surgical fields is not superior to si laparoscopic inguinal hernia repair (tapp) -first experience with the new senhance robotic system robin schmitz 2; 1 intuitive surgical inc, 2 loma linda university medical center introduction: crohn's disease is an incurable inflammatory disorder that can affect the entire gastrointestinal tract. while medical management is considered first-line treatment, approximately 70% of patients with crohn's disease require surgery within 10 years of their initial diagnosis. traditionally, surgery has been performed via an open approach with poor adoption of minimally invasive technique. the aim of this study is to demonstrate the feasibility of robotic-assisted approach as a minimally invasive option for surgical management of crohn's disease and compare the perioperative outcomes with traditional laparotomy. methods: patients who underwent elective resection of the intestine for crohn's disease by roboticassisted or laparotomy approach from 2011 to q3 2015 were identified using icd-9 codes from premier healthcare database. all the procedures were performed by either general surgeons or colorectal surgeons. since hospital characteristics were comparable between the two cohorts before propensity-score matching, 1:1 matching was performed using patient characteristics such as age, gender, race, charlson index score and year of the surgery to create comparable cohorts. sample selection and creation of analytic variables were performed using instant health data (ihd) platform (bhe methods: we conducted a retrospective analysis of 102,241 mis inguinal hernia repairs (1,096 robotic, 101,145 laparoscopic) from 2010 through 2015 with data collected in the premier hospital database. patient, surgeon, and hospital demographics of robotic and laparoscopic inguinal hernia repairs were compared. the adjusted odds ratio of receiving a robotic procedure was calculated for each of the demographic factors using a multivariable logistic regression model. statistical significance was defined as p.05. sas software version 9.4 was used for statistical analysis. results: the odds of a procedure being robotic increased from inguinal hernia repair is one of the most common general surgery procedures with over 600,000 performed annually in the united states. when compared to traditional open inguinal hernia repair (oihr), laparoscopic inguinal hernia repair (lihr) has been associated with faster postoperative recovery rates and lower postoperative pain. with advances in the robotic platform, robotic inguinal hernia repair (rihr) is an available technique that is currently being explored. this study examines lihr and rihr as described in literature to see if one is superior to the other. study design: search terms: ''inguinal hernia repair surgical complications including hematomas (3.9%), seromas (2.6%), and trocar site infection (1.3%) resolved with antibiotics, with a 2.6% postoperative complication rate. conclusion: rihr repair is a safe alternative to lihr, with fewer postoperative complications and a faster recovery time. however, operative time as well as or room time is significantly longer, which may increase overall cost laparoscopic or robotic approach were chosen on a schedule availability basis. data was collected prospectively and it involved anthropometric data, presence of type 2 diabetes mellitus (t2dm), % of preoperative total weight loss (%ptwl), surgical time, postoperative length of stay, 30-day complications, and need for readmission or reoperation. comparison between groups was carried on with t-test for continuous data and with chi-square test for dichotomous variables. a p lower than 0.05 was considered significant. results: overall 131 sagb were performed, 111 laparoscopic and 20 robotic. a long and thin gastric pouch was created calibrated by a 27 fr bougie and a 2.5 cm antecolic antegastric gastrojejunal (gj) anastomosis was groups (laparoscopic vs robotic) were comparable regarding age (46 vs 45.3 years, p=0.77), bmi (48.1 vs 47 kg/m 2 , p=0.53), %ptwl (13.6 vs 16.9 %, p=0.29) and % with t2dm (51 vs there were fewer men in the laparoscopic group (20.2 vs 45% there were 6 (5.4%) major complications in the laparoscopic group: 3 bleedings from the gj anastomosis, one of which required reoperation, 1 severe dumping syndrome, 1 gerd requiring revision and 1 gj stricture that underwent relaparoscopy. the only complication (5%) in the robotic group was an acute pancreatitis. readmission rate was 5% in both groups and reoperation rate was 3% for laparoscopic and 0% for robotic surgeries. conclusions: totally robotic sagb with manual gastro jejunal anastomosis was safe and feasible in this early experience compared to laparoscopic approach multi degrees of freedom manipulator with mantle tube for assisting endoscopic and laparoscopic surgical operations masataka nakabayashi, phd 1 , yuta hoshito, masters student 1 p823 step by step anatomic mapping during laparoscopic transabdominal adrenalectomy lateral flank approach ranbir singh steps analyzed were: right adrenalectomy: step 1) mobilize liver; 2) medial dissection; 3) adrenal vein isolation; 4) inferior dissection; 5) adrenal off kidney; 6) detachment. left adrenalectomy: step 1) division splenorenal ligament; 2) develop plane pancreas/kidney; 3) mobilization medial/lateral borders adrenal; 4) adrenal vein isolatoin; 5) dissection adrenal off kidney; 6) detachment. structures were identified as yes/no and results expressed as percentage total n of cases seen at each step. results: structures identified at each step are shown (table) incisions were made at the oral vestibule under the inferior lip. a 10-mm trocar was inserted through the center of the oral vestibule with two 5-mm trocars above incisors. the subplatysmal space was created down to the sternal notch, and carbon dioxide was insufflated at pressure 6 mmhg to maintain the working space. parathyroidectomy was performed using laparoscopic instruments. intraoperative parathromone levels were measured 10 minutes after excision of gland. primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within 7 postoperative days (sf-36), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. result: one patient experienced a transient recurrent laryngeal nerve palsy which was spontaneously resolved within 1 month. no permanent recurrent laryngeal nerve injury was found no mental nerve injury or infection was found. conclusion: with highly sensitive localising sestamibi and ct scans, focussed exploration is the current standard of treatment. among all minimally invasive surgeries, toepva is a feasible, safe, and almost pain-free surgical option when combined with intraoperative parathormone monitoring for patients with hyperparathyroidism indocyanine green is a water soluble nontoxic compound exhibiting near infrared renal function and long-term survival. indocyanine fluorescence helps in assessing vascular flow, tissue perfusion and aberrant anatomy and thereby leads to lower conversion rates in partial nephrectomy. we aim to present our experience in 44 patients who underwent partial nephrectomy over 7 years. materials and methods: of the 44 partial nephrectomies performed at our institution, 24 were done by laparoscopic approach alone and rest 20 by 260 patients who underwent llr for whole hepatoma in our facility, 176 underwent llr for a solitary hepatoma and were divided into "before standardization" (bs; n=147) and "after standardization" (as) groups (n=29). patient background, characteristics, and perioperative outcomes were compared between these groups. procedure: we chose the devices according to phases of liver transection. a soft-coagulation monopolar device was used for marking surface. an ultrasonically activated device was used for transection of the liver surface within a 2-cm depth. crash and sealing with biclamp were indicated for deep-phase transection. the cavitron ultrasonic surgical aspirator was used if the lesion was close to the major glisson's sheath or the major hepatic vein. results: no significant differences in the patients' background were found between the two groups. the operative durations were 128 min (60-312 min) and 203 min (50-470 min) in the as and bs groups, respectively, with a significant difference (p.001). the blood loss volumes were 5 cc (0-150 cc) and 30 cc (0-850 cc), respectively (p=0.0548). the lengths of hospital stay after llr were 5 days (range, 3-7 days) and 6 days (2-21 days), respectively, with a significant difference iwao kitazono, phd 1 , kentaro gejima 1 , hizuru kumemura 1 , akira hiwatashi 1 , yuichiro nasu 2 , fumisato sasaki 2 , akio ido 2 , yutaka imoto 1; 1 cardiovascular and gastroenterological surgery, kagoshima university graduate school of medical and dental science, 2 digestive and lifestyle disease, kagoshima university graduate school of medical and dental science introduction: in locally-treatable gastrointestinal tumors, laparoscopic endoscopic cooperative surgery (lecs) is a minimally-invasive technique that can avoid excessive resection of the gastrointestinal tract. objective: to share our therapeutic guidelines and surgical technique of lecs for gastroduodenal tumors. subjects: nineteen patients who underwent lecs for gastroduodenal tumors (10 patients with gastric tumor and 9 patients with duodenal tumor).[results] 1) gastric tumors (9 gist, 1 glomus): 1. site of lesion was u (4 patients), m (3), or l (2), 2. operative procedure was acquired in a stepwise manner from classical lecs (4 patients) to inverted lecs (2) to non-exposed endoscopic wall-inversion surgery: news (4). 3. operative outcome revealed no postoperative complications. 2) duodenal tumors (6 adenoma, 2 m cancer, 1 ectopic pancreas): 1. site of lesion was bulbus duodeni (1 patient), superior part (2), or descending part (6); 2. operative procedure was esd followed by laparoscopic continuous suture in a single seromuscular layer for patients with preoperatively confirmed or suspected cancer, or full-thickness resection followed by albert-lembert suture along the short axis for patients unable to undergo esd. in all cases, c-tube was placed to prevent bleeding and perforation at the site of resection due to exposure to bile; 3. operative outcome included successful endoscopic hemostasis upon bleeding from exposed vessel on postoperative day 4 in 1 patient and anastomotic leak in 1 patient. the event of anastomotic leak resolved after 14 days of bile drainage through c-tube and conservative therapy. compared with 26 patients who underwent esd alone, those who underwent lecs had significantly larger diameters of resected specimens and tumors (p.05) but no significant difference in the incidence of postoperative bleeding and delayed perforation. conclusion: for gastroduodenal tumors, lecs is a minimally-invasive and safe therapeutic option as it combines advantages of both laparoscopy and endoscopy. in particular, c-tube placement for bile drainage was effective in reducing exposure of the suture site to bile as well as supporting drainage after anastomotic leak. introduction: in japan, transurethral balloon catheters (tuc) are currently inserted in most surgical patients to maintain a urine outflow route and to measure the urine output both intraoperatively and postoperatively. however, tuc insertion not only causes postoperative pain but can also lead to urinary tract infections. temporary suprapubic catheters (spc) are used in the field of obstetrics and gynecology as a method of postoperative management to avoid performing transurethral procedures. in the field of surgery, especially in laparoscopic surgery, spc also considered how it would be a useful way to reduce patient suffering. here we report our prospective study on whether an spc can be safely inserted as a substitute for tuc during laparoscopic-assisted colectomy. subjects and methods: the subjects in this study were patients who underwent laparoscopic surgery for primary colorectal cancer from 2014 to 2015, and who would normally have had their urinary balloon catheter removed early after surgery. during surgery, an angiomed cystostomy set was installed for patients who gave their consent to participate in this study as an alternative to a urinary balloon catheter. we prospectively collected patient information including sex and age, in addition to other perioperative data, such as, time required for cystostomy, complications accompanying cystostomy, sense of discomfort or pain associated with the vesical fistula after surgery, the time of the removal of the vesical fistula, the frequency of releasing the vesical fistula, postoperative complications. results: our subjects included 52 cases who gave their informed consent to have an spc inserted. an spc was inserted into the remaining 45 case. the mean surgical duration was 229 min, and the spc insertion was performed at a mean of 137 min after the start of surgery. insertion required a mean duration of 158.2 s. the bladder of one case (2.2%) was perforated, and hematuria was observed at the time of insertion in two cases (4.4%), but surgery completed without any incident. six out of 42 cases (13.3%) demonstrated neither urinary urgency nor independent urination on the day the catheter was clamped. however, the clamp was released two to four times, and draining of an average of 586 ml urine, urinary urgency, and independent urination were confirmed 2-4 days later. conclusion: spc is a procedure that avoids crossing the urethra and its associated disadvantages. here we were able to demonstrate that the procedure can be safely used in laparoscopic surgery patients.our objective is to devise methods for proper port placement to overcome the ergonomic challenges. procedure: 3 patients with sit were operated laparoscopically in our hospital in the period of may 2016 to november 2017, 2 males suffering from cholelithiasis without cholecystitis and 1 female with acute appendicitis. after thorough review of literature and proper planning, the patients were posted for surgery. for laparoscopic appendectomy, a thorough initial diagnostic survey is performed on introducing a scope through the umbilical port and confirming the exact location of the appendix. the two working ports are introduced accordingly, which is usually a mirror image of the standard port sites. the appendix was visualised in the left iliac fossa and after meticulous dissection, the appendix and mesoappendix were divided using an endostapler. the operative time was 43 minutes and there were no intraoperative or postoperative complications.the port placement for laparoscopic cholecystectomy in such a case is trickier as the anatomical variation and the contralateral disposition of the biliary tree demand an accurate dissection and exposure of the biliary structures to avoid iatrogenic injuries. it is important to conform to the principles of triangulation during port placement. the mirror image of 4-port placement is convenient for left-handed surgeons. whereas, to make the procedure comfortable for right-handed surgeons, the working ports need to be shifted caudally with the surgeon standing between the patient's legs. the mean operative time was 54 minutes and there were no minor or major intraoperative or postoperative complications.conclusion: ergonomic comfort is vital to a smooth procedure. while mirroring ports suffices for appendectomy, all other procedures require forethought for port placement. it should be noted that ambidexterity is a desirable skill in the operating room for a laparoscopic surgeon.priscila r armijo, md, chun-kai huang, phd, gurteshwar rana, md, dmitry oleynikov, md, ka-chun siu, phd; university of nebraska medical center introduction: the aim of this study was to determine how objectively-measured and self-reported fatigue of the upper-limb differ between laparoscopic and robotic surgical training environments. methods: surgeons at the 2016 sages conference learning center, and at our institution were enrolled. two surgical skills practical environments were utilized: 1) a laparoscopic training-box environment (fls) and 2) the mimic® dv-trainer (mimic). two standardized surgical tasks were chosen for both environments: peg transfer, and needle passing. each task was performed twice. objective fatigue was evaluated by muscle activation and fatigue, and comparisons were made between fls and mimic, for each surgical task. muscle activation of the upper trapezius, anterior deltoid, flexor carpi radialis, and extensor digitorum were recorded during practice using surface electromyography (emg; trignotm, delsys, inc., boston, ma). the maximal voluntary contraction (mvc) was obtained to normalize muscle effort as %mvc. the median frequency (mdf) was calculated to assess muscle fatigue. subjective fatigue was self-reported by completing the validated 10-scale score piper fatigue scale-12 (pfh-12) before and after practice. statistical analysis was done using spss v23.0, with α=0.05. results: this abstract represented the performance of 15 trainees (fls: n=8, mimic: n=7) as part of larger cohort of the study. for peg transfer, emg analysis revealed that mimic had a significant increase in mean muscle activation for the upper trapezius and anterior deltoid, both p\ 0.001. conversely, practice with fls led to significantly more muscle fatigue than mimic for the same muscle groups (upper trapezius: p=0.028, anterior deltoid: p=0.015), represented by a significantly lower mdf. similarly, for needle passing, mimic had a significant increase in mean muscle activation for the upper trapezius (p=0.034) and anterior deltoid (p=0.031), but practice with fls significantly induced more muscle fatigue effort for anterior deltoid (p=0.004). survey analysis revealed a significant decrease in self-reported fatigue after performing fls tasks (before: 3.85±1.66, after: 3.05±1.54, p=0.044), but no difference after mimic tasks (before: 4.00±2.27, after: 4.22±2.56, p=0.417). conclusions: although different muscle groups are preferentially required in the performance of fls and mimic, our analysis for both surgical tasks showed practice with mimic required more activation of shoulder muscles, whereas practice with fls could lead more muscle fatigue for the same muscle groups. interestingly, surgeons reported improved or no change in perceived fatigue after the tasks, despite of having an increase in muscular activation and effort. subjective selfreport fatigue might not truly reflect the level of fatigue when trainees practice surgical tasks using fls or mimic. objective: to investigate the prevalence of musculoskeletal (msk) injuries in bariatric surgeons around the world. background: as the popularity of bariatric surgery increases, efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. however, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with a recent report showing a 73-88% prevalence of physical complaints in surgeons performing laparoscopic surgeries. methods: a web-based survey was designed and sent out to bariatric surgeons around the world. participants were queried about professional background, primary practice setting, and various issues related to bariatric surgeries and msk injuries. results: there were 113 responses returned from surgeons from 34 countries around the world. 68.5% of the surgeons have had more than 10 years of experience in laparoscopic surgery, 65.8% in open and 0.9% in robotic surgery. 66% of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in 27.2% of the surgeons. it was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic, with 29.4% of the surgeons reporting that this pain has affected their task accuracy/surgical performance. a higher percentage of females than males reported pain in the neck, back and shoulder area when performing laparoscopic procedures. supine positioning of patients evoked more discomfort in the wrists, while the french position caused more discomfort in the back region. only 57.7% sought medical treatment for their msk problem, of which 6.35% had to undergo surgery for their issue, and 55.6% of those felt that the treatment resolved their problem. conclusion: msk injuries and pain are a common occurrence among the population of bariatric surgeons, and has the ability to hinder performance at work. therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life.introduction: the use of robotic technology is rapidly increasing among general surgeons but is not being routinely taught in general surgery residency. we aimed to evaluate our first 100 robotic cases during which time we developed a robotic surgery curriculum incorporating residents. methods: the first 100 robotic cases performed at our institution from 2016-2017 by two surgeons were analyzed. a residency curriculum was developed and instituted after the first 6 months. it consisted of online modules offered by intuitive surgical resulting in certification, simulator training, hands on workshops for cannula placement, docking, instrument exchange, camera clutching and other introductory tasks. patient demographics, type of procedure, resident involvement, total operative and console times, comorbid conditions and complications were evaluated. unpaired t tests were performed for statistical analysis. results: 66 females and 34 males comprised this series with an average age of 44 years ±12. the majority of patients, 71% had comorbidities, with a predominance of hypertension, 59% and diabetes, 37%. the bariatric patients had an average bmi of 48±10. a variety of procedures were performed including hernias, foregut and bariatric. residents participated in 40% of cases. there were no differences in total operative and console times in cases with residents except bariatric procedures. there were 3 complications in this series; postoperative ileus, gallbladder fossa hematoma and an enterotomy. there was one early conversion to open in a complex foregut case and no deaths in this series.conclusions: we report our initial experience of robotics in a variety of general surgery and complex foregut cases. the implementation of a robotic surgery program and residency curriculum was safe with similar outcomes related to operative times and complications. as mis expands with the application of robotics in general surgery, residency curriculums will need to be revised. further data is needed to determine residency learning curves between robotics and laparoscopy.background: robotic surgery has made a large impact in the fields of urology and gynecology. its use is significantly increasing in the fields of general and bariatric surgery. evidence remains unclear as to the clinical impact on outcomes, and significant questions remain as to the impact of cost. our goal was to evaluate the economic impact of robotic surgeries in general and bariatric surgery at our institution. methods: this study is a retrospective analysis of minimally invasive general and bariatric procedures done at a single institution from january 2016 through june 2017. we performed a cost and reimbursement analysis of robotic versus conventional laparoscopic surgery. the cost evaluation included operative time, operating room costs, length of stay and overall hospital expenses. in addition, we looked at reimbursement and the contribution margin per cpt code. results: our study included a total of 1927 patients who underwent 1716 laparoscopic and 211 robot assisted general and bariatric surgeries. the average time duration for laparoscopic surgeries was 138 minutes vs 248 minutes for robot assisted. we performed a cost analysis which showed an average total cost of $8,955 for laparoscopic and an average of $15,319 for robot assisted. the total reimbursements were $19,631 for laparoscopic and $21,949 for robot assisted. this translated to an average contribution margin of $10,676 for laparoscopic vs $6,630 for robot assisted. for general surgery we found an average cost of laparoscopic $7,675 vs robot assisted $9,436, with a contribution margin of $7,761 laparoscopic vs $3,473 robot assisted. for bariatric surgeries we found an average contribution margin of $14,149 for laparoscopic vs $6,165 for robot assisted. conclusions: robotic surgery has been associated with higher costs and longer operative times. in this economic climate of increased cost awareness with institutions under increasing financial pressures, judicious use of resources becomes important when determining surgical approach. although cost of robot assisted surgery may decrease with time, other quality factors may be important in patient selection. although there is no clear evidence that institutions lose money with robot assisted surgery, in our experience the contribution margin is lower with robot assisted surgery as compared to conventional laparoscopy.introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for inguinal hernia repairs using the transabdominal preperitoneal approach. our series is the first experience in the field of general surgery utilizing this new robotic platform. methods: from march to september 2017, 76 inguinal hernia repairs in 64 patients were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node (figure 1 ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between 18 and 90 years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than 12 month and a bmi \ 40. a retrospective chart review was performed for a variety of pre-, peri-and postoperative data including but not limited to patient demographics, hernia characteristics, intraoperative and postoperative complications. results: 54 male and 10 female patients were included in the study. median age was 56.5 years (range 22-86 years), and median bmi was 25.9 (range 19.5-31.8 kg/m 2 ). median docking time was 7 minutes (range 2-21 minutes), and median operative time was 48 minutes (range 18-142 minutes). two cases were converted to standard laparoscopic surgery due to robot malfunction and intraoperative bleeding respectively. one patient developed a postop seroma that did not require any further intervention. conclusion: we report the first series of laparoscopic inguinal hernia repairs using the new senhance robotic system. compared to previously published conventional laparoscopic or robotic tapp hernia repairs these data suggest similar outcomes in operative time and perioperative complications. additionally there was no significant learning curve detected due to its intuitive applicability. therefor the senhance robotic system can be safely and easily used for tapp hernia repairs by experienced laparoscopic surgeons. this is a video presentation of 51 years old female, who presented with suprapubic pain and mass to gynecology office. she has a history of robotic hysterectomy and sbladder sling operation 4 years ago. this was complicated with peritonitis and long icu stay, due to what she was called ''bowel injury'' but treated only conservatively with antibiotics and subsequent abscess drainages at that time. she has occasional appearing nodule and pain at the left suprapubic region. ct ordered by gynecology read as abdominal wall hernia with long sigmoid diverticuli in hernia. also there was small amount of subcutaneous air at the tip of herniated diverticuli. after antibiotic treatment and improvement, colonoscopy shows, actually the diverticuli is the limb of the sling going through the simoid and anchored in subcutaneous fat on abdominal wall ahich represents clocutaneous fistula as gets infected. clip was placed on sling and repeat imaging comfirmed that the localion of this sling fits to location of so called ''hernia'' the sling limb was resected robotically and colon was repaired with side stapling of clolonic wall. the abdominal wall defect is repaired with long term absorbable suture. as far as we have found, the presentation and treatment of this complication is unique and could not find a similar case to guide us for the plan. background: robot-assisted surgery using da vinci surgical system (dvss) is thought to have many advantages over conventional laparoscopic surgery. it was reported that the use of the surgical robot might reduce surgery-related complications, then a multi-institutional historically controlled prospective cohort study on the feasibility, safety, effectiveness and economical efficiency of robotic gastrectomy (rg) for resectable gastric cancer was conducted in japan. this study evaluated the safety of rg using dvss xi. methods: this single-center, prospective phase ii study included patients with resectable gastric cancer (umin000019366). the primary endpoint was the incidence of post-operative complications greater than grade iii according to clavien-dindo classification during one month after surgery. the secondary endpoints included all adverse events and completion rate of robotic surgery. results: from oct 2015 to jan 2017, 22 patients were enrolled for this study. the incidence of post-operative complication greater than grade iii was 0%. the overall incidence of adverse events was 18.1% (grade i; 13.6%, grade ii; 4.5%). no patient required conversion to laparoscopic or open surgery; thus, the rg completion rate was 100%. conclusion: this study suggested the introduction of rg using dvss xi for gastric cancer seems to be safe and feasible. priscila r armijo, md 1 , dmitry oleynikov, md 1 , sages robotic task force* 2; 1 university of nebraska medical center, 2 sages robotic task force introduction: while robotic companies continue to aggressively market and promote the use of robots in general surgery, little is known about how this technology is employed by general surgeons, and what is expected of this technology from both novice and experts in the field. the aim of this study is to evaluate the needs of general surgeons who are new to robotic surgery and the needs of established robotic surgeons. methods: the sages robotic task force survey, a one-page survey, was designed and sent electronically to all sages members. questions regarding fellowship training, area of expertise, robotic simulation and in clinical case use, services offered in the current hospital, mentorship, likelihood of switching to a different approach, and expectations for the robot were included in the survey. two groups were created based on previous use of davinci® system in a clinical scenario, or not. statistical analysis was conducted using ibm spss v.23.0.0, using fischer's exact and pearson's chi-squared tests where appropriate. results: 201 sages members answered the survey. surprisingly, 157 respondents (78%) had used the davinci® in a clinical setting. among these, 122 (78%) had additional fellowship training, compared to 27 (63%) in the non-clinical use group, p=0.048. of all surgeons with additional fellowship training, the great majority (26%) had specialization in advanced gi, mis and bariatric surgery, followed by colorectal (10%). most surgeons are performing less than 10 cases per month using the robotic system, and with the majority of cases performed using the platform being hernia repairs (24%), followed by foregut-related procedures (20%). interestingly, from all the surgeons who replied the survey, only 11.3% are planning to switch from open procedures to its robot counterpart, whereas 38.1% are planning to adopt robotic-assisted procedures rather than laparoscopy. conclusions: the majority of sages members who responded to the survey have used the davinci® in a clinical setting in the past. surgeons who stated they perform mainly laparoscopic procedures were likely to continue to adopt robotic techniques, whereas those who perform open hernia repair for example were not very likely to switch to robotic approach. while the use of the robot may be enabling surgeons who used to perform mostly open procedures in the urology or gynecology fields, laparoscopic skills predict robotic utilization in general surgery. hernia and foregut appear to be the most common procedures that are being utilized.aim: while conventional multiport laparoscopic splenectomy has become gold standard for some hematological or splenic diseases, reduced-port laparoscopic splenectomy (rpls) including singleincision laparoscopic splenectomy (sils) is regarded as highly challenging. herein, we describe the technical refinements for safe rpls especially for patient with splenomegaly. methods: in all cases, access was achieved via a 2.5-cm mini-laparotomy at the umbilicus into which a sils tm port or e-z access ® with three 5-mm trocars was placed. a 5-mm flexible scope, an articulating grasper, and straight instruments were used. our rpls is characterized by the followings: a) early ligation of the splenic artery to shrink the spleen, b) application of our original "tug exposure technique," which provides good exposure of the splenic hilum by retracting (tugging) the spleen with a cloth tape, and c) safe introduction of stapler under the guidance with a flat drain into the splenic hilum. results: 27 rpls patients (12 men and 15 women, 43±19 years old) comprised hematological disorder (n=12), splenic disease (n=12), and liver cirrhosis (n=3). in 24 patients (89%), rpls was successfully completed: sils in 22 and sils plus one additional port only in 2 patients. conversion to open surgery was necessary in 3 patients including 1 liver cirrhosis with remarkable collateral varicose veins around the spleen. operation time and blood loss were 214±78 min and 166±312 g, respectively. weight of the extracted spleen was heavier than normal and 341±286 g (maximum 960 g). no intra-or postoperative complication occurred. the postoperative scar was nearly invisible. conclusions: rpls might safely be performed even for splenomegaly (up to 1,000 g). however, care should be taken for cirrhotic patient with collateral veins. rpls can be the procedure of choice even in the patients with splenomegaly and who are concerned about postoperative cosmesis. the aim of this feasibility study was to evaluate laparoscopic sn biopsy for laparoscopic snns in early gastric cancer patients. subjects and methods: this study includes 13 patients with ct1n0m0 (primary tumor \4 cm) gastric cancer who underwent laparoscopic sn biopsy in conjunction with radioisotope and dye methods between jan. 2010 and jul. 2011. first, we looked for green-dyed sns after injection of indocyanine green (icg) without near-infrared light system, and then tried to detect the radioactivity of sns using a hand-held gamma probe inserted through a small incision at the umbilical port. after the areas where sns were distributed were resected, a gastrectomy with prophylactic lymphadenectomy was performed according to the gastric cancer treatment guidelines of the japanese gastric cancer association. we looked for undetected sns in the resected specimen at the back table. results: among 13 cases, there were 11 (85%) in which sns were not detected in the resected specimen. there were 2 cases in whom sns were detected in the resected specimen. in both cases, the primary tumors were located in the middle and greater curvature of the stomach. in case 1, laparoscopic sn biopsy identified the left (4sb) and right (4d) greater-curvature lymph node (lns) as sns, however, lesser-curvature (3) and infrapyloric (6) lns remained as sns in the resected specimen. in case 2, the left (4sb) and right (4d) greater-curvature lns were identified as sns intraoperatively, while the lesser-curvature (3) ln remained as an sn in the resected specimen. the sns overlooked with laparoscopic sn biopsy method were detected by radioisotope only. no cases had ln metastasis, and the 5-year relapse-free survival rate of these 13 patients was 100%. conclusions: our feasibility study of laparoscopic sentinel node biopsy for early gastric cancer showed that we should search for sns of the lesser curvature carefully even if the primary lesion is located at the greater curvature. key: cord-006849-vgjz74ts authors: nan title: 27th international congress of the european association for endoscopic surgery (eaes) sevilla, spain, 12–15 june 2019 date: 2019-09-13 journal: surg endosc doi: 10.1007/s00464-019-07109-x sha: doc_id: 6849 cord_uid: vgjz74ts nan laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. bile duct injury (bdi) is a rare but very serious complication of the procedure, with a significant impact on quality of life and overall survival. the high frequency of bdi with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of bdi is misinterpretation of biliary anatomy. intraoperative cholangiography (ioc) has been advised by many authors as the technique reduces the risk of bdi. however, the procedure has inherent limitations and is therefore reserved for select cases. fluorescent cholangiography using indocyanine green(icg) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. a comparative study was contacted by administering icg intravenously or intrabiliary during the operation. forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups: in group a icg was administered in a dose 2.5 mg in 2 ml solution intravenously 1 hour before surgery. in group b icg was injected intrabiliary in a 0.025 mg/ml solution mixed with the patient's bile. also, we observed and analysed the following parameters, liver function, b.m.i, asa score and possible complications, before and after operation. results: group a. intravenous icg was administered in 20 patients. there was no any reaction and the extrahepatic biliary anatomy was identified well. there was no bdi or any complication related to the procedure. group b. icg was injected intrabiliary in 20 patients during the laparoscopic procedure. in all but one patient the extrahepatic biliary tree was delineated very well. in one patient part of icg solution was injected into the gallbladder wall and this resulted in a partially confusing image. there was no bdi and no postoperative complication conclusions: fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation orintravenous injection 1 h before the procedure. the later technique is more easy to perform and does not require catheterization of the biliary tree. endoscopia digestiva chirurgica, policlinico universitario ''a. gemelli'', rome, italy; 2 ihu, strasbourg, france; 3 camma group, icube, university of strasbourg, cnrs, ihu strasbourg, strasbourg, france; 4 ircad, strasbourg, france; 5 digestive and endocrine surgery, nouvel hopital civil, university of strasbourg, strasbourg, france; 6 digestive and endocrine surgery, ihu-strasbourg, strasbourg, france aim: surgical societies are united in promoting the critical view of safety(cvs) during laparoscopic cholecystectomy(lc). nonetheless, reports have shown a discrepancy between the operative reports and the correct application of cvs, which may explain the stability of bile duct injury rates. therefore, surgeons and computer scientists at our institution are developing a machine-learning algorithm to automatize cvs assessment. however, the lack of a consistent cvs video assessment framework limits the ability to generate data to train the artificial intelligence. here we describe and test a method for cvs evaluation in videos. method: between march and july 2016, 100 consecutive videos of lc performed at nouvel hospital civil(strasbourg, france) were recorded. two independent reviewers assessed the achievement of cvs in the 60 s video sequences preceding clipping of cystic duct and artery. in addition to the 'doublet view' method, a 'binary' video evaluation method was tested: each of the 3 criteria composing the cvs(2 structures entering the gallbladder, clearance of the hepatocystic triangle and lower part of the cystic plate) was classified as achieved or not. if the 3 criteria were met, then the cvs was considered achieved. inter-rater agreement for cvs and for each of the 3 criteria was evaluated. results: twenty-two videos(12 fundus first and 5 partial lc, and 5 broken videos) were excluded from the cvs analysis. cvs elements were assessable in all but one 60 s videos sequences(98.72%). after mediation, cvs was achieved in 32/78(41.03%) of lc. the cystic plate was identified in only 52.56% of videos. inter-rater agreement using the doublet view vs. the binary method was as follows: 83.33%(? = 0.54) vs. 88.46%(? = 0.75) for cvs achievement, 66.66%(? = 0.48) vs. 93.59%(? = 0.79) for the 2 structures, 65.38%(? = 0.45) vs. 82.05%(? = 0.62) for the hepatocystic triangle and 61.53%(? = 0.36) vs. 88.46%(? = 0.77) for the cystic plate ( fig. 1) . conclusions: reliable cvs assessment is crucial to generate consistent data for machine-learning algorithms aiming at decreasing bile duct injury after cholecystectomy. our binary cvs video assessment method showed higher inter-rater reliability than the doublet view, originally described for assessment of photos. further studies are on going to validate the cvs assessment in videos and support our initial results. surg endosc (2019) the vital role of surgeries in healthcare requires a constant attention for improvement. surgical process modeling is an innovative and rather recently introduced approach for tackling the issues in nowadays complex surgeries, involving complex logistics, much technology, and large teams. surgical process modeling allows for evaluating the introduction of new technologies and tools prior to the actual development and is beneficial in optimization of the treatment planning and treatment performance in operating room. in this study, we first discuss the concepts associated with surgical process modeling, aiming to clarify them and to promote their use in future studies. next, we apply these concepts to analyze the procedure of challenging interventions, minimally invasive liver treatment (milt) methods, with the ultimate goal of improving and optimizing the treatment procedure. the procedure model of current treatment activities and planning of various milt methods and the associated techniques, are analyzed and combined into a generic procedure model of milt, which provides a firm foundation for qualitative and quantitative analysis of different milt procedures. the generic procedure model is validated by data from erasmus medical center (rotterdam, the netherlands) and oslo university hospital (oslo, norway) . the proposed procedure model is designed to be a basis for improvement of the procedure and to determine how and where the new technologies can be best, effectively and efficiently, employed in the clinical practices prior to and/or during actual development of the new technologies for milt. as a conclusion, the current work illuminates the importance of surgical process modeling for improving different aspects of treatment procedures and provides an overview of various modeling strategies that can be used to establish surgical process models. the generic procedure model of various milt methods, including laparoscopic liver resection, laparoscopic liver ablation and percutaneous ablation, is introduced and validated which is a basis for introduction of the optimized procedure model of milt objective: to determine the most appropriate time to start total laparoscopic living donor right hepatectomy (tldrh) based on the experience with laparoscopic liver resection (llr). summary background data accumulation of experience in llr is essential before starting tldrh to ensure donor safety. methods: we retrospectively reviewed data of 567 and 78 consecutive patients who underwent llr and donor hepatectomy, respectively, between 2003 and 2017. operative outcomes of laparoscopic major hepatectomy (lmh) were compared between two periods based on tldrh introduction (phase i 2003 -2009 vs phase ii 2010 . learning curve of llr was evaluated using the cumulative sum (cusum) method to determine the optimal time of tldrh introduction. conclusion: accumulating an experience of at least 73 lmh cases is needed in low-volume lt centers before starting tldrh to ensure donor safety. introduction: the number of surgical adverse events is still too high. an important number of these adverse events occur within the operating room (or) and are in fact preventable. in order to reduce adverse events in the or, we simply need to know what went well and what can be done better. the aim of this study was to analyze and debrief a predefined selection of surgical procedures, with the use of an operating room 'black box', to identify commonly observed safety threats and resilience support events. methods: in the period 2017-2018, 35 predefined gastro-intestinal laparoscopic cases were recorded by the or black box'. the postoperative surgical team assessment record (star) questionnaire was used. the recordings were analyzed by specifically trained raters, using the systems engineering initiative for patient safety (seips) model of work system and patient safety to identify relevant safety threat and resilience support events. qualitative data analysis was used to identify the most commonly discussed events during the team debriefings. results: in only 26.5% (n = 65) of times or team members, when asked direct following surgery, indicated that they had noticed aberrations (n = 234) during the case. a mean number of 52.5 (sd 15.0) relevant positive and negative events (e.i. aberrations) per surgical procedure were identified using the black box performance report. on average, 11.5 (sd 4.2) of events identified by the black box were rated as safety threats. most events discussed during the team debriefings were related to communication. conclusion: these results once again highlighting the importance of clear and closed-loop communication in the operating room. theatre staff underestimated the number of aberrations occurring in the or, when asked to retrieve from memory. postoperative structured team debriefing may be important for resolving incorrect assumptions between operating team members to avoid future unnecessary miscommunication. background: the eaes has recently published an intraoperative adverse event classification to assist the direct measurement and routine reporting of minimal access surgery interventions. we aimed to explore the clinically validity and reliability of the classification. methods: a prospective evaluation utilising case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision surgery randomised controlled trial was performed (isrctn59485808). enacted adverse events identified with the observational clinical human reliability analysis technique were graded with the eaes classification by two blinded, independent assessors. test-retest reliability was explored using grades previously applied during the development of the classification with intraclass correlation co-efficients calculated. clinical validity was assessed using 30-day morbidity events, the clavien-dindo classification and the highest eaes grade per case. results: 77 laparoscopic cases (419 h of surgery) contained 1393 error events which were all successfully categorised. excellent inter-rater and test-retest reliability was seen (icc 0.957, 95% ci 0.952-0.961, p \ 0.001 and icc 0.893, 95% ci 0.88-0.904, p \ 0.001 respectively. 61% of patients experienced post-operative morbidity (median 1 event, range [0] [1] [2] [3] [4] [5] . labelling analysed cases by their highest eaes classification grade gave 53% grade 2, 43% grade 3 and 4% grade 4 procedures. 51% of grade 2 cases developed a morbidity event, but this significantly increased in grade 3 and 4 operations (70% and 100%, p = 0.043). the number of complications and highest recorded clavien-dindo grade increased with each additional grade (1.05 ± 1.3 vs. 1.48 ± 1.3 vs. 2.33 ± 0.6, p = 0.145 and median 1 vs. 2 vs. 3, p = 0.023 respectively). anastomotic leak and re-operation were correctly captured by the allocated eaes grade (2.5% vs. 3.3% vs. 100%, p \ 0.001 and 5% vs. 0% vs. 66%, p \ 0.001 respectively). there was a significant rise in length of stay observed with increasing eaes grade (median 6 vs. 7 vs. 61 days, p \ 0.001). conclusion: in the context of major laparoscopic surgery, the eaes intraoperative adverse classification is seen to be a clinically valid and reliable assessment method. psychological medicine, nuhs, singapore, singapore aims: neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop is not properly studied before and we planned to do this using functional near infrared spectroscopy (fnirs) which is a non-invasive optical brain imaging tool that measures cortical oxygenation change which is used as a marker of pre-frontal cortex activity (pfca). methods: this randomised controlled trial examined the pfc activity differences in two groups of novice medical students during the acquisition of 4 basic laparoscopic tasks. 'trained-group' had standerdised oneto-one training on the tasks, while the 'untrained-group' had no prior trainining and was just shown a video of the tasks. the pfca was measured pre and post intervention using a portable fnirs device. primary outcome was the difference in the pfca pre and post intervention. secondary outcomes were the differences in pfca between the 4 tasks and between the sexes. results: 16 trained and 16 untrained medical students with an equal sex distribution and a comparable age distribution were invovlved in the study. all students were right handed. trained group had a significantly attenuated pfca in the 'precision-cutting' (p = 0.011) and 'suture-insertion' (p = 0.025) tasks compared to the untrained group. subgroup analysis based on sex revealed significant attenuation in pfca in trained females compared to untrained females across 3 of the 4 laparoscopic tasks: 'pegstransfer' (p = 0.013), 'precision-cutting' (p = 0.034), 'suture-insertion' (p = 0.03). no significant pfca attenuation was found in male students who underwent training compared to untrained males. conclusion: a standardised laparoscopic training workshop promoted greater pfca attenuation in female medical students compared to males. this suggests that female and male students respond differently to the same instructional approach. these results may have implications for surgical training and education such as a greater focus on one to one surgical training for female students and use of pfca attenuation as a form of neurobiological feedback as a measure of learning curve in surgical training. robot assisted versus laparoscopic advanced suturing learning curve e. leijte 1 , i. de blaauw 2 , c. rosman 1 , s.m.b.i. botden 2 1 surgery, radboudumc, nijmegen, the netherlands; 2 pediatric surgery, radboudumc, nijmegen, the netherlands aims: compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills as minimally invasive suturing. this study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted advanced suturing method: novice participants, with the knowledge of basic surgical procedures, were recruited and performed three suturing tasks on the eosim laparoscopic augmented reality simulator or the robotix robot assisted virtual reality simulator. each participant performed an intracorporeal suturing, tilted plane needle transfer and anastomosis needle transfer task. to complete the learning curve, all tasks were repeated for maximal twenty repetitions or until a plateau was reached three consecutive times. clinical relevant and comparable parameters regarding time (seconds), movements and safety were recorded. intracorporeal suturing was used to visualize and compare the learning curves between the groups. results: forty-six participants completed the learning curve, of which 16 laparoscopically and 30 robot assisted. when comparing the suture time, the plateau was reached much faster in the robot assisted group (7-9 repetitions) than the laparoscopic group (10) (11) (12) repetitions) as shown in figure 1 . there was a significant difference in 'time per suture', during the whole learning curve with median values of 637 versus 251 (first knot), 450 versus 147 (fifth) and 186 and 115 (eighteenth), all with a p \ 0.05. however, the parameter 'adequate surgical knot' was reached earlier in the laparoscopic group than in the robot assisted group. first: 69% versus 60%, fifth: 100% versus 70%, and eighteenth: 100% versus 83%. when assessing the 'needle out of view' parameter, the robot assisted group scored a median of 0.3 and 0.0 s during the first, respectively eighteenth knot, and the laparoscopic participants had their instruments out of view for 41 and 17 s during the first respectively eighteenth knot. conclusion: the learning curve of minimally invasive suturing can be reduced with the use of robot assisted surgery, with a specific reduction in operation time. the rate of adequate knots seemed to remain lower in robot assisted surgery, although this could be due to the virtual reality aspect of the simulator. introduction: endoscopic sleeve gastroplasty (esg) is a novel promising bariatric endoscopy treatment. gastric volume reduction and delayed gastric emptying are the mechanisms driving weight loss. however, little is known about the factors influencing the effectiveness of weight loss overtime. the present study aims at evaluating the correlation between endoscopic suture appearance and excess weight loss (ewl%) at 6 and 12 months follow up. patients and methods: all patients who underwent follow-up endoscopy at 6 and 12 months after esg were included. esgs were classified in 3 groups according to endoscopic appearance of the gastric sutures: optimal (group 1) when all stitches were in place and tights; suboptimal (group 2) when one or more stiches were displaced; loose (group 3) when all the sutures were completely disrupted. bmi at enrollment and ewl% at 6 and 12 months were recorded and compared to the endoscopic appearance. results: a total of 53 patients were included in the analysis. at 6 months, 25 (47.2%) patients had an optimal esg, 24 (45.3%) had a suboptimal sleeve and 4 (7.5%) had complete sutures failure. bmi at enrollment and ewl% were respectively 37.7 ± 4.2 and 36.6 ± 21.3% for group 1, 43.6 ± 6.7 and 22.77 ± 18.7% for group 2 and 50.7 ± 14.4 and 7.8% ± 16.5% for group 3. twenty five patients had 12 months egds: 5(20%) presented an intact esg and were classified in group 1, 15 (60%) in group 2 and 5 (20%) in group 3. twelve months ewl% was respectively 47.6 ± 9.1%, 31.3 ± 29.3 and 12 ± 14.4%. initial bmi significantly correlated with suture status at both 6 (rho -0.528; p \ 0.001) and 12 months (rho -0.423; p = 0.035) follow-up. furthermore, the sutures' appearance itself correlated with ewl% at both time points (rho ?0.416; p = 0.002 and rho 0.439; p = 0.028 respectively). conclusion: our preliminary results show that the aspect of the endoscopic suture has a significantly impact on ewl% at 6 and 12 months after esg. furthermore, bmi at enrollment seems to predict endoscopic suture duration overtime. larger studies and longer follow-up are needed to further validate our preliminary findings. background and aim: endoscopic sleeve gastroplasty(esg) is a relatively novel endoscopic procedure that reduces the gastric lumen with proven less complications and less 6 months weight loss compared to laparoscopic sleeve gastroplasty (lsg) . at present there are no studies investigating the role of multidisciplinary approach in esg. the aims of the present study were to evaluate the role of multidisciplinary assessment(ma) prior esg, weight loss outcomes, quality of live improvements and adverse events. material and methods: from may 2016 to may 2018 all patients that underwent esg were retrospectively evaluated from a prospective database. until september 2017 before esg only psychiatric evaluation was requested, while after this date we adopted the guidelines of the italian society for obesity surgery and all patients were evaluated on a multidisciplinary fashion prior esg. the multidisciplinary team was composed by:gastroenterologist, surgeon, psychiatrist, endocrinologist and dietitian. patients were divided in two groups:group 1 were patients with esg before ma and group 2 were patients with esg after ma. we compared this two groups in terms of weight loss outcomes, quality of live improvements and adverse events. quality of live was measured with the bariatric analysis and reporting outcome system(baros).all procedures were done with the apollo overstitch suturing system(apollo endosurgery) and a double channel gastroscope olympus 2tgif-160(olympus japan).all procedures were done in general anesthesia and with insufflation of co2. all patients had ambulatory visit t 1, 3 and 6 months after esg and weight loss outcomes were measured in terms of excess weight loss (%ewl),the total body weight loss (%tbwl) and baros scale were assessed. statistical analysis was done with chi-square test and \ 0.05 value was considered significant. results: 31 patients were identified (20 female; mean age 45. 4, range 23-73) . mean bmi at inclusion was 41.6(range 31.6-62.4). mean %ewl and %tbwl at 6 months was 37.1 and 16.7 respectively (table 1) .non procedure related complications were observed. comparing the two groups there was significant(p \ 0.05) difference in terms of %ewl and %tbwl (table 2) ,with better results in group 2. there was also a significant improvement in the baros scale in the patients in group 2. conclusions: ma before esg has a fundamental role in terms of better procedure outcomes for both weight loss and quality of live in obese patients. 2 gastroenterology, hadassah medical center, jerusalem, israel, israel aims: the over-the-scope clip (ovesco) is a novel endoscopic tool that enables non-surgical management of gastrointestinal defects. the aim of this study was to report our experience with ovesco for patients with staple line leaks following laparoscopic sleeve gastrectomy (lsg). methods: a prospectively maintained irb-approved institutional database was queried for all patients treated with ovesco for staple line leaks following lsg from 2010 to 2018. primary outcome was complete resolution of leak following ovesco as defined by return to complete oral nutrition and no evidence of leak on imaging. secondary outcome was the number of additional endoscopic or surgical procedures needed following ovesco. results: twenty-five patients (12 males, 13 females) were treated with ovesco for staple line leaks following lsg. the median age was 35 years (range 18-62), and mean body mass index was 44 kg/m 2 . nine patients (35%) were referred from an outside hospital. the median time from index operation to leak diagnosis and from leak diagnosis to ovesco was 18 days (range 2-118), and 6 days (range 1-120), respectively. all patients had upper staple-line leaks near the gastroesophageal junction. initial treatment included antibiotics-6 patients; computed tomography guided drainage and antibiotics-7 patients; and laparoscopic drainage-12 patients. ovesco led to final resolution of leak in 8 patients (33%) within 70 days of clip deployment (range 41-136). leaks which persisted following ovesco were eventually resolved with a combination of ovesco and stent-5 patients (21%), total gastrectomy and esophago-jejunostomy-10 patients (42%), and endoscopic suturing-1 patient (4%). one mortality was noted in a patient who suffered multiorgan failure. the number of additional endoscopic sessions ranged from 1 to 10 (median 2). no procedure related complications were noted. all patients were treated with total parenteral nutrition and the total length of stay was 49 days (range 13-127). conclusions: despite its low success rate, ovesco should be part of the bariatric surgeon's non-surgical armamentarium in treating staple line leaks following lsg. r. bademci 1 , r. vilallonga 2 , p. alberti 2 , r. renato 2 , c. yuhamy 2 , s.s. cordero 2 , l. posadas 2 1 general surgery, istanbul medipol üniversitesi, istanbul, turkey; 2 bariatric surgery, vall d'hebron, barcelona, spain background: in cases of morbid obesity, treatment is generally applied as either a surgical or endoscopic approach. the number of primary obesity surgery endolumenal (pose) procedures is increasing but the reliability and effectiveness is unclear as yet. the aim of this study was to present a series of cases that required revision surgery due to pose failure and to reveal possible alternative surgeries. materials and methods: a retrospective comparison was made of the data of obese patients with pose failure and conversion to surgical procedures between 2016 and 2018 in respect of operation, medical illness and bmi results. results: the patients comprised 60% females, 40% males with a mean age of 44.8 ± 12.4 years and mean follow-up period of 12.6 ± 8.3 months. on average, patients lost 24.1 ± 8.9 kg, with an average excess weight loss of 47.6%. conclusion: no firm conclusions can be drawn from such a small group. although sg seems to be a safe procedure and should be considered as the first technique to be applied following pose failure, it is possible to perform gastric bypass on patients with this endoscopic precursor. introduction: the population of post bariatric surgery patients is rapidly increasing worldwide. due to the altered anatomy post roux-en-y gastric bypass (rygb), conventional endoscopic management for choledocholithiasis is challenging. these patients are now commonly managed by means of a laparoscopic assisted ercp. although effective, this requires significant resource utilization and potential morbidity related to the need for surgical intervention. we present our preliminary experience with a purely percutaneous management of choledocholithiasis in bariatric patients post-rygb. methods: a retrospective single center review identified five patients with choledocholithiasis after bariatric rygb who underwent percutaneous cbd access and treatment by interventional radiology. four patients underwent percutaneous transhepatic cbd access while one patient underwent percutaneous trans-cholecystic cbd access. in three of the five patients conscious sedation alone was sufficient to perform the procedure. results: all patients had radiologically confirmed choledocholithiasis and were clinically symptomatic prior to intervention. the biliary tree was successfully accessed percutaneously and cleared in all five patients. in the four patients where a percutaneous transhepatic access was utilized, three patients required only fluoroscopic balloon sphincterplasty and sweep of the cbd to clear the ductal stones, while the fourth required percutaneous cholangioscopy assisted lithotripsy for clearance. in the fifth patient with non-dilated intrahepatic bile ducts a trans-cholecystistic approach into the cbd was utilized with percutaneous cholangioscopic assistance to clear the ductal stones. all procedures were completed successfully with no post procedure complications. conclusion: percutaneous clearance of cbd stones in bariatric patients presents a minimally invasive alternative to current surgical practice. the use of conscious sedation and the purely percutaneous approach may potentially reduce morbidity and resource utilization for this increasingly common clinical scenario. laparoscopic narbona-arnau procedure to control the gerd after lsg-3 years results of a prospective study i.c. hutopila, c. copaescu background: after the laparoscopic sleeve gastrectomy (lsg) alone or associated with calibration of the esophageal hiatus, for some patients the reflux symptoms worsen postoperatively due to development of a hiatal hernia (hh) or due to the recurrence of the hh previously repaired. for these situations, when the conservative treatment fails, are proposed some surgical solutions, one of them cardiopexy with teres ligament-narbona arnau. objective: is to establish a standardized laparoscopic technique for cardiopexy using the teres ligament (narbona arnau technique) and to analyze the procedure's outcomes. methods: the study was performed in a bariatric and metabolic center of excellence-ponderas academic hospital. all the patients undergoing narbona arnau procedure to control gerd after lsg since 2014 were included and prospectively analyzed. the selection criteria included lsg patients, presenting hh and symptomatic gerd. preoperative investigations were upper gastrointestinal endoscopy, radiological contrast study, ph-metry, computed tomography with oral contrast. results: 28 patients were included into the study. gerd and hh were preoperatively documented in all the cases. one patient was excluded after 2 years of follow up after being converted to a laparoscopic roux-en-y gastric bypass, for intense relux symptoms. no incidents during surgery. for 8 cases laparoscopic narbona arnau technique was performed concurrent with re-sleeve gastrectomy and gastric curvature plication. without postoperative complications. postoperative follow-up at 6 months, 1, 2 and 3 years, the percentage of patients without gerd symptoms and free of treatment with ppis was 64,28%, 82,14%, 71,42%, respectively 66.66%. at 3 years postoperatively the upper gi endoscopy showed remission/ improvement of the degree of esophagitis for 17 patients. for the same period of follow-up, the ph-metry highlighted a normal value of demeester score for 62.96% o patients (all the patients had preoperatively high de meester scores). no objective signs of hiatal hernia recurrence at imagistic investigations and upper gastrointestinal endoscopy were encountered. conclusions: complete preoperative evaluation is mandatory for choosing the optimal intervention. laparoscopic narbona arnau technique after lsg is proved to be a good option for the treatment of symptomic gerd, but further studies with high-volume patients are necessary. introduction: the aim of this study was to investigate the influence of baseline glycated hemoglobin level (hba1c) level in bariatric patients on postoperative outcomes. we found scarce of clinical data regarding influence of baseline hba1c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study. methods and procedures: retrospective cohort study analyzed patients who underwent laparoscopic: sleeve gastrectomy (sg), roux-en-y gastric bypass (rygb) or mini-gastric bypass (mgb) for morbid obesity in seven referral bariatric centers. patients were divided into groups depending on preoperative hba 1c : hba 1c \ 5.7%; 5.7-6.4% and c 6.5%. primary endpoints: influence of hba 1c level on perioperative (30-days) and postoperative (12-months) morbidity rates, operation time, length of hospital stay (los) and readmission rate. results: study group included 2125, 68% females and 32% males. median age was 43 (35-52) years. median hba1c was 5.7 (5.3-6.1). hba1c \ 5.7% was present in 49% patients, hba1c5.7-6.4% in 35%, and hba1c c 6.5% in 16%. percentage of male patients increased in groups from 26% in hba 1c \ 5.7% to 47% in hba 1c c 6.5% significantly. same tendency through groups we observed in case of bmi and age. uncontrolled diabetes (hba 1c c 6.5%) was present in 8.7% patients, while 7.62% patients were not on antidiabetic medications despite having hba 1c c 6.5%. median operative time in patients was significantly longer than in hba1c \ 5.7% and hba1c 5.7-6.4%. 30-days morbidity rate was 5.27% and did not differ groups significantly, as 12-months morbidity rate (excl. 30-days) of 2.02% . los did not differ groups significantly. patients having hba1c in range of 5.7-6.4% and with hba1c c 6.5% did not have significantly increased odds for perioperative morbidity, 12-months postoperative morbidity as compared with those with hba1c \ 5.7%. patients with hba1c c 6.5% had increased or for prolonged los as compared to those with hba1c \ 5.7% (or 1.45; 95% ci 1.07-1.97). hba1c did not influence or for readmissions. patients with baseline hba 1c c 8% had significantly increased chances for hospital readmission (or 3.53, 95% ci 1.35-9.21). conclusion: baseline level of hba1c did not influence chance for perioperative morbidity, 12-months postoperative morbidity and prolonged los. patients with hba1c c 8% have increased chance for hospital readmissions. surg endosc (2019) 33:s485-s781 introduction: surgical resection is crucial for curative treatment of rectal cancer. through improvements in treatment and minimally invasive techniques, 5-year survival improved to over 60% of patients. the most recently introduced surgical technique is robotic-assisted surgery (ras). ras and conventional laparoscopy (cl) seem equally effective in terms oncological control. however, ras possibly provides further advantages e.g. 3d vision or the endowrist function, which have the potential to maximize the precision of surgery and thus has benefits for functional outcomes such as sexual function as well continence. therefore, the aim of this systematic review and meta-analysis was to compare functional outcomes of cl and ras for rectal cancer. materials and methods: this review was done according to the prisma and amstar guidelines andregistered with prosper-o(crd42018104519). the search was planned with the pico criteria and conducted on medline (via pubmed), web of science and central. two independent reviewers first screened titles and abstracts and then eligible full-texts. inclusion criteria were original studies, comparative studies for cl vs. ras for rectal cancer as well as reporting of functional outcomes. quality assessment was done with the newcastle-ottawa-scale for non-randomized studies and the cochrane tool to assess risk of bias for randomized trials. results: the search retrieved 9603 hits, of which 51 studies with 26225 patients met inclusion criteria. preliminary results yielded a lower rate of urinary retention for ras (odds ratio (or)[95%-confidence interval (ci)] 0.64 [0.45, 0.91] ) while there were no differences for ileus (or[ci]: 0.90 [0.77, 1.04] ). erectile function (iief) showed no differences after 3 (mean difference (md)[ci] 0.80 [-1.63, 3.21] , 6 (md[ci] 1.60 [-0.69, 3.89] ) and 12 months (md[ci] 1.11 [-1.70, 3.93] ). in terms of urinary problems (ipss) there were no differences 3 postoperative (md[ci] -0.96 [-2.16, 0. 23]) and 6 month postoperative md[ci] -0.92 [-1.96, 0.11] ), but advantages for the cl group after 12 months md[ci] -1.05 [-1.89, -0.21] ). discussion: ras and cl seem to provide similar functional outcomes after rectal cancer surgery. however, the results need to be interpreted carefully as none of the studies had any functional outcome defined as primary endpoint. future studies should evaluate both surgical approaches in terms of functional outcomes and should be appropriately powered. methods: from april 2014 to november 2018, 252 laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with 72 patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm 3-0 (covidien), second layer using a running suture in pds tm .intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was 121.5 min vs 140.7 min in the hybrid group (p = 0.02). anastomotic leak occurred in 5 (6.7%) patients in the hybrid vs 2 (2.7%) patients in the barbed group (p = 0.24) all patients required a reoperation. intraoperative findings at shows in 2 (0.4%) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to non-infectious complications between the two groups (p = 0.55). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = 0.03). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. conclusion: our results shows that the use of knotless barbed suture for enterotomy closure after laparoscopic intracorporeal right colectomy is safe, reproducible and associated with shorter operative time. aims: the accurate measurement and staging of rectal cancer, in particular the distal margin of low rectal tumours, is of paramount importance to optimise oncological surgical resection whilst preserving function. it is well recognised that the lower the tumour, the greater the technical challenges, operative time and the possibility of a temporary or permanent stoma. accurate localisation of the tumour is also essential to assist the multi-disciplinary team when considering neo-adjuvant chemoradiotherapy (crtx). the objective was to compare tumour height as reported on magnetic resonance imaging (mri) with endoscopic measurement. methods: a retrospective analysis of rectal tumour heights on pre-operative endoscopy and mri in patients undergoing radical colorectal surgery with curative intent over 3 years from january 2015. rectal tumours were identified as within 15 cm of the anal verge (av). all mri measurements were reported by one of two specialist gastrointestinal radiologists. measurements were taken from the lowermost point of the tumour to the av. endoscopic measurements were as recorded by 11 endoscopists including 2 rectal surgeons, 4 general surgeons, 4 gastroenterologists and a clinical nurse specialist endoscopist. results: records of eighty one patients with histologically confirmed rectal adenocarcinoma were reviewed. median age was 64 years (35 to 93). twenty three patients had 2 or more endoscopies. on mri the median tumour height from the av was 10.75 cm (3.5-18 cm) . on endoscopy the median tumour height was 23 cm (1-45 cm) . on comparing endoscopy with mri, the median difference was 12 cm (0-24 cm) . for over a third of patients (36%) tumours were lower on mri than endoscopy, median difference 12.25 cm (0.5-24 cm) . only rectal surgeons documented tumour height in relation to the rectal folds. the majority of the repeat endoscopies were performed by surgeons to locate tumours more accurately pre-surgery. on no occasion was it documented whether the tumour had been measured during insertion or withdrawal of the endoscope. conclusions: precise localisation of rectal tumours is imperative to plan complex surgery and give informed counsel to patients. this study demonstrates the urgent need for a standardised protocol for all endoscopists to use while recording the distal extent of rectal tumours. objectives: the aim of the present rct was to compare the incidence of genitourinary (gu) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (lar ? tme) with high or low ligation (ll) of the inferior mesenteric artery (ima). secondary aims included the incidence of anastomotic leakage and oncological outcomes. background: the criterion standard surgical approach for rectal cancer is lar ? tme. the level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on gu function is poorly understood. methods: between june 2014 and december 2016, patients who underwent elective laparoscopic lar ? tme in 6 italian nonacademic hospitals were randomized to high ligation (hl) or ll of ima after meeting the inclusion criteria. gu function was evaluated using a standardized survey and uroflowmetric examination. the trial was registered under the clinicaltrials.gov identifier nct02153801. results: a total of 214 patients were randomized to hl (n 111) or ll (n 103). gu function was impaired in both groups after surgery. ll group reported better continence and less obstructive urinary symptoms and improved quality of life at 9 months postoperative. sexual function was better in the ll group compared to hl group at 9 months. urinated volume, maximum urinary flow, and flow time were significantly (p \ 0.05) in favour of the ll group at 1 and 9 months from surgery. ultrasound measured post void residual volume and average urinary flow were significantly (p \ 0.05) better in the ll group at 9 months postoperatively. time of flow worsened in both groups at 9 months compared to baseline. there was no difference in anastomotic leak rate (8.1% hl vs 6.7% ll). there were no differences in terms of blood loss, surgica l times, postoperative complications, and initial oncological outcomes between groups. conclusions: ll of the ima in lar ? tme results in better gu function preservation without affecting initial oncological outcomes. hl does not seem to increase the anastomotic leak rate. introduction: robotic single-site cholecystectomy (rssc) has been known to have some advantages such as reducing stress of the surgeon compared to single incision laparoscopic cholecystectomy (silc). however, there are few studies comparing the perioperative outcomes of these two operative methods. patient and methods: between march 2014 and february 2018, 145 rssc and 268 silc were performed for benign gallbladder disease in our center. propensity score matching was performed to control variables including sex, age, body mass indes (bmi), diagnosis, american society of anesthesiologist (asa) score and 145 cohorts were selected among the silc group through 1:1 matching. the perioperative data of these 290 patients were analyzed retrospectively. the diagnosis was classified into acute cholecystitis, chronic cholecystitis, and gallbladder polyp. results: patient demographics between the two groups were evenly matched. total operation time including docking time was slightly longer in rssc group (48.1 min vs. 42.6 min, p \ 0.001), but real working time except the docking or set-up was shorter in rssc group (19.2 min vs. 23.5 min, p \ 0.001). conversion to additional robotic arm or additional port was frequent in silc group (0 vs. 5 cases, p = 0.03). intraoperative bile spillage rate (13.8% vs. 11.7%, p = 0.725) and postoperative hospital stay (1.8 days vs. 1.7 days, p = 0.091) were comparable in both group. conclusion: both surgical procedures performed safely. but the rssc demonstrated the better performance of the operation with shorter working time and the advantage of overcoming unexpected difficulties during the surgery with low conversion rate compared to silc. even though laparoscopic cholecystectomy(lc) is the gold standard procedure for cholelithiasis, patients are still suffering from various causes of pain. one of main causes is high pressure by pneumoperitoneum which makes peritoneal stretching and diaphragmatic irritation. however, there are few well-designed studies for evaluating pneumoperitoneum. therefore, we conducted a study to compare the postoperative pain after lc at serial different pressure methods. a prospective randomised double blind study was done in 147 patients with benign gallbladder disease. they were divided into 3 groups. each 49 patients underwent lc with different pneumoperitoneum method; group a: far-low (6-8 mmhg), goup b: low (9-11 mmhg) and group c: standard pressure (12-14 mmhg). three groups were compared for pain intensity, duration, analgesic requirement and complications. post-operative pain score was significantly least in far-low pressure group as compared to low or standard pressure group during late periods (12, 24 h). but, there were no pain score difference between far-low and low groups during early period (1, 2, 4, 8 h) even though scores of standard group were significant higher than those of low group. number of patients requiring rescue analgesic doses and intraoperative complications were not significantly different among 3 groups. this study demonstrates reducing the pressure of pneumoperitoneum results in reduction in intensity of post-operative pain. this study also shows that low pressure technique is safe with comparable rate of intraoperative complications. however, in immediate postoperative period, there is limitaton of pain relief after low pressure surgery. therefore, there may need new alternatives for pain. background and aim: anatomical hepatectomy with the glissonian approach is widely accepted as an important technique to ensure surgical safety and curability of the carcinoma. however, the histomorphological structure of the hepatic connective tissue is not sufficiently understood by surgeons. this study aimed to clarify the hepatic connective tissue structure using modern tissue imaging and analytical techniques. materials and methods: in total 5000 stained thin slices were loaded onto the computer and were reconstructed as 3dimages and analyzed. results: when the liver capsule enters the liver at the hepatic hilum, it becomes a sheath which envelops the portal pedicle. the hepatocytes in a row that constitute the periportal limiting plate at the edge of the hepatic lobule are firmly supported by the framework of the reticular fiber. the hepatic lobule and the portal area are in contact via the periportal space of mall. the framework of the limiting plate plays a role of a capsule of hepatic lobule (proper hepatic capsule) on the side in contact with the portal area. the binding site between the hepatic capsule and proper hepatic capsule (ppbs) is loose binding and is a layer that is easy to apply to surgical procedures. in order to enter between the liver capsule which became the sheath of the portal pedicle and the proper hepatic capsule at the hepatic hilum, the liver capsule must be dissected to reach the surface of the proper hepatic capsule. then, on the one hand, the portal pedicle is firmly gripped and pulled, on the other hand, the hepatic parenchyma covered by the proper hepatic capsule is pushed to expand between the portal pedicle and the liver parenchyma. at this time, the portal area (glisson's sheath) branched from the sheath of the portal pedicle into the gap of the hepatic lobule breaks like a string. with this dissecting plane, dissecting layer can reach to the next branch of the portal pedicle without entering into the portal pedicle or liver parenchyma. conclusion: understanding the connective tissue constituting the liver and conducting surgery turns the laparoscopic systematic hepatectomy into a standardized procedure. background: postoperative pancreatic fistula (popf) is the primary contributor to morbidity after distal pancreatectomy (dp). to date, no techniques used for the transection and closure of the pancreatic stump showed a clear superiority over the others. this study aimed to compare the rate of popf after pancreatic transection conducted with the reinforced stapler (rs) and ultrasonic dissector (ud) following dp. method: consecutive patients underwent dp from 2014 to 2017 were retrospectively reviewed. we included dps where pancreatic transection was performed by rs or ud and excluded dps extended to the pancreas head. to overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for popf. results: overall, 200 patients met the inclusion criteria. the rs was employed in 108 patients and ud in 92 cases. after the one-to-one propensity matching, 92 patients were selected from each group. the matched rs and ud cohort have no differences in baselines characteristics except for the mini-invasive approach, that was more common in the ud group (34% vs. 51%, p = 0.025). overall, 48 patients (26%) developed a popf, 46 a grade b (25%) and 2 (1%) a grade c. in the rs group the rate of popf was 12% (n = 11) and the ud group 38% (n = 35) with a p \ 0.001. conclusion: the results of this study suggest that the use of rs for pancreatic transection, reduces the risk of postoperative pancreatic fistula. a randomized trial is needed to confirm these preliminary data. aim: this study compares clinical and cost outcomes of robot-assisted single port and open longitudinal pancreaticojejunostomy (rlpj and olpj) for chronic pancreatitis. single incision mis needs more manual skills than conventional multiport operation. the advantage of better operation course is 3d vision and dedicate instrument. this paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for chronic pancreatitis. materials and methods: clinical and cost data were retrospectively compared between open and ralpj. we collected 21 patients since july, 2015 to september, 2018. the patient was supinely placed in reverse trendelenburg position. the assistant surgeon was located between patient's legs. under general anesthesia a trans-umbilical 4.0 cm skin incision was made. a single incision advanced access platform with lagis port, glove portò (nelis, s. korea) and gelpoint combined with the da vinci si and xi surgical system (intuitive surgical, sunnyvale, ca, usa) pure or plus one was performed. the three arms, no. 1, no. 2, and da vinci scope, were in dwelled through the glove portò. pneumoperitoneum of 12 mmhg was established through the port. a rigid 30-degree up scope was used during operation. results: twenty-one patients underwent lpj: 5 open and 16 ralpj. no robot-assisted cases converted to open were noted. patients undergoing ralpj had less intraoperative blood loss, a shorter surgical length of stay, less postoperative pain and lower medication costs. operation supply cost was higher in the ralpj group. no obvious difference in hospitalization cost was found. conclusions: versus the open approach, ralpj performed for chronic pancreatitis shortens hospitalization, less postoperative pain and reduces medication costs; hospitalization costs are equivalent. a higher operative cost for ralpj is mitigated by a shorter hospitalization and less pain control. robotassisted puestow procedure using single port platform is feasible and safe method. the total procedures by da vinci robotic system are safe and easily performed in highly selected patients. 2 general surgery, hospital universitario infanta sofia, madrid, spain; 3 general surgery, hospìtal quirón la luz, madrid, spain aims: the concomitant presence of abdominal wall midline hernias and diastasis recti is frequent. diastasis recti might be a risk factor not only for having but for recurrence of midline hernias. most open surgical procedures not consider the treatment of both pathologies, nor laparoscopic most spread out approaches. the author presents a novel endoscopic, extraperitoneal and retromuscular hernioplasty technique and its preliminary results. methods: a serie of 15 patients is presented. a ct abdominal wall study is performed preoperatively. they all presented abdominal wall midline hernias in presence of a [ 3.5 cm concomitant diastasis recti. there were 8 females and 8 males. a totally endoscopic, extraperitoneal and retromuscular repair was performed, that included a midline anatomic restoration, tension-free hernia gap closure, omphaloplasty and skin treatment, if needed in every case. the tension-free massive-meshed hernioplasty included a bilateral totally endoscopic posterior components separation when needed. no drainages were used. all procedures included a bladder catheterization. results: all patient were dispatched within a period under 48 h. no reoperations were needed in postoperative period. postoperative pain was measured by an eva scale. 85% of the patients have no pain medication after 24-48 h dispatching from hospital. 25% of the patients have a skin suffusion or hematoma. a male patient presented a temporary abdominal asymmetry due to a unilateral posterior component added to his technique. the mean following-up is to 6 months (1-12 months) . no recurrence was observed. conclusions: preliminary results demonstrate this new approach to be a safe, feasible and a reproductible procedure. the 'terra' novel technique could provide of a new minimally invasive approach to abdominal wall midline hernias repair in the presence of a diastasis recti. only time and new results can predict the spreading out of this 'third way'. results: this study comprised 15 males and 12 females. mean age was 62 years (range 33-82 years) and mean body mass index was 30. gh and mh were found intraoperatively in 22 and 5 cases respectively. mean operative time for all hernias (gh/mh) was 122 min (range 70-240 min); 113 min for gh (range 70-155 min); and 169 min for mh (range 105-240 min). in 51.8% of cases, hernia operative measurement was larger than preoperative size, especially in cases of incisional hernias (64.2%). in 29.6% of cases, laparoscopy found additional abdominal wall defects previously undetected by physical examination and by us-and/or ct-scan. a composite mesh and a non-composite mesh (up to 30 cm in size) were used in 96.3% and 3.7% of cases respectively. the ethicon securestrap?? absorbable fixation device straps for sm fixation were employed in 77.8% of cases. mean length of hospital stay was 2.8 days. mean follow-up time was 33 months (range 1-109 months). in our study, there was one early (\ 30 days) postoperative seroma (3.7%), plus one late, small (2 cm) symptomless recurrence, but neither needed reoperation. conclusion: the sutureless sm technique facilitates intra-abdominal introduction, as well as the handling and fixation of large/very large meshes. this new approach is safe and fast, even in cases of gh/mh repair. aims: any ventral hernia (vh) combined with rectus muscle separation (rms) must be repaired along with repairing the rms, otherwise there is a high risk for hernia recurrence. open rms repair is vast and traumatic surgery and laparoscopy is not effective. at 2015 a new era of repairing abdominal wall hernia by assisted endoscopy started with wolfgang reinhold's milos procedure. these procedures are somewhat complexed and real reconstruction of the linea alba (la) was limited, which done better by ferdinand koeckerling's elar technique. we perfected the elar technique to be fully endoscopic with wide mesh fusing to the muscles immediately by fibrin glue: extended endoscopic hernia & linea alba reconstruction glue (eehlarglue), achieving a low traumatic mis for vh and rms with excellent surgical and cosmetic results. methods: our eehlarglue is a totally endoscopic based technique used since 2017. penetrating with optiview trocar and co2 pressure to the anterior rectus sheet (ars) level is followed by an extensive endoscopic dissection of the sub-cutaneous fat tissue from the ars. three trocars are inserted at the supra-pubic line enabling the dissection up to the xiphoid and costal margins laterally. any hernia sac is dissected, and the content reduced back to the abdominal cavity. relaxing incisions of the ars are performed longitudinally in the lateral aspect. the la is reconstructed by running two layers of non-absorbable sutures from xiphoid to pubis. a light mesh 30x15 cm is applied over the repair and the mesh is fused immediately to the muscles by fibrin glue. results: 25 patients underwent the eehlarglue with follow up of 24 months. all had significant rms of 5-10 9 14-26 cm combined with primary or recurrent vh. recovery was smooth with 1-3 days of simple analgesics and return to regular activity within 4-10 days. no one had recurrent vh, but two males had limited rms and two early cases seroma formation. conclusions: our eehlarglue enables endoscopic vh repair and la reconstruction with extrastrength received by immediate mesh fusion to muscles with fibrin glue. thus, achieving low traumatic mis, easy recovering and very effective results-a perfect solution for patients with vh combined with rms. results: twelve blinded prospective rcts were used. when compared to tep repair, tapp repair has comparable seroma formation rates (chi 2 = 7.94; (p = 0.02); ci -4.31, 0.55; i 2 = 75%) and post-op pain at 24 h (chi 2 = 30.28; (p = 0.00001); ci -0.31, 0.06; i 2 = 87%). however, tep repair is associated with a significantly shorter operative time (chi 2 = 502.95; (p = 0.00001);ci 0.24, 0.48; i 2 = 98%), post-op pain at 1 hour (chi 2 = 11.26; (p = 0.004); 0.05, 0.30; i 2 = 82%) and shorter hospital stay (chi 2 = 455.14; (p = 0.00001); ci 0.72, 1.07; i 2 = 99%). conclusion: tep is significantly better than tapp repair with regards to operative time, post-op pain at 1 h and hospital stay. there is no significant difference with regards to post-op pain at 24 h and seroma formation. background: primary hyperhidrosis (ph) is a neurological condition characterized by excessive sweating most often of the face, palms or axillae . palmar hyperhidrosis is treated through sympathetic chain clipping or transection .we aiming to compare the efficacy and results obtained with both techniques. patients and methods: sixty four patients underwent of 128 sympathetic procedures from march 2013 to february 2017. the patients were categorized into two groups: right sided transection sympathectomy and left sided clipping . patients were evaluated to compare the rates of success, satisfaction, compensatory sweating and recurrence either with transection or clipping of the t3 andt4 ganglion .mean follow up was 15 ? _7 months. results: sixty four patients 24 males and 40 females undergoing electro-coagulation sympathectomy on the right side and clipping on the left side. with mean age was 15 years (range 13 to 18 years). all patients had balanced demographic data . no statistical difference between the two groups according rate of success. compensatory sweating was observed in 28 patients (43.75%) overall with 4 cases of severe unsatisfied compensatory sweating. recurrence was reported in one case with transection and 2 cases in clipping. satisfaction was occurred in 63 cases in transection group and 61 cases in clipping group .pnumothorax was occurred in 2 cases in transection group compared to one case in clipping. no gustatory sweating and over dryness were reported in both groups. conclusion: both thoracoscopic sympathetic transection and clipping of t3t4 ganglion are safe and effective procedure in palmar hyperhidosis treatment. with no differences regarding recurrence rate,satisfaction and incidence compensatory sweating. keywords: thoracoscopic sympathectomy,palmar hyperhidrosis, clipping, compensatory hyperhidrosis. introduction: primary ventral hernias and ventral incisional hernias pose a challenge for surgeons throughout the ages. even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardized method that adequately decreases postoperative complications. hybrid hernia repair is a surgical repair, which has not been adopted widely. it combines both a laparoscopic and open component allowing sac excision, primary defect repair as well as laparoscopic mesh insertion. aims: to evaluate the short-term and long-term outcomes of hernia recurrence for patients undergoing hybrid ventral repair (hvr) for the treatment of primary and incisional ventral hernias. methods: between october-2012 and june-2013, hybrid vhr was performed in 24-patients at st mary's hospital, imperial college london. the medical records of these patients were reviewed retrospectively for demographics, comorbidities, prior surgeries, body mass index (bmi), hernial defects, hybrid technique used; mesh selection, operative time, complications and recurrences over a 5-year follow-up. results: twenty-four patients who underwent hybrid vhr were included with surgery performed by two surgeons. the mean age is 48-years with a mean bmi of 33.1 kg/m 2 . 88% had incisional hernias and 12% had primary hernias. the number of hernia defects ranged from 1 to 4, with the average mesh size used was 15x17 cm. extensive adhesionolysis was performed in 58% of patients. 30-day postoperative complications; 2 patients developed post-operative seroma, paralytic ileus in 1, pain control in 1 and urinary retention in 1 patient. there were no conversions to open procedures. the mean length of hospital stay was 2-days. none of the patients developed chronic pain and only one recurrence over the 5-year follow-up period. conclusions: the hybrid technique for vhr is safe and feasible, and has important benefits over an open or purely laparoscopic approach, including a low rate of seroma formation, chronic pain and fiveyear hernia recurrence. future investigation may include randomized controlled trials, to fully evaluate the benefits of hybrid vhr, with careful assessment of patient-centred end-points including quality of life and postoperative pain. surgery, medical faculty-university of tetove, tetove, macedonia; 2 general medicine, medical faculty-university of tetove, tetove, macedonia; 3 anestesiology, medical faculty-university of tetove, tetove, macedonia; 4 surgery, clinical hospital-tetove, tetove, macedonia laparoscopic cholecystectomy is widely used operative technique and it's characterized with less postoperative hospitalization and side effects. duration of the hospitalization after laparoscopic surgery depends on several factors of which pain and physical weakness are the most important. dexamethasone is well known; not only for its anti inflammatory effects but at the same time for analgesic and antiemetic effects, although the mechanism of this effects are not clarified yet. objectives: the aim of our study is the evaluation of analgesic effect of dexamethasone on reducing postoperative pain after laparoscopic surgery. patients and methods: in this study, 200 patients aged 25 -74 years old undergoing laparoscopic surgery, were classified into two groups, 100 patients in each group. the first group were treated with a intravenous injection of 8 mg dexamethasone preoperatively and another dose the next day after operation. the second group received a intravenous injection of normal saline. we evaluated the dose of consumed analgesics and antiemetic's drug during the first 24 h in both groups. results: according to our experience results the total dose of tramadol in a postoperative period in dexamethasone receiving group was smaller than in normal saline group. measure of postoperative pain was assessed using the paper-based vas scale. our result shows that the intensity of post operative pain in a period during first 36 h, after surgery in a group of patients treated with dexamethasone was lower compared with the group of patients treated with normal saline. nausea and vomiting during the first 36 h was significantly lower in the dexamethasone group than in the normal saline group. 2 surgery, hospital quiron sagrado corazon, sevilla, spain; 3 surgery, hospital virgen macarena, sevilla, spain; 4 surgery, hospital virgen del rocio sevilla, sevilla, spain aims: closing the defect (cd) during laparoscopic ventral hernia repair (lvhr) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional lvhr. but tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a component separation (cs) for restoring the midline in medium-large defects.we have developed a new technique for restoring the midline in medium ventral hernias (lira technique) and weanalyzed our results in terms of pain and recurrence compared to our conventional cd series (ccd). methods: we conducted a prospective controlled study of lvhr with ccd from january 2014 to december 2016 and a prospective controlled study performing lira technique from january 2015 to january 2017. we analyzed and compared both techniques in medium size defects (4-8 cms) in terms of postoperative pain (1, 7 days, 1, 3 months and 1 year) using a visual analogue scale (vas), bulging (return to prior distance among rectus muscles with the mesh in the sac in ct that didn't need surgical treatment)and recurrence (by physical examination and tomography). results: ccd was performed in 42 patients (mean age was 58.10 ± 13.15 years old and mean bmi was 33.11 ± 6.61 kg/m 2 ) and lira technique in 12 patients (mean age was 56.5 ± 10.5 years old and mean bmi was 30.12 ± 5.30 kg/m 2 ). the mean average follow-up in both series was 1 year. mean average vas in ccd was 5.35 ± 2.49 (1 day), 2.01 ± 2.13 (7 days) 0.62 ± 1.45 (1 month) 0.10 ± 0.43 (3 months ) and 0 at 1 year. in lira series vas was 3.9 ± (24 h) 1.08 ± 1.78 (7 days), 0.08 ± 0.28 (1 month), 0 (3 months) and 0 (1 year) . there are 6 cases of bulging in ccd series and 1 recurrence. bulging and recurrence were absent in lira series. conclusions: lira technique might be a safe procedure in medium size defects for restoring the midline in lvhr, and could be related to a lower pain rate compared to ccd with no recurrence or bulging. surg endosc (2019) 33:s485-s781 background: the desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endo-surgery [sipes] and needlescopic surgery. intracorporeal suturing and knot tying during sipes remains challenging. the aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. it is an imitation of the principles of sewing machine. methods: the first author discussed the idea of the technique with the co-authors and a demonstration was done on a silicon pad before application of the technique on children with congenital inguinal hernia [cih] for peritoneum closure after needlescopic disconnection of the hernia sac. the main outcome measurements were; feasibility of the technique, knot quality, suture placement accuracy, performance and suturing time and recurrence rate. results: the sutures were snugly applied to the ridges of silicon pad with good approximation and the knot was firmly tightened in all experiments. after applying and mastering the technique on a silicon pad, we shifted to use it on 373 children with 491 hernia defect. all operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. the time required for suturing of the peritoneum around internal inguinal ring [iir] and knot tying, decreased considerably from 5 min 27 s in the first operation to less than 3 min after the fifth operation and stabilized at approximately 2 minute 30 s. no major intraoperative complication and no recurrence. the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of 148 patients were enrolled (70 of them underwent tapp and 78 olr). drop out occurred in 5 cases (2 of tapp and 3 of olr group). patient characteristics were statistically similar between the 2 groups. tapp procedure had less early post-operative pain (p = 0.037), a shorter length of stay (p = 0.031) and less postoperative complications (p = 0.002) when compared with the olr approach. a slightly higher recurrence rate in the tapp group was found. additionally, there is a trend towards a higher postoperative quality of life and less chronic pain in the tapp group. conclusions: tapp procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications. cannizzaro hospital, catania, italy aim: the purpose of this study was to evaluate the long-term results in terms of safety and efficacy of a new technique to repair incisional ventral hernias with a self-gripping mesh, after a mean follow-up period of 15 months. methods: a retrospective, single-centre study was performed from june 2016 to june 2018. all patients undergoing elective incisional ventral hernia repair were included. hernias were diagnosed based on clinical examination at the outpatient clinic. in case of doubtful diagnosis, ct-scan was used to confirm the diagnosis. the component separation technique and, when needed, tar were performed. the self-gripping mesh was placed in sublay position (overlap 5 cm) with the self-gripping surface face down. in all cases drainage tubes were placed in retromuscular and supraaponeurotic position. the following characteristics were collected: age, sex, body mass index (bmi), smoking, comorbidities, number of previous surgical operations, defect size (ehs classification), mesh size, postoperative complications, duration of follow-up. all patients were interviewed by telephone every six months. when patients complained recurrence or other symptoms, visits were organized and when there was the doubt of recurrence a ct-scan was performed. results: a total of 40 patients were included in this study, 21 males, mean age was 59 years. 83% of patients had bmi [ 25, smokers and diabetics were respectively 28% and 9%. the mean defect size was 115 cm 2 . component separation technique was associated with tar in 6 patients. in 11 cases the size of mesh was 20 9 15 cm, while in 7 patients the size of mesh was 30 9 15 cm and in 11 cases this was 15 9 15 cm. in the other patients the mesh sizes were tailored to defect dimensions. subcutaneous seromas occurred in 7 patients, they were treated conservatively in 5 cases and with percutaneous punction in 2 cases. long-term follow-up demonstrated recurrences in one case, while in another one ct-scan revealed a bulging. no cases of mesh infection, pain or sensation of mesh. conclusions: this study with a mean follow-up period of 15 months demonstrated that the use of self-gripping mesh in sublay position is safe and effective to treat incisional ventral hernias. aim: morgagni hernias present technical challenges. the laparoscopic approach was described at first in 1992, however, as they are uncommon in adult life and, little data exist on the optimal method of surgical management. this study purpose was to analyse a method for laparoscopic repair of morgagni giant hernias using laparoscopic primary closure. methods: this case series describes a method of laparoscopic morgagni hernia repair using primary closure. in all patients a laparoscopic transabdominal approach was used. the content of the hernia was reduced into the abdomen and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. demographic data as age, gender and bmi were collected. operative data (operative time, rate of conversion, blood loss) and post-operative data (short and long term complications, length of hospital stay, need of readmission and reoperation) were recorded. results: retrospectively collected data about 9 patients were analysed. there were 1 (11.1%) male and 8 (88.8%) females. the median bmi was 29.14 ± 5.2 kg/m 2 . median operative time was 80 ± 25 min. there were no intraoperative complications nor conversion to open surgery. patients began a fluid diet on the first post-operative day and were discharged after a median hospital stay of 3 ± 1.87 days. in a median follow up of 36 months we did not observe any recurrences. conclusions: transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for repair of morgagni hernia. in our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs. can we predict the success of the laparoscopic approach in the adhesive small bowel obstruction? c. tellez marques, e. sebastian valverde, e. membrilla fernandez, l. grande posa, i. poves prim general surgery, parc de salut mar-hospital del mar, barcelona, spain aims: the laparoscopic approach in the acute adhesive small bowel obstruction and internal hernias (asbo) has shown superior to laparotomy in terms of morbidity and hospital stay. especially, in patients who present simple adhesions or internal hernias. according to this, the aim of the study is to determine those preoperative factors associated with simple adhesions and internal hernias, and consequently, improve the success of the laparoscopic approach in asbo methods: a retrospective study of patients who underwent urgent surgery for asbo was conducted from january 2007 to may 2016. we compare preoperative variables between single adhesions and internal hernias vs complex adhesions. a p value \ 0.05 was considered statistically significant. results: we analysed 262 patients who underwent surgery for asbo, 78 (30%) by laparoscopy and 184 (70%) by laparotomy. conversion rate in laparoscopy was 38.5%. 49.2% of patients presented a single adhesion or internal hernia; and 50.8% were considered complex adhesions. sex and age did not correlate with the type of adhesions. previous surgery (p \ 0.001), number of previous surgeries (p \ 0.001), asa (p \ 0.001) and previous abdominal wall mesh (p = 0.002) were significantly associated with complex adhesions. laparoscopy as the only surgical history was significantly associated with simple adhesions (p = 0.033). only appendectomy (p = 0.139) or supramesocolic (p = 0.076) previous surgeries tended to present single adhesions but it did not reach statistical significance. the need for intestinal resection was not related to the type of adhesions (p = 0.743). there was a significant correlation between the findings in the ct (computed tomography) and the type of adhesion found (p = 0.001). signs of ischaemia on ct were related to the need for intestinal resection (p \ 0.001). in the multivariate analysis, the number of previous surgeries, asa and ct scan findings were identified as independent factors related to the type of adhesion. conclusions: according to our study, a lower number of previous surgeries, asa i-ii and internal hernia in the ct scan are associated with single adhesions and internal hernias. patient selection is a key factor for the success of laparoscopic approach in asbo. aims: there aims of this study were: (i) to compare england with the united states in the utilisation of minimal access surgery (mas) and in-hospital mortality from four common abdominal surgical emergencies (appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel perforation and peptic ulcer perforation). (ii) within england to evaluate the influence of mas upon in-hospital and long-term mortality. methods: between 2006 and 2012, the rate of mas and in-hospital mortality for four abdominal surgical emergencies were compared between the united states and england. univariate and multivariate analyses were performed to adjust for underlying differences in baseline patient demographics. results: 132,364 admissions in england for four abdominal surgical emergencies were compared to an estimated 1,811,136 admissions in the united states. after adjustment for patient demographics, mas was used less commonly england for three conditions; appendicitis (odds ratio (or) 0.30, 95% ci 0.30-0.31), abdominal hernia (or 0.18, ) and small or large bowel perforation (or 0.48, ). in-hospital mortality in multivariate analysis, was increased in england compared to the united states for three conditions; abdominal hernia (or 1.91, 95% ci 1.81-2.01), small or large bowel perforation (or 2.33, ) and peptic ulcer perforation (or 2.02, 95% ci 1.91-2.14). in england, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for three conditions; abdominal hernia (or 1.80, 95% ci 1.26-2.71), small or large bowel perforation (or 1.59, 95% ci 1.37-1.87) and peptic ulcer perforation (or 2.31, . similarly open surgery was associated with increased long-term mortality for three conditions; abdominal hernia (hr 1.32, 95% ci 1. 15-1.52) , small or large bowel perforation (hr 1.30, 95% ci 1.18-1.43) and peptic ulcer perforation (hr 1.69, 95% ci 1.50-1.89). conclusions: minimal access surgery was used less commonly and inhospital mortality was increased in england compared to the united states for common abdominal surgical conditions. given the benefits of mas shown in this large study, strategies to enhance adoption of mas in emergency conditions in england need to be optimised and include appropriate patient selection and improved surgeon mas training and experience. surg endosc (2019) 33:s485-s781 background: in the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related-group (drg) era. factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. the aim of this study is to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. methods: this retrospective study analysed the 1-year experience in inguinal hernia repair in patients undergoing open lichtenstein (ol), laparoscopic totally extraperitoneal unilateral (utep) or bilateral (btep) hernia repair. demographics, results, costs and drg-based reimbursements were recorded and analysed. results: during the study period, 39 patients underwent ol, 82 patients utep and 16 patients btep. the average total cost amounted to 4126 eur in ol, 5134 eur in utep and 7082 eur in btep groups (p \ 0.001*). the hospital reimbursement amounted to 5486 eur, 5252 eur and 6555 eur in the ol, utep and btep groups respectively (p \ 0.001*). finally, the mean hospital earnings were 1360 eur, 118 eur and -527 eur for each patient in ol, utep and btep respectively (p \ 0.001*). conclusions: in-hospital costs were higher in utep and btep as compared to ol. the drg-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in ol group only, and led an overall financial loss in the btep group. surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view. aims: umbilical hernias are common anatomical defects in swine which become a suitable model for surgical training and research in the field of surgical meshes. the aim of this study was to develop a surgical protocol for a successful laparoscopic implantation of stem cell-coated surgical meshes. methods: 9 large white pigs, weighing 25-68 kg and with congenital abdominal hernia were anesthetized for the surgical procedures. non absorbable polypropylene surgical meshes were coated with fibrin glue (fg) (control group) or with fg admixed with porcine bone marrowderived mesenchymal stem cells (fg/bm-mscs). approximation of hernia's borders was performed by intracorporeal suture. the meshes were carefully rolled inside the trocar for laparoscopic implantation. the surgical implantation was performed by laparoscopy using helicoidal staples. laparoscopic inspections and biopsies of the tissue surrounding the mesh were performed at 7, and 30 days post-implantation. at day 30, the animals were euthanized and macroscopically evaluated. ultrasonography was used at day 0, 7, and 30 to evaluate the size of the hernia. the biopsies were then processed for the histological analysis. results: ultrasonography demonstrated that the mean size of umbilical hernias before mesh implantation was 2.49 ± 0.99 cm. a decrease in hernia mean size was observed at day 7 and 30. the laparoscopic procedures allowed a successful mesh implantation in all animals. in most of cases, the implantation site did not show excessive inflammation or tissue adhesions. but one animal showed hernia maintenance. one animal had peritoneal and implant-site infection. foreign body reaction was noted in the histological analysis, although no significant difference was found between the control, and bm-msc group. conclusions: the anatomical similarities between humans and pigs in umbilical hernias make this animal model useful to: i) improve minimally invasive surgical procedures for hernia treatment; ii) evaluate new surgical meshes, and iii) introducing stem cell therapy to hernia surgical repair. the laparoscopic approach is efficient and safe for the implantation of stem cellcoated meshes. gene and protein expression analysis are required to evaluate the molecular changes between the conventional and the stem cell surgical approach. aims: fluorescence angiography with indocyanine green (icg) is used as a marker in the assessment of tissue perfusion, being more frequently used in colorectal procedures. this technology has shown to be a good technique to reduce complications related to vascular supply to the anastomosis. in esophagogastric procedures blood supply to the gastric pouch, jejunum and esophagus could be evaluated by icg fluorescence imaging. it could be also used in bariatric surgery to evaluated the anastomoses, during gastric bypass, and blood supply to the gastroesophageal junction and the angle of his during sleeve gastrectomy. methods: we have collected data during 8 gastric resection due to adenocarcinoma and 53 bariatric procedures that were performed by the same surgeon, using icg fluorescence to evaluate blood supply. the icg was infused before performing the anastomosis in order to evaluate the need to change the transaction line (tl). we analyzed those cases in which the tl was changed and the number of leaks in those cases that we changed this line. results: all the 61 cases were performed by laparoscopic approach: 5 subtotal gastrectomy (sg), 3 total gastrectomy (tg), 26 gastric sleeve (gs) and 27 gastric bypass. there were no changes regarding the tl before performing the anastomosis in any of the four types of procedures (sg, tg, gs, gb). in the analyzed data there is 1 anastomotic leak in one sg procedure (1.6%). conclusions: icg fluorescence angiography could be helpful in assessing blood supply during gastrointestinal anastomosis, although we have not find an influence in the results during bariatric and gastric procedures. however, we do not have the sufficient evidence to determine the value of this technology in this entities, being needed more volume and data to improve the significance of the results. aims: hyperspectral imaging (hsi) combines a spectrometer with a camera to analyze the tissues' optical properties in a broad wavelength range, without the need for a contrast agent. it provides extensive real-time information about tissue physiology, including oxygen saturation (sto2). fluorescence-based enhanced reality (fler) is a software solution providing a dynamic, quantitative analysis of the signal evolution of a systemically administered fluorophore, during fluorescence angiography (fa) . the aim of this study was to compare the performance of hsi and fler to assess bowel perfusion, in a porcine, non-survival model of bowel ischemia. methods: in 6 pigs, an ischemic small bowel segment was created and imaged after 1 hour of ischemia. the imaging modalities were applied sequentially to the same area.hsi was performed first, to acquire the sto2 spectra, by means of the tivita tm system (diaspective vision, pepelow, germany), which provides a spectral range of 500-1000 nm and a 5 nm resolution. subsequently, fa was performed using a nir-capable laparoscopic camera (d-light p, karl storz, germany), after intravenous injection of 0.2 mg/kg of indocyanine green (icg; infracyanine, serb, paris, france). the fluorescence flow was recorded during 40 s, then the slope of the fluorescence flow was analyzed using a proprietary software to obtain a virtual perfusion cartography. the virtual cartography was overlaid onto real-time images to obtain the enhanced reality effect. ten adjacent regions of interest (rois) were selected from hsi datasets and were superimposed to fler-generated cartographies using a custom plug-in software function, allowing for a quantitative comparison of both imaging modalities. hsi was repeated after icg injection. results: the r 2 correlation coefficient between hsi-sto2 and the fler slope was 0.79. at control hsi after icg injection, the correlation coefficient dropped significantly (r 2 0.45). the interference of icg on hsi imaging was clearly identified in the spectral curves. conclusion: sto2 given by hsi provided results comparable to those obtained with fler in our bowel ischemia model, without the need to inject a contrast agent. icg interferes with hsi datasets, disrupting sto2 values. surgical treatment is one of the most effective options for treatment of giant hiatal hernia. laparoscopic approach became is a 'gold standard' over the time demonstrating all advantages of minimally invasive techniques over the open procedures. however the utility of robotic operations still remains controversial. aim of the study: evaluate the initial experience of robotic fundoplication in compare to laparoscopic procedures. materials and methods: since the january till the december of 2017 thirty operations were operated on. mean age was 57.2 (44-76), among them 12 (65%) were female and 6 (35%) were males. mean bmi was 29.4 (24. 1-41.0) . laparoscopic procedures were performed in 8 patients (1st group), robotic procedures with davinci system were performed in 10 patients of the second group. nissen fundoplication modified was performed in 14 patients, toupet fundoplication was used for 4 patients. results: the median operative time in laparoscopic group was 150 min, in robotic group-131,2 min. there were no statistical differences between two groups (p = 0.93). blood loss was minimal in both groups. mean postoperative hospital stay was 4.08 days (2-7 days) in the 1st group and 3,6 days (2-6 days) in the second. there were no statistical differences between two groups (p = 0.19). postoperative course was uneventful in all patients of both groups. surgical stress response is associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction syndrome. robotic assisted surgery has been introduced to overcome the limitations of conventional laparoscopy. this technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. these advantages could result in limited intra-abdominal trauma and hence in attenuated surgical stress response over conventional laparoscopy. aims: this study aimed to synthesize data on the effect of robot assisted surgery on surgical stress response. methods: electronic databases were searched with the search terms 'surgical stress', 'stress response', 'oxidative stress', 'robotic assisted surgery', 'c-reactive protein', 'interleukin 6', 'interleukin 10','cortisol',;'oxidative stress markers', 'antioxidants', 'antioxidant status', 'mda', 'glutathione', 'cortisol', 'acute phase response' up to and including march 2018. results: one hundred forty studies were identified and their title and abstract were reviewed. one randomized controlled trial, six non randomized comparative studies, one experimental study and one case report met inclusion criteria. data were discordant. one prospective trial concluded that cortisol and il-6 were lower in laparoscopic assisted distal gastrectomy compared with robot assisted distal gastrectomy in another study comparing robotic assisted laparoscopic radical prostatectomy with open radical prostatectomy based on plasma measurements of il-6, il-1a and c-reactive protein, it was demonstrated that robotic assisted laparoscopic radical prostatectomy induces lower tissue trauma than open radical prostatectomy. in another study, it was reported reduced expression of genes associated with surgical stress response in patients treated with robotically assisted radical prostatectomy compared with patients treated with open prostatectomy. the case report concerned a case of polymyalgia rheumatic after robotic assisted laparoscopic prostatectomy. the experimental trial demonstrated that cortisol and substance p were significantly higher with open thoracic approach versus robot assisted thoracoscopic oesophageal surgery. conclusion: further research is needed to elucidate the effect of robotic surgery on surgical stress, based on a well standardized protocol for the measurement of surgical stress response. purpose: tissue compression is essential to prepare the tissue for proper staple formation. this study evaluates the risk factors of compression injury on the circular stapling line in vitro. methods: to reproduce the artificial bowel wall, a collagen plate was prepared by mixing collagen extracted from porcine with glycerin. artificial collagen plates with 4 mm and 6 mm in the thickness were made for dry and healthy condition and immersed plates in the tap water for 10 min to make wet and edematous condition. circular stapler (cdh25a, ethicon, usa) was applied in the collagen plates (dry and wet condition) and optimal compressions. compression line was evaluated for compression injury score. risk factors for excessive compressions and unacceptable injury were analyzed. results: in the dry condition, optimal compression didn't cause unacceptable injury. in the wet condition, excessive compressions were occurred in 47.1% with optimal approximation. unacceptable injury was significantly different in proper and excessive compression cases as 18.8% and 5.6%, respectively. on the univariate analysis, thickness (6 mm), wet condition, proximal side, maximal compression, and excessive compression were associated with unacceptable injury. on the multivariate analysis using logistic regression model, excessive compression was significant independent factor to cause tissue injury (p \ 0.001) and this significance was also proved in the optimal compression group (p = 0.021). background: minimal invasive appendectomy gained much popularity due to its better cosmoses, early recovery and less wound site infections. single incision laparoscopic appendectomy (sila) has many disadvantages such as, long operative time, bad ergonomics, surgical site infections, high conversion rate and port site hernia. needlescopic appendectomy (na) using mediflexò facial closure needle expected to be more superior over sila. here in we compare our results of needlescopic appendectomy with single-incision one. material and methods: one hundred and twenty patients with acute non complicated appendicitis were randomly assigned to na and sila 60 children for each group during the period between january 2015 to october 2018. the main outcome measurements included, demographics, operative time, intraoperative complication, conversion rate, post-operative hospital stay, surgical site infection, port site hernia and cosmetic results. results: a total of 120 children underwent appendectomy. there were 60 children who underwent na and 60 children who underwent sila. there were no difference in age (11.5 vs 11.98 years, p = 0.35), weight (42.98 vs 43.46 kg, p = 0.76) and hospital stay (1.51 vs 1.55 days, p = 0.92) between the two groups. there were no intraoperative complication during the two surgical approaches. operative time for na group is significantly shorter than single incision group (20.7 vs 38.2 min, p = 0.0001). no single case of conversion in na group and 18 cases needed conversion in sila group. seven cases of sila showed surgical site infection. 2 cases of sila group presented with port site hernia. the na group was superior as regard ergonomics. the two groups showed equal excellent cosmetic results. conclusion: needles scopic appendectomy and sila are comparable as regard cosmetic results and hospital stay. na proved to be safe, applicable, repetitive and superior over sila as regard better ergonomics, less operative time, absence of surgical site infection and port site hernia. aims: to objectively analyze the surgical performance and surgeon's ergonomics in the use of a novel flexible laparoscopic instrument during intracorporeal suture, and compare it with the use of a conventional laparoscopic needle holder. methods: three experienced laparoscopic surgeons performed five laparoscopic sutures on an organic tissue using the novel flexible instrument (flexdexò) and five sutures using a conventional needle holder with axial handle. the new device is based on a mechanical design with no electrical components, which transfers the surgeon's hand, wrist, and arm movements to the instrument tip in an intuitive manner. the use of the instruments was organized in a random fashion. prior to the study, participants conducted a 15-minute training session with the new flexible instrument. execution time and quality of the suture were assessed for each repetition. besides, flexion and radioulnar deviation of the wrist were recorded using an electrogoniometer (biopac systems, inc.) attached to the surgeon's hand and forearm. the intensity of the forearm's muscle activation was also analyzed by means of a myo armband (thalmic labs). results: surgeons required more time to perform the intracorporeal suture using the novel laparoscopic instrument (87.8 ± 23.333 s vs. 56.467 ± 8.733 s; p \ 0.001), but the quality of the suture was similar with both instruments. the wrist flexion (9.976 ± 7.513°vs 15.440 ± 4.049°; p \ 0.01) and wrist ulnar deviation (21.565 ± 5.19°vs 27.401 ± 3.19°; p \ 0.01) were significantly lower when using the flexible instrument. during the suturing tasks, the use of flexdexò instrument led to a higher muscular activation of the flexor (32.614 ± 3.437 vs 25.23 ± 3.076 rms; p \ 0.001) and extensor (23.341 ± 1.869 vs 20.017 ± 1.307 rms; p \ 0.001) muscle groups of the forearm. conclusions: the presented novel instrument allows surgeons to perform robotic-like laparoscopic suturing. we believe that with a longer training period surgeons could potentially reduce surgical times with this device. the preliminary results of this study suggest that the use of this new instrument provides a quality of the suture similar to that obtained with a conventional laparoscopic needle holder and an ergonomically more adequate wrist posture. aims: the intraoperative real-time evaluation of tissue perfusion is one key element for successful visceral surgery. traditionally, tissue evaluation is performed visually by surgeons. newer devices for objective quantification have in majority been based on the application of the fluorescent dye indocyanin green (icg). a novel method derived from geographic research is hyperspectral imaging (hsi). the aim of this study was the evaluation of hsi as a promising method for the evaluation of tissue perfusion and its implementation in the evaluation of the gastric conduit during esophagectomy in a porcine model. methods: the hsi camera records a 3 dimensional data cube from a 2 dimensional surgical situs obtaining wavelengths between 500 and 1000 nm. the absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. a software calculates 4 different indices in real-time including oxygen saturation. a porcine model (n = 24) is used for esophagectomy with gastric conduit formation. ischemia is induced artificially by magnets simulating staplers. different shapes of the gastric conduit and anastomosis formation are evaluated for perfusion metrics in order to obtain recommendations for the optimal formation of esophagogastrostomy. conclusion: hsi is a promising method for intraoperative evaluation of tissue perfusion that does not require application or injection of any agents. the preliminary results in this study showed that the gastric conduit receives its main blood supply from the gastroepiploic arteries and not via the mucosa. further results from the current evaluations enable formation of an optimized gastric tube and esophagogastrostomy in esophagectomy. surg endosc (2019) pediatric surgery, al azhar university, giza, egypt; 2 pediatric surgery, beni suef university, beni suef, egypt background: varicocele is one of the most common causes of infertility. many surgical interventions are used for varicocele ligation including open and conventional laparoscopic multiport or single incision techniques. the aim of the study is to present a new needlescopic lymphatic sparing varicocele ligation using mediflexò facial closure needle and 14 gauge vascular access cannula. material and methods: twenty-two male children with bilateral varicocele of grade ii-iii. all children were counseled by clinical examination, doppler ultrasonography, abdominal ultrasonography, and routine laboratory investigations. testicular lymphatics were delineated by subcutaneous injection of 1/2 cm 3 methylene blue in anterior wall of the scrotum 20 min prior to surgery. the testicular vessels (both vein and artery) were ligated one cm above the deep inguinal ring using two mediflex needles with preservation of lympatics. the main outcome measurements included; operative time, hospitalization, testicular atrophy, hydrocele formation, recurrence of varicocele and intra or postoperative complication. results: a total of twenty-two male children with grade ii-iii varicocele subjected to needlescopic lymphatic sparing technique. twenty one were bilateral. 15 background and aims: even if the clinical outcomes of robotic rectal resections are under investigation, the related robotic costs have not yet been well addressed, and the differences between the robotic rectal resection costs and the laparoscopic approach are still not well known. we have therefore performed a prospective comparative study of robotic rectal resections (rrr) and laparoscopic rectal resections (lrr) performed at our centre with the aim to evaluate the cost-effective outcomes of robotic versus laparoscopic surgery. study design: this is an observational, comparative prospective non-randomized study which includes patients that underwent laparoscopic and robotic rectal resection reaching a minimum of 6 months of follow up from february 2014 to march 2018, at the sanchinarro university hospital, madrid. an independent company performed the financial analysis and fixed costs were excluded. outcome parameters included surgical and post-operative costs, quality adjusted life years (qaly), and incremental cost per qaly gained or the incremental cost effectiveness ratio (icer). the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of 86 rrr and 112 lrr were included. the mean operative time was significantly lower in the lrr approach (336 versus 283 min; p = 0.001). the main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (rrr: 5.8%, lrr: 11.6%;p = 0.001).the mean operative costs were higher for rrr (4285.16 versus 3506.11€; p = 0.04); however, the mean overall costs were similar (7279.31€ for rrr and 6879.8€ for the llr; p = 0.44). mean qalys at 1 year for rrr group (0.5624) was higher than that associated with lrr (0.5066) (p = 0.018). at a willingness-to-pay threshold of 20,000 € and 30,000 €, there was a 61.18% and 64.09% probability that rrr group was cost-effective relative to lrr approach. conclusion: this study provides data of cost-effectiveness differences between rrr and lrr approach showing a benefit for the rrr aim: the efforts were aimed to the introduction of novel surgical technologies to overcome the intrinsic anatomical and technical constraints of rectal surgery. this was the case of the introduction into the clinical practice of laparoscopy and later on of robotic surgery for rectal surgery. however, whether robotic surgery is actually superior to laparoscopy is still debated. the aim of this study was to compare 3d laparoscopy and robotic surgery for rectal cancer on technical and oncological outcomes. methods: this was a single-center, prospective, randomized controlled trial. all patients more than 18 years of age undergoing elective surgery for rectal cancer situated from 5 to 10 cm from the anal verge were included. patients undergoing abdominal perineal amputation and/or with t4 and/or m1 tumours were excluded. patients were randomized before surgery into two arms: arms a (3d laparoscopy) and arm b (robotic), and gave their consensus to the study. demographic data, data regarding the tumour, operative and post-operative data were collected. patients with a follow up shorter than 24 months were excluded as well. results: twenty patients were enrolled in arm a and 20 in arm b in the period time of one year. patients' population of the 2 arms was homogeneous as concerns demographic characteristics and stage of the disease. robot-assisted rectal resection results in comparable operative time (125.70 vs 170 min; p = 0.068). the conversion rate was significantly lower for arm b (2 vs 0 p = 0.0). postoperative morbidity was comparable between groups. hospital stay was comparable but time required to resolve post-operative ileus was shorter in arm b (2.5 vs 1.2 days, p = 0.048). overall survival and disease-free survival were comparable between arms (98.6% vs 98.3%, p = 0.989, and 97.4% vs 97.6%, p = 0.856, respectively) conclusions: 3d laparoscopy and robotic surgery are two viable options for rectal surgery. robotic surgery can add some in terms of post-operative outcomes and ergonomics. aim: currently, robotic surgery for rectal cancer is a surgical operation that is being performed worldwide. we also introduced robotic surgery in 2015. however, after robotic surgery, we observed a rise in creatinine kinase (ck), which is unlikely to happen in other surgeries. we studied the postoperative complications of rectal cancer patients who underwent either robotic surgery or laparoscopy during the same period of time. methods: from january 2016 to november 2018, 23 patients underwent surgery using robotassisted rectal resection (da vinci si 20 cases and xi 3 cases) and 33 patients underwent laparoscopic rectal resection. in this study, abdominoperineal resection, intersphincteric resection, and lateral lymph node dissection were excluded. result: the operation time for the robotic surgery group was significantly longer than that for the laparoscopic group (424 min vs. 305 min; p \ 0.001). the ck value of the robotic surgery group on 1pod was significantly higher than that of the laparoscopic group (525 iu/l vs. 160 iu/l; p \ 0.001). in addition, one case of compartment syndrome was observed in the laparoscopic group. there were no significant differences in age, body mass index, intraoperative bleeding, tumor invasion depth, urination disorder, or postoperative hospital stay. in robotic surgery, it is considered that the increase in ck value is caused by the extended operation time, contact of the patient's cart with the left thigh of the patient, and the extra force applied to the abdominal wall caused by the displacement of the remote center. conclusion: in robotic surgery, it is suggested that the measurement of postoperative ck value is important. therefore, an attempt to shorten the operation time and paying attention to the surgical field are necessary to improve the outcomes. aims: anastomotic leak remains as one of the most important and life threatening post-operative complications in colorectal surgery. this complication has important consequences, both acute and long term, longer hospital stay, re-intervention, and increased morbidity and mortality. among all different circumstances that have been related to this entity, blood supply is an important factor that might have influence. fluorescence with indocyanine-green (icg) is used as a marker in the assessment of tissue perfusion in colorectal surgery which might reduce the numbers of leaks. methods: a multicenter analysis of the experience of 5 centers in spain is collected in order to assess the value of icg in colorectal anastomosis. 379 colorectal procedures were performed using icg to evaluate vascular supply in the anastomosis. icg was infused before performing the anastomosis analyzing the number of cases in which the transection line (tl) was changed. we also analyzed the number of leaks in those cases that we changed this line. results: out of the 379 cases performed, 15 cases were performed by open surgery, 319 by laparoscopy, 35 by single-port and 10 with transanal total mesorectal excision(tatme). the following procedures were performed: 94 right colonic resection(rc), 9 splenic flexure partial resection(sf), 149 left colonic resection(lc), 3 subtotal colectomy(sc), 2 total colectomy(tc), 6 hartman reversal surgery(hr), 63 low anterior resection with partial mesorectal-escision(lar) and 47 ultra low anterior resection with total mesorectal-escision(ular). leak rate(lr) was 6.59% (3.19%rc, 5.36%lc, 33.33%sc, 11.11%lar, 11 .32%ular). overall lr was 4.3% in colonic surgery and 11.2% in rectal surgery. the tl was changed due to icg in 12.13% of the cases (4.25%rc, 11.1%sf, 16 .77%lc, 50% tc, 7.93% lar, 18.86% ular), being 11.9% in colonic resection and 12.9% in rectal resection. the relation between leaks and the cases in which the tl was changed, were 20% (33.3%rc, 25%lc, 33.3%ular). conclusion: icg fluorescence may play a role in anastomotic tissue perfusion assessment. the lr after colorectal surgery might decrease using icg to detect the proper tl before to perform the anastomosis. however, we do not have the sufficient evidence to determine that the changing transaction line can lead to avoid leaks. surg endosc (2019) aims: to analyse the value of postoperative day 2 crp as an early predictor of safe discharge in robotic rectal cancer surgery. methods: a retrospective analysis was performed, including patients who had undergone robotic total mesorectal excision (tme) in a single centre over a 4-year period (may 2013 -september 2017 . patients who had a permanent stoma (abdominperineal resections or hartmann's procedure) were exluded from the study, leaving 144 patients for further analysis. as the los is currently used as a performance tool in assessing outcomes in colorectal surgery (with a cut-off established at 5 days), we compared the crp values in these 2 groups. results: fourty one percent of patients were discharged home within 5 days. they had an earlier peak of crp on postoperative day (pod) 2 (median 94. 5, 80) . the group of patients that were discharge home after 5 days (59%) had a crp peak on pod 3 (median 151, 168). on pod 3, the group of patients that went home within 5 days had a lower crp (83-70-vs. 151-168-) compared to the group of patients that were discharge after 5 days, p = 0.001). conclusions: a crp peak on pod 2 in robotic tme can predict an early and safe discharge (los within 5 days). background: purposelateral pelvic lymph node dissection (lpnd) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (crt). however, technical difficulties make it possible that lateral pelvic lymph nodes (lpns) are not dissected completely and, thus, remained in the narrow pelvis. near-infrared fluorescence imaging (fi)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. this study aimed to evaluate the efficacy of fi using indocyamine green (icg) to identify lpns during robotic lpnd. methods: 31 rectal cancer patients who were suspected lpn metastasis and had received preoperative crt were prospectively enrolled. icg in a dose of 2.5 mg was injected around tumor preoperatively. all procedures were performed with a totally robotic approach. after completing lpnd, fi was checked again for identifying remained lpns and resecting them completely. results: the lpns were successfully detected in 25 (80.6%) of the 31 patients. however, after accounting for eight cases, having finished adjusting icg injection, the lpns were successfully detected in 22 (95.7%) of 23 patients. the fi-guided lpnd group (n = 25) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic lpnd (n = 62). however, the mean number of unilateral harvested lpns was 10.2 in the fi-guided lpnd group, which was greater than the mean of 6.6 in the conventional group. lpn metastasis was identified in 40% of the fi-guided lpnd group, which was higher than that of the conventional group, 31.7%. conclusion: fi-guided lpnd identifies lymph nodes in pelvic side-wall with great reliability. this contributes to increased number of lpns yield compared to conventional robotic lpnd. this technique should be considered to dissect them completely by preventing subsequent missing of nonvisible lpns. aims: to compare the medium-term oncological outcomes of laparoscopic total mesorectal excision (l-tme) vs. robotic total mesorectal excision (r-tme) for rectal cancer. methods: a retrospective analysis was performed including patients who underwent l-tme or r-tme resection between 2011-2017. patients with disease stage iv at diagnosis or r1 resection were excluded. 680 patients were initially included, and 136 cases of r-tme were matched based on age, gender, stage and time of follow-up with an equal number of patientswho underwent l-tme. we compared 3-year disease free survival (dfs) and overall survival (os). in adittion, a multivariate analysis was performed in order to idenfity independent prognostic factors for 3-year dfs and os. results: pathological outcomes were similar between groups. however, major complications were lower in the robotic group (13.2% vs. 22.8%, p = 0.04), highlighting the anastomotic leakage rate, which was 7.4% in the r-tme vs. 16.9% in the l-tme group (p = 0.01). overall, the 3-year dfs rate was 69% in the laparoscopic group and 84% in the robotic group (p = 0.02). the 3-year os rate was 70% in the l-tme groups and 97% in the r-tme group (p = 0.000). for disease stage iii, 3-year dfs was significantly higher in the r-tme group. os was also significantly superior in the robotic group for every stage, reaching 86% in the stage iii. in the multivariate analysis, r-tme was a significant positive prognostic factor for distant metastasis (or 0.2 95%ci 0.1, 0.6, p = 0.001) and os (or 0.2 95%ci 0.07, 0.4, p = 0.000). conclusions: r-tme for rectal cancer can achieve better oncological outcomes compared to l-tme, especially in stage iii rectal cancers. the robotic approach has demonstrated to be a significant positive prognostic factor for local recurrence and overall survival, due to the better postoperative outcomes. however, a longer follow-up period is needed to confirm the oncologic findings. university hospital for visceral surgery, university of oldenburg, oldenburg, germany; 2 bremen spatial cognition center, university of bremen, bremen, germany aims: in clinical settings, realistic assessment of one's own abilities can enhance performance and promote patient safety, especially in surgical residents, who inevitably have to acquire skills during real surgery. this study thus implemented the global assessment of laparoscopic skills (goals) questionnaire with the aim to explore divergences between resident self-evaluation and specialist's evaluation on laparoscopic performance, as a first step to implement the goals questionnaire as a tool for constructive and objective feedback. methods: between july and october 2018, seven residents from the university hospital for visceral surgery at the pius-hospital oldenburg participated in this study. at the end of every laparoscopic operation where the resident acted as the primary surgeon, the resident and the supervising surgeon independently evaluated the resident's operative performance using the goals questionnaire. the five dimensions evaluated were depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. a cumulative goals-score (with 25 being the highest possible score) was calculated for n = 46 laparoscopic operations. resident's year of training, the level of case difficulty and the type of laparoscopic procedure performed was also analysed. results: residents overestimated their laparoscopic abilities in 64.4% of the operations (goals-scores: residents: median = 16, mean = 16.51; specialists: median = 15, mean = 14.60; p \ 0.001). residents in the first three years of surgical training were more likely to overestimate their performance (residents: median = 16.5, mean = 16.82; specialists: median = 13, mean = 13.14; p \ 0.001) than those with more than three years of surgical experience (residents: median = 16, mean = 16.22; specialists: median = 15, mean = 16.00; p = 0.613). goals score differences did not depend on case difficulty and laparoscopic procedure. conclusions: surgical residents tend to overestimate their intraoperative laparoscopic performance when compared to specialist evaluation. overestimation was found to depend on one's own laparoscopic experience and seem to disappear with gained expertise. these results signify the importance of individually adapted training and the greater need for objective feedback for surgical residents. this approach could in return increase the skill acquisition rate of the resident and in return contribute towards enhancing patient safety. introduction: the delivery of safe surgical care is dependent of various, complex and interrelated factors. substantial data exist regarding the impact of training in human factor skills on surgical outcomes. however, except for the standardized time-out process, the best way to go about improving these skills remains unclear. the aim of this study was to gain more insights in the theatre staff's perception of human factors and their importance on surgical outcome in the operating theatre. methods: the surgical team assessment record (star) questionnaire was used to study the role of human factors, such as communication, situational awareness and organization, contributing to surgical team performance. the self-assessment questionnaire was filled out by the theatre staff, directly after the surgical procedure. conditional logistic regression was used to identify the impact of the role in the operating theatre on the yes versus no answers. results: some 507 questionnaires were completed. the theatre staff rated their team's performance with a median of 4 (iqr 0.0, 5-point likert scale). the surgical fellows (n = 76) rated their personal factors significantly lower compared to the rest of the operating team (median 3 versus 4, p-value \ 0.0001). the staff surgeon (n = 119) indicated significantly more often that there were many distractions (51.3%, yes n = 61) and noticed aberrations (60.5%, yes n = 72) during the surgical procedure (pvalue \ 0.0001) when compared to the rest of the operating team. most aberrations reported by the surgeons were related to technical performance. conclusions: human factors play an important role in the surgical environment. situational awareness may be less developed in members of operating teams, compared to the surgeon of that team. further work is needed to elucidate the impact of human factor skills on team performance. a team-based approach to safety interventions is recommended. future studies should determine what type of aberrations and distractions are most relevant and valuable to embark on with team training. dept. of digestive surgery, school of medicine, tokushima university, tokushima, japan; 2 dept. of digestive surgery, tokushima university, tokushima, japan background: the qualitative evaluation for laparoscopic training of medical students was performed using rubric evaluation, and weak points in conjunction with the lack of anatomical knowledge were derived. to conquer these weak points, virtual reality (vr) ? augmented reality (ar) training for understanding of regional anatomy was investigated. materials and methods: one hundred and six students in 5 th grade of tokushima univ. participated basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator. rubric evaluation, as qualitative evaluation, which includes the evaluation standards for each maneuver were performed before and after basic task training and sham operation. the group which self-evaluation was higher in a rubric evaluation was investigated. the 3d image of vessels and bile duct obtained from mdct of real patient was projected in reality space with microsoft hololens. training of ar image using hololens was performed for understanding of regional anatomy. after training of regional anatomy with hololens, sham laparoscopic cholecystectomy was performed again, and quality of procedure was evaluated by rubric. anatomical questions were. results: rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, several students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. after ar training, all students showed high score in questions related regional anatomy during operation. especially, rubric evaluation of students who showed high self-evaluation in sham operation showed same score with tutor. conclusions: as rubric evaluation showed weak points of detailed parts of maneuver, and vr ? ar was useful for understanding details of regional anatomy for laparoscopic training. background: the eaes has recently published an intraoperative adverse event classification to aid reporting of minimally access surgery events. this includes capture of non-consequential errors. we aimed to investigate the clinical impact of these apparent 'near miss' events. methods: case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision randomised controlled trial was utilised (isrctn59485808). the eaes classification was applied by two blinded assessors to all enacted adverse events identified on video analysis using the observational clinical human reliability analysis technique. the total number of grade 1 (non-consequential) errors were compared with the number and nature of 30 day morbidity events (graded with the clavien-dindo system) and length of stay. results: 77 cases (419 h of surgery) contained 1377 error events of which 809 (58.8%) were classified as eaes grade 1 (median 10 per case, interquartile range 7-13, range 1-28). there were significantly more inconsequential errors recorded in patients that developed any early morbidity event than those who had an uneventful post-operative recovery (median 8.5 (iqr 6-12) vs. 11 (9-14), p = 0.005). a stepwise increase in the sum of eaes grade 1 errors is seen for each additional 30 day morbidity event reported (8.5 vs. 11 vs. 11 vs. 12, p = 0.047) and the highest clavien-dindo grade experienced (9 vs. 10 vs. 11 vs. 12. p = 0.067). positive correlation is observed between the sum of eaes grade a errors and length of post-operative stay (r s = 0.36, p = 0.001). conclusion: in the context of major laparoscopic surgery, near misses are commonplace and correlate with surgical outcomes. this may represent a novel surrogate assessment method for intraoperative performance. aims: diagnostic laparoscopy (dl) is an under-utilised procedure that can replace non-therapeutic exploratory laparotomies in many contexts. to date, no validated education programme for dl exists. this study seeks to evaluate the feasibility, acceptability and face, content, construct validity of the laplat curriculum (laparoscopic learning for abdominal trauma; a simulationbased curriculum for trauma dl). this is in addition to the development of a novel 3d-printed bench-top model for abdominal inspection. methods: this prospective and observational pilot study involved 39 novice medical students and junior doctors. surgeons from the uk and international (n = 8) were involved in a two stage delphi-process to determine the components of the training course which were used to formulate a final curriculum. in the absence of an adequate model for abdominal inspection, a novel 3dprinted abdominal inspection model was designed and produced. after an introductory familiarisation session as well as pre-course cognitive lectures, the novices performed 6 tasks on a virtual reality and bench-top simulator with 5 repetitions of each in a half-day session. outcome measures for construct validity were total time to complete task, accuracy, percentage of horizon maintained and economy of movement. face and content validity as well as acceptability was evaluated by a qualitative and quantitative survey. results: face, content and construct validity as well as acceptability was established. face validity was demonstrated in all components of the course (including pre-course cognitive content and technical tasks) in addition to content validity. all also met an acceptability threshold of 3/5 on a 5-point likert scale. one-way anova tests demonstrated construct validity in all tasks (p \ 0.0002) with learning curves in reducing time observed. using a performance improvement metric, one-way anova tests showed similar rates of improvement per participant between most tasks (p [ 0.05). the course was rated overall mean 8.86/10 (± 1.05). conclusion: this pilot study has demonstrated the feasibility, acceptability and face, content and construct validity of the laplat curriculum as well of the novel 3d-printed abdominal inspection model. randomised controlled trials are needed to establish higher-quality evidence, as part of a wider curriculum with transfer needed to the clinical environment. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; 2 anesthesiology-surgical propedeutics, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; 3 radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania; 4 urology, training and research center, prof. dr. sergiu duca, cluj-napoca, romania; 5 general surgery, training and research center, prof. dr. sergiu duca, cluj-napoca, romania aims: to evaluate the benefits of systematical use of ex vivoliver model and ct imaging in the planning process for swine laparoscopic liver resections done by residents during training programs. methods: twenty four general surgery residents were equally divided into two groups: first one which performed laparoscopic liver resections without planning stage and the second one which systematically used anatomical data from a swine liver model and interactive ct scans 3d reconstructions. the planning stage included an interactive tutorial for establishing the strategy for the next resection followed by performing open liver dissection and the same resection on an ex vivoswine model. a total of twelve models were used during this step. afterwards, laparoscopic procedures were performed on sixteen anesthetized domestic pigs, two swine for every team, composed of three residents. both groups were part of a dedicated and continuous training program and used the same 'step by step' protocol for resections. results: the average time for imagistic planning was 36.7 min and for open dissection and resection was 57.9 min. all teams successfully completed the interventions and followed the standardized protocol without trainers' interventions and with no conversions. the second group obtained better results regarding the time needed for completion and blood loss. also, when the planning stage was applied the resection was more accurate and less functional parenchyma was removed. the 'warming up' by adding the imagistic and anatomical data to the core protocol offer more clarity before laparoscopic liver resections. this also makes an upgrade for our 'step by step' protocol and provides sufficient data to admit this planning stage as mandatory for laparoscopic liver resection on swine during a training program. introduction: submucosal tunnel endoscopic resections (ster) had been increasingly performed for treatment of gastric subepithelial tumors. one of the limitations for ster is the risk of incomplete tumor resection due to close dissection and bridging of tumor capsule. endoscopic full thickness resection (eftr) allowed complete resection of the tumor with margins to prevent recurrence. this study aimed to review the techniques and outcomes of eftr for treatment of gastric subepithelial tumors. method: patients who received endoscopic resection for gastric subepithelial tumors were recruited. the gastric subepithelial tumors were considered eligible for endoscopic resection with size \ 40 mm. all patients received preoperative assessments including eus and ct scan to define the extend of tumors and the proportion of extra and intralumenal components. all the procedures were performed under general anesthesia with co2 insufflation. eftr started after injection with mucosal incision up to 50% of tumor circumference, followed by submucosal dissection to identify tumor margin. further dissection was performed using esd devices. after adequate exposure of lateral margins, incision into muscularis propria was performed to achieve full thickness resection. luminal defects were closed by either clips, clip-loop crown method or overstitch suturing. results: from 2012 to 2018, 10 patients received eftr for gastric subepithelial tumors. the mean age was 60.6 years, and 4 were male. the gist were located at greater curvature (4), cardia (3) , lesser curve (2) and antrum (1) . the mean size was 20.5 mm (10-50 mm) . most of the eftr were performed in operation theatre while two were done at endoscopy. the mean hospital stay was 4.5 days, and mean operative time was 98 min (34-180 mins). there was no conversion to laparoscopy. closure of luminal defect were performed mostly with clips (5), followed by overstitch (4) and clip and loop crown closure (1) . most patients resumed full diet on day 3, and all the pathologies confirmed gist tumors with clear resection margins. conclusion: endoscopic full thickness resection is technically feasible and safe procedure for treatment of gastric gist. future research should focus on refining the techniques of eftr and closure of the defect. next generation endoscopic intervention (project engine), osaka university, suita, japan; 2 gastroenterological surgery, osaka university, suita, japan; 3 research & development, 3-d matrix, ltd., chiyoda-ku, tokyo, japan; 4 research & development, fuso pharmaceutical industries, ltd., cyuou-ku, osaka, japan background: hemostatic peptides have received increased attention. self-assembling peptides (tdms) comprise synthetic amphipathic peptides that immediately react to changes in ph and/or inorganic salts to transform into a gelatinous state. since tdms do not carry a risk of infection, their clinical application as new hemostatic agent is expected to increase. the first generation of these peptides (tdm-621) is currently used as a hemostatic agent in europe. however, tdm-621 exhibits slow gel-formation and low retention capabilities on tissue surfaces. the second generation (tdm-623) was therefore developed to encourage faster gel-formation and better tissuesealing capabilities, and we subsequently verified its usefulness and increased performance relative to tdm-621 in preclinical open surgery. aim: the aim of this study was to verify the efficacy of tdm-623 in terms of its hemostatic effect in endoscopic surgery. materials and methods: evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight female (35 kg) pigs in spine position. following systemic heparinization, we established a bleeding model by utilizing flexible endoscopic grasping forceps on the anterior wall of the stomach and duodenum. in the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and 1 ml tdm-623 was applied to the wound. after tdm-623 gelation, the endoscope was removed, and the acute hemostatic effect (after 2 min) was confirmed. histologic evaluation was subsequently performed on resected specimens. results: in the endoscopic bleeding model, 17 of the 23 cases (73.9%) showed complete hemostatic effects on the anterior wall of the stomach, whereas on the anterior wall of the duodenum, 18 of 20 cases (80%) showed complete hemostatic effects. moreover, none of the gels were displaced from the anterior walls of the stomach and duodenum, and histologic evaluation confirmed no infiltration of inflammatory cells. the new self-assembling peptide (tdm-623) displayed improved hemostatic effects relative to the previous generation (tdm-621) in endoscopic surgery. tdm-623 had potential usefulness for upper gastrointestinal bleeding. our future work will assess its usefulness for laparoscopic surgery. objective: indocyanine green (icg) is a dye used in medicine since the mid-1950 s for different applications in ophthalmology, cardiology and hepatobiliary surgery; thanks to its selective hepatic uptake and biliary excretion, it can be used to evaluate hepatic function in patients scheduled for hepatic resection surgery. the aim of this study is to evaluate the efficacy and the feasibility of icg guided surgery in the intra-operative localization of liver tumors, comparing the pre-operative radiological aspect, the intra-operative visualization and the post-operative histopathological features of the tumors. materials and methods: icg was intravenously injected for a routine liver function test (limonò) in 58 patients who underwent hepatic resection surgery for primitive and secondary liver tumors in the period between november 2016 and september 2018. for each patient was performed an intraoperative visualization of the stain both in vivo and ex vivo, using a nearinfrared imaging system. all the images were recorded. results: a correct differentiation between liver parenchyma and tumor area was obtained in 89.1% of cases. five patients were not evaluable due to widespread uptake or complete absence of uptake; it was probably the first cases enrolled in the study for which we were not able to set doses and timing of administration of icg. in patients in which the method had been feasible, we observed a prevalence of nodular pattern in patients with hepatocellular carcinoma (63%) and a predominance of rim pattern in both cholangiocarcinoma (80%) and metastasis (83%). furthermore, in patients with hccs well-intermediate differentiated (g1-g2) was found predominantly a nodular pattern (82.9%), whereas in poorly differentiated ones was prevalent a rim appearance (60%). regarding radiological correlations, the only one patient who presented an atypical radiological feature in pre-operative evaluation, showed a lesion with no icg captation in intra-operative visualization. conclusions: icg fluorescence imaging is a safe, minimally invasive and quite inexpensive method, that can be easily administered for routine evaluation of pre-operative liver function. it can be a useful support tool in the intra-operative detection of liver tumors, especially in laparoscopic surgery where it is not possible to directly touch the tissue. surgery, bundang cha medical center, seongnam-si, korea; 2 surgery, severance hospital, seoul, korea; 3 surgery, nhimc ilsan hospital, ilsan, korea; 4 surgery, seoul national university bundang hospital, seongnam, korea; 5 surgery, asan medical center, seoul, korea backgrounds & aims: robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. however, robotic liver resection had not generalized, so far. thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by prospective multicenter study. methods: from july2017 to december 2018, five surgeons who were novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed 46 cases of robotic major anatomical liver resection. perioperative patient's clinical data and surgical data were prospectively collected. results: 22 cases of left hemihepatectomy, 1 case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, 2 cases of right anterior sectionectomy, 6 cases of right posterior sectionectomy, and one cases of central bisectionectomy were performed. the most common indications were hepatocellular carcinoma for 21 cases following intrahepatic cholangiocellular carcinomas for 7 cases, liver metastases for 3 cases, sarcoma for 1 case, intraductal papillary neoplasms for 2 cases, mucinous cystic neoplasm for 1 case, hemangioma for 1 case, and intrahepatic duct stones for 10 cases. surgical resection margins for all tumor cases were negative. total average operation time was 378.58 ± 124.31 min and estimated intraoperative blood loss was 276.67 ± 397.41 ml (minimal to 2600 ml). in terms of severe surgical complication, there were 3 cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous trans-hepatic biliary drainage. only one case out of 46 cases was converted to the conventional open left hemihepatectomy because of bleeding. conclusions: in this study, robotic anatomic major liver resection might be safely performed even by robotic beginners but advanced open and laparoscopic liver surgeons. surgical technique: with the patient at 30°on right lateral decubitus, access is gained through the path of the percutaneous drainage catheter after opening of the aponeuroses of the oblique and transverse muscles of the abdomen. a 15 mm laparoscopic trocar is inserted and a cavity is created with pneumoretroperitoneum at 15 mmhg. it is accessed with an optic of 0°and 5 mm, and the work space is extended with aspiration and hydrodissection. with 5 mm grippers, the necrotic material is removed, washed and drained. a two light silicone probe is left, one light for drainage and another one for washing. results: the mean age was 52. background: minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. in fact, the indication for robotic surgery in pancreatic disease has been controversial. the present study aimed to assess the safety and feasibility of robotic pancreatic resection. methods: we retrospectively reviewed our experience of robotic pancreatic resection done in sanchinarro university hospital. clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. aim: this work aims to study the contact pressure between the moving capsule and a synthetic small intestine in order to provide design guidance for prototyping the self-propelled capsule robot for small-bowel endoscopy. method: since small-bowel peristalsis consists of peristaltic contraction and wave distension, the contacts between the capsule and the small intestine are multimodal. we consider three contact cases for the capsule robot. case 1: the capsule moves on a flat small intestinal surface; case 2: the capsule moves in a collapsed intestine with a flat surface support; and case 3: the capsule moves in a surrounded small intestine. by considering these three contact cases, experimental testing and finite element analysis (fea) were conducted by measuring the contact pressure between the small intestine and the capsule. introduction: traditional laparoscopic instruments have limited degrees of freedom and are not ergonomic. this results in severe limitations in performing complex, and even simple tasks in surgery, limiting many surgeons from performing a variety of minimally invasive procedures. handx tm is a hand-held, electromechanical smart instrument with robot-like features. the instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. the instrument is 5.5 mm in diameter, lightweight, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. after the regulatory process was completed we have tested the device clinically through a structured, approved, clinical trial. materials and methods: after irb approval 30 patients were recruited to the trial. we have included a variety of procedures that require suturing and complex tissue manipulation. two experiences surgeons performed all procedures. after completing each procedure the surgeons completed a detailed standard usability (sus) questionnaire. results: 30 procedures were completed successfully without complications or device malfunction. there were 15 female and 15 male patients with an average bmi of 27. procedures performed were 6 right hemicolectomis with intra-corporeal anastomosis, 3 paraesophageal hernia repairs and fundoplication, 3 diagnostic laparoscopies, 2 tapp procedures, 10 ventral hernias with fascial suturing, and 6 laparoscopic cholecystectomies. the average performance score was 84.70/100. the results suggest that the handx device is safe and easy to use and may offer a simple solution for enhancing minimal invasive surgery capabilities and possibly reduce conversion rates while maintaining current standard surgery flow.the handx could potentially extend the surgeon's abilities to access hard to reach anatomy and perform complex maneuvers and present a cost-effective alternative to large console-based robotic systems. objective: endoscopic submucosal dissection (esd) has become widely accepted treatment for rectum neuroendocrine neoplasm. the aim of this study is to evaluate the safety and efficacy of esd with dental floss-assisted suspension traction for rectal neuroendocrine neoplasm. methods: we retrospectively reviewed the medical records of the patients, who underwent esd for rectum neuroendocrine neoplasm at endoscopy center of zhongshan hospital, fudan university. the data of operation time, r0 resection and adverse events were collected analyzed.in dfs-esd group: after the mucosa was partly incised along the marker dots, the next step was to construct traction device, similar to others in esd, with dental floss and hemoclip. the dental floss was tied to any arm of the metallic clip. the hemoclip was attached onto the incised mucosa, another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. the submucosa was clearly exposed with the traction of dental floss and the resection could proceed. results: 37 patients were enrolled in the study. there were 17 patients treated by esd with dental floss-assisted suspension traction and 20 patients treated by conventional esd. the average tumor size was (0.74 ± 0.2)cm in both group. the operation time was 17.9 ± 6.6 min in conventional esd group and (14.7 ± 3.3) min in dfs-esd group (t = 1.776, p = 0.084). according to pathological grading about rectal neuroendocrine neoplasm, there were 17 grade 1 (g1) and 3 grade 2 (g2) in conventional esd group while 13 grade 1 (g1) and 4 grade 2 (g2) in dfs-esd group (?2 = 0.436, p = 0.509). among 37 cases in this study, all the basal resection margins were negative, the en blot resection rate was 100% and the curative resection rate was 100%. however, pathological results showed tumor tissue close to the burning margin in 5 cases of conventional esd group and in 2 cases of dfs-esd group (?2 = 0.364, p = 0.546). conclusions: esd with dental floss-assisted suspension traction for rectum neuroendocrine neoplasm can assist exposing tumor borders, provide good vision during the procedure and offer clearer anatomic structure, so as to simplify operation, reduce operation time and ensure the negative basal margin. it is especially suitable to be promoted in primary hospitals. surg endosc (2019) aims: force feedback and assessment provides detailed insight into tissue manipulation skills. the aim of this study is to evaluate learning curves for basic laparoscopic skills based of force and motion learning curve patterns. morevover, we aimed to detect the favourable time span for this curriculum for each individual trainee. methods: in this prospective cohort study, first year surgical residents participated in a three week at home training course. a mobile box training was equipped with forcesense system for objective force, motion and time based assessment. the system provides seventeen unique metrics. the training goal was set by the mean score of proficient laparoscopic surgeons. each repetition was captured and made available for analyses. continuous force feedback was provided during training. curve fitting was used to estimate the learning curve plateau and the number of repetitions needed to approach the plateau phase and to reach proficiency level. finally, a comparisson between novices and experts was executed. results: a total of 2007 attempts, executed by 20 residents were captured and analyzed. significant improvement of motion analysis parameters (e.g. path length and time) was observed for all training tasks, except for the fifth tasks. tissue manipulation skills (i.e. maximum and mean applied force) significantly improved by training tasks 2, 3 and 6. learning curve analysis revealed various shapes and lengths of the individual learning curves. a large range in learning curve plateaus was found between trainees and between tasks. each trainee managed to accomplish the preset goals within three weeks. conclusion: force-and motion based assessment provides insight into both tissue manipulation and instrument handling skills. when combined in learning curve analysis, these parameters effectively show progression towards proficiency for each individual trainee over time. we emphasize the variation in learning curves between trainees. therefore, we recommend individually tailored courses provided with objective force-and motion-based learning curve tracking. aims: the posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation.the aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and perfusion assessment in the posterior retroperitoneoscopic approach. methods: six pigs underwent synchronous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (pra, n = 12). fluorescence imaging was obtained via intravenous administration of 3 ml of indocyanine green (icg) using two near-infrared camera systems. fluorescence-based visualization of adrenal glands before vascular division (n = 4), after main vascular pedicle ligation (negative control, n = 1) or after adrenal division (n = 7) was followed by completion adrenalectomy. one of the animals had undergone icg injection 3 h previously, during another study. the dynamic evolution of fluorescence signal intensity over time was recorded and analyzed using a proprietary software. the computed color-coded perfusion cartography was superimposed onto real-time images obtained by corresponding left (l) and right (r) camera systems. the slope of fluorescence signal intensity evolution over time in the regions of interest (roi) served to assess adrenal perfusion by means of quantitative fluorescence signal analysis. results: in the retroperitoneum, the adrenal glands were promptly highlighted after primary intravenous icg administration or showed an increase in fluorescence signal intensity upon reinjection (both glands in a recovery pig and one gland in the sequential approach). after left adrenal main vascular pedicle ligation, the gland displayed low perfusion (blue; rois a1-a2 in figure 1 ), while a weak fluorescence signal after completion adrenalectomy suggests perfusion via collateral vessels. with intact vascular supply, the caudal segment of the right adrenal (a3) gland showed a significantly higher perfusion rate (red) than the ischemic cranial segment (a4). quantitative analysis of logarithmic fluorescence intensity showed a statistically significant difference between perfused and ischemic zones (p = 0.005) allowing to assess gland vascularity. kidneys (k) and adrenal glands showed distinct perfusion curves ( figure 1 ). conclusions: prior to dissection, fluorescence imaging allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. during adrenal gland surgery, icg injection complemented by a computer-assisted quantitative analysis helps to distinguish between wellperfused and low-perfused segments. giant adrenal tumors:technical considerations and surgical outcome a. giordano, g. alemanno, c. bergamini, p. prosperi, v. iacopini, a. dibella, a. valeri sod chirurgia d'urgenza, aou careggi, firenze, italy objectives: giant adrenal tumors are tumors with size more than 6 cm. these are rare cancer associated with malignancy in 25% of cases. the size of these tumors is an important topic in literature because of their higher probability of malignancy and possible technical limitations of laparoscopic approach. we report our center's experience on laparoscopic adrenalectomy. materials and methods: in the last ten years we performed about 242 adrenalectomies for benign and malignant adrenal tumors. 45 of these were giant tumors. the medium size was 9.9 cm (7-22 cm). 23 tumors were on the left adrenal gland and 22 on the right. there were 20 women and 25 men, the average age was 55 (21-81 years). 29 of these cancers were laparoscopically removed and 16 with open approach. 2 cases of open conversion. results: betweenn the 29 tumors laparoscopically removed we recorded 6 cases of carcinoma, 2 endothelial cysts, 6 adenomas (3 with aldosterone and 2 with cortisol hypersecretion), 2 myelolipomas, 10 pheochromocytomas and 3 metastases from lung carcinoma. the surgical outcomes in these patients were optimal in terms of good pain control and hospital stay (median 3 days). the average time of the intervention was 110 min with very low blood less (90 ml). no postoperative complications were recorded. the removal of the adrenal gland necessitated 3 or 4 trocars. in the dissection and resection phases we always used radiofrequency scalpel. the follow up after 12 and 24 months didn't show local recurrences. conclusions: laparoscopic adrenalectomy offers significant advantages over the open approach. the size of these tumors is still at the center of debate for the choice of the technique. the tumor size is only a predictive parameter of possible malignancy. the laparoscopic approach is a safe and feasible method in terms of surgical and oncological outcomes also for the giant adrenal tumors, only if performed by expert surgeons and in high-volume centers. vascular or adjacent organs infiltration is a contraindication to the laparoscopic approach. aims: adrenal gland size greater than 6 cm is considered a contraindication to laparoscopic adrenalectomy (la). aim of the present case-control study is to compare the surgical outcomes in patients undergoing la for adrenal gland measuring = 6 cm versus = 5.9 cm in diameter. methods: from january 1994 to august 2018, 552 las were performed in the two authors' centers which follow an identical treatment protocol. eighty-one patients with an adrenal gland size = 6 cm (intervention group) were included in the study. based on body mass index (bmi) class [ 40 kg/m 2 ) , lesion side (right or left), surgical technique (anterior transperitoneal for right and left-sided lesions, anterior transperitoneal submesocolic for left-sided lesions) and lesion type (conn-cushing, pheocromocytoma, primary adrenal cancer or metastases, other type of lesion), 81 patients with an adrenal gland lesion measuring = 5.9 cm in diameter were included (control group) and paired to the intervention group. results: comparing the intervention and control groups, statistically significant differences were observed in mean lesion size ( conclusions: the only significant difference between the two groups was the operative time which was longer in the intervention group. conversion and complication rates were also higher in the intervention group but the difference was not statistically significant. based on the present data, adrenal gland size measuring more than 6 cm in diameter is not a contraindication to a laparoscopic approach. ; and orthopaedics and urologists for the remaining 6.6%.the costs from these claims, differed from 2 to 13% of the total damage burden per year. the review of medical charts of claims related to laparoscopic gynaecologic surgery showed that 82% of claims were filed for visceral and/or vascular injuries (40% bowel injuries, 20% ureter). 38% of the injuries were entry-related. a delay in diagnosing injuries was the primary reason for financial compensation. conclusion: evaluating and learning from complications and claims will improve medical health care. in contrast to overall trends and developments considering medical claims, claims concerning laparoscopic surgery decreased, possible due to a rising learning curve. considering laparoscopic surgery, extra caution is required at moment of entry and the early recognising complications and at pre-operative counselling from patients. the aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations. patients and methods: the study involved 112 patients with spleen injury grade iii who were admitted in our institute in the years of 2013-2018. the patients were divided on two groups. laparoscopic splenectomy was performed in 62 patients (group i) and 'traditional' splenectomy was carried out in 50 patients (group ii). there was no difference in the demographic data and trauma severity between the two groups.non-invasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations (us), x-ray in multiple views and computed tomography (ct) had been performed before the decision about necessity of an operation was made. results: patients after laparoscopic operations had better recovering conditions compare to patients with the same injury after 'traditional' splenectomy. neither surgery related complications no mortalities were registered in both groups. laparoscopic splenectomy was more timeconsuming operation than 'traditional' splenectomy. we suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced. conclusion: laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. the operation is indicated in patients with spleen laceration more than 3 cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (more than 500 ml/h on serial us examinations). the isolated hydatid disease of the spleen is a quite rare condition, liver and lungs being the most common locations. the treatment requires usually splenectomy, open or laparoscopic. there are few reports in the literature describing a spleen-preserving type of surgery. we present a case of a female patient, 51 y.o., with a large cystic lesion of the spleen, 11 cm in diameter. lab tests and ct scan confirmed that is a hydatid cyst. after albendazole treatment and vaccination the patient was referred to us for surgical treatment. the procedure was performed under general anesthesia and laparoscopic approach was performed with the intention to preserve the spleen. after the cyst was identified and adhesiolysis was done, the area was isolated from the rest of the abdominal cavity with sponges with a betadine solution in order to prevent contamination. a needle aspiration of the cyst allowed the evacuation of 550 ml of purulent content, an indicator of a dead cyst. betadine solution was injected into the lesion. laparoscopic excision of the cyst was performed using advanced electrocoagulation devices and the spleen removal was not deemed necessary. two drainage tubes were placed in the remnant cavity. an abdominal ultrasound was performed in the third postoperative day and no collections were identified. the postoperative outcome was uneventful; the patient was discharged in the 6 th postoperative day. the conclusion is that in selected cases, with the cyst located in the anterior part of the spleen, with proper equipment and experienced laparoscopic teams, the cyst can be successfully treated without splenectomy. deep neuromuscular block was induced with rocuronium 1.2 mg/kg. in group1, forty patients were enrolled for reversal of profound neuromuscular block during thyroid surgery (sugammadex 2 mg/kg, after identification of vagus nerve). in group 2, thirty-five patients were enrolled profound neuromuscular block during thyroid surgery(without reversal of nmbd). tof-watch acceleromyograph was recorded in response to adductor pollicis muscle for ulnar nerve stimulation in patients with both groups; recovery was defined as a train-of-four (tof) ratio = 0.9.to prevent laryngeal nerve injury during the surgical procedures, all patients were neurophysiologically detected using ionm. results: the total duration of surgery was higher in group 2 than group 1(63.7 ± 5.6, 82.5 ± 6.1;p \ 0.001). the mean time to recovery of the tof ratio to 0.9 was higher in group 2 than group 1(22.3 ± 2.6, 74.3 ± 5.0; p \ 0.001). the mean duration of vagus reverse (v1:3,5milisecond) was higher in group 2 than in group1(21.3 ± 1.7, 42.9 ± 5.1; p \ 0.001). no significant difference was found between left and right v1-v2 and r1-r2 values in group 1 following nerve monitoring, whereas in group 2, a significant difference was found between left v1-v2, left r1-r2 and right v1-v2 values ( introduction: oeosphagogastric oncology trials have often lacked robust methods of monitoring and surgical quality assurance (sqa), leading to difficulty in interpretation of trial results. this study aims to assess expert opinion regarding challenges to sqa in oncology trials and potential mitigating strategies. method: a purposive international cohort of 71 expert stakeholders with experience in oncology trials were recruited including: 35 surgeons; 17 oncologists; 10 trial methodologists, and; 9 trial managers. semi-structured interviews were thematically analysed using grounded theory. spss was utilised to assess differences between trial stakeholders' opinions. results: 389 emergent themes were identified and 74 consensus themes emerged on qualitative analysis of stakeholder responses. key consensus challenges to implementation of sqa in oncology trials included: insufficient resources; limitations of surgical volume in centre selection; differing oncological beliefs and resistance to change adoption; overly prescriptive protocols and standardisation contributing to difficulty in surgeon recruitment; and cultural factors leading to difficulties in providing and receiving feedback. seminal consensus mitigating strategies to overcome challenges to sqa in oncology trials included: trial centre selection according to case volume (n = 31, 44%); requirement for specific centre attributes for inclusion in trials including specialist centre designation and participation in national audit (n = 29, 41%); consideration for surgeons learning curve in surgeon selection (n = 33, 46%); flexible standardisation of trial operating (n = 22, 31%); operation manual utilisation to aid standardisation of surgical interventions (n = 34, 48%); case monitoring using video (n = 22, 31%) or photographs (n = 11, 16%); direct intraoperative observation by an expert (n = 15, 21%), and; histopathological assessment of resected specimens (n = 10, 14%). other methods of monitoring surgical quality advocated included: recording post-operative outcomes; lymph node yield; case report forms; and real time data monitoring (n = 32, 45%). oncologists were significantly more likely to state the importance of standardisation of surgery in oncology trials (p \ 0.05), and trial methodologists significantly more likely to advocate consideration of surgeons' learning curve in surgeon selection (p \ 0.05). conclusion: surveying international expert stakeholder opinion revealed a wide variety of perceived challenges across all domains of surgical quality assurance. proposed mitigating solutions require consensus opinion to formulate a framework to aid design of sqa measures within future oncology trials. research group did not register a single case of ega leakage while 2 patients in control group (? \ 0,05). had the leakage which was stopped by means of 'endovac' system. there were 2 cases of esophagus postoperative strictures which developed 3 months after the surgery in the research group which was less than in the control group which saw 6 cases of strictures of ega (? \ 0,05). 6 months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to 4 cases in the research group and 11 cases in the control group (? \ 0,05). there were 5 cases of esophagus postoperative strictures which developed 12 months after the surgery in the research group which was less than in the control group which saw 13 cases of strictures of ega (? \ 0,05). neither of the groups had any cases of post-operative mortality. purpose: to investigate the prognostic effects and risk factors of the omission and delay of postoperative chemotherapy of ii/iii gastric cancer (gc), with the goal of providing a reference for interventions of related departments. methods: the clinicopathological data of 1520 patients undergoing radical gastrectomy for ii/iii gc were collected and retrospectively analyzed. we defined the chemotherapy delayed until more than 60 days after radical gastrectomy and the complete omission of chemotherapy as unacceptable chemotherapy initiation (uac group), while the chemotherapy conducted within 60 days of radical gastrectomy was defined as acceptable chemotherapy initiation (ac group). the survival between the two groups was compared, and the trends and risk factors of uac were analyzed. results: the total number of patients who underwent totally laparoscopic distal gastrectomy with uncut roux-en-y and delta shaped billroth-i anastomosis was 244 and 214, respectively. the mean reconstruction time was longer in uncut roux-en-y than in delta shaped billroth-i, (30.5 ± 14.5 vs. 13.6 ± 10.3 min, p \ 0.001). the uncut roux-en-y was used more cartridge than delta shaped billroth-i anastomosis (6.9 ± 1.2 vs. 6.2 ± 1.0, p \ 0.001). however there was no significant differences in operation time, estimate blood loss, number of retrieved lymph node and postoperative course between reconstruction methods. postoperative complications more than clavien-dindo grade iiia occurred in 22 cases (4.8%) of postoperative early complications and 14 cases (3.1%) of late complications. the endoscopic findings showed excellent short and long-term outcomes in terms of very low incidence of bile reflux and reflux-induced remnant gastritis in uncut roux-en-y compared with delta shaped billroth-i anastomosis. conclusions: uncut roux-en-y gastrojejunostomy was a useful reconstruction method with totally laparoscopic distal gastrectomy for cancer, especially for diverting enteral contents from the remnant stomach and preventing remnant gastritis. therefore, it is recommended for young patients with early stage disease who have a long time to live after distal gastrectomy for cancer. operative technique: the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. when seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. the mucosa is then transected with a stapling device to execute fullthickness resection of the specimen. finally, the seromuscular defect is repaired by hand-sewn suture. results: since december 2015, clean-net has been performed in 57 patients with gastric smts. all tumors were resected en-blocwithout rupture. the average operation time ranged from 50 to 220 min with an average of 101.7 min. the postoperative course was uneventful. microscopically the surgical margin was tumor-negative (r0 resection) in all cases. the margin width was small with an average of 5.4 mm ± 2.5. conclusions: clean-net is a useful option in the laparoscopic surgical treatment of gastric smt, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided. background: the type of fundoplication-complete or partial is still controversial for the surgical treatment of gerd. laparoscopic toupet (270 0 wrap) fundoplication has less post op dysphagia and gas bloating compared to nissen fundoplication (360 0 wrap) and is advised to be the procedure of choice when esophageal manometry findings are abnormal, however it is considered by some less effective and more difficult to perform. the aim of this research was to determine in the functionality and efficacy of the different types of fundoplication. methods: explanted pigs stomachs weighing 45-60 kg were studied. two different studies of the les were performed: distensibility and failure point (occurrence of reflux according to volume added to the stomach). for both studies we first disrupted the lower esophageal sphincter using a rigiflex tm dilating balloon. we then performed three different fundoplications-nissen, toupet, dor and measured the distensibility of the egj after each fundoplication. the failure point was determined following each fundoplication type. results: we used 12 pig stomachs for the distensibility study and 11 pig stomachs for the failure point study. there was no statistically significant difference between the nissen and toupet fundoplications when distensibility was measured, however the egj was more distensible following dor fundoplication (p = 0.008 for nissen, 0.016 for toupet). when the failure point was measured, nissen fundoplication was significantly more effective than toupet, and toupet was significantly more effective than dor (p = 0.016,p = 0.017 respectively) conclusions: we studied the differences between the mechanical effects on the egj following three different fundoplications, encompassing 360 0 , 270 0 , and 180 0 of the esophagus. we demonstrated that there is a significant difference between dor fundoplication and nissen/toupet when distensibility was measured. there was no difference in the distensibility of the egj following a 360 0 or 270 0 wrap. there was, however a significant difference of effectiveness between all three fundoplications. these findings suggest that the 360 0 and 270 0 fundoplications have similar functionality while the 360 0 wrap mechanically prevents possible reflux and support proponents of toupet fundoplication rather than nissen due to the similar functional results while decreasing the post op dysphagia and gas bloating complications. surg endosc (2019) aim: to describe patients undergoing surgical treatment of incident gastro-oesophageal reflux disease and the use of anti-reflux treatment in a danish population-based cohort. methods: all adult danes 2000-2015 undergoing upper endoscopy and receiving a diagnosis of gerd within 90 days were identified. patients with previously diagnosed gerd, peptic ulcer-disease, barrett's oesophagus or cancer of the gastrointestinal tract were excluded. in this study, only patients undergoing anti-reflux surgery within two years of gerd-diagnosis were subsequently included. age, sex, charlson comorbidity index (cci), anti-reflux surgery (primary and re-operative) and endoscopic dilatation were identified using the danish national patient registry. mortality was identified using the national civil registry. pharmacological treatment of gerd (proton pump inhibitors, h \ su2 \/su-blockers and other prescription anti-reflux drugs) as well as use of nonsteroid anti-inflammatory drugs (nsaid) and anti-thrombotic treatment were identified using thethe danish national prescription registry. all data was linked on an individual level using the unique identification number that all danish citizen are assigned to at birth or first immigration. results: a total of 674 first-time fundoplications were performed, hereof 98.1% performed laparoscopically (n = 661) and 1.9% performed using open technique (n = 13). at one-year followup, 4.9% (n = 33) had undergone endoscopic dilatation and 2.1% (n = 14) had undergone reoperation. the 90-day mortality was \ 0.5%. patients had a median age of 46 years (18-80 years) and were predominately male (57.9%-n = 390). a total of 93.9% had cci 0 (n = 633). diagnoses were gerd with esophagitis (66.9%-n = 451), gerd without esophagitis (31.5%, n = 212) and gerd without specification (1.6%, n = 11). before initial endoscopy, 91,7% (n = 618) used at least one type of anti-reflux drug, dropping to 32.2% (n = 217) in the year after anti-reflux surgery. however, even when censoring patients with barrett's esophagus or peptic ulcer disease after initial endoscopy and patients undergoing concomitant treatment with nsaids or antithrombotic drugs, 27.7% still used at least one type of anti-reflux drug after surgery. conclusion: in this population-based study, anti-reflux surgery was safe and lowered the use of pharmacological treatment. however, even when adjusting for competing reasons for use of antireflux drugs, 27.7% used at least one type of anti-reflux drug one year after surgery. the new approach to perform nissen fundiplication m. paranyak, v. grubnyk surgery, odessa national medical university, odessa, ukraine nearly 10% of patients who undergo laparoscopic anti-reflux surgery at long-term follow-up need for surgical reintervention mostly because of hiatal hernia (hh) recurrence, wrap migration or disruption. purpose: the aim of our prospective study was to evaluate and compare several technics of wrap fixation and determine whether modified nissen fundoplication(mnf) reduce failure rate in the long term follow up. materials and methods: this was a prospective, randomized, controlled trial. from november 2012 to october 2014 one hundred and thirty-eight gerd patients who underwent anti-reflux surgery were divided into two groups. excluded criteria for our study ware diagnosed hiatal hernia (hh) type iii. in the i group which include 87 patients we performed the following manipulations: nf was supplemented with suturing wrap to the diaphragmatic crura (52 patients) on each side using two non-absorbable stitches. such technique permit us to create more symmetrical wrap. in case of weak conditions of crura or short esophagus (35 patients) fundoplication wrap was sutured to the body of stomach using two non-absorbable stitches on each side. control group (51 patients) underwent classic nissen fundoplication (nf) without wrap fixation. all patients were assessed before and after surgery using validated symptoms and quality of life (gerd-hrql) questionnaires, 24-h impedance-ph monitoring and barium-swallow. results: baseline characteristics were similar between groups. there were no conversion to open procedure or mortality. mean hospitalization was 2.7 days ± 1.4 days. at 41,6 months (range 18--57) of followup, the overall rate of complications after mnf was 1,14% (1 hh reccurence) and nf 7,84% (3 hh reccurence, 1slipped wrap). patient in mnf group show significant improvement in gerd-hrql score, from 19.3 ± 13.2 (preoperatively) to 4.3 ± 3.9 (postoperatively) (p? \ ?0.001). complete ppi independence was achieved in 91%. in the ii group of patients mean gerd-hrql score decline from 18.7 ± 11.9 (preoperatively) to 9.3 ± 7.7 (postoperatively), postoperative ppi treatment was necessary in 29%. conclusions: according to our study mnf minimized risk of slipped wrap and intrathoracic migration of the wrap and can make positive impact on reducing the failure rate of laparoscopic anti-reflux surgery. aims: comparative evidence across laparoscopic antireflux procedures does not exist. aim of this project was to identify direct comparative evidence between laparoscopic antireflux procedures and synthesize evidence using network meta-analytical methods. methods: the databases of medline, amed, central, opengrey were interrogated. pairwise meta-analyses for each pair of interventions using a random-effects model and network metaanalysis in stata was performed using the mvmetacommand and self-programmed stata routines. differences between direct and indirect evidence were explored by comparing direct and indirect estimates though computing the inconsistency factor within each closed loop of evidence. the ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmetacommand in stata. a hierarchy of the competing interventions was obtained using rankograms. quality of evidence was assessed using grade-nma and the cinema application. results: forty-three publications reporting on 32 randomized trials and some 1892 patients were identified. the network of treatments formed a closed loop between 270°, 360°and anterior 180°; and star network between 360°and other treatments; and between anterior 180°and other treatments. laparoscopic 360°, 270°, anterior 180°and anterior 90°were equally effective in the control of heartburn and this was supported by low quality of evidence according to grade-nma. the odds for dysphagia were lower for anterior 90°(high quality evidence), anterior 120°( moderate quality evidence), 270°(moderate quality evidence) and proton-pump inhibitors (moderate quality evidence) compared to 360°. the odds for gas-bloat were lower for 270°and anterior 90°compared to 360°(low quality evidence). the odds for regurgitation, morbidity and reoperation were similar across treatments, albeit these were associated with very low quality evidence. anterior 120°had a 49% probability of being the best treatment in terms of dysphagia. conclusion: under consideration of treatment effect estimates, evidence quality as assessed with grade-nma and other parameters, anterior 90°, anterior 120°and 270°should be preferred over 360°. further research needs to focus on the comparison between 90°and 120°/270°. aims: we have recently demonstrated that the tension of crural closure can be reliably measured intraoperatively (alsgbi conference december 2018). the aims of this study were to further characterise tension at the diaphragmatic hiatus from our prospective pilot study of 72 patients. methods: a prospective analysis was performed of patients undergoing laparoscopic hiatal hernia repair between april 2017 and december 2018. 72 patients underwent crural tension measurement intra-operatively. 24 patients had a pre-operative ct scan of the abdomen within one-year of surgery. hiatal surface area (hsa) was measured intraoperatively and a sauter-fh50 universal digital force gauge was used to measure the tension of crural closure during cruroplasty. outcome measures included the mean tension of the crural closure and the presence of muscle splitting during the cruroplasty. results: for all patients, the mean crural tension measurement was 2.93 n and the mean hsa was 543 mm 2 . pre-operative ct was positively correlated with post-dissection intra-operative hsa (r = 0.5402, p = 0.0064), however, strength of association was weak (r 2 = 0.2918) and ct consistently overestimated the size of hiatal defect intra-operatively (mean of differences 404 mm 2 , p = 0.0016). crural tension was positively correlated with age (r = 0.3321, p = 0.0044), hiatal height (r = 0.6023, p \ 0.0001), hiatal width (r = 0.766, p \ 0.0001) and hsa (r = 0.7753, p \ 0.0001). crural tension was correlated to the hiatal width to height ratio to assess the shape of defect and there was positive correlation (r = 0.4072, p = 0.0004). tension was calculated for the posterior and anterior halves of the suture cruroplasty. anterior tension was significantly higher when compared to posterior tension (3.26 n vs 2.59 n, p \ 0.0001) . 16 patients had evidence of muscle splitting during the cruroplasty. the group with muscle splitting were significantly older (66 vs 53, p = 0.0029), had larger hsa (910 mm 2 vs 347 mm 2 , p \ 0.0001) and higher crural tension (5.69 n vs 2. 14 n, p \ 0.0001). the lowest observed mean crural closure tension causing muscle splitting was 3.52 n. conclusion: there is now a possibility to optimise this operation with objective measures 100 years after it was first described. initial findings suggest that crural closure up to * 4 n could be the permissible tension threshold for suture cruroplasty and higher tension may benefit from the use of mesh reinforcement. background: endoscopic submucosal dissection (esd) and endoscopic full thickness resection (eftr) are advanced endoscopic techniques which can be time consuming using traditional endoscopic instruments. a new endosurgery platform, designed by fortimedix surgical, was developed featuring flexible articulating instruments to use in combination with a standard flexible endoscope. the platform is intended to perform endoscopic cutting, dissecting, and hemostasis. aim: evaluate feasibility of the platform in the upper gi-tract. project description: the platform was tested in a dry esophageal model as well as a second series with a porcine esophagus and stomach. the system has an external docking station affixed to the operative table to stabilize both flexible instruments for the right and left hand of the surgeon. at the tip of the endoscope, a cap containing instrument lumens is attached to allow advancing and removing the flexible instruments. the endoscope with the cap and instrument lumens attached is advanced via an overtube with outer diameter 18.5 mm. in the first series, flexibility and range of motion of the endeffectors was assessed. additionally, the ability to advance the instruments to the intraluminal target area from the docking station and along the scope was evaluated. in the second series, the functional capabilities of the system and instruments were evaluated in a porcine model. preliminary results: : in the dry model, the platform was adequately deployed to the target then range of motion was tested as well as cutting and grasping gastric wall with instrumetn triangulation achieved. the grasping forceps provided enough force to pull the mucosal wall and expose the dissection plane. in the pig model, the distal esophagus and stomach could successfully be accessed and platform deployed. esd was performed using newly designed flexible articulating scissors, dissection-hook, and graspers with good triangulation and sufficient grasping force with traction/counter-traction. the new fortimedix surgical endo-surgery platform applied to a standard flexible endoscope is feasible to perform esd. future studies are planned to determine learning curve and compare it to traditional endoscopic instruments. background: in laparoscopic surgery, we usually observe the organs in the same direction to avoid a mirror-image situation. therefore, we are unable to recognize how far the dissection has proceeded on the other side of the target organs or lesions, especially when the plane of dissection is under the mesentery or organs. this becomes a problem not to understand how far the dissection has progressed and how much more dissection is needed. aim: to solve this problem, we developed a laparoscopic device with tip illumination. project description: the device is configured by the long and narrow part made of polycarbonate resin and a battery-powered light-emitting diode to illuminate the tip by shining light through the polycarbonate resin. during the surgery, the tip of the device is inserted into the deepest part of the dissection area, and the transmitted light indicates how far the dissection has progressed. the tip of the device has a prism structure and light is emitted in a direction perpendicular to its axis. tip position can thus be more clearly identified even with insertion in the same direction as the laparoscopic view. to verify the utility of this instrument, laparoscopic surgeries were performed in a porcine model and cadavers. preliminary results: we performed some laparoscopic surgery such as the medial-to-lateral approach to the white line of the left side of the descending colon for sigmoidectomy, dissection of the posterior surface of the pancreas to the upper edge of the pancreatic body or splenic artery for distal pancreatectomy, and the separation of the anterior surface of the inferior vena cava from the liver to the area between the right and middle hepatic vein for right hepatectomy. we quickly and easily identified the deepest part of the dissection area even if identification had been difficult using other techniques such as placing gauze in the deepest position, inserting forceps into the dissection area or simply depending on the experience of the operator. background: recent advancements within surgery have seen artificial intelligence transform traditional approaches. robotic assistive devices have demonstrated particular success, as safe and cost effective, and are widely supported via industry and local government as a step closer to the future standard of practice. an example of seamless and touchless robotic assistive technology is based on touchless and interactive eye tracker glasses worn by the surgical team thereby enabling the team to perform wider surgical tasks, more efficiently and reduced human error. we introduce a perceptually-enabled, smart operating room (smart-or) based on a novel real-time framework for theatre-wide 3d gaze localisation in a mobile fashion. this framework enables dynamic gaze based user interaction with a robotic scrub nurse to facilitate meaningful practical integration of human and technology intra-opertively. aims: we tested participant acceptability of a novel robotic scrub nurse during simulated surgery. project description: surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses to select surgical instruments on a screen. the robotic scrub nurse(rn) picked up and transferred the instrument to the surgeon. the study compared human nurse(hn) vs rn. gaze-screen interaction was based on a 3d gaze framework we developed with synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for real-time 3d reconstruction of the environment. nasa-tlx and van der laan's technology acceptance questionnaires were collected and analysed using anova. preliminary results: overall, 7 teams of surgeons(st) and scrub nurses(sn) participated. nasa tlx feedback for st and sn revealed no significant difference between in mental, physical or temporal demand. importantly, st and sn reported no significant difference in task overall performance. st reported more significant frustration with rn vs hn. van der laan's scores showed positive usefulness and satisfaction scores in using the rn platform. overall, all outcomes were more positive by sn vs rn. conclusions: this is the first platform of its kind. overall, quantitative and qualitative feedback was positive. the source of frustration has been understood and we believe it can be improved by appropriately modifying robot behaviour. importantly,there was no difference on perception of performance. background: endoscopic tumor resections in the gi tract may be facilitated by more advanced instruments for dissecting and suturing. we have focused on developing an endoscopic suturing technique using a standard flexible pediatric endoscope with new, flexible instruments allowing for complex end-effector movements. aim: perform flexible endoscopic suturing using a standard flexible scope in the gi tract project description: a standard flexible pediatric endoscope and a standard gastroscope were used for testing the new technique. via an overtube, the endoscope and newly designed fortimedix surgical flexible instruments (needle holder; grasper) with a diameter of 5 mm were inserted into the esophagus. suture training was performed in an experimental setting in a box in the dry lab and porcine model . the flexible needle holder was advanced into the esophagus next to the scope, and a suture of the esophageal wall was performed, followed by extracorporeal knot-tying with 3 knots. the test series consisted of training with both resident trainees and surgeons to evaluate the learning curve. each participant performed sutures on the box model and in the pig-esophagus. feasibility, duration of the different steps, and handling problems were documented. preliminary results: test series 01 (box training on esophago-gastric explant) with prototype 01 showed good feasibility. suturing was possible in 9 out of 10 attempts. median duration for single bite: 6 min (5-30); knot-tying: 5 min (2) (3) (4) (5) (6) (7) (8) . test series 02 (training in pig-model) with prototype 02 showed improved feasibility with better flexibility of instrument shaft: median duration of double bite: 8 min (7-15); knottying: 2 min (1) (2) (3) (4) (5) , overall duration intraluminal esophageal double bite suture and closing with 3 knots: median duration: 13 min (12-20). the new flexible endosuture instruments seem feasible to use and perform dependable intraluminal sutures. the training period and learning curve is short and the objective is to apply this system clinically for closure of perforations and fistulas. school of mechanical and aerospace engineering, nanyang technological university, singapore, singapore; 2 general surgery, national university hospital, singapore, singapore; 3 gastroenterology, national university hospital, singapore, singapore; 4 surgery, chinese university of hong kong, hong kong, hong kong background: ideally, endoscopic suturing should mimic surgical closure as the latter is stronger than most endoscopic closure devices. however, endoscopic suturing is challenging due to the confined endoluminal space and lack of dexterity of current endoscopic instruments. we have developed a novel robotic suturing device to overcome these problems. aim: this animal study aims to demonstrate the feasibility of this device in closing perforations. method: the trial was conducted on an anaesthetized live pig. a double-channel colonoscope was first inserted into the rectum. following saline lift, a 10 mm submucosal incision was created in the rectum to simulate a perforation. the robotic suturing device and grasper were inserted into the two colonoscope channels, allowing the endoscope to remain in position for tool exchanges or needle reloading. both the effectors were intuitively tele-operated by the user via a robotic master console. this robotic suturing device manipulated a curved, double-point needle (with a 10 cm 3-0 vicryl suture) to penetrate tissues at desired orientations. the needle could be switched between both jaws of the device through a locking mechanism. this facilitated passing the needle through tissues to form stitches or through suture loops to form surgical knots. the articulated joints and five degrees of freedom allowed dexterous steering to reach targets and triangulation with other tools in a confined space. the robotic grasper facilitated handling of tissue and suture. result: a total of four running stitches were performed and secured with a surgical knot by passing the needle through suture loops. the suture was cut and the needle was removed by the robotic grasper through the channel. 11 min and 4 min were required to stitch and tie the knot respectively. there was no complication. conclusion: our novel endoscopic robotic device can suture perforations resulting from complex endoscopic procedures. as our suturing method is similar to laparoscopic and robotic suturing, closure using our device is expected to be as strong as a surgical through-and-through closure. when developed further, this device can be used to close full-thickness resection sites and orifices in transluminal endoscopic surgery. modelling a collaborative robot with the ieee 11073 sdc standard for combined focused ultrasound and radiation therapy j. berger, m. unger, l. landgraf, a. melzer medical faculty, university hospital leipzig, innovation center computer assisted surgery, leipzig, germany background: surgical robotics require a smooth integration into the operating room (or) . for this propose the ieee 11073 sdc(service-oriented device connectivity) standard has been developed in the or.net project. in preparation for a combined focused ultrasound and radiation therapy (fus-rt) we have shown concepts and evaluations to position ultrasound and interventional devices with collaborative kuka arms. however, the safe and intraoperative cooperation with multiple different or-devices (e.g. an irradiation unit) requires a more sophisticated exchange of the robot's information and functionality. aim: to realize a safe clinical integration, the aim of this work is to implement and evaluate a dynamic connection between the kuka robots and other devices using the vendor-independent sdc communication standard. project description: a kuka lbr iiwa 7 r800 robot (kuka ag, germany) was modeled inside the sdc standard for medical device communication. the interconnection with other devices was implemented and evaluated on a mobile platform to position a clarius l7 wireless ultrasound transducer (clarius mobile health corp, canada). all necessary information of the robot was represented in the medical device description of the sdc standard to be shared via network. for each joint of the robot arm the position, torque, stiffness, damping, velocity and functional-states were represented, resulting in a total of 42 parameters. the software was implemented in c ?? on a standard pc accessing the kuka controller cabinet with ros (robot operating system) via ethernet. the accessibility of each parameter, as well as activation commands for planning and movement were tested with an sdc-consumer application. preliminary results: the sdc-provider functionality of the robot was successfully implemented, allowing for dynamic changes of the robot state during interventions. all appliances (sdc standard compatible) in the robots network can react to state changes and send movement and planning commands to the robot via activations. after testing, 100% of the 42 defined parameters are safely accessible. implementing the medical device communication for the kuka robot enables its integration into any networked operation room that supports the sdc standard. it is, therefore, ready to be set up and evaluated for the application of fus-rt in a clinical environment. background: assessment of perfusion of the left colon with fluorescence during anterior resections for cancer changes surgical decisions in up to 19% of cases. use of fluorescence has been shown to be associated with lower leak rates, and improved short-and long-term outcomes with reduced costs. given the high incidence of colorectal cancer, fluorescence-guided perfusion assessment could be of great importance in contemporary surgical practice. however, there is currently no standardisation of this technique which represents a significant limitation to widespread adoption. aim: to standardise fluorescence-guided perfusion assessment in rectal anterior resection through a computer vision algorithm. project description: videos were collected by a single surgeon in a referral centre for colorectal cancer treatment. perfusion assessment was used before proximal colon division to identify the best location for transection. a bolus of indocyanine green was injected intravenously and a near-infrared camera used to assess perfusion through fluorescence. photographs of fluorescent imaging of the colon were analysed using a non-supervised learning algorithm called 'k-means clustering'. the first step was to digitally subtract all background pixels, leaving only the area of interest of the colon. this area was then subsegmented into 2 'clusters' corresponding to perfused and nonperfused areas. a mathematical model was applied based on the 2 sub-clusters centres to select the area for transection with optimal perfusion of the proximal colon. preliminary results: representative images of proximal colon under perfusion assessment were presented to 8 expert surgeons. the optimal point for transection was selected based on their clinical judgement on previously delimited areas indicated by random letters. this was compared with the results from the automated segmentation using the algorithm ( fig. 1 ). the area identified for section by the algorithm included the area selected by the expert surgeons in 87.5-100% of test cases. these results need to be further validated due to high risk of overfitting. next steps include the collection of multicentre data with a standardised fluorescence perfusion assessment. after robust training, the algorithm will be validated on real-time clinical data to ensure improved outcomes for patients, which is our ultimate goal. background: endoscopic submucosal dissection (esd) is a flexible endoscopic technique that allows for an en bloc removal of lesions of the gastrointestinal (gi) tract. these procedures are typically time consuming due to the difficult control of the tools, and they often require around 95 min for removing lesions, that can reach 3-4 cm in diameter. the probability of intestinal perforation exceeds 18% and the hemorrhage risk ranges from 3.5% to 15.5%. a flexible robotic endoscope may offer a solution to overcome these limitations, by improving the degrees of freedom (dof) and operational efficiency. aim: within this clinical panorama, the aim of this project is presenting the development of a novel miniaturized robotic device to be coupled to the tip of a traditional endoscope for the surgical dissection of gi neoplasms. project description: the robotic platform consists of the miniaturized robot, the actuator housing (hereafter called external platform), the control unit and the master console (i.e.,two geomagic touch phantom) to allow the user driving and control (figure 1a ). during the operation, one surgeon stands close to the patient to maneuver the endoscope for exploring the gi tract and reaching the target area. another surgeon operates the miniaturized robot through the master console, carrying out the surgical procedure. the robot has been designed to be coupled to the tip of traditional flexible endoscopes of 14.5 mm in diameter. it exploits the flexibility of the endoscope for navigation through the intestine and integrates two-active robotic arms (i.e.,cautery and gripper) extending the dofs, and thus enhancing the efficiency during complex tasks such as manipulation and surgical tissue dissection. furthermore, the endoscope provides the optical system for visual feedback and one working channels for conventional instruments. preliminary results: firstly, a mock-up that faithfully reproduces the miniaturized robot has been realized using a 3d printer machine (projet mjp 3600, 3d system, inc.) to verify the feasibility of the design solution. after verifying the potentiality of the 3d printed prototype, a final device, with the same features (i.e.,dof and geometry) of the 3d printed prototype, has been designed, fabricated and assembled ( figure 1b ). background: virtual and augmented reality has been widely used in many fields mainly for entertainment purposes. we think that it could be beneficial to use augmented reality in medical practice. aim: the aim of this study was to evaluate usefulness of 3d holographic images of patients anatomy displayed using augmented reality goggles during endovascular aortic repair (evar). project description: one of the major challenges during endovascular procedures is working on two dimentional x-ray images of three dimentional vascular anatomy. using 3d holograms of patients anatomy could be beneficial during the evar procedure and could make the orientation in vascular anatomy easier for surgeon. we performed two endovascular aortic repairs with the assists of microsoft hololens -smart glasses using augmented reality. we used carna life application created by polish company medapp. it was one of the first use of holograms during vascular procedures in the world (second and third stent-graft implantation using holographic imaging in the world). results: two patients with abdominal aortic aneurysms, 79-years old male and 74-years old female, were operated on. holograms of patient's anatomy made from preoperative angio ct scans by polish company medapp were displayed during the procedures using microsoft hololens. holograms could be displayed in any place and configuration using augmented reality, which means that the images did not interfere with the surgeon's field of vision. microsoft hololens use voice commends which permits the surgeon staying sterile. stent-graft implantations were successful. both patients were discharged three days after the procedure and the hospitalization was uneventful. seeing precise patient's vascular anatomy reconstructions in three dimention certainly helped us to navigate in a vascular tree. we believe that in the future this technology would enable to reduce the operation time and need for radiation. background: interaction with electronically controlled operating room (or) systems embedded in modern surgical environments is everyday practice for surgeons performing minimally invasive surgery (mis). while there is a non-sterile operating nurse available in the or, capable of interacting with these systems upon request by the surgeon, this indirect control is mostly slow, prone for error and disrupting surgical workflow. facing an unanticipated and unwanted outcome may cause distress emotions. distress emotions are undesirable when performing surgery, since they may impact available cognitive workload. furthermore, they may result in negative communication, hampering or-team empowerment and effective leadership. both factors are known to negatively influence quality and safety in the or. aim: the aim of the tedtrial is to investigate what setup best enables surgeons to interact with the endoscopic operating room setup during surgical procedures. as a result, disruptions of workflow, delays and errors may be reduced. outcome parameters will be objectified using medical data recorder (mdr) derived output and biometric analysis using hexoskinó. subjective evaluation of outcome parameters is done using questionnaires. project description: the tedcubeó system is a plug-and-play device enabling wearable sensors to act as a wireless alternative for a regular computer mouse, therefore enabling direct hands-free and sterile control of the or. the study is an observational trial with three different arms: intervention group 1) direct interaction by surgeon with or environment using tedcubeó and myo tm armband, intervention group 2) direct interaction of surgeon with or environment using tedcubeó and plantronicsó wireless microphone headset. the third arm is the control group using indirect interaction of surgeon with or environment using third-person computer interaction. main endpoint of study is the number of workflow disruptions due to the operation of laparoscopic or equipment. secondary endpoints are error rate, delay, team communication, subjectively reported frustration and satisfaction with the system and objectively measured stress as symptom of frustration and anger as distress emotions. preliminary results: primary and secondary endpoints of study are compared among groups. it is anticipated that reduction of miscommunication, error and delay may result in a reduction of distress emotions. trial start is expected q1 2019. anticipating the automated intraoperative tissue recognition: intraoperative tissue classification using hyperspectral imaging and machine background: iatrogenic injuries may occur despite a sound expertise in surgical anatomy. hyperspectral imaging (hsi) is an emerging optical method, combining the use of a camera system with a spectrometer. hsi analyzes optical properties of tissues and acquires 3d data sets with two spatial dimensions (x, y) and one spectral dimension (?). the data sets contain information about tissue physiology, composition, and perfusion. those spectral features coupled with machine learning algorithms might allow for automatic tissue recognition. aim: assessing the ability of an hsi-based machine learning to discriminate the hyperspectral features of different tissues during neck and abdominal surgical procedures. methods and procedures: fourteen pigs underwent laparotomy (n = 6) or neck dissection (n = 8). twenty data sets were acquired in vivo from abdominal organs and 20 from neck structures by means of a customized hyperspectral camera (diaspective vision, germany). different anatomical structures were manually outlined by a surgeon using an image manipulation software (gimp). each pixel contained a hyperspectral curve and each curve was composed of 100 bands (from 500 to 1000 nm with a 5 nm resolution). the curves were normalized using the standard normal variate method. a logistic regression machine learning (ml) algorithm was used to train the model to discriminate tissues, based on the hsi spectral features. the efficacy of the prediction model was tested using the k-fold (k = 10) cross-validation. results: a large number of tissue-related hyperspectral curves could be extracted (4675 thyroid, 9417 vagal nerve, 48546 fatty tissue, 30486 cartilage, 16001 carotid artery, 81567 muscle, 5149 carotid vein, 7148 portal vein, 22973 biliary tract, 73940 gallbladder, 1874 hepatic artery, 16712 pancreas, 2412 duodenum, 34313 abdominal adipose tissue). the algorithm used 4 min to 'learn' all data sets, and prediction was provided as an immediate output. overall, prediction accuracy was 92 and 89% for neck and abdominal structures respectively. in particular, biliary ducts could be identified with a 93% accuracy and the vagal nerve with an 89% accuracy (see figure 1 for details). background: a gaze-controlled robotic endoscope is innovative technology with myriad potential applications in the rapidly advancing field of flexible endoscopy. improvements to the current flexible device to allow examination of the gastrointestinal tract whilst minimising procedural discomfort and complications are desirable. aim: to use a gaze contingent framework to manipulate a flexible endoscope through a simulated upper gastrointestinal tract (ugit) model. description: a flexible gastroscope (karl storz 13801 pks) was attached to a ur5 6 axis robotic arm (universal robots), mounted onto a rail and placed on top of a surgical table. two cogwheel shaped dials were 3d printed and placed onto the up/down and left/right wheels on the head of the gastroscope ( figure 1 ). robotization of these controls was achieved by using two motors (dynamixel rx-24f) to steer the distal tip. this system allows users to operate a robotised flexible endoscope using gaze control. gaze interaction with the screen was based on a 3d gaze framework we developed with the synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for 3d reconstruction of the environment. users are able to control endoscope movements without handling the device. the distal tip of the gastroscope was controlled using eye gaze technology. the ur5 robot was used to enable shaft rotation (initiated by fixed head movements) and linear movements were triggered using a joystick handle (up for forward movement, down for endoscope withdrawal). pause and retroflexion of the endoscope are achieved by moving the joystick left and right respectively. users were asked to navigate an endoscope through an ugit model (chamberlain group) simulating a diagnostic gastroscopy using gaze control and targeting ten points scattered through the stomach. results: four expert endoscopists and one novice used gaze control to successfully navigate a gastroscope through a simulated ugit. all were able to intubate the oesophagus and accurately locate ten targets placed in the fundus, body, antrum and pylorus of the stomach. conclusion: gaze control endoscopy is a feasible concept. it allows ergonomic, user-friendly and intuitive control whilst maintaining the benefits of a flexible endoscope. background: image-guided needle biopsies and histopathological evaluation are the gold standard for the diagnosis of liver neoplasms. most often, however, these are reserved for suspicious, but not diagnostic, situations. radiomic may help to characterize tumor biology by correlating imaging features with relevant tumor-biology information. features derived from radiomic analysis may provide complementary information to support clinical decisions, especially in situations where tissue analysis cannot be performed or is inconclusive. aim: the goal of our technology is to exploit computational capabilities for image analysis in order to identify radiomic features useful for characterizing liver lesions and to identify relevant information related to patient prognosis. project description: 17 patients derived from an internal database and 12 patients randomly extracted from the cancer archive liver dataset were included in this study. 56 lesions were extracted from those volumes using expert annotations (31 secondary vs 25 primary; 34 well differentiated vs 22 non-well differentiated). lesions were then split into training and testing sets. first order statistical features were computed and a lasso regression step was performed to reduce the number of features. both logistic regression and random forest models were built using cross-validation to predict the target classes on the test set. preliminary results: only 2 features namely the energy and the volume of the lesion were sufficient, when combined in either model, to predict the differentiation grade on the test set with an f1-score of 0.74(± 0.07). we are currently working on the addition of higher order statistical features to the analysis in order to differentiate primary from metastatic tumors and identify complementary features that may assist clinical decisions in patients with inconclusive hepatic lesions. objective of the technology or deviceideally, the use of medical simulators could provide trainees with initial background information about indications for procedures, endoscopic technique, and early hands-on training experience that could shorten the initial critical learning curve. rationale for using ex vivo models is that in the beginning of the learning curve, the most important issue is having an initial exposure to the basic movements and maneuvers. our objective of is to create a stomach model from renewable polymer, which would closely simulate normal human stomach with gastric pathology for endoscopic diagnostic or interventional skill acquisition/evaluation. description of the technology and method of its use or application stomach model is based in several steps; the first one is in the in-silicodesign of the overall shape, after that we 3d print the positive two halves of it. the interior detail is obtained shaping the 3d printer parts with ceramic putty. once concluded, this elaborated part will serve as a template in order to build injection bleeding moulds. in the injection bleeding moulding a mesh is placed between layers in order to provide structural attachment points as stiches or several pathological models that will be incorporated after the casting process. we have developed for these instance polyp moulds, fistulae structures in order to attach endoscopic clamps. the two halves are closed once the pathological models are placed inside via a thermic-fusing and stitching creating a leak proof stomach model. preliminary results if available: our models were evaluated by 8 international experts in ircar/ihu france in interventional endoscopy course and were favorable accepting for next trails in these prestigious institutions. conclusions: future directionsa new endoscopic training model of stomach was made and will be evaluated and validated for feasibility in mastering diagnostic and interventional endoscopic skills. clinical trials will be necessary to compare the ability of the simulator to perform training compared with traditional methods of training in endoscopic procedures. background: endoscopes are the eye of surgeons in minimally invasive surgery (mis). conventional endoscopes are mostly chopstick-like and are steered by the assistant. this limits the field of view and results in issues such as endoscope-instrument fencing, surgeon-assistant coordination. existing robotic endoscope holder enables solo-surgery, however endoscope remains blocking the instrument movement and impairs the operational safety. flexible endoscope such as the endoeye provides angulation at the tip and could enlarge the field of view. however, its steering the view is much more complex compared to the rigid endoscope. aim: to provide an intuitive robotic flexible endoscope with enhanced safety. project description: in this work, we present a robotic flexible endoscope for mis with enhanced safety. in the proof-of-concept system, it contains a flexible endoscope module and a robot manipulator. the endoscope contains a proximal rigid shaft and a distal flexible bending section. it is installed onto the patient side manipulator (psm) of the da vinci research kit (dvrk). visual servoing is adopted to achieve autonomous instruments tracking. during the tracking process, movements of the manipulator as well as the endoscope are minimized to save space for the operation and avoid instrument-endoscope fencing. the endoscope could also be controlled by the surgeon. a foot pedal is used to switch between the tracking-mode and control-mode. preliminary results: a prototype was developed and tested experimentally. in tracking a volume of 200*200*100 mm 3 , the spaces required by the flexible endoscope are 15.55% (inside the trocar) and 9.83% (outside the trocar) of that occupied by the rigid endoscope. evaluation with the fls tasks involved 10 subjects. all of the participants completed the tasks under the tracking-mode without failure. in the ex-vivo test with porcine stomach, the endoscope successfully guided the detection, dissection and knotting autonomously. background: fluorescence imaging allows to visualize deep-seated anatomical structures, using a deeper tissue penetration of near-infrared (nir) compared to visible light. the most commonly used fluorescent substance, indocyanine green (icg), is not naturally excreted by the urinary system and requires retrograde stent placement and injection. lighted catheters have been proposed to help visualise the ureter. fluorescent dye-coated ureteral catheters could well represent a more effective and less expensive solution. icg is unsuitable for coating materials. aim: to develop a stable fluorescent coating for catheters to be used intraoperatively, working in the same nir window as icg, to facilitate its use with clinically available systems. project description: the coating was developed based on poly(methyl methacrylate) (pmma), a biocompatible polymer, and on specifically designed fluorescent dyes exhibiting icg-like optical properties. three nir dyes (substances a, b, and c) were tested in order to find the optimal one, in terms of fluorescence signal intensity, and were compared to icg in a polymer form and to an icg-based reference card (green balance tm ). the fluorescent coating was applied onto 3 common ureteral stent materials: hydrophilic-coated ultrathaneò, silicone-coated latex, and pvc. the coating process involved 3 cycles of immersion into the respective dyes blended in pmma polymer (icg, substances a, b, and c), followed by a drying phase. the various tubes were partly inserted into a porcine ureter, next to the icg-based reference card. images were taken in white light and nir modes using the d-light p camera system (karl storz), at a fixed camera-to-target distance. the fluorescence signal intensity was measured for the different regions of interest (each material/coating combination inside and outside of the ureter, reference card) using proprietary software and normalised against the reference card. preliminary results: the signal intensity was significantly higher for all new substances as compared to icg. substance a showed the strongest fluorescence signal intensity among the tested coatings in all tested conditions and materials and was identified as the ideal candidate to undergo further evaluation and in vivo testing. background: endoscopic resection(er) of early gastric cancers provides tremendous patient advantages. however, post-resection findings of deeper sub-mucosal(sm) and/or lympho-vascular invasion can necessitate a second, surgical intervention. we propose that pre-resection evaluation of the submucosal architecture under the tumour can provide critical information for staging and operative planning. we evaluate three techniques to assess the submucosal architecture underlying the gastric mucosa in a pig model. aim: to evaluate three needle-based methods of evaluating the sm before er. project description: 6 acute pigs were used. a simulation of sub-mucosal tumours (endoscopically and eus visible bleb) by injecting the sm with 20 cc of undyed nac. a linear eus was use for all procedures. the tumours were marked and labelled according to geography. methodology: after creating the tumours, anterior lesions were evaluated using the following 19g needle-based modalities: confocal microscopy(cm) using the through-the-needle cellvizio (mauna-kea) system; mini-biopsy(mb) using the micro-biopsy forceps moray (us endoscopy) and fine-needle biopsy(fnb). results: 18 cm examinations were video recorded in all a positions. submucosal vascular visualisation was possible in all cases, excellent in 17/18. mb was performed in 18 lesions with a total of 2 biopsies obtained from each lesion (total = 36). fnb was performed once in the anterior lesions and twice in the posterior lesions with different needle brands. therefore, there was a total of 54 biopsies collected. 2 passes were performed in each biopsy (total = 108). each pass constituted 20-25 insertion/withdrawal movements combined with fanning, slow pull technique, no suction and suction (10-20 cc air negative pressure) to collect the material. all material were sent to an animal anatomo-pathologist blinded to the acquisition method. mean time of confocal examination was 15 min 8sec (6'02' '-30'59'') . mbtook a mean time of 5 min and fnb was a mean of 10 min for each biopsy. cm identified different patterns of vessels in relation to the probe position (superficial/reticular, middle cross-roads or deep/longitudinal). conclusion: eus-fnb, cm and mb are three potential methods to assess the sub-mucosal space underlying the gastric mucosa. cm offered the most architectural information but required more time to perform. these method's may have a role in better staging patients for appropriate er. background: the overall and disease-free survival of patients with rectal cancer is dependant on its staging, and adequate selection of the treatment strategy. mri has a proven efficacy in rectal cancer local staging and recognition of the adverse prognostic features. however, it can be difficult to utilise it as a navigation tool for surgeons, as it represents a complex three-dimensional pelvic space with a series of individual two-dimensional images. 3d image reconstruction has been successfully adopted in other surgical fields to overcome these limitations. aim: our primary aim is to develop a bespoke automated generation of patient-specific 3d pelvic models, which will improve surgical planning and navigation, patient interaction and surgical education. true-size, rotatable 3d models will offer a more realistic three-dimensional representation of the surgical space and its complex relationships, allowing for a more confident surgical rehearsal and potentially better utilisation of minimally invasive techniques in rectal cancer management. our secondary aim is to develop a large multipurpose database of the 3d models of male and female pelvis in health and in the disease. project description: our multidisciplinary team consists of colorectal surgeons, radiologists specialising in pelvic mri imaging and computer scientists. virtual 3d pelvic models are generated based on standard 2d dicom mri images routinely used for rectal cancer staging, which guarantees the high fidelity of cancer delineation. segmentation of the pelvic anatomy is performed with the use of itk-snap, an open-access, multi-platform software. machine learning technology is then employed to automate the 3d model generation, making it time-efficient, allowing for its clinical application. preliminary results: in the initial stage, using the manual segmentation, we have created ten models of normal male and female pelvic anatomy. a good inter-rater agreement level was found, which proves reproducibility of the approach applied. various machine learning algorithms are being explored to fully automate the process of 3d model generation, which will allow for their use in clinical practice and in development of the 3d colorectal database. the technology will be further implemented in creation of dynamic models of functional pelvic floor disorders. 4 surgery, toho university omori medical center, tokyo, japan; 5 surgery, neuchâtel hospital, neuchâ tel, switzerland background: laparoscopic gastrojejunostomies are time-consuming and require a specific training. alternatively, sutureless anastomosis can be achieved by means of endoscopically delivered magnetic rings. objective of the study: assessing the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using magnets coated with a fluorescent biocompatible polymer. methods and procedures: four pigs (2 acute, 2 survival models) and one cadaver were included in this study. the anastomotic device was composed of two magnetic rings (25x8x6 mm; attraction force 30 newton), each one attached to a 75 cm long thread. the distal ring was inserted endoscopically into the first duodenum, and the extremity of the thread was clipped to the gastric mucosa. twenty-four hours later, a two-port laparoscopy (12 mm, 5 mm) was performed, using a near-infrared (nir) laparoscope (d-light-p; karl storz). the magnet's position in the jejunum was detected thanks to the transluminal fluorescence of the dye. magnetic interaction with the metallic tip of the laparoscopic grasper allowed to catch the ring and bring the bowel loop to the future anastomotic site on the gastric wall. simultaneously, the proximal magnet was delivered to the gastroesophageal junction using a flexible endoscope. the magnet was carefully advanced into the stomach allowing precise connection with the distal ring. in one cadaver the procedure was repeated. the sole variation was that, in order to reach the second jejunal loop, the distal magnet was placed using a gastroscope inserted through a transgastric port. in two acute animals, the distal magnetic ring was introduced into the jejunum via an enterotomy. the anastomotic procedure (from the distal magnet detection via fluorescence to the magnetic connection using a hybrid approach) was reiterated 40 times. survival animals were followedup for 10 days and underwent control endoscopies and ct-scans. results: the procedure was easy to standardize and reproducible, with a mean anastomotic procedure time of 2.62 ± 1.42 min. there were no technical problems and magnetic connection could be precisely directed in all cases, at both the anterior and posterior gastric wall. no complications occurred during the survival period and the anastomoses were patent by day 5. transluminal fluorescence allowed for a rapid detection of the magnet. colorectal cancer is the fourth most common cancer in high-income countries counting [ 700.000 deaths worldwide. survival rate reaches 94% in case of early diagnosis, falling down to 11% in case of advanced stage. conventional colonoscopy screening is limited by invasiveness, pain and often need of sedation. wireless capsule endoscopy enables inspection without discomfort, but passive locomotion often leads to incomplete and/or false negative results. the european endoo project (grant agreement 688592) aims to develop a novel system that overcomes most of the drawbacks of conventional colonoscopy, maintaining accurate and reliable diagnosis and therapy. the system is composed of an active robotic platform that magnetically drives a soft-tethered capsule; magnetic guidance is achieved through the magnetic localization of the capsule in combination with a closed-loop control that maintains an optimal and safe link between the capsule and the magnetic end-effector. a stereoscopic camera is integrated in the capsule for enhanced diagnosis though 3d reconstruction and automated detection of lesions/pathologies. the different modules of the endoo medical platform are illustrated in the figures. the robotic guidance systemconsists of an anthropomorphic manipulator that controls the capsule through an external permanent magnet. the robot, positioned on a dedicated trolley, is equipped with sensors for performing safe human-robot collaboration. the medical workstationincorporates: screens, buttons and pedals for visualization and command initiation, a joystick for system teleoperation and a back-end for fluidic control and data communication. the soft-tethered capsuleembeds an internal permanent magnet, magnetic sensors, an accelerometer, white and infrared illumination and an hd stereoscopic vision system with two wide-angle customized optics. a controller serves as the main control unitfor performing real-time communication and closed-loop control of the robot, localization system, capsule and physician commands. the synergistic cooperation of academic, industrial and clinical partners within the project allowed to develop and validate the system in in-vitro \/i [ , exvivoand preliminary cadaver sessions, performing comparisons with state-ofthe-art commercial colonoscopes. in conclusion, the endoo medical platform provides: reduced procedural pressures, user-friendly procedures, similar functionalities and performances of commercial devices, comparable procedural times and considerably lower costs with a new painless approach. background: this study is aimed at the comparison of the process of manual and robotic-assisted positioning of the electrode performing radiofrequency ablation with the usage of multifunctional robot-assisted surgical platform. under the control of the surgical navigation system. the main hypothesis of this experiment was that the use of a collaborative manipulator will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. we also check the stability of the electrode's velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. methods: sphere-shaped tumor phantoms measuring 8 mm in diameter were filled with contrast and inserted in cow livers. 10 livers were used for the robotic experiment and an equal quantity for manual. the livers were encased in silicone phantoms. analysis of ct data gave the opportunity to find the entry and the target point for each tumor phantom. this data was loaded into the surgical navigation system that was used to track and record the position of the rf-electrode during the operation for further analysis. results: standard deviation of points from the programmed linear trajectory totaled in the average 0.3 mm for the robotic experiment and 2.33 mm for the manual operation with a maximum deviation of 0.55 mm and 7.99 mm respectively. standard deviation from the target point was 2.69 mm for the collaborative method and 2.49 mm for manual method. the average velocity was 2.97 mm/s for the manipulator and 3.12 mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was 0.66 mm/s and 3.05 mm/s respectively.thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. conclusions: this experiment was produced as part of the work on the developing of the robotic multifunctional surgical complex. we can confirm the potential advantages of using robotic manipulators for minimally invasive surgery in case of collaborative practice for cancer treatment. surg endosc (2019) background and aims: laparoscopy has reduced tactile feedback compared to open surgery. in neuropsychological literature there is increasing evidence that visual and haptic information converge to form a mental representation of an object. through the combination of these inputs, this representation is believed to be more refined and robust. we investigated whether tactile exploration of a lifelike anatomical object before executing a laparoscopic action on this object in a laparoscopic box trainer improves performance of this action. description: a randomized prospective cohort study with two groups (a ? b) of ten laparoscopically naïve medical students was conducted. we compared the groups for baseline characteristics and performance, using a basic laparoscopic task (post and sleeve). to investigate the effect of haptic exploration, students performed ten repetitions of a laparoscopic needle action on a lifelike silicone caecum model (applied medical, rancho santa margerita, usa). group a did a pre-test visual exploration of the model. in group b manual exploration of the anatomical model was added to the visual exploration before executing the task. the box trainer was equipped with the forcesense tm (medishield, delft, the netherlands) system for skill assessment using objective force, motion and time parameters. results: baseline characteristics and-laparoscopic performance were comparable (p [ 0, 05) . performances of 200 trials on the anatomical model were captured and parameter outcomes were compared between groups. significantly less force (maximal force, maximal impulse, mean force and force volume) was exerted by the 'touch' group (p \ 0.000) (fig. 1 ). this group also completed the task with less distance travelled by the instruments (p \ 0,003). there was no significant difference in time needed to complete the task (p = 0,695). conclusion: this study showed that, when performing a laparoscopic task on an anatomical model, pre-task haptic exploration of the model results in the use of significantly less force and less movement. adding haptic exploration to a laparoscopic training curriculum could therefore result in more efficient and more refined learning of laparoscopic actions. this, in turn, could lead to better, quicker and safer performance of laparoscopic operations. . esophagogastroscopy was performed before gabe and 1-week post-procedure assessing gastric abnormalities. weight and fasting plasma ghrelin were obtained at baseline, 1-, 3-, 6-and 12-months post-index procedure. after 6 months, the sham group was unblinded and received gabe. both gabe and sham crossover to gabe groups were followed for 12 months and received lifestyle therapy (behavioral-diet education). preliminary results: gabe was successful in all patients with no serious complications. significant, progressive weight loss was observed at 6 and maintained at 12 months. ghrelin in gabe group decreased by 22% (67.91 pg/ml) compared to baseline and 12 months levels. weight-loss was approximately 6.5% greater in the gabe group versus sham at 6 months ( table 1) . itt = intent-to-treat, pp = per-protocol analysis preformed using independent-sample t-test and à paired-sample t-test conclusions: gabe using eles is safe, accompanied by significant and so far maintainable weight loss. gabe using the eles demonstrated a reduction in ghrelin levels. aims: transanal total mesorectal excision (tatme) is the latest colorectal approach that continues to be in the spotlight. this study aims to describe the technique in depth by identifying and understanding technical advantages, errors and adverse events. methods: detailed video analysis using observational clinical human reliability analysis (ochra) was completed on 100 clinical tatme cases performed by 27 international surgeons. error frequency and error pathways leading to adverse events were described. tatme expert surgeons were interviewed and engaged in a workshop to elicit error-reducing mechanisms. results: overall technical errors and adverse events per procedure on average occurred 49 ± 32.9 (range 6--194) and 9 ± 6.1 (range 1-45) times respectively. inadequate insufflation and poor camera optics were the most frequent set-up problems. instrument handling errors consisted most commonly of excessive grasper movement during the pursestring phase (321 times total), inappropriate force applied (79 times) with the energy device during the rectotomy, inappropriate force with the grasper (74 times) and excessive movement with the energy device (117 times) during tme dissection. incorrect dissection planes were created during tme dissection mostly due to insufficient retraction (127 times) which didn't allow adequate exposure of the tissue planes. the most frequently occurring consequence was bleeding (mean: 6 times per procedure). rectal perforation (7 cases), vaginal wall injury (4 cases), and prostatic injury (7 cases) were also recorded. adverse events regularly occurred as a result of poor set-up/exposure, inappropriate retraction and/or instrument movement and incorrect plane surgery. error-reducing mechanisms and 'technical tips' describe specific steps and actions, both set-up/equipmentrelated and technique-related, that aim to prevent errors from occurring and avoid adverse consequences. ochra and individual feedback with error-reducing mechanisms developed by this study have been implemented into the national training programme for tatme. conclusion: tatme is an advanced complex procedure during which technical errors and their consequences are not infrequent. tatme requires knowledge of anatomy 'bottom-up', familiarity with its specialised equipment and technical skill working in a narrow space. appropriate structured training and mentorship are therefore recommended. surg endosc (2019) objective: insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. icg has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections and thus possibly reducing the leak rate. objective of this study is to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using intraoperative indocyanine-green dye (icg) angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. methods: this randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative icg or to subjective visual evaluation of the bowel perfusion without icg (clinicaltrials.gov nct02662946). the primary aim was to assess whether icg angiography could lead to a reduction in anastomotic leak rate. secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. results: after randomization, 12 patients were excluded. accordingly, 240 patients were included in the analysis; 118 in the study group, and 122 in the control group. icg angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection, in 13 cases (11%). an anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.). conclusion: intraoperative icg fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. this method led to further proximal bowel resection in 13 cases, however its role in reducing anastomotic leak rate should be studied in further research. endoscopic sleeve gastroplasty (esg) is a promising endoscopic bariatric procedure carried out with the application of transmural sutures resulting in a gastric reduction and gastric shortening. sutures are placed in u shape fashion, from the incisura to the fundus, which is preserved, using an over the endoscope suturing platform (overstitch, apollo endosurgery, austin, texas, usa). the choice of right lankmarks for suturing the gastric wall is extremely important for the efficacy and safety of the procedure. flexible endoscopy suffers from little anatomical reference points. correct spatial relation to precisely target the insertion of the helix device used for retraction and correct orientation of the full thickhness tissue bite require a good undrestanding of the anatomy of the stomach and sourrounding organs including vascular structures that could be inadvertently injured (left lobe of the liver, gallbladder, spleen, short gastric vessels, pancreas, transverse colon). surgeons by training can 'see' the anatomy beyond the gastric wall and undrestand whether they work in a safe layer or whether an underlying structure should be spared. this video illustrates all the potential risks realted with a wrong chioce of endoscopic landmarks when performing esg with respect to gastric and abdominal anatomy. introduction: central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are technically demanding procedures in minimally invasive approach because of difficult expoure and extensive parenchymal transection planes. with limited robotic instruments including absence of cusa, these procedures have been rarely perfomed by robotic approach. method: consecutive robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy were performed. patients were all males and were 67, 71, and 41-years-old, respectively. pathologic diagnoses were all hepatocellular carcinomas of each 4.4, 4.2, and 3.2 cm diameter. operative settings were identical for the three kinds of procedure. the patients were placed in supine with a reverse trendelenburg and right side elevation. umbilical 12-mm camera port, three 8-mm ports and additional 12-mm assistant port were used. glissonian approach and icg fluorescence image clearly demarcated the resection planes. parenchymal transection was performed using the maryland bipolar dissector and harmonic scalpel. the rubber band self-retraction method and third arm of robot system helped for stable and excellent exposure of surgical planes result: there were no conversions to laparoscopic or open surgery. the operative time was 320, 330, and 290 min and estimated intraoperative blood loss was 200, 330, and 250 ml. the pathologic surgical margin was 2.5, 0.5, and 3.6 cm. the length of stay after surgery was 7, 8, and 6 days and there were no postoperative complications. conclusion: robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are still demanding procedures with long operative time. however, these procedures could be performed safely in regard to short-term perioperative outcomes. robot surgical system provided several benefits for anatomical hepatectomies including a stable and excellent operative field and clear surgical planes. suprapubic hernias (less than 5 cm above the pubic arch in the midline) require important anatomical knowledge because of complexity of their repair and low incidence, by approximately 2% of all hernias. the problem to repair this type of hernias is that inferior margin of the defect is very close to pubic symphysis, consequently, mesh overlap is often inadequate. treatment of suprapubic hernias is controversial because of limited evidence in the literatura. this video shows the case of a 40-year-old female patient with suprapubic hernia with a defect of 3x3 cm. we performed a laparoscopic repair with a bilateral peritoneal flap of the groin region (as it is perfromed during tapp) for proper view of the pubic symphysis, cooper's ligaments, epigastric and major vessels, nerves and meticulous dissection the space of retzius. the defect was repaired by reconstructing the middle line with a running sutures. subsequently, titanium helical tacks were used to fix the mesh to the pubis and cooper and following the double-crown technique having special attention when fixing the mesh near to inguinal chanal, due to the possibility of causing chronic pain. the peritoneal flap was fixed over the mesh with abdsorbable fixation devices and seal with fibrin glue. laparoscopic repair of suprapubic hernias can be considered as the first option in treatment, because it endeavors to join the advantages of a minimally invasive approach and it is associated to low recurrence. the main advantages are that allows a proper visualization the anatomy and a proper fixation of the mesh. background and aim: thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. we evaluate our cases who undergone the thoracoscopic esophagectomy and consider the future prospective of this operation.transient recurrent laryngeal nerve palsy after lymphadenectomy in this surgery is not rare and induces not only hoarseness but also aspiration or pneumoniae. new method to avoid this complication is desired. patients and methods: 702 patients who received thoracoscopic esophagectomy in our institute from march 1995 to october 2017 were enrolled and studied retrospectively. operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment or definitive chemoradiotherapy before surgery. overall survival rate of the patients with thoracoscopic approach and with thoracotomy until 2001 was analyzed. long term outcome of the patients with thoracoscopic esophagectomy was compared to the result from comprehensive registry of esophageal cancer in japan. short term results of the perioperative parameters were analyzed between left lateral decubitus position and prone position.we had introduced intraoperative nerve monitoring system for prone esophagectomy from 2014. results: there was no significant differences of the survival rate between thoracoscopic group and thoracotomy group based on pathological stage. 5 year survival without neoadjuvant treatment was 88.9% (pstagei), 71.5%(pstageiia), 68.1%(pstageiib), 40.9%(pstageiii), respectively.5 year survival rate of cstageii and iii with neoadjuvant chemotherapy was 65.7% and 5 year survival rate of the salvage esophagectomy after failure of definitive chemoradiotherapy was 31.4%. every outcomes are as good as any reported results in esophagectomy. in the comparison of the lateral position with the prone position, total blood loss was significantly lower in prone position. inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommended as a minimally invasive procedure for thoracoscopic esophagectomy. transient recurrent laryngeal nerve palsy was observed 30% of patients. conclusion: thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. nerve monitoring is useful for detecting recurrent nerve and avoiding nerve injury. background: laparoscopic total mesorectal excision (tme), in a wide female pelvis is usually technically easier than in a narrow male pelvis. however, this is not always the case, as the uterus and adnexae may obscure the views and hinder safe dissection, especially in obese patients. techniques such as graspers through additional ports or suspension with sutures through the broad ligament may potentially cause injury or need additional ports/assistants. aim: we present a novel technique using a self-retaining gynaecological uterine manipulator to improve access during deep pelvic laparoscopic surgery in female patients. technical tip: the operation is commenced in the standard manner for a laparoscopic rectal excision. once pelvic dissection is commenced, whenever it is felt that uterine retraction would be advantageous (depending on the level of the rectal tumour, size of the uterus and ovaries, obesity etc.) a self-retaining uterine manipulator (as shown in the video) is used. the tip of this disposable device is introduced into the uterus after dilatation of the uterine cervix. once the balloon at the tip has been inflated, the instrument is secure and hence there is no need for active manipulation by an assistant. the shaft can be rotated to allow anteversion/retroversion of the uterus to varying degrees as required to aid dissection. as the video depicts clearly, it acts as a self-retaining retractor for the uterus and is removed at the end of the operation. though the procedure is being demonstrated by a gynaecologist in the video, the instrument is quite easy to insert and some of our colorectal team have been trained as well. conclusion: the self-retaining uterine manipulator is an efficient tool for uterine retraction in laparoscopic rectal surgery and we have been using it routinely in tme in females for the past 8 years, with no complications. this was previously published as a technical tip in the journal of minimal access surgerybut has never been submitted for peer review as a video. the authors present a video of two clinical cases treated by trans-axillary endoscopic approach. methods: a 74 years-old male and a 73-year-old male presented with intermittent dysphagia and frequent reflux (class ii of lahey). one had a history of recurrent respiratory infections. the disease was characterized by oesophagogastroscopy (egd) and oesophagogram. trans-axillary approach with areolar port. step-by-step as follows: (i) dissection anteriorly to the pectoralis major muscle (ii) isolation of the anterior border of sternocleidomastoid muscle (iii) omohyoid muscle's isolation (iv) identification of the thyroid's upper pole (v) zd isolation (vi) myotomy of the cricopharyngeal muscle (vii) zd's resection with stapler and its withdrawn with sac. results: both cases progressed without complications. complete local recovery was verified in both cases one month after the procedure. conclusion: this technique seems feasible and reproducible, allowing zd diverticulectomy with a better cosmetic result and perhaps lower surgical site infections (ssi). in the authors' knowledge, this approach to dz has never been published. background: gastric leak occurs in 1-6% of patients who undergo roux-en y gastric bypass (rygb) for morbid obesity. the pathophysiology may be related to gastric ischemia, fistula, or ulcer.gastric leak is a severe complication of gastric bypass (gbp) that is associated with significant morbidity and mortality. fistula may have several clinical impacts, depending on patientrelated factors, fistula characteristics, onset time, and therapy proposal. abdominal drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. methods: we present a video of a clinical case of 44-year-old lady with body mass index of 45 kg/m 2 who underwent roux-en-y gastric bypass and 48 h later presentedtaquicardia and right cuadrantum pain. the ctscan inform a apical leak at the gastric pouch level. the video shows the relevant aspects of a revisional surgery and the key points to drain the fistula and close de defect laparoscopically. results: after 6 monts, the patient achieved succesful results, defined as a stabel clinical situation with image evidence of gastric fistula remision. conclusions: gastric bypass (gbp) is one of the most efficient bariatric interventions in morbidly obese patients. the most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after gbp. laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed operation worldwide as a primary bariatric/metabolic procedure. however, conversion to other surgical procedures such as roux-en-y gastric bypass (rygb) or one anastomosis gastric bypass (oagb) have been described as treatment options for inadequate weight loss after lsg and unresolved co-morbidities or complications such as leak, stricture, and severe gastroesophageal reflux disease (gerd). we present two clinical cases of weight regain and severe gerd and dysphagia, which account for the main indications to reversal of lsg to either oagb or rygb. aims: we show in the video the surgical technique that we perform by laparoscopic aproach, in order to construct a roux-en-y polipropilene banded gastric bypass lrygb-b. methods: we are performing this procedures within a prospective randomized trial that is design to compare the long term results of lrygb-b versus the standard laparoscopic roux-en-y gastric bypass.the video shows our technique in a case of a 46 years old female with a bmi of 46 kg/m2. first we create a vertical gastric pouch of about 25-30 ml, and a polypropylene mesh (10x65 mm) is placed 20-30 mm proximal to the anastomosis around the gastric pouch, with the help of a laparoscopic band retractor. after that a 150 cm roux-en-y limb is constructed in an antegastric antecolic fashion, been the lenght of the biliary limb 100 cm. a 25 mm gastroyeyunal anastomosis is performed with a linear stapler, and the enterotomy and gastrostomy are closed with a 3/0 barbed running sutures. jejunojejunostomy anastomosis is constructed in similar fashion, but with a lenght of 30-45 mm. the petersen space and the mesenteric defect are closed with polipropilene 0/0 sutures. results: 31 patients has been operated following this technique, and there has been no complications related to the polipropilene band. (the ramdomized prospective trial is still ongoing). conclusions:the video shows a reproductible easy way to perform a lrygb-b using a polipropilene mesh. introduction: a 23-year old female patient presented at our clinic two years after initial rouxen-y gastric bypass. she had had a preoperative bmi of 31,5 and had a significant weight loss which resulted in a bmi of 21,4 at two years postoperatively. she currently suffered from severe dumping with glycaemia levels dropping to 30 mg/dl. pharmacological treatment with metformine, sandostatine and acarbose did not yield any results. on top of these problems she felt less restriction, could eat large portions and had gained 9 kg in the last three months. objective: the usual approach for severe dumping-related hypoglycemia would be to undo the gastric bypass. this patient however was extremely anxious to regain weight, so we sought other options. we assumed that by adding more restriction and slowing down the emptying of the gastric pouch we could alleviate some-if not all-of the dumping related symptoms and prevent further weight regain. methods: in this video we present the banding of a gastric pouch for severe dumping after rouxen-y gastric bypass. results: although unconventional, the banding of the pouch yielded excellent results. the slower pouch emptying and reduced portions resulted in a near complete remission of all symptoms. as an additional benefit we found a slight weight loss of four kilograms six weeks postoperatively. conclusion: the usual treatment of severe dumping-related hypoglycemia would be an undo of the gastric bypass. in this case however the patient was extremely anxious to regain weight, being very pleased with the results her gastric bypass had yielded. in agreement with both the patient and treating endocrinologist we attempted a different approach. the slower pouch emptying and increased restriction offered another way to alleviate the dumping and deep hypoglycemia while concomitantly resulting in weight maintenance. aim: the aim of this video is to present a novel surgical technique to avoid stent migration after endoscopic placement in patients with leakage subsequent to laparoscopic sleeve gastrectomy (lsg) . methods: this video shows the case of a patient (bmi 46,6 kg/m2) who developed an upper gastric leakage 2 days after lsg. a ct scan showed a small leakage at the eg junction complicated by intra-abdominal abscess. a ct guided percutaneous drainage of the abscess was performed. a stent placement was attempted endoscopically three times and failed for migration. we decided to place laparoscopically a non adjustable gastric ring (nagr) around the stomach, in order to avoid stent migration.first of all the stent is replaced endoscopically in order to cover the fistula tract. the patient is placed in a half sitting position and the pneumoperitoneum was obtained using a veress needle in left subcostal space. a 4 port technique is used as in standard laparoscopic sleeve gastrectomy.the procedure starts with the mobilization of adhesions, the fistula is identified in the upper part of the tubule.the gastric tubule is isolated and the lesser omentum is opened. the blunt needle at the tip of the ring is passed retrogastrically, a tourniquet can be useful is the positioning turn out to be difficult. the nagr is then closed over the gastric tubule containing the stent. a drain is finally placed. results: the stent was removed after 4 weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of leakage. after 6 months the patient was in a good condition with bmi 29,4 kg/m 2 . the stent was endoscopically removed after 4 weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of the leakage. after 6 months the patient was in a good condition with bmi 29,4 kg/m 2 . conclusions: this new technique is feasible and effective, as shown in this video; however the nagr can lead to complications, so a strict follow up is needed and if any complication appears, should be considered to remove laparoscopically the ring. introduction: in this case, we will discuss the case of a 72 year old male patient who underwent a laparoscopic cruraplasty and gastric plication resulting in a weight loss of 12 kg. other medical history reported insulin-dependent diabetes, reflux esophagitis and sleeping apnea with cpap. two years after gastric plication the patient presented with passage problems, gastro-esophageal reflux and epigastric pain. to this end a swallow test was performed revealing a large fundus with a restricted passage of contrast. due to the persistent complaints and the abnormal findings on barium swallow a surgical re-intervention was needed. objectives: despite the current bmi of 27 and the age of the patient, conversion from a gastric plication to a roux-en-y gastric bypass was performed. several other surgical options were considered, including an undo of the gastric plication or a dilatation with a resizing of the fundus. methods: in the video we describe the laparoscopic approach for a conversion of a gastric plication to a roux-en-y gastric bypass. results: at 6 months follow-up the patient showed a weight loss of 8 kg and the resolution of his earlier symptoms. the patient had a normal oral intake without any gastro-esophageal reflux or epigastric pain. conclusion: after a gastric plication, partial loosening of the sutures and stenosis are both wellknown complications. as presented in the video, it is apparent that a laparoscopic undoing of gastric plication is not as straightforward as it seems. firm adhesions between folds can compromise the procedure and inhibit a complete separation of the tissues. we believe that in these cases the best surgical approach is to convert to a roux-en-y gastric bypass. laparoscopic sleeve gastrectomy (lsg) is a relatively new surgical approach in the weight loss surgeon's armamentarium. in literature there is a consensus about the importance of mobilizing completely the gastric fundus before transection. the resg (revised sleeve gastrectomyresleeve) may be a valid option for failure of primary lsg. we focused the attention on the consequences that can have an incomplete resection of gastric fundus during an operation of sleeve gastrectomy and how they can be solved by the repetition of this procedure. a sleeve gastrectomy was performed in an obese 34-year-old woman (bmi = 40). three days after the operation, an upper gi x-ray with gastrografin did not show any abnormalities. three months after the surgical procedure, the woman referred frequent episodes of vomiting and a significant weight loss (42 kilos). an upper gi x-ray with gastrografin demonstrated the presence of multiple communicating cavities of the gastric fundus. the esophagogastroduodenoscopy (egd) showed that the gastric tube close to the esophagogastric junction was separated from a recess (2-3 cm in diameter) by an incomplete septum. a severe hypokalemia and consequent ecg abnormalities were treated with intravenous infusion of potassium. then, we performed a laparoscopic operation. the gastric tube was completely released along the suture line of the previous operation and, especially, the posterior surface of the upper part until the left crus of diaphragm became evident. under the guide of the bougie, the recess was removed. results: the clinical course was regular, and the patient was discharged on third post-operative day after an upper gi x-ray with gastrografin which demonstrated the absence of leakage and a normal gastric tube. after 1 year, the patient was very satisfied with the operation. conclusions: the complete mobilization of the gastric fundus allows to see clearly which part should be resected to obtain an adequate gastric tube and facilitate a correct placement of the stapler. in our experience, in patients with a residual fundus, an upper gi x-ray with gastrografin and an egd are needed to exclude the presence of stenosis. then, a resleeve gastrectomy is an efficient and safe procedure to treat this post-lsg complication. weight regain is one of the main problems in bariatric surgery. we have many surgical option but when we evaluate patients with long follow up and bmi of superobese patient before the first surgery, the weight recidivism can arrive up to 50-70% at 5 years.in most cases the first surgery is a restrictive procedure, and in many cases sleeve gastrectomy.here we present a case of weight regain after laparotomic super-magenstrasse (that we consider like a sleeve gastrectomy except for remnant removal) with a big incisional hernia. after a complete multidisciplinary re-evaluation we decided to perform an oagb (one anastomosis gastric bypass) but in this case we decided to create a functional exclusion to the duodenal transit by positioning a minimizer ring. this solution is effective in food diversion and guarantee gastric and duodenal endoscopic exploration in case of need. we think that this technique can represent an option to take in account for selected cases. at the end of bariatric procedure we perform a laparoscopic repair of incisional hernia with mesh in the hope to avoid future surgery and post operative small intestine herniation. patient rejected additional bariatric procedures and in fact she has gained 10 kg two years later (bmi 39.14). conclusions: lagb gastric erosion is uncommon (1.46-3%) . intraoperative (such as perigastric approach) and patient related factors (smoking, alcohol…) have been described as risk factors. the most frequent clinical presentation is weight loss failure; band and port issues (such as infection) are also frequent. erosion is infrequent to present as an acute event (\ 5%: peritonitis, abscess…) or asymptomatically (\ 1%). diagnosis is mostly performed under upper endoscopy. the most common therapeutic technique is removal of the band (by endoscopy or surgery), repair of the stomach, if needed, and band replacement (at least three months later). some authors have performed immediate replacement but the incidence of recurrent erosion seems to be higher. other options are lagb removal alone or conversion to different bariatric procedure. for endoscopic removal, it has been advised to wait until the band buckle is in the stomach and is sometimes very difficult. replacement of the band is not associated with weight regain. she reports 5 years of evolution presenting moderate intensity heartburn that was exacerbated during the night as well as submit occasional rejurgutation. the intensity of the symptoms is attenuated by maintaining a diet without irritants and improving feeding times. denies hematochezia, unintentional reduction of weight, dysphagia or early satiety. the patient has suffered from obesity since childhood, after pregnancy she had progressive weight gain and difficulty in controlling blood sugar, so she is scheduled a gastric bypass roux-en-y . preoperative endoscopy was performed, evidencing submucosal tumor in the gastroesophageal junction at 37 of the dentary arch, approximately 3 cm in diameter. an endoscopic ultrasound was performed, demonstrating subepithelial lesion of the gastroesophageal junction, hypoechoic, with well-defined borders, pseudobilobulated, 2.4 cm x1.3 cm, and dependent on the external muscular layer. a fine needle aspiration is performed in which spindle cells are identified, leiomyoma is likely diagnosed. it is programmed for laparoscopic resection of submucosal gastric tumor, gastric bypass and laparoscopic cholecystectomy. a tumor at the level of the gastro esophageal junction of approximately 2.5 cm is identified in the surgery, which can be resected by laparoscopy without complications. the patient is discharged after 2 days of postoperative stay. the final histopathological result: leiomyoma of 3.3 cm with free edges. cd4 (-) gog1(-) caldesmon (?)s100 (?). background: fifty percent of patients who have undergone gastric bypass, posterior reversal and sleeve gastrectomy and finally complete hiatoplasty presents symptomatic gastroesophageal reflux disease. surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous conversion of sleeve gastrectomy to gastric bypass and hiatal hernia repair. methods: we present the surgical techhnique performed to a patient with initial gastric bypass who underwent sleeve gasterctomy for hipoglycemias and hiatoplastia for severe gerd. persistent gerd requested to undergo ligamentum teres cardiopexy. in this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last 3-5 cm of esophagus in the abdomen. the distal ligamentum teres is fixed with one stitch to the apex of the angle of his, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. the remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. the procedure concludes with diaphragmatic crus closure. results: after 3 months, the patient achieved successful results, defined as resolution of gerd, no protonpump inhibitor (ppi) use, and manometry measurement over 12 mmhg after surgery. conclusions: ligamentum teres cardiopexy combined with closure of the gastric crus is a late alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia. general surgery, ponderas academic hospital, bucharest, romania introduction: as metabolic surgery techniques evolve during the years, we have to face more and more patients with complications ands uboptimal results after the older/initial procedures. vertical banded gastroplasty(vbg) is one of those procedures that gain momentum during the initial experience in bariatric surgery, but has proven to have dissapointing results and a lot of complications, nowadays surgeons having to deal with difficult revisional operations. aim in this video: we want to present from our experience the difficulties encountered during the revisional surgery, rouxen y gastric bypass (rygbp)aftervbg, and the tips and tricks that will make this a safer and easier procedure. objective: after thorough preoperative assessment and a review of the literature multiple treatment options were considered. the procedure of choice ended up being a laparoscopic adjustable gastric banding, with the objective to achieve optimal weight loss with the lowest risk for complications. methods: in this video we present the placement of an adjustable gastric banding in a patient with a cirrhotic liver and portal hypertension and the possible pitfalls. results: postoperatively there were no complications and patient had a satisfying weight loss both 6 months and 1 year postoperatively. in a short review of the literature we've found that bariatric surgery is feasible in patients with portal hypertension as long as the patient is not decompensated or has bleeding varices. conclusion: cirrhosis and portal hypertension are no absolute contraindication for banding, sleeve or rny gastric bypass as long as the patient is not decompensated or has bleeding varices. the type of surgery is dependent on patient and surgeon-related factors. the aim should be to achieve optimal weight loss with the lowest possible surgical risk in this type of patients. surg endosc (2019) 33:s485-s781 introduction: in this case, we will discuss on a 54 year old female patient who had undergone a laparoscopic nissen fundoplication 5 years ago due to gerd grade b. because of morbid obesity a n-sleeve gastrectomy was performed 1 year ago resulting in a weight loss of 12 kg. at presentation she had regained all the lost weight, resulting in a bmi of 42,8. the patient history also reported insulin-dependent diabetes and obstructive sleep apnea with cpap. gastroscopy was performed showing a large residual fundus but no esophagitis. on the subsequent upper gi series a relatively wide sleeve with an intact nissen-collar was detected. objectives: a laparoscopic conversion to a roux-en-y gastric bypass was performed. other potential surgical treatment options are a sadi procedure or a sleeve gastrectomy with transit bipartition (santoro procedure). methods: in the video we describe the laparoscopic approach for a conversion of a n-sleeve to a roux-en-y gastric bypass. results: at 4 month follow-up the patient presented with a weight loss of 12 kg. the patient had good restriction on oral intake and did not have any reflux-related symptoms or complaints. conclusion: conversion from a n-sleeve to a roux-en-y gastric bypass is a challenging procedure. the largest pitfall during the creation of the gastric pouch is to staple a double fold of the nissen fundoplication. we believe that in these rare cases of weight regain after n-sleeve, the best surgical approach is to convert to a roux-en-y gastric bypass. four years later, in 2010, a laparoscopic conversion to roux-en-y gastric bypass was performed because of weight regain. she now presents with satisfactory and stable weight loss over the last few years. she was recently diagnosed with a brca-1 mutation for which she underwent a bilateral ovarectomy and mastectomy. the patient's brother was also diagnosed with this mutation and died of pancreatic cancer at the age of 39. genetic counseling advised a twoyearly follow-up because of an increased risk up to 10% of developing pancreatic cancer. control gastroscopy showed a normal esophagus and gastric pouch. control ct scan revealed hypertrophic stomach creases in the excluded stomach. these results prompted a laparoscopy-assisted gastroscopy of the excluded stomach which uncovered hypertrophic stomach glands and intestinal metaplasia on biopsy. methods: in this video we demonstrate the laparoscopic approach for complex revisional bariatric surgery. conversion from rny gastric bypass to a sleeve gastrectomy in a patient who already underwent a vbg. the focus of the video is on a manual gastro-gastrostomy with partial gastrectomy of the fundus and part of the stomach where the old vbg-band was placed. results: after 1,5 months follow-up the patient had no complaints and a stable weight. upper gi series shows a normal passage of contrast through the sleeve gastrectomy. conclusion: endoscopic surveillance of the remnant stomach and echo-endoscopy of the pancreas is no longer possible after rny gastric bypass. in cases where the need for such a surveillance arises after a rny bypass a patient-tailored approach is necessary. in our patient a laparoscopic conversion from a rny gastric bypass to a sleeve gastrectomy was performed. this approach keeps the patient's wish for weight loss intact while enabling further surveillance through natural-orifice endoscopy. a 47-year-old morbidly obese japanese woman with a body mass index of 41 kg/m 2 suddenly complained of swallowing difficulty 4 months after laparoscopic roux en y gastric bypass surgery with retro-colic roux limb route. an internal hernia of the defect of the transverse mesocolon was suspected by computed tomography, and emergency intervention was performed. the surgery revealed no internal hernia. however, strong inflammation and adhesion were observed between the transverse mesocolon and the retrocolicroux limb. in addition, the roux limb on the oral side of the adhesion site was dilated and bent.the adhesion between the transverse mesocolon and the flexed roux limb was dissected, linearized and re-fixedby suturing to the transverse mesocolon. however, since the difficulty of oral intake persisted re-do surgery was performed again. after resecting the roux limb involved in the severe inflammation, a 'new' roux limb was lifted to the cephalad via the ante-colic route. finally, the gastric pouch and roux limb were re-anastomosed with 3-0 absorbable sutures in an interrupted full thickness single layer manner. in the present case, we experienced difficulty with both adhesiolysis and determining the accurate target line to resect at the 'old' gastrojejunostomy. however, blocking the blood flow of the 'old' roux limb facilitated the accurate recognition of the target line. esofagogástrica, cirugía general y ap digestivo, hospital regional universitario de málaga, malaga, spain; 2 hepatobiliopancreática, hospital regional universitario de málaga, malaga, spain introduction: marginal ulcer is one a serious complications after a bariatric gastric bypass. tobacco, non-steroidal anti-inflammatory drugs (nsaids) and helicobacter pylori (hp) infection are known risk factors. methods: we present a 29-year-old women operated 3 years before of bariatric surgery with a gastrojejunal (gy) bypass technique due to intraoperative dehiscence of the staple line after attempting a vertical gastrectomy (sleeve). she has persistent vomiting and epigastralgia from 3 months after the intervention, affecting his quality of life. upper gastrointestinal endoscopy (uge) was performed, describing an ulcer in the gy anastomosis. she started hp eradication treatment, treatment with proton pump inhibitors (ppis), tobacco and nsaids were discontinued, but she had slight improvement. after 6 months the uge was made again, which show peptic esophagitis and 2 marginal ulcers. the plasma gastrin level was normal. due to the persistence of symptoms despite conservative treatment, we decided reoperation by laparoscopy. we found herniated bowel in petersen space, which were reduced and the space was closed. we proceeded to truncal vagotomy. the gy anastomosis was resected ( fig. 1 ) and performed again. finally, we perform antrectomy. the pathological anatomy showed ulceration. she was diacharged home on the 5th postoperative day without any complications. results: a marginal ulcer after bariatric surgery appears in the jejunal mucosa of the g-y anastomosis. the symptoms are epigastric pain, nausea and vomiting. acid, tobacco, nsaids and hp infection has an important role in their development \ sup [ . \/sup [ the first treatment is medical, discarding out the risk factors, but if it is not effective, it will be surgical, resecting the previous anastomosis. the usefulness of vagotomy is debatable, but the percentage of success increases. in our case, we perform antrectomy to avoid retained antrum syndrome. the hernia through petersen space is a cause of intestinal obstruction and abdominal pain as the case presents. although we believe that the symptoms were mainly caused by the marginal ulcer, the internal hernia was probably a symptomatic cause. conclusion: the treatment of a marginal ulcer is medical, eliminating the risk factors, but if it is not effective, the surgery is indicated. results: bowel's measurements and confection of the gastric pouch are identical in both cases. in the first case, intestinal anastomosis is performed in the inframesocolic compartment once small bowel has been divided. in the second case, such union is made next to the gastrojejunal anastomosis with the bowel uncut, making the section once no leakage has been found conclusions: laparoscopic roux-en-y gastric bypass is currently considered one of the technique of choice in the surgical treatment of morbid obesity. there are variations and alternatives for its realization. to know them can allow to individualize the technique to each type of patient. we present a clinical case of a 47 year old female. she had a vertical banded gastroplasty procedure (in another clinic) 9 years ago with an initial weight loss of 30 kg in a period of 2 months. she was seen at our clinic because she was suffering from dysphagia to solids and general diffuse abdominal pain for the last month. at physical exam we found a bmi of 39 and nothing else called our attention. we did an upper gi endoscopy and egd transit; we concluded that a gastric bypass would offer her the best results. therefore, we converted her vertical banded gastroplasty into a gastric bypass laparoscopically. she had an uneventful postoperative period and was discharged home without complications. aims: sadis emerged as a modification of biliopancreatic diversion with duodeno-ileal switch (bpdds) in which after sleeve gastrectomy (sg), the duodenum is anastomosed to an ileal loop in a billroth-ii fashion. sadis has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients avoiding the high morbidity of biliopancreatic diversion with duodenal switch. clinical case: 50-year-old patient, subjected to bariatric surgery two years ago, including a sleeve gastrectomy (sg). despite this operation and dietary and hygienic modifications, the patient gained weight in recent months, reaching a bmi of 56 kg/m2 and an overweight of 78 kg. an endoscopy was carried out on her, which provided evidence of a gastric remnant of moderate size with flexible tissue, normal peristalsis, and fast disposal speed. the case was discussed in a joint session, leading to the decision to apply revision surgery. the decision was taken to apply sadis, a novel technique that had never been used before in andalucia. the rate of weight re-gain after the use of classical techniques such as sleeve gastrectomy (sg) or the roux-en-y gastric bypass (rybg) is considerable high. revision surgery due to weight re-gain is necessary in many of these cases. sadis emerged as a simplified alternative to the use of bpdds as revision surgery following a gv due to weight re-gain with good short-term results, in terms of both weight control and comorbidity control. since only one anastomosis needs to be applied, chirurgical time diminishes, as well as the rate of surgery-related complications. moreover, it could be used, through laparoscopy, for patients who have undergone previous, complex abdominal surgery. conclusion: sadis showed a promising short-term weight loss outcome and comorbidity resolution rate but long-term data are missing and there is currently a high level of technical variability. on the other hand, further studies are required to measure its cost-effectiveness compared to the currently popular bariatric procedures, sg and rygb. aims: the lps sleeve gastrectomy is the most common bariatric surgery technique because it has a low surgical complexity and acceptable weight loss results. however, 5-11% of patients present with an insufficient weight loss, weight regnances, reflux or dysphagia. in these cases, it is recommended to perform a second bariatric surgery to combine a component of malabsorption such as gastric bypass or duodenal switch. the video describes the technique of a laparoscopic biliopancreatic diversion with duodenal switch with a previous laparoscopic sleeve. the objective is to describe the safety of the technique and the subsequent success of it. methods: a 41-year-old female patient presented morbid obesity with a bmi of 49 after performing a laparoscopic sleeve gastrectomy in 2010. initially, she presented a percentage of excess weight loss of 62%, reaching a bmi of 33 after two years of follow-up. after this, she suffered a reganancia of all the weight lost despite diet and exercise, presenting a bmi 49. a study was made with tegd where no complications of the previous surgery or symptoms of gastroesophagical reflux or dysphagia were observed. the lps duodenal switch is proposed in the obesity unit committee in 2016, without immediate postsurgical complications. the patient presented a favorable postoperative period and was discharged three days postoperatively. results: at the present time, the patient has achieved a 98% excess weight loss and has a bmi of 26.5. presents good oral tolerance with 3 stools a day without urgency. it doesn't present protein deficioncies. vitamin deficiencies are orally supplemented. the lps duodenal switch is a technique that can be performed after a sleeve gastrectomy safely in cases of insufficient weight loss or weight reganancia. the patients presented a greater weight loss after the duodenal switch than after the gastric bypass, observing a lost of excess weight of 74% compared to 64%. the differences being statistically significant. weight regain after gastric bypass is a challenging problem. a number of revisional surgical options have been reported. this is a case of a 48 year-old woman 10 years after lrygb. her initial bmi was 67, lowest after surgery-28, at presentation-48. the video shows a robotassisted laparoscopic conversion of rygb to loop duodenal switch. the roux limb is transected and dissected to the gastrojejunostomy. the gastrojejunostomy is resected and the gastric pouch is recreated over a bougie. the gastric blood suply is confirmed with icg. a gastro-gastrostomy is created to restore gastric continuity and a sleeve gastrectomy is performed. the duodenum is devided and a duodeno-ileostomy is created 300 cm from the ileocecal valve. the remaining roux limb is resected. the patient recovered uneventfully. conversion of rygb to loop duodenal switch requires creation of as little as two anastomoses, in comparison to standard ds, which requires four. it is a safe option for patients with weight regain after lrygb. methods: irb approval and informed consent have been obtained. a dissection is conducted to separate the descending mesocolon of the gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. the peritoneal layer is incised parallel to the vessel and close to the colonic wall. the dissection is continued anteriorly up to reach the resected parietal gutter. a passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. these maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. a caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. it can be very useful to mobilize the colon in any direction: laterally, medially, or upward. the dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. the specimen is extracted by a pfannenstiel incision. the anastomosis is performed transanally with a circular stapler according to knight-griffin technique. results: we performed a laparoscopic segmental colectomy using this approach for 21 patients with benign sigmoid lesions: 13 diverticulitis, 3 flat polypoid lesions (no lift-up sign), and 5 bowel endometriosis. the mean operative time and blood loss were 161.4 ± 15.7 min and 50 ± 40 ml, respectively. there were not a single conversion to open surgery and no any leakage or stricture. only 2 cases of intraluminal bleeding and 1 case of wound infection (treated conservatively) were observed. conclusion: we consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall. aims: to show a clinical case with a video of a patient was operated for colon cancer in hepatic angle by a single suprapubic incision (ssilrh). methods: a 44-year-old male assessed for abdominal pain and weight loss. on physical examination: a painful mass was detected in the upper right quadrant. the colonoscopy revealed an ulcerated lesion in the hepatic angle and the biopsy revealed a moderately differentiated adenocarcinoma. in the abdominal ct a mass of 3 x 4 cm was observed (figure). the patient was operated with ssilrh technique, as shown in the attached video. results: the patient was placed in the supine position and with the legs separated. the surgeon is placed between the patient's legs. a transverse incision of the skin was made in the middle line of 3.5 cm to 1 cm above the pubis. the underlying fascia was divided transversely, the rectus abdominal muscle was exposed, a purse-string suture placed in the fascia. an 11 mm reusable trocar was inserted for the chamber, a 6 mm reusable flexible trocar was placed at the 9 o'clock position and another trocar was placed at the 3 o'clock position. the ileocecal valve was released from the peritoneal parietal foil, as well as the mesocolon right by a lateral to medial approach to the second portion of the duodenum. the hepatic angle was also dissected from lateral to medial. for the anastomosis, the 11 mm trocar was replaced with a 13 mm trocar and a stapler was placed. a 5 mm 30°chamber was inserted through the 6 mm flexible trocar. the small intestine was divided as well as the proximal transverse colon with endogia. an intracorporeal ileocolic anastomosis was performed. the piece was removed through the suprapubic incision. he was discharged after 5 days without complications. the histological studies confirmed a differentiated adenocarcinoma of 8x7x6 cm. the surgical margins were free, without infiltrated lymph nodes (0/26) with stage pt3n0. the ssilrh technique allows a complete resection of the mesocolon and complies with the oncological principles. they can present with abdominal pain, nausea, acute abdomen, symptoms of intestinal obstruction or asymptomatic with incidental diagnosis. their diagnosis can be difficult. the objective is to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology. material and methods: we present a video of the surgical intervention of a 32-year-old patient, with functional dyspepsia, with a casual diagnosis of a pseudocystic mass of the right colon after performing a ct scan: giant diverticulum of the hepatic colon angle with fecaloid content inside it under tension the patient goes to the emergency room for acute abdominal pain, pending colonoscopy, antibiotic treatment is established, and a laparoscopic approach is decided upon after the patient's evolution. results: intervention: complete laparoscopic approach, 4 trocars. large size tumor in the right colon, diverticular in appearance, with stony content inside, with locoregional adenopathies, oncological radical right hemicolectomy, manual intracorporeal anastomosis, correct postoperative, hospital discharge. on the 4th day. definitive pathological anatomy: giant diverticula on areas of intense mucosal ulceration, free edges. conclusion: the laparoscopic approach of the symptomatic diverticula of the right colon is safe and effective. introduction: minimally invasive transanal surgery (tamis) is a surgical technique whose established indications are the complete exeresis of rectal polyps that are not resectable endoscopically or early rectal neoplasms with good prognosis criteria. transanal devices with gel platform facilitate dissection in this field. however, one of the drawbacks of this approach is the oscillation of the right nerve, which hinders dissection and prolongs the surgical time. material and methods: we present the case of a patient with a central depression neoformation, located 8 cm from the anal margin in the posterior aspect of the rectum in a male patient. the lesion occupies 25% of the circumference and was considered unresectable endoscopically. the endoscopic biopsies showed a tubulovillous adenoma with moderate dysplasia. results: an exeresis of full thickness of the rectal wall is performed, with subsequent suture of the defect. we show in the video the use of a glove interposed in the pneumoperitoneum gum to maintain the stability of the neumorectum and the technique of dissection and suture, as well as the stability of the neumorectum with this technique throughout the procedure. the use of a glove as a reservoir to stabilize the nemorectum is an economical and easy-to-use method that can safely replace extra devices. aims: endometriosis is a gynecologic disorder defined by the presence of endometrial glands and stroma outside the uterine cavity. deep infiltrating endometriosis (die) invades 5 mm to the retroperitoneum of the pelvic sidewalls, the rectovaginal septum, or the muscularis of the bowel, bladder or ureters. the rectum is being the most common bowel site of involvement. for symptomatic die, medical therapy should always be the first-line treatment. therefore, a minimally invasive approach using laparoscopy is considered the gold standard option and challenging aiming at complete disease excision. also, there are several advantages of natural orifice specimen extraction when compared with abdominal incision that may directly impact the postoperative results of these young patients. methods: we report a case of a 36-year-old female with a 12-month history of chronic pelvic pain, dyschezia and rectal bleeding. these symptoms were refractory to hormonal, antispasmodic and opioid therapy. magnetic resonance imaging reported a nodule 2 x 2 cm invading the rectal wall 10 cm to the dentate lane. we performed a laparoscopy and we found the nodule at the uterine posterior wall invading the rectal anterior wall. the nodule was invading into the rectum in a large area so we proceeded with segmental resection and added hysterectomy and salpinguectomy because it was the preference of the patient. the anastomosis was created intracorporeally and the specimen was removed through the vagina performing in this way a totally laparoscopic procedure with natural orifice specimen extraction. results: the total operative time was 3 h, the postoperative stay was uneventful and the patient was discharged on day four. the pathological report showed an endometrioma 4 9 4 cm length predominantly involving colonic muscularis propria. conclusion: laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. in addition natural orifice specimen extraction avoids potential complications of abdominal incisions. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy; 2 urology, clinica mater dei, rome, italy aims: we describe a case of a patient affected by a mass in the left kidney and a diverticular stenosis of the sigma. methods: a 65 years old woman complained abdominal pain in the left flank of the abdomen and in the left iliac fossa radiated to the hypogastrium, with fever and no passing flatus. contrast enhanced computer tomography scan (ct-scan) showed a 7 cm mass of the superior pole in the left kidney and a colonic diverticulitis with thickness of the wall and a microperforation of the sigma. she underwent to medical therapy with resolution of the diverticulitis. after 4 weeks a laparoscopic nefrectomy and sigmoidectomy was planned. patient was positioned on the right flank. this position was kept for both the procedures. we performed four trocar accesses along the left subcostal region and a periombelical incision for the specimen extraction. results: post-operative course was uneventful. patient was discharged in 7 post-operative day. istopathological exam showed a renal cell carcinoma confined to kidney with no positive lymph nodes and a diverticular stenosis of the sigma. laparoscopy allowed to perform two fine procedures in a critical situation using few trocar incisions and obtaining good results. background: hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be at least considered in any case. open restoration has been associated with significant morbidity and mortality. many authors have described the advantages of laparoscopic hartmann reversal. we want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique in a patient with 5 previous abdominal surgeries and a rectovaginal fistulae. methods: the transanal and laparoscopic team work simultaneously. by the abdominal approach a pericolostomic incision is made, the distal affected colon is resected and a purse string suture is performed around the anvil of the eea 31 mm single-use stapler with 4.8 mm staples (autosuture, covidien). a 12 mm umbilical trocar is located for a 30°camera and a gelport laparoscopic system (applied medical) with two 12 mm trocars is introduced through the colostomy wound. hard pelvic adhesiolysis was performed and splenic flexure was also mobilized.the gelpoint path transanal access platform (applied medical) is introduced through the anal canal with three trocars in a triangle position. the proximal rectum and mesorectum are dissected until the peritoneal reflexion. the previous stapler line with the resected tissue is then exteriorized throught the anus. the distal rectum is prepared with a circumferential purse string suture. the vaginal defect was sutured transanally. the proximal colon and the anvil are extracted through the rectal stump and connected to the circular stapler, performing an end-to-end anastomosis. results: the total operative time was 5 h. the postoperative stay was uneventful and the patient was discharged on day 5. conclusions: as in patients with rectal cancer, dissection of the stump in hartmann reversal procedure may be better and associated with shorter operative time. as with any new surgical procedure, it is probably too early to draw conclusions but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a hartmann reversal, especially in challenging cases. intravenous and endoluminal contrast enhanced ct revealed the presence of a large retroperitoneal fluid and gas collection, due to diverticular perforation, extended from pelvis to iliac bifurcation, involving the left urether. no hydrosoluble contrast media leakage or massive pnuemoperitoneum were present. after an initial conservative treatment without significant improvement an emergency laparoscopic left colectomy with primary anastomosis and laparoscopic retroperitoneal collection drainage was performed. the laparoscopic approach was very challenging due to the obesity of the patient and the presence of the abscess. the patient was discharged on pod 12 after requiring re-intervention for dehiscence of the left iliac mini-laparotomy on pod 7. conclusion: diverticular perforation in obese patients adds a further challenge to its laparoscopic treatment and deserves an aggressive surgical approach since its outbreak. although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. there are few studies comparing patients who underwent laparoscopic left colectomy with intracorporeal anastomosis or with extracorporeal anastomosis. anyway literature shows that there is no significant difference between intracorporeal anastomosis and extracorporeal anastomosis about oncological result. as for right hemicolectomy, intracorporeal anastomosis seems to show a trend towards a faster recovery after surgery due to the shorter time to flatus and lower post-operative pain expressed in the mean vas scale. laparoscopic left colectomy with intracorporeal anastomosis is associated with a lower rate of post-operative complications as for right colectomy. literature results could suggest that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. as usual further randomized clinical trials are needed to obtain a more definitive conclusion. we show a video of a 58 years old patient with a pure splenic flexure colon cancer who underwent to a laparoscopic left hemicolectomy with intracorporeal anastomosis. case presentation: here we describe a case of a 81 year old asthmatic and hypertensive lady with an asa score of iii who presented to emergency after a right knee replacement with a four day history of lower abdominal pain. she was septic upon arrival to the resuscitation roomimmediately prompting the hospital's local septic management protocol. a ct scan of her abdomen showed a rectosigmoid perforation with free intra-abdominal air and fluid. the patient underwent laparoscopic hartmann's procedure within 4 h of admission. after an uneventful postoperative recovery the patient was discharged home after a total of 4 days of hospitalisation. she was followed up at surgical outpatients with no adverse events over the course of the subsequent months. conclusion: this case exhibits the feasibility of laparoscopic hartmann's procedure as a surgical modality for hinchey stage iv diverticulitis. the positive outcome supports the claim that for experienced surgeons laparoscopic hartmann's procedure remains a safe and viable option for elderly comorbid patients in the emergency setting. introduction: mesenteric cysts are a very infrequent pathology, they usually present an anodyne clinic, and their diagnosis is reached casually. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with intra-abdominal cysts of benign etiology, using material with mini-instruments, reducing surgical aggression, maintaining its safety and efficacy.material and method: clinical case: a 23-year-old man with no personal history of interest. in the last two months he presented episodes of pain in the right hypochondrium, exploration without findings, us-ct scan: a cystic tumor of 6 cm. in hepatic colon angle compatible with uncomplicated benign mesenteric cyst, tumor markers and normal colonoscopy. evidence of interest is exposed. given the evolution it is decided tto. elective surgical. result: intervention: laparoscopic approach, 4 trocars, two of 3.5 mm, optics of 5 mm 30°, benign cystic tumor, with colloid content of more than 7 cm. of diameter in antimesenteric border of colon, which is not possible to separate, mobilization and resection is carried out by endo-gia, including a portion of the colonic wall, appendectomy, extraction in a pocket. good postoperative course, alt to 2nd day. definitive ap: mesenteric cyst, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of benign intra-abdominal cystic pathology, the use of mini instruments reduces surgical aggression, favoring the recovery of the patient. male, 70 yr, wuth doblue post-operative coloanal stenosi and 1 women, with ultralow rectal neoplatis stenosis (4 cm from anla verge). both patients were discharge ater 3 days from prosthesis positionins without pain and complications. the first patient, with protection ileostomy, showed fecal incontinence before the operation and was performed prosthesis positioning because rectal losses of infected material and fever. fecal incontinence was showed also after procedure but he had not fever. second patient, 93 yr, with ultralow rectal tumor, after prosthesis positioning was submitted to radiotherapy and she decided for not to be operated and she survives after 6 months in ful well-being. conclusion: endoscopic prosthesis positioning is a consolidated procedure for treatment of bowel obstruction. this study demonstrated that this procedure is safe and this kind of prosthesis is suitable for correct positioning. results: we present a case of a 67 years old man with faecal occult blood test positivity that was diagnosed by colonoscopy of a villous lesion at 9 cm of anal verge. biopsies were taken showing a tubulovillous adenoma with high grade dysplasia. a rectal mri was done showing the lesion fixed to the postero-lateral left side of the lumen at 9 cm of anal verge. no pathological lymph nodes were reported. extension study was negative. the case was presented in multidisciplinary committee agreeing in local excision. in october 2018 the procedure was done without incidents. the patient was placed in lithotomic position finding a lesion occupying of the lumen. resection was done without incidents and posterior suture with 2 continuous barbed sutures. he presented an uneventful recovery being the patient discharged in 3 rd postoperative day. definitive pathological findings showed a ptis with negative margins. after three months of followup the patient remains with good functional results and waiting for the first endoscopic revision. conclusions: tamis is a safe and feasible technique with low morbidity that gives us an alternative for early rectal cancer or big rectal lesions much less invasive than techniques used until now. complete mesocolon excision and d3 lymphadenectomy are two fundamental points in the oncological surgery of right colon cancer. most of the adenopathic recurrences of colon neoplasia in tumors located in the hepatic angle and the ascending colon are located near the head of the pancreas and the vascular axis of the superior mesenteric vein due to an alleged incomplete dissection. we present a case of right colon neoplasia where we performed a laparoscopic right hemicolectomy associated with a d3 lymphadenectomy. we use medial to lateral dissection of the mesocolon focused on the dissection of the superior mesenteric vein with the identification of ileocolic vascularization, right colic vessels and henle's trunk. this approach is safe and facilitates a correct resection of the mesocolon, which is approached following the embryological plans and a vascular ligature near the bifurcation. the performance of an extended lymphadenectomy allows a wider resection of the mesocolon and the excision of a greater number of lymph nodes, all of which can contribute to a greater survival. the efficacy of pc treatment is related with a properly preoperative imaging diagnosis of the disease, but the poor sensitivity for identifying small peritoneal metastasis are the major obstacle to achieve a complete resection and that leads to peritoneal recurrence. imageguided surgery using icg, could represent an advance in the detection of small peritoneal nodules. there are only a few clinical studies that have analyzed the role of icg for the staging of pc, specially from ccr, and nearly in all of them the selected approach were exploratory laparotomy. this study presents a laparoscopy case, as a non-invasive way of cs in selected patients with limited pc. a new category, tis, was created for low-grade appendiceal mucinous neoplasms (lamns) that invade or push into the muscularis propia by ajcc cancer staging 8th ed. management of these tumors depends on stage and histology. traditionally, laparotomy was the most recommended approach, however, if laparoscopy is safe, it could be used. the laparoscopic appendectomy should be done with 'not touch' technique and a radical approach has been recently proposed for its treatment. the laparoscopic radical appendectomy should start by exploring complete abdominal cavity. grasping of appendix should not be done. complete resection of mesoappendix is obligated. cequectomy with stapled endogia is necessary. the specimen must be extracted in an endobag. methods: we report a case of a 64 year-old female patient with a personal history of three caesarean sections. this patient was studied due to chronic abdominal pain. a computerized axial tomography was performed, showing an appendix increased in size and a thick wall. the colonoscopy evidence a lesion that protrudes from appendiceal base which is biopsied. results: a laparoscopic way was used and large and width appendiceal was viewed (10x2 cm). furthermore, a rounded right anexial tumor was also found. a radical not touch laparoscopic appendectomy with stapled cequectomy was done. the intraoperative study was mucinous appendiceal tumor without serose affection. the final result was ptisnx (lamn) without resection margins affected. after 48 h of admission, the patient is discharged without incidents. conclusion(s): minimally invasive surgery in lamns is possible if it is performed with enough experience, following specific rules and tips to manage this tumors. a correct follow-up should be carried out using tumor markers and computer tomography (ct). introduction: resection of both benign and malignant colovesical fistulae can be particularly challenging and carry with it specific surgical considerations. often there is a large inflammatory mass sat within a narrow pelvis, limiting specimen mobility and consequently access to dissection plains. additionally, with the underlying inflammatory process, the ureters may be displaced anatomically and be at risk of injury. aim: to demonstrate a streamlined and reproducible approach to the laparoscopic management of both benign and malignant colovesical fistula, with specific emphasis on the different modalities for bladder repair. method: the following method portrays an overall technique which is adapted dependant on the clinical scenario and specific intra-operative findings: approach to abdominal cavity in standard fashion.identification of right ureter.poster-medial mobilisation of the mass to facilitate delivery out of the pelvis followed by visualisation of the left ureter on the medial and lateral sides before division of the fistula.division of the fistula in benign disease or resection of the bladder dome in malignant disease.transverse laparoscopically sympathetic suprapubic skin incision.vertical incision through linea alba to deliver bulky specimen.intra/extracorporeal repair of bladder dome. results: all of the considered cases were successfully completed with a laparoscopic approach, irrespective of the malignant status of the disease in question. conclusion: both benign and malignant colovesical fistula disease can make the laparoscopic approach to resection challenging, especially when encountering a bulky mass in a narrow male pelvis. the stepwise and streamlined approach considered here can help facilitate successful and safe laparoscopic completion without the necessity to convert to open. background: primary neoplasms of the retrorectal space are very rare. they are located in anatomically difficult area to be addressed, hence a complete evaluation of the lesion is required to determine the extent of resection and the appropriate surgical approach, which include posterior, abdominal and combined abdominoperineal, depending on the characteristics of the lesion. objective: to show a combined laparoscopic abdominoperineal approach of retrorectal tumor. method: we present a video of a combined laparoscopic abdominoperineal resection of a lowlying retrorectal tumor in a 73-year-old female without prior abdominal surgery. conclusion: retrorectal tumors are infrequent. their anatomical location can make difficult the surgical approach. preoperative imaging can provide useful information for surgical planning. in the recent years, minimally invasive surgical approach has been proposed. laparoscopic approach is feasible and safe, but it is important to select adequately the patients. background: adult intussusception is a rare clinical event representing only 1-5% of all bowel obstruction cases and 5% of all intussusceptions and the occurrence of adult intussusception due to colonic cancer is even more rare. aim: we present this case of malignant colo-colic intussusception and literature review to increase the awareness of the incidence of colocolic intussusception due to colonic cancer. case report and literature review: our patient is a 70 years old female was admitted to our hospital due to central abdominal pain, cea level of 4, she was further investigated with ct scan of the abdomen and pelvis which raised the suspicion of mid transverse colon intussusception due to large polypoid lesion. she was further assessed with urgent colonoscopy which confirmed mid transverse colon tumour with biopsies confirmed adenocarcinoma. laparoscopic extended right hemicolectomy with lymph node dissection was performed. upon laparoscopic exploration it was found that the colocolic intussusception was evident as described on the ct scan and as clearly shown on the video. histologically, the transverse colon carcinoma was a moderately differentiated adenocarcinoma, with no lymph node involvement '0 out 15 lymph nodes', tnm staging of pt3 pn0 pm0 and r0 resection. intussusceptions of the colon in adult are frequently found in the ileocecal portion or sigmoidal colon but rarely in the transverse colon. only two cases of adult intussusception of the transverse colon caused by colonic cancer have been reported. overall 12 cases on literature review reported showing colo-colic intussusception due to colonic malignancy. conclusion: colo-colic intussusception due to colorectal cancer is a rare clinical event, however it should be included in the differential diagnosis of colonic obstruction. laparoscopic surgery is safe in malignant colocolic intussusception. aims: single-incision laparoscopic colectomy (silc) aims to achieve better cosmetic outcomes, less pain, and faster recovery compared to multi-port laparoscopic colectomy, but it also has several limitations, especially the technical difficulties. we report our experience with singleincision robotic right hemicolectomy via video presentation. methods: we arranged robotic-assisted single-incision right hemicolectomy for a 78-year-old female patient with ascending colon tumor. the operation was performed with gloveport singleport device and a three-arm da vinci robotic surgical system through a small midline umbilical incision. colectomy was proceeded by a medial-to-lateral approach along with one or two accessory instruments for maintaining sufficient bowel traction or surgical field exposure. after vessel ligation, complete colon mobilization and right side omentum division, the robotic arms were undocked to perform anastomosis extracorporeally. results: the operation was performed successfully without drainage tube placement. the total operative time was 193 min. the bowel movement returned on post-operative day 5,and the patient tolerated normal soft diet on post-operative day 7. she was hospitalized for 8 days after operation. the pathology report revealed colon adenocarcinoma (t1n0m0, tumor size 1.8 cm), and 19 lymph nodes were harvested. conclusions: single-incision robotic colectomy (sirc) approach seems feasible and safe in treatment of ascending colon cancer. this surgical option provides less pain and wound scar for the patient. moreover, it also achieves further benefits for the surgical procedures compared to silc. reasons being, first, it has better instruments flexibility and precision with endo-wrist, as well as less instruments clashing. second, the improved camera stability achieved through the use of the robotic arm is unattainable through manual hand-controlled methods. third, roboticassisted approach gives us an ergonomic environment, which enables the operator to control the arms while sitting by the console, and also to reassign them whenever they cross each other or block the surgical view. in spite of the advantages above, we still need to sincerely consider each patient's situation for proper management. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify sentinel lymph node, for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification 5 ml of icg solution (0.3 mg/kg) is subserosal peritumoral injected. a full hd image1 s camera, switching to nir mode, in about 10 min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.when tumor is in difficult site, as hepatic or splenic flexure, 5 ml of icg solution (0,3 mg/kg) is intravenous injected. in about 30-50 s a real-time angiography of tumor area is obtained; on this guide, vascular dissection and pedicle ligation is performed.after anastomosis, another 5 ml of icg solution is injected to confirm anastomotic perfusion. if there is an ischemic area, a new anastomosis is performed. from november 2016, 70 patients were enrolled: 22 left colectomy, 38 right colectomy, 2 transverse resections, and 8 resections of splenic flexure. in ten cases, intraoperative angiography led to the identification of vascular anatomy. in two cases the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november 2017, 40 patients were enrolled to perform the slnb: 23 right colectomy, 11 left colectomy, 1 transverse resection and 5 splenic flexure resections. the sln was identified in 37 cases. 17 cases were found to be n0 to the conventional examination and were subjected to ultrastaging. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to reduce the incidence of anastomotic leak, to facilitate the assessment of vascularization in order to perform oncological resections, and to perform the slnb to study its clinical role on nodal status and for the sln ultrastaging in order to identify the micrometastases. background: surgical emptying of lateral pelvic lymph nodes (llnd) is a strategy used differently when compared the approaches to rectal cancer in the west and eastern countries. there is evidence that = 5 mm lymph nodes in lateral compartment should be removed, even in the setting of neoadjuvant chemoradiation. minimally invasive surgery with nerve-sparing technique and sharp dissection with minimal bleeding may help overcome the significant complexity of the procedure that may have been a technical obstacle to implementation in the past. the standardization of the technique may help implementation with shorter learning curves and excellent surgical outcomes. methods: a 56-year-old male with distal rectal cancer underwent neoadjuvant crt for a mrt3cn2m0 mremvi ? mrcrm ? disease. there was one left obturator node of 7 mm prior to crt. following 12 weeks of crt completion, the patient underwent tatme for the primary disease followed by left lateral node dissection by laparoscopy. results: the present video illustrates the most relevant surgical steps to perform lateral node dissection. the procedure has been didactically divided into 7 steps. the left ureter is identified and retracted using a vessel loop (step 1). identification of the common iliac vein and dissection with subsequent identification of psoas and internal obturator muscles (step 2). identification and dissection of accessory vessels. ( step 3) identification of obturator nerve and obturator vessels (step 4). blunt dissection of obturator nerve (step 5). identification and ligation of obturatory vessels. (step 6) umbilical artery is skeletonized to allow identification and clearance of fatty tissue along superior vesical arteries, internal iiliac artery/vein, inferior vesical artery and internal pudendal artery (step 7). postoperative course was uneventful. conclusion: standardization of lateral-node dissection for rectal cancer has paramount importance. laparoscopic lateral-node dissection for rectal cancer provides optimal anatomical view and allows safe dissection of the nodes of interest. aims: the aim of this video is to describe our technique using fluorescence to assess the lymph flow to ensure a complete mesocolic excision and central vascular ligation in order to provide expertise to contribute to the standardization of this new tool. methods: laparoscopic right colectomy with total excision of the mesocolon was proposed in all cases. for the detection of lymph flow, we injected indocyanine green dye (1 milliliter of 25 milligrams dye dilution in 10 milliliter of distilled water) into the subserosal to submucosal layer around the tumor at 1 point with a 21-gauge injection laparoscopically after trocar insertion, and observed the lymph flow using a near-infrared system (visera elite ii, olympus) after injection. we also performed a total mesocolic excision with central vascular ligation in the region where the lymph flow was fluorescently observed. results: 7 (100%) patients were included. no intraoperative or postoperative complications presented. no adverse effects were reported due to the infusion of indocyanine green. the lymph flow was visualized intraoperatively in a satisfactory way helping the surgeon in decision making to determine an appropriate separation line of the mesentery. the section line of the mesocolon was modified in 1 (14%) case based on the findings obtained by fluorescence. the mean operative time was 160 (42) min. the morphometric laboratory data of the specimens to audit the correct complete mesocolic excision were satisfactory according to the oncological standards. conclusion: fluorescence lymphography during colorectal surgery was feasible and reproducible with a minimum of added complexity. fluorescence-guided surgery may be a helpful technique for determining an appropriate total mesocolic excision in colon neoplasms. aims: this video shows our technique for complete mesocolic excision (cme) during right colectomy for cancer. methods: in this video, a 62 years old patient underwent a laparoscopic right colectomy with cme for a cancer of the ascending colon diagnosed with a colonoscopy performed after positivity to fecal occult blood test (fobt). after ct scan staging we obtained 3d printed models to clarify patient's vascular anatomy. patient was placed in supine position, 4 trocars were inserted in left quadrants as for standard right colectomy. cme is performed by sharp dissection between the visceral fascia that covers the posterior lay of the mesocolon and the parietal fascia that covers the retroperitoneum (toldt's fascia). the ileo-colic vessels are used as landmark to identify the right anterior surface of the superior mesenteric vessels. with a caudo-cranial approach, the mesocolon is sharply dissected and the root of tributaries venous is ligated, up to the inferior margin of the pancreas. the gastro-colic trunk is dissected out with ligation of the right colic vein, while the gastroepiploic vein is preserved (harvesting the sixth group lymph node). the pancreas-duodenum fascial plane is entered and all the lymphoid tissue around the vessel surface is harvested. procedure is completed with ileo-transverse intracorporeal stapled anastomosis. results: in our experience, between april 2017 and december 2018, 46 laparoscopic right hemicolectomies with cme were performed. we had no major intraoperative vascular lesions. no patients needed intraoperative blood transfusion. compared to our series of standard right colectomies we did not notice any significant difference in post-operative complications. the follow-up is too short to demonstrate if the cme approach has a better oncological outcome compared to standard right colectomy. conclusions: laparoscopic cme is feasible, although it requires a higher expertise level of surgical know-how. the quality of evidence is limited and does not consistently support the superiority of cme as compared to standard right colectomy. better data are needed before cme can be recommended as the standard of care for colon cancer resections. h. bando gastroenterological surgery, ishikawa prefectural central hospital, kanazawa, japan aim: in case of right-sided transverse colon cancers, it is necessary to dissect the lymph nodes around the root o f the middle colic vessels. but in this area there are dangerous organs, for example : pancreatic head, duodenum, and gastrocolic trunk. it is the point of our technique that we resect the accessory right colic vein and middle colic vein, and then dissect pancreas head and duodenum at early step of the operation. method: we perform the operation by five trocars. the first step is to transect the great omentum, and confirm the lower edge of pancreas.there are much adhesion between mesocolon of transverse colon and stomach, great omentum. it is very important to dissect the adhesion accurately. secondly, the mesocolon is incised at lower edge of pancreas. it is possible to detect the lower edge of pancreas in obese people. the anterior surface of superior mesenteric vein is exposed. the accessory right colic and middle colic vein are resected. and then front face of surgical trunk, pancreas, and duodenum is dissected caudally as possible. the superior mesentery artery is resected below the mesocolon after flip up of transverse colon. this approach is safe and feasible, because the dangerous organs are handled by direct vision. by that, extraction of intestine is easy from small incision. afer flip up of transverse colon, the mesenteric of ileum is incised. the root of ileocecal vessels is exposed and these are resected. the peritoneum of the front of superior mesenteric artery is incised, and the lymph nodes around the surgical trunk are dissected. this dissected area is easily connected with the one done beforehand. uniquely we resect the mesocolon and major omentum from the root of dissected vessels to resected side of transverse colon. and then right-side colon is dissected medial approach. conclusion: we dissect the dangerous organs in advance. that prevent major injury of them. background: good visualisation of the operative field is a fundamental requirement for safe laparoscopic colorectal surgery. over the past 25 years of the senior author's experience, camera systems have evolved from single to three chip, high definition (hd) and most recently, the 4 k system. in parallel, the rest of the infrastructure such as cables, processors, monitors etc. have also undergone improvements, resulting in improved image quality. aim/methods: we present a video of a case of laparoscopic total mesorectal excision (tme), performed with strict adherence to our previously published 'stepwise approach to laparoscopic colorectal surgery' which places particular emphasis on safety aspects. tme was performed in a 54 year old male patient with history of previous abdominal as well as robotic prostatic surgery. the procedure was filmed with all components including the camera head, cables, processing unit, screens as well as the recording/mixing decks being 4 k. multiple external 4 k cameras were also used. live transmission to a remote audience as part of our masterclass was achieved using appropriate bandwidth and projection on to 4 k screens. results: feedback from the operating team as well as from the live audience was that the image quality was far superior to hd systems. the 4 k system accorded a degree of clarity well beyond usual expectations. the depth of field also appeared to be different initially, but within a few minutes of starting the procedure and acclimatisation, the effects were appreciable. the clarity of the image which showed the fine details of the dissection planes and anatomical landmarks as well as the vibrancy of the vasculature gave a distinct three-dimensional effect to the picture. this excellent visualisation added one more layer of safety and complemented our stepwise approach for a successful procedure. conclusion: the laparoscopic 4 k system, in our practice, proved to bea beneficial visualisation tool to enhance the accuracy of dissection. vital structures appeared to be more vivid and clearer with dissection planes being more easily apparent. in our opinion the laparoscopic 4 k system when combined with a systematic approach enhances safety, especially in complex laparoscopic colorectal surgery. accumulating evidence suggests that laparoscopic surgery for colon cancer has feasibility and efficacy equal to or over conventional laparotomy. for cases with pasthistory of laparotomy, especially history of colon resection, however, there is almost no evidence for laparoscopic recolectomy for metachronous colon cancer. since 2016, we have been used submucosal local injection of indocyanine green (icg) around primary colorectal cancer by using intraoperative endoscopy, and complete mescolic excision (cme) have been convincingly carried out, which was clarified by completely resected icg positive area. although evidence on the oncological efficacy of icg guided surgery has not yet been clarified, since it can be easily judged whether cme is performed clearly, it is considered that icg guided surgery for primary colon cancer is useful for education. recently, we are applying this to ensure convincing cme for patients with colorectal cancer who had a history of colic resection. the representative case is as follows. a 60-year-old female was diagnosed as advanced sigmoid colon cancer, and laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery was performed 10 years ago. then she was diagnosed as the metachronous descending colon cancer. the feeding artery of the new tumor should be the left colic artery, however, the left colic artery was already resected and genuine feeding artery was not identified by preoperative examination. by injecting icg into submucosa endoscopically during operation, it was clearly observed that the lymphatic flow from the tumor was directed to the inlet portion of the inferior mesenteric vein (imv). re-cme was performed by ligating the inlet of imv. intraoperative icg was also useful for clarifying the borderline for adhesion detachment of pastoperation between the mesentery and retroperitoneum (figure) . interestingly, icg flow in the mesentery direct to of the anus side was disrupted clearly at the past anastomotic site. we believe that laparoscopic surgery under icg guidance is potential useful tool that can confirm evidence to date more intuitively in real time. further studies, ideally randomized controlled trials, are required for define the oncological usefulness of icg guided surgery for re-do colectomy. the operation movie will be presented at the meeting. background: laparoscopic lateral pelvic node dissection (llpnd) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. in this video, we demonstrate the technique of llpnd for rectal cancer patients with suspicion of lln metastases after neoadjuvant chemo-radiation. methods: the principle of this approach is en bloc resection with bilateral peritoneum. the peritoneum is incised lateral to the ureter following the line between external and internal iliac vessels. in the next step, llpnd dissection of the regional lymph node and high ligation of inferior mesenteric vessels were performed. a contralateral llpnd was performed in the same manner as a mirrored technique. after extracting the specimen, an end-to-end double-stapled circular anastomosis was performed. results: the procedure was done safely without any complications.the surgical duration was 245 mins, and the blood loss was 50 ml. the number of harvested lateral pelvic lymph nodes was 15. the tnm stage was ypt4an2m0. conclusion: this approach enables extended resection during lymph node dissection, allowing autonomic nerve preservation. it is maybe a helpful approach in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis. aims: the aim is to present an inspection method where the anastomosis vascularity is testing simultaneously using the indocyanine green fluorescent angiography intraluminal and intraperitoneal. methods: sixty-five year old female patient underwent standard laparoscopic-assisted low anterior rectal resection for rectal carcinoma. the proximal end of the bowel and the stump of the distal rectum were checked using near-infrared fluorescence imaging with d-light camera. after making sure of adequate perfusion of the bowel, the end-to-end stapled anastomosis was performed under the laparoscopic visualisation. the d-port proctoscope was inserted into the anus. the second icg injection was administered. the perfusion of the anastomosis in transabdominal way and viability of the mucosa in transanal way was evaluated with two d-light cameras simultaneously. the anastomosis was determined 4 cm from the anal verge. an air-water leak and tension of the bowel tests were performed. after evaluation of anastomosis viability with fluorescence imaging, after negative air-water leak and tensions testing, the decision was made by surgeon not to perform preventive ileostomy. results: the patient had no complains for the first three days postoperatively. nevertheless, crp level was growing and was 69.6 mg/l on the second postoperative day, and 103.5 mg/l on the 4th postoperative day. the patient complained of the pain in the right iliac area and below symphysis on the 4th postoperative day. the abdominal and pelvis computed tomography scan with oral contrast was performed which denied our thoughts about the anastomotic leakage. intravenous cefuroxime and metronidazole antibiotics were prescribed. the crp level was 16.3 mg/l on the 10 th postoperative day. the patient was discharged on the 11 th postoperative day without preventive ileostomy. conclusion: using the original, standardized colorectal anastomosis inspection method we can determine which patient doesn't need the preventive ileostomy after low colorectal anastomosis. the 2 important causes of anastomotic leak are local ischemia and staple line defect. the purpose of this study was to investigate the combination of methods aimed to reduce the risk of anastomotic leak after anterior resections for rectal cancer. methods: we retrospectively analyzed perioperative outcomes of the first 30 patients, who underwent modified laparoscopic anterior resection with partial mesorectal excision for rectal cancer without preventive stomy. operative technique was modified and included routine preservation of the left colic artery (fig1)(aimed to improve anastomotic blood supply), manual suture invagination of the 'dog ears' (fig2) (aimed to reduce the risk of staple line defects), transperineal pelvic drainage and pelvic peritoneum reconstruction (aimed to reduce the risk of reoperation in case of leakage). anastomotic leak rate, reoperation rate, left colic artery preservation rate, additional operative time (time required for left colic artery preservation, 'dog ears' invagination and pelvic peritoneum reconstruction), blood loss, morbidity and mortality were analyzed. results: 1 (3.3%) patient developed an asymptomatic leakage, which was managed conservatively. there was no postoperative mortality and no reoperations. median additional operative time was 56 min for the first 15 procedures and 41 min for the last 15 procedures. left colic artery preservation was successful in 26 (86.7%) patients. median blood loss was 35 ml. conclusions: additional techniques used in our modification of laparoscopic anterior resection are safe and may lead to improved perioperative outcomes. however, they are associated with increased operative time, which may be reduced with a better learning curve. introduction: parastomal hernias are a significant cause of post abdominal ostomy morbidity with an overall life-time incidence exceeding 80%. the complications can range from a bulge resulting in stoma bag leakage, to life threatening bowel obstruction. the prevent-trial sought to determine if prophylactic utilisation of polypropylene mesh would decrease the incidence of parastomal hernias, with initial results demonstrating that it was safe to use in permanent end stomas. aim: to demonstrate a reproducible and streamlined technique for laparoscopic parastomal hernia repair with intraperitoneal funnel mesh, and assess the outcomes with the clavien-dindo (cd) classification tool. method: 10 parastomal hernia repairs (7 colostomy, 3 ileostomy) were considered, with the following approach adopted for each: swab sutured in stoma orifice to prevent wound contamination.sharp dissection of the stoma using parachute technique.stoma end refreshed followed by change of gloves and instruments.lateral stay sutures placed to tighten sheath later on.pneumoperitoneum temporarily created to assess/divide adhesions.funnel mesh placed in-situ, orientated in the optimal intraabdominal position, and sutured to the peri-colic fat to prevent slip.medial suture placed to narrow the sheath further.pneumoperitoneum re-created and mesh fixed in place with double crown laparoscopic tacks.redundant portion of end stoma excised and stoma formed. results: at median follow up of 12 months: no recurrence.no reported symptoms of pain or decreased stoma functionality.one superficial wound infection treated with drainage at bedside (cd = grade 1) conclusion: laparoscopic parastomal hernia repair with intraperitoneal funnel mesh for permanent end stomas yielded good outcomes in our patient cohort. a streamlined and reproducible approach ensures that the technique can be adopted for both prophylactic, primary and recurrent repair. parastomal hernias are common and can be associated with significant morbidity. when taking this into account, in conjunction with the recommendations of the initial results of the prevent-trial, one may consider prophylactic utilisation of a mesh in patients receiving a permanent end stoma. general surgery, rambam medical center, haifa, israel 29 year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy. during last year, patient suffered from recurrent episodes of ascending cholangitis. recently, she underwent ercp and severe stricture of middle cbd was diagnosed. plastic stent was inserted through the cbd. mrcp also showed severe stricture of cbd with dilatation of biliary tree, proximal to the stricture. due to severe and resistant (did not resolved by recurrent dilatation) structure of middle cbd, she was referred to operation. patient underwent da vinci robot-assisted excision of the cbd stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of roux-an-y limb. total operating time was 320 min. day three after operation patient started regular diet and was discharged home on day four. final pathology has shoved part of cbd with severe inflammation. aims: extrahepatic biliary duct resection for the treatment of bismuth i and ii stage klatskin tumor is the standard surgical technique [1] . methods: a 85 years old patient present at emergency room (er) with right upper abdominal pain with an elevation of the inflammatory markers at the blood exams and fever. the patient was submitted to a computer tomography (ct) that shows a tumor involving the lower tract of the principal bile duct. an endoscopic retrograde cholangio pancreatography (ercp) with biopsy (intraductal papillary neoplasm of the bile duct,ipnb with high-grade dysplasia) and stent placement was performed. considering the good general conditions of the patient and an absence of vascular and nodal invasion at the preoperative imaging, a minimally invasive surgical resection of the biliary tract with cholecystectomy was performed. results: a four port laparoscopic biliary tract resection with cholecystectomy was performed with lymphadenectomy of the hepatic hilum. no vascular or liver infiltration was found. the hepatic hilum was completely skeletonized. the resection of the biliary duct was performed with adequate free margin. a biliary reconstruction with roux-en-y technique was performed and a fully laparoscopic hepatico-jejunal anastomosis was done. and abdominal retro anastomotic drain was placed. the operative time was 350 min. the postoperative course was complicated by a low rate biliary leakage that was treated conservatively. the patient was discharged at 25 post operative day in good general conditions. the histological examination revealed a moderately differentiated in situ cholangiocarcinoma of the principal bile duct with the involving of the cystic duct with free resection margin (pt1bn0r0). conclusions: laparoscopic resection of the biliary tract is a challenging procedure that allows, in expert hands, to achieve in selected cases negative pathological margin, complete linfonode retrieval and entero-biliary bypass. injury to the extrahepatic bile duct during bile duct or hepatic surgery can be reduced by better real-time visualization. recently, indocyanine green (icg) fluorescence imaging has been used in laparoscopic hepatobiliary surgery. we applied icg fluorescence imaging in patient with huge hepatic cyst which severely deviated extrahepatic bile duct. the patient had received laparoscopic cholecystectomy and huge hepatic cyst stuck firmly with peri-hepatic structures including bile duct. icg fluorescence imaging correctly identified the common hepatic duct and remnant cystic duct and allowed for more meticulous and easier dissection. therefore, icg fluorescence imaging may guide a safe and accurate dissection and excision in hepatobiliary surgery. results: total patients who underwent ercp were 2,321 and 3.2 percent (75 cases) had a first failed ercp and 13 of then were unsuccesfull in the second intent of ercp. intrahospitalary stay was more than 7 days in the 11 percent, in the 89.2 percent was 4 to 7 days, with and average of 6 days. conclusions: before, during or after lcbde, ercp remains the gold standard for manegement of choledocolitiasis confirmed by clinics, laboratory and imagenology. lcbde is a very good option that requires experience and specific skills, and especialized equipment. in 9 years the rate of sucess in our hospital was 95.3% and there were no posoperatory complications such as: biliar peritonitis, pancreatitis or liver abscess. aims: easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared (nir) fluorescence imaging after an injection of indocyanine green (icg). neither radiological support nor additional intervention such as opening the cystic or common bile duct is required, making it an easy and real-time technique to use during surgery. the aim of this video is to describe our experience in fluorescence-guided cholangiography in different clinical situations. methods: intravenous injection of icg is used to illuminate extrahepatic biliary anatomy. however, the simultaneous enhacement of liver parenchyma can disturb the visualization of clinical details. the key is in the used dose of icg, the route of administration and the time since its infusion. in the first case, a scheduled cholecystectomy is shown in which a dose (1 ml of 25 mg dye dilution in 10 ml of distilled water) administered intravenously 3 h before the intervention was used. the second case shows an urgent cholecystectomy in which the dose (30 ml of 25 mg dye dilution in 1000 ml of distilled water) was administered intragallbladder during surgery. all patients underwent laparoscopic cholecystectomy with traditional four-port technique. all procedures were performed using a 30-degree 10 mm laparoscope with nir imaging capability (visera elite ii, olympus). results: there were no intraoperative or postoperative complications. there was no increase in operative time due to the use of icg. in the first case, a clear identification of the cystic duct and the main bile duct was obtained thanks to the biliary excretion of the icg and the intravenous clearance. in the second case, the identification of the cystic duct, the main bile duct and the cystic artery occurred due to the intravesicular absorption of icg. conclusion: fluorescence-guided cholecystectomy clarifies the dissection plane. it can be considered to increase the safety of laparoscopic cholecystectomy. being aware of the doses, times and possible routes of administration is basic to universalize the technique and give it utility in different scenarios. introduction: mirizzi syndrome type 2 is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in hartmann's pouch or the cystic duct with a resultant cholecystocholedochal fistula. the obstructive biochemical changes can be caused by direct extrinsic compression from the impacted gall stone or from the fibrosis caused by advanced chronic cholecystitis, or for the established fistula. objective: we present a case of a mirizzi type 2 syndrome with choledocholithiasis which was solved by laparoscopy approach. material and methods: a 28-year-old female patient with no past medical history. the history of present illness begans with the presence of icteric dye since the last 3 days; she received symptomatic treatment with poor improvement. a liver and biliary tract ultrasound was performed with report of a 12 mm coledochus, 5 mm wall gallbladder. then an endoscopic retrograde clolangiopancreatography was performed with successful endoscopic sphincterotomy and removal of gallstones. but the patient jaundice persisted after the procedure. the patient underwent cholecystectomy and laparoscopic common bile duct exploration, where the findings were a mirizzi type 2 according to the csendez classification, chronic cholecistitis and choledocholithiasis. results: in this laparoscopic approach we performed a partial cholecystectomy, bile duct exploration with removal of residual gallstones. the closure of the choledocotomy was performed with simple knots using vycril 3.0. a subhepatic drainage was left. the patient showed adequate clinical evolution. after 4 days the patient was discharged. conclusions: it is important to properly identify the anatomy at the time of surgery to avoid injury of the common bile duct. operative treatment of mirizzi syndrome type 2 includes either laparoscopic or open subtotal cholecystectomy or placement of a t-tube or choledocoplasty. near-infrared fluorescent cholangiography (nirf-c) is an innovative intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. thanks to the development of laparoscopes/endoscopes with light sources emitting infrared frequencies, it is possible to visualize anatomical structures (vessels, ureters, bile ducts, etc.) through the luminous intensity of substances (fluorescein, blue of methylene, indocyanine green) which are injected into the patient. this technology may be considered as an important teaching tool for laparoscopic surgery, especially for young surgeons in their surgical learning curve and it could lead to reduce the risk of iatrogenic bile duct injuries during laparoscopic cholecystectomy. the following video is characterized by a series of intra-operative images of biliary anatomy by fluorescence, having an important educational interest, while also detecting anatomical variations of the cystic duct. a. umezawa, minimally invasive surgery center, yotsuya medical cube, tokyo, japan aims: laparoscopic cholecystectomy(lap-c) for cholecystolithiasis has become standard. however, serious bile duct injury has been reported as a complication. repeated colic and chronic inflammation in cholecystolithiasis lead to the so-called difficult gallbladder conditions, such as dense fibrosis and scarring of the tissue. dissection of calot's triangle includes the risk of bile duct injury. critical view of safety (cvs) is the most well-known land mark for safe cholecystectomy. in the revised tokyo guidelines 2018 (tg 18), important land marks and bailout procedures had been proposed. those are for the difficult gallbladder which are not able to achieve cvs. methods land marks: baseline of segment4 of the liver and sulcus rouvier should be confirmed. the gallbladder wall itself is also useful landmark. bailout procedure: when the dissection of calot's triangle is considered impossible, bailout procedures should be considered. subtotal cholecystectomy which leave the neck is one of option. the fundus first technique is another approach. however, because fundus first technique has a possibility of leading to serious bile duct injury, it should stop by the neck. in this video, first case shows the importance of landmarks from near miss cases of misidentified injuries. second case shows bailout procedure, subtotal cholecystectomy with fundus first technique. result: in the atrophic gallbladder (case 1, near miss), it is liable to misidentify the junction of common bile duct as the gallbladder neck. the neck and common hepatic duct were lifted together easily. with confirming the landmark, misidentification was corrected and bile duct injury was avoided.in the case2, since the calot's triangle was obscured due to repeated cholecystitis, dissection of gallbladder was performed from the bottom to the neck, and was excised with the cervical portion remained. the remaining neck was reconstituted.in each case, intraoperative cholangiography was performed, and it was confirmed that there was no bile duct injury. without postoperative complications, those patients were discharged pod 2 as usual lap-c. conclusion: during lap-c for difficult gallbladder, the most annoying part is bile duct injury. confirming landmarks and switching bailout procedures can be contributory to avoid bile duct injury and to achieve safe lap-c. aims: choledocholithiasis is an important cause of morbidity and is present in about 18% of patients submitted a cholecystectomy. his treatment should be done in the same operative time, avoiding the morbidity and hospitalization time and costs of multiple procedures.the transcystic approach is preferable to prevent morbidity associated to choledochotomy.large stones can preclude this procedure. the use of laser lithotripsy to stone fragmentation is an option to provide transcystic extraction. methods: we present a video of laparoscopic transcystic common bile duct (cbd) exploration for choledocholithiasis. results: female patient, 65 years old with a previous hospitalization for acute cholangitis with choledocholitiasis.submitted to laparoscopic cholecystectomy with intraoperative cholangiography that showed the presence of stone in distal cbd with 1 cm size. the use of holmium laser lithotripsy made the stone fragmentation and provided his extraction by transcystic route using a basket.the patient was discharged at 4 th postoperative day, with no complications. conclusion: the use of laser lithotripsy for large cbd stones is safe and effective, making possible the transcystic approach and preventing the choledochotomy morbidity. surg endosc (2019) 33:s485-s781 gallbladder adenocarcinoma is rare and extremely aggressive. its' incidence is higher in elder females and its progression is rapid and silent with a dismal prognosis if diagnosed at advanced stages. we present the case of a 77 years-old female with dyspeptic complaints. the abdominal ultrasound revealed a 2 cm solid lesion of the gallbladder suspect for malignancy. the ct confirmed the presence of a vegetant mass on the free border of the gallbladder fundus with 28x13 mm. we performed a radical cholecystectomy with lymphadenectomy and liver bed excision. the post-operative period was complicated with a urinary tract infection, with full recovery after antimicrobial treatment. the histological sample revealed an adenocarcinoma of the gallbladder (t1bn0m0) and the patient remains asymptomatic and tumour free 9 months after the surgery. gallbladder cancer treatment depends of the stage and clinical presentation of the disease. complete surgical excision is the only curative treatment and should include a limited hepatectomy and portal pedicle lymphadenectomy. laparoscopic surgery might be an option in early stages, although it is challenging and requires both expertise in hepato-biliary and laparoscopic surgery. seen at the emergency room for a two month history of abdominal pain associated with jaundice. she is evaluated by the surgical team and diagnosed with acute cholecystitis and moderate risk for choledocholithiasis. the initial surgical plan was cholecystectomy with intraoperative cholangiogram. during surgery, firm adhesions are found from the gallbladder to omentum. friable tissue with edema and easy bleeding. difficulty is encountered during the dissection of calots'triangle. an intraoperative cholangiogram is done through hartmans'pouch without identifying correctly the biliary tract. therefore, an endoscopic retrograde cholangiopancreatography (ercp) is done to visualize the correct anatomy. during the ercp, a stenotic common hepatic duct is found and no stones are visualized. a biliary endoprosthesis is placed. she is discharged asymptomatic. a month later, the patient is back in the emergency room with abdominal pain. after an abdominal ct scan, we found that the endoprosthesis had migrated to the 4 th portion of the duodenum. a second ercp is done and this time we found a big stone (1.5-2 cm) aims: when training in the residency you watch your teacher perform laparoscopic cholecystectomy with ease, and even yourself perform several steps. but as a young surgeon, when confronted with a patient with acute cholecystitis, you're filled with emotions, and you do not know where to start the gallbladder dissection. the aim of this presentation is to show to young surgeons that you can, and must achieve, critical view of safety when performing laparoscopic cholecystectomy for acute cholecystitis. methods: we present the case of a 42 years old female patient, bmi of 36.3, who presented with a grade ii (moderate) acute cholecystitis. following tokyo guidelines, we initiated antibiotics and general supportive care, but without clinical improvement. the patient was proposed for laparoscopic cholecystectomy. results: at initial exploration we identified a 20 cm long gallbladder, with a thick wall, difficult to manipulate. we opted for an anterograde cholecystectomy, in our opinion the best option in acute cholecystitis. the dissection was started with hook electrocautery and then continued with a combination of blunt dissection with the aspirator and with the hook. when reaching the pedicle, blunt dissection was used in order to appreciate the anatomy of the cystic duct and cystic artery. after correct identification of these structures they ware clipped and cut. a drainage tub was then placed, and the abdomen deflated. conclusion(s): as a young surgeon, when dealing with acute you must maintain your calm, and try to achieve critical view of safety before transecting the cystic duct and cystic artery. this can be achieved with a combination of blunt and sharp dissection, keeping your camera clean and with a good collaboration with the assisting surgeon. conclusions: here, an easy and reproducible method is described for future macroscopic analysis by the surgeon following a cholecystectomy. in addition, we depict several frequent macroscopic abnormalities in order to provide surgical colleagues with some cases of abnormal macroscopic gallbladders. the left hepatectomy is a demanding and difficult procedure, still limited to reference centers. the caudal approach and exposure of the middle hepatic vein is a reliable way to achieve a safely and reproductible left hepatectomy. with this technique, exposing the middle hepatic vein, we believe that we can perform a safe and feasible laparoscopic left hepatectomy increasing the quality of this hepatectomy. we present a 47-year-old woman with an intrahepatic and common bile ductlithiasiswhich was previously submitted to an ercp. with an unsolved intrahepatic lithiasis the patient was proposed to alaparoscopic left hepatectomy. the minimally invasive approach for alpps in a patient with a large hepatocellular carcinoma in a liver with severe steatosis is shown. during the first stage a partial alpps is performed. pve is performed in postoperative day one. after 15 days from the first stage both liver volume and function (by hida scan) are re-assessed. right hepatectomy (second stage of alpps) is then conducted by laparoscopic aproach. hepato-bilio-pancreatic, centro hospitalar são joão, porto, portugal a 68 year old woman with a previous history of anxiety and catheter ablation to treat heart arrhythmias, was studied for for multiple pancreatic cysts incidentally discovered on a routine ultrasound. an mri was performed showing multiple cystic tumors throughout the pancreas, the largest of which was 15 mm. this led to a suspicion of multi-focal, side-branch intraductal papillary mucinous neoplasm (ipmn), with minimal dilatation of the main pancreatic duct. an echo endoscopy was subsequently performed indicating probable multifocal ipmn. a fna was carried out during this procedure, with aspiration of cystic content which was sent for cea analysis and cytology. cytology was compatible with mucinous neoplasm with mild atypia and cea 98 u/ml. a splenic preserving total laparoscopic pancreatoduodenectomy was proposed. the procedure was uneventful and the patient was discharged on the 5 th post-operative day. pathology revealeded a 19 mm ipmn, with severe dysplasia and 3 foci of microinvasive ductal adenocarcinoma of 1 mm-pt1n0r0. indocyanine green immunofluorescence guided laparoscopic partial hepatectomy y. tai obtaining negative tumor margin during laparoscopic hepatectomy has always been a very challenging topic for surgeons in that the surgeons are not able to palpate the tumor during laparoscopic surgery. although intraabdominal echo is available, but it demands great experiences and skills. with the guidance of icg immunofluorescence, surgeons can avoid failure of not obtaining enough negative margins nor resect too much healthy liver. icg is often used to estimate the liver function prior to hepatectomy traditionally. it binds to plasma protein and has a peak absorbance at 780 nm and emits fluorescence with a wavelength of approximately 800 nm. icg is preferentially retained in or around biliary malignancies due to impaired biliary excretion of hepatocytes in the affected area. we performed icg immunofluorescence guided laparoscopic partial hepatectomy on a 57 years old male who suffers from hcc located at segment 5 and 6. icg was injected 3 days prior to the operation day. while evaluation of liver is performed, it also allowed us to use a high-end laparoscopic camera system equipped with integrated filters for detection of near-infrared fluorescence. during the surgery, we were able to clearly locate the borders of malignancies through the use of integrated filters combine with icg injection. the pathology study also confirmed that the adequate tumor free margin ([ 0.5 cm) were obtained in both tumors and the patient's condition was stable as well. icg immunofluorescence guidance enables surgeons to obtain optimum result in tumor resection through laparoscopic surgery. it also has the ability to detect bile leakage. with the use of icg immuofluorescence, surgeons will have higher chances to achieve adequate negative margins. background: parenchymal sparing hepatic resection has the advantage of preserving valuable tissue in chemotherapy-treated livers, assuring an adequate future remnant volume without compromising long-term survival. moreover, the laparoscopic approach offers the decreased postoperative morbidity of minimally invasive surgery. whenever technically feasible, this kind of procedure should be considered a suitable alternative to the classic major hepatectomy for the treatment of multiple colorectal liver metastases. methods: 69-year old male with a previous history of laparoscopic sigmoidectomy in november 2014 for a pt2n0m0 sigmoid adenocarcinoma. a control scanner three years later showed liver metastases in segments v, viii, ii and caudate lobe. after chemotherapy (xelox), control mri and pet scans showed a good response. he was proposed for a laparoscopic parenchymal-sparing liver resection. results: total operative time was 3 h and 45 min with no intraoperative complications. patient presented a right atelectasis as the only postoperative complication and was resolved with respiratory therapy. he was discharged in 4 days. pathology report showed that lesions on segment v and viii had no viable tumor (100% fibrosis) and lesions on segment ii and caudate lobe had moderately differentiated adenocarcinoma. margins were free in all the lesions. after a 6 month follow up, the patient has no recurrence and normal liver function tests. conclusion: minimally invasive liver resection is possible in patients with multiple bilobar liver metastases and allows to perform parenchymalsparing surgery safely. difficult localization of lesions such as the caudate lobe are not a contraindication for this type of surgery. laparoscopic approach for perihilar cholangiocarcinoma is still poorly reported in the literature due to technical challenges secondary to the combination of major hepatectomy, lymphadenectomy and biliary confluence resection. despite this, in selected cases it can be a good option to provide a short term benefit to patients. the video reports the case of a perihilar cholangiocarcinoma with involvement of left bile duct and therefore requiring left hepatectomy. komagome hospital, bunkyo-ku,tokyo, japan aims: segmentectomy is an anatomic liver resection, in which the tertiary branches of the glissonean pedicles are selectively transected. however, the branching pattern of the tertiary branches varies depending on the case, particularly in segment 7 (s7) and segment 8 (s8). the extrahepatic approach to the glissonean pedicle from the hepatic hilum is very difficult depending on the branching pattern. furthermore, the distance of exposing the secondary branches that are to be preserved becomes longer, and there is an increased risk of biliary leakage and delayed biliary stricture due to excessive traction in laparoscopic surgery. therefore, laparoscopic s7 and s8 segmentectomy are considered technically difficult. we standardized the intrahepatic glissonean pedicle approach for laparoscopic s7 and s8 segmentectomy. methods: we standardized the intrahepatic glissonean pedicle approach for laparoscopic s7 and s8 segmentectomy. we identify the targeted glissonean pedicle intrahepatically after the parenchymal transection along the major hepatic vein or its branch running on the intersegmental plane, referring to the preoperative simulation by 3d imaging. (a)s7 segmentectomy; after the mobilization of the right lobe, the glissonean pedicles of s7 (g7) can be approached from the dorsal side by transecting the parenchyma between the ivc and the right hepatic vein. after the division of the g7, the parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. (b)s8 segmentectomy; first, the parenchyma is transected along the middle hepatic vein (mhv) from the root side to the peripheral. g8 is typically detected on the right dorsal side of the mhv. after the division of the g8, the liver parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. results: we have experienced 11 cases of laparoscopic s7 segmentectomy and 26 cases of laparoscopic s8 segmentectomy. conclusion: our approach to the g7 and the g8 is safe and very useful. laparoscopic anatomical segmentectomy of right anterior section is technically demanding because it is difficult to dissect the deep tertiary branches of right anterior portal pedicle (rapp). we present three cases of laparoscopic anatomical segmentectomy using the extrafascial and transfissural approach: 1) anatomical resection of segment 5, 2) anatomical resection of the ventral area 3) anatomical resection of segment 8 dorsal area. the extrafascial and transfissural approach means that the liver parenchyma along the fissure lines is opened, then the surgeon can confirm the glissonean pedicles and territory directly. the extrafascial and transfissural approach in laparoscopic anatomical segmentectomy of right anterior section is feasible and effective because this technique can easily be approached to the deep tertiary branches of rapp. repeated liver resection has significant role in patients with recurrent hepatocellular carcinoma (hcc) in several situations. laparoscopic redo surgery is becoming safer along with advance in surgical technique. we have performed laparoscopic re-resection for limited intrahepatic hcc recurrence. the aim of the present study was to investigate its significance comparing with first laparoscopic liver resections. subjects: patients with limited intrahepatic hcc recurrence after open hepatectomy underwent laparoscopic liver re-resection (n = 12). methods: adhesion between abdominal wall and visceral organs was carefully divided, after the first laparoscopic port was safely inserted. adhesion between diaphragm and liver surface or between previous liver cut surface and colon or duodenum was also minimally dissected. approach to the glisson's pedicles at the hepatic hilum was often difficult due to previous surgical procedure, thus pringle's maneuver was generally applied. dissection of hepatic parenchyma approaching to the target glisson's branch was often preceded under the ultrasound-guidance. liver resection was performed using lcs, biclamp, and cusa using intermittent block of the hepatic inflow. operation time, intraoperative bleeding, morbidity, mortality, and postoperative hospital stay were compared with those in patients who underwent first laparoscopic liver resection during the same period (n = 20). results: operation time was significantly longer in the re-resection group, possibly due to the adhesiolysis. meanwhile, no significant difference was detected in intraoperative bleeding, morbidity, mortality and postoperative hospital stay between the first and the redo surgeries. methods: the donor was a 32-year-old gentleman who decided to donate part of his liver to his wife suffering from viral liver cirrhosis and hepatocellular carcinoma. his bmi was 20.3 kg/m 2 and the preoperatively estimated donor's right liver volume was 836 ml, representing 63.6% of his entire liver. with the recipient's weight of 57 kg, the graft to recipient weight ratio (grwr) was 1.6%. the liver had classic hilar anatomy except that the right posterior intrahepatic duct seperately joined to the left main hepatic duct. after isolation and clamping of right hepatic artery and portal vein, indocyanine green of 2.5 mg was injected intravenously. results: the total operation time was 370 min and the estimated blood loss was 150 ml without transfusion. indocyanine green fluorescence image clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. his postoperative course was uneventful and discharged postoperative day 7. conclusion: real-time indocyanine green fluorescence image may be particularly helpful to delineate anatomical surgical plane and to determine the appropriate division point of hepatic duct during laparoscopic living donor hepatectomy. surg endosc (2019) the correct management of intraoperative volemic status is essential in laparoscopic liver resection in order to control bleeding and to perform even complex procedures with a good profile of safety. central venous pressure is not really reliable in laparoscopy, due to presence of the pneumoperitoneum and patient position. monitoring of haemodynamic parameters via vigileo system is a minimally invasive method to control stroke volume variation, cardiac output, cardiac index and oxygen delivery in order to optimize the anaesthesiological management by controlling venous bleeding and avoiding tissutal ischemia. introduction: non-hydatid liver cysts represent a heterogeneous group of disorders that differ in their etiology, prevalence and clinical manifestations.within them, the simple hepatic cyst is the most frequent.the majority of simple cysts are an incidental finding during the performance of an imaging test for another unrelated cause and few of them are symptomatic or are associated with complications, and surgery is not necessary in most of them. described various therapeutic approaches so far there is no consensus about the optimal treatment of simple symptomatic, complicated or growth-showing liver cysts during its follow-up. currently the laparoscopic approach is widely used for the management of cysts hepatic, with results similar to open surgery but with the advantages of laparoscopy. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the approximation of complicated simple hepatic cysts.material and method: clinical case: a 68-year-old female patient with a history of: giant hiatus hernia intervention with laparoscopic nissen, fibromyalgia, previous ischemic colitis. hospital admission due to pneumonia and right pleural effusion with us: simple cyst 64 x90 x99 mm in segment v hepatic, with dilatation of biliary radicals adjacent to the cyst, distended gallbladder with irregular walls in the hepatic side. ct: cystic lesion in segment iv-v of the liver, which has increased in size, with small microabcesses adjacencies to the lesion, thickening of the gallbladder wall, to assess cholecystitis. antibiotic treatment is established with good evolution, deciding surgery. results: intervention: complete laparoscopic approach, 4 trocars, edematous cholecystitis, large retroyuxta vesicular cyst,with thickened walls with serous content. cholecystectomy maintaining the cyst wall, puncturing and taking samples for cytology and biochemistry of the contents, resection of the cyst wall, partial flare of its internal surface, negative intraoperative biopsy, epipoplasty, with drainage placement.correct postoperative course.pathological anatomy: simple biliary cyst with negative cytology, ck7?, ck20-, calretina-. conclusion: the treatment of choice of complicated simple hepatic cysts is laparoscopic.we recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature,we propose cyst enucleation as the best surgical treatment. objective: the objective of the following case is to present a patient with symptomatic polycystic liver disease, which was solved by laparoscopy approach and the management of its complications. material and methods: the case reported is about a 62 years old female patient with abdominal pain in upper right quadrant associated to asthenia, adynamia and hyporexia. ct scan reported heterogeneous liver with multiple ovoid images with regular edges defined which the biggest one measure 102x99x137 mm with volume of 723 cc on segment 2 and 3, which comprises stomach, and the other one in segment 8 with a volume of 1453 cc and others small sized located in segment 6, 7 and 4b. results: in this laparoscopic approach, we performed a cyst unroofing of the two biggest cysts as well as cholecystectomy because of firm and lax adhesions. the patient evolved with fever in the 5 th day postsurgical day and biliary leaking in a volume of 270 cc in 24 hrs. an ercp (endoscopic retrograde cholangiopancreatography) was asked for that was carried out by finding leak at the intrahepatic biliary duct therefore; esphinterotomy with placement of plastic endoprotesis was performed. the patient evolved without complication and was discharged at the 10 th day. conclusions: only symptomatic polycystic liver disease needs to be treated. the choice of treatment is not yet standardized, for voluminous cysts the unroofing ideally by laparoscopy is the gold standard and the ercp is the elected treatment when the biliary leak appears as a complication. introduction: laparoscopic liver resection (llr) for tumors located in the posterosuperior segments of the liver (segments (s) 7 or 8) is a challenging procedure. especially, llr for s7 is difficult because the access of instruments is limited, bleeding control is not feasible, major llr is sometimes required, and obtaining sufficient resection margin is not easy. to overcome this obstacles, we performed llr in s7 with a lateral approach using intercostal trocars. to obtain competent resection margin, llr through right hepatic vein (rhv) first approach was performed for 1.8 cm mass located near the rhv in a 58 year old female. case: after full mobilization of right liver including all short hepatic veins and caudate lobe, rotate the whole liver completely to the left side to approach to the root of rhv. one intercostal trocar was inserted to access the lesion. parenchymal transection started from the confluence of hepatic vein and then, followed along rhv with ligating several small branches from rhv. resection margin was demarcated after localization using laparoscopic ultrasonography. after completion of parenchymal dissection using cusa and ultrasonic shears, hemostatic agents were applied and drain was inserted. operation time and estimated blood loss were 120 mins and 400 ml. the patient was discharged without any complication on postoperative day 7. final pathological assessment confirmed clear resection margin (safety margin : 1.5 cm). conclusion: laparoscopic s7 segmentectomy with hepatic vein first approach technique is safe and recommended to obtain better resection margin. aims: simple liver cysts are the most common cystic lesions of the liver. most are diagnosed casually in image tests such as ultrasound or computerized tomography, most of which are asymptomatic and do not require treatment. in symptomatic patients (abdominal distension with palpable mass, abdominal pain, dyspnea, jaundice, etc.) the clinical manifestations are usually due to the growth of the cysts or the compression of neighboring structures. liver function tests are usually not altered. intracystic complications occur in less than 5% of cases and malignancy is exceptional. in this video, we present the case of a symptomatic patient with polycystic liver disease including a large size hepatic cyst. material and methods: 65-year-old woman with a personal history of arterial hypertension, saos, partial hysterectomy due to endometrial cancer, who was referred to our department complaining of supraumbilical pain and abdominal distension with palpable mases. abdominal ultrasound showed cholelithiasis and multiple simple hepatic cysts. in ct scan, multiple hepatic cysts were found, the largest one of about 20 cm of larger diameter. echinococcus granulosus serology test was negative. there was also no evidence of cancer disease in pet scan. results: a laparoscopic approach was performed with four trocars, three of 5 mm and a hasson trocar inserted thought a umbilical small incisional hernia. aspiration and wide unroofing of the large size cyst and smaller accessible ones was done. the patient also underwent cholecystectomy with intraoperative cholangiography and umbilical eventroplasty. the patient recovered uneventfully and is asymptomatic one year after surgery. conclusion: simple liver cysts rarely require treatment. in some cases, especially in large, complicated and symptomatic simple liver cysts, surgery is indicated. laparoscopic fenestration treatment is the best choice. aims: liver resection is the preferable initial treatment option for solitary or limited multifocal hepatocellular carcinomas. surgical indications for laparoscopic liver resection (llr) are the most important consideration, like liver function, tumor size (diameter less than 5 cm) and location (easy technical access like in the left lateral section or on the surface of the inferior region). partial liver resection or left lateral sectionectomy are the typical procedures for such tumors and are considered the best way to begin llr. with accumulating experience and technical advancement, llr has been performed for tumors larger than 5 cm and for others locations. some requirements to perform llr are to have experience in liver surgery and laparoscopic also, adequate technology and intraoperative ultrasound. methods: a 69-year-old male smoker, ex-parenteral drug users with chronic hcv liver disease child-a stage. he is diagnosed with a single lesion of 7 cm in segment iii of the liver, biopsied twice without conclusive diagnosis and with a three-phase ct suggestive of hepatocarcinoma li-rads 4 with data of portal hypertension (pht) and mild ascites. after the study is commented on tumor committee deciding surgical intervention. results: a laparoscopic resection of segment iii was performed with 5 trocars. liver is explored by intraoperative laparoscopic ultrasound. vascular control was performed using the pringle technique. liver transection was done with sonostar until identification of intraparenchymal segment iii vascularization, which is sectioned with endogia (45 mm) with seamguard. after the resection, we perform hemostasis control with electrocoagulation and hemostatic material. intraoperative bleeding of 300 ml. favorable postoperative evolution, high on the 5th postoperative day. ap: 7 cm trabecular hepatocarcinoma moderately differentiated pt1b, r0 resection. conclusions: llr allows major liver resections with low morbidity and mortality and the advantages of laparoscopic surgery. an efficient learning curve can be achieved by a parallel evolution of procedures and indications (according to modified bclc staging system and treatment strategy). studies suggest that llr results in less blood loss, shorter postoperative hospital stays, lower abdominal wall trauma and lower incidences of ascites accumulation and postoperative liver failure. with respect to oncological considerations, tumor margins are adequately maintained during llr. v. drakopoulos, s. voulgaris, i. iliadis, k. botsakis, p. trakosari, v. vougas 1st department of surgery and transplantation unit, district general hospital of athens « evangelismos » , athens, greece introduction: laparoscopic surgery is gaining acceptance in the treatment of liver metastasis. laparoscopic treatment of liver metastasis often presents technical difficulties and requires an extensive learning curve. material-method: we present the case of a 62 year old woman presented with a liver metastasis in section 3 of the liver. the patient had been submitted to a laparoscopic low posterior resection in february 2018. patient underwent laparoscopic left lateral hepatectomy, with the use of three trocars (umbilical 10 mm, and two in the midclavicular line bilaterally.) left lateral hepatectomy was conducted with the use of a linear stapler. the postoperative period was uncomplicated and the patient remains in good condition three months after surgery. conclusion: laparoscopic approach seems to be safe for treatment of liver metastasis, offering better surgical field view and less postoperative complications. 5 year survival rate after laparoscopic hepatectomy is compared to the open approach. general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan purpose: laparoscopic hepatectomy is a quickly growing method for liver tumor because of modern technology. but for the ihd thrombosis, it is still technique dependent. the video was tried to share our experience for special case. material and method: one 68 y/o female patient suffered from fever episode and image show s56 3 cm hcc with right anterior ihd obstruction r/o tumor thrombosis, hilum ln enlargement, double right portal vein, hilum adhesion with duodenum, no ascites . lab data : no-b, no-c child a, afp 1199, icg clearance rate 4.5%, plt 174000 . heart, lung function exam normal. the laparoscopic right total hepatectomy and hilum ln dissection was conducted. results: laparoscopic approached was performed. the hilum ln dissection was done with vessel and bile duct isolation. hilum ln frozen show negative malignancy. hemi-vessel control was done with resecting the vessel. right hepatectomy was done with preserving middle hepatic vein. the right anterior and posterior ihd was opened and tumor thrombosis was removed from right anterior ihd carefully. the stump of ihd was closed by suture separately. the total op time was 630 min with 345 cc blood loss. post op minimsl bile leakage was found in the drain at day 6. the patient discharged at day 14 with drain. conclusions: laparoscopic hepatectomy may be a feasible method for hcc even with ihd tumor thrombosis. surg endosc (2019) introduction: the progressive laparoscopic learning in gastric surgery and the great development of instruments and laparoscopic material that facilitates the realization of advanced procedures, has led to an increase in the use of laparoscopy in the treatment of gastric cancer. material and methods: we present the case of a 75-year-old man without amc with a history of ischemic heart disease who enters our surgery department for cholangitis secondary to choledocholithiasis. ercp is requested during his admission that describes a gastric lesion from which a biopsy is taken, making it impossible to access vater papilla to perform sphincterotomy and lithiasis extraction due to the existence of duodenal diverticula. the result of pathological anatomy of the gastric lesion was compatible with adenocarcinoma. negative extension study. the clinical case is presented in a committee of multidisciplinary tumors and it is decided to perform surgical intervention of both pathologies. a subtotal gastrectomy was performed with a roux-en-y reconstruction. surgical time of 300 min. choledochotomy was performed with lithiasis extraction, as well as intraoperative exploration of the bile duct and main conduits by means of a choledochoscope. results: income of 9 days, with a clavien ii. the definitive pathological anatomy was an ai stage with a total of 22 isolated nodes without evidence of neoplasia in any of them, therefore it does not require adjuvant treatment. the patient is asymptomatic, with nutritional supplementation with follow-up in ccee of surgery. conclusions: in our case, there were no serious postoperative complications when performing gastric resection and bile duct exploration with drainage of the same. from the oncological point of view, the number of lymph nodes extracted and the surgical margins are similar to those obtained in patients in whom we perform open surgery; therefore, although it is a single clinical case, laparoscopy in expert surgeons is a safe and effective technique. the puestow procedure was initially proposed to alleviate the pain in patients with chronic pancreatitis and dilated wirsung duct. its objective is to provide an efficient drainage of the pancreatic fluids and, in the meantime, to preserve the pancreatic tissue and minimize the risk of endocrine and exocrine pancreatic insufficiency. aims: to describe the particular technical aspects and the efficacy of totally laparoscopic puestow procedure in patients with cystic duodenal dystrophy. methods: a 37 years old patient presenting diffuse epigastric pain, vomiting and weight loss was diagnosed at endoscopic ultrasound and biopsy with cystic duodenal dystrophy. a conservative treatment was decided with octreotide and opioids. however, due to the persistence of symptoms surgery was performed. results: due to the association of a dilated wirsung duct, the patient was submitted to a puestow procedure. the surgical procedure was completed in a minimally invasive manner; after dissecting the anterior surface of the pancreas an intraoperative ultrasound was performed in order to identify the wirsung duct. therefore, the pancreatic parenchyma was transected along the wirsung duct, a totally laparoscopic pancreato-jejunostomy on roux en y limb being performed. the early postoperative outcome was uneventful, the patient being discharged in the sixth postoperative day. at one month and six months follow up the need for opioid treatment significantly diminished. a kinking of the enteral anastomosis required a laparoscopic intervention one year after with a very good evolution after. conclusions: totally laparoscopic puestow procedure seems to be a safe and efficient method in order to treat symptomatic patients with cystic duodenal dystrophy in whom a dilated wirsung duct is present. aims: the approach to the intraductal papillary mucinous neoplasm (ipmn) is various, from a radiological follow-up with magnetic resonance (rm) to the surgical treatment with a pancreatic resection [1] . the surgical approach is various and depends on the localization of the lesion and on the surgical skills [2] . methods: a 67 years old patient was admitted at the chi possy-saint germain-en-laye with an acute pancreatitis. at the ecoendoscopy was found a pancreatic cystic at the junction of the pancreatic body and tail with a wirusng diameter of 5 mm. a second episode of acute pancreatitis occurred a few months later. after that episode the patient was submitted to a computer tomography (ct) that found a cystic lesion of 2 cm with an increasing dilatation of the wirsung duct. the serum ca19-9 was 452 ui/ml. a laparoscopic sils distal pancreatectomy with spleen conservation was performed. results: a trans-umbilical incision was performed with the positioning of the gelpoint sils platform with the placement of 3 trocars. a distal pancreatectomy with a spleen preservation and without a standard linfadenectomy was performed. the pancreatic stump was closed with an endo-gia 60 mm with seamguard device. any drain was placed. the post-operative course was uneventfull. a ct scan was performed in …. post-operative day which didn't show collections. the patient was discharged in -…… post'operative day. the histological examination shows an ipmn with low grade dysplasia. no invasive carcinomatoses cells were found. the distal pancreatic sils resection with spleen conservation is a feasible and safe technique that combine all the advantages of the minimally invasive laparoscopic approach with the esthetic advantages of the sils approach. pancreato-duodenectomy is a complex surgery, requiring several anastomoses to reconstruct the digestive tract. due to its technical complexity, the laparoscopic approach is not yet the goldstandard and there remains some controversy about its oncological safety. worldwide experience is limited, and its safety and effectiveness are yet under evaluation.we present the clinical case of a 70 years-old woman with a prior history of epilepsy. she was studied due to painless obstructive jaundice and a 2 cm pancreatic head tumour was diagnosed on imaging, causing cbd and wirsung channels' dilatation. the tumour was considered locally resectable and she was proposed for a radical pancreato-duodenectomy.we present the main steps of the surgery including the oncological resection with lymphatic basin clearance and totally laparoscopic reconstruction.the post-operative was uneventful, and the histologic sample revealed a ductal adenocarcinoma (t2) with an r0 resection and 0/30 lymph nodes invaded. although technically demanding, laparoscopic pancreato-duodenectomy is safe and effective requiring teams with experience both in pancreato-biliary and laparoscopic surgery. chronic pancreatitis is characterized by a progressive pancreatic fibrosis with loss of endocrine and exocrine function. one of its main symptoms is debilitating pain. surgical drainage of a dilated pancreatic duct is an option to consider in cases of refractory pain. longitudinal pancreato-jejunostomy allows an effective decompression of the pancreatic channel and a significant improvement in the quality of life. we present the clinical case of a 56 years-old lady with a prior history of gallstones. she was treated for an acute pancreatitis in may 2018, followed by recurrent relapses of pain and enzymatic elevation. she required opioid use for partial pain control and a significant 20 kg decrease on body weight due to 'fear of eating'. the endo-ultrasonography and the mri revealed a chronic pancreatitis with an 8 mm wirsung duct with ductal stones and an atrophic body and tail. we proposed a laparoscopic longitudinal pancreato-jejunostomy. the surgery was performed with 4 trocars, with the surgeon on the right side of the patient. we performed a trans-mesocolic 6 cm pancreato-jejunostomy. the post-operative was uneventful, and the patient was discharged on the 8th post-operative day, asymptomatic. laparoscopic longitudinal pancreato-jejunostomy, although effective is a technically demanding surgery but brings the benefits of a minimally invasive approach. background: preservation of spleen in distal pancreatectomy is also useful from the maintenance of platelets and the prevention of overwhelming post splenectomy infection. we have performed laparoscopic spleen preservation distal pancreatectomy: lspdp to benign and low-grade tumors of the pancreatic body tail. the aim of this study was to report our surgical experience with the method of svp: splenic vessel preservation and wt: warshaw technique of lspdp, describe our techniques with videos. method: there are three points of our surgical technique. 1, precede pancreatic dissection, improve the mobility of the pancreas. 2, confirming the courses of splenic artery and classified them into two major types. 3, preserving the left gastro-epiploic vessels and short gastric vessels.the postoperative cases of lspdp which performed from april 2012 to september 2018 was retrospectively studied. result: of 19 consecutive patients were performed lspdp at our institute, 12 were svp and 7 were wt. ages, gender and bmi were similar for two groups. there were no significant differences in operative time, blood loss and length of stay after surgery. comparing pathological finings, wt was associated with a slightly large tumor lesion (median 31 mm vs. 12.5, p = 0.08). among the median observation period of 27 months, splenic infarction was observed in 1 case in svp and 2 cases in wt. however, they were focal splenic infarctions, they did not need surgery or drainage. there were no cases in which late onset of splenic artery occlusion or esophageal / gastric varices. conculusion: after performing lspd, the function of the spleen was good in all cases. both svp and wt were safe and feasible procedures. this is the case of a 61-years-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. msct revealed pancreatic calcifications from 1 mm to 5-8 mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4 mm. the patient underwent laparoscopic local resection of the head of the pancreas combined with longitudinal roux-en-y pancreaticojejunostomy-a technique known as frey's procedure. it is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.after performing the posterior wall of the pancreaticojejunal anastomosis we've faced an intraoperative complication such as volvulus of the roux limb causing serious ischemia of the limb. we were forced to remove all previous sutures in order to untwist the roux limb, thereafter the pancreaticojejunostomy was started anew.the purpose of this video is to demonstrate that frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. we demonstrate that even such serious intraoperative complication as volvulus of the roux limb can be managed without conversion. our center has an experience of over 30 laparoscopic frey's procedures, however this is the first case where we encountered with such complication and we believe this is an experience worth sharing.yet we would like to underline that this approach should be used by highly skilled minimally invasive surgeons experienced in intracorporeal suturing which is the most challenging stage in frey's procedure. v. tomulescu, i. hutopila, c. copaescu spleen preserving distal pancreatectomy (spdp) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. two surgical techniques for spdp have been described. the first technique was described by kimura (spleen preserving distal pancreatectomy with splenic vessel preservation-spdp-svp) and preserves the main splenic artery and vein and excises the tail of the pancreas and those small, short vascular connections to the body;the second technique was described by warshaw and involves resection of the splenic vein and artery before distal pancreatectomy, and conservation of theshort spleno-colic and gastric vessels to keep normal blood flow for the spleen (spleen-preserving distal pancreatectomy with splenic vessel resection-spdp-svr). we present the case of a 50 years old female with 40/50 mm tumor of the pancreatic tail on ultrasonography. ct scan confirmed the tumor and endoscopic ultrasonography with fna have shown a solid pseudopapillary tumor. due to the low grade malignancy we have decided to perform a laparoscopic spleen preserving distal pancreatectomy with splenic vessels preservation (lspdp-svp). for lspdp-svp the difficulty is related with the splenic vessels dissection and manipulation. primary dissection and control of main trunk of splenic artery and vein will help to quickly control bleeding during vascular rupture in small vessels dissection. optimal stapling of any tissue requires an adequate tissue compression time to allow elongation of the tissue being compressed, smooth firing of the instrument, consistent staple line formation balanced against the risk of increased tissue tearing and excessive tensile strength. this is why, for pancreatic division, we prefer choosing a cartridge loaded with higher staplers. the pancreatic stump transection line is evaluated for bleeding and when it is needed, hemostatic clips are applied. histology report confirmed a solid pseudopapillary tumor t3nomxl0v0r0 at this moment with 12 month good follow up. in conclusion lspdp-svp is safe, reproductible and demonstrated very good outcomes when certain indications are respected. surg endosc (2019) aim: advances in minimally invasive surgery has permitted to perform complex techniques by this approach, being the laparoscopic duodenopancreatectomy (lpd) one of these. the aim of this communication is to present a surgical technique video for a complete laparoscopic pd, showing the most important steps of the resective and reconstructive phase, with the anastomosis realized completely by laparoscopy. methods: a surgical technique video is presented showing the main steps for the lpd and a complete laparoscopic reconstruction with an hepaticojejunostomy, duct-to-mucosa pancreatic-jejunostomy and a gastrojejunostomy. results: an 82 years old woman with past medial history of arteria hypertension, dyslipidemia, type ii diabetes mellitus and a breast cancer treated in 2009 with lumpectomy and axillary lymphadenectomy plus radiotherapy, recently diagnosed of and adenocarcinoma of the head of the pancreas. the ct scan showed a neoplasia localized in the head of the pancreas without extension to other organs. a laparoscopic pd was indicated after a multidisciplinary committee evaluation. a supraumibical hasson trocar was used for the pneumoperitoneum, three 12 mm trocars and two 5 mm trocars were used. lpd was performed. the resective phase was done following the conventional steps of the open whipple procedure and for the reconstructive phase, a child limb was used for a termino-lateral hepatico-jejunostomy with an absorbable 4/0 monofilament; a duct-to-mucosa pancreatic-jejunostomy with an absorbable 5/0 monofilament and finally a latero-lateral mechanical gastro-jejunostomy was performed. surgical time was 480 min. postoperative course without complications and the patient was discharged on the 7th postoperative day. definitive anatomopathological exam: intraductal tubulopapilar neoplasia, 16x16x13 mm, with wide high grade epithelial dysplasia. free margins. ptisn0 (0/12). conclusion: laparoscopic pd is a feasible procedure with a high technical requirement which should be performed in specialized centres with high experience in hepatobiliary surgery and in advanced laparoscopic procedures, because of its high morbidity and mortality. conclusions: robotic assistance in whipple may overcome limitations of laparoscopy and offer a minimaly invasive approach to this procedure potentially resulting in lower blood loss and less morbidity. we need further prospective randomized trials in order to determine the exact role of robotics in pancreatic surgery. aims: distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. the most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. spleen-preserving distal pancreatectomy should be attempted in case of benign disease. laparoscopic spleen-preserving distal pancreatectomy (lspdp) is expected to be less invasive than laparoscopic distal pancreatectomy with splenectomy. however, there are few reports regarding the details of the procedure for lspdp, and its safety remains unclear. this study aimed to evaluate the feasibility and safety of lspdp. methods: retrospective analysis of surgery treatment of 48 patients was made. lspdp was conducted in the period from 2014 to 2017 in the department of laparoscopy surgery of state institution o.shalimov national institute of surgery and transplantology. the average age was 45 :1 3.4 years, the body mass index (bmi) was 28.7 ± 1. results: laparoscopic distal pancreatectomys was performed in 100% of cases, were attempted in 36 female and 12 male patients. postoperative pathological examinations revealed 17 cases of serous cystadenoma in the body and tail of the pancreas, 2 case of serous oligocystic adenoma, 20 case of mucinous cystadenoma, 3 case of neuroendocrine tumor (insulinoma), and 6 case of solidpseudopapillary neoplasm. complications related to the surgery were like acute pancreatitis with 3-fold increase normal plasma amylase confirmed by ct-7 cases, fluid collection-4 cases, pancreatic fistula (grade a)-3 cases. the operation time was 195.6 min, (range 157-250 min) blood loss of 50.1 g (range 0-110 g), mean hospital stay was 6.8 days (range 5-11 days). conversion to laparotomy was in 1 case. mortality was 0. conclusion: laparoscopic spleen-preserving distal pancreatectomy is minimally invasive, safe, and feasible for the management of benign pancreatic tail tumors, with the advantages of earlier recovery and less morbidity from complications. aims: a pancreatic pseudocyst is an encapsulated, mature fluid collection occurring withing the pancreas that have a well-defined wall minimal or no necrosis secondary to pancreatic injury and mediated by the enzimatic and inflammatory disruption of pancreatic tissue. it is a common complication of acute and chronic pancreatitis. we present the case of a pancreatic pseudocyst located within the body of the pancreas due to recurrent necrotic pancreatitis. the objective of this video is to show the minimally invasive surgical approach of this entity. methods: a 47-year-old man without medical history was admitted to hospital in the digestive service on 3 times for acute necrotizing pancreatitis. after study in which is evidenced cholelithiasis and pseudocyst in pancreatic body of 6 cm maximum diameter and formation of two peripancreatic collections without signs of superinfection, cholecystectomy is indicated. magnetic control cholangiography was performed after surgery and it showed an increase in the size of the pancreatic pseudocyst, suspecting wirsung's duct disruption. therefore, endoscopic retrograde cholangiopancreatography (ercp) was performed by placing a plastic pancreatic prosthesis and performing a sphincterotomy. after hospital discharge, the patient is re-admitted due to recurrent abdominal pain without analytical alteration. tc abdominal observed an increase in the pseudocyst from 6 to 8 cm. this case was discussed in a multidisciplinary committee and surgical intervention was decided. results: laparoscopic approach is decided and four trocars were placed. initially, a gastrostomy was performed with liquid outlet. an aspiration of the liquid and quistogastrostomy with 45 mm endogia was made. the patient progresses favorably, being high on the tenth postoperative day, without complications. conclusions: almost every pancreatic pseudocyst improves spontaneously and needs no specific treatment. draining is indicated when secondary symptoms to compression, complications or rapidly enlarging are found. depending on the complexity of the pseudocyst, its communication with wirsung's duct and the existence of ductal injury, it may perform a percutaneous, endoscopic or surgical drainage. the goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage. only the surgical procedure is definitive. case: a 29y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. cardiac investigation was negative and gastroscopy showed a grade b esophagitis. he was treated medically but with only partial response. on a thoraco-abdominal cat-scan the diagnosis of a left sided bochdaleks' hernia was made. the hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed. method: given the clear correlation between the patients' complaints and these anatomical findings, he was referred to our service of abdominal surgery. we performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. the patient was tilted to his right side. mobilization of the spleen was necessary to gain maximal access to the hernia. we were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. the defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers. result: postoperatively the patient recovered well with adequate pain relief and pulmonary support. he could leave the hospital after 6 days. control cat-scan on day 5 postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. on follow-up 6 weeks after surgery the patient had regained normal activities and was symptom free. conclusion: a symptomatic left sided bochdaleks' hernia in adults with an ectopic intrathoracic kidney is extremely rare. we hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate. aims: large incisional hernias repair involves an actual problem for surgeons to face. anterior component separation has been an important method allowing to close the fascia defects without tension while also having underlay mesh reinforcement.therefore, we present a case of incisional hernia reparation performing endoscopic anterior component separation with advantages compared with open approach. method: we present the case of a 31-year-old woman, bmi 40 kg/m 2 , with previous laparoscopic gastric sleeve and posterior reintervention using open approach. the patient presented a 10 cm size incisional hernia m3w3. a ct scan was performed, confirming a midline incisional hernia containing colon, with an herniary defect of 11 cm. full minimal invasive abdominal wall repair was proposed. a 2 cm size incision was made in left iliac region to reach the aponeurosis of external oblique muscle. we placed a balloon trocar and subcutaneous pneumo-dissection with 8 mmhg pressure was performed; then, we placed a 5 mm trocar in left lumbar space. the aponeurosis of external oblique muscle was incised and anterior component separation from inguinal to subcostal area was achieved. an extensive intermuscular dissection was performed to achieve complete midline closure. we performed the same procedure on the right side. then, with laparoscopic approach using v-loc n°0 suture, we completely closed the midline. eventually, we placed a 30x15 cm ptfe-c mesh fixed with a double crown of tackers and fibrin glue. results: postoperatory course was uneventful and the patient was discharged 24 h after surgery without any remarkable event during his postoperative stay. the patient has been followed up for 12 months without any complication or recurrence in ct scan, confirming the correct minimally invasive reconstruction of the abdominal wall. conclusions: trends in abdominal wall reconstruction and complex-hernia repairs have advanced rapidly in recent years. the goal is to perform a complete abdominal wall repair with no tension in midline incisional hernias. endoscopic anterior component separation and laparoscopic eventroplasty with closure of the defect, leads to a complete wall reconstruction without tension and avoids drawbacks due to primary close defect in those patients with herniary defects wider than 10 cm. aims: endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. to combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose totally endoscopic sublay anterior repair (tesar), a safe and feasible approach for the treatment of ventral and incisional midline hernias. methods: from may to september 2018 12 patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for tesar. exclusion criteria were: complicated ventral or incisional hernia (i.e. incarcerated hernia), maximum defect width [ 5 cm, contraindications to general anesthesia. the procedure consisted of suprapubic access with 3 trocars, complete endoscopic pre-aponeurotic dissection, isolation and reduction of the hernial sac, bilateral incision of the medial rims of recti aponeurosis and dissection of retromuscular plane to create the retromuscular space, sublay non-absorbable mesh positioning and anterior aponeurosis reconstruction. one drain was always placed in the retromuscular space and one drain in the subcutaneous space. results: all procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. no intraoperative complications were registered. total mean operative time was 148 ± 18.5 min. no post-operative major complications were registered. only one subcutaneous seroma was registered (8.3%), and treated conservatively. the mean postoperative stay was 3.6 ± 0.6 days. at post-discharge clinical checkups drains were checked and removed when indicated. no wound complications nor recurrence were registered to date. cosmetic and functional results were successful in all patients. conclusions: tesar is a safe and feasible technique for the extra-peritoneal sublay repair of ventral hernias with totally endoscopic approach. it provides accurate hernia repair with good outcomes in terms of resolution of symptoms and post-operative complications. r. mizuno, m. kondo backgrounds: abdominal incisional hernia is found in more than 10% after abdominal surgery, and risk factors such as wound infection, obesity, elderly, high abdominal pressure are pointed out. laparoscopic hernia repair using intraperitoneal onlay mesh (standard ipom) is becoming widespread in japan since the insurance release in 2012, and our hospital is actively working on it. recently, ipom plus procedure which also carries out fascia suture in addition to laparoscopic mesh placement has been introduced. aims: we report the clinical results of laparoscopic abdominal incisional hernia repair in our hospital. methods: we performed hernia repairs using a mesh for 36 cases from january 2014 to september 2018. of these, 21 cases were standard ipom and 15 cases were ipom plus. there was no significant difference in the patient background such as gender, age, bmi, etc, and in the intraoperative findings such as hernia orifice diameters and adhesions. surgical time, postoperative hospital stay, and the rate of complications such as seroma, mesh bulging, postoperative pain, hernia recurrence were compared and examined between the two groups. results: as a result, in ipom plus group, the operation time was longer and the incidence rate of postoperative pain was higher, but the incidence of mesh bulging was significantly lower. also, in some cases since 2018, the ' u reverse stitch method ' is used as an ingenuity of fascia suture in ipom plus. conclusions: laparoscopic abdominal incisional hernia repair has the advantage of being able to reliably confirm the hernia orifice from the intraperitoneal side?it is excellent in the identification of the fragile part of the abdominal wall and in the visibility of the restoration range. with regard to the ipom plus procedure which has been introduced in the last few years, although the operation time is extended, it has usefulness such as reduction of mesh bulging. from the viewpoint of cosmetic surgery, usage of ipom plus will increase in the future. introduction: incisional hernia is one of the most common complications after abdominal surgery. several methods have been introduced, and yet, there is no consensus on the best method of repair. we present a novel method for hernia repair which uses the retromuscular sublay mesh repair through a single incision at the pubic area to improve cosmesis. methods: medical records of patients who underwent single-port retrorectal incisional hernia repair from may 2018 to december 2018 were reviewed. patients were placed in supine position and a 3 cm incision was made in the pubic area below the panty line. a flap is made upwards until the defect is found and bilateral rectus sheathes are dissected. a mesh is then placed between the posterior rectus sheath and the muscle. results: a total of 30 patients with midline incisional hernia underwent single-port retro-rectal incisional hernia repair. mean age was 59.0 ± 12.5 years with an average bmi of 23.4 ± 2.7. all the patients had midline hernia defect with an average of 3.4 ± 2.2 cm. mean operation time was 59.6 ± 30.1 min and estimate blood loss was 32.6 ± 36.5 ml. there was no postoperative complication, and 27 (90%) patients were discharged on the day of surgery. conclusion: the single-port retrorectal incisional hernia repair is safe and effective while providing good cosmesis to selected patients with incisional hernia. aims: closing hernia defect during laparoscopic hernia repair is a vast extended technique nowadays. however, this technique is associated with mesh placemnt intraabdominally in contact by the abdominal content. nowadays there is a trend to recontruct the midline and to avoid a mesh intraabdominally in those cases suitable for it, as a new step forward of minimally invasive abdominal wall reconstruction. laparoscopic sublay approach with retromuscular placement of a mesh without mechanical fixation after reconstruction the linea alba migth be considered an option in primary hernias of the midline. methods: we present a case of a 47 year old male with an umbilcal hernia of 4 centimeter in diameter associated with rectus diastasis. a laparoscopic approach was performed, using one 12 and two 5 millimeter trocars placed on the left flank. the first step was to open the lateral side of the posterior fascia of the left rectus muscles, dissecting the retromuscular plane until we reach the linea alba getting into the preperitoneal space where the sac was diseected preserving the integrity of the peritoneum. the contralateral posterior fascia was also dissected all the way to the semilunaris line. the midline was closed, including th hernia defect, using a running double loop suture (maxon-loopò). a self gripping mesh (progripò) is placed in the retromuscular space in a sublay position (21 cm long, 9 cm wide). last, we close the fascia of the left rectus muscle using a barbed suture (v-locò). results: surgical time was 80 min, being discharged of the hospital on postoperative day 1. pain was controlled with conventional analgesia and no postoperative complications, nor seroma was detected. conclusions: sublay approach for ventral hernia can provide a midline reconstruction, reestablishing abdominal function and avoiding the use of intraabdominal meshes and traumatic fixation, decreasing postoperative complications and pain. aims: lumbar hernia is one of the rare cases that most surgeons are not exposed to. hence the diagnosis can be easily missed. this is often related to previous surgery as lumbotomies or primary in the superior lumbar triangle. this leads to delay in the treatment causing increased morbidity. we report a case of adquired lumbar hernia in a middle-aged woman repaired by laparoscopic approach. methods: a 60 years old woman with surgical history of a myelomeningocele surgery by posterior approach over 40 years ago, a laparoscopic left nephrectomy 2 years ago with a left colostomy due to a left colon injury during this procedure. a hartmann reversal by laparoscopic approach 6 months later. patient showed a large lumbar mass over 6 cms in the left lumbar region and a large scar near to spinal cord. it was soft in consistency, reducible and expansible on coughing and straining with defined borders. computerized tomography showed a large defect in the superior lumbar fascia over 6 cms in the grynfeltt-lesshaft triangle with the left colon inside. results: patient was placed in a full lateral decubitus position. in order to optimize exposure, a lumbar roll was placed under the lumbar region. a capnoperitoneum (12-15 mmhg) was built up. one 11 mm and two 5 mm trocars were used and positioned in the left mid axillary line. a 30 optic was used. adhesions were removed and toldt fascia was opened in order to expose the hernia defect bounded by quadrates lumborum, erector spinae muscles, 12 rib and serratus. hernia content was carefully extracted from the sac using a ligasure maryland (covidien medtronic-usa). hernia defect was measured and an intraperitoneal mesh (dinamesh-ipom feg textiltechnik mbh, aachen, germany) was positioned and sutured by tackers to the margins included the bone. patient was discharged in 48 h with a low pain rate and without complications. there is not recurrence in 10 months follow-up. conclusion: laparoscopy might be a safe and feasible approach for repairing lumbar hernias, either primary or adquired, with a low rate of pain and complications s582 surg endosc (2019) after pneumoperitoneum is done, three 5 mm trocars are placed on the left flank. the defect is delimited by drawing it over the skin of the patient with aid of an intramuscular needle and intraabdominal vision. posterior fascia is opened longitudinally at its medial edge and the retromuscular space is dissected. the arcuate line of douglas and the epigastric vessels are identified. from this point, transversus abdominis fascia is sectioned cranially 1 cm medial to the semilunar line, preserving the neuro-vascular pedicles that reach the rectus abdominis laterally. at supraumbilical level, transversus abdominis fibers advance behind rectus abdominis, so they need to be sectioned to access to the space below the ribs. lateral dissection of this space enables a tensionfree closure at midline. once the procedure is repeated on the contralateral side using two 5 mm and one 12 mm trocars on the right flank, a continuous suture of the posterior fascia is performed with a barbed suture. the anterior fascia is closed with a slowly-absorbable monofilament loop-type suture. finally, a double-layer polypropylene mesh is placed at retromuscular level without any suture and fibrin glue is applied. results: the patient was discharged 24 hous after surgery. no recurrence has been presented to the moment. conclusions: the section of the aponeurotic plane from the arcuate line of douglas enables a more accurate dissection of the retrotransversus plane without sectioning its fibers except for its cranial end, preserving the innervation and vascularization of the abdominal wall. this technical modification aims to simplify a complex laparoscopic procedure allowing its estandarization. aims: the authors present a video with their standardized laparoscopic ventral hernia intraperitoneal mesh (ipom) hernioplasty procedure but introducing a novel laparoscopic technique for tension releasing while hernia gap closure and midline anatomical restoration. methods: a 64 years old male patient with a bmi 31 presents a symptomatic ventral hernia recurrence after a sigma colic cancer open surgery. a ct scan study showed a 5 cm transverse diameter midline ventral hernia. a laparoscopic ipom hernia repair procedure is performed using 5 mm instruments and a 10 mm camera. when checking tension while midline restoration suturing, we decide to add a tension-releasing maneuver: a totally laparoscopic transverse abdomini muscle release (taltar). this maneuver allow right rectus posterior sheath to advance some distance to the midline, in order to provide a tension-free midline closure. a double-faced ready-to visceral contact mesh is now placed and fixed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 5 h with a 4 rate in a eva acute pain visual scale. in a 2 year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, lateral asymmetry, umbilical or abdominal wall complications have been reported with this technique. conclusions: depending on the patient characteristics, anatomical hernia factors and surgeon mini invasive experience, a taltar maneuver could be a safe and feasible option for releasing tension when midline anatomical laparoscopic closure. more studies are needed in order to standardized this approach. aims: when primary ventral hernia and simultaneous diastasis recti are diagnosed, there is no consensus among the international surgical community on the surgical treatment regarding indications or surgical technique. however, if diastasis recti is symptomatic of or is associated with midline hernias, the corrective surgery of both pathologies at the same time could be the most recommended option. when we only correct the herniary defect, we risk performing a reparation on an anatomically weak tissue, so the rate of hernia recurrence may increase. we propose a minimally invasive access using totally endoscopic retromuscular hernioplasty. by developing this technique, several advantages are provided, such as no peritoneal opening without intraabdominal access, no mesh fixation needed and simultaneous solving of both pathologies. method: we present the case of a 50-year-old man, with bmi 35 kg/m 2 and no previous medical history complaining of ventral hernia with associated recti diastasis. a 4 cm size umbilical hernia was diagnosed with a 5 cm size supraumbilical diastasis recti associated. full endoscopy retromuscular hernioplasty was proposed. a 2 cm size incision was made in left hypocondrium, openned the anterior rectus sheath and retracted the rectus muscle. we placed a balloon trocar and open the homolateral retromuscular space after placing two 5 mm trocars in left lumbar space and epigastric position. we crossed-over the linea alba and achieve contralateral retromuscular space. after this step, the hernia sac was reduced and we extended the dissection 5 cm caudal to the hernia ring. both medial posterior rectus sheaths were sutured with running barbed suture n°0 and a 20x20 cm size light-weight, big pore, polipropilene mesh was placed in retromuscular space and unrolled properly with enough overlap. a drain was placed and the anterior rectus sheath incision was closed. results: the patient was discharged 24 h after surgery without remarkable events during his postoperative stay. he has been followed up for 8 months remaining asymptomatic. conclusions: totally endoscopic retromuscular ventral hernia repair in men with umbilical hernia and diastasis recti associated, is feasible and reproducible procedure with several advantages compared to traditional laparoscopic ipom in terms of pain and mesh position. aims: parastomal hernia (ph) is one of the most frequent long-term complications of stoma formation, occurring in 35%-50% of patients. surgical treatment for parastomal hernia is the only cure but a fairly difficult field with a recurrence rate ranging from 24% to 54% of cases. due to its advantages, the number of laparoscopic mesh repairs for parastomal hernia has gradually increased over the past decade. according to this common complication, we report a case of laparoscopic reparation of ph using the sugarbaker technique. method: we present the case of a 65-year-old patient with surgical antecedent of laparoscopic low anterior resection due to rectal cancer, presenting in postoperative period an anastomosis leakage with severe peritonitis was identified and a laparotomy with end colostomy was performed. the postoperative course was uneventful. during the follow-up the patient showed a 6 centimetres size paraestomal hernia, being a m3w2 incisional hernia confirmed with ct scan.the patient underwent full laparoscopic hernia repair, performing a sugarbaker technique, exposing parastomal hernia completely to measure the hernia ring size (6 centimetres) and the midline associated defect (5 centimetres). a 26x36 cm size ptfe-c was selected to allow a 5-cm overlap over two defects. results: using this approach, the bowel loop was pushed into the abdominal wall and appropriate place between the mesh edge and the abdominal wall is left to allow the bowel loop to pass through. postoperatory course was uneventful and the patient was discharged 48 h after surgery without any remarkable event during his postoperative stay. he has been followed up for 18 months without realizing any clinical signs or alterations in ct scan. compared with traditional open surgical repairs, laparoscopic repair has certain advantages including its safe operation, postoperative rapid recovery, fewer complications, and lower recurrence rate. however, it still faces challenges regarding parastomal hernia treatment, and there is a need to improve existing surgical techniques. aims: nowadays, the principal disadvantages of laparoscopic approach in hernia repair are the use of intraabdominal meshes and traumatic fixation. first, intraabdominal meshes involve the contact of the prosthesis with the intestinal loops with the consequent risk of adhesion and fistula. also, using helicoidal sutures in prosthetic fixation produces adhesions to the tackers and a non-negligible incidence of chronic pain. when it comes to lead to better results, placing the mesh in retromuscular space avoids the drawback of contact with the loops, and using self-fixation meshes may decrease the rate of acute and chronic pain. accordind to this facts, we present a case of laparoscopic ventral hernia repair with transabdominal retromuscular mesh placement without traumatic fixation. methods: we present a 50-year-old patient with a 7 cm diameter hernia showed in preoperative ct scan, m3w2, with diastasis recti associated. the patient underwent laparoscopic surgery using transabdominal retromuscular route. one 11 mm and two 5 mm trocar were placed in left flank. the posterior rectus sheath on the left side is opened starting 5 cms far from the left egde of the defect. once the retromuscular space is dissected, the hernia ring is dissected and the hernia sac reduced, we continue with the dissection in retromuscular space on the side. craniocaudal dissection is achieved 5 cm distal to the defect margins. the hernia defect with the anterior rectus sheath and the diastasis recti were closed using v-loc running suture. self-adhesive mesh was subsequently placed. the mesh should be overlap 5 cm from the margins of the defect, covering the defect widely, with grips facing upwards. finally, we closed the posterior rectus sheath with peritoneum on the left side with v-loc running suture. results: the postoperative course was uneventful and the patient was discharged 24 h after the surgery. after 18 months of follow-up no clinical or radiological recurrence was showed. conclusions: the combination of laparoscopic approach, retromuscular mesh placement and the use of self-fixation meshes, seems to be an actual useful solution, combining the advantages of each item and avoiding the use of intraabdominal meshes and helicoidal sutures. aims: laparoscopic ventral hernia repair has clear advantages over open repair, including less post-operative pain and earlier return to normal activity. however, a prolonged surgeon learning curve is necessary to perform this technique effectively. robot assistance may improve outcomes of minimally invasive ventral hernia repair with improved three-dimensional visualization and enhanced dexterity with articulating instrumentation. we report a case of robotic rives-stoppa epigastric hernia repair in order to demonstrate the feasibility of the robotic approach. methods & results: a 58-year-old man came to our attention for the presence of a palpable mass in the epigastric region. the abdominal ct scan showed the presence of an epigastric hernia with herniation of omental content, and the presence of diastasis recti. the patient was then submitted to a rives-stoppa robotic hernia repair under general anesthesia. the da vinci-si surgical system (intuitive surgical inc., sunnyvale, ca, usa) was brought into position over the head of the patient and docked after placement of the ports. three trocars were placed in the hypogastric region along the transtubercular line. a fourth trocar was placed in the left iliac fossa and used by the assistant. the operation started with an extended adhesiolysis and hernia reduction. then, the retromuscolar dissection began by incising the posterior sheath starting from 4 cm above the pubic symphysis. an extended dissection of the rives space was performed to create a correct housing for the mesh. the hernia defect and the diastasis recti were closed using a 1-0 absorbable barbed suture. a phasix st tm mesh (bard inc./davol inc., warwick, ri) was positioned in the retromuscular plane, and was anchored with absorbable sutures and glue. the midline incision was closed using a 2-0 absorbable barbed suture. the operative time was 250 minute. the postoperative period was uneventful, and the patient was discharged home on the second post-operative day. conclusions: robotic rives-stoppa ventral hernia repair is feasible, safe, and effective when a standardized approach is performed. whether robotics may improve the outcomes of minimally invasive ventral hernia repairs, including lower recurrence rates, decreased post-operative pain, or shorter surgeons' learning curve, will require careful prospective investigation. aims: the authors present a video with a left chronic bochdaleck hernia classical hernioplasty repair but performing a mini invasive thoracoscopic approach and 3 mm instruments. methods: a 73 years old female patient come to hospital due to chronic left dorsolumbar pain. a ct scan study showed a chronic left diaphragmatic bochdaleck hernia. a lateral right decubitus thoracoscopic repair is performed using 3 mm instruments and a 5 mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 48 h with no pain and a clean chest x-ray. in a 2 year time follow-up, not an anatomical or clinical recurrence has been reported. neither chronic pain or respiratory complications happened, with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, left bochdaleck hernia mini invasive thoracoscopic hernioplasty repair using 3 mm instruments could be a safe and feasible option. more studies are needed in order to standardized this approach. surg endosc (2019) abdominal wall surgery has expanded exponentially in the last decade. many techniques have been developed, mainly in minimally invasive surgery. laparoscopic ventral and incisional hernia repair (lvihr) has become a common procedure because of its feasibility and safety but unfortunately, it is not free of complications. chronic postoperative pain and bleeding are frequent complications, prolonging hospital stay and altering quality of life of the patients. absorbable or non-absorbable tacks are the usual method of mesh fixation and sometimes combined with transfascial sutures to secure the mesh. these 2 mechanical fixations pierce the abdominal wall causing nerve or vessel injuries. some studies showed no differences between absorbable tacks, non-absorbable tacks or transfascial sutures concerning postoperative remarkably high pain. some authors consider that a non-penetrating fixation of the mesh getting an effective mesh-abdominal wall interface will reduce significantly the postoperative pain after a laparoscopic ventral hernia repair. tissue glues are used in different medical treatments and also have been used successfully for extra peritoneal mesh fixation in laparoscopic inguinal hernia repair, open ventral hernia repair but not so in laparoscopic ventral hernia repair in spite of good results published in the literature. cyanoacrylate and its derivatives are 'synthetic glues' and classified as medical devices with stronger adherent properties than fibrin glues. experimental studies have reported good results compared with suture fixationand also tissue toxicity doesn't lead to an increased foreign body reaction. some authors have studied the use of cyanoacrylate in laparoscopic inguinal hernia repair but unfortunately, clinical trial reports in ventral and incisional hernia repair were not found in the literature because the lacking of experimental studies that guarantee the safety of intra-abdominal mesh fixation and the interaction of the glue with the intra-abdominal tissue. our group developed an experimental study demonstrating the feasibility, safety and effectiveness of the cyanoacrylate using for intraperitoneal mesh fixation and after this conclusion, started a clinical study. this video shows the methodology for laparoscopic mesh fixation with only glue in our first cases. aims: small epigastric hernias, associated or not with the rectus abdominis diastasis, and small umbilical hernias are common in middle-aged women, particularly with past history of pregnancy. the aim of this video is to illustrate a new extraperitoneal approach to these clinical situations. methods: patients between the ages of 40 and 60 years old, with epigastric hernia orifice up to 2 cm, with or without associated umbilical hernia (up to 2 cm), were chosen for this procedure. the surgery begins with a vertical umbilical incision for the umbilical hernia's correction, and dissection of the pre-aponeurotic plane. two 3 mm trocars (mini-laparoscopy instruments) are introduced at both flanks to enlarge the pre-aponeurotic plane towards the xiphoid appendix. in this way epigastric hernial defects are isolated. the surgery proceeds with defect suturing with braded suture, midline invagination and mesh placement if necessary. results: all patients had an eventful post-operative period and were discharged home at postoperative day 1. the aesthetic and functional results are optimal conclusion: for selected cases with high aesthetic motivation this technique seems to be feasible and with optimal cosmetic results. this technique allows the mesh placement both in-lay and onlay, protecting it from surgical site infections often present at the classical approac bochdalek hernia is a rare entity in adults. fewer than 200 have been reported in medical literature, the majority of which were incidentally diagnosed. as such, the optimal repair of a symptomatic hernia is unknown. we present a case of adult bochdalek hernia repair. methods: a 30-year-old obese male patient with a 2 years of chronic dry cough and left lung opacity in chest x-ray. a large posterior and lateral bochdalek hernia with herniation of intestinal loops and fat to the left hemithorax was seen in chest and upper abdominal ct scan. the hernia extended to mid-thorax, caused significant atelectasis of left lung. eighteen months later, due to appearance of chest and abdominal pain following a recent motor vehicle accident, a repeat chest ct was done and a slight enlargement of the hernia was shown. results: the patient was operated laparoscopically, positioned in a semi-right lateral decubitus with double lung intubation. a large left posterior and lateral diaphragmatic hernia which contained transverse and descending colon with omental fat was seen. they were pulled in to the intraperitoneal space carefully. the defect was measured to be 10*8 cm. it was reduced to 7*7 cm by suturing with a non-absorbable 0 v-loc suture . advancing the camera to the thoracic cavity showed the left lung to be severely atelectatic. after selective recruitment lung was well expanded. a symbotex composite 20 9 25 cm mesh was fixed to the defect area by suturs and laparoscopic tacker. the operation and post-operative course were uneventful. chest x-ray demonstrated the bowel below the diaphragm. the patient was discharged on pod 3. at 8-month follow-up, chest x-ray was normal. objective: to demonstrate the safety and efficacy of the standardized laparoscopic approach in the treatment of large parastomal hernia. currently, this approach is recognized as the one of choice in parastomal hernia pathology, being controversial which is the best technique of choice: keyhole vs sugarbaker. material and method: clinical case: a 76-year-old woman with a history of laparoscopic abdominoperineal amputation due to rectal neoplasia (pt2n0), a year ago, with symptomatic parastomal hernia with incarceration episodes and inflamation changes in the stomal orifice.tac: large hernia parastomal with intestinal content inside. surgical treatment is decided. result intervention: complete laparoscopic approach, right lateral partial decubitus, 4 trocars, dissection of the hernia defect and reduction of the content, partial mobilization of the pre-stomal colon, with bleeding at the level of the vascular origin, requiring careful hemostasis to avoid ischemia of the colostomy, herniorrhaphy with stitches with extracorporeal knotting, placement of polypropylene/pvdf mesh,fixed with irreabsorbable tackers with administration of biological glue at the edges of the mesh. correct postoperative, discharge at the 3rd day. asymptomatic and without hernia recurrence at one year of follow-up. conclusions: the technique of sugarbaker using a laparoscopic approach is a safe and effective alternative in the treatment of parstomal hernias. objetives: laparoscopic ventral hernia repair provides advantages in term of low infection rates and postoperatory stay when is compared with open repair. trends in laparoscopic abdominal wall surgery is to complete defect closure without tension in midline. closing the defect in ventral hernias wider than 8-9 cms creates high tension in midline and postoperatory pain. it's proposed different techniques to solve this drawback. laparoscopic posterior component separation makes the defects closure easier with no tension and placing the mesh extraperitoneally. methods: 65 years old woman with previous total hysterectomy, a m3m4w3 midline incisional hernia was clinically diagnosed and confirmed with ct scan. full laparoscopic abdominal wall repair with defect closure was proposed. 3 trocars in left side were placed and posterior rectus sheath right side in the defect margin is freed. once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. this allows access to the plane between the internal oblique and the transversus abdominis muscles. it's is made the same steps in the left side with 3 trocar on the right flank. the posterior rectus sheath both side is reapproximated in the midline and 20 9 20 cms polipropilene mesh is placed and unfolded properly. it's fixed using cyanocrilate glue. one drain is left in retromuscular position and 10 mm trocar wounds are sutured. results: postoperatory course was uneventful. hospital stay 24 h. the drain was removed in day 3 after surgery. after 9 months follow-up no complication or recurrence were identified. methods: this video will show the evidence of gangrenous jejunal segment due to superior mesenteric vein thrombosis in a patient with history of breast ca on hormonal treatment.in this video, the gangrenous segment was resected and primary anastomosis was done using endogia 60 mm. results: a second look after 48 h revealed to be negative for any further ischemic bowel. conclusion: therefore, laparoscopy in acute abdomen is diagnostic and for treatment. introduction: gastric pseudo-volvulation is a rare entity of paraesophageal hernia that is characterized by migration of the stomach into the posterior mediastinum. this clinical-radiological picture has severe complications so in certain cases should be operated urgently. another small group of patients are asymptomatic, although the current literature recommends their regulated surgical intervention. we present a gastric pseudo-volvulation in the mediastinum, with a laparoscopic approach, showing that by systematizing the surgery, it is possible to perform this type of intervention with relative ease and safety material and methods: we present a video of an urgent laparoscopic approach in a female patient of 80 years with a personal history of hypertension, smoking and dyslipidemia. with a hiatus hernia diagnosed more than ten years ago. he went to the emergency department due to significant symptoms of heartburn and reflux, as well as incoerctable vomiting and difficulty feeding one week of evolution. a simple abdomen and postero-anterior chest radiograph was performed, showing a paraesophageal hiatus hernia with almost the entire stomach included in the mediastinum. a thoraco-abdominal axial tomography corroborated giant hiatus hernia with pseudovolvulation and incarceration data. urgent intervention was decided by laparoscopic approach in which hiatus hernia reduction and esophageal abdominalization were performed. closure of pillars and reinforcement with bioabsorbable mesh. gastric and gastropexy toupet of anterior face to anterior peritoneum of abdominal wall. results: the patient had a post-operative 48 h without incident, discharged with a crushed diet. the follow-up and evolution has been acceptable without notable complications. conclusion: the laparoscopic approach, in extreme cases of paraesophageal hiatus hernia with incarceration of the stomach and pseudovolvulation of it, is a correct, safe and effective alternative in experienced groups. surg endosc (2019) case report of incarcerated hiatal hernia. 30 years old female was admited to the hospital due to severe chest pain and vomiting for about six h. physical examination and lab test showed no abberations. chest xray revaled incarcerated stomach above the diaphragm. she was rushed to the or. laporoscopic approach was used, the stomach was removed from the chest and nissen fundoplication was performed. day after surgery patient was asymptomatic, got full oral diet. she was discharged on postoperative day two, without a need of any analgetics. gastroduodenoscopy was performed 6 weeks after surgery and showed proper image of oesophagus, stomach and duodenum, neither signs of hiatal hernia nor inflamation were present. laparoscopic approach is good way to treat incarcerated hiatal hernias and is related with shorter lenght of stay, lesser postoperative pain and better patient comfort. and it should be procedure of choice in this kind of cases. she was operated open technique using a 2 cm long incision in right iliac fossa and the appendix was phlegmonous. the patient began feeling bad from the second day postoperative having temperature over 38°c, pain and increasing crp. the general condition worsened the next day when the temperature went up till 39.5°c, extreme generalized pain and crp:343. the ct abdomen control indicates signs for generalized peritonitis and rises the suspicion for a forgotten large gauze. the patient is operated using laparoscopy technique: identifying and taking out the foreign body, doing adhesiolises, extensive lavage and in the end inserting one drain in douglas. the video is presenting what king of special graspers can be used but also tips and tricks when speaking about identifying the anatomy but also dissection in acute and inflamed environment. postoperatively the patient began to feel better and in the 5 th day was released home. conclusion: this case illustrates that even after open surgery, laparoscopy is a viable solution with the condition that there is available experience in minimally invasive surgery. introduction: foreign bodies can enter inside the human body by different mechanisms such as ingestion, aspiration, trauma or in some cases due to medical procedures. they are potentially life-threatening events, the diagnosis could be challenging and its management depends on their location. case report: a 64-year-old male was referred to our hospital due to chronic abdominal pain. he had cholelithiasis, medical history of acute pericarditis and past surgical history of left adrenalectomy, left nephrectomy, distal pancreatectomy and colon resection due to an adrenal adenocarcinoma (stage t4n0m0).abdominal radiograph showed a foreign body in the left lower quadrant of the abdomen, as an incidental finding. this was not detected in ct scans during ten years of oncology follow-up. ct scan revealed an extraintestinal metallic curved object in the right lower quadrant. this finding was not related to any surgical intervention or trauma. diagnostic laparoscopy was performed: the foreign body seemed to be a guidewire, it was included into the omentum and almost stuck to the abdominal wall. the guidewire was reached and carefully extracted through a 10 mm trocar without any evidence of intra-abdominal organ injury. then an elective cholecystectomy was also performed due to his medical history of symptomatic cholelithiasis.the procedure lasted 60 min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: is extremely rare to discover a guidewire that had migrated into the peritoneal space without abdominal injuries.this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive laparoscopic removal. aims: the authors present a video with their standardized laparoscopic groin hernia transabdominal preperitoneal hernioplasty (tap) procedure but using 3 mm instruments and 5 mm camera approach. methods: a 45 years old male patient with a bmi 30 presents a symptomatic bilateral groin hernia for 5 months. us study showed an indirect bilateral inguinal hernia. a laparoscopic tap hernia repair procedure is performed using 3 mm instruments and a 5 mm camera. a selfgripping mesh preperitoneal hernioplasty and peritoneal flap barbed-sutured hermetic closure was performed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 4 h with a 2 rate in a eva acute pain visual scale. in a 2 year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, umbilical or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, a laparoscopic bilateral hernia repair using 3 mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. results: during tapp approach a direct hernia relapse was identified, the previous mesh was included on preperitoneal space and some non-absorbable sutures to inguinal ligament were identified. stitches and nearly total mesh removal (only the part surrounding cord elements was left in place) were performed. 15x15 heavyweight polypropylene mesh was employed fixed with gubran2ò and the flap was closed with running sutures. patient was discharged uneventfully the same day. seven months later he did not need analgesics and had no physical impairment. conclusions: post inguinal hernia repair chronic pain can be severe and disabling, and is becoming more prevalent. the origin is complex and meshes and sutures could play a role. the management is multimodal and demanding. for refractory patients, surgery may be an option. laparoscopic, open and mixed approaches have been employed. they usually combine mesh removal and substitution (often in different planes) and groin nerve therapies. nowadays, triple neurectomy seems to be the most effective treatment (more than 90% pain relief). generally, removal of mesh alone does not lead to lasting pain relief or has worse outcomes compared with associated neurectomy. introduction: mesh repair of inguinal hernia is sometimes followed by adverse effects such as mesh migration, chronic groin pain or recurrence. removal of the mesh is necessary in selected cases. we affront this cases by tapp intervention. methods: we present a video with two intreventions of inguinal recurrent hernia by laparoscopy (tapp). we remar the points to decide explant the mesh or not to explant. the conditions to decide the explant were the proximity to the main vessels in inguinal area (espigastric and femoral vessels) and the plication of the mesh. results: and conclusion as we show in the video, the explant of the mesh is only conditioned by the plicature of the mesh for its migration and recurrence, accompanied usually with pain. we don't remove any time the mesh or the plug if it is in the triangle of doom with firm adhesions to the main vessels. we cover the previous mesh with a new ligthweigth 3d mesh and closing at the end the preitoneum over the new reparation. introduction: tep technique isn't a controversial area in surgical practice for inguinal hernias anymore, but a fully accepted method. the use of general anesthesia has been the mainstay of laparoscopic hernia repair, but epidural anesthesia is not a contradiction to properly selected patients. material-method: the approach of the extraperitoneal area achieved without use of a dilation balloon, but via the indroduction of the camera and the dissection of the regional structures.3 trocars ports were used: a 10 mm trocar through the umbilicus for the camera, exactly as in sils (single incision laparoscopic surgery), another one 5 mm is placed in the midline between the umbilicus and pubis, the last 5 mm trocar is placed in the midclavicular line ipsilateral with the hernia. the key for every operation was the tension free technique with placement and fixation of a mesh 10x5 cm. in 20/25 cases the mesh was placed with tacks on the inside of the inferior epigastric artery-vein complex. all patients were dismissed from the hospital in 24 h, no drain was placed and no major postoperative complications took place. conclusion: tep is a demanding technique with serious learning curve. the use of a dilation balloon for insertion in the extraperitoneal area is not prerequisite. tep is an appropriate method both for first appearing and recurrent inguinal hernias. epiduralanesthesia instead of general anesthesia is no a contradiction for properly selected patients. aims: the aim of this study was to investigate the effects of preperitoneal carbon-dioxide (co 2 ) insufflation during tapp (transabdominal preperitoneal) repair. materials and methods: 20 male patients with inguinal hernia were include in our study. we obtain laparoscopic access at the umbilicus and introduce 10 mm port. two 5 mm working ports are placed lateral. diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. using aspiration needle we insuflate carbon-dioxide (14 mmhg) preperitoneal at the level of anterior superior iliac spine while decrease abdominal gas pressure to 8 mmhg. same procedure is made lateral to the umbilical artery. results: we found that preperitoneal carbon-dioxide (co 2 ) insufflation during tapp facilitate the future parietalisation and even can reduce operating time in future improvements of the technique. there were no intraoperative complications related to this procedure. we did not found any potential risk of the technique when is use by trained surgeons. aims: laparoscopic inguinal hernia repairs (lihr) are performed more and more frequently because they offer some advantages; however, we cannot forget their specific complications. lihr are associated sometimes with peritoneal tears that can lead to bowel obstruction. we present two cases of bowel obstruction related to peritoneal defects post tapp procedure and review peritoneal closure, bowel obstruction and options to repair defects. a 79 year-old male was scheduled for tapp due to bilateral relapse. two 10x15 tio2mesh tm fixed with securestrapò, employed also for peritoneal flap closure, were employed. three days later he was readmitted with bowel obstruction with ct suggesting 'adhesions'. a 56 year-old male had bilateral tapp in another centre. seven days later he presented with bowel obstruction. ct showed metallic tackers and suggested 'adhesions' results: first case: after four days of conservative treatment failure, a revisional laparoscopy showed ileum herniation through a peritoneal defect and firm adhesions to the mesh. bowel was labouriously separated and the peritoneal defect closed with two running sutures. he was discharged on the 7 \ sup [ th \/sup [ postoperative day and three years later he is asymptomatic. second: after two days of conservative treatment failure, on laparoscopy, ileum was filmy adhered to polipropilene mesh through a big defect on flap closure. defect was closed with interrupted sutures. as tears persisted, an omental flap was created to cover the area. patient was discharged on the 5th day and continues asymptomatic three years later. conclusions: lihr bowel obstructions can be divided in adhesive disease and herniation. herniation can be early (through peritoneal defects) or late (trocar site). international guidelines recommends a thorough closure of peritoneal incision or bigger tears (grade b). the closure can be achieved with staples, tacks, running suture, or glue. these last two methods are more time-consuming but less painful. running suture seems to be the best, due to its low costs, tightness and low pain but sometimes can be technically difficult. low intra-abdominal pressures (= 8 mmhg) facilitate suturing. when a herniation appears, careful bowel management is needed and running sutures are recommended. if tears persist, an omental flap can be useful. aims: application of a single port robotic platform to perform an entirely transanal tatme/ tata. methods: the following video demonstrates how a totally transanal proctosigmoidectomy is performed using a novel, single port (sp) robotic platform was used to carry out a totally transanal proctosigmoidectomy, single port robotic tatme/tata. a 38-year-old female patient with a clinical t3n1b rectal cancer at the 3 cm level, status post neoadjuvant chemoradiotherapy (5580 cgy, xeloda) is presented. shown here is the open transanal dissection followed by docking of the sp robot, implementation of the single port instruments (fenestrated bipolar forceps, cadier, scissors, camera, clip applier) through a gelpoint path to complete a totally transanal proctosigmoidectomy including transanal tatme, ima/imv transection, splenic flexure release, and left colonic mobilization, loop ileostomy, and handsewn coloanal anastomosis. results: blood loss was 100 cc. pathology demonstrated a moderately differentiated, rectal adenocarcinoma. the total mesorectal excision was complete (grade 3), margins were negative, and all 17 lymph nodes were negative for metastatic carcinoma. the patient was discharged on postoperative day 4 after an uncomplicated hospital course. there was no postoperative morbidity or mortality. conclusions: application of the single port robot to transanal tatme/tata (sprtatme) is presented here. while much work remains to be done to validate the sp robot's safety, this first demonstration of a totally transanal tatme/tata establishes its feasibility and utility. this single port platform stands to greatly expand the application of natural orifice transluminal endoscopic surgery (notes). as shown, the sp robot offers more than sufficient visualization, technical control, and adequate reach to perform such an operation. we present an exciting new avenue by which to complete operations in an entirely transanal fashion, which are classically performed via a combined transanal and transabdominal approach. methods: this video shows the utilization of a new robotic platform to perform transanal endoluminal microsurgery, rtem. presented here is a 53 year old woman with a recurrent rectal adenoma at the 6 cm level, status post a previous tem resection in october 2017. demonstrated is the utilization of the sp robot through a gelpoint path in order to perform a partial fullthickness and full-thickness resection. the robot is introduced through a 25 mm in diameter cannula via a four-channel face-plate. the instruments' two-jointed mobility at the elbows and wrists as well as the novel navigation system are well demonstrated. the docking of the sp robot, utilization of the dissecting devices, and closure of the defect is shown. results: sprtem was performed with a blood loss of 5 cc, and the patient was discharged on postoperative day 1. there was no postoperative morbidity, mortality, or moderate/severe pain. pathology showed tubular adenoma with low-grade dysplasia in a non-fragmented specimen with negative margins circumferentially. conclusion: initial experience using the sp robot for rtem is demonstrated here. the robot provides wonderful visualization and operative control to the surgeon. articulation of the robot's wrists and arms have the potential to facilitate technical aspects of the procedure. rtem stands as an exciting development in the field of transanal endoluminal surgery. introduction: the application of robotic approach in the esophageal surgical field is in its first phase. the microsuturing and microdissection capabilites of the robotic system can potentially overcome the traditional limitation of the laparoscopic surgery thus enhancing the indications of minimally invasive surgery. methods: we have performed a retrospective analysis of our prospectively maintained database that included 16 patients who underwent robotic-assisted esophagectomy for malignant disease between 2014 and 2017. results: ten out of sixteen patients had squamous cell carcinoma meanwhile six had adenocarcinoma. ten mckeown's and six ivor lewis were performed. the mean operative time was 525 min (332-688) and the median blood loss was 155 ml (70-220). no patients required conversion nor intraoperative transfusion. the morbidity rate was 3/16 (18.7%) : a transitory laryngeal nerve paresis, a pneumotorax and pneumonia. the mean hospital stay was 8 (range 7-23) days. an r0 resection rate of 93.7% was achieved with a mean lymph node yield of 16 (13-21). the 1-year disease free survival was 82.8%, wheres the the 1-year overall survival was 88.5%. conclusions: robotic assisted minimally invasive esophagectomy (ramie) is safe and feasible, it offers promising results while preserving a good oncology adequacy. this video shows our technique for the treatment of an esophageal diverticolum using a robotic left sided transthoracic approach, followed by a heller myotomy and dor fundoplication using a transabdominal approach. our case is a 75 year old male, who suffered from severe dysphagia, halitosis and gastric reflux who on endoscopic and radiological investigations was found to have low grade and a 3 cm wide esophageal diverticulum, 7 cm from the lower esophageal sphincter. initially conservative management was attempted, however following poor compliance and the persistance of symptoms after 1 year of therapy, surgical intervention was indicated. the operation was performed using the minimally invasive robotic system of the davinci siò, starting with the thorax time. the patient is positioned in left side decubitus. the camera-trocar is insert in the thorax via the fifth intercostal space the, two 8 mm and one 12 mm robotic trocars are added. the lung is liberated from pleural adhesions and the esophagus is then prepared exposing the diverticulum which is successfully removed with an endo-giaò. the esophageal muscle fibers, near the suture line is reinforced with separated vicryl stitches and the resected piece is extracted via endo-bag. a 16fr thoracic drainage tube is then placed and the trocar accesses repaired. the patient is the put in supine position with a 15°anti-trendelemburg angle. three robotic trocars (two 8 mm and one 12 mm) are placed and the robot docking is made from the patient left shoulder. the lesser omentum is divided to visualize and prepare the gastric-esophageal junction (gej) sparing the vagus nerve. the heller myotomy is then performed for 4 cm over the gej and 3 cm under it. the mucosal integrity is assured via laparoscopic and contemporary gastroscopic view. the gastric fundus is attached to the distal esophagus completing the dor fundoplication. post-operative care comprehends the removal of the thoracic drainage during the first post-operative day, the pain management and the progressive realimentation. the hospitalized period lasts 6 day and the patient was dismissed without complications occurred. the uniportal video assisted lung lobectomies gained popularity all over the world during the last 10 years. the technique is safely applied for peripheral pulmonary lesions, under 6 cm, but more and more complex cases are being approached while the indications continue to evolve. our aim is to present the particular aspects of this technique in an 11-year-old female patient with a giant bullous lesion located in the lower lobe of the right lung. the preoperative work-up for this case is presented and commented. a multidisciplinary surgical team consisting of thoracic and pediatric surgeons was involved. a single 3.5 cm length incision in the fourth intercostal space was used for the access. due to the fact that the lesion involved almost the entire lobe and the margins were very close to the hilum, we have decided and performed a right lower lobectomy. dissection and stapling were quite difficult. all the anatomical structures had small dimensions, forcing us to perform an 'artery first approach' in a very narrow space. no complications during or after surgery were encountered. the patient was discharged after four days and she went to school on the sixth day. histopathological examination showed that the lesion was a type 1 ccam (congenital cystic adenomatoid malformation). conclussion: the uniportal video assisted lung lobectomy was safety applied for a giant bullous lesion of the right lung. aim: dunbar syndrome, celiac trunk (ct) compression syndrome, caused by median arcuateligament is a rarely diagnosed disease because of its nonspecific symptoms, which cause adelay in the correct diagnosis. the aim of the study was to demonstrate the usefulness andadvantages of laparoscopic approach in the treatment of dunbar syndrome. methods: we performed 3 laparoscopic release of ct in the department of general, minimallyinvasive and elderly surgery in olsztyn in 2018. all of three patients suffered from severepain of abdominal cavity before the surgery. results: in two cases, there were a complete remission of the symptoms. in one case, there was animprovement. all patients reported relief of symptoms in the first days after the operation.there were no postoperative complications. conclusions: the laparoscopic treatment of dunbar seems to be safe and feasible procedure. thelaparoscopic surgery alone can often eliminate discomfort, while angioplasty and stentimplantation are no longer necessary. introduction: the advances in robotic surgery have permitted the application of such technology to various surgical fields, one of the last of these being hernia surgery. we present a case video of the treatment of a dual-hernia using a robotic retromuscular ventral hernia repair(rrvhr) using the davinci siò robotic system. the case report demonstrates the evolution of the trans-abdominal robotic umbilical prosthetic (tarup) in that it utilises a 'double docking' technique to allow the positioning of a large retromuscular mesh. methodology: our patient is a 50-year-old male who presented with chronic epigastric pain. the abdominal ct confirmed two abdominal wall hernias; an epigastric and supra-umbilical hernia with visceral contents and wall defect diameter of 6 cm and 2.5 cm, respectively. using the minimally invasive robotic system of the davinci siò we adapted the well known retromuscular mesh technique. the operation was initially intraperitoneal with access to the retromuscular preperitoneale space using a right sided longitudinal incision.(as per standard tarup technique). we proceed with the dissection of the retro-muscular space until the left lateral edges of the rectus sheath, creating a preperitoneal space for the placement of a specifically modified ultrapro polypro-leneò 25x22 cm mesh. following this we repositioned the davinci siò in a symmetrical manner, with ports placed in the retromuscular space. the mesh is positioned and the peritneum subsequently closed with a v-lock sutureò. finally we opted for a negative pressure jackson-pratt drain, inserted preperitoneally. results: the patient was discharged on the 2nd post-operative day without complication follow up continued until 12 months post operatively during which the patient remained asymptomatic, without signs for hernia recurrance . conclusion: the technique highlighted in our video demonstrates the utility of the robotic system in hernia repair. specifically the approach proved a success as it facilites the placement of the mesh totally extra-peritoneally with closure of the posteriore sheath without tension. the added advantages are that the port-sites are distant from the mesh thus reducing infective risk. additionally this technique allows the treatment of large peritoneal defects. surg endosc (2019) aim: to analyse the performance of a robotic fellow during a robotic total mesorectal excision (tme) at the end of the fellowship, and subsequently compare it with their mentor. methods: the fellow is exposed to 2 robotic colorectal lists per week. during the fellowship, assessment of performance is recorded in a structured proforma covering aspects of autonomy, tissue handling and dissection. at the end of the fellowship, areview of cases performed by the fellow and the mentor was carried out in a blindly manner (video footage). results: robotic tme training was divided into modules in order of complexity and the trainee had to achieve sequential proficiency in each module, before progression. docking of davinci robotic system. inferior mesenteric artery exposure and ligation, development of medial to lateral plane and inferior mesenteric vein division. left colonic and splenic flexure mobilization. pancreas identification. rectal dissection (tme). qualitative assessments were recorded by the mentor; the fellow was 'able to perform with verbal help' most of the steps from early on. by the end of the fellowship, all steps were performed in a similar manner in terms of quality and oncological integrity when compared with the mentor. conclusions: at completion ofan advanced robotic colorectal fellowship, high quality trainees can perform every step of the tme dissection in a similar manner with the trainer, when assessed blindly, without compromising oncological integrity. aims: to find safe and simple method in robotic rectal low anterior resection with low tie arterial ligation and lymph node dissection around the root of inferior mesenteric artery. methods: we performed robotic rectal low anterior resection (rlar) by davinci si system in eight patients with rectal cancer. we applied low tie arterial ligation, just caudally to the origin of the left colic artery in all cases. during the procedure, we used tilepro function of davinci si system which enabled to display two other visual informations through external inputs under the normal 3-dimensional surgeon console view. preoperative 3d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were displayed simultaneously under normal operative camera view in the surgeon console. results: left colic artery preservation was completely done in all 8 cases. the mean time to find and expose the left colic artery from the first incision in sigmoid mesentery was 5 min, which was drastically shorter than conventional method. this method needed lesser mobilization of inferior mesenteric artery (ima), and may be less invasive to autonomic nerve around the root of ima which is very important for ejaculation function. conclusion: robotic rectal low anterior resection with low tie arterial ligation was performed safely and in short time, using tilepro intra-operative navigation method. preoperative 3d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were very useful in the procedure. we present the method in video. nerve sparing tme and pelvic neuroanatomy for colorectal surgeons p. tejedor, f. sagias, j.s. khan aim: to describe the critical points in which the pelvic nerves can be damaged during a total mesorectal excision (tme) for rectal cancer and the benefits of robotic surgery for identifying these points. methods: there are 4 critical points regarding pelvic neuroanatomy: superior hypogastric plexus (shp): located in front of l5-s1. the ganglionic sympathetic fibres form the right and left sympathetic trunk, travel along the anterior surface of the aorta and coalesce in the shp at the level of the inferior mesenteric artery (ima). superior hypogastric nerves: they take an anterolateral course into the pelvis. there is an avascular 'holy plane' around the rectum between these two nerves. inferior hypogastric plexus (ihp): lies over the posterolateral pelvis, almost parallel to the internal iliac arteries. this can be identified at the lower end of the rectum. neurovascular bundles(of walsh): in front of the denonvillier's fascia, at 2 and 10 o'clock position. they are responsible for erectile function. results: lack of knowledge or identification of key structures at these 4 points can lead to increased risk of nerve damage and translate into poor functional outcomes. the ima is dissected up to the origin from aorta and here the shp can be seen. care is taken to avoid any damage to these structures. the tme plane is found at the back of ima as the inner most dissectible layer between mesorectum pelvic fascia. right and left superior hypogastric nerves are identified. dissection is carried out posteriorly, laterally and anteriorly. ihp is identified at the lower third of the rectum, when the dissection is about to reach the pelvic floor. care should be taken in not to go too far lateral and damage this plexus. in the anterior dissection, plane is carried in front of the denonvilliers' fascia. the neurovascular bundles can be seen at 2 and 10 o'clock position and the surgeon has to be careful to stay inside that plane in order to avoid damage. conclusions: the precise dissection in robotic surgery results in minimal tissue damage and better visualization and preservation of the pelvic nerves. aims: to describe and evaluate new contributions and eventual advantages of icg fluorescence to perform an icg guided bilateral pelvic lymph node dissection in a patient who underwent low-anterior-resection for rectal carcinoma. we also present the basic steps to avoid ileostomy during rectal surgery in which icg and ghost ileostomy play an important role. methods: a 68-year-old male patient was referred to our hospital due to abdominal pain and significant changes in usual bowel habits.colonoscopy showed a no obstructing 5 cm middle rectal mass, which was reported as an adenocarcinoma.ct scan and mri revealed a 63 9 52 mm polyp in the anterior rectal wall which was located 7 cm from the anal verge. it was involving mucosa and sub-mucosa with muscularis propia invasion. no pathological lymphadenopathies or hepatic metastatic disease were found (stage t2n0).a laparoscopic ultra-low-anterior resection plus icg lateral lymphadenectomy with total mesorectal excision was performed. a complete splenic flexure mobilization was performed to achieve a safe tension-free anastomosis. transection line of the proximal rectum was checked after icg intravenous injection. icg was injected around the tumor by inserting an anoscope, just before the surgery. after the dissection of the rectum, lateral lymphadenectomy was performed assisted by icg. an end-to-side anastomosis was made. and a vascular loop was passed around the terminal ileum to create a ghost ileostomy.the procedure lasted 120 min. reactive protein c was monitored to identify an initial leak. the patient was discharge in postoperative day 7 and no complication was detected. results: pathological exam reported a rectal adenocarcinoma. pelvic lymphadenectomy results were: 2 negative nodes, 2 negative nodes and 10 negative nodes from right lymph node dissection, left lymph node dissection and rectosigmoid resection specimen respectively. no metastatic disease was found (stage t1n0m0). conclusions: in our experience, icg fluorescence imaging system offers important contributions to rectal surgery furthermore than evaluating vascular supply to the anastomosis. lymphatic mapping of the lateral lymph nodes and avoiding ileostomy could be a potential important use in the future. larger studies and more specific evaluations are needed to confirm its role in colorectal surgery and to find its limitations. background: robotic surgery for colorectal cancer is an emerging technique. potential benefits as compared to conventional laparoscopic surgery have been demonstrated. innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery such as hand-eye coordination, a two-dimensional view, and a restricted range of motion. robotic-assisted surgery was established as a new approach to minimally invasive surgery, overcoming these limitations. the following video shows a total robotic sigmoidectomy step by step on the basis of ourexperience. intervention: a 52-year-old male patient with no previous medical historyand a colon adenocarcinoma, 22 cm from the anal verge, no distant metastases. it was decided to perform a robotic sigmoidectomy. target anatomywas located andwe proceededto the exposure of the mesenteric vessels from medial to lateral. a cautery wasused to open the peritoneum,up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.the vessels weretransected by ligasuretm. we performedthe complete release of the colon taking care to avoid injury to retroperitoneal structures. we usedligasuretm to section the mesocolon in order to prepare the transection of the proximal colon. indocyanine green was used to check the correct vascularization. an endogia tristapletm was used to divide the colon. subsequently, we sectioned the rectumand extracted the specimen through itwith no need to make any auxiliary incisions. we introduced the anvil of the suture device to perform the anastomosis. we sectionedand close the rectum with an endogia tristapletm. finally we opened the proximal colon to introduce the anvil,making a pursestring to fix it and create a side to end anastomosis. outcome: the surgery took 110 min. the patient started oral intake 6 h after surgery and left the hospital on the 3rd postoperative day. pathological examination ruled out a colon adenocarcinoma pt1n0. conclusion: total robotic sigmoidectomy is safe and feasible and can be a procedure of choice to achieve a good surgical qualityand avoid assistance incisions in patients with colon cancer. surg endosc (2019) with more and more data now advocating wait and watch policy for these patients which require close radiological and endoscopic follow-up but unfortunately around 30% of them have regrowth of tumour which will require surgical intervention. the use of robot for cancer resections is becoming more frequent especially in narrow spaces like in an obese male pelvis. the reason being better 3-dimensional views, more angulation of the instruments and exclusion of tremors, which in turn leads to better dissection and preservation of hypogastric nerves. in this video, we present a robotic low anterior resection for rectal re-growth in an obese 55-years old male patient. he was offered neoadjuvant chemoradiotherapy after discussion in mdt. he had an complete response with chemoradiotherapy and was decided to offer him watch and wait regime. unfortunately, he developed rectal re-growth in the first year of his follow up. imaging showed t2 lesion with no distant metastasis and was later confirmed on histology as well. after mdt discussion he was offered robotic low anterior resection. the video starts by showing the clinicopathological features of patient including his radiological and endoscopic images. robotic port sites are shown. the edited video starts with rectal dissection after ligation of inferior mesenteric artery and vein with emphasis on narrow pelvis and preservation of hypogastric nerves, seminal vesicles and intact presacral fascia. postoperative histology was ypt2no and patient was discharged home after 3 days with no postoperative complications. background: minimally invasive surgery for colon resection has improved patient outcome, however a minilaparotomy still is necessary to extract the specimen. this report describes a new approach that combine laparoscopic parellel overlap stapling left colectomy with natural orifice specimen extraction surgery, with the aim to minimize abdominal wall trauma. method: laparoscopic left colectomy for malignant diesease was performed using a standard five-port technique. after releasing the left colon via laparoscopy, divide the proximal and distal of specimen with 60-echelon, and put distal sigmoid colon and proximal transverse colon together. open sigmoid colon 6 cm apart from distal margin, and incise transverse colon at proximal margin. take transverse colon and sigmoid colon side-to-side anastomosis via 60-echelon. incise posterior vaginal fornix to get into the abdominal cavity and extract specimen through vaginal. outcome parameters such as complications, conversions, operative time, postoperative recovery, and postoperative pain were prospectively recorded in a database. results: surgery was performed for 17 patients with left-colonic carcinoma. no perioperative complications or conversions occurred. the median operating time was 157 min. the median visual analogue scale score of postoperative pain was 1, and 2 of 17 patients needed analgesia on postoperative day 1. the median postoperative hospital stay was 6 days. for malignancies, tissue margins were oncologically adequate, the averge number of harvested lymph nodes were 16.9. the 4-week follow-up period was uneventful. conclusion: the described technique, a combination of laparoscopic parellel overlap stapling and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections. background: open surgical skills training has been well established over centuries, however, there are some significant differences in laparoscopic surgical skills training. it is an obvious advantage that the trainee and the trainer have the same view; however, some of the hurdles include the differences in tactile feedback, hand eye co-ordination, spatial awareness, depth perception and maximizing assistance. aim: we present a video highlighting some of the key challenges faced in laparoscopic colorectal surgical training, show-casing our systematic, structured approach. our approach: we have developed a structured approach starting with junior surgical trainees and progressing through to consultant level as per the levels below: level 1: attend courses/ workshops level 2: master camera work level 3: contra-lateral assisting level 4: intermediate level trainee-start operating with trainer scrubbed. the trainer is an additional member of the scrub team and stands on the same side as the trainee (does not replace any assistant) level 5: advanced level trainee-gradual progression from level 4. trainer un-scrubbed but standing next to the monitor throughout the procedure. level 6: trainer in theatre but out of sight of the trainee, with little interference level 7: progression to trainer-once proficiency is achieved at level 5/6, the trainee is trained to become a trainer, for the junior and intermediate level trainees. within each level the complexity of the procedure increases as the trainee progresses through the level. junior trainees (years 1-3 of surgical training) are taken through levels 1-3, intermediate (middle years of training) level 4 or 5 and advanced (last 2-3 years) up to levels 7. this way of training allows multiple members of the team to be trained simultaneously in every case. each operating list is preceded by team briefings where the role of every member of the team is clearly identified and followed by individual and collective feedback. conclusion: this training ladder proved very successful through the years. the feedback from trainees at all stages has been consistently positive. several trainees who have progressed to independent consultant practice, in the uk and abroad, are adopting this approach in their practice. introduction: despite the potential microsuturing capabilities of the robotic surgery, most of the esofago-jejunostomy after robotic total gastrectomy are still performed extracorporeal or through mechanical staplers. this can increase the cost of the procedure, the risk related to a improper functioning of the stapler. methods: we reviewed our prospectively maintained database analyzing patients from april 2015 to september 2017, who underwent robotic total gastrectomy with hand-sewn esophagojejunostomy for gastric cancer. results: a total of 18 patients were included in the study. the mean estimated blood loss was 140 ml (60-257). the overall operative time was 365 min (277-421). length of hospital stay was 6 days (5) (6) (7) (8) (9) (10) (11) (12) (13) . no conversion was necessary nor anastomotic leakage occurred. the morbidity rate was 2/18 (11.1%) and included a subhepatic abscess and wound infection trough pfannenstiel incision. a r0 resection rate was achieved in all cases. the mean of lymph node yield was 32 (14-39). the 1-year disease free survival was 74%, the 1-year overall survival 82.3%. the robotic-assisted hand-sewn esophago-jejunostomy is a safe and no time-consuming technique. it avoids the complication related to the stapler firing and it offers cosmetic benefit to the patient in terms of extraction site. introduction: colorectal endoscopic submucosal dissection (esd) is increasingly practiced for treatment of early colorectal neoplasia. however, colorectal esd is difficult to perform due to lack of retraction as well as instability especially over hepatic flexure. dilumen eip is an external flexible sheath introduced during colonoscopy to stabilize environment for esd. this video demonstrated the use of dilumen eip for performance of colonic esd at the ascending colon method and results: this is a 60 years old lady who received screening colonoscopy and found a 20 mm lateral spreading tumor (lst) type 0 iia lesion at ascending colon distal to ileocecal valve. under general anesthesia, patient received colonic esd using dilumen eip. due to significant looping, the dilumen device was introduced with the techniques of double balloon enteroscopy. after identification of the lst, the balloon in the front would be deployed to the proximal to the lesion while both balloons would be insufflated and created a stable environment. the esd procedure started after submucosal injection with normal saline in mix with indigocarmine, epinephrine and hyaluronate. mucosal incision was performed over the anal side of the lesion, and after adequate submucosal dissection, clips were applied to attach the mucosal flap to the sleeve of proximal balloon and achieved retraction. the submucosa was adequately exposed for dissection using dual knife jet. this enhanced submucosal dissection especially at one area with significant fibrosis. after the procedure, complete closure of the mucosal defect was performed by clips and assisted by the front balloon. the pathology confirmed intramucosal adenocarcinoma with clear resection margins. discussion: the dilumen eip device stabilized the environment within the colon with the double balloon and provide adequate retraction for performance of colorectal esd. surgery, kobe city medical center general hospital, kobe, japan background: robotic surgery has been widely spread all over the world, but robotic gastrectomy is not common and difficult because of complex anatomy and wide-ranging operation fields. in addition, it had been performed only under a few high-volume centers for reasons of the limitation of national health insurance in japan, which means medical expenses not covered by insurance. the situation was changed from this april, so we started robotic gastrectomy to reduce complications more rather than laparoscopic gastrectomy. we report results and aim to present the methods in detail using da vinci si surgical system. methods: we place five trocars, one is umbilical endoscopy port, and other four ports are placed at the reverse trapezoid, almost fan-shaped. using the arm number 3, the organ can be lifted up so that sharp lymphadenectomy is able to be done by almost a scissor as the arm number 1 while applying the countertraction by the arm number 2. in order to achieve a clear and bloodless lymphnode dissection while maintaining the oncological safety, we think not only the ultrasonic coagulating scissor but also the electrocautery of the scissor is very essential in robotic surgery. less postoperative complication such as pancreatic fistula or pancreatitis might be derived from robotic surgery because we can avoid pressing the pancreas during the suprapancreatic dissection of lymph nodes. the billroth i reconstruction can be performed using da vinci endowrist stapler under stable and inflexible surgical fields without needing help of surgical assistant. results: from october 2017 to december 2018, 25 patients with gastric cancer were operated robotic gastrectomy, included 3 total gastrectomy. there was no conversion to open surgery and no conversion to other procedures derived from intraoperative complications, and the overall operation time is gradually decreasing from the 14 th case. we are now on the way of learning curve shortening operation time, but robotic gastrectomy is no less safer and adequate than laparoscopic surgery. we will show our robotic procedures including lymphadenectomy around subpyloric and suprapancreatic area, and reconstruction with several important points in our video purpose: this report describes the benefits and drawbacks in the use of a novel articulating device (artisential), which has a multi-degree wrist freedom like the davinci endowrist, in performing complete single-port d2 lymph node dissection (lnd) in single-incision distal gastrectomy (sidg). methods: the artisential was used in performing sidg with d2 lnd for patients with advanced gastric cancer. all operations were performed by a single surgeon using a threedimensional camera and a passive scope holder in place of a scopist. the artisential was used mainly in the 4sb and suprapancreatic lnd, an area that is relatively far from the single port. in certain cases when the pancreas needed to be pushed down, such as obese male patients, the intraabdominal organ retractor was used to lift the tissue and the artisential to push the pancreas. operative results and short-term outcome were analyzed. results: twelve patients underwent the procedure without any intraoperative events, conversion to conventional laparoscopy, or surgery-related complications including postoperative pancreatic fistula. all patients underwent single port d2 lnd by complete exposure of the portal and splenic vein. mean operation time was 181.9 ± 42.5 mins. and mean number of retrieved lymph nodes was 61.8 ± 11.4. the artisential was found to be useful in grasping the tissues behind the pancreas and the major arteries throughout most of the lnd. the articulating motion also allowed the narrow single-port field of view to be clearly seen without the instrument body obstructing the camera. conclusion: the use of artisential in sidg appears feasible and reproducible, and is mandatory in performing a complete d2 lnd in sidg. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification 0-is g (granular type), ut0n0 eus stage, kudo type iv, nice type 2. the neoplasm measured 6 x 7 cm, and extended from 6 to 12 cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexò robotic system, used here for the first time outside the united states.the system technology utilizes an articulated multi-linked scope that can be steered along non-linear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexò robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board 3d hd visualization. the flexò robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation.the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock 3/0 thread. while illustrating the technique the authors will comment pros and cons of the use of the device. background: hepatobiliary procedures using a minimally invasive approachare demanding, especially in major hepatectomies. the use of da vinci surgical system allows to overcome some of the kinematics limitations of the direct manual laparoscopy maintaining the potential advantages of a minimally invasive approach . we herein present a case of left hepatectomy and local lymphadenectomy for hepatocellular carcinoma, carried out with the use of the da vinci xi. methodology: a 72-years old man with a long-lasting hbv chronic infection and ct scan and mri finding of a 4-cm solid neoplasia of the left hepatic lobe and gallbladder stones, was operated with the da vinci xi platform. the patient was placed in a supine position, with 15°anti-trendelenburg inclination. the trocars were positioned according with the intuitive indication for the upper quadrants surgery. results: the procedure was successfully completed in 360 min.at first, an intraoperative us scan with the use of tile-pro technology was done to determinate the tumor extension. the hepatic parenchyma transaction and the local lymphadenectomy were performed with monopolar scissors and bipolar grasps. the left hepatic vein section was performed with an endoscopic vascular stapler. there were no surgical complications or need for conversion to laparoscopy or laparotomy. the post-operative course was uneventful and the patient was discharged 5 days after surgery. conclusion: the da vinci xi can facilitate some technically demanding procedures and ultimately widen the range of application of minimally invasive surgery such as hepatic surgery. besides the well-known advantages provided by robotic surgery on 3d imaging, increased range of motion and augmented surgical dexterity, one of the most interesting and innovative features of robotic technology is the digitalization of the operative view; furthermore the tile-pro multiinput display allows the surgeon a 3d view of the operative field along with the ultrasound exam for a precise understanding of anatomy and vascularity and of tumor location. during the last few years, robotic surgery as well, as the latest innovation of minimally invasive procedures, takes its position in this particular field with the benefits of overcoming the limitations of conventional laparoscopy. our aim is to demonstrate the advantages of robotic surgery in procedures of hepatectomies, on occasion of a robotic hepatectomy performed by our team. methods: we present video fragments of a robotic left lateral hepatectomy procedure in an elderly female patient with a symptomatic gigantic haemangioma of the left hepatic lobe. we emphasize on the technical aspects and the advantages that the surgeon gains applying the robotic techniques in such procedures. results: the procedure was completed with minimal blood loss and the patient presented an uncomplicated post-operative course, with discharge on the third postoperative day, minimal need of analgesics and full recovery. conclusions: the excellent three-dimensional and high quality visualization that the robotic system offers, combined with the flexibility and the accuracy of the robotic instruments (especially on suturing), provide to the surgeon an important aid, in order to avoid serious complications, such as intraoperative bleeding and post-operative bile leaks. the restriction of the limitations of conventional laparoscopy is far more beneficial and promising for the evolution and the future of minimal invasive liver surgery. aims: the new da vinci xi surgical cart allows multi-quadrant and complex surgical interventions in a minimally invasive fashion. we present a case of robotic appleby left pancreatectomy using this platform and its specific operating bed. methods: a 73-years old woman with ct scan finding of a 30-mm hypo-vascular neoplasm of the pancreas body underwent surgery with the use of the new da vinci xi with four arms upper quadrants trocar' disposition. results: the procedure was successfully completed in 285 min. the pancreatic body was mobilized in order to expose the portal-mesenteric axis. the gland was transected using a robotic endo-stapler as well as the splenic vein. after evaluating the patency of collateral circles with intra-operative ultrasound, the common hepatic artery and the celiac artery were transected. then we increased the right tilted position and the neoplasia was detached from the gastric body by a tangential gastric resection using the robotic endo-stapler. finally, the operation was accomplished with the transection of the posterior attachment of the spleen and the pancreatic tail. no conversion or intra-operative complications were recorded. the post-operative course was uneventful and the patient was discharged 6 days after surgery. the da vinci xi with its specific tools helps in performing challenging procedures such as appleby operation for locally advanced pancreatic cancer. in our experience, the robotic endo-stapler permits the operating surgeon to directly control the transaction phase whereas the specific operating bed allows to perform minimally invasive multi-quadrant surgery and to obtain a better exposition of the operating field. results: the whipple procedure was successfully completed in 570 min. thanks to the dvtm the patient's position changed during the intervention to improve the exposure, with the instruments left inside the abdomen and without undocking the robot. the dissection of the pancreatic head from the portal vein and the section of the retroportal lamina were performed with the use of the endowrist vessel sealer device. a personal modified end-to-side pancreatojejunostomy was carried out, with 5/0 prolene and gore-tex double layer suture. no intra-operative complications occurred and no conversions to laparoscopy or laparotomy were required. the postoperative course was uneventful. conclusions: the use of the new fully wristed vessel sealer extend makes easier difficult maneuvers such as the fine dissection of the pancreatic head from the portal vein and the section of the retroportal lamina, enabling an optimized approach for vessels sealing and cutting and tissue bundles. moreover, the dvtm allows patient's movements without undocking the system or removing instruments from the abdomen, enhancing the surgical workflow. background: necrotizing pancreatitis is a devastating illness which can develop in up to 20% of patients who suffer from pancreatitis. it carries great morbidity with an associated mortality rate between 8 to 39%. many of these patients require drainage of fluid collections to treat sequela related to pain, per-os tolerance, and source control of sepsis if infected. the step-up approach to treatment of this disease has trended towards minimally invasive techniques, considering the morbidity of open debridement. as such, many centers have implemented the use of transgastric debridement via endoscopic cystogastrostomy. this technique, while effective in draining fluid and particulate necrotic tissue, has difficulty in resection of large necrotic tissue, due to instrument and anatomic limitations. current endoscopic accessories designed for polypectomy or foreign body extraction, for example, are not optimal for performing necrosectomy. to overcome this obstacle, additional access sites can be utilized to assist debridement. we describe the first laparoscopic assisted transgastric endoscopic necrosectomy through a percutaneous gastrostomy in a 59 year old male with infected pancreatic necrosis secondary to biliary pancreatitis. aim: to investigate the feasibility of utilizing gastrostomy access to assist in debridement during endoscopic necrosectomy. methods: the patient previously underwent an open necrosectomy and gastrostomy tube placement for acute emphysematous pancreatitis. post-operatively, there was a persistent and enlarging 12 cm infected walled-off necrosis (won). therefore, endoscopic cystogastrostomy was performed using a lumen-apposing metal stent. results: frank pus was evacuated. initial endoscopic necrosectomy was technically challenging due to the large volume of solid necrotic tissue. repeat endoscopic debridement utilized a surgical laparoscopic grasper via the gastrostomy site to aide solid debris extraction (video). this allowed for complete necrosectomy and resolution of the won. the patient did well and was discharged subsequently. conclusion: this is another emerging minimally invasive technique in the step-up approach for debridement and drainage of won. the use of the gastrostomy as a utility port for accessory instruments not only enhanced the technical aspects of the procedure but increased its efficacy as well. further experience is needed to validate the utility and reproducibility of this technique. objective: the presentation of the minimally invasive surgical approach for pancreatic necrosectomy guided by videoretroperitoneoscopy or var (video assisted retroperitoneoscopic), established in our center, as one of the option of the step-up approach treatment for acute necrotizing pancreatitis (anp) methods: the placement of the patient on the operating table should be in decubitus, with right lateral inclination, at 20-30°on the horizontal surface. the pancreatic cell is approached using the drainage catheter previously placed by radiological control (ultrasound or ct) as a guide, which will allow access to the cavity with safety. an incision of 3-5 cm is made around the previously placed catheter, crossing the subcutaneous cellular tissue and muscular fascias, dissolving the musculature. it continues in a blunt dissection, until a loss of resistance is appreciated which generally coincides with the outflow of necrotic or purulent material. once the retroperitoneal cell is accessed, a 15 mm trocar is placed and a pneumoretroperitoneum is performed. the 15-mm trocar allows the joint use of a 5 mm and 0°optic and the surgical material that allows debridement and cleaning. the aspiration and hydrodissection of the necrotic material, and the extraction of the solid component of the necrosis are proceeded. once the collection is drained and the necrotic material removed, a wash and drain system is placed, like a 3-way foley type probe. conclusions: in conclusion, the var is an alternative surgical technique, valid and reproducible in the treatment of anp, which offers comparable results and even superior, in some series, to those of open surgery, with satisfactory results in terms of morbidity and postoperative mortality. aim: lung subsegmentectomy is suitable for small and deep, non-palpable lung nodules. since it is difficult to intraoperatively detect the arteries, veins and bronchi of the subsegment, as well as the intersubsegmental borders, complete video-assisted thoracic surgery (vats) for lung subsegmentectomy is challenging. we use preoperative three dimensional ct to detect the arteries, veins and bronchi of the subsegment before conducting complete vats subsegmentectomy, and perform intraoperative bronchoscopy to detect the bronchi and intersubsegmental borders. i would like to describe our experience of complete vats combined subsegmentectomy for a non-palpable lung nodule. methods and results: the patient was a 67-year-old woman. during health screening, a small groundglass opacity was observed in her right lung on chest ct. the nodule was 15 mm in diameter and was located in s 2b (horizontal subsegment of the posterior segment) near s 3 (the anterior segment). we preoperatively diagnosed the lesion as well-differentiated adenocarcinoma, and planned combined subsegmentectomy for s 2b and s3 a (lateral subsegment of the anterior segment) of the right upper pulmonary lobe. before the operation, the locations of vessels were confirmed by three-dimensional ct angiography. video-assisted thoracoscopic surgery was performed using four ports: two 1 cm ports in the 8th intercostal space in the post-axillary line and in the angulus inferior scapulae line for the operator, a 4 cm port in the 4th intercostal space in the mid-axillary line for the assistant, and a 1 cm port for the camera in the 6th intercostal space in the mid-axillary line. the 4 cm port was also used for removal of the resected specimen. intraoperative bronchoscopy was used for detecting the subsegmental bronchi. she was diagnosed with primary lung cancer (adenocarcinoma in situ, nonmucinous) postoperatively. the tumor was pathologically graded as tisn0m0. no tumor recurrence has been noted in follow-up of twenty two months. conclusions: the combination of preoperative three-dimensional ct angiography, intraoperative bronchoscopy and complete video-assisted thoracoscopic surgery can be used for performing lung combined subsegmentectomy. aims: minimally invasive surgery is increasingly widespread for the diagnosis and treatment of abdominal pathology. laparoscopy is a diagnostic resource for those cases in which mass biopsy is not approachable through image-guided puncture, and is often therapeutic in the same act. it avoids the morbidity and mortality associated with laparotomy, favoring the early treatment of malignant processes. methods: we present a case of a 71 year old male who was incidentally diagnosed with an oval-shaped pelvic mass in the right lateral wall of the pelvis, adjacent to the vascular bundle of the right external iliac at its origin(5 9 3 9 5 centimeter), without sign of infiltration of surrounding structures. no other pathological findings on the abdominal computerized tomography and magnetic resonance imaging were found. due to its localization, it was not accessible to percutaneous biopsy. the first diagnostic impression was a benign tumor of the nerve sheath (schwannoma), without being able to rule out other diagnostic possibilities. to provide a definitive diagnosis the patient was subjected to an elective laparoscopic resection of the tumor. surgical procedure was performed using a 12 millimiter and two 5 millimeter, umbilicus for the optical system and operative on hypogastrium and left iliac fossa respectively. acleavage plan between the tumorand rightiliac vesselswas found. the exeresis of the masswas achieved, and it was extracted using an endo-bagò through the umbilical port site. a drain was put in the surgical bed. results: the patient had a short, uneventful post-operative course, being discharged on postoperative day 1. pathological examination revealed a lymphatic node with metastasis of poorly differentiated carcinoma, with suspected urothelial lineage. cystoscopy was performed with the finding of a 1 centimeter lesion on the right ureteral orifice with calcifications on the surface. biopsies were taken, confirming the bladder origin of the tumor. conclusions: both diagnostic and therapeutic laparoscopy is useful on pelvic masses because of the direct vision into this narrow anatomical space, especially in obese patients, providinga detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor, minimizing the risk of tumor rupture and bleeding. surg endosc (2019) aim: indocyanine green (icg)-enhanced fluorescence has been introduced initially in laparoscopic surgery to provide detailed anatomical information during laparoscopic cholecystectomy and to evaluate vascular supply to garantee correct anastomotic perfussion in order to reduce the risk of anastomotic leak. the uses of icg are increasing, specially in hepatic and oncological surgery in order to identify centinel lymph node and lymphatic mapping.we propose the use of icg imaging during complex laparoscopic colorectal resection in cases presenting ureter obstruction, to prevent iatrogenic ureteral injury. methods: we present a case of a 42 year old female previously diagnosed of pelvic endometriosis with severe pain and symptoms related with episodes of pseudo-occlusion .a colonoscopy was performed finding sigmoid cancer in an area of endometriosis in a narrow colon with difficulties to perform a complete colonoscopy that could be related to the process of pseudo-occlusion. the biopsy was informed as an adenocarcinoma.the ct-scan showed a dilatated left ureter in an area next to the sigmoid colon.we propose a preoperative strategy with a bilateral double j stent insertion, finding a ureter obstruction caused by the endometriosis.icg was injected through the ureteral catheter, guiding us during the surgery to avoid a iatrogenic ureteral injury. results: a laparoscopic left colectomy was performed. the icg allows us to follow the ureter during the surgery, disecting the colon properly from the area attached to the ureter. the prestenotic area of the ureter was marked dilatated up to two centimeters allowing the icg to identify it from the anatomic structures of the areas and guarateeing that there was not spill of icg out of the ureter avoiding a postoperative leak of urine. conclussions: when tumors, or another entities like endometriosis, produce a ureteral occlusion, icg could be injected through a j stent, allowing us to identify and to avoid an injury.icg fluorescence imaging is a safe, cheap, and effective tool to increase visualization during surgery, offering additional information of the anatomy in colorectal surgery. in this video we are going to show three cases of the robotic treatment of splenic artery aneurism and the evolution of the technology that we relied on for the preoperative planning and intraoperative navigation. our preoperative evaluation evolved from a tridimensional virtual reconstruction with augmented reality to patient specific anatomical 3d printed models, initially made of rigid materials and afterwards made of malleable materials, in order to reproduce hollow anatomical structures such as vessels, feasible to simulate the planned surgical plan. the choice of a robotic approach, in selected cases, allowed to restore the continuity of the splenic artery after the exclusion or excision of the aneurism, in order to preserve the spleen. aims: tumor-induced osteomalacia (tio) is a rare paraneoplastic syndrome in which patients presents bone pain, fractures and muscle weakness caused by the fibroblast growth factor 23 (fgf-23), a phosphate and vitamin d-regulating hormone. in tio, fgf-23 is secreted by mesenchymal tumors that are usually benign but small and difficult to locate. when medical treatment is unsuccessful, surgical treatment is indicated and conclusive.this video shows our technique for tio surgical treatment guided by indocyanine green (icg) fluorescent angiography. methods: the patient is an 81-years-old woman with tio confirmed by blood sampling of fgf-23, gallium-68 pet/ct scan and abdominal ct scan which identified a highly vascularized 8 mm nodule in the mesentery along the ileo-colic vascular axis.the patient was scheduled for a diagnostic laparoscopy with tio removal.the patient was placed in supine position. three trocars were introduced in the left quadrants. identified the last ileal loop, following ileo-colic vessels, a small mesenteric bulge was found. the icg fluorescent angiography confirmed the localization of the ipervascularised nodule and helped to define its edges. the nodule was removed through monopolar energy and the hemostasis was optimized through bipolar energy. the specimen was extracted through an endobag using one of the trocar access. results: the postoperative course was uneventful and the patient was discharged on postoperative day 4. histopathological examination showed an extrasurrenalic paraganglioma. conclusion: tio are often difficult to locate for surgical removal. icg fluorescent angiography allows to facilitate tio localization and removal. the minimally invasive technique decreases perioperative morbidity and mortality. laparoscopic removal guided by icg angiography should be considered when tio needs to be removed and is difficult to locate. aim: this video shows our technique to perform laparoscopic resection of a voluminous left paraaortic paraganglioma. methods: the patient is a 16-years-old man with a recent medical history offever, lumbar pain and haematuria.abdomen ct scan, performed during admission at emergency department, revealed a 8 x 7 cm left paraaortic retroperitoneal mass with pseudo-aneurysm. after procedure of angiographic embolization (with spermatic artery sparing), the patient was scheduled for a laparoscopic resection of paraaortic tumor. the patient was placed in the right flank position. three trocars (10 mm) in the abdominal midline and one trocar in left hypocondrium were placed. at initial examination of the abdominal cavity, voluminous left paraaortic mass arising in the contest of left mesocolon was found, dislocating posteriorly kidney vessels. the parietal peritoneum was divided and the paraaortic lesion was dissected on the aortic plane from medial to lateral and from down to up, preserving the inferior mesenteric vessels; the mobilization was carried on to splenic vein. the vessels, supplying the mass and arising directly from aorta, was isolated and taped with vascular clips. on the inferior margin of the lesion a large vessel, probably connected with previously embolized pseudoaneurysm, was dissected with vascular linear stapler. the mobilization was completed through difficult dissection from aortic plane and mesocolic posterior surface. the colonic perfusion was verified with fluorescence angiography. specimen was extracted through an endobag.a drain was left in pelvis. postoperative day 4.histopathological examination showed a morphological and immunoistochemical pattern for benign paraganglioma. conclusion: laparoscopic resection of paraaortic paragangliomas is feasible by skilled surgeon. the minimally invasive technique decreases perioperative morbidity and mortality. careful preoperative planning and surgeon's experience with vascular dissection and visceral mobilization are mandatory for a good outcome. aims: posterior retroperitoneal endoscopic approach has been considered for many years as a very complex and unsafe surgical technique. often attributed to a difficult location and visualization of retroperitoneal structures. in addition, surgeons were forced to work in a small and easily altered space due to discontinuous flow with constant changes of the retroperitoneal vision. lately this approach is emerging thanks to technological advances, mainly better visualization laparoscopic cameras and high definition screens, as well as continuous flow insufflators of co 2 , maintaining stable and smoke-free cavity uninterruptedly. methods: it shows a management of a potentially serious complication and the reproducibility of the technique through the retroperitoneal approach. results: to operate with high pressure of neumoretroperitoneum allows to contain the hemorrhage and to value with relative serenity and security, the best surgical option to repair said injury being laborious due to the reduced workspace. conclusions: the posterior or retroperitoneal approach is feasible, safe and fast. although the possibility of injuring the vena cava in right adrenalectomy remains one of the most serious and feared complications. as shown in the video, posterior retroperitoneal endoscopic approach allows repair of vascular injury correctly and safely. methods: four patients undergoing adrenalectomy, two of them with right adrenal pathology and two left. minimally invasive access, endoscopic approach, is exposed in all of them. results: in the first two surgeries, right gland is shown. initially, transabdominal approach, which requires mobilization and separation of the liver to access the retroperitoneal space and subsequent proceed to adrenal extirpation. later, right retroperitoneal approach is observed, with a meticulous sealing of the adrenal vein prior to complete the dissection of the gland, despite the small cavity created by co2. in the second part, both left adrenal approaches are exposed. transabdominal pathway is necessary to mobilize left colon and spleen to access a narrow space above the upper edge of the pancreas to locate adrenal gland. this is very different in posterior adrenal approach. conclusions: posterior or retroperitoneal approach is feasible and safe, allowing access to adrenal glands, located in retroperitoneal space, without across peritoneal cavity and its disadvantages. colon and small intestine mobilization is not necessary, with a lower rate of intestinal lesions and postoperative ileus. in the same way, liver or spleen mobilization is avoided. aims: when performing a laparoscopic adrenalectomy, especially in the setting of pheochromocytoma, one of the most important steps is to gain control of the adrenal vein early on in the procedure before great manipulation of the adrenal gland. we present the case of a 78 year old female with episodic headaches and tachycardia and severe uncontrolled hypertension, found to have elevated plasma and urine metanephrines with ct scan localizing a 1.2 cm right sided adrenal nodule. the patient was prepared preoperatively with phenoxybenzamine until mildly orthostatic with dry mucous membranes and was taken for laparoscopic right adrenalectomy. methods: after positioning our patient in left lateral decubitus, ports were placed inferior to the costal margin. the right lobe of the liver was mobilized and retracted cephalad and the ivc was exposed. careful and meticulous dissection was carried up the ivc, however no main adrenal vein was encountered. the adrenal gland was then dissected circumferentially and was removed in an endoscopic retrieval bag. there was no difficulty in hemostasis and the patient was deemed to be hemostatic prior to withdrawal of the ports and extubation. results: our patient had no issues with hemodynamic stability and her blood pressure was within normal ranges during and following the case. her hemoglobin was stable postoperatively with 11.1 immediately post op and 9.9 on discharge. her pre-op hemoglobin was 11.7. conclusions: our video demonstrates a right adrenal gland that was congenitally missing a main adrenal vein. it is very possible that small venous branches were taken with dissection however we believe this report to be important to note in the literature for surgeons performing adrenalectomy. surg endosc (2019) aims: adrenal cysts are the most frequently identified adrenal cysts, although they are a rare entity. typically they are presented by abdominal pain or palpable mass, but nowadays, cystic lesions of the adrenal gland are more often discovered incidentally by radiologic studies. adrenal cysts have an extensive differential diagnoses, which makes a difficult definitive diagnosis and a difficulty in later management. the management of an adrenal cyst can be summarized in three fundamental pillars: discard the functional status of the cyst, evaluation of eventual malignancy by images, and avoid possible complications (hemorrhage, infection), especially in large cysts . methods: clinical case: a 45-year-old male patient, with no history, studied for nonspecific pain in the right hypochondrium, without other accompanying symptoms. an abdominal ultrasound was performed, a cystic lesion in hcd without being able to identify the origin was seen. complementary explorations of interest are shown (ct), the biochemical study discards functionality of the lesion, negative serology for hydatidosis. the minimally invasive approach is the gold standard in the surgical treatment of adrenal pathology, so a laparoscopic approach is proposed for this patient. aims: endometriosis is a high incidence disease (approximately 10% of women) with a large impact on women's quality of life and fertility. endometriosis nodules surgical treatment is necessary every time there is evidence of active disease. the aim of this video is to present a minimally invasive technique for the resection of an endometriosis nodule from the abdominal wall. methods: a 41-years-old woman, with past history of endometriosis and a c-section, presents at the office with a palpable nodule at the rectus abdominis left lateral border, close to the umbilical scar. she had complaints of exuberant catamenial pain and magnetic resonance imaging (mri) showed a 33 mm nodule compatible with endometriosis depot. this technique uses 3 trocars (1 9 10 ? 2 9 5 mm) placed at the pfannenstiel scar. stepby-step as follows: (i) dissection of the pre-aponeurotic plane and isolation of the lesion (ii) lesion excision and its removal with sac (iii) closure of the aponeurotic defect braded suture. results: the post-operative period was uneventful and the patient was discharged home at post-operative day one. the aesthetic result was excellent and the patient was asymptomatic one month after the procedure. conclusion: endometriosis of the abdominal wall is related to previous c-section, is a rare event (incidence 0.1-0.4%) and usually located in the subcutaneous fat underlying the scar. the presence of nodules in the depth of the muscle is much uncommon and particularly in this clinical case, the nodule was located 8 cm cephalad from the previous pfannenstiel scar. this technique seems easy and reproducible in the authors' opinio. aims: general surgeons often face gynecological pathological findings, either along with other abdominal pathology, or as primitive cases that need laparoscopic expertise. with this particular presentation, our goal is to demonstrate the essential laparoscopic skills and the basic operative strategy that a general surgeon should be familiar with, in order to manage such cases. the presentation is made on occasion of a woman with multiple uterine fibromatosis of the pelvis, who was treated by our team. methods: we present video fragments of the laparoscopic excisional procedure for multiple uterine fibromyomatosis of the pelvis, highlighting the proper strategy in order to conclude the operation effectively and uneventfully, in a minimally invasive fashion. results: patients with multiple, large or other complex forms of uterine or pelvic fibromas can effectively be treated with a minimally invasive approach, with minimal blood loss, very fast recovery and minimal postoperative pain and complications. 2% of pregnancies require emergency surgery for a non obstetric indication, including acute appendicitis, cholecystitis, adnexal torsion, choledoco-lytiasis, hernias, intestinal obstructions, oncologic pathology or other less frequent indications. laparoscopic approach is the preffered surgical option for the patologies presented above. aims: to present the technical particularities and to analyze the outcomes of the emergency operations in pregnant women operated in hospital. method: a retrospective study including all the pregnant women operated in our hospital between 2015-2018 was performed. the preoperative workup and the surgical indication was discussed by a multidisciplinary medical team. the anesthesic and the obstetrical risk and their management was evaluated and specifically planned for each patient. the intraoperative and post-operative outcomes were recorded. results: 12 patients with gestational age between 16 weeks and 32 weeks who underwent emergency laparoscopic procedures were included in the study. out of the 12 cases we have performed 5 appedectomies, 3 cholecystectomies, 4 adnexal torsions. with a 75 min mean operating time, we had no major intraoperative complications; the technical challenges are presented and discussed. the hospital stay was 1,5 days (1-3 days). no major complications were associated with the laparoscopic approach in these cohort. one pre-term labour in a 31 weeks gestational patient was post-operatively encountered. conclusion: laparoscopic surgery can be the first option for pregnant woman with non obstetrical surgical emergencies; challenges in diagnostic, management and surgical techniques of the multidisciplinary team are expected. the objective of this presentation is to demonstrate step by step the technique to the oncologic surgeon and gynaecologist in training, including some tips and pitfalls. this is a laparoscopic transperitoneal approach in a woman with advanced cervical cancer (figo ib2) that will be treated with exclusive radio-chemotherapy. the purpose of the laparoscopic lumbo-aortic lymph node staging is to define the irradiation field. in this indication false negative in pet ct ranges from 12 to 22% (depending of the existence of pelvic fixation or not). the limits of this lymphadenectomy are: both ureters as the lateral limit of the dissection, iliac bifurcation as the caudal limit and renal veins as the cranial one. since the tumour is cervical and not ovarian, both ovarian veins are not resected. in the pathologic report, 25 lymph nodes were examined free of cancer spread. the patient have had a radio-chemotherapy with restriction of the irradiation field on the pelvis. lymphocele is a frequent complication that only sometimes needs treatment ranging from dietary changing to percutaneous drainage. if conversion to laparotomy for bleeding this technique loose its benefice but this is a rare complication. this technique is feasible and safe but requires advanced laparoscopic skills. objectives: although extremely rare, isolated splenic metastases are being increasingly diagnosed due to the improvement of imaging, survival times, and surveillance of oncologic patients. this video alerts to the growing diagnostic dilemma with primary lesions of the spleen, particularly in patients with history of cancer, and reviews the laparoscopic splenectomy 'step-by-step'. case-report: 58-year-old male patient diagnosed with rectal cancer (g2adenocarcinoma at 4 cm of the anal verge) after a colonoscopy for rectal bleeding. thoracic and abdominal ctscan and pelvicmri, showed a ct3n1 lesion, without distant metastases, except for a 15 mm suspicious splenic lesion. cea-12.2 ng/ml. after neoadjuvant therapy, a complete response was verified at the 8th week post-crt with a stable splenic lesion, and a 'watch-and-wait' program was initiated with no evidence of disease at the 3rd month. pet-ctscan did not show active metabolic features, despite an increase in the splenic lesion. in mdt, elective laparoscopic splenectomy was proposed and afterwards performed uneventfully. with the patient in semi-right lateral tilt, we approached the spleen inferiorly by dividing the splenocolic ligament. then we continued upwards, dividing the gastrosplenic ligament and exposing the splenic hilum, which was then carefully dissected, clipped and divided. finally the splenorenal ligament was divided and the spleen was extracted within an endobag, through a small pfannenstiel incision. pathologic report revealed a splenic lymphangioma. the patient is currently under a 'watch and wait' protocol surveillance with no signs of regrowth or relapse disease after 1 year and 3 months of follow-up. conclusion: one out of five colorectal carcinomas are metastatic at their presentation. isolated metastases to sites other than liver, lung or axial skeleton, are extremely rare, but can be found in the spleen. although the rare splenic secondary involvement is usually associated with breast, lung, melanoma, and gynecologic malignancies, if we consider solitary splenic metastases, colorectal and ovarian carcinomas are important sources. also, imaging including percutaneous biopsy, is frequently insufficient to clarify the nature of splenic lesions. for all these reasons, the decision-making process about this issue can be a true challenge, and will probably end up with laparoscopic splenectomy. therefore, surgeons must be familiarized with a standardized technique. sarcoidosis is a multisystem disease of unknown etiology characterized by the formation of noncaseating granulomas. sarcoidosis should be considered in the differential diagnosis of lymphoid disease. indications for diagnostic splenectomy includes a suspicion of a neoplasic process. the less invasive laparoscopic approach is the gold standard. case report: a 64-year-old female was referred to a general surgery department to complete a study to rule out lymphoid neoplasia. followed by hematology for cytopenias. biopsy of bone marrow and adenopathies were negative for lymphoid process. patient presented ct with multiple solid (8-10 mm) lesions in spleen, in thorax showed no pathological changes. laparoscopic splenectomy was performed. access with optical trocar, in mammary line. 3 triangle 5-mm trocars after pneumo under vision. section with ligasure of gastroesplenic ligament with short vessels and phrenic-splenic ligament. identification and preservation of pancreatic tail. section of splenic vessels at hilar level (branches) with ligasure. lower pole release. release of posterior part with gerota and diaphragm. incision by aid helps in bag without fragmenting. review of hemostasis, extraction of trocars under direct vision. intraoperative findings: spleen with normal external appearance, not megalic. postoperative evolution: satisfactory. first hours without incidents and with analytical control without anemization. tolerance and mobilization starts without incidents. the histopathology report shows granulomas formed by epithelioid histiocytes with the presence of multinucleated giant cells of the foreign body type, in some perisinusoidal granulomas the giant cells with the presence of asteroid bodies in their interior. the material has been revised with the extension of special studies. conclusion epithelioid granulomatosis, non-necrotizing, which suggests sarcoidosis. the procedure lasted 180 min. the hospital discharge was on the next postoperative day and no complication was registered. conclusion: splenectomy can be performed in a classic way, but at present the less invasive laparoscopic approach is the gold standard. indications for splenectomy include splenic tumours of unknown origin, suspicion of a neoplastic process, and splenomegaly. sarcoidosis should be considered in the differential diagnosis for lymphoid disease. postoperative pathological examination confirms the diagnosis. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy aims: we describe an interesting case of a female patient affected by a suspected echinococcus granulosus large cyst of the spleen. methods: a 42 years old woman complained abdominal pain and a sense of gravity in the upper left abdominal quadrant. computed tomography scan(ct-scan) showed a 13 centimetre (cm) cyst of the spleen with thickness of the wall and contrast enhancement uptake referred to an echinococcus granulosus cyst. the sierological blood test assessment, antigens and antybody markes, for echinococcus granulosus infection was negative. a laparoscopic procedure was planned. the patient was positioned on the right flank, four trocars were inserted along the left subcostal region of the abdomen: one 12 millimetre (mm) trocar for camera, one 10 mm for the assistant, and two of 5 mm for instruments. a periombelical minilaparotomy was performed for the specimen extraction. results: post-operative course was uneventful. patient was discharged in third post-operative day. istopathological exam showed a simple epithelial cyst of the spleen. conclusions: laparoscopy is safe and feaseable in case of large cyst of spleen in condition of unclear nature of the cyst. laparoscopy permits to explore the abdominal cavity and to assess the cyst characteristics in a lack overlap between the radiological exam and blood test examination. surg endosc (2019) we describe laparoscopic splenectomy for recurrent splenic cyst after laparoscopic marsupialization and partial resection of splenic cyst. the patient was a 31-year-old woman with abdominal discomfort and with a 24-cm palpable mass in the left upper and inferior quadrant. she undergone 9 years ago in another country a laparoscopic operation for splenic cyst. abdominal computer tomography revealed a cystic lesion of the spleen with concomitant huge splenomegaly. serology and oncological marker were negative. we performed laparoscopic splenectomy for the recurrent splenic cyst. the operation took 180 min. histologic examination of the resected spleen revealed a chronic hematoma. the patient had no abdominal symptoms during 12 months of follow-up. postoperative long term follow-up and examination by ultrasound or computed tomography is required after surgical treatment for splenic cyst to exclude the possibility of recurrence after spleen-preserving surgery. hand-assisted surgery is a recognized technique that combines the advantages of laparoscopic approach with the tactile feedback of the laparotomic one. it proved beneficial especially for the treatment of megaspleens due to lymphoma localization, thanks to safer handling of splenic vessels, major bleeding control and more effective detachment of superior splenic pole from the diaphragmatic dome. here we show an hand-assisted splenectomy for megaspleen reaching the omolateral anterosuperior iliac spine due to lymphoproliferative disease, in which the hand, inserted through a right subcostal minilaparotomy, was very useful during the dissecting manoeuvres, the splenic artery recognition and ligation and the isolation of the superior pole of the spleen from the gastric fundus and diaphragm. in any case of huge spleens, the specimen bagging is very difficult to perform in a pure laparoscopic way, not to mention the inexistence of capable endobag; besides, a minilaparotomy would be necessary for the spleen extraction. hand-assisted approach allow to overcome this not underestimable technical difficulty, reducing operative time with similar aesthetic and functional results to that of laparoscopic approach. aim: the evolution of technology and its application to the minimally invasive surgery of the thyroid gland offers new surgical techniques, like the transaxillary approach. this new procedure is still being implemented in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary endoscopic thyroidectomy and emphasize in the most relevant tips to take into account. also, current indications and limitations of this technique will be addressed. methods: a 49-year-old woman is referred for evaluation of a right thyroid nodule without any associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a 3.5 cm single right nodule with well-defined edges and presence of peripheral vascularization. no other nodules are identified. fine needle aspiracion (fna) of the nodule describes a bethesda iii. after evaluation, a right transaxillary endoscopic thyroidectomy was performed. results: dissection begins in the subcutaneous plane above the pectoralis major muscle until identification of the sternocleidomastoid muscle. dissection continues towards the prethyroid muscles in order to perform a lateral approach of the thyroid gland. section of the upper pole allows better exposure of the recurrent laryngeal nerve (rln) which is being monitored intermittenly. identification and preservation of the parathyroid glands is the next step. surgery is completed with the section of the inferior pole of the thyroid along with the istmus. the postoperative period was uneventful and patient was discharged at 24 h after surgery. final pathology revealed a 3 cm nodule without malignancy. conclusion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients with benign pathology, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). further research is required to make a better assessment of the minimally invasive approaches in thyroid surgery. we present the video of a thoracoscopic esophageal leiomyomaenucleation. it has been widely demonstratedthe advantages of theminimally invasive approach in surgery. esophageal thoracoscopic surgery has been suggested as an alternative to open procedures, presenting less surgical trauma, lower risk of bleeding, less postoperative pain, lower wound infection and lower pulmonary morbidity, showing similar oncologic outcomes. although leiomyomas are the most commonof benign tumors of the esophagus, they are relatively rare, presenting an incidence of 10-40 per 10.000 autopsy series. in our case, the patient was diagnosed of leiomyoma located at the medium third of the esophagus. he referred a history of 6 months of dysphagia for solid and liquids and retrosternal pain. the complementary studies were esophagoscopy, esophagography, ct and endoscopic ultrasonography. the patient was operated by a thoracoscopy approach using 3 ports. it was completed the enucleation of the tumor following the closure of the muscular layer. methylene blue test confirmed no leaks. the patient was discharged on third day postoperative developing no incidences. pathology report: leiomyoma 6 cm size, actin and desmin positive; s-100, cd 34 and cd 117 negative. we want to demonstrate the advantages of a minimally invasive approach in this kind of pathology. aims: this video shows our technique to perform thoracoscopic enucleation of large esophageal leiomyoma. methods: the patient is a 53-years-old woman with a six months history of progressively worsening dysphagia. chest ct scan revealed a 6 cm lesion of middle esophagus with extrinsic compression of mucosa and no increased fdg uptake on fdg-pet scan. barium swallow study showed a lateral deviation of thoracic esophagus due to extrinsic compression. endoscopic ultrasound confirmed the suspicion of esophageal leiomyoma. patient was scheduled for a thoracoscopic enucleation of esophageal tumor. she was placed in prone position and one-lung ventilation was employed. three trocars were placed in intercostals spaces on right hemithorax. azygos vein was identified and transected between vascular clips. esophagus was circumpherentially isolated from mediastinal structures. after myotomy, the lesion was dissected from submucosal-mucosal layer. since air leak test excluded injury of internal layer, muscular layer was closed with a continuous suture. the specimen was extracted through an endobag. a drain was left in place. results: the postoperative course was uneventful and the patient was discharged on postoperative day 7. final pathological examination confirmed esophageal leiomyoma. conclusion: thoracoscopic surgery in prone position allows removal of large esophageal tumor with several advantages. the minimally invasive technique decreases perioperative morbidity and mortality. introduction: spontaneous esophageal perforation is life threatening disease and requires emergent surgical treatment. recently, the efficacy of minimally-invasive surgery such as laparoscopic and thoracoscopic surgery for esophageal perforation has been reported. we report a novel technique of minimallyinvasive abdominal and left thoracic approach (malta) for spontaneous esophageal perforation. case presentation: 64-year-old male, who had been under hemodialysis due to iga nephropathy, complained of chest pain after vomiting several times. since the ct scan showed left hydropneumothorax and pneumomediastinum, and the gastrografin study demonstrated extravasation from left side of esophagus, we diagnosed him with the spontaneous esophageal perforation and planed emergent surgery. the patient was placed in the reverse trendelenburg position, and the legs were split, with the left side of the upper body lifted in order to perform thoracoscopy and laparoscopy simultaneously. first, we explored the thoracic cavity through a 12 mm port in the left 8th intercostal space and added other 3 ports. we identified the rupture site 30 mm in size on the left wall of the lower esophagus and sutured the mucosa and the muscle layer with a running suture respectively. we covered the perforation section with pericardium fat and irrigated the cavity with physiological saline. then transferred to the abdominal cavity, no contamination was found in the abdominal cavity. a feeding tube was inserted into stomach through the round ligament of the liver and the operation was completed. the total operative time was 173 min and the amount of intraoperative bleeding was 1300 ml including pleural effusion. postoperatively, the patient experienced left empyema pleurae but no other severe complications and was discharged on postoperative day 25. conclusion: we experienced a rare case of spontaneous esophageal perforation of a patient under hemodialysis. malta is an effective procedure for emergent esophageal operation because of great visual field of the chest and abdominal cavity without expanding contamination. introduction: digestive caustic injury is associated with high morbidity and mortality with stenosis in the long term. surgical treatment involves resection of the esophagus and reconstruction with the stomach, colon or jejunum. coloplasty provides several advantages but its vascularization is complex and involves 3 anastomosis. classically, vascular assessment was achieved by palpation through laparotomy and color evaluation. indocyanine green (icg) allows a minimally invasive intraoperative angiography in real time. methods: a 43-year-old female with medical history of caustic ingestion and subsequent esophagogastric stenosis, carrier of feeding jejunostomy.1. thoracoscopy (prone position): dissection of the esophagus from the hiatus to the upper thoracic inlet.2. laparoscopy: patient in the supine position, placement of five trocars. total non-oncological gastrectomy, post-pyloric section of the duodenum and omentectomy were completed. mobilization of the righ, transverse and descending colon. measurement of the transverse colon with a tape (distance from the neck and the esophageal hiatus). individualization of the righ, middle (with its branches) and left colic arteries and placement of clamps at the right colic, right branch of the middle colic and left colic arteries. 3 cc of icg were injected allowing for an assessment of the colon vascularization. section of the right branch of the middle colic artery. proximal section of the ascending and distal colon near the splenic angle, preserving the marginal arch. silk point to join the staple line of the descending colon and the pylorys. side-to-side mechanical antiperistaltic anastomosis between the distal endo of the coloplasty and the jejunum. finally an anastomosis between the ascending and descending side-to-side mechanical anastomosis using an assistance incision in the left flank was performed.3. cervical dissection: extraction of the surgical especimen under laparoscopic control. vascular assessment with icg is performed before and after the side-to-side anastomosis is performed. results: there were no intraoperative complications. the patient was discharged on postoperative day 11. discussion: we describe the first case of total minimally invasive colonic interposition with icg assessment of the vascularization. this technique, although technically demanding, avoids the drawbacks of the open surgery and allows for a precise assessment of the vascularization of the graft. surg endosc (2019) introduction: large pedunculated fibrovascular polyps are uncommon, mostly benign, intraluminal massess, usually located in the upper esophageal tract. most frequent reported clinical manifestation is dysphagia, followed by regurgitation, chest pain and intestinal bleeding. ct scan, and mri are the key in the diagnostic work-up revealing a sausage-shaped intraluminal mass. endoscopy with ultrasonography and biopsy add important information for the diagnosis and pedicle location. surgical excision is deemed due to potentially life-threating complication related to airway obstruction. the most frequent polyp resection is performed through cervical esophagotomy or by direct esophagectomy. however, this approach is related to a high morbidity and mortality rate. in the last years, few excisions have been reported by a endoscopical approach with a lower post operative complication. material and methods: this video shows the surgical steps of a trans-oral endoscopic surgical resection of a giant (23 cm) pedunculated polyp in a 43 year old man. the procedure was performed under general anesthesia. a flexible endoscope probe was used and the distal end of the polyp was extracted through the oral cavity with a loop. the endo-gia stapler was used to cut the base of polyp and finally removed. the anatomo-pathological study confirmed the diagnostic of a fibrovascular polyp with no evidence of malignancy. results and conclusions: the patient had an uneventful recovery with no recurrency at 3 years of follow up. this minimally invasive approach is a safe and feasible procedure to treat large esophageal fibrovascular polyps avoiding the complications related to more aggresive procedure. introduction: leiomyomas are the most common mesenchymal tumors affecting the esophagus and they usually grow in the mid to distal third of it. they tend to be asymptomatic, but sometimes they can grow to enormous size and produce dysphagia. case report: 61-year-old male asymptomatic patient was referred to our hospital due to an incidental finding. ct scan revealed a 41 x 35 mm rounded submucosal tumor on the dorsal side of the lower third of the esophagus. upper gastrointestinal endoscopy revealed a cystic lesion in the lower esophagus 37 cm from the incisor teeth, with normal overlying mucosa. an endoscopic-ultrasound-guided fine-needle-aspiration of the mass was performed, which was reported as a likely leiomyoma.conservative treatment was performed, no growth was detected during eleven years of follow-up. but it became symptomatic, the patient complained of progressive dysphagia caused by compression so surgical resection was decided.laparoscopic enucleation of esophageal leiomyoma was performed. the tumor was reached by transhiatal dissection. a careful dissection of the mass was performed, preserving the vagal branches. an intraoperative endoscopy was performed to verify the integrity of esophageal mucosa and that the tumor was completely resected. the muscular layer was sutured after enucleation using absorbable suture material and the hiatus was closed with non-absorbable suture material. a dor fundoplication was also performed. a swallow test with a water-soluble contrast was obtained on postoperative day one. no pathological findings were found so the patient was asked to drink.histopathological exam revealed a tumor measuring 70 mm 9 33 mm 9 17 mm consistent with leiomyoma.the procedure lasted 160 min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: surgical excision is the mainstay of treatment and is recommended for symptomatic leiomyomas and those greater than 5 cm. this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive esophageal surgery. introduction: total esophagectomy by means of minimally invasive surgery has proven to be a valid and effective alternative for performing this procedure. however, this procedure is not implemented in most centers. objective: demonstrate the technique of a total esophagectomy by endoscopic surgery for a benign esophageal stenosis. material and methods: clinical case: a 75-year-old female patient diagnosed with double esophageal peptic stenosis, treated on several occasions with endoscopic dilation by digestive, showing in the last endoscopy: severe esophagitis with stenosis impassable to 22 cms. additional tests of interest are exposed. resolved: intervention: right thoracoscopy in prone position, dissection and complete mobilization of the thoracic esophagus, section of the azygos vein, pleural drainage. laparoscopic time, 5 trocars, gastrolysis respecting the right gastroepiploic vessels, broad kocher until the cava is identified, vascular section of the vessels left gastric, full mobilization of the stomach, subxiphoid minilaparotomy, beginning of the cervical time with dissection of the cervical esophagus, section and fixation of this to a tube, externalization of the piece by abdominal route, creation of the gastric tubular with successive loads of gia, ascending posterior mediastinal plasty with manual esophago-tubular anastomosis, with placement of drainages and feeding jejunostomy. right operative with radiological control with gastrografin on the 6th day, discharge from hospital on the 11th day. asymptomatic one year after surgery, with radiological control without alterations. conclusions: the approach of esophageal peptic stenosis with minimally invasive surgery is safe and effective, adding the advantages inherent to this type of technique. (figs. 1, 2) , showing a cystic lesion in the gastric submucosa with a well defined, medial and superior to the lesser curvature of the stomach with exophytic growth. it causes extrinsic compression of the cardia in the gastric body. within the differential diagnosis are gastric duplication cysts or gastrointestinal stromal tumor. a biopsy was taken, discarding the presence of neoplastic cells. finally, a study of digestive transit showed extrinsic compression at the cardial level, which causes difficulty in passing contrast. a laparoscopic approach was performed beginning with the dissection of the abdominal esophagus. the presence of a cystic lesion on the anterior face of the abdominal esophagus was identified (figs. 3, 4) . we proceeded to the complete resection of cyst. the surgery was completed with 180°f undoplication anterior dor. the patient went home on the 3rd day without incident. results: duplication cysts are congenital malformations of the gastrointestinal tract contiguous with the esophagus, which can communicate with the esophageal lumen. most are diagnosed in childhood, but when it is diagnosed in adults, they used to be symptomatics. it is more frequent in men. although the pathogenic mechanism is unknown, it is caused by an anomaly during embryonic development. they are located in the thoracic esophagus, at the level of the lower and posterior mediastinum and, less frequently, in the abdominal esophagus, as in our case. they can give digestive symptoms(epigastralgia, vomiting) or respiratory symptoms. the diagnosis is made with eda, ct, and ecoendoscopy of choice, although it may be incidental. the treatment of choice in symptomatic patients is complete resection or cystic enucleation. in asymptomatic surgical is not defined, because it can cause complications, and, malignization due to degeneration is very infrequent. conclusion: the most of duplication cysts are diagnosed in childhood, although it's more frequent in adults to be symptomatic. surgical treatment can cure this disease. however, the choice between these becomes difficult in young patients, where the low incidence does not allow get series of long patients and decisions must be based on results achieved in adults. objetivos: to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology, pointing out the importance of having standardized the procedure to achieve better results. material and methods: case report: a 19-year-old man with progressive dysphagia until almost complete afagia, with clinical, endoscopic, radiological and manometric diagnosis,compatible with typical primary achalasia. chagas negative serology,we show the complementary studies of interest.dilatation is not performed, preoperative symptomatic treatment with calcium channel inhibitors. intervention: laparoscopic approach, 5 trocars, aberrant left hepatic artery with signs of severe esophagitis,opening of the gastroesplenic-hepatic ligament, no retroesophageal window, dissection of the hiatus and inferior mediastinal, preservation and mobilization of the left hepatic artery and the anterior vagus,meticulous disection of the cardia,standardized myotomy: first proximal 8 cms. with adequate simultaneous traction of both edges of the myotomy, then distal myotomy including 2-3 cm, including selectively the distal oblique fibers of les, tutorization with fouché and methylene blue to confirm good step and absence of leakage, dor-type funduplication, 4 pts on each side, fixed to both pillars, hiatalmediastinal drainage. egd on the 1st day of normal po, dischargeat 3rd day, asymptomatic and with normal radiological control at 1 year of age. conclusions: laparoscopic mh should be the first therapeutic option, in patients with primary achalasia, even in young patients. the length of myotomy, especially distal to ueg is one of the most important aspects of surgery, most authors (pellegrini) recommend that the myotomy extend 1-2 cm in the stomach, even up to 3 cm below the ueg to achieve an effective disruption of the eei.the standardization of the procedure is fundamental to increase safety and effectiveness in these more complex cases. aims: the surgical treatment of giant hiatal hernias is a complex and demanding procedure, not only in terms of performing the operation in a minimally invasive abdominal fashion by avoiding thoracic approaches, but also concerning the management of large hiatal defects which contribute to high recurrence rates. our aim is to present our surgical technique for the reconstruction of such hiatal hernias, exploiting the benefits of the robotic approach and also to highlight the technical aspects of non-absorbable mesh placement in order to bridge effectively the hiatal defects. methods: we present video fragments from a procedures selected from a series of cases of robotic reconstruction of giant hiatal hernias performed by our team, in which a non-absorbable meshes were utilized to restore the hiatal gap. we emphasize on the clear benefits of robotic surgery in these cases and on the strategy of how to avoid high recurrence rates. results: all of our patients, who underwent reconstruction of giant hiatal hernias with this particular technique, experienced very good early post-operative results, very short hospital stay and no recurrence in a 12-month follow-up. conclusions: the robotic approach for the treatment of large hiatal hernias offers great advantages to both surgeons and patients, by eliminating the restrictions of conventional laparoscopic surgery, minimizing intra-operative incidents and post-operative complications. large hiatal defects are very effectively closed with the use of advanced suturing techniques and non-absorbable meshes in a tension-free bridging fashion. aims: mckeown esophagectomy is commonly used for invasive esophageal carcinoma. as the morbidity and mortality rates for esophagectomy are persistently high, minimally invasive esophagectomy in prone position is expected to reduce respiratory postoperative complications. there is still limited experience for the use of minimally invasive approaches in patients undergoing surgery after neoadjuvant chemoradiation and many concerns about the feasibility, safety, and oncological outcomes of these procedures are still present. methods: we present the case of a 55-year-old female with a middle third esophageal squamous cell carcinoma, who received neoadjuvant chemoradiation. she underwent laparoscopic and thoracoscopic (prone position) mckeown esophagectomy with hand-sewn esophagogastric anastomosis through a left lateral cervical incision. results: the operation was completed successfully, with no conversion to open surgery. the operative time was 6 h with minimal blood loss and the patient was fed on day 5 and discharged on day 7 post-op. r0 resection was achieved and the number of total harvested lymph nodes was 44 (3 positive nodes, n2). conclusions: minimally invasive mckeown esophagectomy in patients with esophageal cancer and prior chemoradiation is feasible and safe procedure with acceptable oncological outcomes. results: preliminary results demonstrated that minimally invasive ivor-lewis esophagectomy procedure, provided of a better postoperative pain control and less respiratory complications. in order to standarise our procedure, the video shows how three different types of esophagogastric anastomosis are performed, depending on the patient characteristics, anatomical factors and safety and comfort for the surgeon: manual termino-terminal, mechanical termino-terminal and mechanical latero-lateral. conclusions: in our way to standardization, we are still looking for the best type of anastomosis, even though, we find out that, manually performed anastomosis are easier to performed, when the section in esophagus is lower, involving medium and inferior third. in the other hand, mechanical termino-terminal anastomosis seemed to be an ideal option for upper sections. more studies are needed in order to standardized one anastomosis, for all cases. because esophagectomy with radical lymphadenectomy is highly invasive, thoracoscopic esophagectomy (te) is attracting attention as a less invasive procedure. we first performed te with the left decubitus position in 1996. in 2009 we developed a hybrid of the prone and left lateral decubitus positions for te, and a total of 470 patients underwent te with a hybrid position . we introduced te with a hybrid position for the following three reasons: (1) mobilization and lymphadenectomy around the middle and lower esophagus are easier in the prone position. thanks to artificial pneumothorax and the gravity, the middle and lower mediastinum are opened, and which give us good surgical field. (2) lymphadenectomy along the left recurrent laryngeal nerve (rln) is more reliable and precise when performed in the left lateral decubitus position. we can dissect lymph node around the rln higher position in the upper mediastinum. (3) unexpected events requiring conversion to thoracotomy (e.g., massive bleeding, injury of other organs, dense intrathoracic adhesion, resection of adjacent organs) are easier to deal with in the left lateral decubitus position. the patient is fixed on the operating table with the semi-prone position and we can easily change patient positions from the left lateral decubitus position to the prone position and vice versa using rotation system of the operation table. the upper mediastinal procedure including lymphadenectomy along the right and left rln is performed with the patient in the left lateral decubitus position, while the middle and lower mediastinal procedures are performed with the patient in the prone position with artificial pneumothorax (7 mmhg). theabdominal procedures wereperformed by hand-assisted laparoscopic surgery (hals) and gastric tube reconstruction through aposterior mediastinal route was performed as a standard surgical procedure in our institution. the magnifying effect of thoracoscope enables us to perform more precise surgery and preserve nerve and vessels, and a hybrid position is thought to be feasible and effective methods. ivor lewis esophago-gastrectomy is a standard procedure for the treatment of distal esophageal cancer. among the years, the surgical community standardized the mininvasive abdominal phase. the thoracic phase is much more complex because usually all surgeons get in trouble in the phase of esophago-gastric anastomosis. in fact, is still very difficult and tricky to perform a mechanical circular anastomosis due to problems with the correct handling of the circular stapler through the minitoracotomy and is also difficult to place the anvyl in the proximal esophagus. the linear anastomosis (side-to-side) is a little bit easier but not so effective as the circular anastomosis in terms of leak rate. we think that robotic approach with its endowrist can allow us to overcome these limits and that a tailored double layer hand sewn esophago-gastric anastomosis could be the right choice. we treated 4 patients with this approach and they were all uneventful in the post operative period except for a case of chylothorax we treated successfully with lipiodol injection in inguinal lymphnodes. we need more cases to analyze the technique in terms of leak rate and major complications but we think this is a promising and cost-effective procedure for robotic approach. aim: anastomotic leakage is one of the most dreaded complication after esophagectomy. indocyanine-green near-infrared angiography (nir-icga) intraoperative use has been recently introduced for visceral perfusion evaluation. in this video we present our technique for gastric conduit fashioning according to the nir-icga blood supply evaluation in a total minimallyinvasive ivor-lewis esophagectomy. methods: a 48 years-old man affected by a siewert 1 adenocarcinoma (ct3, n2, m0) underwent a preoperative neoadjuvant treatment according to cross protocol. at restaging ct-scan no more pathologic nodes were evident (ct3, n0, m0). the patient was submitted to a total minimally-invasive ivor-lewis esophagectomy. surgical procedure: after pneumoperitoneum induction and 4 trocars insertion, the lesser omentum was opened and a lymphadenectomy at stations 12a, 8, 7, 9 and 11 performed. the esophagus was dissected at diaphragmatic hiatus with lymphadenectomy at station 1, 2 and 111. the larger omentum was opened along the right gastroepiploic arcade, that was preserved, the short gastric vessels divided and gastric fundus mobilized. by evaluating the presence of an intense fluorescence at nir-icga, a tailored partial tubulization of the stomach was performed with multiple linear stapler firing. a right thoracoscopy was performed through 4 trocars. the azygos vein ligated and divided. the mediastinal pleura was opened and the esophagus was dissected entirely with an en-bloc excision of nodes at stations 110, 112 and 108. nodes at stations 105, 106, 107 and 109 were removed separately. the esophagus was sectioned above the azygos vein level and a purse-string fashioned. the cardia and the gastric tube were pulled up and a minithoracotomy performed. a new nir-icga was repeated to verify the good blood supply and tailor the site of anastomosis on a well perfused area. the stomach was opened and a circular stapler inserted. after the end-to-side esophago-gastric anastomosis fashioning, the tubulization was completed by 2 linear stapler firing and the specimen removed. results: the post-operative course was uneventful and the pathologic examination revealed a cardial adenocarcinoma (ypt2,n0, r0). conclusions: nir-icga is an interesting and easy-to use tool for surgeons. nevertheless in literature is still not clear which is the best parameter to measure the blood supply. large studied are needed. aim: uses and application of indocyanine green (icg) fluorescence in the field of surgery are growing exponentially. the safety and feasibility of its usage has been proven in several areas and various pathologies of surgery and surgeons are starting to incorporate it into their common practice. however, there are still several aspects to define regarding this technology. we present different uses of icg in the specific area of esophageal cancer. methods: we used icg fluorescence at different moments of a two-field minimally invasive esophagectomy. first of all, peritumoral injection of icg may offer a lymphatic mapping, both in the abdominal phase of the surgery and the thoracic one, improving lymph node dissection by allowing a more targeted and less morbid approach that includes all relevant nodal stations. at the moment of the gastric section, intravenous injection provides assessment of gastric conduit perfusion, therefore optimizing the construction of the graft to avoid the inclusion of poorly perfused areas that may increase the risk of leak of the anastomosis. besides that, the esophagogastric anastomosis can be tested in the thoracic phase of the operation in order to check an adequate perfusion and prevent further complications. results: we consider that icg fluorescence is a promising technology that could be easily introduced in the surgical routine of the esophageal surgeon as an instrument to assess the anastomosis perfusion. icg is also feasible in detecting lymph node drainage from the esophagus, although its technique of application needs to be defined. conclusions: icg fluorescence has opened a new world of possibilities in all the different surgical specialties. its use in the esophagectomy is safe, simple and feasible. in a near future, its application to esophageal cancer surgery could improve survival by predicting and preventing anastomotic leak and guiding in a tailored lymphadenectomy. further research is needed to demonstrate these promising applications. introduction: the oesophagectomy is currently still mandatory in the curative treatment of the malignant oesphagic pathology. this procedure is defined by important morbidity and mortality. the minimally invasive approach aims to reduce the complications without repercussion on the oncological outcomes, however it's not exempt from them being a demanding surgical technique like it is. aim: we present the video of three complications after a three-stage oesophagectomy (mckeown-like) with the thoracic stage via thoracoscopy and the minimally invasive surgical solution for both of them. methods: all three cases represent a three-stage oesophagectomy for malignant esophageal pathology. the first one was a 50-year-old male who suffered an intraoperative left main bronchus injury. the second case was a 62-year-old male with no intraoperative complications whatsoever. nonetheless, on the second postoperative day, milky drainage started to appear through the thoracic tube. the third and final case represents an intraoperative hemorrhage, which is the most common complication of this kind of surgery. results: the first case was diagnosed and treated intraoperatively with the use of an adhesive matrix. during the postoperative period the patient showed no further complications. the second case was a chylothorax, diagnosed on the second postoperative day. it was treated initially with conservative measures. due to bad evolution, he underwent surgery on the tenth postoperative day. we can see how we ligated the stump of the thoracic duct in the original surgery and then how we repaired the unexpected leak. after the second surgery, the patient was discharged on the sixth day. the last patient was also diagnosed and treated intraoperatively successfully, with no repercussion whatsoever in the postoperative time. conclusions: the minimally invasive surgery has many advantages in the upper gastrointestinal field. it is a demanding technique, so it is important to be able to treat the complications that may arise with this approach. surg endosc (2019) aims: the use of icg fluorescence is incrising in surgery, mainly as a test of vascular supply in colonic anastomoses. during the last years, other potential uses have been described, such as the identification of the sentinel lymph node and lymphatic mapping in oncological surgery. these advances could allow a better staging in order to decide the most appropriate treatment to each patient. gastric cancer is one of the fields where this could play a key role in the near future. we present a case of a patient who underwent a laparoscopic total gastrectomy with icg-guided d2 lymphadenectomy, where a personalized lymphatic mapping was performed. methods: a 37-year-old male patient underwent gastroscopy for gastric discomfort, and a gastric carcinoma was detected at the greater curvature of gastric body. endoscopic biopsy was informed as diffuse type gastric adenocarcinoma. the preoperative staging was completed with echoendoscopy and ct-scan (t1bn0m0). we decided to perform a laparoscopic total gastrectomy with icg-guided lymphadenectomy. the preoperative day, a gastroscopy was performed to inject 0.75 mg of icg in four submucosal areas around the tumor. results: intraoperatively, the lymphatic mapping marked by icg was checked, allowing the identification of the territory of drainage of the tumor to lymph nodes at the lesser curvature, the greater curvature and the splenic artery. a d2 lymphadenectomy and a total laparoscopic gastrectomy with roux-en-y reconstruction was performed. during the lymphadenectomy, we were able to observe marked lymph nodes in territory 11, and also observed that the paraaortic lymph node behind the celiac trunk did not become green and the lymphadenectomy at this area was not continued. the patient presented no postoperative complications, and was discharged on the seventh postoperative day. the histological results showed a diffuse type gastric adenocarcinoma pt2n1 and 26 isolated lymph nodes, being one of them possitive (corresponding to the adenopathy marked at the greater curvature). conclusions: lymphatic icg-mapping in gastric cancer is a potential revolutionary advance that could ensure a correct lymphadenectomy, avoiding lymph node understaging. it is necessary to continue carrying out studies that will allow developing protocols to define appropriate lymphadenectomy based on icg-mapping. introduction: petersen's hernia is one of severe postoperative complication after gastrectomy, which may result in massive resection of small intestine. it is considered an essential proscedure to close the petersen's defect for all cases after such reconstruction after gastrectomy as roux-en y method. we report a case of petersen's hernia after radical gastrectomy, which was repaired laparoscopically. patient: the patient was 59-year-old male, who underwent laparoscopic distal gastrectomy for gastric cancer (d2 lymph node dissection followed by roux-en-y reconstruction) two years ago. the closure of petersen's defect was not performed in the initial operation. he was aware of abdominal pain and visited emergency unit in our hospital. abdominal ct scan showed internal hernia of petersen's hernia. surgical procedure: in laparoscopic examination, dilation of small intestinal and mastoid ascites was observed. massive small intestine including y-limb entered into petersen's defect from left to right side. we carefully pulled through the small intestine and confirmed absence of ischemic change in the whole small intestine. then the petersen's defect was closed by continuous suturing with 3-0 non-absorbable barbed suture. results: the operation time was 95 min and the estimated blood loss was 10 ml. oral intake was started from the next day of the operation. there was no postoperative complication. the patient was discharged on the 10th postoperative day. conclusion: we could safely perform laparoscopic repair for petersen's hernia. regarding technical points in the procedure, it is important to judge the direction of the small intestine into the petersen's defect, to manage the dilated small intestine gently, and to close the petersen's defect by laparoscopic suturing. introduction: in this case we present a 52-year old male with a history of morbid obesity, sleep apnea and psychiatric affliction including alcohol and nicotine abuse. in 2009 he underwent a laparoscopic roux-en-y gastric bypass. the results were satisfactory, with no complications post-surgery, and a steady weight loss over time (pre: 162 kg, post: 125 kg). in november 2017, he presented with complaints of dysphagia and weight loss (12 kg in 3 months). laryngoscopic examination by the otorhinolaryngologist was negative. he was referred to gastro-enterology for gastroscopy. biopsies showed a mildly differentiated adenocarcinoma of the gastro-esophageal junction with submucosal invasion. objective: after negative staging assessment, multiple treatment options were considered. the route of choice ended up being a laparoscopic radical gastrectomy with esophago-jejunostomy, with the objective to achieve optimal oncological results. methods: the procedure is demonstrated in this video. the gastric pouch as well as the remnant stomach, greater and lesser omentum were resected laparoscopically. due to the invasion of the carcinoma into the distal esophagus, a segment of the esophagus was resected as well. following anatomopathological examination on frozen section, the resection margins were reported malignancy free. results: postoperatively, there were no complications. ct scan with contrast showed no signs of leakage. anatomopathological examination confirmed the tumor to be a mildly invasive and poorly differentiated adenocarcinoma with local signet-ring cell differentiation (pt1bn0). there was no need for adjuvant therapy. oral intake was sound. conclusion: adenocarcinomas of the gastric pouch are rarely seen following gastric bypass. this patient presented with complaints of dysphagia, and an adenocarcinoma was diagnosed. consequently, the patient had a total gastrectomy at our hospital. the surgery was performed laparoscopically, and was executed with success. to conclude, it is feasible to treat adenocarcinomas after gastric bypass laparoscopically via total gastrectomy and omentectomy. 80 year old, female patient presented with upper abdominal discomfort and microcitic anemia. an ulcerative lesion was found on gastroscopy examination in body of the stomach (near the grate curvature). biopsy was done and pathology result showed poorly differentiated adenocarcinoma. chest computed tomography (ct) was without any significant findings. abdominal ct showed the lesion in stomach without enlargement of regional lymph nodes. her blood laboratory examinations were within normal limits, including serum cea. patient underwent laparoscopic total gastrectomy with modified d2 lymphadenectomy and roux-en-y esophagojejunostomy. total operating time (ort) was 218 min. three days after operation, patient has developed none st elevated mi and respiratory failure. she was intubated. on day 6 after operation she was extubated, on day 9 patient started regular diet and was discharged home on day 13. final pathology result confirmed poorly differentiated adenocarcinoma of the stomach. this video shows our favourite technique for laparoscopic d2 subtotal gastrectomy. we usually perform the procedure with 4 or 5 trocars; after the coloepiploic detachment we perform the gastric transection first! this manoeuvre provides a perfect view for the lymphadenectomy. at the end of our dissection we transect the duodenum with seamguard reinforcement. before going on with the reconstructive phase, we prepare the roux en 'y' with double loop technique, usually without dividing the mesentery. then we remove the specimen through a periumbilical 3-4 cm minilaparotomy; we think it's important anyway to check margins and distance from the tumor before going on with the reconstructive phase. from the same minilaparotomy we retrieve the prepared limb for roux en y and we perform a side to side mechanical linear anastomosis outside.then we proceed with performing the anastomosis between the gastric pouch and the alimentary limb by laparoscopy. we like very much this technique for the increased exposition of tissues during lymphadenectomy. laparoscopic roux en 'y' d2 surg endosc (2019) a body-tc was performed in which axillary, mediastinal adenopathies and images suggestive of hepatic metastases were identified. the biopsy confirms a gastrointestinal stromal tumor. the case discussed in a multidisciplinary committee and the pet-ct study was completed, subcardial gist t4n1m0 was diagnosed. neoadyuvance was decided with imatinib for one month and surgery was performed using a laparoscopic approach. the approach was performed with 5 trocars (11 mm supraumbilical, two 12 mm subcostal left and right, 5 mm subxifoid and 5 mm left flank). gastrectomy was performed with d1 lymphadenectomy following the oncological principles of subcardial tumors. the piece was removed in a bag by extending the 11 mm port to mini-laparotomy. esophagogastric anastomosis was performed by hand assisted circular mechanical suture. methylene blue test was carried out. no nasogastric tube left, but drainage tutoring the esophagogastric anastomosis was left. results: the postoperative evolution was favorable. oral tolerance without incidents at fourth postoperative day. the patient was discharged without incidences on the seventh postoperative day. the pathological study of the piece was reported as subcardial gastrointestinal stromal tumor 3 cm with respected surgical margins and 11 lymph nodes free of malignancy, postoperative diagnosis of t2n0m0. one month after surgery, the patient has adequate oral tolerance. she does not report gastroesophageal reflux and at 6 months remains asymptomatic and with good evolution. conclusions: laparoscopic proximal gastrectomy is a technique that is not currently used but can be performed through a laparoscopic approach. it is a safe technique with good clinical and oncological results, especially in the early gastric cancer and gastrointestinal stromal tumors. however, long-term studies are necessary. laparoscopic gastrectomy is a perfectly safe option nowadays for the treatment of gastric cancer. every year the percentage of the laparoscopic approach is rising not only in the east but also in the west. we present a case of a 44 year old female patient with a gastric tumor of the antrum-g3 adenocarcinoma with a ct2n0m0 staging. we perform a subtotal laparoscopic gastrectomy with a d2 lymphadenectomy and roux-en-y anastomosis. the patient begin clear liquids on the first post operative day and was discharged on the 5th. the final anatomopathological result of the specimen was a adenocarcinoma (g3)-pt1n0. there were 37 nodes resected all negative. the case was discussed in multidisciplinary team and was decided for clinical follow up with no further treatments. the patient was evaluated one month after surgery with no complaints and will continue the follow up. upper gi surgery, university of verona, verona, italy laparoscopic endoscopic cooperative surgery is an option in medium size submucosal cancers invading the muscular layer, mainly in border area were wedge resections are nor feasible.in this video we report a case of prepiloric gist treated with news technique (nonexposed endoscopic wall-inversion surgery).we think that this technique is feasible and safe and should be considered a valid option with a view to preserving the organ. aim: laparoscopic wedge resection or partial resection is a safe and feasible stomach preserving approach to gastric submucosal tumors (smt) such as gastrointestinal tumors (gist), and it has been widely performed recently. however, it should not be applied to the tumors at cardia in order to avoid stenosis or disruption of anti-reflux mechanism. we have introduced percutaneous endoscopic intragastric surgery (peigs) for smt at cardia since 2013 to preserve function of cardia. we will report the tips, techniques, and clinical result of our peigs. methods: from september 2013 to august 2018, seven patients with smt at cardia underwent peigs in our hospital. we insert the 12 mm port at umbilicus and investigate the abdominal cavity at first. then the incision is extended to 2.5 cm and lap-protector tm is equipped with the site to perform mini-laparotomy. using peroralendoscopy, a stomach was insufflatedand incision is made at an anterior wall of gastric body under direct vision. additional lap-protector tm is placed into the stomach so that the stomach is fixed on the abdominal wall. it enables us to keep direct access to gastric lumen and stable operative field. ez access tm is attatched on lap-protector tm , and intragastric operation is started. subsequently, two trocars are inserted using funada's gastropexy instrument. tumor is dissected by using energy devices, avoiding injury of capsule of the tumor. the defect of the gastric wall is closed by intragastric suturing. we should take particular care not to damage egj during the suturing, inserting peroral endoscopy in and out. results: the mean operation time was 145(117-149) min and the amount of intraoperative bleeding was 5.0(3.0-7.5) ml. the maximum diameter of tumors was 30(15-30) mm. one case was low risk gist and otherwise were leiomyoma. the postoperative course was uneventful in all cases, without leakage or stenosis. total hospital stay was 9(8.5-9) days. no patient had symptoms of esophagitis. conclusions: peigs for smt at gastric cardia is a feasible and safe approach, preserving function of cardia. our procedure achieves great stability and excellent visualization during the operation, which may have led to the fine surgical results. laparoscopic lymphadenectomyin gastric cancer is considered a feasible and safe procedure. data on the compliance of lymphadenectomy in the various lymph node stations is not yet well understood; moreover it is not clear if there are particular conditions relate to the patients impairing the oncological results. this video reports the use of the icg for the lymph node dissection of station number 6 in a case of obese patient and a case of a cirrhotic patient. fist patient, m.a., was a 67 year old man with distal cancer ct2n0 and a 32 bmi. second patient, t.d., was a 56 year old man with distal cancer ct2n0 and a alcoholic cirrhosis child b7. in both cases, intraoperative endoscopy was performed 20 to 30 min before the onset of lymph node dissection. 0.1 mg of icg was injected into the submucosal layer in 4 quadrants of the primary tumor. a laparoscopic subtotal gastrectomy was conduced with d2 lymphadenectomy. lymph note navigation were analyzed by novadaqò detector. using navigation system we removed the n6 basin. in both cases dissection were effective and pancreatic surface were easily detectable. number of lymph nodes retrieved was 8 in the case of obese patient and 3 in the case of cirrhotic patient. pathological tnm were pt3n0 (0/50 n ?) in the first case and pt3n1 (2/40 n ?) in the second. no n ? metastases were detected in n6 station for both cases. no pancreatic fistula was recorded. icg lymph node navigation system should be considered a valid support for the surgeon for completion of a correct lymphadenectomy in surgical challenging cases. aims: morgagni hernia is the rarest of congenital diaphragmatic hernias (2-3%). its presentation is rare in adults and its finding is usually incidental. it was first described by giovanni b. morgagni in 1769. it is located in the anterior region of the diaphragm. it is caused by a congenital defect in the fusion of the transverse septum of the diaphragm and the costal arches. the need for surgery depends on the presentation, it is recommended early repair before the development of complications. classically, the surgical approach was thoracotomy or laparotomy. currently, the tendency is to use a minimally invasive approach, which has shown good results, lower morbidity and faster recovery. the need to repair the defect with a mesh is controversial, recommended when it is not possible to close the defect without tension. the objective of this video is to demonstrate the safety and efficacy of the laparoscopic approach for the repair of this type of hernia, as well as the different types of mesh that can be used. aims: the treatment of the non-metastatic gastro intestinal stromal tumour (gist) is the surgical resection [1] . the duodenal gastro-intestinal stromal tumour (gist) is a relatively rare clinical entity. from all the resected gist, only 5% are duodenal [2] . the clinical presentation could vary from the most common acute gastro intestinal (gi) bleeding, chronic anaemia, but also acute abdomen caused by tumour rupture and intestinal obstruction. methods: a 69 years old patient present at the emergency department of the chi poissy-st germain-en-laye (paris, france) with acute gastrointestinal bleeding. at the laboratory exams the haemoglobin was 9.1 g/ dl. the patient perform a computer tomography (ct) which shows two hyper vascularised lesion at the 4th duodenum; this lesions has an intra and extraluminare growing. the ct scan didn't show any other abdominal lesions. the patient were submitted to a minimally invasive surgical operation with the multiport laparoscopic technique. results: the resection of the 3th and 4th duodenum and of the first 5 centimetre of jejunum was performed with a four trocar laparoscopic technique. a latero-lateral duodeno-jejunal mechanical anastomosis was performed. the operative time was 90 min. the patient start with oral alimentation on the third post-operative day after a ct scan with oral contrast that was negative for anastomotic dehiscence and collections. the post-operative course was globally uneventful and the patient was discharged at fifth post-operative day without complications. the histological examination shows a low risk gist, cd117 positive and with a ki-67 inferior of 2% (classification tnm 7th edition pt1 aims: gastric volvulus are a rare condition that sometimes represent a diagnostic challenge for surgeons. here we present the video of a recent case of a gastric volvulus in our area that was treated with a minimal invasive approach. methods: we report the case of a 58-year-old woman who was admitted in the emergency room (er) with epigastric transfixing pain and impossibility to vomit that had started 8 h prior to the admission. the physical exam showed good vital signs, and her abdomen was soft, with a tendency to tenderness with palpation in the epigastrium without guarding or rigidity. her lab tests were normal and the conventional radiology showed a double gastric bubble. we run an urgent computed tomography scan (ct scan) and a upper gastrointestinal (gi) endoscopy that showed a big type ii hiatal hernia that was complicated with a gastric volvulus. results: first, a nasogastric (ng) tube was placed for decompression of the stomach at the time when the endoscopy was made. the patient experienced a great improvement of the pain with that initial measure and remained stable. after almost a day of appropriate resuscitation, she underwent urgent surgery: we performed a hernia reduction, resection of the hernia sac, hiatal closure and a gastropexy and nissen fundoplication. the patient suffered no complications in the immediate postoperative time and was discharged after six days. conclusion: gastric volvulus are an uncommon emergency that we need to keep in mind. a simple abdomen x-ray can be very helpful, given that the double gastric bubble sign is a typical sign of this condition. it's always mandatory to perform an upper gi endoscopy in order to get to the diagnose and place a ng tube promptly. the surgery can be safely delayed in stable patients with no signs of ischemia, and a laparoscopic approach is associated with a shorter hospital stay and good long-term outcomes in this kind of patients. aims: during laparoscopic treatment of hiatal hernias the dissection can be complicated, but even more so the closure of the pillars, especially in giant hiatus hernias with a large defect. the use of prosthesis is controversial due to the lack of long-term studies and the possibility of secondary complications. the aim of this video is to demonstrate the safety of mesh hiatoplasty in hiatus hernia surgery. methods: we present the case of a 78-year-old woman with hypertension, hypothyroidism and right hemicolectomy for neoplasia 18 years ago. the patient presented with malnutrition, with a weight loss of 15 kg in the last months. a gastroscopy was performed in which a large hiatus hernia, that caused gastric volvulation, was shown. the upper gastrointestinal oral contrast study revealed esophageal tertiary waves and good passage to the gastric chamber, with an organoaxial volvulation of the stomach that was completely included in the thoracic cavity. results: through a five trocar laparoscopic approach, a large paraesophageal type iv hiatal hernia (7 9 6 cm hiatal orifice) with complete herniation of the stomach and greater omentum to the mediastinum was observed. after reduction of the hernia content, complete dissection with partial resection of the sac was performed. an extended mediastinal dissection of the esophagus, with descent of the esophagogastric junction until achieving an abdominal esophagus of 3-4 cm, was carried out. after posterior and anterior phrenorrhaphy with nonabsorbable sutures, dislacement of the right pillar without diagragmatic opening was evidenced. it was decided to reinforce the hiatorraphy using a c shape composite mesh fixed with nonabsorbable sutures. the procedure was completed with a nissen-type fundoplication. postoperative course was uneventful and the patient remains without hernia recurrence 9 months after the intervention. conclusion: prosthetic reinforcement in hiatal hernia repair can be a very useful resource in large hiatal defects in which a stress-free hiatus closure cannot be achieved. however, its use must be individualized according to the characteristics of the patient, the quality of the tissues involved and the result of simple hiatorraphy. aims: heller myotomy is an advanced laparoscopic surgical technique for the treatment of achalasia, a rare disease in which long time is needed to achieve the learning curve. surgical simulation, using animal models with an anatomy similar to humans, could help improving surgeon performance in a shorter time. the aim of our video is to show an ex-vivo and in-vivo animal model for heller myotomy training. methods: a cadaveric porcine model was developed using a tissue block including the esophagus and the stomach, without the diaphragm, mounted in a physical laparoscopic simulator. training procedures were also performed in an in vivo porcine model. experiments were carried out in the ' jesús usón' minimally invasive surgery centre in cáceres. results: the surgical technique is described step by step, first in the esophagus-stomach ex-vivo model and later in the live animal model. conclusion: surgical simulation using cadaveric an live animals offers a realistic representation, allows training in a safe environment, and can be very useful for advanced laparoscopic training in low incidence pathologies. introduction: esophagic perforation is one of the least frequent complications after laparoscopic nissen fundoplication, but it remains one of the most dreaded because of its morbidity and mortality rates and its technically difficult reparation. aims: to present how the authors dealt with an iatrogenic esophagus perforation post laparoscopic nissen fundoplication. methods: the authors report the clinical case of a 65-year-old woman who underwent a laparoscopic nissen fundoplication because of a symptomatic large hiatus hernia in a different hospital. the second postoperative day and after resuming oral intake, she presented respiratory and hemodynamic instability. she needed a chest tube that drained purulent content. the patient was referred to our hospital for clinical management. an urgent ct scan with oral contrast was performed without showing any leakage. results: in spite of the results, as the patient was unstable, she underwent an emergent diagnostic laparoscopy. it was found a small anterior esophagus perforation with right mediastinic collection. a running suture of the perforation was carried out and the nissen fundoplication was converted to a dör fundoplication. the operative time was 120 min. she went to the intensive care unit for ten days. five days after the surgery, she was given methylene blue with no exteriorization through the drainages. as postoperative morbidity, she suffered from a right pneumonia and a thoracic collection that was treated by thoracic surgeons. the patient was finally discharged on the 64th postoperative day. she did well at home. she attended follow-ups without clinical reflux or any other particular condition. conclusions: esophagic perforation is a life-threatening complication that can be managed laparoscopically if it is detected soon after surgery and an expertise is available. surgical treatment of achalasia fails in 10-20% of patients. the most frequent responsible cause is a previous incomplete myotomy, followed by fibrosis and aspects related with antireflux procedure. revisional surgery can represent a greater difficulty and a challenge. in this video we show 3 revisional surgeries after heller's myotomy with dor fundoplication for achalasia. all cases presented a recurrence of the symptomatology and a revisional surgery was proposed. surgeries were characterized by the presence of a herniation of the previous fundoplication, fibrosis around the prior myotomy and/or the formation of a pseudodiverticulum. we show the steps followed and the aspects to consider during the dissection. these cases demonstrate that laparoscopic reoperation for achalasia is feasible, even after open surgery. aims: upside-down stomach (uds) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. uds is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. surgical repair is the only curative treatment option and therefore recommended for these patients. standard procedure includes a hiatoplasty followed by an anti-reflux procedure. in a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences. methods: a 78-year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. she reported a weight loss of 14 kg in the last 6 months. ct scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately 10 cm, with intrathoracic uds. results: we performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (tutomesh tm ) augmentation. finally, a toupet fundoplication was performed to recreate the antireflux valve. in consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. the esophageal mucosa was unaffected. we treated the lesion laparoscopically with a simple interrupted suture (vicryl tm 3-0). an intraoperative patent blue v leak test did not identify any leaks. the recovery was uneventful. the patient was discharged on day 12 after surgery and was free of symptoms in her follow-ups. conclusions: patients with large hiatal hernias and uds can be treated successfully and effectively with laparoscopic mesh repair. intraoperative complications can be handled laparoscopically in a safe manner. iatoplasty followed by nissen fundoplication represent the gold standard treatment of hiatal hernia; however it has been reported high hernia recurrence rate, especially in case of giant hiatal defects. in order to reduce recurrence rate, various techniques of hiatoplasty reinforcement have been implemented, such as prosthetic materials apposition. however, in literature have been reported various mesh complications such as esophageal and proximal stomach erosion and late esophageal perforation after ischemia, especially in case of synthetic non absorbable materials.in this video we are going to show the repair of a huge hiatal hernia by hiatoplasty and positioning of an absorbable biosynthetic 'bio a' mesh which is replaced by connective soft tissue over six months, therefore decresing complications and recurrence rate.as usual, we start with the mobilization of gastric fundus and isolation of diaphragmatic pillars by sectioning the aderences between them and herniated viscera. we proceed then with intrabdominal esophagus mobilization and higher mediastinal dissection in order to obtain an adequate esophageal lenght. after the exposition of the hiatus, we approximate the pillars with some non absorbable stitches and we reinforce the hiatus positioning a 'u' shaped bio a mesh over the esophagus, simply fixed to crura with single stitches. then we go on performing nissen fundoplication.the use of this prosthetic material appears to be cost-effective; first series in literature show very low complication rate and less recurrences of hiatal hernia than hiatoplasty without reinforcement. this video demonstrates the technique of laparoscopic identification and complete dissection of the sac of a totally intrathoracic stomach. identification of the sac is performed centrally by scoring the peritoneum overlying the arch of the diaphragmatic hiatus. the inferior edge is retracted and series of blunt dissection is undertaken. once the areolar tissue of the avascular plan is visualized; a raytec sponge is placed and advanced cephalad to expose the extra-saccular space. this raytec is kept in place to allow carbon dioxide to infiltrate and further delineate the anatomy. we then proceed with dissection at the left crus and right crus. complete reduction of the stomach can be achieved without grasping it. this can be performed by applying caudal retraction on the sac. this maneuver exposes the plane outside the sac. this space is divided into two compartments (right and left) separated by a septum which indicates the proximal extent of the sac. this plane is avascular and blunt dissection can easily free the hernia sac from the mediastinal structures and the pleura. this was followed by excision of the sac and hiatal repair which is reinforced with bioabsorbable mesh. the proximal short gastric vessels were then divided and a standard toupet fundoplication was performed. v257-upper gi-reflux-achalasia introduction-objectives: the mixed giant hiatus hernias with paraesophageal component are hernias of difficult surgical correction, the laparoscopic approach of these implies a greater experience of the surgical team, given the complexity involved in its management, being the recurrence a complication that neither the use of meshes in this surgery has been able to avoid. in very high-risk patients, the gastric anterior pexy (boerema) may be an alternative to treat or alleviate the symptoms of these large hiatal hernias, although the frequency of recurrence with this technique is very high. material and methods. objective: the objective of the following case is to present a patient with type-1 hiatal hernia, barrett's esophagus without dysplasia and situs inversus. method: a laparoscopic partial fundoplication was performed on a 47-year-old male patient with a history of situs inversus totalis, who was seen in our general surgery service presenting a clinical history of retrosternal pain, heartburn and regurgitation. an endoscopy was performed, which reported hiatal hernia type 1 and incompetence of lower esophageal sphincter, with squamocolumnar junction biopsies with report of barrett's esophagus without dysplasia. results: surgical time was programmed, for toupet type fundoplication; there were lax adhesions from omentum to wall, the lax hiatus and already known situs inversus. partial funcuplication was performed, with the usual technique adapted for structural anatomical abnormality, postoperative course without complications, oral initiation at the next day, drainage penrose type was set draining just a little serohematic liquid, diet was progressed and patient was discharged on the third postoperative day without complications. conclusion: situs inversus is the mirror image of situs solitus, which presents subdivision in situs inversus totalis, which is the most usual form, characterized by the mirror location of the intraabdominal and thoracic organs including the heart; in the case presented, the patient was referred with situs inversus and barrett's esophagus, performing laparoscopic fundoplication. the gold standard of surgical management is laparoscopic in benign esophageal pathology. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. in rare instances gerd is associatedwith type iv hiatal hernias in which the part of stomach and other organs migrate into mediastinum.nowadays this condition can cause problems for some surgeons.patient was a 64-year-old man. he was diagnosed with hiatal hernia in 1992. the condition had beenhaving asymptomatic course until 2003. patient takes omeprazole 20 mg for 15 years. he startedexperiencing chest pains when inhaled and dyspnoea in june 2018. co-morbidities were: arterialhypertension, chronic obstructive pulmonary disease (copd) and obesity (body mass index was 43.9 kg/m 2 ). the posterior mediastinum contained the part of stomach, large bowel and small bowelaccording to chest roentgenography. sizes of esophageal hiatus were 145 9 98 mm. in our clinical centerwas performed laparoscopic removal of hernia, cruroraphy, mesh repair of the esophageal hiatus andnissen fundoplication in 2018 july. during the surgery stomach, the part of small intestine, greatomentum and transverse colon were relocated into abdominal cavity. after cruroraphy, repair of theesophageal hiatus with prolene mesh was performed. the patient was in intensive care during 9 h.total enteral feeding was initiated on second day. patients had been discharged within 5 days aftersurgery. patient was re-examined by a surgeon in september 2018, there were no signs of a reccurence.this case report shows an efficiency and feasibility of the laparoscopic approach to the treatment gerdassotiated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon,great omentum and small intestine to enter the hernia sac. aims: the authors present a video with their standardized laparoscopic hiatal hernia repair and anti-reflux nissen procedure but using 3 mm instruments and 5 mm camera approach. methods: a 42 years old female patient with a bmi 29 presents a symptomatic gastro esophageal reflux disease (gerd) for 20 years. manometry and ph-metry showed a lack of esophageal motor disorders and a severe acid pattern with a 96.35 demeester score. panendoscopy study showed a 3 cm hiatal hernia and a los angeles-grade 2 esophagitis. she decided not to go with ppi treatment anymore. a laparoscopic hiatal hernia repair and standardized nissen procedure is performed using 3 mm instruments and a 5 mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of 6 h with a 3 rate in a eva acute pain visual scale. in a 2 year follow-up, there has no been an anatomical or clinical recurrence. no chronic dysphagia, anatomical recurrence or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, hiatal hernia and anti-reflux mini invasive standardized repair using 3 mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. background and aims: parastomal herniation a very frequent complication in stoma patients. in isolated parastomal hernias (type i or iii)* a laparoscopic sugarbaker repair with intraperitoneal mesh is our preferred technique. if a concomitant incisional hernia is present (type ii or iii)* we currently opt for a retromuscular mesh repair as described by pauli. we adopted a minimal invasive approach using the robotic platform. methods: we performed a robot-assisted laparoscopic pauli repair for a wide incisional henria needing component separation and a small parastomal hernia (type ii)*. a non-slit retromuscular mesh was placed after a bilateral tar (transversus abdominus release) and lateralization of the colon. results: the operation was performed robot-assisted laparoscopically with 2x3 trocars without the need to convert to an open procedure. the procedure lasted 300 min. the patient was discharged from the hospital on post-operative day three. one month after the repair our patient presented with a parastomal skin infection for which she received surgical cleaning and wound dressing. ct scan three months postoperative shows good positioning of the mesh with a reinforced abdominal wall. conclusions: the modified sugarbaker repair in parastomal herniation is feasible following a pauli approach (retromuscular mesh positioning) completely laparoscopic, albeit robotically assisted. short-term follow up is promising. long-term postoperative follow-up in these patients is needed. methods: case presentation results: a 67-year-old caucasian female patient was admitted on emergency due to a progressive alteration of her physical condition and weigh loss, caused by intermitent and intense epigastric pain and vomisments. symptomes occurred several years prior to admittance, but used to be mild and rare. during the last months, the described episodes became more intense, lasted longer and occurred more frequently. percutaneous ultrasound raised the suspicion, while thoraco-abdominal ct revealed an enormous intrathoracic morgagni hernia and gastric volvulus inside the hernial sack. after a careful preoperative preparation (restoring of the nutritional and hydric inballances, amelioration of respiratory parameters), laproscopy confirmed the diagnosis; we gently reintegrated the herniated organs from the thoracic hernia into the abdominal cavity (small bowel, large omentum, transverse-doloco-colon, and thisted stomach); a laparoscopic exploration of the hernial cavity was followed by a thorough hemostasis. do to patient's frailty, we decided to leave the hernial sack in situ. surgical direct repair of the defect technique was done by using extracorporeally tied separate sutures through separate skin incisions. the postoperative outcome was completelly uneventful; patient was discharged on postoperative day 5. barium contrast at 3 mounths followup showed a slight esophageal diskynesia, but normal gastroduodenal passage; due to aerocolia, the normal position of the transverse colon could be confirmed aswell; no signs of reccurrence where detected. conclusions: although very rare, a morgagni hernia should be suspected and included in the differential diagnosis of patinets with dispeptic syndrome and epigastric/thoracic symptomes. thoraco-abdominal ctscanning is the imagistic technique of choice. laparoscopic approach became the gold standard, being far mora addvantageous as compared to laparotomy or thoracoscopy. direct suture with extracorporeally separate sutures through separate skin incisions was chosen for being less time consuming; for the same resons, the hernial sack was left in situ, with no consequences so far. aims: the giant fibrovascular polyp is one of the rarest benign lesions of the oesophagus. the most common locations of origin are the upper oesophagus or crico-pharyngeal region. the lesion is more common in elderly population, particularly men. symptoms include dysphagia, odynophagia. management options include surgical resection or endoscopic removal with endoloop. we aim to demonstrate the optimal management of these rare lesions using an endoscopic approach. method: we demonstrated the management of 75-year old patient with a giant oesophageal polyp, excised by minimally invasive endoscopic resection. the patient was placed in supine position and tracheal intubation was performed under general anaesthetic before an endoscopic approach was taken. the oesophago-duodenoscopy visualised a cresenteric shaped lumen due to an intraluminal mass occupying two thirds of the oesophageal diameter. the procedure was a multidisciplinary approach with the upper gi surgical and gastroenterology consultants. the polyp stalk was located in the oesophagus at the level of t2 and an endoloop was manipulated to surround the polyp. the polyp was then separated from the stalk by cauterisation and resected from the patient. the stalk was then injected with adrenaline to prevent haemorrhage. results: the excised specimen was a 15 cm polyp with stalk originating from the t2-t3 level. histology confirmed diagnostic suspicions of a benign pedunculated fibrovascular polyp. the polyp was covered by non-keratinising squamous epithelium with a discoloured tip demonstrating ulceration. there was no evidence of dysplasia or neoplastic process. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification 0-is g (granular type), ut0n0 eus stage, kudo type iv, nice type 2. the neoplasm measured 6 x 7 cm, and extended from 6 to 12 cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexò robotic system, used here for the first time outside the united states. the system technology utilizes an articulated multi-linked scope that can be steered along nonlinear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexò robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board 3d hd visualization. the flexò robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation. the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock 3/0 thread. while illustrating the technique the authors will comment pros and cons of the use of the device. surg endosc (2019) the video shows the use of a barbed suture of novel concept. this first prototype thread developed together with assut europe (roma, italy) is characterised by a bidirectional 3/0 barbed suture, of 24 cm length overall, with two needles 22 mm in diameter, and circumference. in order to fix the thread to the tissue, on the exact midline of the thread a small (2 mm) ball of the same material of the thread is fused with heat. this button as the entire thread is made of polydioxanone, a monofilament material for long-term absorption, self-retaining. this small advancement offera a consistent advancement in endorectal surgery helping in making transverse wound closures as easy as never before. the first stitch is placed on the transverse midline of the rectal wall defect, this way approximating proximal and distal edges. the button keeps the thread under tension allowing the completion of a running suture towards one of the two lateral ends of the would. when the first end is reached the needle is cut and the other needle is grabbed in order to perform the other half of the running suture keeping the right tension on the thread, with no risk of lumen stenosis. the two lateral ends of the suture are self-blocked passing them through the last stitch. no need for clips, knotting or buttonholes to pass through. while illustrating the technique the authors will comment pros and cons of the use of the device. background: the usefulness of robotic surgery has been largely reported; however, there are not enough reports on gist's treatment. the aim of this study is to report a single center experience on gastric gist's robotic resection. gastrointestinal stromal tumor (gists) are the most common mesenchymal tumors (overall incidence 1-3% of all gastrointestinal malignant tumor). they are most frequently located into the stomach. complete surgical resection still remains crucial for patients with gists. in cases of difficult localization of tumor (e.g. posterior wall, his angle) and bigger tumor (more than 5 cm in diameter), there still exist apparent difficulty and limitation to conduct laparoscopic resection. robotic assistance provides wide movements of its arms and was recognized particularly useful in case of difficult tumor localization, especially for those positioned at the posterior side of the stomach wall or around the lesser curvature. methods: six consecutive patients were analyzed focusing on safety (conversion/complications rate; hospital stay), oncological (margin resection, recurrence rate) and feasibility (operative time, technical tip and tricks) profile of robotic approach. results: the mean operative time was 173 ± 39 min, the mean hospital stay 3 ± 1 days. conversion rate was nihil. no intra and post-operative (mean follow-up 12 months) complications were registered. in all cases, the resections were classified as r0. conclusions: our experience supports the usefulness of robotic system in case of gist located at anatomically difficult gastric portion, such as lesser curvature or fundus close to gej, confirming the excellent oncological outcomes (100% r0) and the encouraging safety profile (0%). regarding the operative time our data are similar or better as compared to those reported by the previous literatures and didn't differ by the most recent published data for laparoscopic gastric resection. the anatomical hand-sewn reconstruction performed by precise hand-sewn suture instead of the usage of mechanical staplers represents a real great advantages of robotic resection. in our series, no patients suffered from stenosis or leakage after operation. background: we describe the use of a different suture from those historically used in the elaboration of a widely spread surgical technique such as the nissen fundoplication, for the treatment of pathological gastroesophageal reflux or symptomatic hiatal hernias. in our unit we have implemented the use of 2/0 irreabsorbable barbed suture to close the diaphragmatic pillars and the 360°fundoplication with the same continues suture. aim: the objetive of the use of the irreabsorbable barbed suture in the nissen fundoplication is to shorten the surgical times, which would achieve benefits for the patient and the institution, increasing the number of ambulant patients and the number of patients to be operated the same surgical session. objective: the goal of the present study was to demonstrate that intraoperative icg fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. method: fifty milligrams of icg dissolved in 20 ml of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys 2 weeks before a laparoscopic lymphocele marsupialization procedure. results: during the first exploratory laparoscopy, in the flank and right iliac fossa, near the 2 renal grafts, fluorescence was identified in 3 raised areas that were the internal side of the lymphocele lobes. the lymphocele wall was dissected and 300 ml of serous fluid was aspirated after puncturing. a 5 cm breach was then made in the cyst wall using the ultracision harmonic scalpel (ethicon us). afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by 2 stitches. conclusions: laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. intraoperative icg fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery. conclusions: this method proved safe and risk-free, easily reproducible and without the need for a different toolkit than the one of a modern operating theatre. the preliminary analysis shows a strong correlation between the perfusional data so far obtained and the early outcome of the graft. thus opening the way to further analysis aimed to a future better management of post-operative immunosuppressant and support therapy. these results are quite encouraging, even if our study is at an initial stage. conclusions: results show a persistent dread across specialities regarding ai. rather than be seen as threat, ai should be embraced by clinicians as it will ease the ever-increasing daily workload faced. this will enable clinicians to focus their skills on patient centred activities, interventional procedures and development. despite current regulatory hurdles, ai implementation in medicine is unavoidable. this coming revolution presents a unique opportunity for endoscopist and radiologist to refocus their expertise in novel areas. project description: from february to july 2017 a three-armed proof of concept study was conducted at three hospitals, in three groups of patients; recurrent ventral hernia, aortic aneurysm, and healthy controls. patients were measured once at the outpatient clinic using an electronic nose based on three metal oxide sensors. measurement data were compressed to low-dimensional vectors using a tucker 3 like algorithm, and used to train an artificial neural network (ann) to provide a classification between patients (?1) and healthy controls (-1). preliminary resultsa total of 64 patients (hernia n = 29, aneurysm n = 35) and 37 controls were included in the study. based on receiver operating curve (roc) analysis, the ann could differentiate between recurrent hernia patients and controls with the following details: area under the curve (auc) 0.74, sensitivity 0.79, specificity 0.65. aortic aneurysm patients and healthy controls could be differentiated with an auc of 0.84, sensitivity of 0.83, and specificity of 0.81. the aeonoseò enose can reliably distinguish patients with weak collagen (recurrent hernia and aortic aneurysm patients) from healthy controls. validation of these results in a prospective cohort study is required before clinical application of the device. background: laparoscopic and endoscopic cooperative surgery (lecs) has been performed gastric submucosal tumor (smt) or duodenal tumor. although minimally invasive surgery using thoracoscopy has been the usual approach for esophageal smt, the treatment method combined thoracoscopy and endoscopy has not been established. in addition, submucosal endoscopic tumor resection (set) for esophageal smt was reported using the technique of submucosal tunnel. aim and project description: we planned to resect large esophageal smt located in the upper or middle thoracic esophagus by a combined endoscopic and thoracoscopic approach. because set is only recommended for tumors up to 40 mm in size owing to the limited submucosal space available and the left thoracic approach is restricted by the aortic arch and the trachea. preliminary results (case presentation): a 47-year-old woman was diagnosed with a benign schwannoma of length 60 mm originated from either the submucosal or the muscular layer of the middle thoracic esophagus by endoscopic ultrasonography, enhanced computed tomography, and ultrasound-guided fine-needle aspiration biopsy. since the tumor had increased in the 5 years and she had a symptom of dysphagia, we planned to resect it by a combined endoscopic and thoracoscopic approach. on endoscopy in the supine position, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its only oral end was dissected from the mucosal and muscular layers. this was followed by the resection of the entire tumor by left-sided thoracoscopic procedure in the prone position. endoscopic mucosal closure was achieved by using clips. no postoperative complications were observed. large benign esophageal tumors can be safely excised with minimally invasive surgery by using a combination of endoscopy and thoracoscopy. background: haemorrhage remains a major cause of morbidity and death in all surgical specialties. in laparoscopic surgery. relatively small amounts of blood can obscure the view of the operative field and increase the risk of injury to surrounding structures. excessive bleeding often leads to longer hospital stays, increased healthcare service utilisation, and higher healthcare costs, among other negative consequences. aim: the aim of this study was to analyse the feasibility of purastatò, a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery. project description: this was a prospective observational non-randomised study. consecutive patients undergoing laparoscopic colorectal surgery were enrolled. informed consent was obtained from all patients inclusion criteria was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended/ appropriate due to proximity to ureter, pelvic/sacral veins and other important structure. preliminary results: twenty patients were enrolled (12 males (60%) and 8 (40%) females). mean age was 61 years (± 2,4 years). all patients were undergoing elective laparoscopic colorectal cancer surgery (4 right hemicolectomy, 5 sigmoid colectomy, 11 anterior resection). we utilised 3 mls of purastatò in all patients. the mean area of application was 5, 35 cm 2 (± 2.25 cm 2 ) with the amount of purastatò needed per centimetre being 0.56 mls. the mean time to apply the product was 40 secs (± 17 s), whereas the mean time to achieve haemostasis was 17, 5 secs (± 3.5 s). there were no post operative complications in this cohort of 20 patients. mean operative time overall was 185 min (± 45.2 min). none of the patients experienced delayed post-operative bleeding and the mean hospital stay was 5 days (± 3.4). in conclusion, according to the purpose of this preliminary study, we have demonstrated that purastatò can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. this is a feasibility study and additional controlled studies would be useful in the future. during last three years the laparoscopic method of surgery in the presence of common bile duct stones was carried out. after performance of intraoperative cholangiography and visualization of stones in the common bile duct laparoscopic, choledochotomy and bile duct stones extraction was undertaken in 56 patients, using flexible choledochoscopy control. in all patients with gallbladder stones was then performed laparoscopic cholecystectomy. results: laparoendoscopic intervention on common bile duct was successfully performed in 48 patients (85.7%) and the operation was completed by common bile duct drainage by kehr. in 8 patients due to technical difficulties conversion to open surgery was carried out. postoperative morbidity in the form of bile leakage were diagnosed in 9 patients (16.1%). in three cases they stopped spontaneously in 5-6 days after the operation. 6 patients were operated on repeatedly and additional suturing on choledocholithiasis was carried out. postoperative mortality was 2.4%. the death of the patient of 92 years was caused by acute cardiovascular failure. institute for image guided surgery, ihu-strasbourg, strasbourg, france; 2 hepato-digestif, nouvel hôpital civil, strasbourg, france; 3 image guided surgery, nouvel hôpital civil, strasbourg, france; 4 gastroenterology, chu-besancon, besancon, france; 5 gastroenterology, chu-lyon, lyon, france; 6 gastroenterology, clinic de trocadero, paris, france background: eus is difficult to learn and has a steep learning curve. therapeutic eus (teus) is even more so. simulators, ex-vivo models and phantoms are the most common current teaching modalities but are felt by many to be unsatisfactory for high-level training. aim: we designed a training curriculum for teus that uses high-fidelity animal models and present a validation study performed by 4 teus experts. project description: 3 different simulated pathologies were created in each of 9 acute pigs. 4 teus experts performed 15 therapeutic procedures in two or more animals over two days. each intervention was evaluated simultaneously using a structured survey by an non-expert observer. data included demographics and procedure details as well as likert-scale evaluation of the quality, realism and education utility of the simulations. global evaluation of the experience was captured from the experts as written comments. all data was consurrently registered and subsequently analysed by two blinded surgical educators. methodology: three types of models were created using surgical access: 1-tumors (injection of 4 types of hydrogel), 2-retro-gastric collections (5-7 cm long intestinal loops filled with oatmeal, oil-water and gel), 3-obstructions (bile duct and ureteral ligations 2 days prior to experience). gastric, pancreatic and liver tumor models were used for fna and fnb practice. retrogastric fluid collections and choledochal/ureteral obstructions were used for cyst gastrostomy, hepaticogastrostomy, gallbladder drainage and kidney drainage. results: experts age: 45-63, median intervention time 22 min , total of 60 interventions evaluated, overall quality of experience: 37 (68%) ranked 8-10 (excellent), 14 (27%) from 7-4 (good), 3 (5%) from 1-3 (poor), 54/60 procedures were successfully completed. models were rated good to excellent quality (7-10) in 42 (70%), poor quality in 8 (13%). for 17% (10) of the interventions the model was considered not good enough to be repeated (solid retrogastric tumor and peripheral hepatic lesion). conclusion: high-fidelity live animal models with simulated pathologies are considered to be excellent training tools by experts and may provide a better learning experience for teus. surg endosc (2019) in our short videos, we present scenarios in which this technology helped: to distinguish a significantly dilated cystic duct from the cbd, to identify an anterior cystic artery in the contest of acute inflammation, to identify a luksha duct, to exclude a leak after endoloops positioning on cystic duct. intra-operative augmented visualisation of biliary anatomy with indocyanine green cholangiography is an essential technology tool with the potential to extend the 72 hour window of safety for emergency cholecystectomies, with significant logistics benefits. introduction: endoscopic resection of subcardial polyps has its limitations; especially when it is necessary to dry out the entire gastric wall. uniportal intragastric surgery is a good alternative for the exeresis of subcardial premalignant lesions with gastric preservation. patient and method: we present a video with two cases. technique: we perform a laparoscopy to explore the entire abdominal cavity, then we open a 1.5 cm hole in the great curvature; a 2 cm incision is made in left hypochondrium and the uniportal device is placed inside de stomach. we inject serum in the submucosa with a endoscopic needle. when submucosa is completely separated from muscular lay; a submucosal exeresis can be made; but when there is not a complete separation after injection, then we perform a entire wall resection with a 1 cm circular margin. if a complete wall resection is made, then we close the defect with a barbed suture. results: case 1: 45 years old male with a 1,5 cm subcardial polyp, preoperative biopsy was informed as severe dysplasia. in the laparoscopy we saw an unknown lesion in the great curvature that looked like a gist. we placed the uniportal device intragastric and proceed to the submucosal serum injection. as the submucosal lay was completely separated from muscular, then we performed a submucosal exeresis. we close the gastrotomy and made the resection of the great curvature lesion with endostapler. the pathological analysis confirmed the severe dysplasia in subcardial lesion and gist in the great curvature lesion. patient was discharged with no complications after 2 days. case 2: 58 years old male with a 2 cm subcardial polyp. preoperative ecoendoscopy suggested a muscular layer infiltration but only severe dysplasia was found in the previous biospsy. laparoscopy did not found more lesions, and uniportal intragastric device was placed. a complete wall resection was made, and the defect was closed with manual barbed suture. pathologyst confirmed severe dysplasia and unaffected margin. patient was discharged with no complications after 4 days. conclusion: uniportal intragastric surgery is feasible and safe and may be useful for subcardial premalignant lesions when endoscopic resection is very difficult or not feasible. introduction: the role of icg in bariatric surgery is still unclear. knowing the lack of perfusion in the gastric pouch could be of great interest in revisional surgeries; but the question remains: is the current icg technology reliable enough to make intraoperative decisions in bariatric surgery? methods: we have carried out a check of tissue perfusion with icg fluorescence in several cases of primary and revisional bariatric surgery. a solution of 0,1 mg/kg was injected intravenously and icg fluorescence was performed. we looked for the correct staining of the entire gastric pouch and the intestinal loop trying to rule out areas of tissue ischemia. results: the 15 cases in which the test was performed showed a minimal delay of 10-15 s between the intestinal loop stain and the pouch. a correct staining was observed in all but one case shown in the video. is the case of a 46 years-old male patient who was operated 8 years earlier in another center; at that time he underwent a sleeve gastrectomy. we evaluated the patient for persistent gastroesofhageal reflux of 5 years of evolution with esophagitis. we offered revisional surgery to perform gastric bypass and hiatal closure. fundus was dilated so a funduplasty was performed instead of using endostappler in the vertical side of the pouch. manual anastomosis gastric bypass was performed. when the icg test was performed, a corner of the pouch does not stain green (an area of 1,5 cm) . so the decision was to resect that part and redo the anastomosis or wait and see. it was decided not to resect and the patient was discharged two days later with no complications and good outcome with a 12 months follow up. conclusion: icg fluorescence may be useful in bariatric surgery in the future but more evidence is needed of its usefulness in making intraoperative decisions. background: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least 30% of node negative patients will suffer disease recurrence within the first 5 years after surgery. this may be due to understaging of lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc99 and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results for detection of aberrant lymphatic drainage outside of the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems in order to identify the lymphatic nodes. aim: the objective of the experimental study is to investigate the possibility to detect the sentinel lymph nodes after the injection of different solutions with indocyanine green in the subserosal colonic layer in the pig. project description: twelve female large white pigs were operated with laparosocpic approach and spies optic filter (karl storz, germany). indocyanine green was injected in the subserosa of the colonic wall (1 ml at 2 points). lymphatic flow was observed at 1-3-5-10-15 and 20 min, searching for the migration of the icg by the lymphatic channels and its introduction in the sentinel nodes. preliminary results. the identification of the sentinel nodes is very difficult with the solution of icg-sterile water. with this technique we can see the lympjatic channels but not the lymphatic nodes. the adition of 5% human albumin as a transporter of the icg is very helpful for the correct identifiaction of the lymphatic channels at 5-10-15 min and the correct visualization of the lymphatic nodes at 20 min after the bowel injection. addition of other transporters like dextran solutions may be helpful too but the time to the correct visualization is longer. there was significant difference among the three groups as regards postoperative les and postoperative ph metery.the incidence of persistent dysphagia was significantly higher in the group i. postoperative gerd symptoms were significantly higher in group iii (23.3%. p \ 0.0001). recurrent achalasia was significantly higher in group i (11 patients 15.9%, 8 patients in group ii (7.1%) and nil in group iii (p \ 0.02). in conclusion: longer myotomy on the gastric side ([ 2.5 cm) ensures complete division of the les with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative gerd. therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative gerd. c/t scan of his abdomen revealed a large groin hernia with signs of small bowel obstruction and collapsed distal bowel. emergency theatre was organised for this patient with anaesthetic assessment prior to his surgery. initial plan of local exploration with possibility of small resection was changed once he was under full anaesthetic with muscle relaxation. his abdominal girth provided an opportunity to utilise laparoscopic intervention as an initial approach. laparoscopy with 0 degree lens revealed moderately distended loops of small bowel and a large omental mass along with a loop of small bowel incarcerated in right direct inguinal hernia site. background: robotically assisted surgery is a rapidly developing modality of minimally invasive surgery with proven advantages in the management of cancer. despite its increasing prevalence, there is still an ongoing debate regarding its future role in colorectal surgery. while the prospective randomised multi-centre studies provide research evidence for its potential efficacy, an assessment of its effectiveness and realistic outcomes in everyday clinical practice can add an important perspective to this discussion. the international robotic colorectal registry will allow to compile and pool the international robotic colorectal experience. aims: the aim of the international robotic colorectal registry is to monitor the safety and outcomes, as well as the quality of specimen of robotically assisted colorectal surgery for malignant and benign diseases of the colon and rectum. the primary endpoint is a composite oncological failure. the secondary endpoints include anastomotic leak, resection margin involvement, conversion rate, operative time, post-operative 30-day morbidity and mortality, long term oncological outcomes, quality of life, functional outcomes and cost-effectiveness. project description: the international robotic colorectal registry is a multicentre web-based, online secure database. the registry has been awarded an ethical approval by a relevant national committee. all surgeons performing robotic or robotically-assisted surgery are invited to participate. the data collected includes patient demographics, cancer characteristics, operative details, histology of the specimen, wound healing, post-operative therapy, readmission, quality of life and functional (bowel, urinary and sexual) outcomes. all the sensitive patient information is encrypted before its introduction into the database. preliminary results: so far, twenty robotic colorectal centres have joined the international robotic colorectal registry. the preliminary results will be published once 600 patients have been enrolled. univariate and multivariate analyses will be performed to identify possible risk factors for poor outcome.the possibility to record open, laparoscopic or other minimally invasive colorectal procedures will facilitate comparison of the outcomes of the robotically assisted surgery and other modalities. the registry will also allow each surgeon enrolled to monitor their skill progression and outcomes over the time. results will be published in surgical literature and presented internationally. background: gastric outlet obstruction (goo) due to benign strictures is an uncommon surgical entity today. this paucity relates to the decrease in its aetiological factors in the modern era as well as to advances in both prevention and medical as well as endoscopic treatments of such condition. the most common of causes relating to peptic ulcer disease, has been subdued for decades with quality acid control medications. on the other hand advances in gastroscopic dilatations skimmed even more the frequency of these cases from arriving to surgical intervention. aim: this presentation gives an update on the standing of this pathology and its surgical management today. it will also shed a light on our early experience in this condition at the royal hospital of muscat in oman. project description: a case series of all patients with goo, who were surgically managed between 2010 and 2015 results: there were a total of 16 patients, 10 males and 6 females. the cause of obstruction was peptic ulcer disease in 10, corrosive injury in 2, iatrogenic perforation in 1 and idiopathic hypertrophic stenosis in 2 . emergency presentation was seen in 4. management included jaboulay pylorpolasty in 2, resection in 10 (distal gastrectomy in 9, total gastrectomy in 1) or a bypass (gastrojejunostomy) in 4. in 14 of the above, the procedure was done by laparoscopy. post operatively, temporary gastric paresis delayed recovery in 5, however all symptoms resolved in 15. there were no recurrences at minimum of 2 years of follow up. in spite of advances in medications and gastroscopy interventions, we still seem to identify this condition within our population. although infrequent, they demand awareness from surgeons since they could be managed successfully, especially laparoscopically, with minimal morbidities and early recovery. the introduction of advanced laparoscopy to the unit's setup in recent years, made such option feasible with satisfactory and durable outcomes. background: gists of the upper gi are found mainly in the stomach (60-70% of cases) and small intestine (30%). duodenal gists however, comprise a smaller subset with a frequency of 6 to 21%. the optimal surgical procedure for duodenal gist is still evolving. since wide margins and extensive lymphadenectomy are not required, restrain from more radical resections in this area would be a valid option. aim: this is a video case report of a patient with a gist involving the third part of the duodenum treated by laparoscopic lateral duodenectomy and end-side roux-en-y duodenojejunostomy case report: 55 years lady presented with recurrent mid abdominal postprandial pain with anorexia, nausea and occasional vomiting an ultrasound showed well defined hypoechoic mass of 3 9 2.5 9 2.2 cm at the right para-aortic region . ct scan defined the mass as retroperitoneal, intimately related to the pancreas uncinate process and the third part of duodenum with no clear cleavage line between them. an mri endorsed the diagnosis of gist of the duodenum. she was operated upon through a laparoscopic lateral duodenectomy including the gist at the third part of the duodenum. a frozen section confirmed the clear margins . reconstruction was done by a roux-en-y duodenojejunostomy with the alimentary limb taken 30 cm from the dj flexure. she had an uneventful post operative recovery and was discharged well. the histology confirmed a low grade gist tumour hence no further treatment was needed. at follow up six months later, she was doing well and gaining weight. conclusion: complex anatomy of the pancreatico-duodenal area makes conserving the duodenum for tumours rather than a major resection a challenging option. in our case however, with the disease in the third part being of a moderate size, a lateral duodenal wall resection including the mass was possible rather than a segmental resection. this procedure could be an ideal choice for benign, moderate sized tumours in the third and fourth part of the duodenum. background: during laparoscopic colectomy, laparoscopic lymph node dissection and extracorporeal intestinal anastomosis is commonly performed. an umbilical incision of 4-6 cm and wide-range mobilization of the intestinal tract is required for extracorporeal anastomosis. previously, we introduced intracorporeal overlap anastomosis in june 2017 as a minimally invasive treatment. here, we report its short-term outcomes. aim: we retrospectively compared the surgical outcomes of 21 cases of extracorporeal anastomosis and 8 cases of intracorporeal anastomosis, all of which were performed between june 2017 to may 2018. procedures: after lymph node dissection and sufficient mobilization of the intestinal tract, the proximal and distal intestines were resected perpendicularly to the intestinal tract with a 60-mm linear stapler. the anastomosis was performed after the specimen was extracted from an umbilical incision. the opposite sides of the mesenteric margin 3 cm from the staple line of the one intestinal tract, and 7 cm from the staple line of the other intestinal tract, were marked, and then the respective intestinal tract was positioned to join the opposite mesenteric sides together. an insertion hole was made in the intestinal tract at the marked site. side-to-side anastomosis with a linear stapler was performed, and then the insertion hole was closed with a linear stapler after several temporary sutures. preliminary results: in the extracorporeal anastomosis group, the mean operation time, blood loss, and post-operative days were 270 min, 127 ml, and 13.2 days, respectively. furthermore, there were three intraoperative cases of bleeding (14.3%), and two postoperative cases of lymphorrhea (9.5%) that occurred. however, in the intracorporeal overlap anastomosis group, the mean operation time, blood loss, and post-operative days were 284 min, 75 ml, and 12.5 days, respectively. additionally, there were no cases of intraoperative complications, and only one postoperative case of lymphorrhea (12.5%). conclusion: intracorporeal overlap anastomosis in laparoscopic colectomy is safe and feasible, and can be used as a minimally invasive treatment. nowadays 3d-printing it's not a new technology any more but with an exponential developing. there are beliefs that in 2027 10% of everything that will be produced will be 3d-printed. in medical field this technology knows the same exponential developing. first used in orthopedics and maxilo-facial surgery now 3d-printind is used in many other fields for different reasons, like preoperative training models, surgical special instruments, in medical education, etc.. liver surgery is in continuous developing and this is the reason why we need experimental liver model for training and testing. a best liver experimental model should heave liver consistency, to be flexible, to heave the same ultrasound feedback, to be cheap and easy to be reproduced. this is why we developed a liver experimental model made of gelatin by a simple recipe, using a 3dprinted mold, created after a human liver ct-scan. first was made the segmentation of the liver. after segmentation we create the 3d virtual liver model and the negative image of the liver, which was used for creation of the 2 pieces of the liver mold, with connections between them and a hole on the top to pour the gelatin solution. (1) ethical concerns on learning and training with real patients and substitutives such as animals, and (2) reconciling time devoted to learning with clinical practice, considering the european work time directives. simulation in medical education is and has been the preferred route to address both pedagogical needs. virtual simulation has proven to be a valid tool for training; however, current systems restrict usage to tasks and modules offered, without possibility of personalization. we present the minimally invasive surgery simulator scenario editor (mis-sim) an environment where users can create, edit and run virtual reality tasks designed for medical training. the environment features an editor allowing users to develop learning tasks, defining its learning objectives and task goals in an easy way. a first proof of concept has been implemented for surgical training and training activities (demostrators and short courses) have been carried out in three european sites: spain, the netherlands and hungary. during training activities, 10 different exercises have been created and uploaded to the contents' database. trained technical skills include handeye and bimanual coordination, instrument handling and pulling. preliminary results with 30 users have shown mis-sim training potential, although some functionalities should be made easier. personalization has been highlighted as the key added value of mis-sim with respect to the current competitions in the market: the ability for target users to use virtual reality based learning tools while remaining in complete control of the learning process. mis-sim aspires to break the barrier between vr and medical education by empowering users to create their own tasks. with mis-sim teachers/course creators and learners (healthcare professionals & future healthcare professionals) will benefit from an innovative tool to (1) create personalised medical learning contents tailored to preferred learning styles, allowing the creation of individualize learning paths; (2) improve the efficiency of training by focusing on the training needs of the learners and (3) share and sell vr-based didactic contents. c. tiu 1 , p. sánchez-gonzález 2 , m. chmarra 3 , d. gutiérrez 4 , c. guzmán-garcía 5 , l. sánchez-peralta 6 , g. wéber 7 , f. sánchez-margallo 8 , b. pagador 9 , j. dankelman 10 aims: currently surgical training is largely based on the improvement of technology enhanced learning solutions. the progress of engineering and the diversification of training facilities outside the operating theater results in an even greater contribution of technology in the future. the main reasons to encourage these changes are increased efficiency of simulators and directly increased patient's safety. the goal assumed by the easier project is to develop multi-skill, online platforms for minimally invasive surgical (mis) procedures-based on common pedagogical principles with reference value in a multinational space. the platform will allow the connection of external assets (such as simulators) to centralize all training data from residents. this work presents the milestones of the project during its first year of life. methods: the consortium's activity started with a knowledge elicitation process organizing brainstorms and workshops including experts in mis and interventional techniques, from spain, romania and hungary. this experience led to the formulation of a questionnaire that was implemented online and sent via email to surgeons and residents from the participating countries. results: accumulated experience was used to define the pedagogical needs of the platform. the pedagogical needs form the starting point for defining the technical requirements and specifications. based on them, the design of the platform has been achieved, including its architecture and communication protocol between external assets design, facilitated by the use of state of art educational standards. discussions and conclusions: next steps include the implementation of the easier platform, as well as the definition of cases studies selected by the clinical partners in spain, romania and hungary to solve applications of the platform dedicated to cholecystectomy, lumbar puncture and arthroscopy. a pedagogical model, built by the experience of the consortium, is being used to guide instructional design of the course. finally, results will be validated in a multi-center validation study.the easier project will create a training platform with reference value for european surgery. the structure of the consortium, based on the confluence between collectives with clinical, technological and pedagogical experience, will generate a complex learning tool in surgery embodying technology-based training systems with clinical experience. background: the treatment of groin hernia is an important part of our daily surgical activity. aim: we proposed to evaluate outcomes of the laparoscopic trans abdominal pre peritoneal treatment (tapp) of the groin hernia. project description : one hundred and fifty patients who underwent a tapp for a groin hernia were included in a retrospective study between january 2014 and november 2018. results: the gender ratio was 5. the average age was 57,4 years. twenty percent of patients had a history of abdominal surgery. the operative indication was a unilateral hernia in 25% of cases, associated with an umbilical hernia in 40% of cases, a recurrent groin hernia in 30% of cases and a bilateral inguinal hernia in 45% of cases. the conversion rate was 1.33%. the hernias were classified according to the ehs classification in l3 type in 31% of cases, l2 in 24% of cases, l1 in 19% of cases, m2 19%, l2 r in 20% of cases and f1r in 15% of cases. a contralateral inguinal hernia was discovered in 15% of patients. a polypropylene mesh 15x15 cm was fixed by a stapling in 59% of cases and by a suture in 41% of the cases. the average operation time was 55 min. the hospital stay average was 0,7 day. an antalgic treatment was prescribed in 15% of patients. the average time to return to normal physical activity was 5 days. a postoperative seroma was noted in 14% of patients. no cases of mesh suppuration were noted. chronic pain was noted in two patients. no recurrence was noted with an average follow-up of 25 months. conclusion: laparoscopic treatment of the groin hernia by tapp had good results concerning the postoperative pain, early recovery of physical activity and aesthetic damage. a larger setback is needed in our study to evaluate the recidivism rate. background: surgeon's training in ultrasound is viewed and understood differently in different parts of the world. if in united states the need for surgeons' training was accepted and taken over by the american college of surgeons, in europe the practice is completely different from one country to another, from one city to another, from one department to another within the same premises hospital. in some european countries, surgeons currently use ultrasound for diagnosis-especially in urgency, for follow-up, intraoperative, or as guidance for many surgical gestures. during this time, access to ultrasound of other surgical specialties-gynecology, urology, ophthalmology-is considered natural. material and method: once the decision to initiate an ultrasound course for surgeons was taken, a team of experts with technical or clinical expertise in ultrasound was organized. at the initiative of the technology commission, the courses were to be organized at the eaes congresses or others communication events endorsed by eaes. starting from the importance of each ultrasound application in surgery, it was decided to develop different modules to solve different training needs. at this time, the course offered at seville covers the capitols like abdominal ultrasound, guided punctures and trauma. a module dedicated to intraoperative ultrasound is under construction and will be available in november 2019. the course has a skill abilities dominant character, two thirds of it being thought of as a hands-on application on stationary, classical ultrasounds with large screens and also on small size wireless actual devices. results: after his debut in frankfurt in 2017, the course was resumed in london and in bucharest, twice. in this process, new modules and better teamwork skills have been developed. the participants' satisfaction quizzes, coming from all continents, were really encouraging. for the intraoperative ultrasound module the team approach is unique. students will have the opportunity to practice on live animals both laparoscopic and open abdominal procedures conclusions: the ultrasound for surgeons course initiated by eaeas was received with interest. the team will seek to inspect the real needs of training surgeons in this field and will complement and diversify the current platform surg endosc (2019) preliminary results: a total of 26 procedures (3-12, ± 5.2) were carried out in 5 patients. the indications included acute (2 leaks following esophageal resection, 1 rupture of the strictured anastomosis following pneumatic dilatation) and 2 chronic conditions (esophagopleurobronchial and gastropleurobronchial fistulas following the resection of esophageal diverticulum and sleeve gastrectomy). the initiation of the therapy was in 13, 18 and 1 day in case of acute conditions, and after 2 years of the duration of the unsuccessful therapy in 2 chronic cases. the successful closure was observed in 2 patients, 1 patient passed from mods and ards. in 1 case, the initiation of evac was provided as a combined surgical and endoscopic intervention (ct proven distant intraabdominal abscesses). in 2 chronic cases, 1 was discontinued due to the haemophagocytic syndrome of unknown etiology, in the second one, success in reduction of the lesion and symptomatology with long term duration was observed following just 3 applications of evac, despite minimal remanent leakage. the success is to our experience linked to early initiation of the therapy and presumes complex intensive care. the future investigation should specify the timing including preemptive use of evac and the combination of evac with other endoscopic, interventional and surgical therapeutic modalities. the aim of this feasible study is to investigate complete robotic esophagectomy with total mediastinal lymph node dissection (retm) only by the robotic arms. methods: the patient is placed hemi-prone position with one lung ventilation by blocking balloon tube under general anesthesia. the robotic trocar for 1st arm of da vinci xi surgical system is placed in the 10th intercostal space (ics) on the scapular line, the trocar of 2nd arm is placed in the 7th ics on the posterior axillary line, 3rd arm trocar is placed in the 5th ics on the middle axillary line, 4th robotic arm trocar is placed 3rd ics on the middle axillary line, and assistant trocar only for taking in and out of gauze is placed in the 8th ics on the middle axillary line. on the upper mediastinal lymph node dissection, robotic camera exchanges from 2nd to 3rd robotic arm to close and identify anatomical structures. esophagectomy with lymph node dissection starts from middle and lower mediastinum to upper mediastinum including along bilateral recurrent laryngeal nerves. all procedure perform under close-up view along the robotic enhanced anatomy to preserve organ functions. background: complete stenosis of the duodenal lumen secondary to a surgical suture in the treatment of a duodenal ulcer is a rare complication. the usual surgical resolution corresponds to a gastrojejunostomy associated or not, to an antrectomy with vagotomy, as a treatment for the peptic disease. the endoscopic resolution of this complication requires the use of complex maneuvers and specific therapeutic instruments. aim: to describe the endoscopic resolution of iatrogenic occlusion after raffia of perforated duodenal ulcer. description: a 43-year-old man was admitted to the emergency service for four days of pain and abdominal distension associated with abundant retention vomiting. performed ten days ago of a perforated duodenal ulcer, in which manual raffia was performed in two planes and drainage. abdomen and pelvis ct showed great distension and diffuse thickening of the gastric wall. the endoscopy showed abundant gastric retention content, pylorus, and bulb edema, and complete closure of the duodenal lumen, secondary to suture material; it was possible to count three suture threads. with a tipped papillotome and electrocautery, all the suture threads were sectioned, identifying a filiform opening through which a hydrophilic guide is inserted under fluoroscopy until it is sure to overcome the stenosis; we dilated the trajectory with a dilator of 10 mm in diameter and 4 cm in length. with a contrast medium, we observed an adequate trajectory and installed a partially covered duodenal metal stent (hanaro stent) of 14 cm in length by 20 mm in diameter in order to sustain the dilation. he was sent to home with inhibitors of the proton pump. after two weeks, the stent was removed, without complications. he was controlled two weeks after withdrawal, and, with pharmacotherapy, the patient was asymptomatic, making a normal life. conclusion: in this case, the result was positive. satisfactory results can prevent major surgery, which reduces the risk and possible complications. a new range of non-invasive medical tools with a remarkable improvement on the existing market. a manual laparoscopy, with the important novelty of having a bending head with a high degree of movement. this head can get multiple spatial positions to work in surgery and is very easy to use, with the same scissors thimble who controls it, so its performance and learning is very simple and intuitive. the tools can be easily reusable and they can be cleaned and sterilized by ordinary methods, very ergonomic and lightweight . the generic type models we initially have developed are focused in general surgery, but gradually we will develop new applications and different heads for specific medical conditions such as arthroscopy, laryngoscopy, otolaryngology, ophthalmology, orthopedics . its operation is simple and functional, simply moving the scissors thimbles, where they have a dual role, combining the head tilt and the action of opening and closing of this is achieved.the design of this tool allows us to work with some degrees of unparalleled freedom from the existing tools. our instruments replicate the movements of the robot with a simple handheld mechanical instrument, our philosophy is to position our instruments in between a long empty field between the surgeon and the robot. the tip of our instruments are providing the surgeons with angulations impossible to reach with the traditional instruments unless applying huge movements from the hands of the surgeon. we consider that this devices will have a very fast acceptance from the market as this robotic type movements can be managed by the surgeon through the traditional 5 mm trocars, without the need to change to a new surgical technique, just with the traditional method and a very brief training. background: diverticula of the middle thoracic esophagus are infrequent, its etiology may be secondary to traction or pulsion mechanisms. when the etiology is a mechanism of pulsion, they are associated with esophageal motor disorders and its prevalence is estimated between 0.02% and 0.77% of the population . they are rarely symptomatic and the diagnostic is usually incidental. the most common symptoms are episodes of food impaction, chest pain or bronchoaspiration.diverticulectomy and esophageal myomectomy by minimally invasive approach is the treatment of choice in those with large size or associated symptoms. aim: to describe a clinical case of esophageal diverticulum solved by minimally invasive surgery approach. clinical case description: a 74-year-old patient with a history of epilepsy and hypothyroidism consulted for atypical chest pain and dysphagia to liquids and solids. a study with esophagogastroduodenoscopy was performed: 27 cm from the dental arch, a large wide-mouth diverticulum was identified. we complete the study with an esophagram with barium: voluminous diverticulum in the right lateral face of the middle esophageal and a thoracic ct scan showing esophageal diverticulum located in the carina, from 5.6x4.5 cm to 13 cm from the esophagogastric junction. due to the suspicion of associated motor disorder, high resolution manometry was performed showing a significant motor disorder with alteration of peristalsis and exit obstruction with incomplete relaxation of the inferior sphincter and superior hypertonic sphincter. preliminary results: the patient underwent surgery: diverticulectomy and complete esophageal myotomy by thoracoscopy minimall invasive approach. the patient evolved favorably and was discharged after 5 days with a previus control esophagram without pathological findings. currently, it remains asymptomatic 6 months after surgery. , rectus muscles are re-approximated from xiphoid to pubis using laparoscopic running self-locking, pds sutures to restore anatomy and physiologic function of the abdominal wall. unlike the standard access to the abdominal cavity executed with 3 lateral access, the lap-t technique is performed through 3 sopra-pubic aesthetic approaches, using one 3 mm and one 5 mm bariatric (45 cm) instruments laterally, and one 8 mm camera in the middle.the entire procedure is performed in gas-less laparoscopy, with laryngeal mask and intra-peritoneal liquid anesthesia. the repair is consolidated placing an intra-peritoneal semi-absorbable mesh. preliminary results: in all cases abdominal functioning was successfully restored; no higher pain related to the continuous laparoscopic suturing has been reported compared to bridge ipom laparoscopic repair, while allowing for a more physiologic outcome and a stronger repair. the use of miniaturized instruments allowed for minimal tissue trauma and accurate surgical gestures; the tiny trocar sites did not require skin suturing and might reduce the risk of trocar hernias. no intra operative bleeding, no seroma formation, chronic pain, nor mesh infection have been recorded. 98% follow up at 24 months, 89% at 36 months with no recurrences observed. the lap-t technique allowed for a sound and anatomic reconstruction, reduced trauma, faster recovery and more satisfactory aesthetic results. surg endosc (2019) background: anastomotic leakage is a serious complication, associated with significant morbidity and mortality. one possible cause of anastomotic leakage is insufficient vascular supply. markers of sufficient perfusion include pink color of the bowel wall, visible peristalsis, palpable pulsations and bleeding from the marginal arteries. these signs are subjective and may be misinterpreted even by experienced surgeons. aim: the assessment of bowel perfusion with the use of indocyanine-green fluorescence angiography might be helpful in decreasing the number of anastomotic leaks. project description: we report a case report of a middle-aged patient without significant medical history who was treated by transanal total mesorectal excision (tatme) for rectal carcinoma. the patient underwent neoadjuvant treatment with radiochemotherapy. during the surgical procedure, indocyanine-green fluorescence angiography showed adequate perfusion of the bowel. the postoperative phase was uneventful and the patient was discharged home on the 9th postoperative day. preliminary results: indocyanine-green fluorescence angiography is a safe, cost-effective and feasible tool for assessment of tissue perfusion during colorectal resections. background: to properly learn how to perform a laparoscopic suture, along with safe tissue handling, applying an appropriate magnitude of the force on the tissue is essential. for this reason, it is fundamental to investigate and validate if training with real-time visual force feedback improves the suturing performance of laparoscopic novice surgeons. capturing all of the forces applied in laparoscopic in surgery in an unobtrusive way has been difficult in the past. sensor has supplied a novel force-sensing film (forcefilm) that can detect all of the forces applied with laparoscopic instruments without changing the surgical workflow or operation of the instruments. aim: to evaluate the effect of visual force feedback on surgical performance, applied force and surgeon's ergonomics during training of laparoscopic suturing using the sensor technology (sensor medical laboratories ltd.). methods: twenty novice laparoscopic surgeons participate in this study. they perform a laparoscopic suture on an ex vivo stomach tissue from a pig. participants are assigned, in a random fashion, to either group that receives visual force feedback (a) or the control group (b) without visual force feedback. five training trials (t1-t5) are carried out in order to assess the learning curve. in addition, an evaluation pretest (t0) and posttest (t6), without visual force feedback but recording the force applied, will be performed after the training trials. the applied force on the tissue and visual force feedback of each instrument are provided by means of the sensor technology. it accurately measures the forces exerted on the tissue from the instrument tip and wirelessly communicates the force information to the surgeon via visual force-feedback. during each trial, several parameters are evaluated such as execution time, applied force, surgical performance, and mental and physical workload. preliminary results: laparoscopic training using visual force feedback leads to an improvement of suturing skills with a reduction of the applied force and therefore providing a potentially positive effect on patient outcomes and surgeon's ergonomics. background: hiatal hernia is a frequent disorder, characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the diaphragmatic hiatus. current anatomic classification is mainly based on the location of the gastroesophageal junction and the presence of a true hernial sac, differentiating sliding from paraesophageal hernias. there is no solid evidence to support an association between gastric carcinogenesis and peh. however, chronic reflux is considered as one of the strongest risk factors of developing adenocarcinoma of the esophagus and proximal stomach. aim: herein, we report a case of an 83-year-old caucasian female with dysphagia, regurgitation and heartburn accompanied by an iron deficiency anemia, a remarkable total body weight loss and recurrent lower respiratory tract infections due to microaspirations. subsequent work-up with ct, upper endoscopy and barium esophagram confirmed the presence of synchronous distal gastric adenocarcinoma and a giant paraesophageal hernia with complete intrathoracic stomach. after mdt discussion and keeping in mind the patient's age and comorbidity, a 3d laparoscopic distal gastrectomy with a synchronous hernia reduction with posterior cruropexy was scheduled. project description: the patient was placed in a supine position, five thoracoscopic ports were introduced, and a diagnostic laparoscopy of the abdominal cavity was performed. the stomach was identified through the dilated hiatus into the left thorax. the hernia sac was dissected away from mediastinal structures, then excised to untwist the stomach. after reduction of the stomach to abdominal cavity, a total d1 ? gastrectomy with a roux-en-y reconstruction was performed. maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency and safety. hampered vision is commonly caused by laparoscopic lens fogging (llf) and lens condensation which has prompted the development of various antifogging fluids and warming devices. numerous tricks have been proposed to overcome this issue, such as heating the scope into a sterile thermos flask filled with hot water, or using one of the commercially available antifogging solutions. however, whether one method is superior to another remains elusive. as most surgeons know, none of these tips are totally efficient, as they don't treat the cause: the temperature difference. taking into account this need, we have developed ehs (endoscopy heater system), a thermoadjustable system by microcontroller, which is implemented in the manufacturing process of the rigid endoscope focused on laparoscopy. the technology enables the self-modulation of the temperature of the endoscope within the different conditions during the surgery, avoiding the 100% of laparoscopic fogging. with the adoption of ehs surgeons get a clear field of vision avoiding continues repetitions of extraction and insertion of the endoscope in the body during the intervention. in this way the risks of the patients are reduced with a more efficient and shorter duration procedure. ehs also represents an alternative that meets sustainability criteria by reducing energy costs and eliminating much of the waste currently generated by this procedure. therefore, this innovation will disrupt the laparoscopic device market by enhancing safety and effectiveness without introducing new components that could complicate surgical procedures. case report: we presented the case of a 63 year old women with chronic coloenteric fistula. conservative treatment was unsuccessful. the orifice was then closed with two subsequent clips, and the patient recovered well. to our knowledge, this is the first successful case of coloenteric fistula treatment with ovesco discussion: ovesco system is a technique that enables the closure of gastrointestinal defects (perforation sites, leaks, fistulas) . after the system application, the patient can be treated at home as was the case with our patient. a successful closure of the leak or fistula is possible when no extraluminal abscess is present. in our case, we had a cavity (previous sinus or abscess) that drained into the small bowel, thereby forming the coloenteric fistula. this allowed us to succeed with a fistula closure, as the cavity could drain into the small bowel conclusions: looking through the reports, one notes that the success rate of the otsc system procedure for insufficiency of anastomosis or colorectal fistula was 57-100%, but only nine successful reports of chronic colorectal fistula were found). a 100% success rate is reported if the clip is placed within a week of occurrence of the leak . on considering the financial side, clips could reduce costs and time of hospitalization and avoid patients having to undergo a surgical repair . the major advantage of ovesco clips seems to be their ability to grasp more tissue compared to the standard clips and their strong grip on the wound margins because of their sharpened teeth. the drawback of the clips in fistula sealing is their incomplete grasp when the tissue is fibrotic. most authors agree that ovesco is not very appropriate for fistulas larger than 12-15 mm. inguinal hernia repair is one of the most performed interventions in minimally invasive surgery. in this opportunity we report a new technique through the use of innovative devices such as the robotic clamp and magnetic deviceswith this technique and thanks to the magnetized devices and the robotic clamp we have demonstrated to reduce the surgical time between 10-20 min as well as to optimize the ergonomics of the surgeon.we explain the technique with a demostrative video and exposition of the devices that are necessary for make it.with this new technique we get a greater capacity of mabiobra for dissection of the peritoneum and later a greater facility for the suture of the same in the repair of the inguinal hernia. a motorized and computerized laparoscopic tool that can be customized to the specific surgeon and procedure a. szold aim: surgeons have different levels of skill and use instruments for different tasks, but laparoscopic instrument are commonly simple mechanical instruments that allow limited degrees of motion, and the same instruments are used regardless of the surgeon or the task. robotized articulating instruments so far have added degrees of freedom, but perform in a standard way for all users and procedures. technology: human xtensions has developed a \ u[hand-held \/u [ motorized smart laparoscopic instrument, that was recently introduced in human procedures. the device has several features that enable to customize it to the user and procedure. the degrees of freedom can be reduced from 7 to 5, the scale of rotation motion has 3 options that can control both speed and range of rotation, a feature especially useful for the variable types of suturing tasks. results: the variable features were tested in different procedures requiring suturing and grasping. the combination of all optional settings made the instrument customizable to the different skill levels of the surgeons. as such, it enabled to control the complexity of the device and take the surgeon through the learning curve until full control of all features was achieved. in addition, the combination of different controls was used for performing specific tasks requiring different levels of maneuverability. in september 2016, the results of a bomss survey regarding the routine use of pre-operative bariatric surgery were published. they found that 10% of units surveyed considered routine preoperative ogd completely unnecessary. as part of newly launching bariatric services in a single isolated centre we protocoled that all bariatric patients had to undergo pre-operative ogd, including a clo test, and reviewed if the ogd findings had influenced our surgical choice of operation and any necessary treatment before surgery. all patients embarking on the bariatric programme since its launch in jan 2017 to sept 2018 were included and had an ogd. the results of these ogds and all the clo tests were reviewed. these ogds were all performed by a single consultant to minimise any potential subjective differences. of the 45 patients, 7 (16%) tested clo positive of which 3 had normal findings on ogd. 9 patients had a hiatus hernia, 5 gastritis, 8 oesophagitis, 12 gastritis and oesophagitis, 9 had other findings e.g. ulcers, polyps' or nodules. the 7 positive clo patients underwent eradication of h pylori. studies have shown that this is a treatable and preventable cause of gastritis/ gastric cancers and potential surgical complications causing prolonged hospital stay in 22% of patients. knowing about the presence of a hiatus hernia prior to surgery also contributed to the surgical planning, including allowing time for the concurrent correction of the hiatus hernia in the operation. all patients with demonstrable oesophagitis (44%) had their operative choice changed to roux en y gastric bypass thus aiming to prevent post-operative reflux which would have been exacerbated had they undergone a sleeve gastrectomy instead. carrying out a pre-operative ogd had a significant impact in operative choice and additional treatment before surgery and therefore should be advised in all patients. general surgery department, ahievran university, kirsehir, turkey the majority of fatalities worldwide in people under the age of 35 years are caused by trauma 1 . blunt mechanisms account for 78.9 to 95.6%of injuries [2] [3] [4] [5] ,with the abdomen being affected in 6.0 to 14.9% of all traumatic injuries. this case contribute to the literature: a patient with sleeve gastrectomy has distorted anatomy at duodenogastric junction, if has bat,her/his small bowel perforation(sbp) will occur on more distal segment. this a unique case before unpublished. 33 years old female who had sleeve gastrectomy 3 years ago presented to emergency department sustained blunt abdominal trauma (bat). when she arrived pyschical exam (pe) revealed an abdominal guarding, tenderness, normal vital signs but those increased 8 h later. wbc values also increased 8 h later. hb was normal.fast showed in 3 cm thickness fluid early in douglas pauch (dp), 50 mm in supravesical, 33 mm diameter in dp 4 h later. abdominal ct: 37 mm diameter fluid in interloop, dp free air at 5th h from the accident. a diagnostic laparoscopy(dl) was done with diagnossed acute abdomen.there were a sbr-located 60 cm from treitz, intraperioneal fibrin deposits and fluid-repaired with a primary suture.the patient discharged on5 days without any event. repeat ct scans are recommended for patients with initial suspected bowel injury. we could not do this; cause ct exam could taken in rush hours only but we did repeatly pe that peritoneal iritation signs increased,resulted a dl,surgical therapy. according to the literature; dl may be a good treatment option in these patients, to reduce morbidity or mortality, time to surgery has been emphasized. long interval between presentation and surgery was found to be associated with complications. very few reports of isolated jejunal transection following blunt abdominal trauma have been published in literature. the literature mentioned; the patients with sbp are hemodinamically stable on arrival to the hospital like our case are, a rupture of the jejunum was seen just distal to the duodenal-jejunal flexure but there were a perforation 60 cm below treitz ligament and caused me to think the patient had sleeve gastrectomy and some brid around gastric and duodenal proximal jejunal part of intestines and also caused a new descended treitz ligament. normally external forces across to spine produce a blast effect on small bowel between treitz and ileocolic ligament. introduction: sasi bypass is a novel metabolic/bariatric surgery operation based on minigastric bypass and santoro's operation.it can be offered for patients with weight regain after sleeve gastrectomy. sleeve gastrectomy (sg)is a commonly performed bariatric procedure.weight regain following sg is a significant issue.yet,the understanding of this phenomenon is still unclear.rates of regain ranged from 5.7% at 2 years to 75.6% at 6 years.sasi bypass was an option for some candidates having sg done 2 years back and failed to achieve the required weight loss or having weight regain.in sasi bypass, resleeve gastrectomy of the dilated gastric pouch is done followed by a side to side gastro-ileal anastomosis. the aim of this study is to report the clinical results and the outcomes of sasi bypass as a therapeutic option for patients with weight regain after sg methods: we conducted a retrospective study for 25 morbidly obese patients having history of sg done more than 2 years back and failed to achieve and/or to maintain the required bmi. exclusion criteria:patients with recent history of laparotomy(less than 12 months). procedure was done at sidra hospital in kuwait from november 2016 to november 2018. using 5 ports, resleeve gastrectomy was performed over36 fr bougie tube starting 6 cm above the pylorus then gastro-ileal anastomosis (side to side)was performed 6 cm above the pyloric ring to an ileal loop counted 250 cm from the ileocaecal valve. data was collected from the patients including:weight loss progress,laboratory full results. discussion and results: during the study period:25 morbidly obese patients with a mean bmi of 44 ± 6 kg/m 2 were evaluated. -%ewl(excess weight loss)reached 85% at one year. -diabetes was cured in the 2 known diabetic patients (type2)within 6 months,and the one known type 1 diabetic patient had better control and less insulin daily doses(results were guided by glycated haemoglobin results every 3 months). follow up laboratory results were normal in 88% of patients (all were kept on regular vitamins and proteins supplementation)-one patient had postoperative leak(day1)from the anastomotic line that was treated conservatively. conclusion: sasi bypass is a promising operation that offers a good weight loss for morbidly obese patients having weight regain after sg conclusions: our study demonstrates a good agreement between the degree of liver steatosis and monocytes fat accumulation as well as between plin2 levels in liver and circulating monocytes. this suggests that ectopic fat deposition is a generalized feature of insulin resistance in obesity. sg reverses monocyte fat accumulation and restores insulin signalling, which correlates well with insulin sensitivity. moreover, circulating mmp9 levels significantly dropped after sg suggesting that the state of generalized inflammation characterizing obesity normalizes. her stomach stapled,a foreign tube like body was seen on cut surface of the stomach.the foreign body seen in dissected stomach wall is the tube is in placed a gastric banding insuflation tube.a laparatomy was made and the tube is extracted her stomach sutured primarily,nasogastric decompression,peritoneal drainage was made.her peritoneum was drained.she has a septic condition, leave in icu for a long period.her general status being well and discharged from hospital in 50 days.we learn after the operation not before;she had a gastric adjustable banding and extraction the gastric band, but the tube of gastric band is not removed. alkhaffaf et al present a case of fistulation of the lagb tubing into the jejunum a review of the published data to identify the salient learning points with this and similar rare complications fistulation from lagb tubing is a rare complication that tends to follow removal of an infected port. the clinical presentation is nonspecific, rendering the preoperative diagnosis difficult. the tube and band can be removed laparoscopically, with closure of the small bowel fistula site. securing the tubing to the abdominal wall fascia after intentional detachment from the port might reduce the incidence of this complication.katherine j et al report a late and rare complication of a small bowel obstruction in a 52-year-old woman from an lagb placed for 2 years. although not a common complication, one that could easily see the safety record of lagb patients tarnished if this small subgroup of patients is not acted upon promptly by emergency departments' unfamiliar lagb surgery. in our case we already made esophagogastroduodenoscopy before operation, ofcourse take past medical history from the patient.the patient hide past operation (gastric banding and removing band and port but leaving insuflation tube). ). there was no difference in the two groups regarding follow-up rate. basic demographics were the same, and other long-term results were similar between the groups. regression models for both post-op complications and failure as defined by baros score did not show that gender is a risk factor. discussion and conclusions: in our study, revisional sleeve surgery were similar. we did not see any significant difference in post-op complications, success of the operation as defined by baros, or subjective feeling of the patients. we do believe that gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling, and that in the case of a sleeve post a band gender is not a risk factor for complication or failure of the procedure. objective: the internal hernia is a rare but a potentially fatal complication of laparoscopic roux-en-y gastric bypass (lrygb). the aims of this study are: (1) to determine the impact of mesenteric defects closure on the incidence of internal hernia after lrygb; (2) to determine the symptoms, characteristics and management of internal hernias after lrygb. the median interval between lrygb and reoperation was 53 months in group a and 26 months in group b. the median percentage of excess weight loss (%ewl) was 61% vs 67%, respectively (p = 0.79). the median percentage of total weight loss (%twl) was 39% vs 37%, respectively (p = ns). 14 patients, 70% (5 in group a), were admitted to the emergency room with acute abdomen pain. a ct scan was performed in 8 patients, 40%, and showed signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed using laparoscopy in 8 patients, 40%, and using laparotomy or conversion in 12 patients, 60%. conclusions: the closure of mesenteric defects during lrygb is recommended because it is associated with a significant reduction in the incidence of internal hernia. our study intends to analyze the long term results of 112 sleeve gastrectomies performed by 3d laparoscopic approach. materials and methods: a prospective cohort study was conducted to perform gastric sleeve for morbid abesity. all surgeries were performed by the same surgeon over a period of two years. the operating surgeon is a senior most laparoscopic surgeon with vast experience in laparoscopic surgery. during two years period, 112 cases were operated using 3d laparoscopy system. scientific calculation was done using spss release 18.0 windows software. results: 112 patients, 74 female (66%) and 39 male (43%), with median age of 42.3 ± 12.6 (15-70) the excess weight lost (ewl) was 68% in the first year, 72% in the second, 73% in the third, 71% in the fourth, 70% for the fith year, 68% for the sixth and 67% for the seventh. postoperative complications were 3 stenosis of the sleeve always located in the incisura and treated with endoscopic dilatation except one that required conversion to oagb. three leakages, all of them reoperated with drainage and introducing prosthesis by endoscopy in the same act. we have never had a postoperative bleeding of the sleeve. conclusions: 3d gastric sleeve laparoscopy is a safe and feasible technique for morbid obesity and related pathologies. the ewl is correct in long time. complications are rare but is necessary to have a good level of suspicious in order to a rapid solution. the worst complication is the leak of the sleeve. the oversewn of the gastric section is a good technique to avoid this complication. surg endosc (2019) aims: leak is one of the common complications of laparoscopic sleeve gastrectomy that result prolongation of hospital stay, morbidity and even mortality. methods: i report new approach for the treatment of 17 leaks presented to me post laparoscopic sleeve gastrectomy with laparoscopic roux en y bypass to the leak site at the level of gastroesophageal area. this new approach is possible and feasible, and avoids stenting due to high failure rate, prolonged hospitalization and saves life of patients. results: all leaks healed 7 days from surgery due to well vascularized small intestinal patch, except for 2 leaks that healed after 2 weeks of conservative treatment. aims: analyse the effect of one anastomosis (mini) gastric bypass (mgb/oagb) in the treatment of gastro-esophageal reflux in patients previously submitted to laparoscopic sleeve gastrectomy (sg). methods: a retrospective analysis was performed on the data of patients who underwent mgb/ oagb after a previous sg at policlinico san marco, italy, from january 2014 to june 2017. a total of 40 patients, 36 female and 6 males (85% f/15% m) underwent mgb/oagb after sg, due to the development of significant gastro-esophageal reflux disease (gerd), refractory to proton pump inhibitors (ppi), detected with the gerd questionnaire (gerd-q) and esophagogastroduodenoscopy (egds). in three patients (5%) a weight regain was also observed (mean bmi 41.3 kg/m 2 , range 39.3 kg/m 2 -42.5 kg/m 2 ). mean patients age was 40.6 (35-60 years old). before sg none of the patients had declared symptoms of gerd or was subjected to a therapy with ppi, preoperative egds did not show signs of esophagitis. mean bmi of the 37 patients who developed gerd without weight regain was 31.4 kg/m 2 (28 kg/m 2 -33.7 kg/m 2 ) at the time of surgery, with a medium ewl% of 51% (68.3-42.5%). patients were treated unsuccessfully with ppi for at least six months before programming revisional surgery. mean gerd-q score was 12. results: after mgb/oagb, with a mean follow up of 19 months (24-15 months), mean bmi was 28.5 kg/m 2 and gerd-q score was 5. however, five patients out of 40 (13%) developed an anastomotic ulcer or a grade c esophagitis. we did not observe any post-operative immediate complication nor any death. conclusion: mgb/oagb is a simple, effective and safe surgical procedure for patients who underwent a previous sg and who developed gerd, with satisfactory results in the short and medium post-operative time, even if there is still concern regarding the complications linked to biliary reflux. v.s. kyosev aims: laparoscopic adjustable gastric band (lagb) was one of the common techniques in bariatric surgery worldwide. the advantages included the possibility of regulation, ease of placement, acceptable weight loss and low rate of perioperative complications. a late complication of lagb is penetration of the gatric band through the gastric wall and migration into the lumen of the stomach. hereby, we present three cases of gastric band migration following lagb. methods: from 2013 to 2017 we observed 3 cases of gastric band migration in between 5 and 7 years after lagb placement. the patients were hospitalized in surgical department complaining of sudden sharp epigastric pain, nausea and vomiting, with symptoms onset in the last few days. all patients underwent abdominal ultrasound examination, x-ray investigation of the abdomen with oral contrast administration, fibrogastroscopy. in 2 cases the imaging studies revealed gastric band migration into the stomach's lumen and in 1 case-obstruction of the jejunum by the gastric band. all patients underwent laparoscopic surgery. results: two of the patients underwent gastrotomy, extraction of the gastric band and roux-and y-gatric bypass. the patient with jejunal obstruction underwent laparoscopic enterotomy, extraction of the gastric band and cholecystectomy due to concomitant cholecystitis. two of the patients had no additional perioperative complications and were discharged at the 5th postoperative day. one patient developed fever, left pleural effusion and partial insufficiency of the gastrointestinal anastomosis in the early postoperative period without the need of surgical treatment. the patient was discharged on 20th postoperative day. all patients were prescribed a diet and monthly blood test of ion balance. conclusions: lagb was one of the most common treatment methods due to the epidemic spread of morbid obesity in western countries. detailed knowledge on possible lagb complications is essential for the treatment of these patients. the diagnosis of lagb complications is often delayed due to its relative rarity and nonspecific clinical manifestations, but in most of the cases it requires emergency surgery for management of life-threatening conditions. results: there was conversion in 2 patients (short mesentery of the small intestine). such postoperative complication like anastomotic leak in 1 patient (2.7%) and staple line bleeding in 1 patient (2.7%), which was managed laparoscopically. compensation for type 2 diabetes was achieved in 9 (50%) patients, improvement was recorded in 7 (38.9%), dyslipidemia in 4 (23.5%) and 7 (41.1%) patients, arterial hypertension in 16 (55.1%) and 9 (31%) patients respectively, what led to metabolic syndrome resolution in 11 (55%) patients. the liquid is allowed to take after 1 day. average postoperative hospitalization-4.1 ± 1.9 days. %ewl for 48 months 69%. conclusions: laparoscopic mini gastric bypass is an effective method of surgical correction of body weight and metabolic disorders in patients with morbid obesity and allows to receive an adequate and stable correction of arterial hypertension, lipid and carbohydrate metabolism, which are components of a metabolic syndrome. introduction: over time laparoscopic sleeve gastrectomy lsg has become the most popular bariatric operation worldwide. a critical step during lsg is ensuring sleeve-size consistency. gastrisail device (gastric positioning system) is a three in one surgical device replacing the standard bougie used in lsg for the application of suction, decompression and to serve as a sizing guide for gastric sleeve creation. the aim of this study is to evaluate the possible merits of gastrisail device in lsg over the standard laparoscopic sleeve gastrectomy. methods: a prospective study of 40 patients randomly divided into two groups: group a composed of twenty patients who undergo lsg with the use of gastrisail and group b composed of twenty patients who undergo lsg with the standard bougie without the use of gastrisail comparing both according to operative time, consistent sleeve formation, delineation and visualization, intraoperative and post-operative complication rates, the lenght of hospital stay,gastric pouch design and percentage of excess weight loss (%ewl). results: regarding intraoperative time, the mean time was 72.0 ± 13.58 and 79.0 ± 11.74 for group a and b respectively,while no patients in group b had consistent sleeve formation,12 patients (60%) had consistent sleeve formation. delineation and visualization were accomplished in 100% of group a patients, was not accomplished at all in group b patients. the alignment of the stomach was reached in 12 patients in group a but no patients at all in group b, the mean of hospital stay was 2.20 ± 0. 42 and 2.40 ± 0.84 for group a and b respectively, the smaller tube design illustrated by gastrograffin x-ray at 3rd post-operative day was accomplished in 8 patients (80%) and 2 patients (20%) in group a and b respectively. there was no significant difference in %ewl in both groups. conclusion: the use of gastrisail device is superior to the standard lsg in consistent sleeve formation, visualization, delineation and good alignment and accomplishment of a small tube design while no significant difference in %ewl. bariatric surgery has spread all over the world. since japan has few patients with morbid obesity compared with western countries, it has been implemented only in limited facilities. however, bariatric surgery in japan is rapidly spreading recently, and many facilities are about to install bariatric surgery. effects of bariatric surgery are known to last for a long time, but some cases require reoperation which is called revision surgery due to late complications or rebound. because of thick subcutaneous and visceral fat, open surgeries are not even always a good solution to make surgery easier in morbid obese patients and all procedures must be completed laparoscopically. therefore, especially in revision surgery, the incidence of complications tends to be increased. as the number of bariatric cases to be increased in japan, cases requiring revision surgery is likely to increase. in revision surgery, it is necessary to select the procedure according to patient condition, and it is necessary to familiar well with those procedures. we will present cases that underwent revision surgery in our department and show the clinical outcome. we have done four revision surgeries after sleeve gastrectomy so far. operative indications are 2 mid-gastric stenosis and 2 rebounding disease. for stenosis cases, we performed roux-en y gastric bypass with distal stomach resection, and for rebounding cases, we performed re-sleeve gastrectomy with duodenal-jejunal bypass. average interval from initial operation to revision surgery is 69 months in rebounding cases, and 9 months in stenosis cases. duration of operation was 269 min in average, and mean estimated blood loss was 18 ml. no postoperative mortality was observed. in rebounding cases, excess bmi loss at 1 year after surgery was 40.9% in average, and both cases achieve diabetes remission at 1 year. one cases of mid-gastric stenosis required a nutritional support with formula diet temporally. in particular after sleeve gastrectomy, revising to roux-en y gastric bypass, re-sleeve gastrectomy, and adding the duodenal-jejunal bypass will be the main techniques. along with an increase of bariatric surgery in japan, it is necessary to acquire sufficient knowledge and skills to carry out revision surgery. methods: we present the case of a 45 year old woman who underwent lsg after lagb removal and lgcp. the patient underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation or erosion. we emphasize that the patient, had undergone three operations of gastric band placement, gastric band removal and gastric plication before sleeve gastrectomy. however, a successful lsg was achieved. results: no severe postoperative complications were mentioned. conclusion: weight loss in the first year was 70% of the excess weight.sleeve gastrectomy after gastric band removal and gastric plication, for morbid obesity seems to be safe and efficient, especially in casesof absence of gastric erosion. surg endosc (2019) department of surgery, 19 patients were observed with serious septic complications many years after gastric banding operation. we detected a female dominance (16 female, 3 male) in patients with a mean age of 41.6 years. the leading symptoms were: dysphagia, upper abdominal tenderness and pain, spontaneous fistula formation, fever, masked septic signs, bowel and urinary obstruction. patients underwent video-endoscopy, chest and abdominal ct (computed tomography), fistulography and cystoscopy. results: in still morbid obese patients, laparoscopic procedures were performed with a conversion rate of 50%: atypic gastric and cardia resection in 4 cases, gastric suture in 9 cases, small bowel resection and suture in 4-4 cases. in one case, fistulectomy, abscess evacuation and combined urinary bladder suture and drainage were carried out. the duration of the surgeries were over 2 h with minimal blood loss (\ 200 ml). the foreign bodies were completely removed in every case. intraoperative complication was not occurred. early physiotherapy were promoted, oral feeding were gradually built up from the 2th postoperativ day depending on the type of the operation. early postoperative complications included recurrent fistula formation (n = 2) and wound infection (n = 11). all the fistulas were closed after conservative treatment. average hospital stay was 8 days, regular check-ups were held on the 3rd, 6th and 12th months of follow up. conclusion: gastric banding is the most common, routine and safe technique for the treatment of morbid obesity. the development of late, severe septic complications draws attention to the crucial importance of follow up. the surgical management of these patients is recommended in specialized centers in regard to difficult operative conditions and atypic treatment options. aims: single anastomosis duodeno-ileal bypass with sleeve gastrectomy (sadi-s) has been proposed as an alternative to biliopancreatic diversion with duodenal switch (bpd-ds) in order to maintain the outcome of the original procedure simplifying the technical complexity and to avoid potential complications. moreover, it potentially represents the more natural second step bariatric procedure after sleeve gastrectomy (sg). we aimed to report the initial experience with sadi-s of our high volume bariatric center. methods: retrospective analysis of patients who underwent bariatric procedure between july 2016 and november 2018 was conducted. the primary aim was the evaluation of the safety of sadi-s, defined as the rate of postoperative complications. the secondary endpoint was the bariatric efficacy of the procedure, defined as percentage excess weight loss (%ewl). results: among 813 patients who underwent bariatric procedures at our institution 36 (4.4%) patients were scheduled for sadi-s. all patients had multiple comorbidities. initial indication for sadi-s was failed sg in 8 patients (median pre-sg bmi 52.1 kg/m \ sup [ 2\/sup [ ; median 39 months after initial operation respectively) and primary procedure in 28 patients (median pre-operative bmi 56.5 kg/m 2 ). the surgical procedure was accomplished with robotic-assisted approach in 4 cases (median operative time 198 min) and with laparoscopic 4 trocars standard approach in the remaining 32 cases (median operative time 130 min). the duodeno-ileal anastomosis was fashioned using a double layer hand-sewn running sutures. no patients showed early post-operative complications, the median postoperative stay was 3 days. at a mean follow up of 12 months the median %ewl was 66.1. to date no patients experienced surgical. one patient develop wernicke encephalopathy 6 months after surgery, but he was non-compliant to multivitamin supplementation. conclusions: at least in a high volume bariatric center sadi-s, both as second step after sg and as primary surgical option, seems to be a safe and effective bariatric metabolic procedure based on solid physiopathologic principles. on the other hand, longer follow-up is necessary to support the use of this procedure as a better alternative to bpd-ds. m.r. elkeleny 1 , a. abo khozima 2 1 git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; 2 git surgery department, faculty of medicine,alexandria university, alexandria, egypt four bariatric cases 1. female patient with intragastric balloon, minor leak from the balloon leading to ballon migration to the jejunum;hance, small bowel obstruction occured. emergency diagnostic laparoscopy was done, enterotomy and extraction of the balloon, direct repair of enterotomy and balloon extraction through 10 mm port site. 2. male patient presented after 5 days of lsg with small bowel obstruction due to entrapment of small bowel loop through one of the port sites;therefor, emergency laparoscopy was done with reduction of the herniated segment and closure of the port site. 3. female patient presented with stricture of the ogj after re-sleeve gastrectomy managed by balloon dilatation which recur after 2 weeks .she was managed by expandable metallic stent for 6 weeks with good response and the stent was removed.4.38-year-old male patient presented with sever peripheral neuropathy following 5 months after sleeve gastrectomy, and the patient was getting worse; thus, he used wheel chair. he has been making good progress on vitamin b complex injections. the aim of our study was to compare histopathological findings of gastric specimens to preoperative clinical symptoms and to conclude about the need for ugi endoscopy as a routine prior to surgery. methods: the last two years, 44 morbid obese patients were selected to undergo laparoscopic sleeve gastrectomy (lsg) in our institution. for the needs of our study, all of them had ugi endoscopy and were reviewed for upper gi symptoms. histopathological reports obtained according to our protocol, after surgery. results: gastric histology from specimens revealed: no findings in 16/44 patients (36.4%), gastritis in 19/44 patients (43.2%) and focuses of incomplete intestinal metaplasia without dysplasia in 8/44 patients(18.1%). finally, two minor leiomyomas with low cellular proliferation rate were fully excised in a patient's specimen. there was no inconsistency between preoperative symptoms and gastric histology, while leiomyomas found were no reported to ugi endoscopy due to size. conclusions: some of the patients with clinical features of food intolerance, gastroesophageal reflux disease, and peptic ulcer disease had finally findings in histopathology of their stomachs. history of helicobacter pylori infection implements a raised incidence of mucosa pathology as well. because only one case revealed carrying significant pathology (leiomyomas), we consider that is safe to proceed with surgery in an otherwise asymptomatic patient based on his previous medical records and blood tests. aims: splenic abscess following laparoscopic sleeve gastrectomy (lsg) is a rarely seen complication. the aim of our study was to present a case of splenic abscess in a morbid obese patient who underwent lsg. as the main concern in these cases is leakage from the staple line, we present our diagnostic and treatment approach. methods: a 42-year-old, female morbid obese patient (bmi 56.6 kg/m 2 ), without any predisposing risk factors, underwent elective lsg in our department. following an uneventful course, she was discharged at the 2 nd postoperative day. however, at the 20 th postoperative day, she readmitted to our unit with high temperature of 38.4 o c, left upper quadrant tenderness and leukocytosis. contrast computed tomography (ct) revealed an abscess at the upper pole of the spleen 4,5 cm in maximum diameter, without leakage from the staple line. results: the patient was treated with broad-spectrum antibiotics and radiological percutaneous drainage of the abscess. although there was a partial clinical improvement, a week later, a new ct scan revealed the continuous presence of the abscess. despite the stable general condition of the patient a laparoscopic splenectomy was performed and a gradual recovery was followed. the presence of splenic abscess without splenic trauma or leakage from the gastric staple line, is an extremely rare complication and only a few cases have been previously reported. the cause has not yet clarified, but the proposed mechanism involves infarction of the spleen, due to vascular compromise and subsequent infection. most of the reported splenic abscesses were diagnosed during the late postoperative period. in our report we present a case of early onset, hence highlighting the need of clinical awareness for early diagnosis and treatment. introduction: obese surgical patients with obstructive sleep apnea (osa) have a higher risk of peri-and postoperative desaturations and subsequent morbidity and mortality. currently, the best perioperative management of patients without known osa remains unclear. although routine osa screening has been advocated, sleep studies are costly and time consuming. we hypothesized that bariatric patients can be safely monitored on a surgical ward by continuous postoperative pulse oximetry without preoperative screening for osa. objectives: to evaluate outcomes of continuous postoperative pulse oximetry without preoperative osa-screening, and to compare the results to outcomes of patients with osa and continuous positive airway pressure (cpap) treatment. methods: all patients who underwent bariatric surgery between 2011 and 2017 were included in this single-center retrospective cohort study. all patients were postoperatively monitored with continuous pulse oximetry on the surgical ward. patients with less than two documented saturation measurements were excluded. patient files were reviewed for osa diagnosis, cpap usage and perioperative details. primary outcomes were 30-day complication rates, intensive care unit admissions due to cardiopulmonary causes and postoperative desaturations of spo 2 \ 90%. secondary outcomes were icu admissions following all causes, length of stay and rates of reoperation and readmission. results: in total, 5203 patients were included. 675 patients (13%) were preoperatively diagnosed with osa, 511 (9.8%) were cpap users. complications occurred in 7.2% of patients without osa and in 9.6% with osa(p = 0.028). desaturations were documented in 1.4% and 4% (p \ 0.001), respectively. in both groups, 1 patient was admitted postoperatively to the icu for cardiopulmonary causes that could be related to osa (p = 0.119). both recovered without further complications. icu admissions, regardless of cause, occurred in 0.42% of patients without osa and in 1.18% with osa(p \ 0.001). no significant difference between groups was observed in complications based on clavien dindo classification, length of stay, reoperation-and readmissions-rates. conclusions: these findings suggest that continuous postoperative pulse oximetry without preoperative osa-screening is a safe perioperative management strategy for bariatric surgical patients. future studies are needed to assess cost-effectiveness of pulse oximetry vs. routine preoperative osa-screening in a prospective clinical setting. background: the pathology of colon is one of the most pressing and socially significant problems of modern health care, because it leads to reduction of the working population employed in manufacturing, in some cases to disability and reduced quality of life. mini invasive surgery of the colon has a great advantage: speed recovery, shorter hospital stay and better cosmetic results, the quickest return of patients to work. as a result, mini invasive endovideosurgery is firmly established in clinical practice of coloproctology. objective: the choice of optimal surgical method for treatment of colostasis, achievement of favorable outcomes of treatment. introduction: laparoscopic roux-en-y gastric bypass (rygb) is one of the most important bariatric surgical procedures performed worldwide and it can produce an important loss of weight with reversal of metabolic disorders like diabetes and dyslipidemia. even though it has good results, some complications occur after gastric bypass. a rare but serious complication of rygb is the so-called postprandial hyperinsulinemic hypoglycemia. its prevalence has been estimated less than 1% of cases and its pathophysiology remains unclear. methods: the aim is to present a case series of reversal surgery in patients with severe hiperinsulinemic hypoglycemia after rygbp in the hospital general universitari de la vall d'hebron. unit of endocrine-metabolic and bariatric surgery (eac-bs center of excellence for bariatric and metabolic surgery by ifso). it is a retrospective analysis of a prospective database same surgical team. we present in this study, the main features of those patients. results: between 2011 and 2018, 13 patients underwent a laparoscopic reversal procedure to normal anatomy and age mean was 57 year (22 years to 70 years). mean preoperative body mass index (bmi) was 31.2 kg/m 2 (range 28-39.4 kg/m 2 ) and 10 were women. all patients presented hypoglycemia symptoms 5 years after and the longest was 15 years after the procedure. the first step of the standard approach was a laparoscopic reversal to normal anatomy with resection of the alimentary rygb limb in 7 cases. a concomitant sleeve-like gastrectomy (sg) was added. four patients presented postoperative complications: gastrogastric anastomosis leak (1) introduction: laparoscopic sleeve gastrectomy is the most performed bariatric procedure, but complications might interfere with patient's long-term evolution based on its compliance and tolerance, surgical attitude and unpredictable evolution. materials: we present the case of a female obese patient, with type ii diabetes mellitus and blood hypertension, with multiple, sequential bariatric minimally-invasive interventions: sleeve gastrectomy in 2012 complicated by postoperative acute gastric dilation and mediogastric stenosis, reoperated for viscerolysis and cholecystectomy, with endoscopic gastric dilations, initially converted to functional one anastomosis gastric bypass (200 cm limb), with a non-adjustable gastric ring positioned instead of stapled division. the last operation was complicated 12 months after by persistent biliary gastro-esophageal reflux, chronic abdominal pain, and gas bloat syndrome. in 2018 the patient underwent conversion to laparoscopic r-en-y gastric bypass, with gastro-enteral anastomosis resection, band removal and viscerolysis. results: conversion to r-en-y was complicated by biliary leakage post-viscerolysis, treated with laparoscopic approach in the 9 \ sup [ th \/sup [ po day. after multiple surgical and endoscopic interventions, the patient presents short-term favorable outcomes, with no reflux or abdominal pain, with further weight loss and diabetes improvement. conclusion: bariatric surgery has unpredictable evolution in same cases, and conversion to r-en-y seems to be the best solution. lgcp is widely used in developing countries due to its lower cost and good results. material and methods: we performed in our department 120 lgcp for morbid obesity. excess weight loss (%ewl) was 55% at 6 month after surgery and 65% at one year. in 12 cases revision surgery was needed for different complications and in 22 cases for inadequate weight loss or weight regain after 18 month follow up. in 8 cases we performed sleeve gastrectomy (in 3 cases after taking down the plication) and in 14 cases we performed a re-plication in one row. results: the rate of revision surgery was 28% overall and 18% for inadequate weight loss (excess weight loss \ 50%) or weight regain. major complications occurred only in one patient (leak with abscess) but it was solved by laparoscopy. minor complications as vomiting and nausea appeared in 5 patients (22%) and were solved with medication. after one year follow up %ewl in these cases was 85%. conclusions: revision surgery after lgcp is possible. a new plication or sg was the option in our series with good results. further studies are needed to evaluate the use of lgcp in the armamentarium of bariatric surgery. background: roux-en-y gastric bypass (rygb) is one of the most commonly performed bariatric procedures around the world.however, rygb it sometimes carries the risk of rarebut serious long-term complications such as malnutrition and liver failure. we report a case of laparoscopic reversal of rygb. methods: in march 2017, a laparoscopic rygb was performed for a 53-year-old female without comorbidities and with a bmi of 54 kg/m 2 . all laboratory test results at the preoperative evaluation were within the normal range. abdominal ultrasound revealed moderate hepatic steatosis and oral endoscopy a hiatal hernia with grade b esophagitis. one year later, patient experienced an important weight loss of 75 kg (from 155 to 80 kg) with a bmi of 28 kg/m 2 . however, patient presented general weakness, abdominal pain, ascitis lower extremitiy edema, anemia, progressive caloric and protein malnutrition, vitamin (a, d), mineral (copper) and folic acid deficiencies, nonalcoholic steatohepatitis (nash) and liver function was progressive worsening. results: a laparoscopic reversal of gastric bypass was performed. the operation was successfully performed via laparoscopy. operating time was 70 min. postoperative was uneventful and patient discharge home at day 6. hepatic biopsy revealed nash with steatohepatitis of 80% (fibrosis f2-3/4). eight months after reversal of gastric bypass, patient has improved her clinical situation (no asthenia), maintains of weight (80 kg) and has improved her nutritional status and liver function parameters. conclusion: laparoscopic reversal of rygb is technically feasible and might be performed safely after thorough preoperative evaluation in carefully selected patients with malnutrition and liver failure. conclusion: laparoscopic sleeve gastrectomy it's a safety obesity procedure before major abdominal hernia repair. it's a minimally invasively technique with an absence of anastomoses. these factors prevent fewer complications, without using the small bowel, and skin problems and allow resolution of obesity-associated co-morbidities. body weight loss after surgery may be an opportunity to repair the severe loss of domain incisional hernia. bibliography borbély, y., zerkowski, j., altmeier, j., eschenburg, a., kröll, d. and nett, p. general surgery, benhazi medical center, benghazi, libia, 2 general surgery, royal bahrain hospital, manama, bahrain obesity is a worldwide epidemic with an increasing incidence trends and as a consequence obesity related health problems become priority to healthcare authorities in all the countries. laparoscopic gastric plication is an emergent restrictive procedure which claimed to be low cost because they do not need staplers and carries less complications as compared to laparoscopic sleeve gastrectomy. we present here a 37 years female who was operated for morbid obesity four months back where she underwent laparoscopic gastric plication with no immediate post operative complication and her wight loss was adequate. two days before presentation to our emergency department she started to complains of sever attacks or upper abdominal pain and vomiting.clinical examination was unremarkable apart of abdominal tenderness in left upper abdomen. all blood routine were normal and all inflammatory markers were within normal range.ct abdomen showed large cystic lesion around the greater gastric curvature containing fluid and raised possibility of collection. patient was admitted to hospital, in despite of medical treatment her pain persists and necessitate immediate laparoscopic exploration. gastro-gastric hernia at the greater curvature through loosen ethibond suture that was used to plicate the stomach in the previous surgery. we released the suture to liberate the strangulated stomach which is not gangrenous. re-plication was not possible because of the extensive gastric wall edema and as preoperative discussion with the patient she refused conversion to sleeve gastrectomy no intervention was done. post surgery patient was free of symptoms and tolerating oral diet and discharged home on third post operative day with no complications. gastro-gastric herniation could progress to gastric wall gangrene which will result in high morbidity and even mortality. high index of suspicion is required to diagnose the condition . preoperative patient counseling is important to explore the surgical options if deemed necessary to convert to another bariatric procedure. k. chouillard, a. d'alessandro, l. chahine background: bariatric surgery is the best available, long-term treatment for morbid obesity. currently, laparoscopic sleeve gastrectomy (sg) is the most commonly performed bariatric procedure in france. despite its safety and efficacy, long-term complications of sg are not rare including gastro-esophageal reflux disease (gerfd), twisting, stenosis, insufficient weight loss, and weight regain. the goal of this study was to analyze the pattern and short-term results of surgical revision in patients with sg. methods: revisional bariatric surgery, regardless of its motivation, was always a multidisciplinary decision after clinical, biological, endoscopic, and radiological assessment. patients who had revisional surgery after sg were retrospectively identified and subsequently divided in 4 subgroups according to preoperative body mass index ( we aim to present the management and the particular aspects of the surgical technique in a gastrobronchial fistula after gastric sleeve . the mean time between intervention and diagnosis is 6.7-7.2 months. methods: between 2011 and 2018, 4253 laparoscopic gastric sleeve resections were performed in our bariatric center. we had one case of gastrobronchial fistula associated with an inferior lobe abscess of the left lung, diagnosed 3 months after the gastric sleeve. the patient was subject for medical treatment for 24 h, than a laparoscopic intervention was performed in order to drain the lung abscess and the gastric fistula and to place a feeding jejunostomy. 2.5 months after this intervention (5.5 months after gastric sleeve) a laparoscopic roux-en-y fistulojejunostomy was performed. the evolution was monitorized with blood tests, upper gi contrast series and ct scans. results: the surgical drainage of the lung abscess, along with the antibiotherapy, controlled the infection and allowed the lung cavity to reduce in size, and thus the drainage tubes introduced in the thorax through the diaphragmatic orifice were retracted progressively. also, the feeding jejunostomy allowed a proper nutrition for the patient with a good recovery. however, 2.5 months after the drainage intervention, the gastric fistula was not healed, and a decision to interrupt the communication with the lung cavity was made, by creating a laparoscopic fistulojejunostomy. after this, the evolution was favorable, with the healing of the lung cavity, oral feeding was permitted and the jejunostomy was suppressed. conclusions: the treatment of the gastrobronchial fistula is complex (medical, endoscopic or surgical), phased and long lasting until healing. surgery was our initial choice for treatment due to the existence of the lung abscess, which needed to be drained. key words: gastrobronchial fistula, lung abscess, laparoscopy, fistulojejunostomy s.i. filip, i. hutopila, c. copaescu introduction: leakage remains one of the most dreadful complications in metabolic surgery. the main cause of leakage is poor tissue oxygenation due to inadequate vascular perfusion. the study of intraoperative tissue perfusion in real time due to icg enhanced fluorescence could provide valuable information for the surgeon in order to prevent postoperative fistula. aim: to present our experience in using icg enhanced fluorescence in laparoscopic bariatric surgery material and method: in 30 cases of gastric sleeve, 12 cases of gastric bypass and in 10 cases of revisional surgery or redo cases we used intraoperative icg mediated fluorescence to assure the optimal vascularization of the involved tissues. in our video we present intraoperative aspects before and after using icg in different cases. results: in all cases of primary gastric sleeve and gastric bypass with intraoperative use of icg we did not encounter inadequate perfusion. in one case of redo gastric bypass after failed vertical banded gastroplasty for morbid obesity despite intraoperative laparoscopic normal aspect of the gastro-jejunal anastomosis, icg mediated fluorescence allowed to identify an unexpected ischemic anastomosis and we could prevent consecutive postoperative leakage. discussion: presented cases are discussed and result with referral to literature is made. conclusion: intraoperative use of icg is a valuable tool in assessing the perfusion of the tissues and provide essential information for the surgeon in order to avoid postoperative leakage. , including 1270 patients, hemostasis with clips has been performed in all cases. however, among these cases nine patients required reoperation for early postoperative bleeding. in five cases a bleeding source from the stapled line was identified while in 4 cases no identifiable source was found. during the second period (2015 to present) 2967 patients were submitted to bariatric surgery and hemostasis was performed by over sewing with a running suture. among these cases reoperation for postoperative bleeding was needed in 13 cases (0.4%), but no bleeding from the staple line being encountered (0%). the difference has statistical significance. no significant complications related to the use of this type of reinforcement were encountered. conclusions: over sewing the gastric stapled line in bariatric surgery is superior to hemostatic clip application in preventing the postoperative bleeding from the stapled line postoperative bleeding. a protocol of active search of the bleeders during the bariatric procedure should be implemented and respected in all the cases. gastroenterological surgery, saitama medical university international medical center, hidaka-shi, saitama, japan intestinal endometriosis is a rare disease which is associated with about 10 to 30% of patients with endometriosis, and it is favorable to the rectum and sigmoid colon. here we report 5 cases (shown in the table) underwent laparoscopic resection for intestinal endometriosis. there were no postoperative complications in all cases, and all patient was discharged on 5-8 \ sup [ th \/sup [ postoperative day. before the operation, 2 of 5 patients were diagnosing intestinal endometriosis, and it was difficult to preoperatively diagnose. among them, the symptoms at the time of menstruation were clear was one case. in case of submucosal tumor, preoperative diagnosis seems difficult. additional image examination at menstruation may be useful for diagnosis. d2 dissection was performed for case 1, 2, 4 because malignant disease could not be denied as a preoperative diagnosis. 2 of them were strongly doubted endometriosis in surgical findings. in intestinal endometriosis surgery, pelvic adhesions and fibrosis are often advanced. in the sigmoidectomy, the average operation time was 152 min and the blood loss was 10 ml. in the rectal resection, the average operation time was 282 min and the blood loss was 17 ml. in case 1 and 5, pelvic adhesion was severe, residual rectum could not be straightened, and side to side anastomosis was performed. in intestinal endometriosis surgery, intestinal anastomosis method should be considered flexibly. conclusion: laparoscopic surgery for intestinal endometriosis was safe, but technically difficult because of fibrosis and adhesion. it is important to accurately diagnose from clinical symptoms and image also intraoperative findings. anastomotic method should be decided according to the case. aim: the aim of the study was to identify and highlight some of the complications one can encounter in bariatric surgery-specific-sleeve gastrectomy and discuss the therapeutic options one has at his disposal. methods: the study was retrospective. we identified a number of 260 patients which had a sleeve gastrectomy done in our clinic for a 2 year period. of these 10 had important surgical complications encountered during the surgery or in postoperative care. results: the group included 260 patients, with an average bmi of [ 40 kg / m 2 . average hospital stay was 7 days, with an average of 4.5 days which increased to 30 days when fistulas were encountered. the most frequent surgical complications were bleeding from the gastric suture (6) and gastric fistula (4 cases). other complications encountered were wound hematoma. surgery was required in 4 of the 6 cases of bleeding and 3 of the fistula cases required reintervention. one case was resolved with endoscopic stenting. conclusions: laparoscopic gastrectomy is considered a safe procedure with good results for the patient. although complications are rare they pose a series of technical difficulties for the surgeon due to the weight of the patient and frequent comorbidities which come with obesity. a thorough understanding of the symptoms and good follow-up ensures the best results. aims: to achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (lagb) can be converted to a laparoscopic roux-en-y gastric bypass (rygb). there is limited data on the feasibility and safety of routinely performing a single-step conversion. we assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. to the best of our knowledge this series represents the largest single-center study on conversion from lagb to rygb methods: between october 2004 and december 2017, a total of 1383 patients who underwent lagb removal with rygb were identified from a prospectively collected database. in all cases, a single-stage conversion procedure was planned. the feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. results: a single-step approach was successfully achieved in 920 (86.5%) of the 1383 patients. during the study period, there was a significant increase in performing the conversion from lagb to rygb single-staged. no mortality or anastomotic leakage was observed in both groups. only 49 patients (3.6%) had a 30-d complication: most commonly hemorrhage (n? = ?23/49), with no significant difference between the groups. conclusion: converting a lagb to rygb can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. with increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. only a migrated band remains a formal contraindication for a one-step approach. surg endosc (2019) . six months after surgery the mean hrql score, was 2 (0-6) in 5 patients underwent to lsg and 0.6 (0-2) in 3 patients underwent lgb. twelve months after surgery the mean postoperative questionnaire score was 6 (0-12) in 2 patients who underwent lsg. at ph-manometry the mean percentage time of acid reflux in orthostatism was 7.3 (range 6-8.6) and in clinostatism 5.3 (range 0.3-10.4). the mean demeester score at the distal electrode was 33.1 (13.7-52.5). conclusions: in asymptomatic patients, complete gerd evaluation before bariatric surgery allows better selection of surgical procedure, to reduce the postoperative occurrence of severe or de novo gerd. postoperative gerd evaluation provides useful data regarding the impact of lsg on gastroesophageal reflux. a larger patient sample size is required. aims: vertical calibrated gastrectomy (usually know as gastric sleeve) as unique technique gives better results than the roux y bypass in terms of improvement of anthropometric measures, reduces comorbidities and has a lower rate of postsurgical complications, with an improvement of quality of life. material and methods: an observational, longitudinal, retrospective and comparative study with 95 patients, aged 18-65 years,during a period of 3 years. everyone must comply with the protocol of the unit. demographics of the population and the anthropometric data will be measured in the presurgical consultation, the month and the year after the surgery: weight, height, bmi, weight loss percentage,bmi percentage and percentage of excess weight lost. we took data on the cardiovascular risk by the framingham score. the quality of life is measured by baros scale. mayor comorbidities are hypertension, diabetes, dyslipidemia. complications will be measured in absolute frequencies. for de statistical study, we apply type t student or chi square being statistically significant p equal to or less than 0.05. results: there was not statistically significant difference between the 2 techniques of surgery month (p = 0, 83), but they were evident to the year of the same (p 0.003). not gender or age differences were apparent. mayor complications did not appear in gastrectomy (no leaks), highlighting the number of bleeds with this surgical technique. the bypass there were two leaks. there was no statistically significant difference in cardiovascular risk (p = 0, 07) between the two techniques. there was a more significant decrease in number of comorbidities in gastrectomy against the bypass, with a total disappearance of patients with dyslipidemia. there were no statistically significant differences in baros score, although it was higher in gastrectomy. conclusions:-the vertical gastrectomy as unique technique can be considered superior in the short term, as well as safe, according to the aec quality parameter. we think it will be necessary to continue their studies into the medium-long term. aims: analyze the impact of different bariatric surgeries technics in carbohydrate metabolism and pancreatic beta cell population of none obese adult wistar rats. methods: we used twenty healthy not obese adult wistar rats divided in five groups randomly assigned. each with n = 4. the control groups were divided into fasting control (f) and sham (surgical control). the surgical groups were separated into vertical gastrectomy (gs), 50% resection of the middle small bowel (ri50) and gastric bypass (gb). in each group was assessment: beta cell mass modifications, pancreatic islets histomorphometry, proliferation, apoptosis and neogenesis in beta-cell pancreatic population; intraperitoneal glucose test tolerance, body weight and food intake. statistical analysis as evaluated using mann whitney test. results: the malabsorptive and restrictive group have a significantly smaller increase weight than the control groups. the intraperitoneal tolerance glucose test reports incremental glucose area under curve (auc) was significantly higher in the malabsorptive group and lower in the restrictive group compare to the control groups during the second (p \ 0.01) and third (p \ 0.05) month of the study. the beta-cell mass was significantly higher in the ri50 group compared with control groups respectively. there was a significantly increased number of beta-cell per pancreatic insulin positive area in gs and gb. proliferation was significantly increased in ri50 and gb group, and significantly decreased in sg compared. there was no significantly difference during apoptosis assessment among surgical and control groups. in neogenesis differences between groups were assessed qualitatively by the presence pdx -1 expression, being higher in rygb. the endocrine pancreas in our model is altered by the anatomical and functional conditions arising from surgical techniques. carbohydrate metabolism conditions are affected by temporary adaptive processes due to surgical alternatives. there is a hyperplasia and hypertrophy of the beta cells in surgeries with a malabsorptive component, as well as greater neogenesis. these results could explain part of the existing relationship between the enteropancreatic axis and the existing incretins. m. buza, c. copaescu introduction: nowadays, we have high volumes of obese patients for whom surgery is the answer, but unfortunately the psychological evaluation has no standard recomandation in preoperative evaluation of bariatric patients. it is argued that surgery success, in addition to the operation itself, relies on behavioral changes and that one of the goals of the preoperative assessment is to prepare the patient for the postoperative period, aiming to optimize surgical results. aim: although no formal standard exists in the literature, there is growing recognition of the important elements to be addressed and the appropriate means for collecting the necessary data to determine psychological readiness for these procedures. methods: information regarding the components of the clinical interview and the specific measures used for psychological testing are discussed. given the limited data on predicting success after surgery, determining psychological contraindications for surgery is addressed. additionally, the multiple functions served by the psychologist during this assessment procedure are highlighted along with the value of this procedure in the patients' preparation for surgery as well as the postoperative follow-up. in our center of excelence for bariatric and metabolic surgery (coe) we introduced since 2013 a mandatory pre-and postoperative psychological evaluation for all patients addressing the metabolic program. results: psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also-and more so-to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and the associated lifestyle changes. postoperative follow-up is necessary. the psychological evaluation of the patient undergoing bariatric surgery is an invaluable piece of the larger pre-and post-surgical assessment, aiming better results in the short and long term after bariatric surgery. introduction: a mesenteric cyst is defined as a benign abdominal tumors that is located in the mesentery of the gastrointestinal tract, identified in * 1 of 100,000 hospital admissions. mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. the preoperative diagnosis requires all the common abdominal imaging techniques. usually the correct diagnosis may be made only at the operation stage or during the histological examination. all mesenteric cyst should be resected in order to avoid their complications, complete surgical resection is recommended and curative in the majority of cases with a low risk of local recurrence. the laparoscopic approach is the gold standard in the treatment of intraabdominal mesenteric chylous cyst. laparoscopic resection provides less pain, shorter hospital stay, and early recovery for the patient. case report: we report a case of 28-year-old saudi woman who presented to our clinic complaining of upper abdominal pain and mass in the epigastrium for one week, no history of nausea, vomiting, or recent changes in bowel habits. her medical and family histories were clear and she had never had any abdominal interventions. abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant, ultrasonography and with computed tomography of the abdomen revealed an approximately 93 9 72 9 66 mm unilocular cyst closely related to the mesentery in the left side of upper abdomen not related to the pancreas .the cyst was excised by laparoscopy complete surgical excision to avoid recurrence within healthy borders, it is contained milky white fluid. the histopathological findings were chronic inflamed mesenteric cyst. a review of the literature considering this rare entity was also performed to evaluate our treatment strategy. conclusion: mesenteric chylous cysts represent a diagnostic challenge and they should be considered when a physician encounters an intraabdominal mass. usually the correct diagnosis may be made only at the operation stage or during the histological examination. the treatment of choice is the complete surgical excision that can be safely performed by laparoscopy. surg endosc (2019) background: diverticulum of appendix is relatively rare, and appendiceal diverticulitis was reported to have a higher risk of perforation than appendicitis. in the us and europe, because of the high risk of perforation, preventive appendectomy is recommended to appendiceal diverticulosis, even if the patient has no abdominal pain. methods: we retrospectively reviewed the records of 672 post-operative patients, who were diagnosed appendicitis or appendiceal diverticulitis on the pathological findings in our institution from january 2012 to october 2018. all patients were performed computed tomography (ct) before operation. 652 patients underwent laparoscopic surgery, including appendectomy, cecal resection, ileocecal resection and right hemicolectomy, while 20 patients underwent open surgery. total of 12 cases of appendiceal diverticulitis were analyzed in our study. result: 11 patients had abdominal pain before surgery. 4 patients were diagnosed appendiceal diverticulitis by preoperative ct. all patients underwent laparoscopic surgery (10 appendectomy, 1 cecal resection, and 1 ileocecal resection). on the pathological findings, perforation of appendix was found in 5 patients and the pseudo type of diverticula with no muscle layer was found in all patients. 660 patients with appendicitis were treated surgically during the same period. among them, a perforation of appendix was found in 78 cases. the perforation rate was 11.8%. on the other hand, the perforation rate of appendiceal diverticulitis was 58.3% in our study. conclusion: the perforation rate of appendiceal diverticulitis was higher than of appendicitis in our study. for the examination of the treatment strategy, including preventive appendectomy, the accumulation of more cases will be expected. case presentation: a 59-year-old man was referred to our hospital with right lower quadrant abdominal pain for 2 days. his fever was 38.4°c. his white blood cell count was 30,200/ ll, and c-reactive protein level was 8.3 mg/dl. ct revealed multiple diverticula of cecum and appendix. micro-abscess and free air were found around appendix. we diagnosed this case as appendiceal diverticulitis and laparoscopic appendectomy was performed. a perforation was found in resected appendix. microscopic study revealed a pseudo-diverticulum. the inflammation of appendix was stronger in serous membrane side than in mucosa side. this finding accorded with appendiceal diverticulitis. introduction: in order to reduce the abdominal trauma and the length of scar incisions (also during laparoscopic surgery) many approaches during the last decade has been proposed, such as single access laparoscopic surgery (sals). the aim of our paper was to update the data of our previous paper with a greater cohort of patients and a longer follow-up, also showing the single access laparoscopic left colectomy (salc) technique in particular with inferior mesenteric artery preservation imap (valdoni's technique). materials and methods: we made a retrospective analysis from october 2009 and october 2016 of all patients who underwent a sals approach for colorectal disease in the department of general and mininvasive surgery of san camillo hospital of trento. statistical analysis was performed using ibm spss statistics 23. continuous data were expressed as mean ± standard deviation (sd). categorical data were expressed as absolute number and percentage. the results are presented as 2-tailed values with statistical significance if p values \ 0.05 results: from october 2009 until october 2016, 72 salc for colorectal surgery were performed in our unit. of this 72, 58 were for left colectomy. in 12 cases we performed an imap. the salc with imap were performed only in case of benign disease. the mean operative time was 149.74 ± 27.93. only one intraoperative complication were recorded, that was a splenic capsule tear, resolved with apposition of fibrillar haemostats. according to clavien dindo classification there were in particular 2 grade ii complications, a bleeding solved with blood transfusion and one pancreatitis solved with medical therapy; 2 grade iiia complications that was anastomotic bleeding solved endoscopically (the two complications raised in patients with imap) and 2iiib complications due to anastomotic leakage which needed reoperation. the mean length of incision was 3.64 ± 0.86 cm. logistic regression did not show any correlation between imap and any complications. conclusion: in conclusion, salc is a safe but very challenging technique which need a longer learning curve than the conventional laparoscopic one. in laparoscopic colectomy, also, imap seems to be safe and effective without correlation with post-operative complications also if performed in single access laparoscopic approach. aims: to describe an infrequent anatomical variation that can give rise to diagnostic and therapeutic difficulties. methods: patient with ivermark syndrome (situs ambiguus and polysplenia) with acute appendicitis and bibliographic review results: a 41-year-old male who consulted for flank and right hypochondrium pain of 18 h of evolution, associated with nausea without vomiting, no fever noir other symptoms. to the physical examination good general condition. painful to palpation selectively on the flank and right hypochondrium, with involuntary defense and positive decompression at this level. the signs of rovsing and psoas were negatives. in the analytical performed leukocytes of 17,000 with neutrophils in 82% and rpc (reactive protein c) in 22 mg/l. abdominal ct (computed tomograph): cecum and the ilio-cecal valve were visualized at the subhepatic level with tubular structure on the side and seemed to correspond to the cecal appendix which is increased in size (12 mm), with findings suggestive of acute appendicitis. sigma and descending colon located in right hemiabdomen. second per duodenal portion located anterior to the superior mesenteric artery. superior mesenteric vein located to the left of the superior mesenteric artery, rotating around it, (radiological signs compatible with intestinal malrotation). no free fluid collections nor pneumoperitoneum. laparoscopic appendectomy on phlegmonous acute appendicitis without incidents. correct post-operative course, being discharged at 48 h; the pathological anatomy was reported as acute appendicitis in phlegmonous. conclusions: ivermark syndrome is a genetic alteration with a multifactorial inheritance pattern, characterized by an alteration in the situation of the mesenteric vessels, which leads to abnormal rotation of the intestine during the embryonic period and alteration of the situation of different intra-abdominal organs, without a specific pattern that is pathognomonic, is associated with congenital heart anomalies between 50 and 90%. reaching adulthood only between 5 and 10% of them. a case of acute appendicitis is presented in a patient with this anomaly, which can lead to diagnostic and therapeutic difficulties due to the anatomical variations involved. abdominal tomography is the image method that provides the best performance for the diagnosis of acute pathologies in this type of patients. background: the clinical manifestations which occur in relation to decompression during scuba diving are variable. mild symptoms have often been reported in gastrointestinal tract. this is one of the severe cases with gastrointestinal barotrauma. ischemic colitis caused by air embolism very rare, therefore it is to be reported and discussed. case presentation: a 58-year-old man visited our emergency room with diffuse abdominal pain and bloody diarrhea 2 days ago. the patient was a skilled diver who took seafood through diving for 30 years. two days before presenting, the patient had severe abdominal pain just after diving for 2 h at a depth of 30 meters. he was immediately transferred to a local hospital for hyperbaric oxygen therapy, but there was no improvement with the symptom. abdomen ct angiography showed terminal ileal, ascending, sigmoid colonic and rectal decreased enhancement with wall thickening. sigmoidoscopy showed diffuse huge ulcerative lesions and ischemic changes on mid rectum and sigmoid colon. emergent subtotal colectomy and temporary loop ileostomy were done, and pathologic findings revealed diffuse mural infarct with serosal abscess formation in whole colon and transmural infarct in terminal ileum. conclusion: surgical approach could be one of the treatment options, though it depends on severity of the symptoms and the patients' conditions. colonic lipomas are extremely uncommon benign tumours, with an incidence ranging between 0.035% and 4.4%. although they are most frequently asymptomatic, when colonic lipomas are [ 2?cm, they may present symptoms such as constipation, abdominal pain or rectal bleeding. most colonic lipomas typically occur in middle aged women and are located in the ascending colon and the caecum, while occurrence in other parts of the colon and rectum is rare. in this case report, we describe a lipoma that caused descendent bowel intussusception. a 55-year-old male presented with longstanding history of constipation. personal history of interest included active smoker, hypertension, hypercholesterolemia, psoriasis with joint affectation and reiter syndrome. he had had no previous surgery. he attended the emergency services on 17th july 2018 with a two-day bowel obstruction, without fever or nausea, being attended by our surgical emergency unit. he had been assessed during the previous months by gastroenterology, with a colonoscopy that showed a 4 cm submucosal lesion that partially occluded descendent bowel, with inconclusive biopsy. an abdominal contrast-enhanced computed tomography (ct) was performed, confirming a welldefined mass located in splenic flexure of descendent bowel, conditioning a large bowel intussusception, nevertheless with no obstructive acute signs. the surgery was scheduled a few weeks later, performing a laparoscopic segmental resection with primary anastomosis including oncologic margins. the patient evolved satisfactorily in the postoperative period and was discharged six days after the surgery without any complications. likewise, he was monitored on a regular basis at our outpatient department and was free of symptoms at the 1-month follow-up visit. the histological analysis revealed a 5 cm ulcerated lipoma affecting 60% of bowel circumference. the molecular study, using fluorescent in situ hybridation (fish) showed no mdm2 gene amplification. laparoscopic segmental resection of the large bowel is a safe and feasible technique for the treatment of large bowel intussusception caused by a colonic lipoma. the complete removal of the lipoma will condition the prognosis. furthermore, in the future, endoscopic surgery using colonoscopy could be employed when having a certain preoperative diagnosis of lipoma. surg endosc (2019) introduction: acute appendicitis is one of the most common abdominal surgical emergency, the diagnosis of which mostly relies on conventional methods such as physical examination and blood tests. the use of ultrasonography and ct abdomen aids in more precise diagnosis especially in patients with atypical presentation or in elderly. aim: this study aims to evaluate the ability of the neutrophil/lymphocyte ratio (nlr), platelet/lymphocyte ratio (plr) and mean platelet volume (mpv) in predicting the diagnosis of acute appendicitis. methods: retrospective analysis of prospectivly maintained data of all patients (98) admitted with acute appendicitis to the emergency department at a tertiary hospital in the middle east between january 2016 till september 2016. medical records and database of patients,who had appendicectomy for clinically and radiologically proven appendicitis, were reviewed. the retrieved data included patient's demographic and laboratory values of white blood cells (wbc), neutrophil (n), lymphocyte (l), and platelet (p) along with their ratios for comparison. results: spss 23 version was used for tabulating the data. the recommended cutoff value of the nlr, plr and mpv in predicting the diagnosis of acute appendicitis was decided by using receiver operating characteristic (roc) curve analyses. at least for nlr, the confidence interval (ci) was 0.47 which is 47 percentage of the positive values, since the confidence limit was between 35 to 58%. our results showed that the laboratory parameters were fairly significant since the confidence interval was 0.47 in predicting the diagnosis in our population. conclusion: although appendicitis is a clinical diagnosis but laboratory parameters specially nlr, plr and mpv can be used as an adjunct in the diagnosis of acute appendicitis. literature is scarce concerning the validity of such parameters in our part of the world and prospective randomized controlled trials are needed to prove the efficacy of such rationale. objective: tumors of the cecal appendix represent a subset of colonic neoplasms whose early diagnosis is a real clinical challenge. correspond to 0.5% of all gastrointestinal tumors and their prognosis depends on the type of injury, being the most frequent variety the carcinoid type. appendix involvement in endometriosis is rare, accounting for 3% of all endometriosis cases, and sometimes mimicking cecal tumors. methods: a 43-year-old woman with a history of hypothyroidism due to autoimmune thyroiditis and atrophic gastritis with gastric neuroendocrine tumors resected by endoscopy that in the digestive unit reviews, tac with double contrast was requested, showing a lobulated lesion in the cecum adjacent to the ileocecal valve, with contrast enhancement of approximately 27 9 21 9 20 mm, suggestive of tumor. the colonoscopy evidenced a protruding appendicular osteum with inflammatory aspect that was biopsied. the pathological anatomy of the biopsy reports chronic congestive colitis with edema of the own blade and minimal acute activity, with moderate local eosinophilia.the case was presented in the multidisciplinary oncology committee and it is decided, due to the patient's background, to perform surgery on the lesion. laparoscopic right hemicolectomy was performed, with extracorporeal latero-lateral mechanical anastomosis with endogia signiaò 60 mm. results: the patient evolves favorably, with good oral tolerance and depositional habit. she is sent home at the sixth postoperative day. the pathological anatomy reports tumor injury in the appendicular ostium compatible with endometriosis at the base of the cecal appendix implantation, ruling out malignant tumor pathology. conclusions: gastrointestinal tract endometriosis represents 3-15% of cases, being most frequently located in the rectal-sigmoid region. appendix involvement in endometriosis is rare, accounting 2-3% of all endometriosis cases and presents a preoperative diagnostic challenge, because sometimes mimicking a carcinoid cecal tumor. in our case, due to the patient's history, we assumed that the cecal lesion was a carcinoid tumor, so we performed a laparoscopic right colectomy, but if we had known that it was an endometriosis, we could have performed an appendectomy, although in both cases the laparoscopic approach gives us some benefits compared to the open approach aims: the natural history and predictive factors associated with chronic anastomotic complications have not been clearly studied. the aim of this study was to evaluated the predictive factors related to chronic anastomotic complications methods: from january 2010 to december 2016, a total of 53 patients who underwent anastomotic leakage were enrolled in this study. all patients underwent anterior resection with or without defunctioning stoma due to colorectal cancer. the patients received follow-up by clinical examination and abdominopelvic computed tomography (ct). they underwent a follow-up ct every 6 months for the first 1 year and then every 12 months for the next 2 years after that. complicated group (cg) underwent chronic anastomotic complications. normal group (ng) didn't underwent chronic anastomotic complications like stricture, fistula, chronic sinus, etc. results: there were no significant differences in gender, age, preoperative chemoradiotherapy and operation type between two groups. low rectum lesion and defunctioning stoma at the time of primary surgery were more frequent in cg (p = 0.013, 0.021). there were no significant differences in type of anastomotic leakage, international leakage grade and ct findings at the time of diagnosis of anastomotic leakage. however, abnormal ct findings at the time of 6 month were more frequent in cg group (p \ 0.0001). in multivariate analysis, abnormal ct finding at the 6th months was only significant factor related to chronic anastomotic complications. conclusions: abnormal ct findings at the 6th month associated with prediction of chronic anastomotic complications. aims: acute appendicitis is the most common cause of acute abdomen requiring surgical intervention in the world. nowadays, standard treatment of acute appendicitis involves a surgical approach, eitherlaparoscopic or open.the purpose of the present study is to evaluate the safety of a discharge within less than 24 h after performing appendectomy as a result of an uncomplicated acute appendicitis. conclusions: patients who undergo appendectomy (open or laparoscopic) for acute uncomplicated appendicitis, without surgical incidents and an adequate social/family network, can be discharged in less than 24 h without a higher risk of post-operative complications or readmissions than patients with longer postoperative stays. it will be necessary to conduct more prospective studies with higher level of evidence that could corroborate our results. aims: median arcuate ligament syndrome (mals), also known as the celiac axis compression syndrome, is a rare condition caused by to the compression of the celiac trunk and the nerves located in this area (celiac plexus) by the median arcuate ligament. it is believed that mals is caused by the median arcuate ligament compression of the celiac plexus nerves over the celiac trunk, but another probably cause may be the lack of blood flow to the organs supplied by the celiac artery, however, this theory is controversial. the first clinical sign of mals is the apparition of postprandial abdominal pain in the upper abdomen. this typical pain forces patients to avoid eating, which can lead to loss weight (often more than 20 pounds). other associated symptoms may include nausea, diarrhea, vomiting and delayed gastric emptying (a delay in food moving from the stomach into the small intestine). in relation to this uncommon condition, we present a clinical case of laparoscopic management of mals. methods: we present a 23-year-old patient with complaints of recurrent epigastric pain, postprandial vomiting and loss weight. blood tests and gastroscopy were performed to help ruling out more common causes of his symptoms, such as gastroesophageal reflux disease (gerd), gastritis or gastroparesis. as a part of the differential diagnosis, mals was suspected and a mesenteric doppler ultrasound was ordered to check blood flow through the celiac trunk and evaluate a possible compression of the celiac plexus. also, an angio-ct scan was also performed to confirm the diagnosis. once the mals was diagnosed, we decided to perform a laparoscopic approach as definitive surgical procedure. results: the patient was discharged 48 h after surgery with no remarkable events during his postoperative stay. he has been followed up during 6 months, remaining asymptomatic. conclusions: laparoscopic approach in mals offers a superior visualization during the surgery and involves lower morbidity in compare to open approach, which makes it an optimal treatment for this condition. aim: pilonidal sinus is a common disease with annoying and often painful symptoms. traditional surgical techniques for its treatment are characterized by either intense postoperative pain and prolonged wound-healing periods (wide resection, marsupialization) or unsatisfying aesthetic results (advancement or rhomboid flaps). 'endoscopic pilonidal sinus treatment' (epsit) is a new minimally invasive technique which utilises the meinero scope, primarily designed for the endoscopic treatment of complex perianal fistulas in a technique known as vaaft. we present our experience and outcomes in three treatment centers in northern greece. methods: between july 2015 and november 2018 we treated 61 patients with pilonidal sinus using the epsit technique. the mean age of patients was 30, and 85% of them were male. 4 patients were treated in the acute phase with the presence of pilonidal abscess. all operations were performed by two laparoendoscopic surgeons specifically trained in the technique. most patients were treated on a day-case basis. postoperative wound care included daily tract irrigation with 10 ml of saline for a total of 10 days. results: there were no immediate postoperative complications. medium postoperative pain was 2.8 on a vas scale. 91% of patients were discharged on the same day, 4 patients remained in hospital for one day mainly due to social reasons. return to daily activities was immediate. in a maximum follow-up of 24 months we observed 5 recurrences. conclusions: epsit is a promising minimally invasive technique for the treatment of pilonidal sinus. what makes it mostly attractive is the minimal amount of postoperative pain, the excellent cosmetic result and the fast recovery with return to daily activities. introduction: isolated acute chylous peritonitis is a rare event. when presented as an acute abdomen warranting surgical intervention, it is often difficult to determine the cause pre-operatively. here, we report a case of acute chylous peritonitis due to meckel's diverticulitis presented with the clinical features suggestive of acute appendicitis. presentation of the case: a 32-year-old female presented with abdominal pain and clinical features consistent with acute appendicitis underwent diagnostic laparoscopy. she was found to have four-quadrant chylous peritonitis and ileus caused by an inflamed meckel's diverticulum adhered underneath a loop of small bowel and mesentery leaking chyle. after uneventful postoperative recovery, she was discharged at post-operative day two with oral antibiotics and was advised to take a low-fat diet. aims: perforated diverticulitis with purulent peritonitis (hinchey iii) has traditionally been treated with surgery including colon resection and stoma (hartmann procedure) with considerable postoperative morbidity and mortality. laparoscopic lavage has been suggested as a less invasive surgical treatment. methods: a 78-year-old woman with a 10-day history of abdominal discomfort exacerbed during the last 48 h. ct scan showed neumoperitoneum accompanied by free fluid and a 6 cm collection adjacent to descending colon showing diverticula suggestive of covert perforation. after 48 h of non-response to medical treatment, associated with the impossibility of percutaneous drainage through interposition of intestinal loops, colon and lumbar vessels, urgent surgical intervention is decided. results: laparoscopic lavage of all 4 quadrants was performed with saline, 3 l or more, of body temperature, until clear fluid was returned. two non-suction j-pratt drains were placed. intravenous antibiotics were continued for a minimum of 72 h, then oral antibiotics were continued for 1 week. oral fluids were commenced on the first postoperative day and solids were subsequently introduced, depending on clinical progress. conclusion: laparoscopic management is reasonable alternative to the traditional open resection for hinchey grade ii-iii perforated diverticulitis with generalized peritonitis. this approach has a low mortality rate despite patient co-morbidity and disease severity. benefits include stoma avoidance and minimal wound infection. subsequent elective resection is probably unnecessary and readmission in the medium term is uncommon. background: constipation and fecal incontinence are common annoying complications after pull through procedures for hirschsprung disease (hsd). many causes could be the etiology of these problems. perineal descent syndrome could be the major hidden cause of these complications. the aim of this study is to evaluate the role of perineal descent syndrome in the development of post pull through constipation and fecal incontinence in addition to evaluate the role of laparoscopic rectopexy for treatment of these problems. \ b[patient and methods: \/b [ 380 patients treated with pull through for hsd over the period of five years. 62 out of the 380 patients presented with constipation and fecal incontinence. 23 patients with constipation and 39 patients with fecal incontinence. rectal exam, anorectal manomety, defecography, contrast enema, rectal biopsy, emg, proctoscopy and endorectal ultrasound were performed to all patients. patients with stricture, missed aganglionic segment, injured internal anal sphincter, and loss of the sensory mucosa above the dentate line were excluded from the study. anterior wall rectopexy was performed for anterior wall rectocele. posterior wall rectocele was treated by retro rectal mesh rectopexy. emg is repeated 7 weeks and 7 months after surgery. outcome measurements included constipation, fecal incontinence and pudendal nerve latency. results: 62 cases of post pull through constipation and fecal incontinence. 23 patients with constipation and 39 patients with fecal incontinence.7 patients with stricture, 3 patients with missed aganglionic segment,2 patients with loss of anal sensory sensation and 2 patients with injured anal sphincter were excluded from the study. defecography showed 40 patients with anterior rectocele (22 males and 18 females) and 8 patients with posterior rectocele (2 males and 6 females). the patients mean age 8.93 ± 2.4 years . emg showed prolonged pudendal nerve conduction in all cases. anterior wall and retro rectal rectopexy were performed laparoscopically without complications. constipation was resolved in all patients after surgery. all patients showed fully control in defecation. pudendal nerve latency decreased in all patients. conclusion: perineal descent syndrome proved to be a major hidden cause of post pull-through constipation and fecal incontinence. laparoscopic rectopexy showed a good solution of these complications. cystic lymphangioma is a rare entity. the surgical indication is determined by the size and symptomatology, and consists of the complete exeresis of the tumor. the laparoscopic approach is feasible in these cases, allowing a broad visualization of the anatomy, accessibility to the retroperitoneum in the context of a minimally invasive approach and a better recovery of the patient, without providing an increase in morbidity compared to the conventional. in this way we defend as a technique of choice laparoscopic surgery against these rare tumors for the general surgeon in the abdominal cavity, betting on a minimally invasive surgery. aims: laparoscopicposterior sutured rectopexy is one of the accepted treatment options for fullthickness rectal prolapse. recently, reduced port surgery(rps) has beenan emerging concept that, compared with conventional multiple port surgery (mps), yields reduced postoperative pain and improved cosmesis. the aim of the study is to evaluate the feasibility and safety of rps for fullthickness rectal prolapse. methods: rps was performed by single-incision plus one puncture, using internal organ retractor(ior) to secure operative field. straining one ior by 3-4 strings in 3-4 directions makes it possible to retract the internal organs three-dimensionally. this multi-directional flexible retraction could secure good operative field. from 2012 to 2018, 32 patients (rps: 22 cases, mrs: 10 cases) underwent laparoscopicposterior suture rectopexyfor total rectal prolapse. shortterm outcomes were compared between the two procedures. results: there was no significant difference between rps and mps in median operative time (175 vs 167.4 min, respectively, p [ 0.05). the median blood loss volume was not significantly different between rps and mps groups (7.7 vs 8.0 ml, p \ 0.05). the duration of median hospital stay after surgery was not significantly different between two groups (12.9 vs 13 days, respectively, p [ 0.05). the frequency of complications after surgery were not different between them. conclusions: reduced port lap-rectopexy can be a good therapeutic option for total rectal prolapse. a prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over mps. the piccolo project proposes a new compact, hybrid and multimodal photonics endoscope based on optical coherence tomography (oct) and multi-photon tomography (mpt) combined with novel red-flag fluorescence technology for in vivo diagnosis and clinical decision support. for its development it includes different phases of validation. within this framework, the present study has as main objective: to characterize a model of rat colonic hyperplasia, which will be used for the development and validation of the previously mentioned endoscopic technology. secondary objectives: procure the reproducibility of the model chosen and determine the optimal time, after induction of the model. material and methods: 12 animals (rattus norvegicus), wistar, males and females \ 1-yearold, randomly distributed. group 1 (n = 2): by laparotomy, a non-resorbable suture (silk 4/0), not stenosing, is placed through the wall of the colon. group 2 (n = 2): by endoscopy, a 0.3 mm long segment of a polymeric catheter is inserted, which is fixed to the wall of the colon by means of a suture. group 3 (n = 2): by means of endoscopy, a self-expanding and uncoated metallic stent are placed in the colon. group 4 (n = 2): a superficial laser resection of the colonic mucosa is performed by endoscopy. group 5 (n = 4): as an extension of the most optimal model. weekly, the animals were anesthetized again to perform a colonoscopy, which determined the degree of mucosal growth in descending colon and colonic biopsies were extracted weekly (4 weeks). results: group 1. growth around the sutures after the second follow-up, diagnosed as hyperplastic polyps after a histopathological analysis. aim: the role of laparoscopy in the management of generalized appendicular peritonitis is controversial. this is due mainly to the lack of scientific data. through this study and a laborious bibliography research, we proposed to report our experience in terms of postoperative results, in the laparoscopic treatment of generalized appendicular peritonitis and to try to identify the risk factors associated with the occurrence of global morbidity and conclude on the feasibility of this technique in its treatment. methods: we conducted a retrospective study including all cases of generalized appendicular peritonitis managed laparoscopically, in the general surgery department of charles nicolle hospital between january 2006 and december 2016. results: we identified 93 patients. the mean age was 31.7 years. one fifth of the cases required a midline conversion (20.4%). the mean operative time was 146.6 ± 36,7 min. the overall morbidity rate was 15% including 7 surgical complications. there were no deaths. in uni-variate analysis, comorbidity, crp [ 200 mg /l, operative time exceeding 170 min and midline conversion were significantly associated with postoperative morbidity. co-morbidity, diabetes, asa score [ 2, delay of consultation [ 3 days, intra-abdominal abscess and operative time exceeding 170 min were significantly associated with medical complications. the univariate analysis also revealed that crp [ 200 mg /l and midline conversion were predictive of surgical complications.the multivariate analysis identified the midline conversion as the only independent factor significantly associated with post operative morbidity (odds ratio = 6.57, 95% confidence interval [1.28-33.7] ). conclusion: based on our results, it appears reasonable to continue the laparoscopic management of diffuse appendicular peritonitis. however, enhance this technique is basic in order to reduce midline conversion rate and to shorten operative time, which can lead to post operative complications. aims: currently, acute appendicitis is the most common surgical emergency. laparoscopic appendectomy is the usual procedure to treat acute appendicitis. the aim of this study is to evaluate the safety of electrocoagulation in the treatment of mesoappendix in laparoscopic appendectomy. methods: we have retrospectively studied a prospective database of operated patients of appendecectomy in emergency surgery unit. we have reviewed laparoscopic appendectomies from june 1st, 2014 to december 31st, 2017. the mesoappendix was electrocoagulated in every laparoscopic appendectomy. the statistical analyses has been done with spss 24.0 version. results: our group consists of 294 patients of which 59.2% were male and 40.8% were female. the average age was 37.94 years with a standard deviation of 18.14% and p75 was 51.5 years. the most common total stay was 1 day (100 patients). the usual post-operative stay was one day (144). we classified the diagnosis in complicated apendicitis (82 patients) and no complicated apendicitis (198 patients). the conversion rate was 3.1% (9). the main surgical complications were: surgical wound infection (1.4%); intraabdominal abscess (6.8%); and bleeding (1%). only one of the patients that suffered bleeding had complicated appendicitis. the medical complications were catheter sepsis (0.7%); respiratory infection (0.3%); cardiologicals (0,3%); and paralytic ileus (4.1%). the treatment of mesoappendix with electrocoagulation is safe and effective since the complications rate is very low. even so, it would be necessary to conduct more prospectives randomized studies in order to get enough evidence about the treatment of mesoappendix with monopolar electrocoagulation. introduction: the difficulty of resection of the rectum is determined by its anatomical relationships, intimately in contact with the bladder, seminal vesicles, prostate and urethra in the case of the male, vagina in the woman and nerve structures that will give defecatory, genital and urinary functionality. this structure creates a big impediment due to problems of visualization and difficult dissection, in such a way that conventional surgical techniques instigates a series of complications derived from this difficulty. we propose a new approach in rectal surgery in patients with inflammatory bowel disease. material and methods: a 49-year-old man with a history of ulcerative colitis developed a severe acute outbreak refractory to treatment. a total laparoscopic colectomy with a terminal ileostomy was performed in 2016. in 2018 he was notified for reconstruction. we evidenced a rectal stump of about 10 cm with signs of inflammatory disease at the mucosal level. a transanal proctectomy was performed with confection of 'j-pouch' and ileoanal anastomosis about 4 cm from the anal margin by laparoscopy. the postoperative courses favorably, being discharged on the sixth day. currently in follow-up in digestive and general surgery, he is asymptomatic and he has an optimum level of quality of life valued by the sf-36 12 weeks after the intervention. conclusions: our service introduces the transanal approach to the performance of proctectomy in cases of inflammatory disease, a technique that provides clear advantages by improving visualization and the identification of anatomical structures. in this way, a safe dissection of the pelvis is achieved, adjusted to the serosa of the rectum, with preservation of the mesorectum and the hypogastric plexus, and with the consequent improvement of the genital and urinary function. the result is an equally safe surgery, which implies little increase in operative time and with better and shorter postoperative recovery.the conservation of the pelvic innervation avoids disorders of ejaculation, vaginal lubrication and bladder and rectal motility. the transanal approach for the performance of proctectomy provides benefits in terms of the preservation of the hypogastric plexus, minimizing the anatomical difficulties involved in rectal surgery and maintaining urinary and sexual function. aims: to evaluate the feasibility and outcomes of laparoscopic appendicectomies in both simple and complicated appendicitis, given the increasing trend towards a laparoscopic approach in the last four decades for the treatment of acute appendicitis. we present data from a district general hospital over a 7-year period. methods: we retrospectively analysed a single consultant's continually updated database of laparoscopic appendicectomies between 01/03/2012 and 15/12/2018 (82 months). patient demographics, investigations, intraoperative findings and postoperative outcomes were recorded and analysed. complicated appendicitis was defined as the formation of appendiceal mass or abscess with or without perforation and peritonitis. results: 81 cases of laparoscopic appendicectomies were identified during the specified period. the median patient age was 30 (range 10-89 years). true positive rates for uss and ct were 33% and 84%, respectively. the rate of negative appendicectomies was 14%. transanal minimally invasive surgery (tamis) has been used for the treatment of rectal neoplasms such us benign polyps and early rectal cancer. when the tumour is located in the upper rectum or close to the rectosigmoid junction, this approach may be technically dificcult.we present a video of a tamis resection of a large polyp located 20 cm from the anal verge. after properative examination and ct and mri were performed, the patient was prepared for surgery, and a trasnanal minimally invasive surgery was proposed.resection of the polyp was performed with the aim of an endogia and conventional laparoscopic materials. total resection of the polyp with free margin was possible. the postoperative pathology report confirmed a high grade displasia villo-tubular adenoma with a lesion free margin. tamis resection of tumours located above the rectosigmoid junction may be a safe and feasible technique in selected patients. aims: pelvic organ prolapse (pop) is a very relevant problem for women's quality of life and has a prevalence of about 5% defined by symptoms and up to 50% when established by physical examination. nowadays, sacrorectopexy for posterior pop and sacrocolpopexy for apical pop are considered the gold standard techniques. recently, we have seen that laparoscopic lateral suspension is a feasible procedure for apical pop, obtaining a success rate higher than 90% at one year. these results are similar to what we can achieve with sacrocolpopexy. methods: we herein present the case of a 70-year-old woman with apical and posterior pop, this was provoking an important impact on her quality of life, with obstructive defecation (needing digitations) and urinary incontinence. we proposed sacrorectopexy for her posterior pop and laparoscopic lateral suspension for her apical pop. in the video we can see how we perform a ventral mesh sacrorectopexy, following d'hoore technique; and a laparoscopic lateral suspension with preperitoneal dissection, following the technique described by the team headed by dubuisson and veit-rubin. we used 4 laparoscopic ports (12, 5, 2.9 and 2.5 mm). results: patient was discharged home on the second postoperative day and has not had any sign of recurrence or extrusion after more than two years of follow-up. in addition, she has not suffered lower urinary tract symptoms, constipation or pain. conclusions: we present a case in which we have carried out a laparoscopic lateral suspension instead of a sacrocolpopexy for an apical pop, obtaining good short-term and long-term results. we consider it is very soon to assess this technique's efficacy and it has to be validated in studies with larger source of patients. nevertheless, we think this procedure might become an excellent alternative to sacrocolpopexy for apical pop. aims: laparoscopy is a minimally invasive approach with low morbidity. the aim is to show the usefulness of the laparoscopic approach for massive intra-abdominal abscesses, which it is controversial. we report three patients who underwent emergency laparoscopy for peritonitis or massive intra-abdominal abscesses not amenable to percutaneous approach that were suspected to be caused by acute diverticulitis. methods: all patients had diagnosis of acute diverticulitis (hinchey ii-iii grade) with pelvic abscesses situated between sigma and bladder or diffuse peritonitis. the patients with hinchey ii grade had failed conservative management with antibiotics. they underwent emergency laparoscopy under general anaesthesia, with three abdominal ports. intra-abdominal abscess cavities were exposed and the purulent exudate was sampled and aspirated. copious irrigation was performed under direct vision and thorough examination without other findings. the procedure was completed laparoscopically in all cases. results: all patients had favourable evolution. one of them had a properly drained faecal fistula which changed to a purulent fistula on the twentieth postoperative day. this patient underwent laparoscopic left colectomy three months later because he had have a new episode of acute diverticulitis. other two cases showed very good clinical evolution, without evidence of fistula in postoperative period and they were complete asymptomatic one month later. conclusion: in our experience laparoscopic drainage is a feasible, safe, and effective for the treatment of pelvic abscesses and diffuse peritonitis secondary to acute diverticulitis. n. pinheiro, a. ziegler introduction: solitary rectal ulcer syndrome (susr) is characterized as a rare disease whose pathophysiology remains uncertain. it was first described in 1829 by cruveilhier and his clinicopathological feature was reported in 1969 by mandigan and morson, where he is associated with defective disorders, internal rectal prolapse, and psychological changes. according to works about 26% of the patients are asymptomatic. when symptomatic the diagnosis can be made through physical examination, clinical history and, often, confirmed by endoscopy with biopsies. treatment depends on the severity of the symptoms and the existence of associated rectal prolapse. according to the literature, conventional surgical options include local excision, rectal mucosectomy, retopexy, and segmental colonic resection. rolato: a 28-year-old male complaining of anal bleeding at bowel movements 10 years ago. he performed, several times, conservative treatment, but without improvement. he sought proctological care and underwent colonoscopy, in which he showed an ulcerated lesion on the anterior wall of the distal rectum. new investigation with videodefecogram revealed colorectal intussusception with associated mucosal prolapse, being considered the factor causing the ulcer. elected by the sacropromontofixação. evoluiu with improvement of anal bleeding, mucorrhea and anal discomfort. after a proctological examination, which was normal, a control colonoscopy performed after 5 months of surgery revealed rectal mucosa, with residual scarring and disappearance of the submucosal nodule present in the initial examination. reassessed after 12 months, the patient is asymptomatic. conclusion: rectal solitary ulcer whose causal factor was a colorectal prolapse (intussusception) with mucosal exteriorization through the anal canal, which was individually treated with sacropromontofixation. j.p. mali, p.j. mentula, a.k. leppäniemi, v.j. sallinen approximately 15-20% of patients diagnosed with colonic diverticulitis have an intra-abdominal abscess as a complication. abscess diameter of 3-6 cm is generally accepted as a cut-off determining the choice of treatment between antibiotics alone and percutaneous drainage. the aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. this was a retrospective cohort study which was conducted in helsinki university hospital, an academic teaching hospital functioning as secondary and tertiary referral center. patients with computer tomography-verified acute left-side colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during 2006-2013. altogether, 241 suitable patients were included in analyses. those treated primarily with percutaneous drainage or antibiotics alone (29 and 150 patients, respectively) were further compared in regards to treatment results. the main measured outcomes were need of emergency surgery and 30-day mortality. abscesses under 40 mm were mostly treated with antibiotics alone with high success rate (93 out of 107, 87%). in abscesses over 40 mm, the use of emergency surgery increased and use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at 13-18% regardless of abscess size (figure 1 ). there were no differences in failure rate, 30-day mortality, need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage versus antibiotics alone, even when groups were adjusted for potential confounders. white blood cell count = 15.0 * 10 9 /l, abscess diameter = 50 mm, and corticosteroid medication were independent risk factors for failure of treatment with antibiotics alone. patients without these risk factor had 95% and patients with one risk factor had 78% success with antibiotics alone. percutaneous drainage as treatment for large abscess does not seem to be superior to treatment with only antibiotics. majority of patients with abscesses over 60 mm in diameter undergo surgery as primary intervention. introduction: even today, 'chronic appendicitis' is a clinical term that is not widely accepted nor well documented amongst the medical community. its etiology is the presence of a mass (e.g. fecal mass, hyperplasia of lymphatic tissue, etc.) that continuously and partially obstructs appendix lumen. it is presented as a low intensity, intermittent, with exacerbations and remissions, abdominal pain that is located at the right iliac region. the pain lasts up to several months and it is usually underestimated by the patient. its diagnosis is based on imaging examination. appendectomy is the treatment of choice for chronic appendicitis. the operation is challenging for the surgeon who has to cope with an intensively inflamed area around the appendix without the ease of access to that area. purpose: to present our laparoscopic approach to a chronic appendicitis case and to review the literature. case report: a 56-year-old woman is hospitalized due to chronic appendicitis. the patient was treated conservatively with the use of intravenous antibiotics in two separate hospital admissions dated 2 and 4 months back respectively. eight weeks after the last exacerbation, she underwent a laparoscopic appendectomy. results: even though the procedure was planned six months after the first episode, the laparoscopy revealed a severe inflammation of the appendix, which was extended to the caecum and the surrounding preperitoneal tissues. although the difficultness of the operation it was completed successfully laparoscopically. the histological examination confirmed without any doubt the existence of 'chronic appendicitis'. the patient was discharged uneventfully the third postoperative day. conclusions: chronic appendicitis is an existing clinical entity that the surgeon may come through during his career. in the hands of experienced laparoscopic surgeon, the laparoscopic approach is feasible and safe. introduction: ventriculo-peritoneal shunting (vps) used in the treatment for hydrocephalus is associated with several complications.the exact cause of such extrusion is not known. visceral perforation is an unusual but serious complication with consequeces such as peritonitis, meningitis or encephalitis. management involves prompt removal of shunt, intravenous antibiotics, an adequate recovery gap so that cerebrospinal fluid culture is sterile and then followed by shunt replacement on opposite side. aim: multidisciplinary approach of extrusion of vps through anus by laparoscopic and external ventricular drainage. case exposure: a 49-year-old woman had a vps inserted 11 year ago after excision of gangliocytoma due to lhermitte-duclos disease. she was admitted in the emergency department without symptos after trans-anal protrusion of vps catheter. the neurological and abdominal evaluation was normal. laboratory tests did not reveal disorders and abdominal ct-scan suggested perforation, itshowed the insertion of the end of the catheter in sigma, without pneumoperitoneum or intraabdominal free fluid. cranial ct-scan did no describe sings of hydrocephalus. the patient underwent an emergencysurgical intervention. first of all, antibiotic therapy was initiated and neurosurgery's team was performed an external ventricular drain and they disconnected the proximal catheter side. after that, an exploratory laparoscopy was performed. it revealed a microperforation and collection beside to an appendix' base due to the proximity with the catheter. additionally, the catheter was freed from adhesions at the point of entry into the colon and after careful dissectionwe release the vps from colon with a 1.5 cm transmural trajectory at the sigmoid level. no free fluid was seen and rest of the bowel appeared normal. the distal end was removed through the anus and the proximal end through a laparoscopic port. we performed a laparoscopic segmental cecum resection and an extracorporeal colo-colonic anastomosis was performed for a mini-pfannestiel laparotomy of assistance. there were no complications in the postoperative period, being discharge on the 5th day. conclusion: the multidisciplinary approach and the laparoscopic support in the diagnosis and treatment of patients with colon perforation caused bay vps catheter is a feasible and safe option in third level centers. background: acute appendicitis continues to be the most common source of complicated intraabdominal infection worldwide. the high incidence of postoperative complications and dissatisfaction with the results of treatment in cases of complicated appendicitis and peritonitis gave the reason for conducting this study. aim: to evaluate the effect of different laparoscopic trocars position in case of laparoscopic appendectomy for diffuse appendicular peritonitis for the incidence of postoperative complications methods: the results of laparoscopic treatment of 116 patients with acute appendicitis complicated by diffuse peritonitis were analyzed. the first group consisted of 37 (32%) patients operated by triangulation access (type 1 trocar placement according sages guidelines for laparoscopic appendectomy (sages qla). the second group consisted of 79 (68%) patients operated by sectorisation access (type 4 sages qla). postoperative complications were classified by clavien-dindo classification. results: the duration of the operation for the analyzed groups was 91.1 ± 29.9 vs 84.5 ± 24.9 min. there were no deaths among this group of patients. the incidence of postoperative complications for both group was 36.2%. postoperative complications in the triangulation and sectorisation group were 43% and 21.6% respectively (p 0.043). clavien-dindo iiib complications were noted in 4.3% (n-5) patients and presented with intra-abdominal abscesses (iaa). all patients with iaa were operated in sectorisation group. conclusion: sectorisation trocar placement increases the incidence of intra-abdominal complications for laparoscopic appendectomy for diffuse appendicular peritonitis. introduction: the diverticular disease of the colon is a chronic entity with a variety of abdominal symptoms that can present with recurrent episodes of acute diverticulitis (ad). the prevalence of diverticulosis is not influenced by gender and increases with age, which, according to the increase in life expectancy, explains the accumulation of cases in western countries. the classic diagnostic-therapeutic algorithm of the disease is it has been based on the hinchey classification, the use of antibiotics and the intervention of hartmann (ih) at the acute time and elective colectomy in the multirecurrent cases. the use of laparoscopy with washing and drainage is actualymore extended in cases with peritonitis. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with diverticular disease complicated by severe inflammatory plastron with 'covered' perforation, with several recurrent episodes. material and method: case report: a 46-year-old man with ap-diverticulitis 10 years ago with complete resolution and normal control colonoscopy. he presents in the last two months three compatible episodes of acute diverticulitis, exploration with plastron-mass in hypogastrium without defense, tac-marked thickening of a segment of 10 cms. of medium sigma, collection not drainable in mesosigma, of 3 cm, which loses the plane of cleavage with loops of thin neighbors with a linear tract that suggests fistulization. evidence of interest is exposed. given the evolution, it is decided surgical elective treatment. result intervention: preoperative ureteral double catheterization, laparoscopic approach, is exposed by video, rectosigmoid resection by diverticular plastron, with negative io biopsy, mechanical colorectal anastomosis. good postoperative course, discaharge at 5th day. defini-tive ap: perforated diverticulitis, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of complex and severe diverticular disease. aim: tamis resection has been described for the treatment of rectal neoplasms, wether benign or early malignant tumours. since tamis appearance, many different indications have been reported.we aim to show an special indication as seen in this video of a tamis resolution of a rectal stenosis non treatable by endoscopy. method: we present a video of a female patient, previously treated for a large rectal adenoma treated by trasnanal apporach, with a postoperative sepsis which required lateral colostomy and trasanal drainage. after surgery, the patient suffered from a rectal stenosis which couldn' t be solved by endoscopy, so the patient was sent back for a surgical treatment.we decided to performed a trasnanal apporach by tamis and a long and circunferiential stenosis around 6 cm from the anal verge was seen.we performed a rectotomy by electrocautery in the posterior rectal wall until the perirectal fat was seen and the stenosis was passed. a dilatation with a foley catether was also performed. results: postoperative course was uneventful and after 6 months she was prepared for colostomy closure with no complications and remains asymptomatic nowadays. conclusion: tamis approach of rectal stenosis may be a safe and feasible technique in selected cases if conservative treatments fail. iatrogenic endoscopic colon perforation it is a severe, but rare complication of colonoscopy. the incidence of this complication is estimated to be 0.016-0.8% for diagnostic colonoscopies and 0.02-8% for therapeutic colonoscopies. the management of these complications depends on the size of the lesion,the time elapsed between the lesions were produced and diagnostic of the lesions and associated pathology. the treatment can be consevative,endoscopic or surgical(clasic/ laparoscopic) in our sevice in last 10 years we treated 5 cases with iatrogenic colon perforation after diagnostic colonoscopies. all lesions were at sigma level. one case was admission in our service at 3 days after a diagnostic colonoscopy.the pacient was operated clasic,in emergency,we found a fecaloid peritonitis,a perforation at sigma level.we made a colostomy, lavage, drainage but the pacient died after 4 days. in 4 cases we made the operation at maximum 2 h after the lesion was diagnosticated by the endoscopist(directly visualisation).we didn't made radiologic investigation.the pacients were operated laparoscopic,we made suture,lavage,drainage. evolutions of the pacients were good. conclusion: iatrogenic colonic perfortion are rare,but severe complication. laparoscopic surgery can be a choice in treatment of this complication introduction: complicated diverticulitis with fistula is responsible for about 20% of surgical procedures in diverticular disease and is commonly found in patients with diverticulitis of the sigmoid colon. colovesical fistulas are the most frequent (65%), with highest incidence in males. only a third of these patients have a history of diverticulitis. in most cases, treatment is surgical, and colectomy is performed, whether or not in association with vesical recession. case report: 61 year old male with pneumaturia and fecaluria for the preceding 4 months. the colonoscopy identified a diverticulitis of the sigmoid colon and the subsequent pelvic mri suggested a colovesical fistula. the cystoscopy was not able to identify any fistulous opening, but a double j catheter was placed in the left ureter, as surgical treatment had been proposed. a subsequently abdominal pain motivated a preoperative ctscan which revealed a pneumoretroperitoneum and a fluid collection near the left ureteral tract. the multidisciplinary team on the case decided to perform a percutaneous nephrostomy, followed by an exploratory laparoscopy. the fistula tract was identified and a laparoscopic sigmoidectomy with partial cystectomy was performed, as well as a ureterorenoscopy (with double j replacement). there were no intra or postoperative complications, and the patologic repport had no signs of malignancy. video of the surgical procedure is presented. conclusion: a laparoscopic approach to complicated diverticulitis with colovesical fistula is safe and effective when performed by experienced colorectal surgeons. introduction: diverticular disease is characterized by its high prevalence, being one of the most frequent causes for hospital admission when it comes to gastrointestinal pathology. even though it is more frequent in older patients, there has been an increase in incidence amongst lower age groups. the approach to the disease has also suffered changes in the last few years, showcasing a tendency for less invasive options, deferring elective surgery to later in the course of the disease. this study examines the therapeutic approach to diverticular disease in our hospital. methods: retrospective analysis of demographic data, therapeutic options and surgical outcomes in patients admitted for diverticular disease between january2015 and june2018. results: 154patients(n = 154)were included in the study:75(49%)were male and79 (51%) were female, with an average age of 61 years. 135patients(88%) underwent medical treatment, with surgery reserved for the remaining 19 patients, 11 of which were emergencies, with the other8 being elective(5%).about89% of patients were only admitted once,9%were admitted twice and2% had3or more episodes. for the single-admission group, the most common treatment was medical(93%of cases), as was the case for the group with3or more episodes(in which 58%of cases were subjected to medical treatment). in the patient group with2episodes,53%were submitted for surgery, most of which elective.as far as the surgically operated group is concerned, no statistically significant differences were found with regards to patient sex. age, however, was significantly greater for the group that underwent emergency surgery vs that submitted to elective (65.2 years vs 45.2 years,p \ 0.001).the most common procedure overall was colic recession, with hartmann's operation standing out as the most frequent for the emergency surgery group. length of hospital stay was again higher for the emergency group (vs elective;14 vs 5,p \ 0.001),as well as the morbidity rate. no statistically significant differences were found with regards to mortality rate. conclusion: knowledge of the natural history of diverticular disease led to changes in the approach to treatment, with a tendency to adopt a less aggressive therapeutic. despite controversy around aspects such as selection of patients for elective surgery, among others, it is key to the approach to diverticular disease that existing recommendations are taken into account, treatment is individualized and outcomes are closely monitored. surg endosc (2019) aims: the objective of this analysis is to establish if there is differences after the procedure of laparoscopy appendicectomy comparing the use of endoloop (el) vs. endostapler (es) in complicated and non-complicated acute appendicitis. methods: we performed a retrospective analysis of a prospective database of 499 patients from february 2012 to june 2018. we divided the patients in two groups: depending on that the procedure of the appendicectomy was with endoloop or endostapler. the groups were created selecting 229 patients in order to be homogeneous as to perforation appendix rate, thus a propensity score was performed for sex, age and perforation rate. an univariant analysis was carried out in regard to the differences in the use of el vs es in the apparition of abdominal complication, as well as hemorrhage, ileo, surgical wound infection, collection, reintervention or hospital readmission.qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. introduction: intramural haematomas can develop anywhere within any the gastrointestinal tract3. these are most frequently associated with blunt trauma above the level of the sigmoid colon and very rarely occur in the rectum1. spontaneous, non-traumatic haematomas are a rare clinical condition usually secondary to haematological blood disorders or anticoagulant therapy2. case summary: a 56-year old gentleman presented to the emergency department with a 2 day history of worsening lower abdominal pain and bloody stool. he presented twice within the previous week with worsening, generalised abdominal pain. the patient had been taking regular aspirin and clopidogrel following insertion of coronary artery stents. on clinical examination, he was guarding with a distended, generally tender lower abdomen but all observations were stable, afebrile. an initial computer tomography of the abdomen reported pneumoperitoneum with haemorrhagic ascites; a differential diagnosis being perforated sigmoid colon with a large localised haematoma. the patient underwent an emergency laparotomy and hartmann's procedure (appendicectomy, sigmoid colostomy and rectal stump). he recovered well with no significant post-operative complications. histology reported the rectal perforation macroscopically associated with an opened haematoma and no evidence of malignancy. the appendix shows reactive appendicitis with serousal inflammation background: ulcerative colitis (uc) is one of the risk factor of developing sporadic colorectal cancer. approximately 15% of uc patients develop an acute attack of severe colitis, and 30% of these patients require colectomy. one third of the patients will not respond to steroid therapy. thus, a long-term follow-up has been recommended. case report: we reported a single case of completed 5 years follow of colorectal cancer related ulcerative colitis on 54 years old female patient undergoing emergency operation (2 staged total colectomy and j-pouch ileo-rectal anastomosis) after 1 year no responsed of medical treatment before, presenting with bloody diarrhea and anemia. there was no post operative complication reported. pathologic finding was early adeno carcinoma, closed follow up was done each year and for another five years later, no progression of the disease was found in this period and the patients has good quality of life after this procedures. is becoming a standard and feasible surgical method worldwide. 20% of patients with crohn's disease (cd) and 80% patients with ulcerative colitis (uc) will require an operation during their life. over the last decade, there have been many studies documenting the safety and feasibility of the laparoscopic approach for ibd in well-selected patients. methods: patients with a cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon and rectum stenosis, patients with uc with ineffective medical therapy, steroid dependence or dysplasia underwent the lcs. from 2009 to 2018, 247 ileocolic resections, 63 hemicolectomies, 74 subtotal colectomies and 35 restorative proctocolectomies with ileopouchanal anastomosis were performed either totally laparoscopically or laparoscopically assisted (n = 419).the average time of the procedure was 105 min (55-295 min), average blood loss 125 ml (0-350 ml) and the conversion to laparotomy was in 8.2%. average return time of the bowel function was 3.5 days (2-9 days) and the average hospital stay was 7.1 days (6-11 days). complications occurred in 24 patients (5.7%). 3 cases of the early ileus due to adhesions, 2 cases of the anastomotic bleeding threated conservatively, 1 case of the instrumental perforation of the small bowel, 7 cases of the incisional hernia in minilaparotomy and 11 wound infections occurred. conclusion: in well-selected patients with ibd, thanks to superior short-and long-term outcomes, the laparoscopic approach should be considered a safe and effective method when performed by experienced surgeons. supported by mo1012. aim: over 80% of patients with crohn's disease (cd) will require a surgical resection within 10 years of their diagnosis and one quarter will have another resection for disease recurrence. laparoscopy should by preferred approach in surgery in cd due to reduced morbidity, faster recovery time, shorter hospital stay and reduction in adhesions and hernial formation. methods: patients with cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon stenosis were indicated for the laparoscopy. from january 2009 to november 2018 we performed 246 ileocolic resections, 63 hemicolectomies and 72 subtotal colectomies either totally laparoscopically or laparoscopically assisted. the average time of the procedure was 92 min (55-240 min). the average return time of the bowel function was 3.5 days (2-9 days) and the hospital stay was from 6 to 10 days. complications occurred in 14 patients (3.7%) . in 3 cases early ileus developed due to adhesions, in 1 case was anastomotic bleeding threated conservatively, the incisional hernia in minilaparotomy occurred in 6 cases and 4 wound infections occurred. conclusion: minimally invasive surgery is becoming a gold standard in cd. it is safe and feasible in well-selected patients thanks to short-and long-term outcomes. laparoscopic approach for recurrent disease is still in debate. supported by mo1012. aim: the aim of the study was to observe when laparoscopy is avoided when treating surgical complications of crohn disease. methods: we did a retrospective study which included all of the patients diagnosed and operated in our clinic for complications of crohn disease during a period of 3 years. results: we identified a number of 62 patients operated for complications of crohn disease. of these 15 were operated by minimally invasive procedures. we observed that laparoscopy was avoided in the case of intestinal fistulas (p = 0,02). also when sepsis associated the surgical complication-laparoscopy was avoided (p = 0,01). age under 43 years represented another factor to avoid laparoscopy (p = 0,04). conclusions: although laparoscopy offers numerous advantages careful selection of the patients is of utmost importance so the safety of the procedure can be ensured. retroperitoneal sarcoma represents approximately 12-15% of all sarcomas and less than 0.5% of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore radical surgery remains the only valid option. complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. hypoglycemia is a rare but potentially lifethreatening presentation of soft tissue tumors the etiology of hypoglycemia may be difficult to diagnose, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. the most likely mechanism of hypoglycemia appears to be production of insulin like substance and increased utilization of glucose by the tumor. laparoscopic surgery represents an alternative technique for radical resection of such tumors rather than traditional surgery. only few cases of retroperitoneal tumors resected laparoscopically were reported in the literature. we report a rare case of 53 years old male presented to ed unconscious due to hypoglycemia.he was resuscitated and admitted for further investigations. hypoglycemic attack recurred again during the same evening of admission. initial investigations were within normal except for serum glucose 35 mg/dl (2.0 mmol/l). his tsh, glucagon & cortisol levels were within normal, insulin and c-peptide levels were undetectable. only hypokalemia (2.3 meq/l). he tested negative for the anti-insulin antibodies. his abdominal ultrasound as well as his ct scans showed the presence of a large retroperitoneal tumor (15 cm 9 12 cm 9 7 cm) with a heterogeneous contrast effect. a glucose supplement was required to maintain the plasma glucose level within normal limits during which complete resection of the tumor which was performed laparoscopically. diagnosis of such hypoglycemia inducing retroperitoneal fibrosarcoma represents great challenge especially when patients presents only with hypoglycemia and no other abdominal symptoms, management using minimal invasive technique to resect and remove such tumors from the retroperitoneal region shows superiority in recovery and limitation of complications when done by experienced surgeons. solitary fibrous tumor (sft) is a rare fibroblastic mesenchymal neoplasm, tipically arising from the pleura, less frequently from other anatomic sites. sft is an indolent neoplasm, but it have been described cases of greater aggressiveness in terms of local recurrences and more rarelly of distant metastases. among the various extrapleural sites, intrabdominal, retroperitoneal localization is the most common site, followed by the pelvis soft tissues and parenchymatous organs. the most common clinical finding of intraabdominal localization is a palpable mass, and the pain is the most frequently associated symptom. the diagnosis is performed by imaging, but the histological as well as immunohistochemistry characterization of the lesion is the latest goal. furthermore, histological features are used to attempt to identify the patient with a hight risk of malignant evolution of the tumor. the gold standard treatment is surgical approach, meanwhile there are no evidences about the efficacy of any adjuvant treatment. we present the case of a 62-year-old man affected by symptomatic tfs arising from mesosigma treated by surgical radical excision. finally, we propose a review of the literature of last decade. background: laparoscopic right hemicolectomy involves making an additional incision to remove the specimen and perform the anastomosis. recently, natural orifice specimen extraction surgery (noses) has been reported as an alternative approach without any additional incisions or extensions, may lead to better outcomes compared to conventional laparoscopic right hemicolectomy. in this video, we aimed to evaluate the safety and feasibility of noses for laparoscopic right hemicolectomy. methods: we describe the technique with transvaginal specimen extraction and d3 lymph node dissection in laparoscopic right hemicolectomy by this video. we performed intracorporeal anastomosis combined with a transvaginal route of specimen extraction after medial-to-lateral mobilization. transverse transvaginal posterior colpotomy was performed under aid with visualization. the specimen was pulled into the sterilized plastic bag, passed transvaginally. the vaginal incision was then closed with a running suture. results: the operation time was 230 min and the hospital stay was 6 days. an excellent postoperative recovery was demonstrated and has shown future potential for less incision. the pathologic tnm stage is t3n0m0. conclusions: this video has shown that laparoscopic right hemicolectomy with the noses technique is feasible and safe for selected cases. the long-term benefits of this procedure need to be more evaluated. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify the sentinel lymph node (sln) to search micrometastases that can be missed with the conventional pathological exam, and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification 5 ml of icg solution (0.3 mg/kg) is subserosal peritumoral injected. a full hd image1 s camera, switching to nir mode, in about 10 min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.after the transection 5 ml of icg solution is injected to confirm the stumps perfusion. if there is an ischemic area, a new resection is performed.after the anastomosis is performed, another bolus of icg is intravenous injected to confirm the anastomotic perfusion.when the sentinel node is negative for cancer metastases by conventional histological examination, ultrastaging is performed by serial sections. when no micrometastases are identified on these sections, immunohistochemical techniques are applied. from november 2016, 70 patients were enrolled: 22 left colectomy, 38 right colectomy, 2 transverse resections, and 8 splenic flexure resections. in two cases, one left colectomy and one right colectomy, the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november 2017, 40 patients were enrolled to perform the slnb: 23 right colectomy, 11 left colectomy, 1 transverse resection and 5 splenic flexure resections. the sln was identified in 37 cases. 17 cases were found to be n0 to the conventional examination and were subjected to ultrastaging. the serial sections showed micrometastases in two cases. in the other cases the immunohistochemistry was performed but the exam is still in progress. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to assess the anastomotic perfusion in order to reduce the incidence of anastomotic leak, and to perform the slnb for the sln ultrastaging in order to identify micrometastases. methods: for the last 3 years, tem was performed on 28 patients' with early rectal cancer. there were 19 women and nine men, age 68 to 87. localization of tumors was 4-12 cm from anus. mean size of tumors was 3.8 cm. full thickness excision was performed in all patient with suturing of mucosa. during follow-up in three patients' metastasis in lymph nodes of mesorectum were detected. all of these patients were re-operated: laparoscopic colectomy with total mesorectal excision (tme) was done. for the last year in 9 patients with early stage rectal cancer we used indocyanine green (icg) with fluorescent imaging for mapping sentinel lymph node. icg was injected in four quadrants to submucosa around the tumor. during the laparoscopy, sln was detected and removed with morphological examination. results: among nine patients in 8 patients, sln was negative. tem was performed in these patients with good results. after 10-12 months no recurrence or metastasis were detected in these patients. in two patients with positive sn laparoscopic tme was performed with low colorectal anastomosis. anastomotic complication was occurred in one patient. conclusion: tem procedure is highly effective in selected group of patients with early rectal cancer. mapping and examination of sln can clarify indication for the tem in the patients with early rectal cancer. purpose: laparoscopic surgery for colorectal cancer provides better short-term benefits and similar long-term outcomes compared with conventional open surgery. unlike minimally invasive surgery, natural orifice specimen extraction (nose) can provide additional advantages by reducing morbidity and postoperative pain related to the surgical extraction site. this study aimed to evaluate the efficacy and safety of a nose procedure using needlescopic instruments for colon cancer surgery. methods: between november 2013 and february 2018, 6 patients underwent laparoscopic nose using needlescopic instruments. the first port for the camera was placed at the umbilicus. a 5-mm or 12-mm port was inserted in the right lower quadrant. a 3-mm or 5-mm port was inserted in the right upper quadrant. individual needlescopic forceps for the assistant were inserted into left upper and lower quadrant ports. thus, a total of 5 ports were placed. the superior rectal artery and inferior mesenteric vein were ligated with clips, and colonic mobilization was performed using a medial to lateral approach. after rectal stump irrigation, the distal rectum was transected using an endoscopic linear stapler. the proximal colon and associated mesentery were transected. after the rectal stump was opened, a wound retractor was pulled through the anus and inserted in the rectal lumen. the resected specimen was transanally extracted through this route. an anvil was intracorporeally attached to the proximal colon, and the open rectal stump was reclosed using an endoscopic linear stapler; colorectal anastomosis was then performed using a double-stapling technique. results: of the 6 patients, 4 were male and 2 were female, with a median age of 71 years (44-76 years). median body mass index was 21.8. the tumor site was in the sigmoid colon in 4 patients and rectosigmoid colon in 2 patients. median operative time was 309 min and blood loss was 13 ml. there was no conversion to open surgery. no postoperative complication was observed. median postoperative hospital stay was 8 days (7-12 days). conclusions: nose surgery using needlescopic forceps is an easily performed type of reducedport surgery with a conventional port arrangement. this procedure is feasible for the selected patients. introduction: splenic flexure colon cancer accompanying obstruction is usually managed stent insertion as a bridge to surgery and left hemicolectomy, or subtotal colectomy. however, stent insertion can fail more often than in sigmoid colon because it requires longer colonoscopic approach in the circumstance of impossible bowel preperation. although subtotal colectomy has advantage in the aspect that it is 1-stage treatment, it needs open surgery in most cases, right colon has to be sacrificed without oncologic neccesity, and preoperative staging and evaluation can be insufficient. despite colostomy is reluctant procedure when considering quality of life, in splenic flexure colon cancer obstruction, we can obtain prompt stabilization of patient state, suffient time to preoperative staging and evaluation, and also we can achieve minimally invasive surgery by using colostomy site as mini-laparotomy and close colostomy before discharge. colostomy site, tumor location, and minilaparotomy site for next radical surgery have to be considered comprehensively before making colostomy incision. colostomy site has to be appropriate as mini-laparitomy site for feasibility of laparoscopic left hemicolectomy and the colostomy has to be included in the specimen with caution to prevent unneccessary lengthening of the specimen. we experienced 3 cases which were treated succefully in this strategy and report them. result: temperary loop transverse colostomy and laparoscopic left hemicolectomy via colostomy site in splenic flexure colon cancer obstruction has advantage of quick stabilization of patient's status, suffient preoperative staging and evaluation, achieving minimally invasive surgery, and also rapid colostomy closure before discharge. our tatme procedure for locally advanced low rectal cancer following chemoradiotherapy y. nakamoto 1 , r. okamoto 1 , f. kimura 1 , h. yanagi 1 , t. nakajima 1 , h. yoshie 2 , n. yamanaka 1 1 surgery, meiwa hospital, nishinomiya, japan, 2 surgery, yoshie clinic, itami, japan background: short-course chemoradiotherapy using hyper-fractionation method (scrt; 25 gy/ 10 fraction/5 days ? s-1 or xeloda) is performed to secure circumferential resection margin (crm) due to tumor shrinkage, reduction of cancer cells with viability, reduction of radiation hazard for resectable locally advanced lower rectal cancer (more t3 or n1). the patient underwent radical surgery after one month of scrt. for more locally advanced lower rectal cancer (t4 or n2), induction chemotherapy is performed before scrt. for patients with poor efficacy of chemotherapy, we also do normal 25 fraction 45 gy radiotherapy. methods: we introduced tatme from last august, and 18 cases were performed so far. in all cases temporary stoma has been constructed, and intersphincter resection (isr) is based on partial isr avoiding total isr considering postoperative anal function. if possible, colonic j-pouch is added, and pelvic floor repair may be added for esr cases and older people. at first one team preceded with the anal operation and shifted to the abdominal procedure, now it is done with two teams with the advantage of getting good visual field from both sides when there is difficulty identifying the right dissecting layer. tatme is very useful in cases such as large tumor, obesity, and narrow pelvis. furthermore, when it is difficult to identify the dissecting layer by scarring after crt, it is more possible to control the crm/drm of cancer. results: 14 cases of isr, 3 case of apr, 1 case of tpe were performed, and in 10 of these cases lateral lymph node dissection was also performed (one side 5, both sides 5). postoperative complications were 2 anastomotic leakage, 4 pelvic floor infection, 2 perineum infection, and 1 bowel obstruction. conclusions: tatme for locally advanced lower rectal cancer is useful even after chemotherapy and scrt. background: although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (sils) and conventional laparoscopic surgery (cls) for colon cancer, few have directly compared the costs of them. we aimed to compare costs between sils and cls for colon cancer. methods: we analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from july 2009 to september 2014 at severance hospital; 288 were used for analysis after propensity score matching. the total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed. results: the total hospital charges were similar in both groups ($8770.40 vs. $8352.80, p = 0.099). however, the patients' total hospital bill was higher in the sils group than in the cls group ($4184.82 vs. $3735.00, p \ 0.001) mainly due to the difference of the cost of access devices. there was no difference in the additional costs associated with readmission due to late complications between the two groups ($2383.08 vs. $2288.33, p = 0.662). conclusions: sils for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with cls. therefore, sils can be considered a reasonable treatment option for colon cancer for selective patients. aims: technology improvements in medicine allow the development of new minimally invasive approaches. despite every single advantage of these new devices they also can cause technical problems and difficulties for the surgical team. well known from last few years-laparoscopic assisted transanal total mesorectal excision for distal rectal cancer is perfect example for a quite new procedure, based on the combination of forgotten old surgical principles and technology advances. the aim of the study is to analyze the rate of technical problems during the procedure and to measure the impact of them on the operative time. methods: we conducted prospective observational study related to technical problems during the procedure. for the period between september 2017 and november 2018 in the department of endoscopic endocrine surgery and coloproctolgy at military medical academy-sofia have been performed 25 laparoscopic assisted transanal total mesorectal excisions. we used standard local preoperative work up and postoperative care protocols. we defined technical problem as intraoperative event different from complication leading to delay in operative time. every technical problem during the procedure was recorded and time for resolving the problem was measured in seconds. results: overall technical problems occurred in 11 of the cases. most of them were related to the insufficient smoke evacuation during the 6 cases. the second most common technical problem were the excessive rectal stump spasms during the procedure-this complication occurred in 3 of the patients. mean delay of the procedure related to technical problems is 21 min. in our series we experienced only one intraoperative complication which was specimen perforation during the dissection. three complications occurred in postoperative period-two urinary retentions and one perianastomotic abscess, without need of reoperation. conclusion: technical problems during the procedure can be source of delay in operative time. correct use of devices in operating room is the key to reduce technical issues. technical problems can increase the rate of intraoperative near miss events and complications during the transanal total mesorectal excision. surg endosc (2019) aims: anastomotic leak after rectal cancer surgery constitutes a severe complication associated with poorer oncologic outcome and quality of life. preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity of creating a defunctioning stoma. methods: studies on rectal cancer surgery published between 2000 and 2015 were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses of individual participant data (prisma-ipd) guidelines. with the aim to generate a score for anastomotic leak, all available per-operative covariates were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. a receiver operating characteristic curve (roc) analysis was generated. we selected as threshold the value that allowed a missing rate of anastomotic leak \ 2%. the predictive power of the previously selected cut-off was validated in an independent set of patients. results: twenty-six centers provided individual data on 9735 patients. with a threshold value of the roc corresponding to 0.0791 in the training set, the area under the roc curve (auc) was 0.585 (p \ 0.0001). sensitivity and specificity of the model's probability [ 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. accuracy of the threshold value was confirmed in the validation set with 77.8% of sensitivity and 35.2% specificity. conclusions: we trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. the score is now available online (http://www.real-score.org). in 7 (12.5%) cases laparoscopic interventions were performed in patients with diverticular colon disease. in the group of patients with colorectal cancer localization of the tumor in the right parts was observed in 27 (36%) patients, in the left-in 30 (39%), in the rectum-19 (25%). results: in the adenocarcinoma of the sigmoid colon, performed a left laparoscopic hemicolectomy (19 cases) and resection of the sigmoid colon (11). was executed high clipping and intersection of the lower mesenteric vessels, aorto-iliac lymphatic dissection. in the standard scope, lymph node dissection was performed with removal and testing of not less than 12 epi-, para-and mesocolical lymph nodes (max 21). the average length of the laparoscopic stage is 125 ± 22 min. laparoscopic right hemicolectomy (27 cases) was performed in accordance with the principles of cvl (central vascular ligation) and cme (complete mesocolic excision). intracorporal ileotransversoanastomosis was formed by a semimanual method with endogia universal and v-lock suture material. the average length of the laparoscopic stage was 125 ± 25 min, the open phase was 56 ± 14. in the tumor of the lower and middle ampullary parts of the rectum (19 cases) after neoadjuvant chemoradiotherapy, was executed a laparoscopic total mesorectumectomy. conclusions: the use of minimally invasive technologies in colorectal surgery provides a complete revising of the abdominal organs, adequate scope of resection and lymph nodes dissection in surgical interventions. background: it is thought that complete mesocolic excision (cme) improves the oncologic outcomes for colon cancer. but, precise mesenteric mobilization from retroperitoneum and safe ligations at the origins of central vessels are considered to be technically difficult in single port surgery(sps). to resolve this problem, we utilize retro-mesenteric medial approach for right side colon cancer. herein, we introduce this technique and assess its outcomes. operative procedure: the multi-trocar platform is placed in the umbilical site. 3d laparosopy is inserted from one of this channels. the surgeon manipulates instruments via the other 2 channels. 1st step: right colonic mesentery is mobilized medial to lateral from the head of the pancreas and retroperitoneum along the embryonic plane. 2nd step: the origins of ileocolic and right colic vessels are divided and central lymph node dissection is achieved. 3rd step: hepatic flexure is taken down from cranial. and right lateral attachment is dissected away and cme is achieved. 4th step: specimen is extracted and anastomosis is performed using a functional end to end anastomosis extracorporealy. results: from april 2009 to december 2018, 125 consecutive patients underwent sps-cme with right side colon cancer. there were 52 in stage i, 32 in stage ii, 30 in stage iii and 11 in stage iv. the mean operative time was 207 min. the mean estimated blood loss was 42 ml. there was no conversion to open surgery. additional port was placed in 4 patients (3.2%). intraoperative bleeding was occurred in 1 patient. anastomotic leakage was observed in 1 patient (0.8%), intestinal obstruction 1(0.8%) and wound infection in 3(2.4%). conclusion: these results suggest that retro-mesenteric medial approach in single port surgery with right side colon cancer is useful and safe technique. aims: this multicenter, randomized controlled trial (simple trial) aimed to investigate the quality of life (qol) and patient satisfaction of single port laparoscopic surgery (spls) for colon cancer, compared with multiport laparoscopic surgery (mpls). methods: patients with histologically diagnosed adenocarcinoma in cecum, ascending and sigmoid colon were eligible for this trial. eligible patients were randomly assigned to the spls or mpls group at a ratio of 1:1. qol was measured with the eortc qlq-c30 third edition (korean version) preoperatively and postoperatively at month 1, 3, 6 and 12. in addition, patient satisfaction was surveyed with a five-point questionnaire at postoperative 12 month. to exclude the impact of adjuvant chemotherapy on qol, subgroup analysis for patients with or without adjuvant chemotherapy were carried out. (clincaltrials.gov identifier: nct01480128) results: total 359 patients were randomly allocated into the spls group (n = 179) and mpls group (n = 180). in total patients, global health status and five functional scale steadily increased and nine symptom scales also gradually improved over time. but, nausea/ vomiting and appetite loss temporally deteriorated at postoperative 3 month. pain score was significantly worse in the mpls group (11.6 in the spls group vs. 17.6 in the mpls, p = 0.002) at postoperative 1 month and appetite loss score was significantly worse in the spls group (19.9 vs 13.5, p = 0.017) at postoperative 3 month. except for that domains, all the other items of qol between groups were not different until postoperative 12 months. patient satisfaction was significantly higher regarding the operation (p = 0.025) and the abdominal wound (p = 0.025) in the spls group. in patients without adjuvant chemotherapy, some items of qol (global health status, physical functioning, role functioning, emotional functioning, fatigue and pain) were significantly better in the spls group at postoperative 1 month. since postoperative 3 month, all of qol domains (except pain score) were similar between groups. conclusion: although postoperative pain was temporarily better in the spls, most of qol domain were similar between the spls and the mpls group until postoperative 12 month. in patients without adjuvant chemotherapy, spls showed better outcomes in some of functional scales and symptom scores at postoperative 1 month. coloproctological surgery, juntendo university, tokyo, japan; 2 gastroenterological surgery, juntendo university, tokyo, japan introduction: laparoscopic surgery causes less postoperative pain compared with pain after laparotomic surgery, and its low invasiveness should be considered for pain control. we have previously controlled postoperative pain by epidural anesthesia. in this study we compared postoperative multimodal analgesia centering on acetaminophen in patients who underwent laparoscopic colorectal cancer surgery with the conventional method. subjects: the subjects were 39 patients who underwent laparoscopic colorectal cancer surgery between january 2018 and june 2018. surgery was performed under epidural anesthesia in 24 patients and multimodal analgesia in 15: periodic acetaminophen administration ? transverse abdominis plane (tap) block in 6, periodic acetaminophen administration ? local anesthesia of the wound in 2, and periodic acetaminophen administration ? intravenous patient-controlled analgesia (ivpca) in 7. the operating roomoccupying time, postoperative pain (nrs), frequency of taking analgesics as needed, and postoperative nausea were investigated for 3 days after surgery and the duration of urethral catheter placement and postoperative intestinal movement were investigated in the epidural anesthesia and multimodal analgesia groups. results: while the time from entering the operating room to initiation of surgery was significantly shorter, the time from completion of surgery to leaving the room was significantly longer in the multimodal analgesia group. there was no difference in the operating room-occupying time. the frequency of postoperative pain was significantly lower in the multimodal analgesia group on postoperative day (pod) 2. the frequency of taking analgesics as needed was significantly lower in the multimodal analgesia group on pod1, 2, and 3. no significant difference was noted in the duration (number of days) of urethral catheter placement or postoperative nausea between the 2 groups. regarding postoperative intestinal movement, discharge of gas occurred significantly earlier in the epidural anesthesia group. the total number of incidents of complications in the epidural anesthesia group was 12. discussion: in laparoscopic colorectal cancer surgery, the effect of multimodal analgesia centering on periodic administration of acetaminophen without epidural anesthesia for postoperative analgesia was sufficient compared with the effectiveness of epidural anesthesia. this approach to analgesia may be useful because none of the potential complications of epidural anesthesia occur. surg endosc (2019) in the last years the application of new technologies like 3d vision or virtual reality have provided to surgeons the possibility of establish a preoperative surgical plan of each surgery and of each patient. these advances are specially useful in minimally invasive colorectal surgery due to the variability in location, anatomical relationship with other organs and vascular variants of these type of surgeries. the aim of our work is to built a digital 3-dimensional virtual model of the colorectal ct scan imagen of patients with colorectal cancer. the virtual models are obtained from the preoperative ct scan. the ct scans that we use to this work are general electric healthcare revolution gsiò and siemens somatom perspective 64ò and the size of each image is 1 mm. a medical software let us build a reconstruction of colorectal digital images where a radiologist has marked the exact image of the tumor so we obtain a 3d reconstruction which can provide an enhanced understanding of crucial anatomical details like the exact location of the tumor and the relationship with other organs and structures of the patient which can be selectively displayed or hidden. this information has an important applicability into clinical practice since it lets surgeons estimate the colorectal anatomy, tumor size and relationships, providing key landmarks to choose the most appropiate surgery, the best trocar location and a safer dissection specially in some cases whose location can change the kind of surgery radically. we present some cases where virtual models were crucial for the preoperative and intraoperative surgical plan, showing the potential interest of these 3d reconstructions in colorectal surgery. in conclusion the ct scan colorrectal image reconstruction can provide an enhanced understanding of crucial anatomical details of the colon and tumor location and relations which could contribute to choose the best surgical option and to improve safety in colorectal surgery. background: anastomotic leakage (al) after colorectal procedures are a common surgical experience and represents a significant burden both for patients and surgeons. the incidence of al has been reported to vary between 0.5% to up to 21%, with rates for the colon and rectum of 3-7% and 13-18%, respectively. they, not only add to potential postoperative patient morbidities and to overall costs of postoperative patient care, but also are considered a quality indicator in colorectal surgery. aim: we aimed to evaluate the clinical burden associated with anastomotic leaks following colorectal surgery. methods: we conducted a retrospective analysis of 641 colorectal patients who underwent conventional or laparoscopic colorectal surgery for colorectal cancer (crc), from january 1st, 2013 to december 31st, 2016 in a single colorectal centre (centro hospitalar de leiria). patient demographics, intraoperative and postoperative aspects were collected and analysed. all statistical analysis will be conducted using stata software (statacorp lp). results: in our cohort of 641 pts, 35 developed a clinical al (5.46%), mostly males (90%), with an average age of 71 ± 10.57. male gender and conversion were independent risk factors. the group with al had a higher lohs (25.2 days vs, 6.59-p \ 0.0001). 6 out of 35 al have been detected after the discharge. the mean diagnostic day was the eighth, and mode estimated at day 5. when compared with a control group, wcc, eosinophils and crp were statistically significant different in al group, at day 3 and 5. conclusion: in the present study, no statistically significant risk factors for al in crc surgery were detected, except for male gender and conversion. clinical methods and biomarkers were useful for early diagnosis. technology combined with experience and common sense may be the embodiment of the clinical method. conclusions: our regional screening program has significantly improved early diagnosis and quickened surgical treatment of crc. thanks to this, we obtained an earlier stage at diagnosis, a less invasive surgical approach, and a lower rate of complications and emergency surgery need were obtained also with an improvement in both os and dfs. introduction: surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. we evaluated the outcome of silc in patients of over 80 years with colon cancer with a propensity score matched comparison to assess its perioperative and long-term oncological outcomes. methods: this retrospective cohort study analyzed our experience with silc for colon cancer over 5 years. eighty-seven patients of over 80 years with colon cancer who electively underwent silc were included in this study (elderly group). eighty-seven patients were then chosen out of a collective of 257 patients less than 80 years old in a propensity score matched design (younger group). short-term clinical outcomes in both groups were compared and verified its long-term oncological outcome. results: american society of anesthesiologists score and post-operative complication rate were significantly higher in elderly group. however, the other short-term clinical outcomes including post-operative hospital stay were equivalent in two groups. the rates of 5-year cancer specific survival were 78.0% in elderly group and 70.9% in younger group, respectively, and the 5-year overall survival rates were 64.6% and 66.8%, respectively. no significant differences were seen between two groups. conclusions: our initial experiences suggested the oncological and clinical safety of silc in patients of over 80 years with colon cancer. however, further studies are needed to demonstrate the advantages of this procedure compared to conventional laparoscopic colectomy. aim: some clinical trials have reported the safety and efficacy of laparoscopic colectomy for colon cancer. on the other hand, transverse colon cancer was excluded in these trials because of the difficulty of laparoscopic colectomy for transverse colon cancer. in this presentation, we report the tips for laparoscopic colectomy for transverse colon cancer. tips: in our department, 87 transverse colon cancers has been resected by laparoscopically so far. to complete cvl and cme, lymph nodes around middle colic artery should be resected, however many important structure, duodenum, pancreas, superior mesenteric vein (smv) and so on, may be obstacles. this is most difficult point for this surgery. our surgery is as follows. mobilization of ileum and ascending mesocolon from caudal sideconfirm duodenum and pancreasexpose smv and ligation root of ileocecal artery and veindissect lymph nodes around smv and ligation of middle colic artery and accessary right colic veinconfirm pancreas from caudate side of transverse mesocolon and incise the peritoneum along the caudal side of the pancreasdissect lymph nodes sufficiently by dissection from both side of transverse mesocolonmost important point. to dissect lymph nodes safely, confirmation from both side of transverse mesocolon is necessary and dissection should be performed along important structure, smv, pancreas and so on. introduction: we have developed and previously reported single-incision plus one port laparoscopic anterior resection of the rectum (sils ? 1-ar) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. a consecutive experience from its introduction of sils ? 1-ar for rectal cancer is reviewed, and its 5-year oncological outcomes are evaluated retrospectively. methods: one hundred and forty-one patients (53 female) with a mean age of 67.6 years adopted the sils ? 1 procedure for rectal cancer. a lap protector (lp) was inserted through a 2.5 cm transumbilical incision; an ez-access was mounted to the lp and three 5-mm ports were placed. a 12-mm port was inserted in the right lower quadrant. results: one hundred and thirty-six patients (96.5%) completed with sila ? 1-ar. the tumor locations in the rectosigmoid, rectum above the peritoneal reflection (ra), and rectum below (rb) were 44, 63 and 29, respectively. the median follow-up interval was 42 months. aims: colovesical fistulae came from inflammatory disease or cancer and do have a significant morbidity. the most common location is the sigmoid colon and the most common aetiology is diverticulitis. the treatment of choice is a surgical procedure. the aim was studying compare laparoscopic approach in patients diagnosed by benign (diverticulitis) and malignant (colon adenocarcinoma) colovesical fistulae. methods: from january 2001 to march 2005 all characteristics of surgical patients with diverticular and colon adenocarcinoma colovesical fistulae were reviewed. patient details (sex, age, symptoms, diagnosis, medical history and anaesthetic risk), surgical approach, hospital stay and complications were recorded. both groups were compared with significance level set at p \ 0.05. results: nine laparoscopic (71%) and 4 open approaches (29%) in diverticular colovesical fistulae were performed, with a conversion rate of 33%. the procedure done was sigmoidectomy. there were also performed 3 laparoscopic (14%) and 16 open approaches (72%) in colon adenocarcinoma colovesical fistulae. the procedures done were sigmoidectomy, pelvic exenteration, left colectomy, low anterior resection and loop colostomy. comparison between the two groups didn't show significant differences in characteristics but did show significant differences regarding the approach, with more cases performed by open approach in colon adenocarcinoma colovesical fistulae (p = 0.03). conversion rate didn't show significant differences. patients diagnosed for malignant colovesical fistulae had more complications, 15 cases (68%), 10 (45%) i-ii and 5 (23%) iii-iv-v according to clavien dindo classification, manifesting significant differences (p = 0.03). laparoscopic approach didn't show significant differences regarding complications. conclusions: generally, surgical approach with colonic resection and partial or total cystectomy is the treatment of choice in colovesical fistulae, although vesical resection can be avoided if it is suspected benign aetiology. whenever laparoscopic approach is performed by experienced surgeons, is feasible in colovesical fistulae and the morbidity and mortality numbers are acceptable. laparoscopic approach allows the advantages of a minimally invasive treatment but implies clinical trials to stablish stronger evidence. aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many center. most centers use multiport laparoscopic colectomy with extracorporeal resection and anastomosis (mce). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sci) remains controversial. the aim of the present study is to compare these two techniques using propensity matching analysis. methods: this study analyzed 171 patients who underwent laparoscopic right hemicolectomy including 119 mce surgeries and 52 sci surgeries from december 2015 to december 2017. short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sci group was significantly shorter than in the mce group: median (range) 3 (2-10) cm verses 4 (3-8) cm (p \ 0.0001). the vas score after surgery was significantly less in srhi than in mrhe. significantly fewer patients required analgesia after srhi after surgery. there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. the cost effectiveness was significantly cheaper in srhi than in mrhe. conclusions: sci for right colon cancer is safe and technically feasible. sci reduces the length of skin incision and postoperative pain compared with conventional mce. aim: this study was designed to clarify the utility of laparoscopic surgery for advanced lower rectal cancer after neoadjuvant chemoradiotherapy (ncrt). patients and methods: we investigated 3-year disease-free survival rate, operative outcomes and recurrence risk factor in 73 patients with lower rectal cancer (ct2-4, n0-2) who underwent laparoscopic surgery after ncrt from 2010 to december 2017 in kitasato university hospital. results: of 73 patients, 43 patients underwent low anterior resection (lar), 4 patients underwent intersphincteric resection (isr) and 27 abdominoperineal resection (apr). there were 7 anastomotic leakage, and 1 urinary disorder and 2 sexual dysfunction. ypcr rate was 24.7%, but 15 patients (20.5%) had recurrence (7 liver,7 lung and 2 lymph node and 1local recurrence; there is some overlapping). ypt4 and lymph node metastasis were detected as a recurrent risk factor. the 3-year relapse-free survival rate (rfs) was 79.5% and the 3-year overall survival rate (os) was 92%. conclusion: in this examination, ypt4 and lymph node metastasis were risk factor for recurrence. the operative outcomes, 3-year rfs and the 3-year os are relatively good results. we will conduct further follow-up, and it is necessary to investigate a long term prognosis. laparoscopic surgery is warranted for rectal cancer after ncrt. surg endosc (2019) introduction: synchronous colorectal neoplasia presents an incidence ranges from 2% and 7%. classically its surgical treatment consisted in the realisation of a subtotal colectomy (stc), however, several authors have proposed that in certain occasions the realisation of two segmental resections with two anastomoses was not accompanied by an increased risk of anastomotic failure. the objective of this study was to compare the feasibility and safety of the laparoscopic approach of synchronous colorectal neoplasia using two different techniques: stc versus two segmental resections with two anastomoses. methods: we retrospectively reviewed the clinical data of patients over 18 years of age who underwent colorectal surgery between 1998 and 2018 at a single center. we included patients with a synchronous colorectal neoplasia who underwent laparoscopic surgery, either stc or double resection (dr). results: a total of 24 patients met the inclusion criteria. mainly males (86%) with an average age of 75 years, with a scale of the american association of anesthesiologists superior to ii in 53% and with an average body mass index of 29 kg / m2. the mean operative time was 251 min in the dr and 281 min in the stc, the stc resulted in a higher conversion rate (23% vs 11%) and intraoperative bleeding (39% vs 22%), in addition to a postoperative period with more complications, only 15% of the patients undergoing stc didn't present any complication while 67% of the patients with a dr didn't present any complication. 38% of the stc presented anastomotic failure and only 11% of the dr. the mean hospital stay was 8 days in the dr and 18.5 in the stc. in the dr, an average of 47 cm of colon was resected with an average of 24.8 lymph nodes, while in the stc, 127 cm of colon was resected with an average of 24.2 resected nodes. conclusions: the double resection with two anastomosis is a less aggressive surgery, with fewer complications and a shorter hospital stay, providing similar oncological results. there were no differences in morbidity, re-operations or hospital stay. regarding tumor stage there were no differences between the three groups. as for the resected nodes, we found a mean of 21 in stc, 16 in lc and 14 sr with no statistical difference. there were no differences in the affected nodes among groups. in our patients we didn't find differences in the recurrences rate or in the distant metastases rate.the average follow-up was 76 months (range: 30-114), with no differences in overall survival. conclusion: segmental resection of splenic flexure neoplasias is safe and feasible, with no differences in morbidity or in the oncological outcomes compared with more aggressive surgeries. introduction: the evaluation of perfusion in colorectal anastomosis is still a field of study and progress for the development of new modalities that allow reducing the ratio of dehiscence or anastomotic leakage (al) in said surgery. our objective with this work is to highlight the utility of indocyanine green (icg) in the said evaluation after colo-rectal surgery. methods: we present a series of 85 cases of colorectal surgery (benign and malignant disease) intervened in the period between 2014 and 2018. the population sample has been homogenized according to age criteria, risk factors and comorbidity. a retrospective database has been developed with the spss v.22 software for the evaluation of the results obtained. the primary outcome measure was al rate with at least 1 month of follow-up. results: a significant reduction in the incidence of al was observed in patients who underwent colo-rectal surgery (p = 0.005). low al rates were shown in rectal cancer surgery (p = 0.02). there was no significant decrease in the al rate when colorectal procedures for benign and malignant disease were combined. conclusions: the use of the image by fluorescence with indocyanine green is a safe, reproducible and relatively simple method with which to evaluate the perfusion of the colorectal anastomosis as well as reduce the rate of anastomotic leak in the postoperative period. large well-designed randomized control trials are needed to provide evidence for its routine use in colorectal surgery. introduction: currently colonoscopy is the gold standard investigation for colonic evaluation. although caecal intubation is one of its quality indicators, it is not attained in up to 20% of cases. this remains a significant concern. limited data are available on the follow-up of patients with incomplete colonoscopy. aims: to assess colonoscopy completion rate, the reasons for incomplete colonoscopy, and the methods used to complete colonic evaluations after incomplete colonoscopy. methods: we performed a retrospective study of incomplete colonoscopies in our unit over a one year period (2017) these results compare favorably with published data. few statistically significant differences between groups suggest varying modalities of treatment broadly result in similar qol. this data highlights a need for well-delivered support programmes for specific issues, for example stoma care and sexual dysfunction. future studies will need to include a baseline questionnaire to truly measure the impact of surgery and measure quality in an increasingly elderly and comorbid population. splenic flexure cancer (sfc), comprising the tumours raised in the distal transverse colon and proximal descendingcolon, accountfor 2 to5%of all surgically treated colorectal cancers.in cme forsfc, dissection of both the transverse and descending mesocolon must be considered. however, the use of laparoscopic surgery as a curative treatment for sfc, has never been investigated in adequate controlled trials, because of difficulty in deciding on the appropriate operative procedure, as well as technical difficulties with laparoscopic lymph node dissection. the aim of this multicenter study is to evaluate the oncologic effectiveness of laparoscopic segmental resection with cme with for cancer located at the splenic flexure. we performed a retrospective analysis of all cases of sfc treated with a laparoscopic segmental resection with cme in five different institution. intra and post operative were evaluated. 112 patientes were evaluated, the mean operative time was 155.17 ± 48.54 min. a total of 6 (5.4%) conversions occurred, 2 due to splenic artery lesion, one for difficult adesyolisis and three due to locally advanced tumour. recurrence was observed in 13 (11.6%) patients. there was a significant association between disease stage and recurrence (p \ 0.001) with a higher proportion of stage iv patients in the recurrence group (46.1% vs 7.1%). at 30 days follow-up no mortalitywere recorded.during a median follow-up of 43 months (range 12-149), 13 deaths occurred (all of them for disease progression). keplan mayer curves showed a compareble suvival with other colo-rectal cancer. in conclusion, laparoscopic segmental resection with cme and cvl seems to be an oncologically safe and effective procedure for treatment of sfc. it may be regarded as the standard surgical method for elective management of this disease. in the future, more tailored patient-and tumor-specific segmental resection might be achieved with the use of routine lymph node road mapping. it is very important to establish a minimum number of lymph nodes to analyse for a correct staging. it has been established as 12. the treatment of colorectal cancer is essentially surgical. the review of the medical literature indicates that laparoscopic colorectal surgery is a safe procedure that has not found significant differences in the survival rate from open surgery. aim: the aim of our study is to compare the outcomes of laparoscopic and open resection for colorectal cancer surgery evaluating lymph node assessment. methods: the patients were collected in our hospital during the period from 1/11/2017 to 1/12/ 2018 and the number of lymph nodes obtained in lymphadenectomy has been studied comparing the laparoscopic and laparotomy approaches. results: 81 interventions were performed. 55 were laparotomic, 20 were laparoscopic and 5 converted laparoscopic (fig 1) . the average number of nodes found in these interventions was 15, 36. nowadays, the recommendations to obtain a proper lymphadenectomy is to find more than 12 lymph nodes. analysing our procedures, 61 surgeries had obtained a good lymphadenectomy. according to the approach, 62,3% of the interventions (38) are laparotomy, 31,2% (19) are laparoscopic procedures and 6,5% (4) are by reconverted laparotomy (figure 2 ). the average number of lymph nodes isolated was similar. laparotomy approach found 16,45 nodes while 13,5 nodes were found in laparoscopy. converted laparoscopy found 12,2 ( figure 3 ). conclusion: the treatment of colorectal cancer is essentially surgical. today, there are a lot of studies that support that laparoscopic surgery has a survival rate similar to laparotomy surgery. according to our study, the data collected indicates that the number of isolated lymph nodes in both approaches is very similar. to sump up, laparoscopic colorectal surgery is safe and has demonstrated oncological adequacy comparable to open approach and better short-term outcomes due to a less invasive approach. background: laparoscopic low anterior resection highlights the advantages of laparoscopic surgery (better surgical field, less bloodloss, less postoperativepain, better cosmeticresult). defunctioning ileostomy prevents anastomotic leakage in low rectal cancers, butincreases morbidity, degrades thequality of life and requires a second surgery for its closure. method: in the last 24 months we performed 8 laparoscopic low anterior resections for rectal cancer, whithout performing any protectiveileostomy, afterchecking the anastomosis intraoperatively(5 men, 6 women. average age: 65 years). the typical placement of trocars included one supraumbilical 5 mm trocar, two right sided 10 mm trocars in the midclavicular line, one 5 mm in the left midclavicular line and one 5 mm trocar in the suprapubic midline which is also used for specimen removal, after a 2 cm transverse extension of the incision. we present themain stages of the procedure (dissection andmesorectal excision, division of the rectum with linear stapler using the 'chinese hat-parnex' technique, creation of an end-to-end intracorporeal anastomosisusing circular stapler under direct laparoscopic vision). results: no major postoperative complication was observed. the mean operative time was 250 min (180-300) and free surgical margins were achieved. in one case a conversion to open surgery occured. the average length of hospital stay was 8 days (7-9). conclusions: the laparoscopic approach facilitates access to the middle and lower rectum, total mesorectal excision and avoidance of ileostomy if possible. it is a demanding operation with extended learning curve, and requires adequate experience in laparoscopic surgery and colorectal surgical oncology. background: in colorectal cancer, local excision is an attractive treatment option, but additional resection is considered when lymph node metastasis(lnm) is expected at high rate. in lower rectal cancer, advanced surgery techniques are required, so it is often difficult to make judgments. the aim of the current study is to assess the reliability of laparoscopic surgery for submucosally invasive rectal adenocarcinoma (pt1) analyzing short-term outcomes and long-term survival. method: this cohort study analyzed 217 patients who underwent laparoscopic rectal resection for submucosally invasive rectal adenocarcinoma (pt1). conversion rate and functional and oncologic outcomes were analyzed. data on long-term results and survival were evaluated. result: surgical procedure was low anterior resection / intersphincteric resection / abdominoperineal resection: 190/23/4, and conversion to open surgery was needed for 6 (2.8%) patients. sphincter-preserving procedures were performed in 204 (97.2%) patients. there were no perioperative mortalities and positive resection margin. the mean length of hospital stay was 10.5 days. complications beyond clavien-dindo grade iii occurred in 14 (6.4%) patients,the anastomotic leakage rate was 3.6% (8/217). the positive lymph node metastasis rate was 12.9% (28/217). high tumor budding (p = 0.006), lymphatic invasion (p \ 0.0001), and mucinous /poor histological differentiation (p = 0.01) were significantly associated with lymph node metastasis on univariate analysis. on multivariate analysis, only lymphatic invasion was associated with lymph node metastasis (p \ 0.001).the median follow-up time was 50 months (range, 6-151 months), recurrence free survival rates was 96.3% (209/217). conculusion: the outcomes of this study suggest that laparoscopic surgery can be used for safe and radical resection of submucosally invasive rectal adenocarcinoma (pt1)?and the absence of lymphatic invasion, budding, and mucinous /poor histological differentiation are each associated with low risk of lnm. risk stratification models integrating these factors need to be investigated further. conclusions: this study highlights the complex nature of sarcopenia, as well as its common incidence. minimally invasive surgery had a higher incidence of sarcopenia than that of open surgery when both were performed within an enhanced recovery setting. despite colorectal patients being a typically well-nourished cohort at low risk of complications, there may well be benefit from interventional strategies such as perioperative immunonutrition or pre-habilitation to reduce the incidence of this poor prognostic indicator. backgrounds: urinary dysfunction is frequently observed after rectal resection and justifies urinary drainage. the concept of enhanced recovery after surgery (eras) has been widely spread from the early 2000 s. however, the optimal duration of postoperative urinary drainage is unknown. aims: the aim of this study was to comprehend short-term outcome of early removal of urinary catheter after robotic rectal surgery (rrs). patients and methods: (patients) the data of 44 consecutive patients who underwent rrs at two hospitals between april 2015 and november 2017 were retrospectively reviewed. the main indication of rrs was the patients who need rectal mobilization with autonomic nerve preservation regardless of benign or malignant disease. perioperative management: none of the patients received epidural anesthesia for postoperative analgesia. our basic principle was to remove urinary catheter on postoperative day (pod) 1. after removal of urinary catheter, trans-urethral catheterization (tuc) was performed in the following situations:1) no autonomous urination over 6 h after removal 2) the decrease in urine volume (\ 150 ml/6hr) 3) the appearance of subjective symptoms like abdominal distension. when tuc was required even once, residual urine volume was measured with ultrasonic examination device since then. results: twenty seven male and 17 female were included. the median age of patients and bmi were 67 years old and 22.7 kg/m2, respectively. the surgical procedures included anterior resection (n = 33), intersphincteric resection (n = 4), abdominoperineal resection (n = 5), hartmann's procedure (n = 1), and total coloproctectomy (n = 1). only one patient received lateral pelvic lymph node dissection. urinary catheter was removed on pod1 in 40 cases (90.9%), on pod2 in 4 cases (9.1%). although tuc was needed in three cases (6.8%) immediately after removal, tuc was no longer needed within three days in all three patients. late dysuria was observed in two cases (4.5%), and bladder overdistension was suspected in these two cases. conclusions: our study showed that urinary catheter could be safely removed on pod1 after rrs. however, careful follow-up observation to avoid bladder overdistension is essential after removal. introduction: intersphincterian low rectal resection is a valid alternative to lower rectal cancers located at about 4-7 cm from the anus. methods: we present 19 cases from our personal experience for tumors localized 4-7 cm from the anus. 13 of them required preoperative radiochemotherapy. in 12 cases, abdominal surgery was performed laparoscopic, 7 having the surgical specimen extracted transanal. lone star device was used for the perineal procedure in all cases. 6 cases required a manually, separate wires anastomosis; the others 13 cases benefited from mechanical anastomosis performed endoanal with 29-31 mm circular stapler. we performed complete mesorectum excision in all cases, ligation at the origin of inferior mesenteric artery, complete mobilization of left splenic flexure and lateral protective ileostomy. all pacients underwent inspection rectoscopy before transit reintegration, and 16 cases were reintegrated over a period of 3-12 weeks, except for 3 cases which developed a colo-anal fistula, that closed under conservative treatment over a period of 3-9 months. results: there were no postoperative anal incontinence. in one case, a relative anal stenosis occured, which required endoscopic dilation. there was 1 case of tumor recurrence and required abdominoperineal resection. conclusion: literature data sustain a 3-4/1 ratio for very low rectal resection versus rectum amputation. the limit resection under the tumor is accepted as 0.5 cm. very good functional results by considering oncological principles, is a sustainable argument for choosing this kind of procedure as an alternative of rectum amputation. in the few studies conducted on crcs, the reported rate of sln micro-metastases is up to 20-30%. the aim of this ongoing prospective study is to assess the predictability of the ex-vivo nirf sln mapping and of the research of micrometastases in nnd crc patients to propose adjuvant chemotherapy. materials and methods: fifty-eight patients undergoing standard oncological crc laparoscopic resection have been prospectively enrolled in two centre. as previously described by the authors, the intact surgical specimen was extracted and opened longitudinally and 1 ml of indocyanine green (icg; 5 mg/ml) was injected submucosally at four corners around the tumor in order to identify the lymphatic pathway and the slns. each sln presenting as negative at conventional histological analysis, was further investigated with ultrastaging techniques including serial sectioning and additional immunohistochemistry, in order to detect the presence of micrometastases. results: thirty patients were n ? , and 28 were nnd. overall, a total of 1085 lymph nodes were retrieved. a total of 117 sln were identified (mean 2.01 per case) and 54 of those were nnd. after ultrastaging investigations, 4 micrometastatic cases were found in nnd patients. the patients were so upstaged to n1. sln located deeper in the mesenteric and mesorectal fat could easily be identified by nirf (even after nchrt). conclusions: in our preliminary series, the ex-vivo nirf sln mapping rightly predicts the status of loco-regional nodes, as confirmed by the histological investigations. the micrometastases' identification let selected patients to undergo the adjuvant treatment with the aim to reduce the risk of recurrence. (3/13) in lateral node positive group and 18.8% (3/16) in lateral node negative group. four of 6 local recurrence were lateral lymph node recurrence. two patients recurred the other lateral side of previous lpl, then they were laparoscopically resected and no recurrence (52, 58 months). two patients recurred the same side after lpl were not curable because of liver metastasis and extensive invasion to the common iliac vessels. conclusion: selective lpl for rectal cancer was safe and good local control for lateral lymph node positive patients. also curable local recurrence resection was possible for non-treated lateral lymph node recurrence. intestinal malrotation is an embriologic anomaly generally discovered in the first months of life due to bowel obstruction. adult presentation is rare and its association with colon cancer is far more rare. we report a case of a 70 years old man affected by asymptomatic intestinal malrotation incidentally found during an abdominal computed tomography (ct) performed for retroperitoneal colonic perforation in a patient with an endoscopically diagnosed aenocarcinoma of the caecum and a large polyp of the descending colon. preoperative vascular anatomic study allowed us to plan a laparoscopic approach safely also with adequate lymphoadenectomy. the abdominal cavity was entered throught a right flank 12 mm optical trocar on the transverse umbilical line. three additional 5 mm trocars were placed in right iliac fossa, right and left hypocondrium respectively. exploratory laparoscopy confirmed midgut malrotation and a fresh flogistic area at the descending colon perforation site. caecum and ascending colon were on midline and attached due to adhesions to sacral promontory. ileocolic artery (ica), middle colic artery (mca) and ima were selectively ligated but not at their origins due to aberrant anatomy. laparoscopic subtotal colectomy with intracorporeal stapled ileosigmoid anastomosis were carried out (endogia 45 mm, double layer 3/0 polyglicolic acid suturing of the breech). the anisoperistaltic nature of the anastomosis is due to the disposition of the mesenterium which did not allow an isoperistalting orientation of the two resected stumps. the specimen was extracted throught a pfannestiel incision. the postoperative course was complicated by intestinal obstruction conservatively treated with slow bowel function's restoration. the patient was discharged from the hospital in 15th postoperative day. unexpectedly specimen histology revealed two villous adenomas with high grade dysplasia. 17 lymphnodes were retrieved from the specimen (ptisn0). to date our case is the only fully laparoscopic colonic resection reported in literature in malrotation as well as the first intracorporeal stapled ileo-sigmoid anastomosis for such disease. the median hospital stay was 6 days. in-hospital mortality was nil. the overall morbidity was 20%. the median length of follow-up was 23 months. conclusions: our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles. robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). in rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. aims: postoperative inflammation have been reported as one of the independent prognostic factors in several types of malignancies.the aim of this study is to clarify the impact of laparoscopic approach on postoperative inflammatory status after surgery for colorectal cancer, and to analyze the association between postoperative inflammation and prognosis in patients with colorectal cancer. methods: a total of 636 patients with stage l-lll colorectal cancer (crc) who underwent curative surgery were retrospectively analyzed. the maximum crp value measured between the times of surgical resection and discharge was defined as 'max crp'. the optimal cut-off value of max crp that best predicts rfs was determined to be 10 mg/dl by the minimum p-value approach. methods: trainees working in this firm were responsible for data collection. patients who underwent emergency surgery during the calendar year of 2018 had the following details collected-the presence or absence of a complication in the 30-day post-operative period, the type of complication and description of complication along with the grade of the complication (see fig. 1.) . patients who underwent intermediate to major surgery were followed up at outpatients and were specifically asked for the occurrence of complications from the point of discharge up until the outpatient appointment. with one centralised national hospital-the people who were discharged and subsequently experienced considerable or major complications invariably represented back to hospital via the a&e department. results: a total of 148 emergency surgeries were performed by this surgical firm in 2018, 63% of these being done laparoscopically. of these 148 cases-29 patients experienced post-operative complications within the first 30 days after their procedure. this equated to a complication rate of 19.59%. the most common complications were abdominal pain, nausea & vomiting, and wound infection. there were 8 complications for each of these 3 categories. post-operative bleeding occurred in 5 cases with fistulas or leak of an anastomosis occurring in 3 cases. death of a patient occurred in 3 instances once as a result of post-operative bleeding from the site of anastomosis after a whipple's procedure, the 2nd occurred subsequent to post-operative bleeding from a peptic ulcer and in the 3rd case occurred in an instance of faecal peritonitis as a result of anastomotic failure after a roux-en-y bypass for a patient with pancreatic malignancy. conclusion: the davien-clindo classification proved to be simple, efficient and useful in analysing post-operative outcomes. the results indicate that despite the emergency setting & elderly cohort of patients-minimally invasive surgery proved to be a safe and viable option. conclusions: in this prospective study, we observed greater rates of detection of adenomas among endoscopists. screening colonoscopy on symptomatic and/or high risk group for crc is valuable in early detection and the prevention of crc. large sample size and long period of screening colonoscopy was needed. limitation of our study was the small sample size and no use of high detention endoscopy. results: the mean intraoperative blood loss volume was significantly less in the lap group than in the open group (735 vs. 4447 ml, respectively, p \ 0.01). the mean operative time was not significantly different between the lap group and the open group (738 vs 679 min, respectively, p = 0.276). the incidence of severe postoperative complication (grade 3 or higher in the clavien-dindo classification) was lower in the lap group (4/17 (24%) vs 16/35 (46%), respectively). the mean postoperative hospital stay was significantly shorter in the lap group than that in the open group (39 vs. 454 days, respectively, p = 0.022). conclusions: lap-tpe can be a safe and feasible procedure. background: amyloid light chain (al) amyloidosis is a rare protein deposition disorder with an incidence ranging between 3-8 cases per million people. it can present insidiously with localized or multisystem symptoms and usually occurs later in life. prognosis is poor as al typically presents at an advanced stage. intestinal pseudo-obstruction is a rarely reported complication of al amyloidosis. here we report a case of al amyloidosis which was identified during surgery for intestinal pseudo-obstruction. case presentation: a 56 year old male presented to the emergency department with a 4 month history of abdominal pain and distension, as well as marked swelling of his lower limbs. this had worsened in the previous 2 weeks and he had developed intermittent diarrhoea. ct showed ileitis with marked dilation of the proximal small bowel. laparatomy revealed small bowel that was grossly distended that rapidly developed multiple petechiae and subsequent haematomas upon handling. two days later a repeat laparotomy was performed and 3.45 m of ishaemic small bowel was resected. histology showed amyloid deposition with positive congo red staining. subsequent cardiac events led to an echo being performed that showed concentric left ventricular hypertrophy attributed to amyloid deposition within the myocardium. free serum light chain ratio was sent and confirmed the diagnosis of al amyloidosis. he has recently been started on a treatment regimen consisting of cyclophosphamide and dexamethasone. discussion: systemic al amyloidosis frequently involves the gastrointestinal tract, typically presenting with chronic diarrhoea and associated malabsorption. only 1 case presenting with pseudo-obstruction has been reported in the literature. al amyloidosis presents insidiously with non-specific symptoms depending on which organs are affected. treatment aims to prevent further deposition of protein within the organs. prognosis is determined by the organs that are affected and the extent of protein deposition within them. cardiac involvement holds the worst prognosis ultimately causing sudden cardiac death. the mainstays of management are early identification and treatment implementation to prevent protein build up and subsequent organ failure. conclusion: a diagnosis of amyloidosis should be considered in patients with intestinal pseudo-obstruction to expedite the diagnosis of al amyloidosis and improve survival. aim: in the management of locally advanced rectal cancer (larc), the achievement of a complete total mesorectal excision (tme) with clear resection margins was demonstrated to be the main predictor of overall and disease-free survival. predicting surgical difficulty in larc patients may be of particular importance to choose the best surgical approach. this study proposes a mri-based score to identify preoperatively larc patients with a high risk of having a difficult surgery. methods: this is a retrospective study based on the european mri and rectal cancer surgery (eumarcs) database, including patients with mid-low larc who were treated with neoadjuvant chemoradiation therapy and laparoscopic tme with primary anastomosis. data on pre-treatment and restaging through magnetic resonance imaging were available for all patients. surgical difficulty was defined as high or low grade taking in to account operative (e.g. duration of surgery), and postoperative factors (e.g. hospital stay). score accuracy was evaluated by estimating sensitivity, specificity and area under the receiver operating characteristics curve (aroc). results: seventeen (12.5%) of 136 larc patients were graded as high surgical difficulty. the eumarcs score was developed using the following significant predictors of surgical difficulty: bmi [ 30, interspinous distance \ 96.4 mm, ymrtstage = t3b, and male sex. the score ranged from 0 to 10. the cut-off score to best differentiate patients with a high probability of difficult surgery was = 3 points. this cut-off value showed the best balance in sensitivity and specificity. the eumarcs score demonstrated high accuracy (aroc: 0.0802) conclusions: the eumarcs score was found to be sensitive and specific in predicting surgical difficulty in larc patients who were candidate for laparoscopic tme. the score has the advantage of considering patient and cancer related characteristics that can be all assessed preoperatively and it can be useful in the decision making process. this score has not yet been externally validated. background: recently published two non-inferiority randomised control trials has raised questions on laparoscopic surgery for rectal cancer, showing lower quality pathological specimens to those achieved using an open technique. locally advanced rectal cancers add to the level of difficulty for laparoscopy approach. our study was aimed to assess feasibility of laparoscopic rectal surgery, comparing short term outcomes, quality of surgical specimen, morbidity and mortality, between propensity score match groups of locally advanced and early rectal cancers. methods: prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer at the minimally invasive colorectal unit in united kingdom between 2006 and 2014. locally advanced rectal tumours were identified as t3b or t4 with pre-operative mri scans. all the patients were operated by the same team and the procedures were performed laparoscopically. 1:1 propensity score matching was performed to create a perfect match in terms of tumour height. results: total of 369 laparoscopic rectal resections were performed during the study period, out of which 87 patients had locally advanced (la) disease and were propensity-score matched for tumour height with non-locally advanced (nla) patients. median operative time was higher for the la surgery group (270 min vs 250 min p = 0.024). however, conversion to open surgery (p = 0.621), readmission (p = 0.295), re-operation (p = 0.747), clinical anastomotic leak (p = 0.589) and 30-day mortality rates (p = 0.497) were all equivalent between the two groups. r0 resection was achieved in 89% of la group as compare to 94% of nla group (p = 0.177). conclusion: this study demonstrate that standardised approach to laparoscopy is safe and feasible in locally advanced rectal cancers. comparable post-operative short-term clinical and pathological outcomes were seen between la and nla groups. aims: the application of colorectal cancer screening programs, has showed a decrease in recurrence and mortality. for this reason, these programs are being implemented at a national level in the different spanish regions, as has happened in our community.to present the initial short-term results on the morbidity of the immediate postoperative period to 90 days of colon cancer, mortality and hospital stay after the implementation of a screening program in our center. methods: a retrospective study was performed. 73 patients aged between 60 and 69 years were included in the study, diagnosed with colon cancer. they underwent minimally invasive surgery, in most cases, with any type of colonic resection, from january 2010 to december 2017. all patients were diagnosed, conventionally or through a screening program, the latter according to the plan implemented in our community. the sample was divided into two groups of patients according to the way of being diagnosed (group si screening = 25 patients, group no screening = 48 patients) and they were compared according different variables: dependent factors of the patient, factor of type colon cancer, factors of colon cancer resection and follow-up. results: both groups were comparable in all study variables. regarding the variables included in the follow-up, no statistically significant differences were found in terms of postoperative mortality-clavien-dindo v. however we found differences statistically significant in postoperative morbidity (p = 0.006) and in its classification according to clavien dindo i-iv (p = 0.018). the complications analyzed independently, such as anastomotic dehiscence (p = 0.023) or postoperative ileus (p = 0.033), have also presented significant differences, unlike surgical wound infection (p = 0.115). conclusion: at our center, the application of the screening program has not influenced in the initial stage of colon cancer or its surgical approach. however, we have found a lower overall morbidity rate and minor complications, justified by a lower incidence of anastomotic dehiscence and postoperative ileus. background: colorectal carcinoma is one of the most common malignancies. surgery is the only definitive method to achieve cure for this illness and can be performed via an open or a laparoscopic approach. the pros and cons of each approach have been discussed extensively, with the oncologic efficiency of the laparoscopic approach being one of the leading topics. objective: the aim of this study was to establish oncological non-inferiority of the laparoscopic approach to colorectal cancer. primary outcome measure was defined as number of harvested lymph nodes. secondary outcome measures were medium-term disease free and overall survival as well as length of hospital stay, time to oral feeding and short-and long-term complication rate. methods: this was a single center retrospective chart review. all consecutive patients who underwent colon or rectal resection due to colorectal carcinoma at hadassah medical center between the years 2014-2017 were included. patients who were operated on for recurrent disease or who had metastatic disease at the time of surgery were excluded. patients were divided into three groups according to the surgical approach: laparoscopic, open or converted. medium-term oncological outcomes were the same for all groups. time to oral feeding, length of hospital stay, short-and long-term complication rate were all significantly improved in the laparoscopic group. conclusions: we were unable to prove non-inferiority of the laparoscopic approach regarding the number of harvested lymph nodes. however, all surgical approaches yielded a high number of harvested lymph nodes which is most probably oncologically sufficient, as reflected by the non-existent difference in medium-term oncological follow up. this study supports previous studies showing the superiority of the laparoscopic approach regarding short term recovery and overall complications rates. aims: two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high quality surgery are equivalent to those achieved by open technique. we intend to present short and long-term postoperative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic tme for rectal cancer. we describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. methods: prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon (ap) at the minimally invasive colorectal unit in portsmouth between 2006 and 2014 were analysed along with data acquired between 2010 and 2017 from surgeons (tq,nf,ah) at three further international centres. end-points were overall and diseasefree survival at 5 years, and early post-operative clinical and pathological outcomes. results: 263 consecutive patients underwent laparoscopic tme surgery by the principal surgeon (ap). at 5 years overall survival was 82.9% (dukes' a = 94.4%; b = 81.6%; c = 73.7%); disease-free survival was 84.0% (dukes' a = 93.3%; b = 86.8%; c = 72.6%). post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, incomplete resection, major morbidity and 30 day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. conclusion: laparoscopic tme produces excellent long-term survival outcomes for patients with rectal cancer. a standardised approach has the potential to improve outcomes by setting bench-marks for surgical quality, and providing a step-by-step method for surgical training. results: analysis of association of tumor location (sigmoid, right or left colon), operation time, blood loss, extraction site, type of surgical sutures used for wound closure with postoperative complications or specimen quality either did not show significant correlation or could not be conducted due to data nature. unexpectedly, a significant difference was demonstrated between two surgical teams in terms of hernias. majority of cases-44 (64.7%) were performed by surgeon 1 (s1), surgeon 2 (s2) operated on 22 (35.3%) patients, nevertheless minilaparotomy closure was usually performed by junior members of the team. conversion rate was 4.5% for s1 and 18.2% for s2 (p = 0.089). operation time and blood loss were smaller in s1 group compared to s2 (153.6 ± 62.5 min vs 179.3 ± 55.2 min, p = 0.037 and 59.7 ± 45.7 ml vs 100.0 ± 74.0 ml, p = 0.027 respectively). specimen quality and early postoperative complications did not differ. postoperative hernia rate was 2.3% for s1 and 22.7% for s2 (p = 0,013). both surgeons used the same specimen extraction sites and materials for wound closure. hernias were more frequent after vertical minilaparotomy-25% (1 of 4 patients), and in converted patients 33,3% (2 of 6 patients), compared to 5, 5% (3 of 56) in transverse minilaparotomy group. there was no association of hernias and wound infections. conclusions: our study demonstrates, that besides consultant dependent surgical surrogates, steps which are often performed by other members of surgical team (such as wound closure) may contribute to complication rate as well. more thorough supervision of wound closure may be needed. aims: laparoscopic complete mesocolic excision (cme) right hemicolectomy is considered a demanding procedure and it is actually adopted in few centers from the west. the aim of the present study is to analyze the safety of laparoscopic cme right hemicolectomy and to compare its short-term results with standard right hemicolectomy in a single western center. methods: prospectively collected data from 56 patients who underwent laparoscopic cme right hemicolectomy between june 2014 and november 2017 were retrospectively analyzed (cme group) and compared with data from 49 patients submitted to standard laparoscopic right hemicolectomy between april 2013 and november 2017 (s group). results: no differences were observed between the cme and the standard right hemicolectomy groups in terms of clinical characteristics. in the cme group, 39.3% of patients were = 75 years old, 28.6% of patients were asa class 3, 46.4% of patients had = 2 comorbidities, 30.4% of patients had bmi [ 28 and 14.3% of patients had = 2 previous abdominal surgeries. no differences were observed in terms of duration of surgery (215 ± 59 min vs. 208 ± 58 min; p = 0.573) and intraoperative complications (5.4% vs. 4.1%; p = 0.759) between cme and s groups; mean blood loss was lower in the cme group (50.5 ± 45.9 ml vs 75.7 ± 62.6 ml, p = 0.029). the percentage of overall (42.9% vs. 46.9%; p = 0.412) and severe (clavien-dindo = 3) complications (8.9% vs. 8.2%; p = 0.875), redo surgery (3.6% vs. 8.2%; p = 0.414) and readmission (3.6% vs. 6.1%; p = 0.662) was comparable between cme group and s group. a significant difference was observed in the length of specimen (329 ± 79 mm vs. 270 ± 98 mm; p \ 0.001) as well as in the length of proximal (159 ± 96 mm vs.121 ± 70 mm; p = 0.028) and distal margins (134 ± 64 mm vs.110 ± 61 mm; p = 0.05) in favor of the cme group. the number of lymph nodes harvested was slightly higher in the cme group (21.9 ± 9.6 vs. 25.7 ± 10.2; p = 0.055) as it was for the percentage of cases with less than 12 retrieved lymph nodes (8.2% vs. 1.8%; p = 0.143), although these differences did not reach statistical significance. conclusions: this study represents one of the few western experiences demonstrating the safety of laparoscopic cme right hemicolectomy. cme technique showed good short-term results and better quality specimens when compared with the standard procedure. aim and background: peritoneal dissemination of colorectal cancer (pc) makes the complete resection of cancer lesions impossible. in such cases, multidisciplinary therapy is essential with mainly chemotherapy. preoperative diagnosis of pc is usually uncertain by ct or mri image. for diagnosis of pc needs surgical materials with laparotomy. but the laparotomy and resection of pc with general anesthesia tends to make impossible for immediate chemotherapy. less invasive diagnosis of pc is necessary and expected.endocytoscopy (ec) makes the histological diagnosis with precise images gained by high magnification (x 520). as a preliminary examination, ec diagnosis for resected specimens of pc were evaluated. methods: two cases of pc diagnosed in operation were evaluated. under general anesthesia, laparotomy was conducted. peritoneal dissemination lesions obviously diagnosed as pc were resected. immediately the lesions were stained by methylene blue solution for 120 to180 s. ec observation was done according ec classification1) and ecv classification2). results: in two cases, ec observation was successfully done. images of dilated surface microvessels of a nonhomogeneous caliber or arrangement were observed in nbi ec corresponding to ec-v3. histopathological diagnosis of resected specimens was metastatic colorectal carcinoma in peritoneum in both cases. conclusions: histological diagnosis for pc is gained by ec with resected specimen. as the result of this investigation, ec examination via camera port in laparoscopic operation might be possible for diagnosis for pc of colorectal cancer in vivo. aims: the aim of this presentation is to demonstrate and analyze surgical complications, arising during laparoscopic colorectal resections for cancer and to analyze the reasons of adverse events. methods: we demonstrate videos from our surgeries, where different types of complications occurred and share our classification of types of mistakes, that may lead to intraoperative complications and ways to prevent them. results: we divide mistakes in laparoscopic colorectal resections into two large groups-'false strategy' and 'dangerous techniques'. the first includes poor diagnosis, too extensive or insufficient extent of surgery and improper enthusiasm in using platforms. prevention of first type mistakes is in thorough training and peer-review of each consultant practice. second type of mistakes includes two subtypes : 'faulty habits'-use of unsafe techniques (blind port insertion, poor vascular exposure prior to clipping, not obtaining 'critical views', unsafe use of energy and stapling devices etc.) and 'failure in a certain case'-when despite correct general approach a complication occurred (misinterpretation of fascial layers or vessels). prevention of 'faulty habits' lies in supervised training in high volume colorectal departments including dedicated surgical devices training. to avoid 'failure in a certain case' standardization of surgical procedure is essential, as the most efficient way to prevent this type of mistake is 'pattern recognition'ability of a surgeon to compare the picture he sees during a procedure with a 'standard' view, he used to have during previously performed standard surgeries-this is apparentely impossible when every procedure is done differently. regular reviews of own surgeries recording and other surgeons' procedures may also fascilitate pattern formation. in case a complication occurres we use the four step course of action: preservation of the view, temporary control, decision on conversion, permanent control. conclusion: as popularity of laparoscopic colorectal resections is growing rapidly the number of intraoperative compliactions is increasing as well. we demonstrate videos of complications and our approach to classification of possible mistakes. systematic aproach to reasons, underlying certain mistakes helps to produce a strategy to reduce intraoperative complication rate. introduction: the drains placement inside the abdominal cavity has traditionally been carried out to evacuate hematic remains or postoperative collections. there is no scientific evidence of the prophylactic use of drainage in elective colorectal cancer (ccr) surgery to avoid anastomotic complications or other complications. however, it is traditionally used. when the anastomotic leak is produced, it is generally agreed that drainage system should be used for therapeutic purposes. aims: the aim of this study is to evaluate the effectiveness of the use of prophylactic drainage in elective surgery of ccr. we would check if they avoided the appearance of complications, and if they are useful when the anastomotic leak appears. methods and results: we analyzed the data collected in our hospital from 1/11/17 to 12/12/18. we studied the number and type of interventions in which prophylactic drainages were placed, the appearance of anastomotic complications and if these drains were effective. 93 interventions were performed during this period of time. 72% of these procedures had used prophylactic drainage (67 interventions). this percentage was up to 100% in patients who have performed a left colon surgery as a sigmoidectomy or rectal procedure. during this period, there were 10 cases of anastomotic leakage. in all of them had been placed drainage but only 3 of them were effective. conclusions: we have seen that prophylactic drainage is a common practice independently of the location of the anastomosis. the last multimodal rehabilitation guidelines recommended the nonuse of drains systematically above the peritoneal reflection with a high level of scientific evidence. they cause discomfort to the patient and delay early mobilization. however, it may be useful to use drains in the first 24 h of a pelvic floor procedure. there is not enough evidence to show sistematic drainage after colorectal anastomosis prevents complications of the anastomosis or other complications. aims: colonic cancers of the splenic flexure is uncommon and associated with poor prognosis. several studies were published aimed to identify the optimal surgical option for the best oncological outcomes. however, whether an extended colectomy or a segmental resection is required is still controversial. the aim of this study is to analyse the outcome of the two different approaches through the experience of a single centre. materials and methods: retrospective data of consecutive patients with diagnosis of colonic cancer situated at the splenic flexure of our department between 2004 and 2017 were analysed. based on type of surgical procedure, patients were enrolled in arm a (segmental resection) and arm b (extended resection). arm a patients were treated with segmental resections with a wide mobilisation of the transverse and descending colon and ligation of the left colic artery, sparing the middle colic artery and the inferior mesenteric artery. functional lateral to lateral anastomosis was performed extracorporeally. arm b patients were treated with more extended colectomies, both associated with central vascular ligation. results: out of 200 patients included, 141 were allocated in arm a and 59 in arm b. patients' population of the 2 arms was homogeneous as concerns demographic characteristics and stage of the disease. operative time was comparable (108,9 min vs 119 min, p = 0,332). the length of the specimen was significantly shorter in arms a (15, 7 vs 32, 1, p = 0, 0351) . the number of harvested lymphnodes did not differ between the two groups (12,5 vs 17 p = 0,167)postoperative short term complications was comparable in both arms (17 vs 1, p = 0,692). no postoperative mortality was observed. overall 5-year survival and disease free survival rates were similar in arm a and b (81.3% vs 83.05%, p = 0,321 and 78,6% vs 80,5%, p = 0,534). hospital stay was similar in the two groups (p = 0,99). conclusions: despite a shorter length of surgical specimen after limited resections, postoperative complications, lymph node harvest, and survival were comparable in both.in our opinion the extracorporeal anastomosis is functional to both the achievement of a cleaner operative field and a better control of the resection margins. incidence of neuroendocrine tumours in the rectal area has increased in recent years.before the onset of minimally invasive colorectal surgery, these lesion had to be treated by a more radical technique when not suitable for endoscopic resection.selection of the cases is mandatory in order to achieve good results not only surgical, but also oncological. we present our series of 3 neuroendocrine tumoirs treated by tamis approach, including technical aspects, deffect closure techniques and data regarding pathological findings.all cases were low grade carcinoid tumours. resection with free margin was obtained in all cases. defect closure was performed in all cases. the tumours were settled 9,10 and 15 cm form the anal verge. postoperative course was uneventful, ann no adyuvant therapy was needed.tamis apporach for rectal neuroendocrine tumours is a safe and feasible technique. proper selection of the cases is mandatory in order to achieve good results. surg endosc (2019) aim: to assess the safety and efficacy of single layer of barbed vs double layer 'hybrid' (interrupted and running) suture for the closure of anastomotic stapler access enterotomy after laparoscopic right colectomy with intracorporeal anastomosis. methods: from april 2014 to november 2018, 252 laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with 72 patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm 3-0 (covidien), second layer using a running suture in pds tm 3-0 (ethicon). intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was 121.5 min vs 140.7 min in the hybrid group (p = 0.02). anastomotic leak occurred in 5 (6.7%) patients in the hybrid vs 2 (2.7%) patients in the barbed group (p = 0.24). all patients required a reoperation. intraoperative findings show in 2 (0.4%) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to noninfectious complications between the two groups (p = 0.55). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = 0.03). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. aims: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least 30% of node negative patients will suffer disease recurrence within the first 5 years after surgery. this may be due to understaging lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc99 and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results as it is not influenced by body mass index or lymphatic invasion. intraoperative fluorescence icg navigation also aims for detection of aberrant lymphatic drainage outside the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems to identify the lymphatic nodes. our objective with this study is to rate the use of the intraoperative lymphogram in cases of elective colorectal surgery to evaluate if there were changes in the surgical attitude regarding the performance of lymphadenectomy. methods: indocyanine green was injected into the submucosal layer around the tumor at 2 points with?a 23-gauge localized injection before lymph node dissection and the lymph flow was observed at 1, 3 and 5 min after injection, using a near-infrared camera system. in addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was observed to be fluorescent. the following table summarizes the 10 procedures carried out as well as the lymphadenectomy performed before and after the use of icg. in brief, after the application of intraoperative icg it was observed that in 20% of patients additional lymph nodes were obtained after the expansion of the surgical plan, moreover 10% affected lymph nodes were spotted after the expansion of the surgical plan. conclusions: intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery is feasible and a helpful technique for lymph node mapping which may lead to intraoperative changes in lymphadenectomy. tamis resection of rectal tumours has proven to be a sefe and feasible technique, specially for lesion located in the mid and low rectum.when the tumour is located in the upper rectum, and specially near the colorectal junction, tamis resection may be more difficult, not only due to technical aspects, but also due to the risk of a free perforation, specially when a full thickness resection is performed.we present our results of 6 tamis resections of lesions located around the colorectal junction. four resections where performed with the aim of an endostpaler in order to achieve full resection without the risk of a free colonic perforation.in 3 cases, an abdominal combined laparoscopic exploration was made, in order to help and assure proper resection of the lesion as well as avoiding intraoperative complications.distance from the anal verge ranged from 12 to 20 cm.postoperative course was uneventful in all cases, and a complete specimen resection was obtained in all cases.tamis resection of tumours located in the rectosigmoid junction may be a safe and feasible technique in selected patients. methods: between january 2015 to april 2018, 83 patients with diagnosis of right colon adenocarcinomas underwent right hemicolectomies. the data was analysed for patients demographic, histology, type of surgical approach, intraoperative details (length of surgical procedure, blood loss, blood transfusion, conversion rate) and short-term post-operative outcomes including complications. introduction: postoperative ischemic colitis is a life-threatening vascular gastrointestinal condition, that mainly occurs after cardiovascular surgery. we present a surprising case following a laparoscopic rectum resection. case report: a 77-year-old diabetic patient with upper rectal adenocarcinoma undergoing laparoscopic anterior rectal resection (partial mesorectum excision) and mechanical anastomosis following chemotherapy / radiotherapy. after 48 h postsurgery he presented abdominal pain, distension and fever. on adominal computed tomography (ct) scan (contrast enema) no anastomotic leakage (al) finfings were revealed. neither digital palpation nor proctosigmoidoscopy (3th day) showed al signs. the patient clinical situation improve with conservative treatment (antibiotics, digestive rest …), c-reactive protein levels decreased and the blood cultures were negative. on the 11th day he was discharged presenting semiliquid stools. eight days later he needed hospital readmission: air and feculent/purulent discharge from the previos abdominal drainage orifice. ct scan: no evidence of dehiscense found although rectum and sigmoid colon distention and an image of a 'large fecaloma' were observable. on the 4 th day of hospitalization he expulsed a large malodorous segment of tissue with necrotic asppearance (image) through the anus with surprising histologic features: 'complete-thickness necrotic colonic wall'. further rectosigmoidoscopy: complete anastomosis, signs of ischemic colitis proximate to the anastomosis and a fistulous orifice. surprisingly, the patient progressed favorably, being discharged the 12th day for ambulatory control with a low debit enterocutaneous fistula. histopathological diagnosis: ypt3 n0 m0. follow up: the fistula discharge quantity increased maintaining diarrheal stools through anus along with persistent anemia and malnutrition. a exploratory laparotomy was schedule. fistulous tract towards a small stenotic segment of colon inmediately proximal to the colorectal anastomosis was identify and resected. finally a terminal colostomy was performed. subsequent postoperative without incidents. currently the patient is asymptomatic. comments: it seems indisputable that a colon segment, proximal to the anastomosis, was necrosed and expelled through a colorectal anastomosis. the mechanism seems inexplicable to us. it is even more disconcerting that there was no disruption of the anastomosis. objectives: fluorescence-guided surgery has emerged as a new imaging modality to improve the detection of liver and lymph node metastasis in colorectal cancer. in right-sided colon cancer, the standard lymphadenectomy should reach the ileocolic vessels and the right branch of the middle colic vessels. the purpose of this study is to perform an objective estimation of lymphatic drainage and metastatic lymphonodes in right-sided colon carcinoma through indocyanine green (icg) lymphography. methods: patients with right-sided colon adenocarcinoma were included, excluding those in stage iv, t4 and those who underwent urgent surgery. 2 cc of icg peritumoral were injected using a peripheral intravenous catheter at the beginning of the intervention. the lymphatic drainage mapping of the tumor was identified. lymphadenectomy of the ileocolic vessels and right branch of the middle colic vessels was performed extending it to the left branch and origin of middle colic vessels if it was shown in the mapping. results: 16 patients were included. the average age was 58. in 10 patients the tumor was located in the ascending colon and in 6 patients in the hepatic angle. in 11 patients, the mapping showed lymphatic drainage to ileocolic vessels and right branch of the middle colic vessels. in 5 patients (31%) it showed drainage to the left branch and origin of the middle colic artery, therefore extended lymphadenectomy was performed at that level. in 14 patients, the postoperative period was uneventful. 1 patient presented infection of the surgical wound and another patient developed a 6 cm perianastomotic collection treated with percutaneous drainage. the anatomopathological report showed nodal metastasis in 4 of the 5 patients (80%) in whom lymphatic drainage was observed in the territory of the middle colic vessels with icg. these patients presented the tumor in the hepatic angle. therefore, 4 of the 16 patients with right-sided colon carcinoma (25%) presented nodal metastasis in the territory of the middle colic vessels. conclusions: fluorescent lymphography may improve the results of lymphadenectomy in colon cancer. in patients with tumors of the hepatic angle, lymphadenectomy extended to the left branch and origin of middle colic vessels, could be an adequate alternative. introduction: over the last decade, the common principles of surgical treatment in colon surgery are central vascular ligation (cvl) and complete mesocolic excision (cme). however, the superior mesenteric vessels anatomy, while performing the right colectomy is characterized by wide variability, which can lead to complications, especially during minimally invasive surgical intervention. objective. the purpose of this study is describing vascular variations around the superior mesenteric artery and vein-middle colic, right colic and ileocolic vessels, henle trunk in the laparoscopic right colectomy. materials and methods: the study was held in the 'dobrobut' clinic and o. o. bohomolets national medical university, department of general surgery (kyiv, ukraine) during the 2016-2018 period. 24 patients were included to the study, 13 females (45.8%), 11 males (54.2%) in the average age of 71,4 ± 9,8 years. all the patients underwent the laparoscopic right colectomy (cme ? cvl) with d3 lymph node dissection. recorded video materials from each laparoscopic right colectomy were analyzed during the study. results: ileocolic vessels were the most stable. there were typical anatomical position in all cases. 58.3% of cases, ileocolic vein was identified anteriorly to the ileocolic artery, while 41.7% being posteriorly. right colic vein was absent in 29.1% of cases. right colic vein drainage was to henle trunk and inferior mesenteric vein in 62.5% and 37.5% respectively. the right colic artery was present in 75% of patients, it's origin was superior mesenteric artery in 94.4% and 5.6% the middle colic artery. the middle colic vein was present and drained to superior mesenteric vein in 100% of cases. same as the middle colic artery with the superior mesenteric artery origin. henle trunk was present in 91.7%, gastro-pancreato-colic trunk in 45.5% of cases gastro-pancreatic trunk in 40.9%, gastro-colic in 13.6%. conclusions: knowing the options of surgical vessels anatomy, while performing the right colectomy, altogether with surgeons preparation, using the ct-scan data can reduce the risk of iatrogenic damage and complications risks. introduction: the enhanced recovery after surgery (eras) protocol was designed to accelerate convalescence, reduce morbidity and shorten the length of hospital stay (los). one of its major interventions is balanced perioperative fluid therapy. the impact of this single intervention on short-term outcomes is widely discuss. aim: the aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes. material and methods: the analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between november 2012 and january 2018. patients were divided into two groups: balanced (= 2500 ml) or unbalanced ([ 2500 ml) perioperative fluid therapy. all patients were treated according to eras protocol. study outcomes were: recovery parameters, morbidity rate, los, 30-day readmission rate. results: group 1 consisted of 361 and group 2 of 80 patients. there were no statistically significant differences between the groups in terms of demographic and operative parameters. morbidity was lower in group 1 (27.4% vs 38.8%, p = 0.044). patients in group 1 were discharged home earlier than in group 2 (4 vs 5 days, p \ 0.001). moreover, we observed differences in recovery parameters between the groups: tolerance of an oral diet on the 1st postoperative day (76% vs. 59%, p = 0.002) and patient mobilization on the day of surgery (90% vs. 78%, p = 0.005). 30-day readmission rate was lower in group 1 (7.8% vs. 15%, p = 0.041). conclusion: a balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter los and lower 30-day readmission rate. methods: a retrospective analysis was performed including patients who underwent lcs or ocs for cancer treated as emergency in a single centre between 2014 and 2018. patients who underwent palliative surgery were excluded. lcs were 1:1 propensity score-matched based on pposum and stage of disease with ocs. short-term outcomes included oncological quality, length of hospital stay (los) and postoperative mortality. for long-term outcomes, 3-year overall and disease free survival (os and dfs) rates were analyzed. results: during the study period, a total of 406 emergency colorectal resections were performed. of them, 25% (n = 101) were coloniccancers. 38 lcs were matched to an equal number of ocs.median age was 71 (21) years and 62% were females. median follow-up was 18 (22) months. the majority of resections were right hemicolectomies (47%), followed by sigmoid resections (36%) and subtotal colectomies (17%). operative time (188 (90) background: total mesorectal excision (tme) offers the best reported rates for local recurrence and survival in patients with rectal cancer. our series from a single high-volume center, assessed the feasibility, safety and long-term oncologic adequacy of laparoscopic total mesorectal excision methods: we reviewed the prospective database of 266 consecutive unselected patients undergoing laparoscopic tme for rectal cancer between 1995 and 2009 at the department of general surgery, onze-lieve-vrouwziekenhuis hospital (olv), campus aalst, belgium. the objective of the present study was to evaluate the effectiveness of laparoscopic tme, with an emphasis on perioperative variables and long-term oncological outcomes. results: 266 pts with mid and distal rectal cancer up to 10 cm from the anal verge had laparoscopic tme resection. 161 patients (60.5%) underwent a sphincter-preserving surgery and the remaining 105 patients (39.5%) had an abdominoperineal resection. end-to-end anastomoses: 68 pts (42%), j-colonic pouch: 92 pts (58% introduction: the rica clinical pathway (intensified recovery in abdominal surgery), also called surgical multimodal rehabilitation, is the application of a series of perioperative measures and strategies in those patients who are going to undergo a surgical procedure with the objective of reducing secondary stress to the surgical intervention. in this way, we achieve a better recovery of the patient and significantly reduce complications and morbidity. objective: s to analyze, through our database of patients undergoing crc, the percentage of postoperative ileuses and the following quality indicators: the postsurgical hospital stay, the anastomotic leak, and the infection of the surgical site. to check if the implantation of the rica pathway has meant an improvement in our postoperative hospital stay and with that, a lower sanitary cost. methods and results: we analyzed the data collected from those patients who underwent ccr in our hospital between 01/11/2017 and 12/12/18, during which time we implemented the rica clinical pathway. the average hospital stay was 8 days. of the 78 patients, 8.97% presented anastomotic leak, 12.82% infection of the surgical wound and 19.23% paralytic ileus. we have verified how the average hospital stay increases with the appearance of anastomotic leak (18.86 days), infection of the surgical wound (16.10 days) and paralytic ileus (16.80 days). when we divided this 12-month period into two halves to see the impact of the implantation of the clinical pathway, we obtained the following results: the post-surgical hospital stay in the period from 01/11/2017 to 05/01/2018 was 8.33. the stay from 05/01/2018 to 12/12/2018 was 5.33. the implantation of the rica clinical pathway is providing us with important advantages in our clinical practice, with greater postoperative comfort and an improvement in our quality indicators, such as the decrease in the average hospital stay of our patients. on the other hand, after starting its implementation we have encountered the resistance to change clinical habits and the one that requires a multidisciplinary participation, so adherence to this is being progressive, and requires periodic audits to reinforce and consolidate our achievements, and identify our points of improvement. however, tem has not yet achieved widespread use. recently, transanal minimally invasive surgery (tamis) using single-port surgery devices has been reported. initially facilitated by existing single-port surgery devices, two platforms for transanal access, the gelpoint ò path (applied medical, rancho santa margarita, ca, usa) and the sils tm port. the gelpoint ò path is the only platform to be specifically designed for tamis y tatme. objetive: in the present study, usesa gelpoint ò path was performed in 35 patients with lower rectal neplasms. results: complete full-thickness excision was performed in all cases of tamis and free margins over rectal cancer. on two cases no neoplasm was visualizad. the patient characteristics, operative techniques and operative outcomes were evaluated. the mean age of the patients was 63.0 years (range 48-76). the mean operating time were 186 min (range 55-110). 23 patients was selsted for tatme, 10 for tamis and two patients for evaluation and biopsy if was necesary. additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. tamis using a gelpoint ò path was revealed to be easy and safe to perform. although only a small number of cases were treated, and the operation was demonstrated to be sufficiently feasible. conclusion: gelpoint path is a good tool for colorectal surgery in tatme, tamis and evalluation of anastomoses or de novo lesions introduction: several improvements in rectal cancer treatment, in the last decades, resulted in a markedly increased survival. nevertheless, surgery remains the prevalent treatment and 60 to 90% of operated patients experience some kind of functional abnormalities. as nowadays we acknowledge the importance to focus not only on survival rates but also on quality of life, we craved for a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, we performed a thorough translation with cultural adaptation of the patient reported outcome tool, low anterior resection syndrome (lars) score, to the portuguese language (lars-pt) and population. methods: according to the current international recommendations, we designed this study encompassing three main phases: (i) cultural and linguistic validation to european portuguese; (ii) feasibility and reliability tests of the version obtained in the previous phase; and (iii) validity tests to produce a final version. the questionnaire was completed by 154 patients from six portuguese colorectal cancer units, and 58 completed it twice. results: the portuguese version of lars score showed high construct validity. regarding the test-retest, the global intraclass correlation showed very strong test-retest reliability. looking at all five items, only items 3 and 5 presented a moderate correlation. lars score was able to discriminate symptoms showing worse quality of life in patients submitted to preoperative radio and chemotherapy. conclusion: lars questionnaire has been properly translated into european portuguese, demonstrating high construct validity and reliability. this is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, his sistematic use should be implemented. oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (podh) represents a potentially life-threatening surgical complication characterized by an underestimated occurrence rate and unknown related risk factors. this study analyses the experience of two tertiary designated centers in order to evaluate key elements concerning development and treatment of podh. a cohort of consecutive patients affected by a clinically resectable oesophageal cancer (any t, any n and m0) underwent ivor-lewis oesophagectomy between march 1997 and april 2017 according to three different approaches: totally open incision procedure (oilo), hybrid (hilo) and totally mininvasive to esophagectomy (milo). all population was retrospectively observed in the context of a postoperative calendarised follow-up in order to record the incidence and postrepair results of podh. 414 patients underwent ivor-lewis oesophagectomy for cancer and 22 (5.3%) developed podh within a median follow-up period of 16 months (6-177). surgical repair was generally applied by the mean of laparoscopic cruroplasty (77%) with a conversion rate of 24%. postoperative morbidity did not include early recurrences but exclusively cardio-pulmonary complications (5 patients) with one case of respiratory failure leading to death. the discharge was reached after a median hospital stay of 6 days (2-95) while 3 recurrences (14%) occurred over a median followup period of 10.1 months. a wide univariate analysis identified statistically significant associations between podh occurrence and the administration of preoperative chemoradiotherapy, the complete pathological response (cpr) and a lymph node harvest (lnh) larger than 33 stations (p-value of 0.016, 0.001 and 0.024 respectively). the strong influence of an extended lnh was confirmed by the multivariable analyses (0.026) along with cpr which should however be considered as longer survival-related bias. the minimally invasive surgery and the neoadjuvant chemoradiotherapy represent a considerable part of multimodal treatment for oesophageal cancer presenting a not statistically significant association with podh development while a lnh including more than 33 nodes resulted to be an independent risk factor mirroring the extent of surgical demolition in oesophagectomy. l. barbulescu aim: to asses the safety and effectiveness of robotic total meso-rectal excision vs laparoscopic total meso-rectal excision and to analyse the primary outcomes. methods: the operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of tme. in our center were performed 30 robotic rectal resections and 48 laparoscopic resections from january 2018 to present. results: the rtme was associated with longer operation time, early bowel movements, lower risk of conversion and shorter hospitalization. the statistical equivalence was seen between rtme and ltme for non-oncological variables like blood loss, morbidity and reintervention risk. the oncological variables such as number of harvested nodes and positive circumferential resection margin risk were also comparable in both groups. the length of distal resection margins was similar in both groups. conclusion: rtme in patients with rectal cancer was associated with a lower rate of conversion and less incidence of urinary retention. the operative time in rtme was significantly longer than in ltme. the initial oncological and function outcomes of rtme seem to be equivalent with ltme. c. athanasiou aims: two randomized controlled trials failed to show non-inferiority of the laparoscopic total mesorectal excision (ltme) compared to open. ltme becomes particularly challenging in low rectal cancers and in narrow pelves. many surgeons report that robotic tme (rtme) may be beneficial in that setting. our aim was to systematically review the literature and compare the pathologic outcomes of open, laparoscopic and robotic tme for rectal cancer methods: medline, embase, scopus, cochrane library and web of knowledge databases were searched for randomized controlled trials (rct) reporting patholologic outcomes of open, laparoscopic or robotic tme with no language restriction. our primary outcome was quality of tme on macroscopic assessment of the specimen. secondary outcomes included positive circumferential resection margin, distance to radial margin, number of lymph nodes and positive radial margin. the included studies were quality assessed and the jadad score was reported. the grade approach was used to rate the certainty of each network estimate. results: fourteen rcts were included in our study. seven rcts compared the otme to the ltme, six compared the ltme and rtme and one study the otme to the rtme. no statistical significant difference was found in quality of tme when the the ltme was compared to the otme or = 1.36 (0.99, 1,85) or the rtme or = 1.33 (0.82, 2.16) . no difference was found in pcrm for the laparoscopic or = 1.23(0.90, 1.69) or the robotic approach or = 0.87 (0.44, 1.75) when compared to open. distance to radial margin and number or lymph nodes didn't differ between the groups. conclusions: no significant advantage on pathologic specimen quality has been found with the robotic approach. the ltme doesn't seem to compromise the quality of the specimen. h. samura 1 , j. arakaki 2 , k. sugata 2 , y. hori 2 , y. nagamine 2 , f. kohagura 2 , h. motonari 2 , s. kameyama 2 , t. ishimine 2 1 division of digestive and general surgery, urasoe general hospital, okinawa, japan; 2 department of surgery, urasoe general hospital, okinawa, japan colorectal cancer often invade adjacent organs and it is known that prognosis improves with resection of the involved organ. we report our experience of invaded adjacent organ resection, which include seminal vesicle, uterine and bilateral appendages, posterior wall of the vagina and bladder wall. method: although the range of resection is predicted by image study preoperatively, at the time of operation, it was decided by palpation with a forceps. each operation is evaluated by operation time, blood loss, blood transfusion volume, postoperative complication, postoperative hospital stay, and short term prognosis. result: resection cases of seminal vesicle, posterior vaginal wall, uterine and bilateral appendages and bladder wall were 5, 4, 4 and 1, respectively. the results are shown in the order of seminal vesicle / vaginal posterior wall / uterine / bladder. median age was 70, 67, 54 and 74 years old. the median operation time was 541, 630, 623, 249 min, the median blood loss was 580, 340, 310, 10 ml, and only one case of uterine and bilateral appendages resection required the blood transfusion. the average postoperative hospital stay was 40, 38, 45, 15 days. nine cases have postoperative complication, that include delayed wound healing, anastomotic leakage and rectovesical fistula, postoperative ileus, chyle ascites and neurogenic blodder. all of those were improved with conservative treatment. the mean hospital stay in complication cases was 48 days (38-88) and 19 (14-29) days without complications. the median observation period was 773 days (166-2166), and there was no local recurrence. all of the case of stage iv were dead. there was no local recurrence and all patient without stage iv are alive, it seems that the resection range was sufficient. conclusion: even with adjacent organ invasion colorectal cancer, it was possible to determine the resection line by palpation with laparoscopic forceps manipulation, and possible to resect margin free of cancer. laparoscopic low rectal resection with/without diverting ileostomy p. ihnát, m. tesar, p. ostruszka, p. gunková, p. vávra background: the construction of diverting ileostomy (di) is recommended to avoid septic complications of anastomotic leakage. the aim of our study was to assess the benefits and risks of di constructed during laparoscopic low anterior resection (lar). methods: retrospective clinical cohort study was conducted in university hospital ostrava, czech republic. all patients undergoing laparoscopic lar with tme because of rectal cancer within a 6-year study period were assessed for study eligibility. results: a total of 151 patients (73 patients without di, 78 patients with di) after laparoscopic lar were enrolled into the study and underwent analysis. both study subgroups were comparable in terms of demographic and clinical features. postoperative 30-day morbidity was significantly lower in patients without di (23.3% vs. 42.3%, p = 0.013). anastomotic leakage frequency was higher in patients without di (9.6% vs. 2.5%, p = 0.090); surgical intervention was necessary in 6.8% of patients without di. stoma-related complications were noted in 53.8% of patients with di; some patients had more than one complication. surgical intervention because of stoma-related complications was needed in 9 patients (11.5%). distinctive complications of di laparoscopic construction (small bowel obstruction due to di semi-rotation around its longitudinal axis) was noted in 3 patients (3.8%). mean stoma period (interval between lar and di reversal) was more than 10 months in our study; only 19.2% of patients were reversed without delay (= 4 months). postoperative morbidity after di reversal was 16.6%; re-laparotomy was needed in 2.5% of patients. conclusions: despite benefits of di in protecting low rectal anastomosis, ileostomy construction remains fraught with many stoma-related complications and long stoma periods associated with significantly decreased quality of life. aims: single port laparoscopic is a minimally invasive surgical technique that joint the cosmetic advantages with the well recognized benefits of the standard laparoscopic approach [1] . we describe a laparoscopic single port hartmann reversal in a patient by the use of the umbilical colostomy site for surgical access [2] . methods: a 42 years old patient was submitted to a laparoscopic single port hartmann procedure with an trans-umbilical colostomy for a recurrent sigmoid volvulus that was treated at the beginning by endoscopic de-rotation. after three months the patient was reevaluated for a hartmann reversal with a laparoscopic single port technique. after routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. by the use of a gelpoint system with 3 trocars, the intra-abdominal adhesiolisis in performed. the splenic flexure is mobilized to achieve a sufficient mobilization of the left colon that allows the fashion of a tension free anastomosis. the rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. a tension-free colorectal anastomosis is secured with a standard circular 31 mm stapling device inserted transanally. the colostomy wound is closed. the operative time was 60 min. results: the postoperative course was uneventful, the patient was discharged at forth postoperative day, oral intake started on postoperative day three. conclusions: single port laparoscopic hartmann reversal thought the umbilical stoma site is a minimally invasive surgical option that is safe in selected patients and offer the best cosmetic results. [ the progressive evolution of surgical techniques and oncologic protocols on rectal cancer disease facilitates surgeons to challenge the skills for anus preservation in low rectal cancer surgery. the laparoscopic surgery is already one of the best ways to reach the pelvic floor and to try procedures, which were previously difficult to apply through open surgery. the anastomotic leakage has particularly high occurrence if the anastomosis is performed in the anal or distal rectum area. it is evident that although the fecal diversion does not decrease post operatory mortality, it significantly reduce the risk of anastomotic leak and the risk of a second major surgery when the leak occur. diverting stomas are low-risk procedures from a technical point of view, but they potentially expose the patients to postoperative morbidity, impacting the patients' quality of life. it is not easy to decide whether the fecal diversion is needed or not. this decision must be made on a case to case basis, trying to apply the stomas only when they are really needed. we report our initial experience by living a transmesenterial cotton loop around the pre terminal ileum which extremities are turned out usually through the lateral trocar wound in laparoscopy or by applying a dedicated mini incision in open surgery. the purpose is to perform (in case of suspected fistula), a mini invasive diverting procedure, by widening the loop wound and by pulling up the ileum in a lateral loop ileostomy. we applied this procedure to 12 consecutive patients with low colorectal anastomosis and in two of them we performed a lateral loop ileostomy with good results. we believe this can be an alternative that needs to be standardized. purpose: sarcoidosis is a chronic, multisystem inflammatory disorder with unknown aetiology characterised by noncaseating granulomas within involved organs. gallbladder involvement in sarcoidosis is extremely rare and literature review revealed only 7 reported cases to date. in this paper, we present a case of gallbladder associated sarcoidosis. method: a 67-year-old lady was known to the clinic for regular surveillance of liver steatosis and incidental gallbladder polyps. the largest polyp was 4 mm at presentation in 2008 and has grown to 7 mm in 2017. in view of worsening symptoms of biliary colic and growing polyps, a laparoscopic cholecystectomy was performed. results: laparoscopic cholecystectomy was unremarkable and specimens of the gallbladder and lymph nodes were sent for histology. histological examination revealed chronic cholecystitis with polypoid cholesterolosis of the gallbladder and noncaseating granulomata within a lymph node, which strongly suggest sarcoidosis. conclusion: in conclusion, we report a case of incidental finding of gallbladder sarcoidosis over the course of treatment of biliary colic and symptomatic gallbladder polyps. therefore, the definitive treatment for patients with symptomatic gallbladder sarcoidosis is a cholecystectomy. the surgical management of cholelithiasis can be associated with significant morbidities. despite the relatively low incidence of bile duct injuries during laparoscopic cholecystectomy, the total number is large due to the high frequency of the operation. the subtotal cholecystectomy with its variants is a well known bailout strategy to the surgical community. however, there is no agreement on when and how to perform these procedures. indeed, the majority of surgeons will adopt these solutions when there is a struggle to identify the critical view of safety. this struggle results increases the risk of injuries. we hypothesize that a primary intent gall bladder lithotomy and disconnection (glad) when the dissection of the gb pedicle is anticipated difficult dissection is a safe and feasible strategic option. methods: out 347 patients elevtively admitted to aberdeen univesity hospital with gall stone disease between march 2017 and november 2017, 75 consecutive patients were operated with glad procedure based on intraoperative criteria. the primary outcome was the operative time. secondary outcomes were length of hospital stay, the criteria to do this procedure will be explained, the outcomes will be listed. indocyanine green is a molecule that becomes fluorescent when excited struck with light of a specific wavelength in the infrared spectrum (nir-infrared), allowing the visualization of anatomical structures in which it has accumulated. the aim of the study is the application of icg enhanced fluorescence in laparoscopic cholecystectomy in order to identify the anatomy of the biliary tract, to reduce the risk of iatrogenic lesions and the conversion rate. the study involves laparoscopic cholecystectomy for cholecystitis and gallstones of main biliary tract. the evening before the surgery, a vial of icg (25 mg) diluted in 100 ml of saline solution was intravenous injected. during the procedure, after opening the calot triangle, switching to the nir mode on the camera, the anatomy of the biliary tract and in particular of the main biliary tract is visualized. the cystic duct and cystic artery are isolated, their section between clips is cut and the cholecystectomy is performed. from january 2018 11 patients were enrolled: 9 cases of acute cholecystitis, 2 cases of gallstones of main biliary tract, undergoing preoperative ercp. in 8 cases of cholecystitis, the angiography allowed the visualization of the main biliary tract. in one case, an abnormal course of the cystic duct was identified. in two cases of gallstones of common bile duct, it favoured the visualization of the biliary tract anatomy. all cases were completed with laparoscopic technique. there were no intra-and post-operative complications. icg-enhanced fluorescence is a safe, effective, cheap and rapid tool that can also be applied in small hospitals with no need for training. its use does not extend the time of surgery and allows the visualization of the anatomy of the biliary tract, especially in situations where it can be altered by reducing the conversion rate and potentially the risk of iatrogenic lesions of the main biliary tract. case presentation: patient is a 22 year old female with no significant past medical or surgical history presented to the emergency department with a 2 day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and po intolerance. the pain started a few months prior, however it was self-limited with diet modifications. an ultrasound demonstrated a contracted gallbladder with a 15 mm gallbladder wall. white blood cell count was within normal limits and total bilirubin was slightly elevated to 1.8 mg/dl. no palpable mass was noted on physical exam. an mr cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring 11.5 x 2.5 cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. the patient proceeded with a laparoscopic cholecystectomy. intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. the gallbladder was subsequently removed without any complications. patient's remaining hospital course was uncomplicated. surgical pathology returned demonstrating acute on chronic cholecystitis. discussion: cholecystomegaly or 'giant gallbladder' disease is a rare pathology encountered in the surgical world. there have been few reported cases, most of which occurred in the elderly ([ 65 years). kuznetsov et al. defined an enlarged gallbladder to have a volume of 200-300 cc and a giant gallbladder as exceeding 1500 cc (the average weight of the liver). the etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. preoperative imaging, such as mr cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. the cause of cholecystomegaly still remains uncertain and warrants further research. the management and treatment remains similar to acute cholecystitis. aims: mini-laparoscopic cholecysectomy (mlc) is considered to be the best variant of minimizing surgical trauma and improving cosmesis in laparoscopic cholecystectomy. the most challenging techniqual step of mlc is clipping the cystic duct. it may be impossible or unsafe when diameter of cystic duct exceeds 3 mm, which is common in severe chronic colecystitis or acure cholecystits. there is very limited data in the literature about the use of mlc in acute cholecystits. the aim of study was to access the first results of new technique of mlc. methods: five women with the mean age of 39 years (32-48) underwent mlc. the 1st 10-mm troacar was inserted in the umbilicus and used for the camera and removal of the gallbladder. the 2nd 5-mm troacar was inserted in subxyphoidal area and used for the main working instruments, including medium-large polymer clip-applier (hem-o-lok type). the 3rd and 4th 3-mm troacars were placed in right subcostal area and used for mini-graspers (karl storz). in initial 4 procedures we used conventional 5-mm clip-applier with adopted medium-large titanium clips. to improve safety, we aplied 5-mm hem-o-lok type clip-applier for the last patient with acute cholecystitis. in this case the diameter of cystic duct was 3,5 mm. the clipping was performed successfully. the 3-mm drain was placed via subcostal troacar incision. also, in this case we applied original technique of removal of the bladder using wound retraction instrument (karl storz). results: in all the cases there were no intra-or postoperative complications. the mean duration of procedures was 120 min (100-180 min). the postoperative stay was 2 days in every patient. the patients estimated their pain on postop day 2 as 'almost absent' and cosmethic results 1 mo postop as 'exellent'. conclusions: 1. new technique of mlc alowed to perform the clipping of cystic duct safely, which is essential in acute calculous cholecystitis. was conducted in department of surgery lumhs jamshoro. all the patients having age = 18 year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as cholelithiasis included in the study and were planned either for mini-laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy were explored for outcome while the patients with empyema gallbladder, gangrene, mucocele gallbladder and adhesions were excluded from the study. results: during one year study period, total five hundred patients were diagnosed as cholelithiasis with means age 53.21 ± 6.83 (sd). of five hundred, 127 (25.4%) were underwent for mini-laparoscopic cholecystectomy with 15 (11.8%) were males and 112 (88.1%) were females. the outcome were measured as postoperative pain (vas) 1.61 ± 0.92, size of wound (umbilical 10 mm, epigastrium 5 mm and subcostal 2 mm), excellent cosmetic results, mean ± sd for hospital stay (hrs) and operative time (minutes) was 12.86 ± 5.73 and 30.83 ± 10.85, early return to work 115 (90.5%), minor oozing 07 (5.5%), port size hernia 2 (1.5%). remaining 373 (74.6%) were underwent for conventional laparoscopic cholecystectomy with 38 (10.1%) were males and 335 (89.8%) were females. the outcome were measured as postoperative pain (vas) 3.53 ± 1.95, size of wound (umbilical 10 mm, epigastrium 10 mm and subcostal 5 mm), mean ± sd for hospital stay (hrs) and operative time (minutes) was 49.95 ± 8.95 and 30.83 ± 7.72, early return to work 310 (83.1%), port size hernia 10 (2.6%) along with zero (0%) mortality. conclusion: it has been concluded that mini-laparoscopic cholecystectomy is superior and feasible than conventional laparoscopic cholecystectomy and has decreased early postoperative incisional pain, avoided late incisional discomfort and safe procedure with nearly scarless wounds with superior cosmetic effect especially for young female patients. objective: to determine the outcome of immediate versus late laparoscopic cholecystectomy in acute cholecystitis at tertiary care hospital hyderabad / jamshoro sindh pakistan patients and methods: the descriptive case series study of one year (2016 -2017) was conducted in department of surgery lumhs jamshoro. all the patients having age = 18 year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as acute cholecystitis (cholillthiasis) included in the study and were planned for laparoscopic cholecystectomy and were explored for outcome as immediate (within 48 h) and late components ([ 6 weeks). the frequency and percentage was calculated for categorical variables and mean ± sd was calculated for numerical variables. as this was descriptive case series so there was no any statistical test of significance was applied. results: during one year study period, total one hundred patients were diagnosed as acute cholecystitis with means age 55.72 ± 8.95 (sd). of one hundred, 80% were females and 20% were males. the immediate outcome reported as tissue fragile 10%, pancreatitis 2%, slipage of ligature of cystic duct 5%, empyema gallbladder 5%, mucocele 15% and gangrenous gallbladder 2% while the late outcome reported as adhesions 70%, cholecystoduodenal fistula and mirizzi syndrome 1% and 6%, gallstone ileus 2%, perforated gallbladder 8% and cholidochiolithiasis 20% while the mean ± sd for hospital stay (days) in immediate as 1.51 ± 0.32 while in late outcome (days) during acute cholecystitis 4.50 ± 0.55 and after surgery (6 weeks later) as 2.85 ± 1.21 respectively. conclusion: it has been concluded that early lc for acute cholecystitis with cholelithiasis is safe, low cost and feasible intervention and offering the additional benefit of shorter hospital stay and reduce the economical burden. surg endosc (2019) 33:s485-s781 general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan background: the treatment of common bile duct (cbd) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. a minimally-invasive approach choledocholithotomy is feasible, but can be difficult and converted for the unclear anatomy of the biliary tree. near-infrared (nir) cholangiography by systemic administration of indocyanine green (icg) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. nir fluorescence cholecysto-cholangiography by direct biliary tree administration of the icg can enhance the biliary tree without background noise signal. we created the nir cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application. material and method: ten patients who suffered from obstructive jaundice due to cbd stone and 5 patients received percutaneous biliary tree drainage as first treatment and 2 patients received endoscopic biliary tree drainage. those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. 5 patients received biliary tree icg injection via drain tube and 5 patients by systemic injection. visualization and fluorescence patterns around cbd was recorded. results: in our series, one patient received previous gastrectomy and 4 patients had previous biliary tree surgery. background: laparoscopic cholecystectomy (lc) has become the gold standard for the treatment of gallstone disease. multiple studies have confirmed its safety, lc at index admission is still not widely practiced in ireland. we present our experience in performing index cholecystectomy at cuh after the start of acute care surgery program in may 2017. aim: the aim of this study is to determine the safety of laparoscopic cholecystectomy at index admission, complications,re-admissions, and los. methods: electronic records, theatre records and imaging reports were searched to enroll all patients who underwent lc for gallstone disease at index admission from may17 to october18. patient demographics, indication for surgery, postoperative complications, readmission and conversion rate were recorded.in addition timings of mrcp and ercp, imaging findings, and los were also noted. results: a total of 117 patients underwent lc during the study period. median age was 47 years (18-79). male to female ratio was 1: 1.78. 75(64%) patients had acute cholecystitis, 12 (10%)had acute biliary pancreatitis, 10 (8.5%)biliary colic and 9(7.6%) had cholecystitis with signs of cbd obstruction. 7(5.9%)patients had obstructive jaundice and one with adenomyomatosis.50 patients (42%) had preop mrcp while 23 (19%) underwent pre-op ercp. all except 3 patients undergoing ercp had preprocedure mrcp.2 patients had pre-op cholangiograms. in terms of complications, 2(1.7%) patients had bile leak and one(0.85%) had re-operation. one patient had the post-op hematoma which was drained percutaneously, one patient had procedure abandoned because of bradycardia upon induction of anesthesia. there was no common bile duct injury, no conversion to open and no 30 days mortality was reported. the average length of hospital stay has been 6 days. (2to18 days). conclusions: laparoscopic cholecystectomy at index admission for cholecystitis, choledocholithiasis, and biliary pancreatitis, has been a safe and feasible treatment option in our hospital. a safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-led service. index cholecystectomy service can be provided safely across the country to prevent diseaserelated morbidity and multiple re-admissions in patients awaiting interval surgery. when to use the two-stage surgery to treat choledocholithiasis: the size aims: the treatment of choledocholithiasis has been provided by various of studies worldwide. the most common accepted minimal invasive treatment was two-stage treatment using endoscopic retrograde cholangiopancreatography before or after laparoscopic cholecystectomy(ercp ? lc), and one-stage treatment with laparoscopic exploration of the common bile duct(lcbde). in fact, despite several large studies have been published in recent years, the debate for the ideal treatment of choledocholithiasis is way from being concluded. we aim to find the proper treatment option for the patients with variable sizes of choledocholithiasis. methods: we retrospectively analyzed 136 patients who underwent treatments for cholidocholithiasis in our institute between january 1, 2011 and july 31, 2016. the patients who received either ercp and lc in the same admission, and the patient who received lcbde, irrespective of trans-cystic(ltcbde), or choledochotomy(lcd), were included. the data was analyzed with chi-square test and mann-whitney u test. results: the stone size of the ercp ? lc group is significantly smaller than the lcbde group. we further analyzed the ercp failure case, and the group of stone size [=9.5 mm has a significantly higher rate of procedure failure. the failure rate is increasing with the stone size. conclusions: both the treatment of lcbde and ercp ? lc have similar safety and success rate, and the rate of residual stone was also similar in both group. however, the failure rate for ercp is significantly increased when stone size is larger than 9.5 mm in this study. aims: the xanthogranulomatous cholecystitis (xc) is a rare entity that can cause doubt in the choice of surgical treatment, because of differential diagnosis with gallbladder carcinoma (gc). methods: a 70-year-old patient presented acute abdominal pain in the right upper quadrant, nausea and low-grade fever with signs of peritonitis. he had elevated pcr, leukocytosis with neutrophilia. abdominal ultrasound showed an acute xanthogranulomatous cholecystitis. a laparoscopic cholecystectomy was decided but it was converted to open surgery due to the difficulty in the dissection, with fundus embedded in the hepatic bed and intraoperative finding of hilar adenopathic conglomerate .the postoperative period was torpid, with abdominal pain, jaundice, elevated bilirubin and enzymes of cholestasis. postoperative abdominal tomography showed injury in the iv segment of the liver suggestive of neoplasia. metastatic adenopathic conglomerate at the hepatic hilum caused extrinsic biliary obstruction with hepatic failure later so an internal-external drain was placed in the bile duct. the patient was died a week later. the pathological anatomy reported a stage four of gc. results: xc is a rare, non-neoplastic, inflammatory and destructive entity of the gallbladder wall, considered a variant of chronic lithiasic cholecystitis. it may be due to extravasation of bile or ulceration of the mucosa, causing an inflammatory reaction and fibrosis, with xanthomatous cells. the prevalence is 1 to 2% in the resected gallbladders. it is more frequent in 60-70 years oldfemales. its clinical presentation does not have specific characteristics that differ from cholelithiasis, except for the weight loss. radiologically it is characterized by nodular thickening and increased attenuation of the vesicular wall with signs of cholecystitis, indistinguishable from a vc. the xanthogranulomatous inflammatory foci infiltrate the hepatic parenchyma, having an invasive behavior; hence, it mimics a neoplastic disease. the confusion in diagnostic and the risk of gc (up to 10%) makes treatment contentious. conclusions: the xc can simulate an advanced gc that sometimes makes us wonder if we should perform a radical surgical treatment; when presented in an emergency situation, our therapeutic decision can focus on solving the acute problem and be conditioned by the patient's general condition. single port transumbilical laparoscopic surgery (sptls) is a techinque that has been around for about 18 years. although the enthusiasm for this type of surgery seems to have diminished in recent years it is expected to rise considering the recent development of sophisticated devices for its execution . we report retrospectively our 8 year experience with 253 procedures performed by sptls technique. in a private practice setting in mexico city. procedures include cholecystectomy (107), appendectomy (69), inguinal hernia tapp and tep (26), hiatus and esophageal (15) , sleeve gastrectomy (2), colon (6), gyn (28) . 4 different access platforms were employed. we explain our selection criteria for the application of the technique and describe the evolution of the instruments employed during the past 8 years, from laparoscopic conventional to curved and bendable; regular scopes to extra long telescopes with different angles. or time, top bleeding, conversion rate, the need to employ an extra trocar, complications, pathology reports, scheduled or urgent kind of surgery and length of hospital stay were recorded from the beggining; patients variables such as bmi, asa status, tep risk, satisfaction with the procedure and other were recorded . we describe the evolution of our technique, and our learning curve with cholecystectomies. we compare our group of sptls transvaginal assisted laparoscopic hysterectomy (tvalh) patients vs tvalh multiport patients. we explain the feasibilty, and efficiency of the procedure in our hands compared to other series. background: in japan, the severity of acute cholecystitis(ac) is assessed by the severity classification of the tokyo guidelines 2018 (tg18). the value of c-reactive protein (crp) is not included in the severity classification criteria. the first line treatment, according to tg18, for mild (grade i) to moderate (grade 2) ac is laparoscopic cholecystectomy, but laparoscopic surgery may not be feasible in some cases due to adhesion or local inflammation of the gall bladder. aim: the aim of this study is to assess the effect of crp on the open conversion rate in laparoscopic cholecystectomy for acute cholecystitis.method: we conducted a retrospective study. 41 patients who were diagnosed with ac and treated with emergent laparoscopic cholecystectomy between june 2017 and may 2018 in our institution are included. we set the cutoff value for crp at 20 mg/dl and compared the open conversion rate. secondary endpoints are amount of bleeding, operation time, post-operative course (peak in body temperature and inflammatory markers) and the frequency of complications according to the clavien-dindo classification. results: 10 out of 41 patients had a crp value greater than or equal to 20 mg/dl. the median crp values for the crp \ 20 group and crp = 20 group were 4.4 and 23.1, respectively. the open conversion rate of the crp = 20 group was significantly higher than that of the crp \ 20 group (3/10, 1/31, p = 0.01). the most common reason for these conversions was local adhesion (3/4) . there were no differences in the amount of bleeding, operation time, post-operative course, and frequency of complications with clavien-dindo grade ii or higher. background: reports about clinical value of fluorescent cholangiography using indocyanine green (icg) during single-incision laparoscopic cholecystectomy (silc) were increasing. we report clinical value and pitfalls of fluorescent cholangiography during silc for the patients with the infraportal type of the right posterior bile duct. methods: our silc procedure utilized the sils-port with an additional 5-mm forceps through the umbilical incision. before silc, 1 ml of icg (2.5 mg) was administrated by intravenous injection. for fluorescent cholangiography, icg fluorescent laparoscope system was used. results: we performed fluorescent cholangiography during silc in 13 patients with the infraportal type of the right posterior bile duct. all procedures were completed successfully. the interval from the injection of icg to the first obtained fluorescent cholangiography before the dissection of calot's triangle ranged from 40 to 60 min. detectability of infraportal type of the right posterior bile duct before dissection in claot's triangle was 23.1% (n = 3) and that during dissection in calot's triangle was 53.8% (n = 7). the infraportal type of the right posterior bile duct could be identified under fluorescent cholangiography only when it joined into the common hepatic duct. conclusions: utilization of fluorescent cholangiography can lead silc to safe even for the patients with the infraportal type of the right posterior bile duct. its benefit is emphasized when the infraportal type of the right posterior bile duct joins into the common hepatic duct. aims: due to the development of laparoscopic surgery and the progress made in surgical treatment ofhydrocephalus, surgeons may come across patients with ventriculoperitoneal (vp) shunt, as candidates for laparoscopic procedures. according to this fact, we report a case of an unusual complication of laparoscopy surgery that can appear in this kind of patients. methods: we present a case of a 66-year-old man with medical history of normotensive hydrocephalus with vp shunt, that came to the emergency room complaining of abdominal pain and fever since two days. blood test showed an elevation of infection parameters and inflammatory markers, and the ultrasound study revealed an emphysematous cholecystitis. therefore, we decide to carry out an emergency laparoscopic cholecistectomy. the patient did not present any adverse event during the surgery or the immediate postoperative period, being discharged the third postoperative day and evaluated ambulatory one month after the surgery with no complications. two months after surgery, the patient returned to the emergency room presenting alteration in consciousness and fever. results: during the study of the pacient, an abdominal ct was performed, showing a complete section of the vp shunt in the subcutaneus space of the upper abdominal wall and intraperitoneal migration of the remaining catheter. the patient was transferred to neurosurgery to carry out an emergent replacement of the ventriculoperitoneal shunt. after surgery and intravenous antibiotic treatment, the patient evolved favourably and was discharged a few days later. conclusions: the rate of serious complications associated with a laparoscopic approach is overall low and up to 50% of them occur during the abdominal access for camera or port placement and may not be recognized until postoperative period. vp shunts should not be a contraindication for laparoscopic surgery. however, laparoscopy approach must be carry out with good anesthetic and monitoring facilities and taking several previous considerations, such as verifying the proper functioning of the vp shunt, identifying the path of the catheter within the abdominal wall to avoid inadvertent damage to the catheter during trocar placement and ensuring that the intraperitoneal portion of the catheter is not twisted or obstructed prior to decompression of the abdomen. surg endosc (2019) introduction: since advantages of robotic surgery is being more emphasized, robotic cholecystectomy (rc) cases are increasing. ajou group had introduced a method called which technique places the trocars transversally on the bikini line and it makes cosmesis and pain beneficial. however, rc with low incision port has several limitations. therefore, we changed port placement which may be a one of safe tehniques for rc. method: this study retrospectively reviewed data for patients who received rc with port changing method (rcpc, n = 33) and rc with low incision port (rcli, n = 81) from february 2016-february 2017 and surgical variables were analyzed. results: patients in both groups had similar demographic features and indications for surgery. the rcpc group required no conversions to conventional robotic surgery and no additional operation, whereas the rcli group had one incisional hernia (1.2%) and two bowel perforation (2.4%) cases. length of stay (4.29 ± 0.72 vs. 5.13 ± 0.93 days, respectively; p = 0.123) did not significantly differ between the rcpc and scli groups. however, the rcpc group had shorter operative time (71.30 ± 48.88 vs. 74.70 ± 30.16 min; p = 0.772) than the rcli group, although the parameters mentioned above were not statistically significant. conclusion: robotic cholecystectomy with bikini line incision has some limitations even though it has cosmetic benefits. whereas robotic surgery with changing port method is one of safe and feasible procedures for performing robotic cholecystectomy. also nothing more to say that it gains cosmesis effect and escapes complications. mini surgery, odessa medical university, odessa, ukraine the aim of the study was to optimize the diagnostic and therapeutic tactics for yatrogenic injuries of the extrahepatic bile ducts. methods: 15 patients were examined. typical manifestations were jaundice, cholangitis, biliary peritonitis, external biliary fistula, subhepatic abscess.cholecystectomy main cause of damage.a visual, manual and x-ray examination of the hepato-choledochus and cholangioscopy were performed. ultrasound, endoscopic retrograde cholangiopancreatography, fistuloholangiography or percutaneous transhepatic cholangiography play a leading role in diagnosing. the results: high damage to the bile duct was detected in 53.3% of patients, low-in 46.7%.percutaneous transhepatic drainage under ultrasound control was performed in 66.7% of patients.emergency laparotomy, sanation of the abdominal cavity and external drainage of the bile ducts were performed with bile peritonitis. recovery operations produced 60.0% of patients. reconstructive interventions were performed in 40.0% of patients after 6-8 weeks after the first stage. the covery operations were successful in 66.7% of patients. 33.3% of the sick had complications in the form of biloma. a scar stricture formed in 33.3% of patients after 4-6 months. 1 patient underwent recanalization of the stricture zone with a dilatation balloon through interchangeable transhepatic drainage. balloon dilatation was performed retrogradely through the large duodenal papilla in 2 patients. deaths in the postoperative period was not observed. conclusions: the surgical team should be strengthened by an experienced surgeon when intraoperative diagnosis of yatrogenic damage to the bile ducts.the operation should be completed by external drainage of the bile duct and the abdominal cavity in the absence of an experienced specialist.recovery operations are shown only with lateral injury of the ducts.the patient must be sent to a specialized institution for radical surgical treatment after stabilization of his general condition. aim of the study sub-hepatic bile collections, biloma and hematoma are rare complications and we present our experience in treatment this complications. material and methods: from 750 laparoscopic cholecystectomy performed in our clinic, three patients (two women and one men) to whom it was performed laparoscopic cholecystectomy, came back two weeks later after they were released from the hospital because of epigastric discomfort, fever and nausea. results: clinical examination after rehospitalization showed tenderness in the epigastrium and right subcostal region. in all patients were measured high levels of leukocytosis and crp . an ultrasound examination of the abdomen revealed a large hypoechoic collection in the sub hepatic space, after the abdominal ct scan was performed, the density of the collection did not indicate the presence of blood in two patients. percutaneous drainage of the collection in both patients was realized under us guidance and 8-10 fr catheter was inserted in the sub hepatic region. in the first patient 800 cc of bile-stained liquid, and in the second patient 650 cc of biliary liquid was drained. in a third patient 16 h after surgery signs of significant hypotension and limited tenderness at the right subcostal region occurred. a complete blood count (cbc) showed a decrease in the level of haemoglobin to 10.4 g%. ultrasound examination revealed a fluid collection in the sub hepatic space, which is also confirmed by computed tomography. laparotomy was performed and the large sub hepatic hematoma was evacuated. after that the 18 fr abdominal drain was inserted into the sub hepatic space. the postoperative course of all three patients was not complicated. conclusion: sub hepatic biloma and hematoma are rare complications of laparoscopic cholecystectomy, while early diagnosis followed by percutaneous drainage or open laparotomy is the only way to resolve these complications. (3), hemoperitoneum 3.4% (1) . the average number of days of hospitalization was 7.6 days. there was no mortality at 30 days. conclusion: in the emergency setting the rendezvous technique has an adequate success rate of cannulation and clearence of the bile duct, an acceptable surgical time, few complications, these being more frequent in those patients with inflammation of the gallbladder and without associated mortality at 30 days. there is a need for controlled randomized studies with a greater number of patients recruited and follow-up to determine the usefulness of this technique. intraoperative cholangiography could serve as a fundamental solution to avoid the bile duct injury during laparoscopic cholecystectomy. however, it is difficult to identify the cystic duct to which the contrast catheter should be inserted in cases with high degrees of adhesion around the calot's triangle. in these cases, it is not possible to conduct cholangiography from the cystic duct. for these types of cases, intraoperative cholecystography may serve as an option. however, since the bladder is a bag-like organ that expands when liquids are entered, directly inserting a contrast dye into the bladder would make the bladder itself expand, which makes it impossible for to maintain enough pressure in the contrast dye to flow into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct. also, since it is difficult to control leakage of the contrast dye from the catheter insertion site, it is not possible to obtain enough images to sufficiently understand the anatomical characteristics of the bile duct in many cases. therefore, cholecystography is not generally recognized as a method to be used during surgery. in our facility, we insert the contrast catheter through the bladder after stretching the gallbladder neck as much as possible, hold the gallbladder neck with a removable intestinal clamp, and then apply the contrast dye to the bile duct. through this method, it is possible to insert enough contrast dye into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct to understand the anatomical characteristics of the bile duct, allowing us to obtain appropriate images of the biliary tract. because this method uses equipment that is highly versatile, we believe that it is inexpensive and convenient. during this presentation, we will also conduct a case presentation of the methods of bladder contrasting that we utilize in our facility during laparoscopic cholecystectomy. introduction: retrieval of a thick walled gallbladder during a difficult laparoscopic cholecystectomy (lc) for an acute or chronic calculous cholecystitis can be exasperating. it increases operative time and often necessitates enlargement of 10 mm port to deliver the specimen. the 'in-situ cholecystotomy', which we wish to call the 'delhi maneuver' is very helpful in improving the ergonomics of specimen retrieval, saves time and conserves cosmesis. patients & methods: one hundred and ten patients of acute or chronic calculous cholecystitis were placed randomly in 2 groups. a disposable transparent plastic bag was used in all cases to retrieve the gallbladder specimen through the 10-12 mm port using a rampley's sponge holding forceps. retrieval was done using conventional technique in 60 patients (group b). the delhi maneuver was used in the remaining 50 patients (group a). it involved cutting the gall bladder inside the plastic bag in a certain fashion, delivering the gallstones in the bag, and removal of gallbladder preceding the stones. the retrieval time, number of insertions of sponge holder, any rupture of plastic bag as well as the number of cases needing port enlargement were noted. results: the average time taken by delhi maneuver (group a) was 9 min as compared to was 14 min by conventional method (group b). the number of insertions of sponge holder ranged from 3-11 in group a (mean 5) and 5-18 in group b (mean 13). four patients needed port enlargement in group a (8%) while 17 patients needed enlargement in group b (28.3%). there were 2 incidences of bag rupture in group a (4%) and 3 in group b (5%). the delhi maneuver improved the ease and speed of specimen extraction at laparoscopic cholecystectomy for thick walled gallbladders. it also decreased the need for port enlargement for specimen retrieval. the bile duct injuries are a very complex desease to confront, the inciian managment is to clasificate the injury and to identifie the mechamism of the injury. it's important for the optimal heal of the patient to have a multidisciplinary approach including internal medicine, surgery, endoscopy and interventional radiology specialists. the laparoscopic cholecystectomy responsible for 80%-85% of them.this is a retrospective study on the incidence, classification and management of bile duct injuries in a private sector hospital in monterrey nl. mexico. in this study, 17 bile duct injuries were identified in 10 years of experience in a single center. were categorized using the strasberg classification. variables were evaluated such as type of injury, mechanism of injury, hospital stay, if the surgery was scheduled or of emergency, the moment in which the surgeon evidenced the injury, the way in which the surgeon became aware of the injury performed. the type of management that was given to this lesion was also studied and the days of intrahospital stay and the number of reinterventions or procedures performed were compared.the average age of the patients was 53 years, 10 patients belonged to the female sex, although there were lesions of all kinds in this work, there was a greater incidence in strasberg type a lesions, which represented 41% of the lesions. the most common diagnosis presented was cholecystolithiasis. in 7 surgeries the evidence and repair of the bile duct was in the same intervention aims: bile leak is a rare but recognised complication after laparoscopic cholecystectomy. this usually occurs after a difficult procedure complicated by adhesions, unusual anatomy or if the surgeon is inexperienced or unfamiliar with the anatomy. this video aims to demonstrate the laparoscopic diagnosis and treatment of this complication particularly for surgical trainees. methods: we report a case of significant bile leak occurring soon after a straightforward laparoscopic cholecystectomy due to very short cystic duct (cd). the procedure was carried out uneventfully but the cd was clipped flush with the bile duct. the patient was discharged on the day of surgery feeling well but readmitted with abdominal pain 48 h later. results: after readmission the patient underwent a ct demonstrating only a small amount of fluid suggestive of a small collection. she was treated conservatively but suddenly deteriorated and a repeat ct confirmed significant intraperitoneal fluid. a diagnostic laparoscopy was carried out urgently confirming a cd stump bile leak where the clips had sloughed off causing the leak. two litres of bile was aspirated with copious irrigation and a latex t-tube inserted into the cbd. patient made a full and rapid recovery. conclusions: this is a rare complication and learning opportunities for trainees are therefore infrequent. this video demonstrates a successful laparoscopic approach to management of postoperative bile leak showing t-tube insertion technique and highlighting the need for careful cd closure techniques during laparoscopic cholecystectomy when the duct is very short. about 10-15% of bile duct stones could not be extracted using conventional endoscopic techniques (baloon, sphincterotomy). there is lower success rate in elderly patients; among the biggest challenges are intrahepatic stones, size of stone is large, etc. aims: to present the case of a recurrent intrahepatic lithiasis and its management using spyglass choledochoscopy.to expose, other cases and the main outcome and complications of other difficult cases of bile duct stones that solvedusing this choledochoscope vs. the traditional one and the beneffits. we present a case of 85 years old male who presented with cholangitis caused by an intrahepatic stone that required multiple sessions of endoscopic retrograde cholangiopancreatography with spyglass for clearance. one year later, he presented again with cholangitis, that required another session of spyglass lithotripsy and cholecistectomy. conclusions: besides ercp, there are different approaches to treat difficult bile duct stones, as transhepatic percutaneous drainage, surgical techniques, or other endoscopic techniques (doubleballoon, enteroscopy). ercp and sphincterotomy are the first step of endoscopic treatment with more than 90% of success rate, and a low mortality and morbility rate; other steps include some lithotripsy techniques, or the use of biliary stent as a bridge before definite treatment. spyglass is a visualization & intervention system used when common ercp has been unsuccessful, and it is first line for better and direct image of biliary ducts, with 12°range of motion, with multiple advantages like the concomitant use of lithotripsy devices. aims: the number of elderly people has increased, because of the strong association between age and gallstone disease, both prevalence and incidence of this disease are increasing. this presentation aims to review our current management options of octogenerian patients with acute cholecystitis. methods: we retrospectively analyzed 173 octogenerian patients who were admitted to the our hospital with the diagnosis of acute cholecystitis between january 2013 and october 2018. the patients were initially allocated to four different treatment groups as follows: immediate surgery, delayed surgery, medical treatment and cholecystostomy. differences in the outcomes between the treatment groups were evaluated. results: there were 67 males (38.8%) and 106 females (61.2%) with a mean age of 85.7 years (range 80-90 years). the patients had different co-morbid diseases, especially hypertension (65, 37.5%) cardiovascular disease (43, 24.8%) and diabetes mellitus ( methods: a retrospective observational study where were analyzed patients older than 75 years who underwent urgent surgery for ac who fulfilled an indication for surgery according to tokyo guidelines 2018. the type of cholecystitis, stay and postoperative complications, the type of intervention, the conversion rate, the need for reoperation and re-admissions in patients older than 75 years were analyzed and compared with those of patients operated on for cholecystitis younger than 75 years. outcomes: a total of 289 patients were registered, 55 older than 75 years (19%) and 234 younger (81%). in 128 cases, cholecystitis were complicated (44.3%), 34 cases older than 75 years (26.56%) and in 94 cases younger than 75 years (73.44%). the approach was laparoscopic in 89% of the cases older than 75 years, with a conversion rate of 10.2%, not finding statistically significant differences with younger than 75 years (91% laparoscopies with 4.2% of conversions). 18% of patients older than 75 years had some type of postoperative complication, not finding statistically significant differences in patient younger than 75 years (17%); being the most frequent complication the intrabdomintal abscess (3.66% of patients [ 75 years, and 4.27% of those \ 75 years = '' span = '' [ being not statistically significant with 95% ci. any patient older than 75 years required re-entry after discharge, compared to 8 patients younger than 75 years who were re-entered, not being statistically significant; and any patient older than 75 years required reintervention, while it was necessary to reoperate 3 patients younger than 75 years (1%), being not statistically significant. mortality was very low, finding 1 case in older than 75 years (1.8%) and 1 case in younger (0.4%), not obtaining statistically significant differences. the postoperative stay in patients younger than 75 years of age has a median of 3 days and in older than 75 years a median of 4 days, not finding statistically significant differences with 95% ci conclusions: laparoscopic cholecystectomy is safe and effective in the treatment of elderly patients with (ac), there being no differences with younger patients. introduction: significant bile leak is an uncommon but serious complication of laparoscopic cholecystectomy. our study aims to evaluate the efficacy of relaparoscopy in treating symptomatic bile leak and biloma formation. material and methods: 125 patients presenting with postoperative bile leak after different operations on extrahepatic biliary tree from january 1993 to december 2018 were reviewed retrospectively (in total, 23,590 laparoscopic surgical interventions were performed for the period under study). the sites of bile leaks were the cystic duct stump in thirty seven patients, the bile ducts of luschka in fifty two, liver beds in 16 cases after hepatectomy, in 13 had small injury of cbd, and seven patients with tubular stenosis of the common bile duct. results: three main approaches of mini-invasive treatment of bile leakage was used: (1) percutaneous puncture with or without drain under ct-scan or ultrasound guidance in 45 patients; (2) endoscopic management in 50 patients (in 35 patients (70.0%) were managed with ercp alone and fifteen (30.0%) were treated with a percutaneous intervention followed by ercp. endobiliary stent placement was performed after es in 23 patients and without es in twenty seven patients (3) relaparoscopy has been performed in 30 patients, in cases of biliary peritonitis. conclusions: relaparoscopy was the ultimate method of treating postoperative complications of laparoscopic surgery in 94.3% of patients. in general, this method, as well as laparoscopic intervention, is highly effective in the diagnosis and correction of postoperative complications, with minimal surgical trauma for the patient, with great therapeutic effect and subsequent rapid social rehabilitation of patients. introduction: laparoscopic operations have already become routine, even for pancreatoduodenectomy for periampular cancer. for unresectable cases, endoscopic bibliary stenting or hepaticojejunostomy are usually used. these methods are quite expensive and may be accompanied by complications. materials and methods: laparoscopic cholecystogastroanastomosis was performed in 72 patients with unresectable periampullary cancer. there were 34 females and 38 men and average age was 72,6. the indications for surgery in all patients was unresectable periampullary cancer and biliary hypertension with preserved patency of the cystic duct. the level of bilirubinemia ranged from 89 to 520 lmol/l (the average level was 179,8 lmol/l). we used 3-port technique. optical trocar was placed in the right iliac region, one 10 mm above the navel and one 5 mm in the right hypochondrium after punction gallblaber and aspiration of bile, we cut the apex of the gallbladder and gastric antrum up to 2.5 cm and performed cholecystogastroanastomosis with barbed-suture v-loc. results: we had not conversion to open surgery. the average operation time was 37 min. postoperative stay was average 4 days and on median follow-up of 12 month. post-operatively, there were no major morbidity and nil mortality. we had 2 cases of leakage of bile through drainage for up to 3-5 days, which spontaneously stopped. all patients showed a decrease in the level of bilirubinemia. 12 patients were later radical operated (pancreatoduodenectomy), while they did not have such phenomena as cholangitis, pancreatitis, inflammation of the hepatoduodenal ligament elements, which we often observe after endoscopic biliary stenting. conclusions: laparoscopic cholecystogastroanastomosis is safe, effective and feasible for patients with periampular cancer and obstructive jaundice. aims: surgeons with the expertise and resources to perform laparoscopic common bile duct exploration often prefer the 'one stage approach' over endoscopic retrograde cholangio-pancreatography (ercp) for the management of common bile duct (cbd) stones. this case series aims to evaluate the effectiveness of lcbde in a single benign upper gastrointestinal (gi) unit. methods: all patients with suspected and confirmed pre-operatively cbd stones who underwent a lcbde between january 2015 and october 2018 were included. lcbde was performed on the basis of pre-operative suspicion of cbd stone confirmed by intra-operative imaging. results: 187 patients with confirmed choledocolithiasis had lcbde during this time period. the indications for lcbde were deranged liver function tests, dilated cbd or confirmed stones on preoperative imaging. median age was 63 (range 19-91), 67% of whom were female. 36% of patients had confirmed cbd stones pre-op. 70% of cases were performed as emergencies and conversion rate to open was 6.5%. choledocotomy was performed in 60% of cases. in 17% of these t-tube was left in situ. transcystic approach was used in the remaining 40%. despite positive intraoperative imaging no stones were found on cbd exploration in 11 cases (6%). in 3 patients stones were unable to be cleared with lcbde. the overall morbidity was 20%. 11% of patients had gallstone related complications. overall mortality was 1% (due to bile leak). 19/187 patients required re-intervention with re-look laparoscopy (n = 6) or ercp (n = 13). 3 patients re-presented within 3 months with cbd stones. overall median length of stay was 5 days. conclusions: our case series demonstrates that lcbde is an effective and safe treatment for choledocolithiasis in both the elective and emergency settings. complication rates are comparable with therapeutic ercp (10% specific complications) followed by laparascopic cholecystectomy (10% 30 day morbidity). the variability in anatomic location of subvesical bile ducts puts them in danger during hepato-biliary operations. its prevalence varies between 3% and 10%. the origin and drainage of these ducts were limited mainly to the right lobe of the liver, but great variation could be seen. some authors think of them as small bile ducts that drain directly into the body of the gallbladder; others consider them to be networks of miniscule bile ducts between the liver capsule and the gallbladder. recent studies suggest that clinically relevant bile leaks complicate approximately 0.4-1.2% of cholecystectomies. injury to a subvesical duct is one of the most common causes of cholecystectomy associated bile leak and occurs as often as major bile duct injuries and leaks from the cystic duct stump. indeed, recent studies suggest that about 27% of clinically relevant bile leaks are caused by inadvertent injury to a subvesical bile duct. there are four types of subvesical bile ducts, including (1) superficial variations of segmental and sectorial bile ducts, (2) superficial or intercommunicating accessory bile ducts, (3) hepaticocholecystic ducts, and (4) aberrant bile ducts.we present a case of 73 year old patient who developed a coleperitoneum after a routine daycase colecystectomy due to the inadvertent injury of a hepatocholecystic duct. a superior comprehension of ductal anatomy is essential in preventing and managing operative injury to the subvesical ducts, although some times is unavoidable. nowadays, the diagnosis of liver cancer is primarily radiological, as recommended by the principal international societies. in doubtful cases or due to the clinician needs, diagnostic evaluations can eventually be completed with a liver biopsy. the goal is to perform the examination, or the examinations, that guarantee the most elevated sensibility and specificity levels being as little invasive as possible. nevertheless, even using the best radiological tools, the diagnosis is not certain, due both to device limitations and radiology experience. recently, various diagnostic algorithms have been proposed, relating with contrast enhancement characteristics, different radiological techniques, blood examinations and cross evaluations from different radiologists. one of the most recent algorithm purposed is liver imaging reporting and data system (li-rads), that evaluates ct and mri imaging to classify hepatic lesions in different diagnostic categories, in order to perform a better and more precise diagnosis of hcc or other liver benign or malignant lesion. through a retrospective study, we evaluated and compared preoperative imaging and post-operative histological reports. results reveal that li-rads routine use increases hcc diagnosis up to 95%. background: we previously developed a modified difficulty scoring system (dss-ihd) of laparoscopic liver resection (llr) for patients with intrahepatic duct (ihd) stone. we validated dss-ihd in patients who underwent llr for hepatolithiasis. methods: dss-ihd was based on the extent of liver resection (2 to 4), stone location (1 to 5),atrophy of liver parenchyma (0 to 1), ductal stricture \ 1 cm from the bifurcation (0 to 1), and combined choledochoscopic examination for remnant ihd (0 to 1). results: the dss-ihd ranged from 3 to 12 and divided to 3-level groups of low group (score 3 * 5; n = 26), intermediate group ( objective: improving the surgical treatment of patients with cholangiogenic abscesses of the liver through the application of minimally invasive technologies. material and method: in the presented study presented results of treatment of 49 patients with biliary liver abscesses. surgical interventions for hepatic abscesses were performed simultaneously with the elimination of the primary pathological process of the biliary system, which caused the occurrence of cholangitis, or in the near future (up to 3 days) after biliary drainage drainage. among 49 patients with biliary liver abscesses, treated with minimally invasive methods, 29 revealed abscesses of the right hepatic lobe, 15-abscesses of the left hepatic lobe, 5-abscesses and right and left hepatic lobes. single abscesses were detected in 39 patients, and in 10-two or more abscesses. in terms of liver abscesses, more than 3 cm were detected in 43 patients, more than 5 cm in 6 patients. drainage of the biliary tract was carried out endoscopically transpapillary and (if the endoscopic approach was unsuccessful) with transcutaneous transhepatic approach. results: drainage under ultrasound guidance was performed on 21 patients with solitary and 7 patients with two or more cholangiogenic abscesses of the liver. laparoscopic interventions were performed on 21 patients. among the patients operated on using minimally invasive technologies, 7 occurred complications (14.3%). 1 patient died due to the development of biliary sepsis (2.0%). conclusion: percutaneous drainage of liver abscesses under ultrasound control is appropriate not only for single abscesses, but also for their larger number, which has many advantages over other interventions. it was proved possibility of simultaneous drainage of liver abscess and bile duct. percutaneous drainage of the liver abscess, drainage of the biliary tract and laparoscopic surgical intervention are complementary aspects in the treatment of liver abscesses of biliary origin. after laparoscopy residual calculus can be removed endoscopically in more favorable conditions after stabilization of the patient's condition is achieved and the infection-associated disorders are eliminated. in case of localization of abscesses in the marginal segments of the liver, laparoscopic atypical resection of the liver with an abscess is most desirable. general surgery, rambam medical center, haifa, israel background: recently robotic surgery has emerged as one of the most promising surgical advances. despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (hbp) surgery remains relatively unexplored. our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies. methods: a retrospective analysis of a prospectively maintained database on clinical outcomes was performed for 26 consecutive patients that underwent robotic assisted surgery for benign hbp disease at rambam medical center during 2013-2015. results: there were 26 robotic assisted surgical procedures performed for benign hbp pathologies during the study period. there were 3 anatomical robotic liver resections for symptomatic hemangiomas, 9 cases of giant liver cyst, 5 robotic assisted surgery for type i choledochal cyst, 2 case of benign (iatrogenic) common bile duct (cbd) stricture, 3 cases of robotic (cbd) exploration due to large intra choledochal stones and 6 cases of cholecystectomy for cholelithiasis. the median postoperative hospital stays for all procedures were 3.5 days (range 1-6 days). general morbidity (minor) was 2%. there was no mortality in our series. conclusion: robotic surgery is feasible and can be safely performed in patients with different benign hbp pathologies. further evaluation with clinical trials is required to validate it's real benefits. most liver cysts are asymptomatic and tend to have a benign clinical course. however, symptomatic or complicated liver cysts sometimes require surgical intervention. needle aspiration is safe and can be the lease invasive procedure, this procedure is however associated with a high failure rate and rapid recurrence. surgical approach is the crucial and provides definitive treatment for such cysts. thirteen cases were nominated from shonan kamakura general hospital between january 2015 and december 2018. mean age and body mass index (bmi) were 67.8 and 20.8, respectively. all patients have had any complaint such as upper abdominal pain, dyspnea, and fever. two cases were clinically diagnosed as the infectious cyst and serum crp was elevated before surgery. additional cholecystectomy was planned for one case of chronic cholecystitis with gallbladder stones. all cases were prompted the reduced port surgery (rps) and 4 cases were performed rps with trans-vaginal approach (hybrid notes) and 4 case was chosen in single port surgery. cyst unroofing was performed for all cases. mean operation time and blood loss of all cases were 122.3 min. and 62.7 ml, respectively. no surgical complication has been occurred in all cases, an infectious cyst case was however required additional drainage for infectious control after surgery. although statistic difference was not shown, fewer blood loss and shorter hospital stay was seen in non-infectious cases, compared to laparotomy cases. mean hospital stay after surgery of whole cases, non-infectious cases, infectious cases was 5.5, 2.5, 22.5 days, respectively . no recurrence of any symptom was shown in any cases in observation period (10-1392 days) . laparoscopic unroofing is the definitive treatment for the complicated or symptomatic liver cyst. however, for the infectious cyst, infection control such as intensive drainage and/or administration of antibiotic before surgery may be needed to avoid additional treatment, leading to longer hospital stay. laparoscopic unroofing of liver cyst can be the first choice for symptomatic or complicated liver cyst. also, reduced port surgery can be nominated to achieve less invasiveness. introducction: laparoscopic liver resection (llr) has been increasing since it was first reported in 1991. three international expert consensus conferences on llr surgery were held in louisville, ky, usa, in 2008 , morioka, japan in 2014 and southampton, uk, in 2017 . while most initial minimally invasive liver resections were typically done for benign lesions in anterior o left segments, llr is currently being applied for major anatomic resections, malignancy, cirrhosis and liver donor hepatectomy. clinical case report: this is a 78-year-old male patient with a history of hta and liver cirrhosis due to hepatitis b virus. hepatocarcinoma is diagnosed in liver segment vi with a size of 3 cm . in the digestive study the patient presents a child a stage, meld \ 9, without signs of portal hypertension. complete analytical with normal afp and cea 19.9 markers. after presentation of the patient in a multidisciplinary committee and being a stadium according to the early bclc classification, laparoscopic surgery with segment vi resection was decided. discussion: laparoscopic liver resection is becoming widely accepted for the treatment of hepatocellular carcinoma. liver resection is a first-line option in very early and early-stage disease. many meta-analysis have shown that llr is better than open liver resection in terms of short-term outcomes for patients with child-pugh a cirrhosis, solitary tumors, and minor resections. in the long-term setting, the results demonstrate that a minimally invasive approach is comparable to an open approach in terms of overall. in conclusion, the current evidence conclude than llrs for hcc are safe and may be considered a standard practice in specific settings. results: there were 6 women (43%) and 6 men (57%). the age of patients ranged from 43 to 82 years. the patients underwent complex examination including abdominal ultrasound, esophagogastroduodenoscopy, and some of them underwent ct (computed tomography). all patients in the first stage were performed antegrade external drainage of biliary tracts with x-rays of the biliary tracts, and specifying the level and extent of the block.total 28 miniinvasive interventions were hold. two patients in connection with the uncoupling of equity ducts were performed antegrade bilobar stenting with preliminary split external bile release.there were complications after carried out interventions in 10 cases, which were associated with dislocation of holangiostomic drainage in 5 patients (35.7%); with acute cholecystitis in 1 patient (7.1%); with hydrothorax in 2 patients (14.2%); perihepatic biloma in 1 case (7.1%).1 patient (7.1%) had a recurrence of obstructive jaundice due to germination of endobiliary stent in the late period after stenting. lethal outcome appeared in 1 patient. conclusions: ultrasound examination allows us to determine the level of obstruction of the biliary tract, to substantiate the tactical position in the application of mini-invasive technologies. antegrade miniinvasive technologies in the treatment of tumor lesions of the proximal bile ducts allow timely and effectively stop biliary hypertension and to determine further treatment strategy. acknowledgements this study was supported by the russian science foundation under project ? 18-15-00201. background: repeat hepatectomy is an effective treatment, with long-term surgical outcomes for recurrent hcc and colorectal liver metastasis(crlm). however, the efficacy of a minimally invasive surgical approach for recurrent liver tumor is not yet confirmed. the purpose of this study is to examine the efficacy of laparoscopic repeat hepatectomy(lrh) compared with open repeat hepatectomy(orh) for recurrent liver tumor. we retrospectively analyzed the clinicopathological features and short-term surgical outcomes between lrh and orh. methods: from 2006 to 2018, 158 patients with liver cancer underwent repeat hepatectomy. of those patients, 113 patients underwent partial hepatectomy, 37 patients were undergone laparoscopically, and 76 patients underwent open hepatectomy. we compared the clinicopathological and surgical parameters in the lrh group with those in the orh group. results: there were no significant differences in patients' gender, age, viral infection status, child-pugh classification, tumor size, tumor number, and tumor location in the two groups. the operative times were similar, but blood loss was significantly lower in lrh group (68 vs. 310 ml, p \ 0.001). the postoperative hospital stay was significantly shorter in the lrh group (9.0 vs. 11.5 days, p = 0.016). postoperative complications(cd = 3a) were observed only in the orh group, with a complication rate of 9.2%. conclusions: we demonstrate that lrh reduces blood loss and postoperative complications compared with orh. lrh might be a feasible and effective procedure for the selected patients. background: the liver is the most common site of metastatic disease with up 40-50% of all cancers having the potentiality for sending liver metastasis during the disease. consequently, increasing value for surgical resection of hepatic deposits of different types of cancers, the need for accurate evaluation of the extent of hepatic metastasis was established for choosing the most suitable patients for surgery and in planning the extent of hepatic resection. the aim of this work is to evaluate the role of intra-operative ultrasound in the detection of hepatic deposits in intra-abdominal malignancies with special emphasis on its accuracy, sensitivity, specificity. patients and method: this study was carried out on thirty patients who were admitted to the gastrointestinal surgery unit, main alexandria university hospital with intra-abdominal malignancies for whom elective open surgical intervention was recommended in the period from 1st of september 2017 till the 31th of march 2018. results: in the present study consisted of 17 males (56.7%) and 13 females (43.3%). their mean age at admission was 52.77 ± 9.12 years. six of the included patients (20%) were found to have hepatic lesions by using ious including the four cases (13.3%) already detected by preoperative imaging. two cases (6.67%) were newly discovered in the operative room by using ious. conclusion: the current study has proved that ious demonstrates superior lesion detection over the various non-invasive preoperative imaging modalities causing significant impact on change of the planned surgical strategy laparoscopic approach to the liver has become an integral part of surgery. two consecutive international consensus meeting recommends major hepatectomy has been on the expert hands. tumors located in the right posterior section are considered to be difficult for laparoscopic resection. patients and methods: since 2005, until 2017, cnuhh has been performing 260 laparoscopic hepatectomies including 67 major hepatectomies. among 67 major ones, there are 36 rh, 13 lh, 16 rps, 2 ch, and 1 as. we analyze data on patient demographics, tumor characteristics, operative date, and posterior outcome retrospectively. results: during 2014-2017, 16 laparoscopic rps were performed. the diagnosis were hcc in 13 and crlm in 3 patients. median operative time was 405 min, and median blood loss was 850 ml. no blood transfusion was occurred. median tumor size was 38 mm, and median resection margin was 12.3 mm. six of the 16 patients (38%) were cirrhotic on pathology. there was no conversion and was no postoperative mortality. median hospital stay was 11.6 days. conclusion: laparoscopic rps is known challenging procecedure. strict preoperative planning and operative procedure is mandatory. even though it should be performed by the experienced hands both on hepatic surgery and laparoscopic skill, it can be an good option for treatment of the tumor locating over right posterior section. purpose: previously we developed a new sponge (named endoractor) as an organ retraction device in laparoscopic surgery in 2009 and have reported that it is useful in various surgical procedures including rectal surgery we confirmed that it is also useful in laparoscopic radiofrequency ablation of the liver in terms of pulling and protecting organ, so we report it materials and methods: a case is an 82-year-old female with liver cirrhosis. she had primary hepatocellular carcinoma in s8 lesion with a diameter of 1.8 cm very close to the inferior vena cava and middle hepatic vein root and in s3 lesion with a diameter of 2.0 cm we thought she could not put up with hepatic resection because of her poor hepatic reserve capacity. and we could not expect treatment effect by embolization therapy since contrast effect was poor. so we decided to select ablation therapy in the puncture and ablation of the s8 tumor, since there was concern about the thermal damage of the middle hepatic vein and the cooling effect by the inferior vena cava, we would dissect the right coronary mesentery sufficiently and pull the liver apart from the inferior vena cava and the middle hepatic vein as much as possible using our endoractor also, in the puncture and ablation of the s3 tumor, it was feared that the stomach would be thermally damaged, so we would place endoclactor between the liver and the stomach to protect the stomach results: when ablating the s8 tumor, we could pull the liver securely without slipping, so we did not cause thermal damage to the middle hepatic vein. and there was no cooling effect by the inferior vena cava, so we could obtain sufficient cautery margin. in ablation of s3 tumor, we were able to puncture by stabilizing the lateral segment of the liver on our endoractor, and avoid thermal damage of the stomach conclusion: it seems possible to perform safe and reliable puncture and ablation by using our endoractor as well in laparoscopic radiofrequency ablation surg endosc (2019) surgical reinterventions in patients with complicated hepatic hydatid cysts usually occur as a result of diagnostic or technical failures during the initial procedure. according to recent studies, the most common complication after liver hydatid cyst surgery is local sepsis at the residual cavity and long-term biliary leak. we report the case of a 21-year-old male with a history of liver hydatid disease four years before the current episode, admitted in our surgical department for intense upper right quadrant pain. abdominal ultrasonography, ct and mri scans revealed three cysts in the gastrosplenic ligament, in liver segments vii-viii, and ii-iii respectively, sized between 4 and 8 cm. the intraoperative aspect during laparoscopy was strongly suggestive for liver hydatid disease. laparoscopic fenestration with tunneling for the hepatic cyst in segment viii, partial cystectomy in the left liver lobe and ideal cystectomy in the gastrosplenic ligament were performed. postoperatively, the patient displayed a constant biliary drainage output of 500-600 ml from the cavity remnant in the segment viii. conservative therapy for external biliary fistula and concomitant treatment with albendazole for 3 months were initiated. evolution was slowly favorable with decreased biliary drainage to 200 ml two months after surgery and complete symptom resolution five months after hospital discharge. aims: this study aimed to evaluate the effectiveness of fluorescence imaging with indocyanine green (icg) during laparoscopic deroofing of hepatic cysts. methods: this was a single-center, case-control study. we included 14 patients who underwent laparoscopic deroofing between november 2008 and october 2018. imaging with and without icg fluorescence was performed in 10 (icg group) and 4 (non-icg group) patients, respectively. icg was intravenously administered between 15 min and 6.5 h before surgery. we performed a standard laparoscopic procedure. we detected a thin bile duct on the hepatic cyst on using intraoperative icg fluorescence imaging. we adjusted the resection line of the cyst wall and ligated the bile duct at the point at which it crossed the resection line. data on age, sex, cyst size, resected cyst size, operative time, estimated blood loss, post-operative hospital stay, complications, and recurrence were compared between the groups. results: the mean cyst size was 139 ± 30.9 and 138 ± 32.5 mm, the mean resected cyst size was 139 ± 51.1 and 86 ± 39.9 mm, and the mean operative time was 95.8 ± 30.8 and 152 ± 72.8 min in the icg and non-icg groups, respectively. using icg fluorescence imaging, the bile duct was detected on the cyst wall in 4 patients (40%). all surgeries were completed laparoscopically, and no post-operative complications occurred in either group. recurrence of the hepatic cyst occurred in one patient (25%) of the non-icg group. conclusions: fluorescence imaging with icg is used widely in hepatobiliary surgery for intraoperative identification of biliary and vascular anatomies. this method does not require complicated techniques or instruments. icg fluorescence imaging may facilitate the prevention of intra-or post-operative complications, such as biliary leakage, in laparoscopic surgery. in this study, icg fluorescence imaging was found to be effective in detecting the bile duct on the cyst wall intraoperatively, allowing for wider resection of the cyst and avoiding inadvertent injury. our study suggests that wider resection of the cyst wall might prevent recurrence of hepatic and that icg fluorescence imaging could ensure procedural safety. abdominal ct showed: large hepatic cyst (18x17,8x22 cm size), with no malignity signs, that occupies practically the whole right liver, causing subsegmentary atelectasis of the middle lobe, superior and inferior cava vein compression, and displacement of right kidney, pancreas and right atrial. due to breath involvement, a percutaneous drainage is performed achieving clinical improvement and reduction of the size of the injury. the patient was released but a cyst superinfection occurred; once this problem was solved, the drainage was removed. results: in light of the complication, surgical treatment was decided, which confirmed the large cyst located in right posterior hepatic segments with tight diaphragmatic adhesions. we carried out the cyst evacuation and a wide laparoscopic resection of the cyst walls, until the posterior area of the cava vein, combining supra and infrahepatic access. the patient was released on the sixth postoperative day and continues asymptomatic. conclusions: simple cysts can be approached in a no surgical way (punction-aspiration with/ without sclerosing products injections) or in a surgical way (cyst wall fenestrations, cystectomy or liver resections). a conservative treatment will obtain symptomatic relief but with a high risk of recurring. recurrence is the main drawback of unroofing. cystectomy is the better option but may be too complicated depending on the cyst's location. to our patient, we carried out a wide laparoscopic unroofing (even though its posterior localization) to minimize recurrence possibilities. in conclusion, laparoscopic resection of the cyst wall is a simple and effective approach in symptomatic or complicated cases. background: single-incision laparoscopic surgery or laparoendoscopic single-site surgery is emerging as an alternative to conventional multiple-incision laparoscopic surgery. it has a potential benefit of less postoperative pain and faster recovery compared with conventional multiple-incision laparoscopic surgery. single-incision laparoscopic hepatectomy (silh) has been reported in only a few small series and the majority were minor resections. case report: a 54 y/o male patient is a case of chronic viral hepatitis b and early cirrhosis of liver. two atypical hepatocellular carcinomas (up to 2.4 cm in diameter) located at the junctions of segments 6 & 7 and segments 5 & 6 were impressed by liver magnetic resonance imaging (mri). we performed single-incision laparoscopic anatomical hepatic resection of the right posterior section via a 5-cm transverse incision on the right middle abdominal wall. inflow control was carried out with an extra-glissonian approach before parenchymal transection. the glissonean pedicles of segments 6 and 7 were divided by linear staplers respectively as well as a major branch of the right hepatic vein in segment 7. the operative time was 580 min and the estimated blood loss was 150 ml. the pathologic examination revealed two foci of hepatocyte dysplasia with a safe margin of 4 cm. the patient was discharged eight days after the surgery uneventfully. conclusion: single-incision laparoscopic anatomical right posterior sectionectomy is feasible and safe by experienced laparoscopic surgeons. it provides a fast recovery but needs a long operative time. the mortality in the patient with liver cirrhosis is very high. the aim of this work was to decrease mortality and morbidity by using endoscopic local heamostasis and laparoscopic operations, in the patients with bleeding from cirrhosis by variceal bleeding. methods and material: we observed 692 patients with cirrhosis complicated by variceal bleeding during 12 years. there were 260 patients with child phue a, 279 ones with child phue b, 153 ones with child phue c. all the patients were performed prolonged endoscopic heamostasis with conservative therapy. the main methods that we used were the ligation in 345 cases, sealing in 50 cases, sclerotherapy in 158 cases. in 18 cases we couldn't stop the bleeding with band ligation method and introduce the danis stents into esophagus and stopped the bleeding successfully. to prevent the re-bleeding we performed the laparoscopic dissection the abdominal part of esophagus with suturing the venous vessels, coagulations and dissection of short gastric vessels between stomach and spleen, clipping the left gastric artery and vein in the 67 patients. in 29 patients we performed laparoscopical suturing the variceal veins by introducing the laparoscopic trocars into the stomach. in 35 cases with varices vien of stomach, with non-effective local endoscopic heamostasis we performed laparoscopic resection the fundal part of stomach. results: endoscopic local heamostasis were successful (in 85%) in 588 cases. the relapse of bleeding were in 85 patients. 25 patients died. there was no mortality after laparoscopic operations. there were 7 cases for trocar wounds infection, 3 cases of subphrenic abscess. goals: the advance of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those affecting the liver and pancreas. there are multiple indications that laparoscopy has in hepatobiliopancreatic surgery, both in benign and malignant pathologies. material and methods: we present the video of a 78-year-old male patient with a history of right hemicolectomy due to disease-free intestinal lymphoma who, in the control analysis by his attending physician, detects the elevation of tumor markers. an extension study was started showing a hepatic lesion in the caudate lobe with a pathological anatomy suggestive of hepatocarcinoma and an adenopathy suspicious for malignancy adjacent to the right renal vein. the clinical case is presented in a multidisciplinary tumor committee and it is decided to perform surgery. a laparoscopic caudate lobe resection was performed, previously performing intraoperative ultrasound and a lymphadenectomy of the portal territory, vena cava and exeresis of adenopathy of the right renal vein. introduction: major vascular complications during laparoscopic surgery occur approximately in one in 1000 cases, but mortality rate can reach 8-17%. most major vascular injuries lead to conversion to laparotomy but successful laparoscopic repair is also possible. simulation training improves laparoscopic performance and possibly reduces surgeons mental strain. materials & methods: during two editions of advanced laparoscopic training course 12 participants had a task to control a major vessel damage (damage). before the task an educational video explaining the methods of obtaining haemostasis was shown. the algorithm of the 'damage' task was as follows: without previous preparation a 1 cm injury of a major vessel was done with l-hook electrocautery. after the injury participants were free to control the damage the way they wanted. heart rate of the participants was measured with an ear electrode. measurements were carried out 3 times-before the injury, immediately after, and afterwards obtaining vessel control. after participants were interviewed for their feelings after the 'damage' task. results: there were 12 vessel injuries in 10 animals. one animal died during the 'damage' task 20 min after desuflation due to relapse of bleeding. there was no conversion to open procedure. temporary vessel control was obtained with different methods. all participants used vicryl 2.0 or pds ii 3.0 suture for final hemostatic purposes. heart rate of the participants before injury were 52-85 ± 3.33 bpm, immediately after the injury it rose to 75-120 ± 4.31 bpm, and after obtaining vessel control were in the range 50-100 ± 4.83 bpm. a statistically significant difference was found between the ratio of the first and second hr measurement (p = 0.01, t = -9.727), and second compared to the third (p = 0.02, t = 4.177) measurement. participants judged their experience on a 5-point scale (1was not helpful at all; 5-was extremely educative). the educational value of the task received 5 points in 11 cases and 3 points in one case. conclusion: participants feel stress during major vessel bleeding even in animal model, and this stress can result in a serious intraoperative mental strain and significantly increase heart rate. participants found the 'damage' task very useful for their daily practice. the aim of study was to improve the results of treatment of patients with hepatic echinococcal cysts by using of argon plasma coagulation. methods: the analysis of treatment results of 66 patients was put into the basis of this study. it was 12 (18.2%) men and 54 (81.8%) women in total. an average age of them was 47.7 ± 15.9 years. the main difference between groups was a way of liver parenchyma coagulation in order to make reliable hemostasis. in main group the final stage of surgical intervention on liver was argon plasma coagulation. it was performed to 45 (68.2%) patients. alternatively, monopolar coagulation was performed to 21 (31.8%) patients (comparison group). results: in main group in the 86.6% cases pericystectomy was conducted. the resecting surgeries was performed to 13.4% cases. in comparison group was conducted in 28.6% cases. in early postoperative period in main group the complications were observed in 4.4% of cases. the same parameter was 4.8% in comparison group. it led to relaparomies. the forming of external biliary fistulas was observed in 2 (4.4%) patients in main group and in 3 (14.3%) patients in comparison group. however, all the fistulas have closed spontaneously on 7th-10th day in both groups. hernias of abdominal wall and peritoneal adhesions that manifested by intestinal obstruction of different degree were considered as complications of late postoperative period. these values were 0% and 4.4% in main group versus 19% and 14.3% in comparison group, respectively. the resection of hepatic echinococcal cysts with further application of argon plasma coagulation on the cyst bed was accompanied by complications quantity decrease in patients that underwent surgery in early as well as in late postoperative period. in this case more positive dynamics of functional liver values improvements was observed. aims: indocyanine green (icg) fluorescence imaging has been reported as a reliable and safe navigation tool in laparoscopic hepatectomy. however, the factors affecting the sensitivity of tumor detection with icg fluorescence imaging is relatively unclear. the aim of the present study is to analyze the factors of successful icg fluorescence in laparoscopic hepatectomy. methods: this is a retrospective single-center study. this study population consisted of 80 laparoscopic hepatectomies from january 2018 to november 2018 undertaken at kurashiki central hospital. we excluded patients whose tumors were located more than 10 mm from the liver surface, those who did not receive icg fluorescence imaging, and those who were not injected with icg dye (0.5 mg/kg) intravenously within 7 days of surgery. the pinpoint endoscopic fluorescence imaging system was used to detect the tumor location. we evaluated the relationship between successful fluorescence and the timing of injecting icg before operation, tumor size, icg r15, liver damage and bmi. results: following exclusion, 15 patients were eligible for analysis. among the 16 tumors resected, icg fluorescence imaging detected 9 tumors (56.3%), including 6 hepatocellular carcinomas and 3 liver metastases. icg fluorescence imaging detected all 9 tumors in the patients injected with icg 2 to 5 days before hepatectomies . icg fluorescence imaging detected all 9 tumors which were more than 10 mm in diameter. there was no relationship between indocyanine green fluorescence with icg r15, liver damage and bmi. conclusions: the injection of icg 2 to 5 days before operation and a tumor size of more than 10 mm can be factors in successful fluorescence in laparoscopic hepatectomy. introduction: cysts in the liver have a wide variety of aetiologies. it is important to characterize the cystic lesion before treating it. the simple cyst has a low prevalence and is more frequent in women. fenestration is a useful option for the treatment of simple cysts in selected patients. case presentation: a 40-year-old woman was referred to our hospital with a one-year history of intermittent, right upper quadrant pain, with no other associated symptoms. computed tomography and magnetic resonance imaging showed a large cyst (14,4 x 13,2 cm) in the right of the liver. the cyst presented lobulated morphology, smooth edges and well delimited. there were other smaller cysts in the left lobe. hepatic function in blood analysis was normal. biomarkers, tumor markers and hepatitis virus markers were negative. outpatient follow-up and symptomatic treatment of pain was decided. after six months of follow-up, the pain persisted, so surgical treatment was proposed. a laparoscopic fenestration was performed, widely resecting the free wall of the cyst. there was no evidence of a connection to the bile duct. there were no complications. on 3 days she was discharged. discussion: some giant hepatics cysts become symptomatic due to mass effect. persistence of pain is an indication of surgical treatment. laparoscopic fenestration is an alternative for the management of simple hepatic cysts. aim: laparoscopic liver resection for malignant pathology such as colorectal cancer metastases has been a matter of discussion for several groups in the last years. it has been proposed as a safe and feasible treatment but subjects like short and long term outcomes and oncologic results have not been adequately assessed. methods: we performed an observacional retrospective study of patients undergoing laparoscopic liver resection for colorectal metastases in our center. from november 2007 to november 2018 a total of 113 patients underwent laparoscopic liver resection. data for resection margin, hepatic and extrahepatic recurrence and both disease free survival and overal survival were collected. patients were discussed in a multidisciplinary group with oncologist, radioterapic oncologist and surgeons. the surgical procedures were perfomed by the same team in all the cases to minimize bias. results: a total of 9 patients (7.9%) were non resectable at the time of surgery.the mean overall survival was 19 months with a maximum of 132 months. we got a mean of disease free survival in our patients of 11.7 months. the hepatic recurrence was 28%, most of them in high risk patients, and from this group 67.74% underwent a new liver resection. major complications took place in 9 patients (7.96%) two biliar leaks, one bowel perforation, two hepatic failure, one evisceration and three respiratory insufficiency needing urgent surgery in three of the cases. mean hospital stay was 5.84 days. a mean of 2 days of this stay were in an intensive care unit. conclusions: laparoscopic liver resection for colorectal liver metastases could be a feasible technique when perfomed by trained surgeons. it improves the postoperatory recovery with a reduction of hospital stay and less postoperatory pain without increasing the development of major complications or mortality in the first 30 days after surgery. we got good oncological results that have been improving with the experience acquisition of the surgical team. aged 29 to 71 underwent surgery for cirrhosis with massive refractory ascites child c (9-10), without obvious signs of hepatic encephalopathy. major etiological factors were: viral hepatitis c (47 patients (48.0%)), b (29 patients (29.6%)), b ? d (17 patients (17.3%)), toxicity (5 patients (5,1%) ). to prevent possible bleeding at the first stage, endoscopic filling of esophageal varices with fibrin glue was performed in 81 patients (82.7%). after testing the effectiveness of varices filling, in the following 5-7 days decompression surgery of thoracic lymphatic duct was performed under local anesthesia to improve lymphatic drainage from liver and abdominal organs. simultaneously, laparoscopic sanitation of abdominal cavity was performed, with complete evacuation of ascites fluid, rinsing and drainage. fractional post-surgery rinsing was repeated daily for 3-5 days towards removing peritoneum edema and improving its absorptive properties. results evaluation was performed 3, 6 and 12 months after surgery, based on criteria of liver reserves and ascites volume. results: post-surgery mortality from liver failure was 5.1% (5 patients) . 7 other patients died of the same cause the following 3-6 months. annual survival rate was 87.6%. complete ascites regression over 3-12 months after surgery was noted in 53 patients (55.8%), significant regression and stabilization in 25 (25.6%), moderate regression with need for periodic decompressive laparocentesis in 8 cases. in all patients, functional liver reserves and life quality significantly improved. conclusions: the use of the given technique of refractory ascites correction, in patients with depleted liver cirrhosis, by laparoscopic sanitation with post-surgery fractional rinsing of abdominal cavity, with simultaneous decompression of thoracic lymphatic duct showed very high efficiency and deserves establishment as a clinical practice. t. urade, hepato-biliary-pancreatic surgery, kobe university, kobe, japan aim: anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target territory were established as essential methods for the curative treatment of hepatocellular carcinoma (hcc) and then subsequently applied to other malignancies. however, laparoscopic anatomical liver resection (lalr) is much more difficult to reproduce these procedures and to confirm demarcation of the hepatic segment visually on the monitor. recently, laparoscopic fluorescence imaging system has been used as a tool for real-time intraoperative navigation in llr. the aim of this study is to demonstrate how to perform lalr using indocyanine green (icg) fluorescence imaging. methods: three patients underwent pure lalr using icg fluorescence imaging. the following operative procedures were performed: 1 partial liver resection for hcc, 1 segmentectomy for liver metastasis and right anterior sectionectomy for hcc. in all patients, preoperative 3d simulation images from dynamic ct were reconstructed using a 3d workstation to decide on cutting points of the glissonean branches. after mobilization of the liver, intraoperative ultrasonography was performed to identify the location of the tumor and glissonean pedicles corresponding to the tumor-bearing hepatic region. we dissected or transected the hepatic parenchyma to encircle the glissonean pedicles. after clamping or closure of them, 2.5 mg of icg was injected intravenously to identify the boundaries of the hepatic segments under near-infrared light. parenchymal transection was started according to the demarcation on the liver surface. the lateral aspect of the parenchymal transection was carried out based on the demarcation between non-fluorescing and fluorescing liver parenchyma as far as possible. results: in all the 3 cases, demarcation lines on the liver surface could be visualized clearly after injection of icg. in addition, boundaries of cone units, segments and sections could be recognized to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. these procedures were completed successfully, and the postoperative courses were almost uneventful. aim: sintrahepatic cholangiocarcinoma is the second most common primary liver cancer after hepatocellular carcinoma (hcc). although the laparoscopic approach of these tumours is not frequent due to its complexity, it is performed increasingly by hepatic surgeons.traditionally, the abdominal surgery in cirrhotic patients has been reserved to selected cases secondary to the high rate of complications. the advance on the treatment of the hcc on liver cirrhosis and the higher safety when performed by laparoscopic approach has encourage some surgeons to extend surgery to child b-c or portal hypertension patients. methods: we present a male of 56 years old, diagnosed in 2010 of liver cirrhosis accompanied with portal hypertension. on mri in 2012 was found a solid lesion of 25 mm located on segment ii hepatic. biopsy confirmed the diagnostic of intrahepatic cholangiocarcinoma. after a liver function evaluation (child c, meld 17), an hepatic chemoembolization was performed. sequentially ct scans indicated a complete radiologic response. after 6 years of follow up, mri showed a recurrence of 25 mm between segment ii and iii of the liver.on multidisciplinary committee liver resection was decided due to suitable liver function and low aggressiveness of the tumour. a laparoscopic left lobe liver resection was performed. sonastarò and ligasure tm were used to perform the liver transection and endo gia tm for portal and hepatic veins sections. the surgery develop was complicated due to trend to bleeding that finally was achieve through cauterization. results: early after the surgery, the patient presented a haematic debt through the drain of 900 cc accompanied of hypotension, therefore an emergent surgery was indicated. an exploratory laparoscopy was performed finding hemoperitoneum and diffuse bleeding of the liver surface that was controlled. the patient had a proper recovery and was discharged on the 11 th day post-surgery. the analysis of the specimen showed a 6.5 cm cholangiocarcinoma with a 0.4 cm margin of resection. conclusion: there is an augmented risk of complications on liver resection of cirrhotic patients with portal hypertension. the laparoscopic approach allows to reduce potential complications, despite bleeding continuous to jeopardize this surgery, this option could be proposed on selected patients. introduction: accessory spleen itself is found in approximately 7% to 15% of the population. most (80%) are located near the splenic hilum but intrapancreatic accessory spleens (ipas) are the second most frequent location (16.8%) of accessory spleens. in adults, ipas are clinically silent. they may become clinically important because of their radiographic similar appearence of cancer. intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and is located in the pancreatic tail in approximately 1% to 2%. ipas can be difficult to differentiate radiologically from hypervascular pancreatic tumors such as pancreatic endocrine neoplasms because theycan share a similar enhancement pattern. as a result, most of the reported cases of ipas have been diagnosedonly after distal pancreatectomy was completed. material and methods: we present the case of a 55-year-old male patient with a history of large vessel vasculitis followed-up for rheumatology, which showed a pancreatic nodule in a control ct so he was referred to digestive for study. an echoendoscopy was performed. it showed, at the level of the tail, in the third distal, a lesion of 16x12 mm, hypoechoic, with rounded morphology and well-defined edges that can not be biopsied given the absence of adequate window for the realization of fine needle aspiration biopsy (fnab). based on these radiographic findings, the differential diagnosis included a pancreatic endocrine tumor. due to the high suspicion of malignancy and the absence of biopsy, he was referred to general surgery for scheduled surgery. a laparoscopic corporocaudal pancreatectomy was performed without incidents and the definitive histology showed an intrapancreatic accessory spleen in the pancreatic tail that excluded the presence of cancer. conclusion: intrapanceratic accesory spleen is a challenging diagnosis to make and it should be included in the differential diagnosis of pancreatic neoplasm. its early identification precludes surgical resection. however, the preoperative diagnosis of ipasmay be difficult, and distal pancreatectomy is a safe and relatively simple operation, most of the reported cases of ipas being diagnosed correctly only after surgery there are various options for treating pps. this paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts based on an anatomical classification. methods: we adopted the laparoscopic approach in 28 patients who had pps requiring surgical drainage. the laparoscopic method had been decided according to preoperative computed tomography (ct) and intraoperative findings. the results shown represent median (range). the aim of this work was to decrease mortality and morbidity in patients with combined trauma. methods and material: for 5 years 667 patients were brought to our clinic with combined trauma. everybody was performed ct and ultrasound examination. 286 patients were performed open laparatomic operation due to massive liver rupture, spleen rupture and massive trauma of bowels, pancreas and kidney with massive bleeding. in 106 circumstances we didn't found the trauma of the abdominal organs and the massive abdominal bleeding after ct observation. those patients were cured conservatively. in 275 circumstances with combined trauma after ct examination we performed laparoscopic operation. in 97 circumstances from the 275 patients, who we started laparoscopic operation in, we conversed to laparotomy, due to massive liver rupture, and trauma spleen and hollow organs. in those 112 circumstances we performed urgent laparotomies with suture ligation of bleeding points, suturing of liver and hollow organs and drainage of abdomen cavity. results: we performed laparoscopic operation in 178 patients. in 107 circumstances with trauma of liver we performed laparoscopic electro coagulation and argon-plasma coagulation. in 66 circumstances with trauma of liver we performed electro coagulation with packing the omenture to its surface. in 5 circumstances with trauma of spleen we performed argon plasma coagulation and used fibrin glue. after laparotomic operations mortality were in 35 circumstances, morbidity were in 87 patients. after laparoscopic operation mortality were in 5 circumstances of severe combined trauma with multiple abdominal trauma and morbidity in 11 patients. conclusion: laparoscopic operations in patients with combined trauma decrease mortality and morbility. aims: in laparoscopic distal pancreatectomy, getting away liver and stomach from the surface of the pancreas is sometimes difficult. when we separate the pancreatic body from the retroperitoneum, we must not injure the pancreas to prevent breaking a tumor. when we cut the dorsal side of the spleen from the retroperitoneum, we rarely cut into the spleen accidentally. based on our experiences, we gradually explored a set of procedural operation steps to resolve these problems. our three-step maneuver simplifies the procedure and improves the efficiency and safety of laparoscopic distal pancreatectomy. methods: as the first step, to get away the liver we sutured the round ligament of liver and crus of the diaphragm using 3-0 pds and the both ends were tugged form the outside of the body through both side of the xiphoid process. and the stomach was hung from the outside using two nylon thread like a bridge, so we could see the surface of the pancreas body with a good view. the second step was a rolling up maneuver of the pancreas. when we separate the pancreatic body and tail from the retroperitoneum, we rolled the pancreas with gauze for use in laparoscopic surgery and lifted the gauze up in only one assistant's forceps. then we could find the correct line for dissection clearly. the last step was a hanging maneuver of the spleen. when we cut the dorsal side of the spleen from the retroperitoneum, we hanged the hilum of spleen with cotton tape. with this technique we could find easily the correct line to dissect. results: the operation time was 4 h and 7 min and the estimated blood loss was a little. we did not injure the tumor or spleen in this operation. the patient recovered uneventfully after short hospitalization. conclusion: our three-step maneuver can be effective to perform laparoscopic distal pancreatectomy. about 10-20% of patients with pancreatic collections will develop walled off necrosis, with an associated 8-39% mortality. there are multiple options for intervention and drainage, usually the outcomes after endoscopic drainage are related with the nature of the collections. aims: to evaluate and present the rol of endoscopy in pseudocyst and walled off necrosis treatment, and favorable outcomes. methods and results: we present a case of a 48 years old male, who presented biliary pancreatitis treated with cholecystectomy and transoperative cholangiogram 6 weeks ago. he continued with persistent abdominal pain; his ct scan showed a big walled off necrosis; he was taken to surgery for an endoscopy-assisted laparoscopic cystogastrostomy with necrosectomy, he was discharged 14 days po. conclusions: the step-up management of walled off necrosis has proven to be a better option than conventional surgical or endoscopical techniques alone; by reducing complications and mortality vs conventional necrosectomy. the use of endoscopic treatments reduce the pro-inflamatory response. drainage of walled off necrosis can be done by a transpapilar or transmural endoscopic apporach each one with its own advantages. some authors avoid the use of endoscopy in walled off necrosis because of a higher rate of complications, re-interventions and a greater lenght hospital stay. in our experience, we have achieved excellent results with this combined technique. nearest and longpatients underwent chemotherapy after electroporation procedure. 90 day mortality was 4.3% (n = 1) in electroporation group. it was found that erreversible electroporation improved local recurrence-free survival (12 and 6 months, respectively, p = 0.01) and distant recurrence free survival (15 and 8 months, respectively, p = 0.03) . overall survival was 18 and 11 months, respectively (p = 0.03). conclusion: irreversible electroporation of locally advanced pancreatic cancer is safe. four month chemotherapy followed by surgical procedure is associated with good local response and better overall survival compared with chemotherapy alone. these data will be validated in further multicenter study. introduction: pancreatic pseudocysts are the most frequent complication of acute or chronic pancreatitis. usually asymptomatic, they can be managed conservative or, in case of complications, by several methods, endoscopic, percutaneous or by surgery. material and method: we present the case of a 41 years old patient known with an episode of acute pancreatitis five years ago, who was hospitalised now for an upper gastrointestinal bleeding with hematemesis. the upper endoscopy showed a subcardial bulking with an erosion of the posterior gastric wall, with signs of recent bleeding, managed by clipping. patient work-up showed a 12 cm pancreatic pseudocyst at endoscopic ultrasound. taking into consideration the history of the patient, the size and the complication of the cyst, the patient was proposed for a drainage intervention. results: a minimally invasive approach was decided. using ultrasonography guidance, a posterior gastrotomy was performed with the cystotome, establishing the comunication with the pancreatic pseudocyst. dilatation of the path with 8 mm cre baloon, with partial evacuation of turbid liquid. the drainage consisted in 2 pigtail 10 fr plastic stents. the patient was discharged the following day in a good health condition.the endoscopic ultrasound control at 3 weeks showed complete resolution of the pancreatic cyst and was followed by stent removal. the endoscopic drainage of the pancreatic pseudocyst represents the first treatment option as an alternative to the surgical intervention, being minimally invasive, with low risk and fast recovery. clinical case report: a 69-year-old man was admitted to the hospital with a diagnosis of severe acute pancreatitis and multi-organ failure. during the first month patient has in uci and non invasive procedures were attempted: enteral feeding by a nasoduodenal tube was started and antibiotics were administered to control sepsis. on day 30, percutaneous drainage was performed for large retroperitoneal abscess. on 67 days, endoscopic transgastric necrosectomy was performed and the left collection was resolved. due to the multi-organ failure persistence and the evidence of size increase of the right retroperitoneal collection, a vard was decided.the right collection was accessed following the previously pigtail catheter. a 12 mm trocar was placed to create retro-pneumoperitoneum with a pressure between 6-8 mmhg. a trocar of 5 mmhg was placed, purulent content was aspirated and a debridement was performed. irrigation and aspirate was performed with normal saline and povidone-iodine solution. drainage was used to perform washes with physiological saline and urokinase.on 146 days, the ct confirmed collection resolution. on 190 days he was discharged. after 8 months, the patient is in good clinical condition. discussion: drainage of the retroperitoneal abscesses via laparotomy is highly invasive and risky. vard enables radical necrosectomy and drainage less invasively. in this patient, the complete resolution of the right collection is obtained with retroperitoneal debridement without complications. we conclude that careful retroperitoneal necrosectomy is a valid alternative for the management of right collections. aims: in this study we analyze laparoscopic approach for hepatocellular carcinoma in order to clarify iwe can take advantage in some outcomes as complications, postoperative recovery or long-term survival outcomes. methods: a retrospective case consecutive study has been taken analyzing: age, sex, body max index, comorbidity, surgical extension and tumor size. the outcomes analyzed were: operation time, intraoperative blood loss, blood transfusion, postoperative morbidity and mortality, intensive care stay, hospital stay, tumor size, r0 resection, conversion rate, early reintervention, disease-free survival rate, overall survival rate results: in this study 15 patients were analyzed 12 males and 3 females with ages between 54 and 73 years (mean age 62) and diverse comorbidities: arterial high pressure (7/15; 46%), diabetes (2/15; 13,3%) ; dislipemy (5/15; 33,3%) , hepatophaty measured as liver cirrhosis (14/15; 93,3%). all of them underwent laparoscopic liver surgery, in 9 cases non-anatomical resection was performed while in the other 6 a segmentectomy was performed. in 12 cases the laparoscopic was strict, in 3 and assistance incision was needed. operative time was 120-525 min (mean: 282 min). blood loss mean was 1,2 g/dl and only 2 intraoperative transfusion were needed. massive blood loss was reported in 1 case. postoperative medical complications were observed: hepatic failure and renal insufficiency and in 1 case we observed a postoperative hemorrhage that needed an urgent reintervention. the mean of intensive care stay was 1 day and hospital stay was 4.93 days. about oncological outcomes r0 resection was achieve in 9/15 (60%), r1 in 6/15(40%). at 3 years 9/15 cases were free disease, 3 dead by progression of disease and 2 dead by other causes. aim: the purpose of this study is to analyze our initial experience with laparoscopic duodenopancreatic resection. introduction: laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. laparoscopic pancreatoduodenectomy and laparoscopic distal pancreatectomy(ldp) are advocated to improved perioperative outcomes, including decreased blood loss, shorter length of stay, reduced postoperative pain and expedited time to functional recovery. however, the indication to minimally invasive approach for pancreatic surgery is often benign or low grade malignances. material and method. the steps of ldp procedures are similar to the open procedure. we perform destructive part of procedure totally laparoscopically and we prefer to do reconstructive part of procedure using hand-assisted techniques. for the period 2014-2017, we have been perform 76 pd, 24(32%) we have done with laparoscopic approach. 6(31%) of patients were operated totally laparoscopic and 18(69%) of patients were operated by handassisted techniques. results: a significantly higher conversion rate was encountered when lc was done 2-6 weeks after es, as compared to 1 week after ercp. it is estimated that pancreatitis after ercp affects roughly three to 10 percent of patients and many endoscopists quote a post-ercp pancreatitis rate of 3-5%. however, 10-15% is probably a more realistic answer for the majority of ercp endoscopists. wise endoscopists inform their patients that there is a spectrum of post ercp pancreatitis severity, from mild ([ 95% of cases) to severe (1-5% of cases). in mild forms, pancreatitis after ercp may resolve itself. conclusion: endoscopic retrograde cholangiopancreatography is a procedure used to diagnose and treat disorders involving the pancreatic and bile ducts. acute pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography. the assumption is that the duration of the laparoscopic method is longer, but on the other hand the patient have better wound healing and fewer possibility of developing postoperative hernia . the postoperative period is much more simple due to the significantly shorter hospitalization and the faster recovery, and according to patients the level of pain is much smaller as well. however the oncology results are the same. introduction: spiegel hernias are a rare, representing only between 0.1% and 2% of all abdominal wall hernias. due to its location, below the spiegel line, its diagnosis requires a high index of suspicion. the physical examination only detects 50% of the spiegel hernias and, in many occasions, imaging tests are necessary for the diagnosis. goals: our objective is to describe the case of an urgent laparoscopic repair of a case of high grade bowel obstruction secondary to a spiegel hernia. material and methods: we present the case of a 75-year-old male patient with no medical history that comes to the emergency department of our center due to an eight hour evolution of abdominal discomfort associated with nausea without vomiting or other symptoms. the patient was afebrile and hemodynamically stable at all time. on physical examination, the abdomen is soft and depressible, painful on the left flank where a tumor compatible with spiegel's hernia is palpable. in the blood count there is no leukocytosis nor alteration of inflammatory parameters. an abdominal computed tomography (ct) scan was requested from the emergency department which demonstrated a high-grade small bowel obstruction caused by an entrapped loop of distal jejunum conditioned by a left-sided spiegel hernia. given the situation, an informed consent was obtained, and the patient was taken to the operating room for emergency laparoscopic repair. we performed a laparoscopic hernioplasty with ventralpatch mesh between oblique major and transverse and primary closure of defect in continuous suture. after this, the evolution of the patient is favorable, with good oral tolerance and re-establishment of intestinal transit, being able to be discharged 48 h after surgery. the spiegel hernia is a rare entity that requires a high index of suspicion for its diagnosis. despite the limited evidence published in the literature on the laparoscopic repair of incarcerated spiegel hernias, the studies published so far suggest that the laparoscopic repair is a valid alternative to the classic approach when it is performed by a well-trained laparoscopic surgeon. introduction: repair of lateral abdominal wall hernias (both primary and incisional) can be challenging due to the complexity of anatomy, issues with fixation and the low incidence of such cases. a good understanding of abdominal wall and retroperitoneal anatomy, coupled with proficient laparoscopic technique is essential for successful repair via the minimally invasive approach. methods: a retrospective review of a prospectively maintained database was performed to identify patients with lateral abdominal wall hernias who underwent laparoscopic repair from january 2015 to july 2018. results: 11 patients with 12 hernias were identified (6 primary, 6 incisional). mean patient age was 60 (range 22-81) and mean bmi was 27.1 kg/m 2 (range 18. 2-34.6 ). according to ehs classification, the incisional hernia defects were located at subcostal (l1, n = 1), flank (l2, n = 3), iliac (l3, n = 1) and lumbar (l4, n = 1) regions. background: it is commonly admitted that laparoscopic surgery has the advantage of abdominal wall preservation. however, the increased use of laparoscopy has resulted in certain complications specifically associated with the laparoscopic approach, such as trocar-site incisional hernia. until today, it is not finally clarified 'patient-dependent' factors contributing to the occurrence of postoperative hernia after laparoscopic abdominal surgery. methods: between 1996 and 2017, 256 patients were operated due to trocar-site incisional hernia in one surgical centre. 'the patient-depending' factors which caused postoperative trocar site incisional hernia data was collected and retrospectivily analysed. results: port site incisional hernia occurred in 98% (250 patients) after the use of trocars with 10 mm or larger diameter. the presence of metabolic syndrome was the decisive factor in the development of postoperative incisional hernia in 62% (159 patients). in 15% (38 patients) the postoperative hernia occurred on the background of a long cough symptoms caused by chronic obstructive pulmonary diseases. the cause of postoperative hernia in 13% (33 patients) of patients was the condition of lifting a one-time severity or heavy physical work. in 10% (26 patients) of postoperative patients hernia developed due to prolonged constipation of chronic inflammatory colon diseases. conclusions: thus, when the aponeurosis of the trocars is adequately closed, the reason of the occurrence of postoperative hernias was caused by patient-dependent factors which increase intra-abdominal pressure. for this method, small midline incision 3 cm in length 5-6 cm away from hernia orifice was carried out initially. dissection of intraperitoneal adhesion was carried out by sils with sils device. subsequently after closure of initial laparotomy unilateral anterior rectus sheath was incised from the same incision and dissection of retro-rectus space up to preperitoneal space was done under laparoscopic vision. dissecting the other side was carried out by same fashion. initial dissection of linea alba could be done by open surgery from initial incision. further dissection of linea alba, retro-rectus space, and hernia orifice was carried out by sils. defect closure of anterior and posterior rectus sheath using barbed suture was also done by sils and self-grip mesh was inserted. additional trocar to assist retro-rectus dissection, defect closure, and decompression of intraperitoneal cavity was inserted as required. aims: the laparo-endocsopic approach of inguinal hernia contiue to bring many clarifications concerning inter-parieto-peritoneal space of this region through in vivo exploration, obtained by magnification by means of specific optic intrumentation. our study aimed to revalue the in vivo fascias, to establish their embryological correspondences and to reunite the variable nomenclature existing in the classical anatomy of this region. these observations find their applicability in tapp and tep hernia procedures, as the old anatomical descriptions are no longer operative. methods: we have tried to identify the structures that delimit the anatomical regions of retzius and bogros in 20 recording of tapp procedures performed on men, on the right side, for small indirect hernias on patintes with clear view of the structures. additional, a review of literature on this subject has been performed through a search in the detabases according to the following keywords: bogros space, retzius space, preperitoneal approach, urogenital fascia. results: retzius and bogros are the medial and lateral compartments of the inter-parietalperitoneal space, located between the transversal fascia and the parietal peritoneum. these narrow, virtual spaces are best highlighted today with the help of insufflation techniques during laparo-endoscopic procedures. a competent and careful dissection confirms a 'deep and superficial' stratification, highlighting embryonic relics derived from the uro-genital fascia: urinaryprevesical fascia and spermatic fascia. in addition, the real retzius space is located previously and the real bogros space is located behind this strcuture. the confluence area of the two spaces is a critical point of laparo-endoscopic dissection, its non-recognition may 'wander' the dissection. conclusions: literature data in this topic reflects a certain terminological confusion using general terms such as 'preperitoneal tissue' or 'arreolar tissue' to denote what we consider to be the urogenital fascia or its prologations. the data obtained were synthesized in several drawings and diagrams very useful in training surgeons to use tapp / tep techniques. aim: spigelian hernia containing epiploic appendage is really rare entity. in this paper, we present a very rare case of spigelian hernia involving epiploic appendage performed laparoscopic hernia repair. case report: a 60-year-old woman presented to the emergency department with sudden onset abdominal pain in the left lower quadrant. on physical examination, she had a small, palpable tender mass in the left lower abdominal quadrant. temperature and white blood cell count were normal. an inflamed epiploic appendage with an oval shape, a fatty core, and a central thin hyperdense line in the hernia sac was detected on abdominal computed tomography. its intraabdominal relationship with the normal wall of the sigmoid colon was well appreciated (figure 1a, 1b) . diagnostic laparoscopy was performed. (figure 2 ) adhesions between the sac and epiploic appendage are released using sharp dissection. a peritoneal flap is then created (figure 3 ). laparoscopic tapp repair was used without closing the defect (figure 4) . the patient was discharged on 3th days uneventfully. aims: morgagni's hernia is an in infrequent, congenital, anterior or retrosternal diaphragmatic defect. the right side is the most frequently affected, up to 90% of cases. it represents between 2 and 5% of congenital diaphragmatic hernias. in childhood, they usually attend asymptomatically or with respiratory symptoms. up to 5% are diagnosed in adulthood, incidentally or after gastrointestinal obstruction debut. the treatment is surgery, which can be by laparoscopic or open approach.we present a case of laparoscopic approach with intra-abdominal mesh placement of giant morgagni's hernia diagnosed in senile age. methods: 84-year-old woman with a history of advanced alzheimer's dementia, partially dependent in daily life activities and institutionalized who consulted for intermittent episodes of oral diet intolerance associated with vomits of one month of evolution. abdominal examination was anodine. chest radiograph revealed a right lower lung field mass with fluid collected. thoracoabdominal scan showed small bilateral pleural effusion and large, right anterolateral morgagni's hernia, which contains dilated segment of transverse colon and greater omentum . results: laparoscopic approach was performed. hernia was reduced and hernia sac was removed. the defect was repaired with a dual-component (absorbable and non absorbable) mesh anchored with intracorporeal suture. patient recovered and was discharged 4 days after surgery. conclusion: laparoscopic approach for morgagni's hernia reapir is secure and offers the advantages of less post-opertive pain, faster recovery and short postopatory stay. introduction: recently, laparoscopic operations for ileus are increasing. we have undergone laparoscopic operation to adhesive ileus with umbilicar incision at the beginning. the umbilicar incision at the beginning makes it possible to secure the laparoscopic field by peeling the adhesion under direct view, and makes it easy to repair damage to the intestinal tract. surgical procedure: at first, the umbilicus 3-4 cm incision was made and peeled the adhesion as much as possible under direct vision. secondly, ez access was set and inserted one 12 mm port, therefore laparoscopic operation was performed with 2 or 3 pieces of 5 mm ports. when the repair or resection of small intestinal due to damage is necessary, it is pulled out through the ez access. objective: to investigate the possibility of problems of laparoscopic ileus operation to adhesion ileus by umbilicar incision at the beginning. introduction: small bowel obstruction (sbo) during pregnancy is a rare condition with an incidence of 0.001-0.003% and in around 70% of cases it is most caused by adhesions from previous abdominal surgery. other diagnosis, such as, hernias, malignancy, volvulus or intussusception are extremely rare. when sbo occurs in pregnancy, it carries a significant risk to mother and fetus. its diagnosis of can be difficult to make as symptoms are often attributed mistakenly to the pregnancy. goals: a case report of congenital bowel obstruction during the second trimester of pregnancy handled by laparoscopy. material and methods: we report the case of a 38 year old woman with a history of chronic lung disease, pregnant because in vitro fertilization (17 ? 3 weeks) who attended the emergency department with abdominal pain and bloating accompanied by nausea and vomiting for two days. on physical examination she showed a distended, soft, depressible and painful abdomen without peritonism. laboratory tests were normal. a nasogastric tube was placed with generous output fecaloid intestinal contents. abdominal ultrasound by expert radiologists in abdomen showed a moderate amount of free abdominal fluid with normal uterus moderate and sbo to the ileum because of intestinal adhesion. this results were confirmed with an magnetic resonance imaging (mri). results: the patient was operated by laparoscopic approach with three trocars. the main problem was discovered. we founded a congenital adhesion which conditionated the obstructive syndrome. postoperative recovery was uneventful and the patient was discharged 48 h after surgery. conclusion: the non-obstetrical acute abdomen in pregnant patient is a reality that occurs in one of every 500 pregnancies. its diagnosis in more difficult than in nonpregnant patients requiring or high index of suspicion. the laparoscopic approach of acute abdomen during pregnancy is a valid and safe option, even in the early hours after diagnosis of bowel obstruction when it is performed by a well-trained laparoscopic surgeon. aim: intestinal malrotation (im) without midgut volvulus in adults is a rare clinical entity, which is the result of an incomplete rotation of the small bowel during embryogenesis, due to the nonlysis of the ladd bands. these ligaments spread between the duodenum and caecum and do not allow the gastrointestinal tract to take its normal position into the peritoneal cavity. im appears in 1 to 300-500 newborns and is usually asymptomatic. diagnosis is usually made in the first month, and presents with findings of an acute abdomen, small bowel ileus and volvulus. im in adults is a rare entity. most of the times it is asymptomatic, but it can cause chronic abdominal discomfort and constipation. we present the laparoscopic management of an adult patient with intestinal malrotation. methods: our patient, a 22 year old female, presented to the emergency room with a 3-month history of abdominal pain and nausea. all blood tests were normal. an abdominal mri showed intestinal malrotation without volvulus. due to persisting symptoms, she underwent a diagnostic laparoscopy with complete lysis of the ladd bands. the only unusual finding was a slight oedema of the duodenum. results: her symptoms settled postoperatively and she was discharged on the 2 nd postoperative day. since her discharge, she has not developed any similar abdominal pains or complaints. conclusions: symptomatic intestinal malrotation in adults is an unusual clinical entity, but it is definitely one of the differential diagnoses we need to consider in case of chronic abdominal symptoms. the management consists of the division of the ladd bands, and this procedure can be performed safely with laparoscopy. many small intestinal obstructions are due to adhesions after laparotomy, but small bowel obstructions without history of open surgery is relatively few. in diagnostic imaging such as preoperative ct examination, the cause is diagnosed to some extent, but details are sometimes unknown unless operative observation is actually made. in many institutions, laparoscopic surgery is also actively introduced into the operation to relieve bowel obstruction, and its effectiveness is beginning to be recognized. we examined the usefulness of laparoscopic surgery for patients with small bowel obstruction without history of laparotomy from experience in our hospital. aim: from december 2000 to october 2018, we searched cases of laparoscopic surgery for a small bowel obstruction without previous laparotomy at our hospital, and clinical findings, surgical results, and postoperative course were examined. results: there were ten cases. eight men and two women. the median age was 57 years (15-90 yrs.) . reasons for intestinal obstruction were adhesions 5 cases, internal hernia 3 cases, persimmon stones 1 case, small intestine tumor 1 case. four cases of adhesions were emergency surgery. there were 7 cases of emergency surgery and 3 waiting surgery. five laparoscopic operations were completed and five cases during laparotomy transition. the median surgical operation time was 103 min (75-302 min), and the median bleeding amount was 10 g (5-230 g). there was no fatal case after operation, only one complications of ileus. the median length of hospital stay was 14 days (10-29 days) . conclusion: laparoscopic surgery for intestinal obstruction with no history of laparotomy was thought to be a safe and effective procedure. although the transition to laparotomy would be higher in case of emergency, but there was no case of large incisional laparotomy. conclusions: laparoscopic surgery for sbo reduces postoperative complications and contributes to shortening the postoperative hospital stay and to decreasing the rate of recurrences, although it is a retrospective study, which is a safe and a useful approach. furthermore, first episode of sbo without previous operation seems to be an appropriate indication for laparoscopic surgery. background: postoperative adhesion after abdominal surgery may cause intestinal obstruction, chronic pain, or female infertility, which constitutes the major problems after surgery. adhesion formation are reported to be reduced by laparoscopic surgery and the use of anti-adhesion barriers. seprafilm composed of sodium hyaluronate carboxymethylcellulose bioresorbable membrane has been widely used to date, especially in open surgery. the characteristics of seprafilm, which is easily stick when wet, conversely brittle when dry cause it difficult to deliver into the abdominal cavity via the small incision in laparoscopic surgery. therefore, seprafilm is not much used in laparoscopic surgery. although various methods of insertion of seprafilm have been reported, some need special devices, or some acquire skill. methods: we adopted the pre-moistening technique for the replacement of seprafilm in 210 consecutive cases of laparoscopic gastrointestinal surgery. a sheet of seprafilm was cut into 4 equal pieces. to soften the sheets, one of the pieces was placed on a folded wet gauze until it became naturally curled then it was reversed, and the same procedure was repeated. softened sheet is easily to deliver into the abdominal cavity via a small incision by pushing with digital finger. moistened sheet expands naturally in the abdominal cavity. one or two pieces were needed to cover the incision. this process took only a few minutes. results: in all cases, the sheets were successfully introduced into the abdomen and spread widely enough to cover the incision. there have been no adverse effects, no postoperative complications, or gastrointestinal obstruction due to adhesion in the observation period of median two years. conclusions: short term outcomes were good after applying this technique. however, to record the incidents of intestinal obstruction and chronic pain, over 10 years observation is indispensable. long term follow-up studies are required to clarify the usefulness of the anti-adhesive barrier in gastrointestinal surgery. b. east, 3rd department of surgery, motol faculty hospital, prague, czech republic aim: since 1994 when the ipom acronym was used for the first time our views at intraperitoneal mesh positioning has changed several times. despite growing evidence on its possible long term consequences it is still preferred method at some centres for large number of patients. the aim of this study is to point out the pitfalls of this method but also show that ipom is a good technique but only for highly selected cohort of patients. methods: this is a review of the literature focusing on the indications and complications of ipom pointing out controversies among the published articles over last two decades. some mesh material characteristics are being discussed as they are basic for understanding this complex and highly sensitive issue. results: a wide range on indications of ipom from little umbilical to large incisional hernias is advocated by many. however, some opinion leaders promoting this technique as universal and ideal for everyone just few years ago are advising to avoid it if possible lately. a necessary overlap has also been questioned recently. despite improving anti-adhesion barriers and methods of fixation in may 2017 a surgical mesh has become classified as risk class iii by the eu parliament and council on medical devices hoping to prevent physiomesh like incidents in the future. the need for post market registries and long term follow up is obvious. conclusion: us as surgeons implant a mesh in our patients and therefore we should be aware of its possible long term effects. no mesh on the market has a long term safety evidence especially in the intraperitoneal space. ipom is a good technique but possess a significant risk of long life complications and therefore should be spared only for those unfit for other methods of repair, patients with too high mesh infection risk, obese or older patients. introduction: acute appendicitis in elderly patients is relatively uncommon and could represent an underlying neoplasm. hence patients over the age of 40 are often referred for a follow-up colonoscopy after management of acute appendicitis. the current routine use of computed tomography (ct) scans in the evaluation of suspected acute appendicitis in elderly patients prior to surgery coupled with intra-operative findings at laparoscopy question the role of follow-up colonoscopy for these patients. aims: to determine the role and optimal timing of colonoscopy in early detection of colorectal neoplasia after treatment of acute appendicitis in elderly patients. methods: all patients aged 40 years and above with confirmed appendicitis admitted to our hospital during the period 1/1/15 to 30/9/17were included. follow-up colonoscopy, diagnosis of colorectal neoplasia and its location in this patient cohort was evaluated. results: number of people aged 40 and above in olol who had appendectomies from the dates 1/1/15 to 30/9/17 = 184. out of them 44/184 (24%) had full colonoscopy within 2 years of the appendectomy.of them 25 of the 44 colonoscopies done were maleand 19 were females. 30/44 (68%) of these colonoscopies were completely normal.1 colonoscopy identified colorectal carcinoma in ascending colon (2.3%). other pathologies identified included: benign polyp 3 (7%), polyp with low grade dysplasia 4 (9%) and others 6 (13.6%) (lymphocytic colitis, ulcerative colitis, medication related ulceration, diverticulosis, melanosis coli, haemorrhoids). conclusions: in elderly patients above 40 years of age: there may be an increased risk of colorectal cancer after acute appendicitis. only 24% of this patient cohort underwent colonoscopy after appendectomy. the current recommendations suggest the need for follow-up colonoscopy in elderly patients post acute appendicitis. further studies are needed to decide whether routine colonoscopy is indicated after acute appendicitis patients over 40 years. introduction: it is generally accepted that the main aetiology of appendicitis is obstruction due to appendicoliths in adults and lymphoid hyperplasia in children. in contrast, incidental appendicoliths have been reported to occur in up to 32% of the asymptomatic population. controversy still exists regarding the association of appendicolith and appendicitis. is the appendicolith a causative factor or merely an incidental finding? aims: to determine the association between the presence of appendicolith and acute appendicitis (perforated or non-perforated) vs healthy appendix. methods: we collected the data retrospectively from the electronic records of all appendicectomies performed between january 2012 and december 2016 in our institution. data collected included: age, sex, appendix histology and the presence of appendicolith. interval or incidental appendicectomies were excluded from this study. we analysed the data using spss software version 2010. results: during the study period 2348 appendectomies were performed (males: 1137, females: 1211, age range: 2-89 years). 1794 cases were histologically confirmed cases of acute appendicitis and of these, 61 were perforated. a normal appendix was identified in 288 cases. the remaining 266 cases were due to chronic appendicitis, sub-acute appendicitis, lymphoid hyperplasia, parasitic infestation, and neoplasm. appendicolith was found in 43 cases, of which 33 were found in a normal appendix and 10 were found in an inflamed appendix. out of the 33 cases of appendicolith with normal appendix: 23 cases were aged between 1 and 20 years old, 9 cases were aged between 21 and 40 years old and 1 case was aged between 40 and 60 years old. out of 10 cases of appendicolith with acute appendicitis, 7 cases were aged between 1 and 20 years old, 2 cases were aged between 21 and 40 years old and 1 case was aged over 41. conclusions: appendicolith may merely be an incidental finding and is not the primary cause of appendicitis. no significant correlation between gangrenous/perforated appendicitis and the presence of appendicolith. contrary to popular belief appendicoliths are more common in paediatric appendicitis than in adult cases. further research is recommended. over the last 20 years, patient satisfaction surveys have gained increased popularity. nowadays, respect for patients' needs is central to our health care system. hospitals use patient satisfaction surveys to assess quality of care. many hospitals routinely survey patient satisfaction but relatively little data has been published. our acute surgical assessment unit operates from 8am to 6 pm monday to friday and in its first year saw 2079 surgical patients, of whom 1308 were discharged and 771 were admitted to the hospital for further management. aims: to assess the levels of satisfaction of patients attending asau at our lady of lourdes hospital. methods: a random sample of patients seen in the asau was surveyed to determine their level of satisfaction and the experience they had whilst attending asau. a novel self-reported patient satisfaction questionnaire was developed and used to assess patients' opinion regarding the treatment they received, the doctor's explanation of their condition, the waiting time and the service in asau. also the questionnaire encouraged patients to suggest improvements to the service. aim: sintestinal obstruction is a very common cause of presentation to an emergency department. the most common cause in patients with prior abdominal surgery are adhesions, but the list of differential diagnosis is large. internal hernia is a very rare cause of obstruction, with a reported incidence of between 0.2 and 0.9%. the herniation related with broad ligament defects is even more uncommon. methods: we report the case of a 63-years-old woman with antecedents of liver transplant, tubal ligation and appendectomy. the patient was admitted refering abdominal pain in the epigastrium of 24 h duration, accompanied by nausea and vomiting. on physical examination, abdomen was depressible, tender in the right low quadrant, without evidence of peritoneal irritation. laboratory studies were normal except for an elevated leukocyte count with a left shift. computed tomography (ct) revealed dilated small bowel loops with a transition point in right lower quadrant. radiological diagnosis was intestinal obstruction, with fibrous adhesion as the most probably aetiology. management was conservative at the beginning, with intravenous hydration, nasogastric tube and administration of gastrografin (diatrizoate) without a good response. results: at 24 h, an exploratory laparoscopy was perform, finding dilatation of small bowel loops and a 3 cm defect in the right broad ligament in which a segment of ileum was herniated. ileal segment was liberated without evidence of ischemia. the hernial defect was closed by laparoscopy with simple silk stitches. the postoperative course was excellent, tolerating oral feeding next morning. the patient was discharged 72 h after surgery. conclusions: internal hernias of the broad ligament are an extremely rare cause of intestinal obstruction, but must be added to the differential diagnosis for female patients due to the risk of intestinal strangulation and perforation. even if clinical and radiological diagnose is difficult, ct is the best tool to delineate the cause and location of the obstruction. laparoscopy allows reduction of the hernia and closure of the defect with minimal invasiveness. because of that, the laparoscopic approach of bowel obstruction should be considered as the first choice if there is the suspicion of an internal hernia, without signs of necrosis or perforation. the laparoscopic approach is a safe and effective tool in the management of postoperative complications. it is well tolerated in critically ill patients and avoids respiratory and wound related morbidity associated with laparotomy. it also reduces diagnostic delay and a considerable number of unnecessary laparotomies, with a high resolution rate and minimal morbidity. it thus represents a valid and necessary alternative in surgeon's armamentarium. in the management algorithm of our institution we always choose the laparoscopic technique as the fisrt tool in case a reoperation is necessary. , small bowel obstruction (11.20% vs 9.09%), and colorectal cancer obstruction (9.09% vs 8.23%) was found higher for acs unit group, and also progressively higher during the last years. conclusion: according to our study, laparoscopic approach in abdominal emergencies shows an upward trend, and surgeons from acs units seem to have higher rates of laparoscopy than general surgeons in emergency procedures. background: incarcerated and strangulated hernias present a major problem in emergency medicine. there is scarce data about the role of laparoscopy in the management of these patients. laparoscopic repair offers the benefits of the ability to survey the incarcerated organ and to evaluate its viability, apart from the obvious advantages of laparoscopic surgery. the use of mesh repair in these emergent operations is also a major concern, due to the un-sterile conditions in which they are performed. objective: to evaluate the safety and short-term efficacy of laparoscopic emergent repair of incarcerated hernias. methods: retrospective review of prospectively collected data of all the patients who underwent emergent laparoscopy due to an incarcerated hernia between november 2017 and october 2018. results: during the study period, 13 patients underwent emergent laparoscopy due to incarcerated hernias (5 females, 8 males). 10 had incarcerated inguinal hernias, and 3 had incarcerated umbilical hernias. mean age was 63.3. all inguinal hernias were repaired in the tapp approach, and using an absorbable mesh. all umbilical hernias were repaired using the ipom approach. 7 patients had bowel obstruction, 5 had incarcerated omentum, and one patient had incarcerated urinary bladder. 3 patients underwent resection of an ischemic organ (1 bowel, 1 urinary bladder, 1 omentum). mean hospital los was 2.6 days. during the follow up period there were no mortalities, and no recurrences. one patient had a wound infection that resolved with antibiotics. conclusion: laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach. further studies with longer follow up time need to be conducted, in order to evaluate the added benefit of the laparoscopic approach. gibraltar is a small overseas british territory with a residential population of approximately 30,000 inhabitants, that increases up to 50,000 daily due to incoming tourists and cross-frontier workers. as a geographically isolated center we have to provide a varied service including emergency surgery, and elective operating such as colectomies, gastrectomy's etc. one of the challenges faced is the limited stock of red blood cell (rbc) units within gibraltar and reliance on platelets (plt) from across the border from spain. given the immanent brexit we need to prepare for the challenges we will face in these times of political and distribution uncertainty. a prospective audit of all blood use within gibraltar was carried out over 4 months. the number and type of units requested, the number of units given, the speciality, location and indication for requests was recorded. introduction: the use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. the advantages with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer complications. we have collected the cases and indications of laparoscopy in abdominal trauma in the main hospitals in the andalusian capitals and compared with the national registry material and methods: a total of 25 patients who underwent laparoscopic surgery in the main hospitals of seville, cordoba, malaga, cadiz, huelva, jaen, granada and almeria were analyzed. they have been compared with the 567 traumas archived nationally by the spanish association of surgeons taking into account age, sex, score of the american society of anesthesiologists, hemodynamic stability and mechanism of injury. the intra and postoperative variables were compared between groups. results: at the national level, the main cause of abdominal trauma were traffic accidents, therefore, it was the patients who had a greater number of laparoscopies (35.3%), followed by stab wounds (9, 03%) and run over (11.2%). in our series, the average age of the patients is 41 years and 68% are male. only eco-fast was performed in 45% of the patients, being positive in 15.9% of the cases. as they were stable patients, in 95% of the cases a tac was possible. in our data, 60% of the laparoscopies were performed for therapeutic purposes as well as being diagnostic, thus avoiding a posterior laparotomy. conclusion: slaparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. we found that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss and faster return to normal diet. based on our findings we establish the indications of laparoscopy in these patients aims: submucosal aneurysm of small intestine is extremely rare, but its rapture can be lifethreatening. due to the unstable hemodynamics and unknown site of bleeding, emergency laparotomy has been widely performed for the rupture. we will present case reports and show the strategy for minimally invasive treatment for ruptured aneurysm. methods: we experienced two cases of ruptured submucosal aneurysm resected by laparoscopic surgery. case 1 is a 16-year-old male who was taken to our er with massive hematochezia. ct showed arterial bleeding in the small intestine and angiography revealed bleeding from the ilial artery. selective embolization using gelatin sponge and micro coil was performed and hemostasis was obtained. video capsule endoscopy found the hemispheric elevated lesion with protrusion at the top in the ileum. using balloon assisted enteroscopy, the site of aneurysm was marked with injecting india ink, which allows surgeons to accurately and easily identify the part of small intestine with aneurysm. subsequently, a single incisional laparoscopic assisted partial ileectomy was performed for the purpose of definitive diagnosis and preventing re-bleeding. the ileum with aneurysm was easily identified in laparoscopic exploration owing to the marking, and it was taken out from the incision to perform resection. case 2 is a 21-year-old female who was transferred to our emergency department with sudden onset of massive melena. ct and angiography were perfomed, and bleeding from the 3 rd jejunal artery were confirmed. subsequently, therapeutic embolization was performed in the same way as case 1. enteroscopy revealed submucosal elevation similar to case1 in the jejunum. we carried out endoscopic tattooing, followed by single incisional laparoscopic assisted partial jejunectomy. results: the operative time in case 1 and case 2 were 130 min and 68 min, respectively, and the amount of blood loss was both 5 ml. the postoperative course was uneventful in both cases. case 1 was discharged on the postoperative day 7, and case 2 was on postoperative day 6. conclusions: our experience indicates that ruptured submucosal aneurysm of the small intestine can be effectively managed by a laparoscopic surgery with combination of therapeutic embolization and enteroscopic evaluation, which is safe and minimally invasive. background: laparoscopic bilateral inguinal hernia repair may be completed with one large selffixating mesh crossing the midline in front of the bladder. no studies have investigated in detail whether preperitoneal mesh placement induces temporary or more lasting urinary symptoms. methods: urinary and hernia related symptoms were evaluated preoperatively and postoperatively at 1, 3 and 12 months in 100 patients using the iciq-mluts questionnaire and eurahs-qol score. results: voiding symptoms and bother scores were unchanged at 1 or 3 months, but there was significant improvement at 12 months compared with preoperative findings (symptoms p \ 0.001; bother score p \ 0.01). incontinence symptoms improved at 1 month (p \ 0.05) but not at 3 or 12 months, with a bother score significantly improved at 1 month (p \ 0.01) and 12 months (p \ 0.01). diurnal and nocturnal frequency did not change significantly postoperatively, but 12 months nocturnal bother score was decreased (p \ 0.05). eurahs-qol scores showed significant improvement in all 3 domains for all measurements compared to previous measurements. postoperative symptoms were improved at 12 months, compared with preoperative pain scores (-6.1), restriction of activity (-10.1) and cosmetic scores (-4.7) these findings were statistically significantly (p \ 0.001). at 12 months, there were no patients with severe discomfort (score = 5) for any of 3 domains. no recurrences were diagnosed with 95% clinical follow-up at 12 months. conclusion: placing a large preperitoneal self-fixating mesh for bilateral groin hernia repair did not cause new urinary symptoms and demonstrated significant improvement in voiding symptoms at 12 months. incontinence and nocturnal bother score were significantly improved. introduction: tep/tapp hernia repair is an increasingly widely used surgical methods for minimally invasive treatment of inguinal hernia. tep advantages to tapp are noincision of the parietal peritoneal sheet, therefore no need for its recovery-sewing or sticking at the end of the procedure, and no need for attachment of the prosthetic mesh to the structures of the anterior abdominal wall, which results in a reduction in the financial cost of operation.various types of meshes with different characteristics are used, depending on the surgeon's preferences.the aim of this study is to highlight mesh-related postoperative complications, which can be serious and life-threatening. material and methods: a retrospective cohort study of 68 cases of unilateral or bilateral tep and tapp hernia repair performed at the university hospital for the period 2016-2018 with a study of early and late postoperative complications potentially causally related to the implanted prosthetic mesh and methods of their treatment. results: for a 3-year period 22 tapp (12 bilateral) and 46 tep (33 bilateral) have been performed. three complications (clavien-dindo iva, ivb and v) were found, of which 2 were early postoperative (up to 20 pod)-one in tapp-5pod small bowel adhesive ileus due to suture dehyscense of the peritoneal sheet and adhesion of a bowel loop to the surface of polypropylene mesh.one in tep-2pod-a large preperitoneal hematoma with haemorrhagic shock at 86 years old female in anticoagulant therapy-an open revision of the preperitoneal space and definitive haemostasis; followed in 12 pod established bladder lesion from erosion from the edge of self-locking polypropylene mesh. suture and drainage performed, but the patient died of decompensation of concomitant diseases. a late complication-11 months after bilateral tep-erosion of soft polypropylene mesh of sigma (probable undetectable lesion of the peritoneum) with faecal peritonitis-hartmann procedure with laparostoma followed by restitution but persistent chroniosepsis with established abscess in retzii. 24 months after-revision with abscess incision and extraction of infected meshes. discussion: use of biologic meshes is quite expensive, however synthetic non-resorbable meshes implanted in preperitoneal layout is a prerequisite for specific severe postoperative complications. inguinal hernia repair is one of the most performed procedure all over the world, with more than 20 million procedures performed each year, it represents one of the top three most performed procedures. the lichtenstein procedure is one of the first procedures that a young trainee in general surgery learn, not only for its reproducibility and for the great numbers of procedures that could be done in each department, but also because during inguinal hernia repair the trainee learn a lot of skills which are the basis of major surgical interventions. the surgeon's performance for any procedure could be evaluated by way of established learning curves that can predict the minimum number of procedures required to reach the same intra and post-operative outcomes as an experienced surgeon performing the same technique. the aim of our multicentre study was to analyse how many cases are required to stabilize operating time (ot) and intra and post-operative complication rates over the course of the learning curve period for a lichtenstein procedure. from january 2014 to december 2018 all lichtenstein procedures from four different institutions were recorded in a prospective maintained computer database. the results of the first 100 consecutive procedures performed by three different trainees (group a; group b; group c) were compared with the same numbers of procedures by two senior surgeons of the same institutions (group e, group f). cusum analysis was performed to evaluate the achieving of learning curve. no differences in terms of biometric and hernia type were recorded between the five groups. cusum analysis showed that the trainees achieve the learning curve between the 37-41 procedures. no intra or post-opertive complications were recorded during the training period.in conclusion after our analysis we found that at least 40 procedures are needed for the trainees to achieve the learning curve for lichtenstein procedures. background: since its first description in the 1990 s, the total extraperitoneal (tep) technique has established itself as a popular endoscopic method for the repair of inguinal hernias. the tep repair is generally viewed as a technically-demanding procedure requiring adequate experience to minimize and handle complications. in this case report, we describe an uncommon complication of urethral injury, which was successfully repaired laparoscopically. case report: mr r is a 25 year old gentleman with no significant past medical history who presents to the department of general surgery, tan tock seng hospital, with a two-month history of a reducible right inguinal hernia, associated with some tenderness. an ultrasonography confirmed the diagnosis of a fat-containing indirect right inguinal hernia. in view of persistent pain, mr r was counseled for a laparoscopic repair of his right inguinal hernia. as mr r was able to empty his bladder just prior to surgery, no urinary indwelling catheter (idc) was inserted. an infra-umbilical incision was made to access the posterior rectus sheath and a balloon was used to bluntly dissect the pre-peritoneal plane. on inspection of the operating field, persistent pooling of blood was noted in the retropubic space. careful inspection revealed a defect in a tubular structure just inferior to the bladder neck. an idc was inserted, which confirmed a 1.5 cm defect in the pre-prostatic urethra. decision was made for primary repair using absorbable sutures in two layers. the bladder was subsequently filled via the idc, which did not reveal any leak. we then completed the right inguinal hernia repair using a mesh. mr r made an uneventful recovery and was discharged on post-operative day 1 with instructions to keep the idc in-situ for two weeks. the idc was removed after two weeks and a micturating cystourethrogram was performed, which showed no filling defects along the urethra and no contrast leaks. discussion: though uncommon, urethral injuries can be a complication of laparoscopic tep repair. the key to managing these complications is in the early identification of such injuries intra-operatively. with early recognition and careful assessment, such complications can be managed laparoscopically with minimal post-operative morbidity. aim: the purpose of this study is to report surgical technique and outcome of hybrid tapp procedure (a combination of tapp and ipom) for inguinal hernia patients complicated with preperitoneal space adhesion. methods: hybrid tapp procedure is applied if peritoneal dissection or closure of the peritoneum is difficult due to severe adhesion. the peritoneum should be dissected as much as possible. for the site where adequate dissection was achieved, the collagen mesh is placed outside the peritoneum. in the part where dissection was difficult it is placed inside the peritoneal cavity. in order to prevent mesh migration, the mesh should be directly fixed to the cooper's ligament with a tacker. for this purpose, the peritoneum around the cooper's ligament must be well-dissected, even if it is strongly adhered, so that the ligament can be exposed. the crucial points in the hybrid tapp procedure are fixation of the mesh and prevention of the bowel herniation into the preperitoneal space. at the site where peritoneal dissection is possible, the mesh is directly fixed on the fascia using a tacker. if it is difficult, the mesh is placed in the peritoneal cavity and fixed over the peritoneum. if there is a risk of migration along with peritoneum, transcutaneous full-thickness fixation can be performed using non-absorbable sutures. the preperitoneal space should be closed tightly as soon as possible in order to prevent the bowel herniation into the preperitoneal space. at closure of the preperitoneal space, the peritoneum is fixed on the collagen mesh using non-absorbable sutures. objective: show a tapp approach using a self-fixating mesh(15x10 cm. progrip tm laparoscopic self-fixating mesh, medtronic) with bipolar peritoneal defect sealing, avoiding the use of tackers and performing an easy and sutureless peritoneal closure. material and methods: 62 years old male, asa ii, medical history of beta-latacm allergy, high blood pressure, dyslipidemia and bilateral knee surgery. diagnosed of bilateral inguinal hernia at consultation due to inguinal disconfort. surgical site infection prophylaxis with iv vancomycin. balanced general anesthesia. supine decubitus position with shoulder supporting to allow a forced trendelemburg. 30 degree optical device with 3 trocars disposition: one 11 mm umbilical trocar and 2 5 mm trocar in both flanks, same distance and height to umbilical trocar. peritoneal opening and flap creation with monopolar energy, blunt maneuvers and pneumoperitoneum dissection. anatomical landmarks identification(cooper's ligament, epigastric and iliac vessels, hernia defect and spermatic cord elements). reduction of hernia sac content(pseudosac in this case, direct hernia) and complete peritoneal dissection to achive a correct mesh placing. mesh is folded in 3 parts(one inferior part, two superior parts) in vertical axis outside the abdomen to facilitate the posterior intraabdominal maneuvers. introduction: into abdominal cavity with grasping forceps and correct unfolding mesh assesment: medially(pubic bone), caudal(cooper's ligament) cranial(more than 5 cm of hernia defect/ deep inguinal ring) and lateral(anterior superior iliac spine). finally, we use a bipolar forceps to close de peritoneal defect. in order to facilitate this step, its necessary to decrease pneumoperitoneum pressure and to use the grasping forceps to bring together both peritoneal flap edges prior to bipolar energy sealing. results: 60 min. surgical procedure. 24 h hospital discharge, no complications. routine outpatient follow up(week, month, 3 months and 6 month later) with an epididymitis episode 2 months after surgery(treated with oral ciprofloxacin). conclusions:-this procedure is an easy implementation technique once the intraabdominal mesh unfolding procedure control is reached.-the use of a self-fixating mesh avoid the use of tackers and its potential disadvantages(e.g. increasing postoperative pain).-bipolar peritoneal sealing offers a quick, easy, cheap and safe peritoneal closure, avoiding the contact of the mesh with the viscera in the same manner. results: we performed 53 procedures within 42 patients. the average age was 54 years. twenty six percent of hernias were bilateral, 11,3% were inguinoscrotal and 56% in the right side. the median asa score was 1. the conversion rate was 3,7%. the average duration of the procedure was 88,21 min 34 min. overall morbidity was 19%. there were 5 seromas (9,4%) . on 2-year follow-up, one recurrence (1,8%) was found and chronic postoperative pain in one case . we had no mortality. in the univariate analysis, male sex, inguinoscrotal hernias, hernias classified as nyhus 3a were significantly associated with overall postoperative morbidity. a chronic obstructive pulmonary disease was the only variable significantly associated with the occurrence of medical complications. conclusion: given these results, the tapp technique is a good alternative in the treatment of groin hernias. however, enhancing this approach is essential to reduce the operating time and the postoperative outcomes. introduction: studies have emphasized the impact of a strong safety culture on patient outcomes. consequently, many interventions focus on improving the safety culture, of which teamwork and safety climate are important ingredients. it is known that differences in culture and safety attitudes may also impact teamwork. implementations of safety interventions, such as a ' black box', are dependent upon these differences. the aim of this study was to assess the safety culture at the operating theatre complex, along with the theatre staff's attitude towards a specific quality improvement intervention, a black box in the operating room as a tool for structured team debriefing. methods: the validated dutch version of the hospital survey on patient safety culture was administered to all healthcare professionals working in the operating room complex at one academic medical centre. this survey was supplemented with 10 questions regarding the use of a 'black box', a medical data recorder in the operating room, to measure the staff's attitude towards this quality improvement tool and its potential contribution to patient safety. aims: the aim of the study was to compare two methods of treatment of dunbar syndrome: thelaparoscopic release of median arcuate ligament alone and the hybrid method consisting ofsurgery and percutaneous stent implantation to celiac trunk. methods: we performed 6 laparoscopic release of ct in the department of general, mini-mallyinvasive and elderly surgery in olsztyn in 2016-2018. all of patients suffered from severepain of abdominal cavity before the surgery. three patients underwent doppler percutaneousangioplasty of the ct with stent implantation one month after the laparoscopy. results: all patients reported relief of symptoms in the first days after the operation. in two cases fromboth groups, there were a complete remission of the symptoms. in one case respectively,there was an improvement. there were no postoperative complications. the results of both methods do not show the differences therefore the surgery alone seems tobe a safe and feasible procedure. it increases the comfort of the patient and brings theopportunity for normal functioning. the method of wedge resection of lungs in patients with limited forms of chemo-resistant pulmonary tuberculosis is developed. in order to evaluate the efficacy, 80 patients underwent surgery (the main group). for comparison, the data on similar operations in 100 patients, made according to the traditional method (with the help of a cardboard weaving machine yo-60) were selected. compared the duration of the stage of resection itself, the frequency of need for additional hemostasis of the parenchyma sutures, the degree of deformation of the pulmonary tissue in the seam area, the frequency of postoperative complications and reoperations, the duration of postoperative inpatient treatment. the developed method, in comparison with the traditional one, has the following advantages: simultaneously leak proofness and hemostasis with minimal electrothermal damage to tissues are provided and there is no need for additional hemostasis, there are no negative effects of manual stitching of parenchyma of lung with abandonment of foreign material, a significant reduction in the duration of wedge resection of the lung from 27.5 to 9.2 min, a decrease in the number of postoperative pulmonary-pleural complications is achieved by 96.4% and caused by them reoperations-by 99.1%, shortening the duration of postoperative inpatient period of treatment from 20.7 to 14.5 days. introduction/aims: laparoscopy is a diagnostic and therapeutic resource that is largely used in elective gastrointestinal surgery due to its well-known advantages over the classic open approach. nevertheless, there is still some discussion about its application in emergency surgery. our aim is to analize the use of the laparoscopic approach by the members of the surgical emergency unit from our medical center. methods: a descriptive research based on the data of 12920 patients who required emergency surgery, that was performed by the members of the surgical emergency unit of a spanish hospital between november 2000 and may 2018, was conducted. these data were analyzed according the pathology that motivated the surgical procedure and the chosen form of surgical approach (open versus laparoscopic). results: out of the 12920 patients in whom emergency surgery was performed, 9712 suffered from a pathology that actually allowed the laparoscopic treatment. laparoscopy was used in 38.8% of these patients. according to pathology, the most common were acute appendicitis and cholecystitis, in which the laparoscopic approach was used, respectively, in 56% and 62% of the cases. regarding other less frequent pathologies, such as gastroduodenal perforation, bowel obstruction, diverticulitis and pancreatitis, laparoscopy had a less significant role. according to the year, a general tendency to increase the use of the laparoscopic approach was found, most notably in the cases of acute appendicitis and cholecystitis (with rates above 90% in 2018). conclusions: despite our positive results in the terms of the implementation of the laparoscopic approach in emergency surgery, there is still room for improvement, especially in regards of the less common pathologies. furtheremore, additional studies are needed in order to identify the factors that have had an effect, in favour or detriment, in the development of emergency laparoscopy in our center. aims: laparoscopic surgery, which produces small scars, has become widespread. when performing surgery through small laparoscopic incisions, a surgeon manipulates tools inserted into the abdomen through ports. for minimally invasive accurate procedure, the port as the pivot point should be stabilized on the abdominal wall. however, these laparoscopic incisions are loaded while manipulation because it is difficult for the port to be fixed on. thus, it is necessary for the patient friendly manipulation to be fixed the port mechanically. we developed a new pivot restraint device (prd) attached to a trocar for guiding the tool. the purpose of this study is to evaluate both of reducing the operating time and the load of the port with the prd experimentally. methods: the prd uses gimbal mechanism for two rotating axes and a linear guide mechanism for the insertion axis though into the forceps. in the experiment, the left hand forceps with or without the prd and the right hand forceps without the prd were set on the training box. the box had a measuring system created with a pressure sensitive sensor for the continuous force (resolution 0.1 n, 30fps) applied to abdominal wall fulcrum. the experiment task was performed as following three steps. (1) the surgeon lifted the 225 g weight for 5 s at the initial position using the right hand forceps. (2) the weight was transferred from the right hand forceps to the left hand forceps, and held for 5 s. (3) the weight was moved to the predetermined position, held for 5 s, and returned to the initial position. the surgeons were five endoscopic specialists and five non-specialists. the operating time and the time ratio exceeded 1 n for the left hand forceps were measured. two grouped datasets with or without the prd were compared using two-sided t-test. results: the prd was associated with both of reducing the operating time (33.2 s vs. 38.2 s; p \ 0.01), and the load of the port (13.3% vs. 58.0%; p \ 0.01) at the statistical analysis. conclusion: the prd could be used for reducing the operating time and the load of the port in minimally invasive accurate procedure. background: pathophysiological changes during laparoscopic surgery and positive pressure pneumoperitoneum (pp) may include (beside cardiovascular changes) elevated intra-thoracic as well as intracranial pressures. however, the possibility of physiological and functional cerebral impairment under pp is still debated. aim: to study the effects of pp on brain activity during different modes of anesthesia and ventilation during laparoscopic cholecystectomy (lc). patients and methods: thirty patients undergoing elective lc were divided to those who were ventilated by intermittent positive pressure ventilation (ippv, 16 pt.) and by high frequency jet ventilation (hfjv, 16 pt.). in those under hfjv we used total intravenous anesthesia (tiva). in those under ippv we either used inhalational anesthesia or tiva. intra-ocular pressures were detected in both eyes, trans-cranial doppler was used to measure the changes in flow of the middle cerebral artery, and cerebral oxygenation (o2 saturation) was measured too. each parameter was detected during anesthesia before surgery, several times during surgery under pp and after co2 evacuation. a novel computerized signal analysis by a continuous recording through a single electrode was done to explore cerebral cognitive activity during surgery. results: all surgeries went uneventful and without complications, pp was set to 14 mmhg, and each patient was positioned in a 15 degree anti-trendelenburg posture. cerebral perfusion and oxygenation were not changed significantly during pp. intra-ocular pressures decreased during anesthesia and increased during pp, but to a lesser extent under tiva. however, pressures during pp did not exceed pre-surgical values. we did not observe changes in cognitive brain activity during pp, although enhanced cerebral activity was seen under hfjv. conclusions: increased intra-abdominal pressure during laparoscopic surgery was not accompanied by decreased cerebral functions, maybe due to cerebral circulatory auto-regulation. changes in cerebral cognitive functions under hfjv might be explained either by the different cerebral effects of tiva in comparison to inhalational anesthesia, or due to dissimilar hemodynamic changes during hfjv. aims: gallstone ileus (gi) is a rare complication of cholelithiasis and accounts for 0.1-5% of small bowel obstructions. intermittent and non-specific presentation often results in late diagnosis. the triad of rigler is pathognomonic (pneumobilia, small bowel obstruction and ectopic gallstones), so an image test is usually mandatory in order to assure the diagnose. our aim is to expose our experience regarding this topic to show that a minimally invasive approach is feasible in selected cases. methods: since january 2016 we treated 12 cases of gi, 5 of whom (42%) underwent laparoscopic surgery. in all cases a ct was made to reach diagnosis. enterolithotomy alone is our preferred procedure for the resolution of this pathology. here we present a descriptive analysis of our data in those cases where a laparoscopic treatment was attempted. epidemiological variables, surgical technique, postoperative complications, days until hospital discharge, recurrence, etc. has been collected. results: 80% of patients were female(4) and 20% male (1). mean age was 68. size of gallstones varied from 20 to 34 mm and ct located them all in the ileum. two conversions to open surgery were made (40%), in one case because the gallstone could not be found and in the other case due to the need of an intestinal resection. in two cases (40%) la aparoscopic-assisted surgery was performed using a pfannestiel incision for the gallstone extraction and enterorrhaphy. only one case was total laparoscopic approach (20%). two cases needed an intestinal resection and anastomosis, one of them was complicated with a leak that needed reintervention. there were two cases of recurrence during the follow-up time. hospital stay varied from 4 to 27 days, mean of 10 days. conclusion: the widespread use of ct facilitates early diagnosis with high sensitivity detecting rigler's triad. a totally laparoscopic procedure might be ideal for patients specially with solitary stones even though a laparoscopic-assisted approach is an easier technique for surgeons with less experience in laparoscopic surgery. although experience in minimally invasive surgical treatment of gi is still developing, it may be recommended in selected cases and experienced hands. introduction: most of surgical interventions in hospitals in the world, where laparoscope is used, it is common that the vision inside the human body is constantly interrupted by fogging in laparoscope tip. the laparoscope fogging is caused by the difference of temperatures between the optic tip and the abdominal cavity. material and method: we replaces the traditional laparoscope for the ehs (endoscope heater system) with resistance between the internal and external tube that maintains the temperature of laparoscope at (30-50°celsius) without modifying the external architecture of traditional laparoscope. results: ehs does not generates any waste like other anti-fog systems, like liquids, plastics covers or electric heater. reduces intervention time, can keep same instruments or accessories for the intervention. all of the above means a saving of resources with have a positive environmental impact. conclusions: the discomfort transmitted by surgeons about the fogging in laparoscopy tip make success of the product and it will replace the current laparoscope which is fogged. aim: synchronous locally-advanced low rectal cancer and prostate adenocarcinoma represent a rare condition and a challenging situation for colorectal surgeons and urologists. the simultaneous resection of both adenocarcinomas after long-course chemoradiation therapy combines two major surgical procedures associated with a potentially increased postoperative morbidity. in the other hand, simultaneous resections minimize the risk of difficult dissections, which are expected if the two procedures are scheduled sequentially. in the past decade, robotic-assisted minimally-invasive surgical techniques have been increasingly used to treat both rectal and prostatic malignancies. especially in case of prostatic malignancy, the robotic approach is considered the treatment of choice because it is associated with significantly lower blood loss and transfusion rate, and much greater functional outcomes compared to laparoscopy. methods: we present the case of a 66-year-old male patient (bmi: 30.6) diagnosed with a histologically proven locally-advanced rectal adenocarcinoma (ct3an0) located at 5 cm from the anal verge and concurrent histologically proven prostatic adenocarcinoma [gleason score of 8 (4 ? 4)] located in the postero-basal right lobe. the preoperative total-body computed tomography (ct) scan showed no evidence of metastatic disease. after discussion in a multidisciplinary meeting, the patient received a long-course neoadjuvant chemoradiation therapy (ncrt). at the restaging positron emission tomography / magnetic resonance imaging (pet-mri), the rectal lesion was classified as ymrt0n0. preoperatively, the surgical difficulty was assessed as high, based on the calculation of the eumarcs score (equal to 6/10). moreover, due to the high-risk status of the prostate cancer (gleason 8), it was decided not to preserve the neuro-vescular bundles during the radical prostatectomy. results: the patient was operated on after 12 weeks from completion of ncrt by using the da vinci robot system si with a single docking approach, as previously described, in order to address both cancers. conclusions: this video shows the main surgical steps of the simultaneous robotic resection of the low rectal adenocarcinoma first, of the prostatic carcinoma then, and the mechanical colo-anal anastomosis followed by drain positioning and ileostomy. this video demonstrates the perioperative safety and feasibility of the minimally invasive robotic approach in case of extended and challenging oncologic resections. general surgery, rambam medical center, haifa, israel 75 year old, male patient presented with melena, without abdominal pain, nausea or vomiting. patient underwent colonoscopy and tumor was found in ascending colon (near the hepatic flexure). biopsy from the tumor has showed moderately differentiated adenocarcinoma. his blood laboratory examinations were within normal limits except of hgb level-11.0. cea and cea19-9 were normal. abdominal computed tomography was normal . patient underwent da vinci robot-assisted right hemicolectomy with extracorporeal anastomosis. total operating time was 150 min. three days after operation patient started regular diet and was discharged home on day four. final pathology result confirmed diagnosis of moderately differentiated adenocarcinoma. introduction: one of the goals of colorectal surgery is to decrease the number of leaks once an anastomosis has been performed. this life-threating entity after elective surgery has been related to the clinical history of the patients, the location of the tumor and to technical reasons, specially due to tension in the anastomosis or to lack of vascularization. tension could be identified during surgery, while vascular supply is evaluated by the surgeons based on a subjective analysis of the color of the colon/ileum. fluorescence tries to make these subjective parameter more objective in order to avoid an anastomosis with lack of vascularization, decreasing the numbers of leaks related to this factor. patients and method: the study presents a quasi-experimental analysis made from january 2009 to october 2017 in two hundred and eighty-five patients who underwent elective colerectal surgery, performing either a colo-rectal, ileo-rectal or intracorporeal ileo-colic anastomosis. vascular supply was eveluated using indocianyne green (icg) in one hundred and forty-five patients, while one hundred and forty subjects were operated in a previous period without using this technology, being considered the control group. the number of time that the attitude changed and the number of leaks were collected. results: out of the 285 cases performed, 80 were right colectomies (rc), 162 left colectomies (lc) and 43 rectal excision (re). in 20% the transection line was changed (2, 8% in rc, 11, 1% in lc and 6, 3% in rr) . in comparison with the control group, the icg group had a significantly less indicence of anastomotic leak compared to the control group (2,8% vs. 8,6%, p = 0,04), lower rate of terminal stoma after reoperation (0,7% vs. 5,7%, p = 0,018), a shorter length of hospital stay (4 days vs. 5 days, p = 0,02 respectively), and a low morbidity and mortality. conclusions: the rate of leaks after colorectal surgery decrease using icg to detect the proper transsection line before to perform the anastomosis in comparison with control group. these findings might influence in the final results although it is necessary in the future to find a system that provides greater objectivity by quantifying icg. aims: anastomotic leaks continue being one of the most important complications when a colorectal surgery is performed. this complication is usually related to the level and type of resection, the patient clinical history and surgical technique, where tension and vascular supply are the most important. indocyanine green (icg) fluorescence angiography seems to be helpful in order to evaluate the vascularization at the resection margins. methods: we have collected data on 187 colorectal procedures that were performed by the same surgeon using icg fluorescence angiography to evaluate vascular supply to the anastomosis. in order to asses in which of the different type of colorectal procedure has more value to be used, we analyzed the type of surgical procedure, the percentage change in the resection margin and the number of anastomotic leaks (al). results: all of the 187 cases were performed by laparoscopic approach: 77 left colonic resection (lc), 66 right colonic resection (rc), 9 splenic flexure partial resection (sf), 15 low anterior resection with partial mesorectal escision (lar), 19 ultra low anterior resection with total mesorectal escision (ular) and 1 total colectomy (tc). there was a change of transection line (ctl) in 21 lc (27,2%), 4 rc (6%), 1 sf (11,1%) and 10 (28,5%) in rectal anastomosis (lar, ular and tc). as far as al we found: lc 1 (1,2%), rc 2 (3%) and 2,8% in rectal procedures. lc, sf and rectal procedure showed more ctl and less al, while rc showed less ctl and more al. conclusion: icg fluorescence angiography as an additional tool to try to reduce the anastomtic leak rate seems to have more value in the procedures that involve the left colon and the rectum, since that is where we have observed the greatest number of ctl, this could be explained by the riolan's arcade and the variability of the vascular anatomy. however, it seems that this is a line of research should continue developing with longer and larger studies, so in that way we can have more significant results. retrorectal tumors ara rare and often found incidentally. the majority of retrorectal tumours are benign, but they have potential for malignant transformation and therefore should be resected when found. a case of a 44-year-old female patient with a retrorectal tumor is showed. the tumor was found incidentally on ct scan of the abdomen for evaluation of non specific right side abdominal pain. a mri was also performed and imaging was informed as a probably congenital retrorectal tumor (tailgut cyst) there was no evidence of involvement or invasion of other structures the tumor was palpable at rectal examination. a transanal minimally invasive surgery (tamis) approach was proposed. preoperative preparation was done with a full mechanical and oral antibiotic bowel preparation. preoperative parenteral antibiotics werw administred. under general anesthesia, lithotomy position. the contour of the tumor is not visible due to the small size. palpation of tumor and placement of clips to lolocate was done. placement of gel point path and rectal insufflation. a longitudinal incision was made to the posterior left side of rectal wall. the insufflation of the perirectal extraperitoneal space allowe for excellent exposure of the tumor. the tumor was disected with ligasure. then the tumor was extracted transanally.the proctotomy was closed in a single layer with reabsorbible monofilament continuous suture (pds). no complications after the procedure. the patient was discharged at 2 days. discusion: traditionally, the retrorectal tumors have been resected using a posterior parasacrococcygeal approach, an abdominal approach or a combined abdominal and posterior approach. with the advent of minimally invasive surgery, laparoscopyc approach has been described too. however, tamis approach is feasible, with low pain, morbidity, fester recovery and excellent cosmetic (no scare) results. it can be accomplished using standard laparoscopic equipment, with transanal access. we think that perhaps it could be the gold standar approach for this tumors. aimes: robotic-assisted laparoscopic surgery (rals) is a promising advanced technology that can overcome the inherent limitations of conventional laparoscopic surgery (cls). its advantage includes free-moving multijoint forceps, a motion scaling function, high-quality three-dimensional imaging, and stable camera work by an operator. this study aimed to clarify the short-term outcomes of rals for rectal tumors. methods: this study group comprised 25 patients who underwent rals for rectal tumors (cancer in 24 patients and gastrointestinal stromal tumor in 1 patient), excluding ones with distant metastasis from november 2016 through december 2018. the clinicopathological findings and short-term outcomes in rectal tumors were analyzed. results: the median operative time was 372 min (309-682). the median console time was 207 min with a median blood loss was 5 ml (5-394). conversion rate was 0.0% (0 / 25). the median postoperative hospital stay was 11 days (6-17). 2 patients (8.0%) had postoperative complications. 9 patients (36.0%) had lymph nodes metastases. the mean harvested lymph node was 17.6. the r0 resection rate was 96% (24 / 25). conclusions: these results suggest that rals for rectal tumors is safe and feasible, and the perioperative outcomes are acceptable. introduction: anastomotic healing defects are a feared complication which might have a fatal impact on the patient. fundamental conditions for proper anastomotic healing include sufficient blood supply. fluorescent angiography using indocyanine green in the spectrum of near infrared light facilitates the monitoring of tissue perfusion during a surgery. aim: a presentation of the results of our non-randomized study in which we assessed prospectively obtained data from a perioperative assessment of anastomosis perfusion by fluorescent angiography using indocyanine green during robotic rectal cancer surgery. method: thirty patients with rectal cancer, who underwent a robotic resection with primary anastomosis, were consecutively included in the study between april 1, 2017 and june 21, 2018. the study included patients facing a least invasive surgery with a guaranteed payment by a health insurance company. during the surgery, we monitored and assessed the quality of the perfusion of the resection line of the sigmoid colon and subsequent anastomosis by means of fluorescent angiography using indocyanine green in the spectrum of near infrared light. the data were obtained prospectively and subsequently analyzed. results: between april 1, 2017 and june 21, 2018, we consecutively included 30 rectal cancer patients in the project: 16 men and 14 women. monitoring of the perfusion of the resection line and anastomosis was successful in all cases and perfusion quality was satisfactory across the sample. perfusion insufficiency requiring a change in the resection line level or anastomosis adjustments was not detected with any patient. in two cases (6.7%) of tme, we gave up the planned protective ileostomy owing to quality perfusion of the anastomosis. one patient (3.3%) suffered from defective anastomosis healing without clinical symptomatology (type a). we found no technical complications related to fluorescent angiography or undesirable effects due to the application of indocyanine green. conclusion: even though we did not register insufficient perfusion in our sample and hence we did not have to change the resection line level or adjust the anastomosis, we may state that fluorescent angiography performed by an experienced colorectal surgeon may potentially reduce the frequency of complications linked to defective anastomosis healing.supported by mo 1012 aims: the aim of our study is to demonstrate whether robotic surgery has any influence on the reduction of complications in the aged population undergoing rectal cancer. methods: we performed a retrospective analysis of a prospective database of 151 patients who underwent robotic surgery for rectal cancer. we divided our population in 3 groups: under 65 year old, between 65 and 80 year old and above 80 year old. we recorded complications in each group intra and post procedure. qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. the analysis of data was applying fisher's exact test or chi-squared test for qualitative variables and variance analysis or student'-t test for quantitative variables. statistically significant values of p \ 0.05 underwent multivariate logistic regression analysis. results: the present study included 151 patients (94 males).seventy seven patients were under 65 year old, 73 patients were between 66 and 80 year old and 11 patients were above 80 year old. the analysis showed conversion rates of 10.38%, 13.69%, 27.27%, and complication rate of 23.4%, 23.8%, and 27.3% in each group. univariate analysis showed no differences between the three groups. nevertheless, there were statistical differences from bmi, asa and neoadjuvant therapy. in multivariant analysis only neoadjuvant therapy was significant. conclusions: robotic approach do not decrease complications in elderly population. introduction: it has been described the advantages of total transanal mesorectal excision (tatme), with better visualization and access to the lower rectum. we use this access whith the gel point path device, to repair a rectovaginal fistula with stenosis of low rectal anastomosis in two patients, that would be difficult by conventional abdominal approach method: we show our surgical technique for repair a rectovaginal fistula with stenosis of low rectal anastomosis in two female patients operated due to rectal neoplasia. one of the patients underwent prior chemo-radiotheratpy. rectoscopy and image test was performed at the patients prior the intervention. no recurrence signs are recorded at mri.we describe the operation technique: a new anterior rectal resection was performed with a combined transanal (gel point path) and abdominal minimally invasive approach. redo anastomosis whith eea 31 stappler was performed, vaginal repair and epiploplasty. the intervention was especially laborious due to the fibrous tissue. pathology: fistulous path without tumor infiltration in the two patients. at two months, a opaque enema show permeability and absence of leaks in the two patients. the ileostomy was closed at three months. discusion: we believe that transanal access through the gel point path can be a good option for rectovaginal fistula and stenosis of low rectal anastomosis, allowing a better visualization and acces, and making more easy a very difficult intervention. introduction: tamis or transanal minimally invasive surgery for polyp resection has increased fame for several situations in which adenomas with or without dysplasia cannot be removed with conventional colonoscopy. in this video we show the step by step technique performed with the da vinci xi system. material and methods: in this video we show the setting and the location of the patient-side cart and the arms to perform the resection of polyps in different patients and how to develope the procedure. results: after placing the patient-side cart the arms are connected to 3 ports and the camera, double fenestrated grasper and scissors are connected to the arms through a transanal gel-port device. a line is described around the polyp with monopolar energy to determine the place of the dissection. the scissor is exchanged by a robotic harmonic wrist instrument and the complete dissection is performed. the wound is closed using a robotic needle holder and a suture. results: transanal robotic surgery could be safely performed after a standardized technique is stablished. aims: robotic rectal cancer surgery has demonstrated to obtain at least the same results than laparoscopic surgery. however, robotic surgery is associated with high rates of costs, specially when conversion to opened surgery occurs. the goal of this study is to create a predictor nomogram of conversions for robotic rectal cancer surgery. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer from october 2008 to november 2017. we performed a bivariant analysis and detected the variables which were related with the conversion: body mass index (bmi) and the t. we divided the patients of the population in two groups depends on obesity (bmi of kg/m2) and on t (t1-2/t3-4). we registered conversions in each group calculating the pretest risk. we performed likelihood index (lr ?/-) for under and above 30 kg/m2 of bmi, adding in a second step the lr of t; obtaining the prediction index for four groups by using a standardize nomogram. results: the present study included 194 patients (128 males). 143 were under bmi of 30 kg/m2 and 51 above. regarding t, 54 were with a tumor of t1-2 and 150 with t3-4. the analysis showed a conversion rate of the statistical sample of 14%. univariant analysis showed significative differences in the bmi (p = 0.005) and t (p = 0.022). a nomogram was performed; as regards the bmi, the positive likelihood index in the group of bmi [ 30 a prediction index of conversion of 50% (lr ? 4,95) and in bmi \ 30 the prediction index of conversion is 5% (lr-0,52). adding the t group data, for bmi [ 30 and t1-2 the conversion prediction rate is 3.5% (lr-1,2); for bmi [ 30 and t3-4 the conversion prediction is 92% (lr ? 5,6). bmi \ 30 and t1-2 the conversion prediction is 2% (lr-1,2); imc \ 30 and t3-4, the conversion prediction is 30%. conclusion: a standardize nomogram with the variable bmi and t facilitates the selection of patients for robotic surgery in rectal cancer avoiding conversion to open surgery. background: 3d-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice surgeons due to better depth perception. however, the benefits for experienced laparoscopic surgeons are still discussed. aim: the aim of this study is to compare the results of right hemicolectomy (rc) using a conventional (2d hd) laparoscopic system with rc performed using a 3d laparoscopic system in terms of duration, complications and results. material and methods: from all laparoscopic right hemicolectomies performed in our clinic we selected all procedures performed by the same team of 2 consultant surgeons using the same technique and divided them in 2 groups. the study group comprised of all patients operated using our 3d einstein vision 2.0 system; all other patients which were operated using our standard wolf hd laparoscopy system comprised the control group. all patients were retrospectively analyzed in terms of patients characteristic, or time, duration of operation, intra-and postoperative complications, length of hospitalization, pain score, necessity of analgesics and number of lymph nodes retrived. risk factors for complications (bmi, smoker, diabetes, copd, bph) were also registered. results: there were 54 patients included in the study group, while the control group comprised of 98 patients. mean operation time in the study group was 123.3 min in the study group, while mean or time was 157.4 min. mean operation time in the control group was 128.1 min, while mean or time 145.4 min. one reintervention was noted in the control group and two in the the study group; no conversion to open surgery was noted. there were no significant differences regarding patient characteristics, pain score, wound complications, hernia rate, length of hospitalization or number of lymph nodes removed. conclusions: there were no significant differences regarding the outcome of rc using 3d laparoscopy; total or time was significantly higher in the study group due to the time needed to set up the 3d-laparoscopy unit. this is biased by the fact that the 3d system needs to be set up manually while the conventional hd system is integrated in the or. also, there was no significant difference in complication rate. background/purpose: robotic approach can be a treatment option for patients with pelvic recurrence after primary resection for rectal cancer. however, data regarding patient selection, complication rates, and oncologic outcomes are rarely reported. we aimed to present initial experience and to evaluate feasibility, safety, and oncologic outcomes of robotic salvage surgery for recurrent rectal cancer. methods: ten patients who underwent robotic salvage surgery for local recurrence at the anastomotic site, lateral pelvic side-wall, or lateral pelvic lymph nodes (lpns) were retrospectively evaluated from a prospectively maintained database. results: two patients underwent pelvic mass excision with en bloc resection of anastomosis and redo-anastomosis, and eight patients underwent lateral pelvic lymph node dissection (lpnd) for lpn metastasis; one of these eight patient underwent additional en bloc resection of anastomosis. all patients achieved r0 resection. the median operation time was 165 min and the median estimated blood loss was 50 ml. there were no conversions. as for intraoperative complications, one patient experienced ureter injury during lpnd because the metastatic lpn was closely abutting to the ureter. the median hospital stay was 7 days. in six patients who underwent lpnd, the median number of harvested lymph nodes was 7 (range 2-13) and the median number of metastatic lymph nodes was 1 (range 0-2). with median follow-up 26 months, one patient developed lung and pelvic recurrence at 36 months after salvage operation and seven patients remained in disease-free state at the last follow-up. conclusion: initial experience of robotic salvage surgery for pelvic recurrence in rectal cancer indicated that it is safe and feasible. therefore, the robotic approach can be considered as a treatment option for the treatment of local recurrence in selected patients. introduction: there is uncertainty regarding the effects of simulated patient death. several reports showed increased cognitive load and poorer learning outcomes, and others increased performance without causing stress to learners. we have not found any report studying the impact of animal death in the simulation lab. methods: this was an observational cohort study to assess the emotional and cognitive load of surgeons who experienced animal death in the simulation lab. seventy-four faculty and residents from different surgical specialties training minimally invasive surgery participated in the study. one cohort consisted of surgeons whose animal died during surgery, and the other by those whose animal survived. emotions were assessed using the scale for mood assessment and cognitive load with nasa task load index. results: twenty percent of participants experienced mortality while training anti-reflux surgery (11 cases) and other procedures (3 cases). causes of death included intraoperative pneumothorax (n = 10), hemorrhage (n = 1), and cardiac dysrhythmias (n = 3). participants exposed to animal death had higher levels of sadness and anxiety, and lower levels of happiness (p [ 0.05). cognitive load was slightly higher in the exposed cohort (p [ 0.05). conclusions: these findings suggest that mortality in the animal lab do not have a significant effect on cognitive workload and emotions of surgeons training complex laparoscopic procedures. introduction: the visuospatial profiles of expert laparoscopic surgeons remain unaccounted in the current literature for as the influence of visuospatial ability on laparoscopic learning has mainly been investigated in medical students or novice surgeons and using simulators as means of performance measurement. such knowledge is critical, as without understanding how clinical experience may impact visuospatial processes in surgeons, we hinder our efforts to utilize the available knowledge to support surgical education for the future. this study is aiming to explore the development and influence of visuospatial processes on intraoperative laparoscopic learning. method: the study reports the interim baseline results from the ongoing longitudinal study throughout a 2-year period of training on laparoscopic surgery. data from 35 surgeons including 17 residents undergoing training were captured and compared to 18 specialists who are working in departments of general and visceral surgery at two large hospitals. the mean experience of the surgical residents was 4 years. the mean laparoscopic experience among the senior surgeons is 17 years, with each surgeon performing an average of 6 laparoscopic procedures per week. visuospatial ability was tested using mental rotation test (mrt), guay visualization of views tests (gvvt), spatial perspective taking and spatial orientation test (ptost) and pictorial surface orientation (picsor). spearman correlation coefficient was used in this study with a p-value of significance at \ 0.05. results: senior surgeons have an overall good visuospatial profile, in the sense that they performed close to optimum on all measurement scales. the spearman rho revealed a significant correlation between scores on gvvt and picsor (r = 0.607, p = 0.012) and between ptost and picsor (r = -.686, p = 0.003). a significant correlation between years of laparoscopic experience and ptost score was also observed (r = 0.587, p = 0.035). when comparing residents and senior surgeons, no significant difference on the mrt was observed (m = 10.2, sd = 4.33), nor between baseline scores of senior surgeons and resident surgeons on all tests. conclusion: the results of this study carry important clinical and theoretical implications, as the results hint towards the idea that intraoperative laparoscopic experience lends little to no influence over the development of visuospatial ability. learning models and laparoscopic technical skills, how to adapt each case to improve objectives: according to da. kolb learning is the result of how people perceive and then process what they have perceived. the aim of this study is to identify the personal characteristics of learning in of the participants in a course of laparoscopic technical skills according to the styles described by kolb. methods: between june 2016 and november 2017, 35 participants performed a 50 h course distributed over five consecutive days performing laparoscopic manual intestinal anastomosis in endotrainer. they all filled in kolb's learning style test adapted to spanish. the anastomoses were performed in 'ex-vivo' swine intestines. in each anastomosis we evaluated the quality at the end and execution time. the test and quality variables were analyzed through statistical studies. results: in our study, 69% of the participants were women and 31% wew men. 49%were staff surgeons and 58% were resident. the median age among residents was 29 years and among the staff 39 years. the most frequent learning model in the sample studied was converging (31%). the predominant model among women was assimilating (37%), which, however, represented only 8% in men. in men, converging model was predominant (39%). among the staff, the most frequent model was diverging (35%). adaptation style prevailed among residents (39%), being rare among the staff (12%). the mean time of the anastomosis was 74 min for both the adapter model and the assimilator, 68 min, for the convergent and divergent models. the quality of the anastomosis performed by each participant was 80% for the adapter model, 37% for the assimilator model, 42% for the convergent model and 45% for the divergent model. the predominant style in our study was convergent. among women, the most frequent model was assimilator wheras in men it was the least frequent. in the residents, the most frequent model was adapter however, it was very rare in adjuncts. among residents we do not find divergent styles. the highest quality of the anastomosis was achieved by those who worked with an assimilating style. knowing previously the training style we can individualize the teaching methodology in order to improve competences. aims: assess whether laparoscopic appendicectomies (la) are a superior option to open appendicectomies (oa). specifically, comparing the time taken, complication rates and whether it is more appropriate to perform an la overnight, as opposed to oa. finally, to find out how a range of outcomes differs between different grades of surgeon. methods: an information request was sent to the clinical coding department to derive patient identification numbers for all appendicectomies over a ten-month period (180 total surgeries). these numbers were then inputted into the hospital information system where the electronic operation note is present, and specific outcomes were derived and analysed. results: 68% of operations were oa and 32% were la. mean la times for consultants, sas and spr were 88.4, 78 and 92 min respectively and oa 63, 57 and 59 min respectively. their respective conversion rates were 27%, 16% and 0%. oa had a complication rate of 16.3%, la was 10.2%. conclusion: oa are performed more than la. spr doctors had the slowest completion times for la but the lowest conversion rates. sas doctors had the fastest completion times for la and oa but higher conversion. la takes longer than oa but has lower complication rates; key factors when performing at night. key statement: laparoscopic appendicectomies require more surgeon-hours and have the potential to be converted to open, however the rates of complications and serious complications are significantly lower. background: paper based resources have been the standard sources for information for centuries. however, more and more people (patients and staff alike) are looking online for information. while the internet often provides excellent resources, there is often conflicting and confusing material of doubtful veracity. trainee staff and patients/carers should be able to access reliable resources whenever and wherever they are. the aim of this project was to create a high-quality resource fulfilling these needs. aim: we present a video demonstrating our integrated colorectal education website ( http://www.colorectaleducation.com/). our approach: high quality health care provision requires highly trained staff as well as wellinformed patients. information resources for these two groups are usually accessible from different repositories. our integrated website provides a common platform for all those involved in colorectal surgery, to use, learn and reflect on. users are directed to separate sections for patients and colorectal professionals. multiple disclaimers prevent patients accidentally stumbling across clinical/ operative information, whilst providing access to those who wish to do so. trainees struggle with balancing their educational needs with their service commitments. this website gives them the opportunity to view detailed operative training videos on the go. many of videos are chapter based allowing them to stop and re-start with ease. modules are also available for nurses providing them access to relevant educational material. the modular design of the website allows us to build upon it with more topics planned to be added over the next eighteen months. the resource also has detailed chapterised videos for patients due to undergo various colorectal procedures. all have been approved by a multi-professional panel including patients and are designed to provide information, offer support and to allay any anxiety. videos with the care pathway and previous patients' experiences are accessible on demand. conclusion: on demand information has now become the norm with the use of smart phones/ tablets. this website provides patients, surgical trainees and other healthcare professionals access to information and education in a clear and reliable format anywhere in the world. colorectal education, on demand and just a click away! objective: in the last decade the growing interest in robotic surgery is evident as shown by several published articles. the aim of the present study is to evaluate the main outcome of a single center experience and to describe the organizational system we have progressively established in our center in order to improve the development of robotic program in all surgical area. materials and methods: we report a case series of patients who underwent robot-assisted surgery at sanchinarro university hospital since the beginning of the program (october 2010) until november 2018 main patient demographic characteristics, type of surgery, peri and postoperative data and follow-up were evaluated. results: a total of 326 robotic procedures were performed for a total of 323 patients. the prevalence of malignant disease was 86%. a total of 72 pancreatic surgery were performes; 22 liver resections (mean operating time: 190 min); 33 gastrectomy (mean operating time 310 min); 18 esophagectomy (mean operating time: 490 min); 152 colorectal resections (100 rectal resections, 23 sigmoidectomy 19 hemicolectomies right, 10 left colectomy) (mean operating time: 220 min); 6 nissen procedures (mean operating time: 130 min), 2 esofagheous myomectomy for achalasia (operating time: 90 min); 3 adrenalectomy (mean operating time: 240 min); three biliary surgery for benign desease, 2 splenectomy. eight partial resection of the duodenum, one yeyunal resection, one mesenteric cyst resection and 3 retroperitoneal tumor have been performed. conversion rate was 6%, total morbidity have been 17%. there has been no peri and postoperative mortality up to 30 days after surgery. the average hospital stay and intensive care were respectively16 days (range 6-45 days) and 1.9 days (range 0-12 days). conclusions: the organizational model defined in our center is facilitating the constant and progressive development of the robotic program. a broad and flexible availability of the robotic system, a progressive increase of young surgeons joining this technology as well as the institutional and departmental economical effort are the points with which the robotic system may increase its development in a surgical department. aims: endoscopic surgery has been widespread in the field of general surgery. however, in japan, there is no standard program for endoscopic surgery training, and its competency has not been considered for the acquisition of board certified surgeon. the purpose of this survey was to investigate the current situation of endoscopic surgery training and autonomy of young surgeons for endoscopic surgery in japan. methods: the survey was planned to target general surgery members of the japan society for endoscopic surgery (jses) who was post graduate year 10 or less. after approval by the ethics committee of jses, the request for the participating in survey was mailed to 2296 object members. questionnaire responses were available in print or online media. the contents of the questionnaire consisted of 19 items, about the conditions of endoscopic surgical training, experienced case number, and the self-assessment of autonomy from 1 to 4 point by zwisch scale in 9 specific procedures of endoscopic surgery. results: the total response rate was 28.5% (645/2296). sixty five answers were excluded due to inadequate response and 580 answers were analyzed. of the questionnaire respondents, 87% were male and 13% were female. the ratio of board certified surgeon was 67%. although 87% of the teaching hospitals had simulators for basic training of endoscopic surgery and 94% of the respondents practiced basic skill of endoscopic surgery, only 34% teaching hospitals had specific training programs for endoscopic surgery. the surgeons who operated 20 cases of laparoscopic appendectomy and inguinal hernia repair and 50 cases of laparoscopic cholecystectomy, right hemicolectomy and sigmoidectomy, felt confident to perform each procedure independently. regarding with laparoscopic rectal resection and gastrectomy, even though the surgeons who had 50 cases of experience, they didn't had confidence to perform those procedures independently. conclusions: this study is the first national survey to investigate the status of endoscopic surgery training in japan and the autonomy of young surgeons for endoscopic surgery. in order to develop a training system for not only basic skills but also advanced procedures of endoscopic surgery, cooperation of each teaching hospital, academic surgical society, medical specialty board is necessary. currently there is a debate about what is the most optimal work schedule for residents of general surgery, it is important to respect the free time of residents to avoid burnout, however it is also important have enough exposition to clinical cases that allow a satisfactory development in the clinical practice. this becomes even more important when we talk about the learning of surgical skills. this is where the laparoscopic simulation industry opens a large area of opportunity, for a reasonable price it is possible to practice basic laparoscopic skills without compromising patient safety. this is a pilot study that was carried out during the period from january 2018 to june 2018, in a public hospital in monterrey, nl, mexico, the composition between the execution of the standardized exercises of the fls (fundamental laparoscopic surgery) in an endoscopic simulator was performed to 20 residents of general surgery (from first to fifth year) 24 hrs before being on call vs these same residents post call. a series of questions was asked to each resident in each measurement, so in this way they answered the same questions twice, then a comparison of the results of both questionnaires was made. the results of the exercises were assessed and rated by the same person using the criteria established in the fls for the scores of each exercise and for the final grade. an average age of 27 years was obtained, measurements were taken of 20 residents of which 16 are male and 4 female. on average, the residents before be on call performed the exercises with 7 h of having slept while the post call performed the exercises with 2.15 h of having slept, the residents before be on call had on average 10.9 h without sleep while the post call had 25 h without sleep. the average number of hours worked per week is 111 h, measured by the time in and out of the hospital. in this study, conclusive results were obtained regarding the null relationship of sleep deprivation with the performance of laparoscopic skills in surgical residents. aim: 'precision cutting' is one of skills tasks of the fundamentals of laparoscopic surgery (fls) program, which is cutting a circle on a piece of gauze under laparoscope and assessed by completing time (maximum time limit: 300 s). there is no definition of quality of the final product. the aim of this study is to develop an assessment tool of laparoscopic precision cutting and test its reliability. method: an assessment tool of laparoscopic precision cutting was developed with four items based on completion, degree of deformation, degree of being pulled, and overall appearance of the final product of laparoscopic precision cutting by experts' meetings. the scale of each item was 5 points likert scale. a descriptive sheet with a legend and a text description for each scale (fig) was attached for assessors' reference. for our high school entry medical students, they gained hands-on experiences of laparoscopic skills first time by attending a 1-hour course at minimally invasive surgery training center, national taiwan university hospital (ntuh). we invited students to participate this study after this training. we collected participants' final products of ' precision cutting' station and assessed them by using this assessment tool. this study was proved by institutional review board, ntuh (irb no:201512051rinb). results: 35 students were enrolled between february 2016 to june 2016. two non-medical assessors and a senior surgeon were invited to assess the products. the mean score and cronbach' s alpha value of each item were as followed: completion 2.2 ± 0.9, 0.91; degree of deformation 2.11 ± 0.9, 0.96; degree of being pulled 3.1 ± 1.1, 0.85; and overall appearance 2.6 ± 0.9, 0.95. conclusions: in summary, we successfully developed an assessment tool for laparoscopic 'precision cutting' and showed its reliability. the tool could provide qualitative descriptions for objective feedbacks. validating this tool in a large scale is undergoing. purpose: to evaluate whether the participants who experienced this scenario could recall an interventional scenario for testing trainees' situational awareness and intra-operative decision making when they participated this training again. methods: we designed an iodm training course for junior surgical trainees and nurses by using live pigs since sep 2016. in the first simulation, we created an interventional scenario and then provided an educational session. a researcher disconnected the ekg monitor on purpose for creating a scenario that the pig would lose vital signs when the team nearly finished a diagnostic laparoscopy. if the team did not aware the situation after 1.5 min, a researcher would remind the team (fig). we used a new developed assessment tool of iodm and an assessment tool for nontechnical skills for surgeons (notss) for self-evaluations and objective assessments. we also discussed with them about their reactions while encountering this interventional scenario. results: between sep 2017 to june 2018, 14 teams participated this training and experienced this interventional scenario. fourteen 2 nd year surgical trainees have experienced it before. only one participant (7%) recalled it and made a quick decision while encountering this interventional scenario again. the results of iodm assessment and notss did not show statistical difference comparing their self-assessments in the first and second year. based on the analysis of the discussions, most of them remembered this this interventional scenario and reminded themselves to react it properly before the simulation. however, when they were the primary surgeon of diagnostic laparoscopy, they focused on performing this procedure and tutoring their junior trainee. they had no capacity in their brain to notice the change of vital signs. in addition, although they increased their situation awareness in clinical settings after the 1st time iodm training, they did not show this ability in the simulation. conclusions: recalling of an interventional scenario for testing situational awareness of surgical trainees was very poor (1/14, 7%) among the 2nd year surgical trainees. qualitative analysis of discussions showed their brain capacities were occupied by performing new procedures and tutoring others. how to enhance trainees' situational awareness should be addressed. aims: a well-designed learning curve is essential to measure the progress of surgical abilities. learning curves are very important to test the skills of trainees. however, there are still no welldefined criteria for developing good learning curves. as a result, many authors use subjective evaluation criteria. the purpose of this review is to analyse this field of surgical education and to identify the key criteria for good learning curves. methods: learning curves were investigated in the field of laparoscopic and robotic minimally invasive surgery. surgery of appendectomy, cholecystectomy, cholectomy, inguinal hernia repair and gastrectomy were considered. the type of surgery, the year of publication, the design of the study, the surgeon's experience (resident, young or senior), the surgical technique, the number of patients involved in the study and the suggested learning curve by the different studies were taken into account. in the selection of articles, more importance was given to those based on the activity of young surgeons or residents. results: the literature analysis showed conflicting results. the different learning curves for the same surgery may be due to the different evaluation criteria considered. only a few studies investigate the learning curves of young surgeons and residents. conclusions: the data available in the literature on learning curves are contradictory. several factors need to be evaluated in order to create more accurate learning curves. we suggest the introduction of checklists with a score for each parameter to be examined, in order to develop more objective and standardized learning curves. aim: the uk training programme for transanal total mesorectal excision (tatme) has completed its first round of training. the study aim was to design a reporting platform that provided trainees with video-assisted feedback in a clear, concise and useful manner to support their training. methods: an established method of video analysis called observational clinical human reliability analysis (ochra) was used to assess the surgical performance of the trainees during their clinical tatme cases. a reporting form for the ochra results was designed identifying areas of difficulties in each procedure and providing error reduction mechanisms. this was piloted during the national training programme for tatme in the uk. results: the ochra reporting form underwent three modifications before the content and format was agreed upon. the final version is divided into three sections: a. case details, b. ochra findings, and c. suggested error-reducing mechanisms. for part b the tatme procedure was divided into four phases of the operation: 1. pursestring, 2. rectotomy, 3. tme dissection, and 4. connected phase when the abdominal and transanal teams work together synchronously. for each phase, ochra findings described the most frequently occurring technical inaccuracies/errors, number of consequential errors/adverse events and the most frequent and serious consequences encountered. suggested error-reducing mechanisms in part c were developed and established by an expert workshop and individual interviews with international surgeons experienced in tatme.trainee and mentor feedback stated that the reporting form had a clear format, easy to follow and understand. the error-reducing mechanisms were particularly useful and allowed the trainee to focus on improving specific technical aspects in their subsequent cases. conclusion: video analysis using ochra can provide a wealth of information on surgical performance, especially for trainees at the start of their learning curve. as an exploratory study, validation of the reporting platform is required; however, its potential to offer detailed, individualised feedback to enhance training is promising. laparoscopic pelvic surgery training program-using a new concept 3d-printed versatile pelvi-trainer r.c. elisei 1 , f. graur 2 , c. popa 2 , e. mois 2 , l. furcea 2 , n. al hajjar 2 1 general surgery, bistrita emergency county hospital, bistrita, romania; 2 general surgery, regional institute of gastroenterology and hepathology ,,prof. o. fodor,,, cluj-napoca, romania pelvic laparoscopic surgery (rectal, urological, or gynecological laparoscopic surgery) is an advanced surgery which require advanced skills, not easy to acquire. there are a lot of training programs for advanced laparoscopic skills but many of them are not affordable for most of surgery residents in eastern europe, where the training programs are far behind from those in western europe. because of that those training programs need to be improved and optimized. in the european union we want equal and high skilled surgeons. this is why we designed a new concept of pelvi-trainer, a versatile one in order to offer the residents the possibility to achieve advanced laparoscopic skills like perfect coordination, precise movements, ability to cut and suture after a well defined route, all of them in the pelvis tight space. we 3d-printed this pelvitrainer which has multiple characteristics: cheap and easy to produce, easy to be used, versatile because offer the possibility to achieve the skills named above, and many others, but also to train on real ex vivo animal rectum (suine model). we also believe that with a proper training a medical student and a young surgery resident are able to achieve the same skills like experienced surgery residents or specialists. in order to demonstrate that we need a study to compare the time to perform 4 or more exercises in this new concept pelvi-trainer by the medical students, young and experienced residents and surgery specialists. what we want to achieve with this training program project is to have more and more skilled surgeons in advanced laparoscopy and an equal laparoscopic surgery training all over the country, close to the level of training in the western europe. also we want this training program to make a standardization of the pelvic laparoscopic surgery training first in our country and then in other countries if possible. aims: the objective of this systematic review is to provide an evidence-based overview of the different components of laparoscopic training curricula, emphasizing the value of objective forcebased assessment and how this in implemented in modern laparoscopic training. methods: bibliographic databases of pubmed and embase were searched till april 2018 to identify studies reporting on evidence-based laparoscopic skills training. abstracts of retrieved studies were reviewed by two authors independently and those meeting the inclusion criteria were selected for full-text review. results: the search yielded a total of 2010 individual records. a total of 96 articles were included. the articles were divided into nine different categories, which include 'metrics', 'benchmark criteria', 'measurement systems', 'timetable', 'training modalities', 'camera settings', 'training tasks', 'serious gaming', and 'competition'. a descriptive analysis of the data is provided. motion analysis parameters, such and path length and time are frequently validated and used for assessment. the results of validation studies on tissue manipulation parameters, such as maximum force and mean force show proved their discriminating power between different levels of proficiency. however, implementation of these metrics remain restrained. conclusions: numerous studies on laparoscopic skills training have been conducted over the years. nevertheless, no consensus is reached towards the use of objective assessment tools. although the value of validated metrics is described well, implementation of objective metrics is limited. we recommend to consider objective force-and motion metrics for feedback and assessment during laparoscopic skills training. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; 2 anesthesiology, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; 3 radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania aims: the aim of the study was to create a new easy learning method of swine liver anatomy for residents in training. based on human liver surgical anatomy we put 'face to face' the similar structures and also the differences using ex vivo porcine models and ct reconstructions from live pigs. methods: having in mind the human liver anatomy, in the first stage we used data obtained from dissection of twelve porcine liver models to create an anatomical pattern, which summarized the most important surgical information. in the second stage, anatomical data obtained from ct scans of twelve living anesthetized pigs were analyzed. the ct reconstructions and volumetry data were added to the gross anatomy pattern to create a more complex learning module. results: the residents established the most frequent description of swine liver anatomy by putting together the information from ex vivo model dissection. the liver parenchyma is divided into four main anatomic lobes: left lateral, left medial, right medial and right lateral. all those lobes are connected only in the posterior part, which allows a very good separation between them by deep fissures. just as in humans, we found eight distinct segments with independent vascularization and biliary drainage. portal vein has a specific 's' shape; in most cases hepatic artery was found like a trifurcation and extrahepatic biliary tree has a very thin wall. in the right hemi-liver, the inferior vena cava passes through the liver parenchyma. most frequent, we found five hepatic veins which are running completely intraparenchymal. the imagistic data offered a very useful 3d reconstruction with anatomical positions of the vascular-biliary tree and liver segmentation and gave us the possibility to create practical scenarios for resections. perhaps the most important information was to discover and see the section plan and to calculate the volume of the remaining liver after resection. conclusions: the anatomical-imagistic pattern based on \ i[ex vivo \/i [ model disections combined with imagistic data offers a unique mindset before intervention. the concept 'human \ i[vs \/i [ swine' to create an easy method of learning for residents in training can be applied to swine liver anatomy. the learning of surgery is traditionally based on the behaviourist model . goals are set, standards of care fixed, with regular assessments of the level achieved. the teacher exercises control over the student, imposing rules and models, supported by 'reinforcing' actions (reward or punishment). the theory of skinner's program of education, from 1954, is reflected in surgical learning. it foresees a gradual progression by level of difficulty, following a transmission-imitation model . these theories seem currently outdated to face the new challenges of medicine and surgery and to keep up with technological developments. bruner, one of the theorists of the constructivist model, proposed in 1990 a method of collaborative learning between those who teach and those who learn. the goal of the method was to improve strategic problem solving. the comparison between various perspectives (between teacher and student), allowed the learner to better absorb knowledge and improve critical thinking. in 2008 kapur published on the theory of 'productive failure'. this model makes the error of a single person useful for all his colleagues, privileges the practice of theoretical knowledge, contextualised learning as opposed to abstract learning, and 'guided' practice compared to a 'guided' theory. bruner and kapur's systems favour creativity, critical analysis of a problems origin, and the practical use of knowledge. they represent a hypothesis of learning, based on constructive discussion and a continuos 'give-take' feedback system. in order to put these new models into practice in the clinical context, one may hypothesise and propose the adoption of a formal discussion of clinical cases that are complicated or difficult. thereby making the theoretical lessons more collaborative, intuitive and inclusive. in the surgical field, one could adapt such a concept to surgery simulation, virtual reality and anatomical models. aim: large hiatal hernias have a surgical indication when the patients suffering disabling symptoms such as anaemia, dyspnea, chest pain, gastric reflux. several studies showed that in the case of large hernias the placement of a prosthesis was safe and could protect against recurrence. mini-invasive surgery is the preferred approach for hiatal hernia repair and anti-reflux procedure and the toupet fundoplication has been shown to be the best surgical technique for the hiatal hernias repair.the laparoscopic approach is currently the surgical gold standard but is burdened by technical difficulties especially in the case of large hiatal hernias. the robotic system is designed to overcome some technical difficulties of laparoscopy and the studies available in literature report the safety and effectiveness of the robotic approach in complex hiatal hernias repair. methods: we present the case of a grade iv hiatal hernia treated with a robotic approach in a 73 years old woman (bmi: 31 kg/m 2 ). the medical history consisted of a road accident with a probable mechanism of deceleration, three years before. the patient had been suffering from dyspnea for three years. due to the recent discovery of an anaemia, the patient was subjected to an endoscopic examination with the identification of a voluminous grade iv hiatal hernia. a subsequent computed tomography (ct) scan showed also the partial herniation of the transverse colon. results: the patient underwent to surgery by using the da vinci robot system siò (intuitive surgical, sunnyvale, usa) with a single docking approach. the surgery consisted in the liberation of the hernial sac, the placement of a goretex prosthesis and the packaging of a toupet fundoplicatio. the surgery was performed without complication. conclusions: the robotic approach in the hiatal hernia surgery seems to be a valid alternative to laparoscopy, especially in complex cases. the surgical ability in robotic surgery is of paramount importance. general thoracic surgery, kawasaki municipal hospital, tokyo, japan aim: video-assisted thoracoscopic surgery (vats) with carbon dioxide (co 2 ) for mediastinal surgery is known to improve the visualization of medaistinal space. we report our experiences with two cases that underwent vats thymectomy using co 2 insufflation under the one-lung ventilation general anesthesia by double lumen tube. methods: the instruments that were used for vats thymectomy were only the 5-mm 30-degree rigid thoracoscope, maryland jaw energy device, cotton made-dissectors, and straight endoscopic grasping forceps. they were used through sealed ports designed for laparoscopic surgery. lowpressure co 2 insufflation set at 8 mmhg were used for compression of surround tissue of mediastinal tumor during the releasing procedure. results: the patients were an 81-year-old male and a 54-year-old female. thoracoscope with the 8 mmhg co 2 insufflation provides excellent visualization of the medaistinal space and operation could be done smoothly without any hemodynamic compromise. their pathological diagnoses were thymic cancer and thymoma, type b1. the operative times were 115 min and 66 min. the postoperative courses were uneventful and the patients were discharged on day 10th and 3 rd . conclusion: we have just begun to routinely use co 2 insufflation for mediastinal tomorectomy and present our early experiences of successful vats thymectomy by utilizing co \ su2 \/su insufflation. aims: this retrospective study aims to evaluate the feasibility of single-incision thoracoscopic surgery (sits) for primary spontaneous pneumothorax (psp), using a novel multichannel port (x gateò). methods: between october 2015 and november 2018, ten patients who underwent sits using x gateò. nine patients were male and 1 was female, with mean age of 22.6 ± 8.7 years old. a 2.5 cm incision is placed in the middle axillary line on the 4th or 5th intercostal space, depending on the lesions. postoperative outcomes of these patients were compared with those of 33 patients with psp who underwent conventional three-port video-assisted thoracic surgery (vats). results: there were no conversions from sits to vats. mean operative time of sits group was significantly shorter than that of three-port vats group (55.4 ± 14.3 min vs 79.8 ± 26.0 min, p = 0.003). mean number of staplers used in surgery was 2.5 (1) (2) (3) (4) in sits group and 3 (1) (2) (3) (4) (5) in vats group (p = 0.698). mean duration of postoperative drainage was also shorter in sits group (1.0 ± 0 days vs 1.3 ± 0.6 days, p = 0.05). no recurrence and wound infection were observed in sits group. conclusion: sits using x gateò is feasible when performed for selected patients with psp. x gateò provides good visualization of intrapleural space and esthetic outcomes, as well as a superb maneuverability by decreasing mutual interference of surgical instruments. although conventional three-port vats for psp is well established, sits using x gateò can be a permissible alternative. further examinations are required to evaluate efficacy of sits using x gateò. aims: haemorrhage remains a leading cause of potentially preventable death in trauma. in particular non-compressible torso haemorrhage is approximated to cause 60-70% of mortality in civilian trauma patients with otherwise survivable injuries and 80% in war setting. we performed a literature review to assess the potential for using endovascular stenting in traumatic venous injuries and explore the evidence of their efficacy and safety with different venous injury patterns. methods: systematic online search of pubmed performed using key words'endovascular stent', 'venous injury', trauma, penetrating, blunt, abdominal and pelvic. inclusion criteria included all studies that explored the use of endovascular stents following traumatic abdominopelvic venous injuries. english language studies were used. results were presented according to prisma guidelines. results: of the 112 studies generated by the search,there were only four case reports in the literature documenting the use of endovascular stents in traumatic venous injuries dating back to 1997 and most recently 2009. the four cases included three retrohepatic ivc injuries, two secondary to blunt trauma and one penetrating; whilst the final case a blunt injury at the ilio-caval bifurcation. all four cases reported successful deployment of stents via the femoral or internal jugular veins, with subsequent resolution of haemorrhage. length of time taken for stent insertion ranged from 9 to 52 min. three of four patients made full recoveries and discharged from hospital, with one patient subsequently dying of a brain injury independent of the successful venous stent insertion. no complications were reported at up to 8 months follow up in remaining cases including stent leak, stenosis or migration. conclusion: endovascular venous stents have been used successfully in managing complex abdominopelvic traumatic venous injuries. in particular retrohepatic venous injuries refractory to hepatic packing and vessel embolization, which are not amenable to direct surgical repair due to anatomical location. however before endovascular stenting can be added to the arsenal of interventional radiologists for abdomino-pelvic trauma, further development of stents custom made for venous injuries as well as prospective studies examining their long term safety and outcomes is needed. tracheal papilloma is a rare neoplasm growing from the tracheal or bronchial epithelium and has no specific clinical presentations. this is a 40-year-old female who complained of progressive dyspnea for about 2 months. physical examination was unremarkable and the there was no abnormal finding by the chest plain film. chest computed tomography was arranged and revealed a mass lesion located at the tracheal lumen with more than 80% luminal obstruction. we used fiberoptic bronchoscopy to evaluate the airway and found a mass lesion with pedicle originated from the posterior tracheal wall. cryotherapy was considered for the tumor mass removing to establish a patent airway. the pathologic report revealed tracheal papillomatosis without any malignant component. dyspnea was immediately improved and the patient chose closely observation after the bronchoscopic cryotherapy. aims: recent advances in laparoscopic surgery, both in techniques and instrumentation material, have led to the emergence of innovative technological fields, among which robotic surgery stands out.one of the handicaps of this surgery is its high cost as well as the long learning curve. in this stage a new tool arises, the flexdex semi robotic arm, which combines the precision and the range of movements of robotic surgery with the greater availability, simplicity of use and learning of conventional laparoscopic surgery.the objective of this study is to evaluate the efficacy and safety of the flexdex device in different laparoscopic procedures. methods: flexdex's is a three-axis gimbal technological device integrated in a conventional laparoscopic instrument that translates the surgeon's hand, wrist, and arm movements from outside the patient into corresponding movements of an end-effector inside the patient's body.the greater accessibility provided by the flexdex allows the surgeon to perform sutures in areas of difficult access where mobility with conventional laparoscopic instruments is not optimal. the comfort of the surgeon remains fundamental in any type of surgery, even more when we are in anatomical locations with complex access, especially for the realization of sutures. here is where surgical innovation instruments such as flexdex provides ergonomic comfort for the surgeon and improves the patient's safety, especially in high-risk situations, such as when performing anastomosis. results: we present a prospective series of 10 laparoscopic procedures carried out by the same surgical team being the initial experience in our environment in the use of the flexdex semi robotic arm for the realization of complex anatomical sutures.this is a case series of 10 patients to whom different surgical techniques requiring manual suture have been performed. these being 2 tapp procedures, 6 nissen-type fundoplicature and 2 reinforcements of colorectal anastomosis. it is important to note that in none of the cases complications were recorded conclusions: flexdex can provide an excellent alternative to the robotic systems in complex surgical procedures, offering surgeons the precision and control they desire while maintaining the balance of cost, outcome and patient benefit. background: a new single-port device (fsis-flexible-single-incision-surgery) is presented. this new platform has three working channels, two for rigid instruments and one for the flexible endoscope. the channel for flexible instruments offers a pneumatic sealing to avoid the air's leak of the cavity (abdomen, rectum, vagina) . in this study the preclinical data are shown testing the feasibility and safety for laparo-endoscopic instruments. methods: experimental evaluation of feasibility and safety in two stages. in the first stage a working channel with pneumatic sealing was tested in simulators to use a flexible endoscope. in the second stage (animal model) the single incision device that makes possible to use laparoscopic instruments and flexible endoscopes was tested. the measured variables were: time of the procedure, co2 employed, adverse intraoperative events, grip's losing, losing of pneumatic sealing, feasibility and safety of the procedure for the surgeon. results: the hysterectomy and double adnexectomy was done with a median time of 7.1 min. the median of the co2 consumption was 32.5 litres. only in one case (16.6%) the surgeon had problems with the abdominal navigation of the endoscope that was easily solved. the grip's lose wasn't a major problem. the median size of the skin incision was 5.4 cm. the median surgeon' score for the feasibility was 10 and for the safety was 9.6. conclusions: the surgeons considered that the use of the device was very feasible and safe. the fsis-device is a universal platform for single-incision-surgery for surgeons and gastroenterologists and for abdominal, rectal and vaginal access. aim: despite the near-infrared fluorescence (nirf) via the intravenous administration of indocyanine green (icg) improves the visualisation of the cystic duct (cd) and the extrahepatic biliary tract (ebt), the back fluorescence of the liver reduces the signal-to-noise ratio.we have modified the technique of nirf cholecystocholangiography with intragallbladder icg injection by using the arrow-karlan tm balloon cholangiography catheter instead of the purse string at the gallbladder's fundus. this procedure allows a high rate of visualisation of the ebt, with few cases of icg leakage.aim: of this study is to confirm the feasibility of this different technique and to analyse the icg spillage from the gallbladder and to identify the ebt. methods: we enrolled nine patients undergoing laparoscopic cholecystectomy for cholelithiasis. the gallbladder was perforated with the cholangiogram catheter, the balloon inflated with 0.5 ml of saline and tightened. the bile was drained and the icg bolus injected. a titanium clip was the placed on the catheter strict closely to the gallbladder in order to prevent the catheter dislocation. results: the cd and the ebt were visible before dissection in 6/9 and 8/9 patients respectively. after dissection the cd was visible in all the patients and the ebt again in 8/9 patients. there was only one icg spillage due to a tardive positioning of the clip. in a case of inflamed gallbladder this technique helped in the identification of the dissection plane. conclusions: our preliminary results of this ongoing study confirm the feasibility of this different approach as a possible alternative to the purse string and a good visualisation of ebt. introduction: robotic-assisted surgery is a promising technique for overcoming the limitations of laparoscopic surgery, especially with regards to complex and advanced surgical procedures. here, we describe the establishment and implementation of our robotic upper gastrointestinal (gi) and hepato-pancreato-biliary (hpb) surgery program within our center of excellence for minimally invasive surgery as well as the first-year results. method: robotic-assisted surgery was performed using the davinci xi surgical system tm and performed by two surgeons specialized in minimally invasive surgery (db and tk). our robotic surgery program of upper gi and hpb surgery was established in three steps: (1) first, surgical procedures with easier degree of difficulty were performed robotically, including cholecystectomy, minor gastric resections and fundoplications. (2) then, pancreatic distal resections, enucleations, adrenalectomies and atypical liver resections were robotically performed, as procedures with moderate degree of difficulty. (3) finally, advanced and highly complex procedures were performed, including right hemihepatectomy, complex pancreatic head resections (including portal vein resections), total gastrectomy and esophagectomy. data collected from july 2017 till july 2018 were retrospectively analyzed with regard to conversion rate, morbidity (clavien dindo grade £3) and mortality. results: within the first year, a total of 66 robotic assisted upper gi and hpb resections were performed. the first step of establishing our robotic surgical program included eight procedures. here, conversion rate, morbidity and mortality were 0%. within the second step of establishment 31 procedures were performed. conversion rate, morbidity and mortality were 27%, 10% and 0%. the last step included 27 of advanced and highly complex procedures. these procedures resulted in a conversion rate of 48%, 30% morbidity and 0% mortality. conclusion: our stepwise approach enables a safe implementation of a robotic surgical program for upper gi and hpb surgery with low morbidity and no mortality even for highly complex procedures. however, highly complex procedures required a high conversion rate, which might be caused by the early stage of experience. the standard surgical procedure of choledochal cyst is a complete excision of the cyst with rouxen-y hepaticojejunostomy and laparoscopic surgery had been increasingly used. this is still a challenging way to perform anastomosis due to the small diameter of bile duct and the possibility of bile leak or stricture. robotic system can overcome the shortcomings of laparoscopy with providing three-dimensional view, magnification, and articulated instruments. from jan 2014 to dec 2017, 22 patients underwent robotic cyst excision and hepaticojejunostomy by single surgeon. we reviewed the clinical data and compared with laparoscopic outcomes of early (from 2009 to 2011) and late (from 2014 to 2017) group, retrospectively. patients of robotic series were all female with mean age 35.3 years and bmi 23.7. the mean size of cyst was 3.2 9 5.0 cm, and todani type ia 10, ic 6 and iva 6, respectively. total 5 trocars were used with 3 robotic working arm and 1 assist and 1 camera. the mean operative time 248.5 ± 52.9 min, and it was similar with late laparoscopic group (236 ± 62.9 min) and significantly shorter than early group (395 ± 85.9 min).there were no open conversion in robotic and late laparoscopic group, however, the early laparoscopic group involved 35% of conversion rates. the hospital length was 7 ± 3.8 days in robotic group, and it was similar with late group (7 ± 3.5) and more shorter than early group (9.3 ± 6.8). in robotic series, postoperative complications occurred 3 patients. one case included cholangitis which was resolved after conservative treatment. bile leakage was developed in 1 patient, and treated with drain that inserted intraoperatively. last cases showed incisional hernia at postoperative 4 months, and was corrected by laparoscopic herniorrahphy. complications (n = 7) in late laparoscopic group included hepaticojejunostomy stricture and stone, bleeding of jejunal branch, portal vein thromobosis, acute pancreatitis, and adhesive ileus. there were no mortaility case in any groups.robotic surgery of choledochal cyst is a safe and feasible option with short-term results that are comparable to laparoscopic approach. general surgery, sanchinarro university hospital, madrid, spain background: the incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. the surgical management of these patients is still under debate. the aim of this paper is to evaluate the safety and feasibility of robotic enucleations. methods: we retrospectively reviewed our prospectively databases from november 2018. demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. results: 18 patients were included. the mean age of the patients was 61 years (48-74). the median body mass index was 26 (24-29). ten lesions were located in the pancreatic head, 4 in the pancreatic body, 4 in the pancreatic tail. operative time was 250 min (range 114-356), no intraoperative transfusion were needed and in one patient conversion to open approach was needed. in three patients grade b pancreatic fistula occurred. the mean postoperative stay was 8,4 days. conclusions: robotic enucleation is a feasible and safe approach, with low incidence of morbidity. the results of surgical treatment of patients with pulmonary tuberculosis were evaluated depending on the prevalence of the tuberculosis process and the type of surgical intervention used. according to the results of the questionnaire, 556 people operated on pulmonary tuberculosis in the period from 1 to 9 years ago, the frequency of cases of tuberculosis reactivation, the complicated course of the remote postoperative period, as well as the mortality and causes of lethal outcomes were assessed. it was found that after sublobular resection and lobectomy, treatment failure was noted at 3.2%, relapse of tuberculosis-2.2%, pleural empyema-1.1%, bronchial fistula-0.8%, cardiovascular insufficiency-in 1.3% operated. the mortality rate was 3.2% with a total clinical efficacy of 96.0%. after combined resection and bylobectomy, treatment failure was noted at 8.9%, relapse of tuberculosis-15.0%, pleural empyema-12.0%, bronchial fistulae-6.3%, cardiovascular failure-5.0% operated. the mortality rate was 12.6% with a total clinical efficacy of 87.4%. after pneumonectomy, treatment failure was noted at 5.6%, relapse of tuberculosis-5.6%, pleural empyema-3.8%, bronchial fistulae-3.8%, cardiovascular failure-3.8% operated. the mortality rate was 10.0% with a total clinical efficacy of 90.0%. robotic reduced-port splenectomy using single-site platform j.h. lee background: in the era of minimal invasive surgery, single incision laparoscopic splenectomy can offer some advantages compared to conventional laparoscopic splenectomy. but it requires expertise in minimally invasive techniques due to technical difficulties. the da vinci robotic reduced-port splenectomy using single-site platform permits greater freedom of movement and higher levels of accuracy than previous laparoscopic surgery through two small incisions. methods: we performed a retrospective review of all patients who underwent robotic reduced-port splenectomy using single-site platform at our institution between january,2015 and november,2018. one 3 cm periumbilical incision was made for glove port insertion and the other incision was made at left side of abdomen for additional 8 mm port insertion.the surgical technique is much same as open procedure. short gastric artery was ligated, firstly. splenic artery and vein were ligated individually. during the surgery, any stapling device was not used. vessel sealer was used for hemostasis and mobilization of spleen. a specimen was removed through umbilical port site within lap-bag. result: eight patients (6 female and 2 male) with median age of 33.5 years underwent robotic reducedport splenectomy using single-site platform (one case with combined robotic cholecystectomy for gall bladder stones without additional trocar). the indications were; hematological disease (n = 3), splenic mass (benign n = 4, malignant n = 1). preoperatively measured spleen size was ranged 5.5 cm to 16 cm (mean 11 cm). there were no intraoperative complications and open conversion. mean operative time was 132 min. (range 74-206 min) including docking (mean 19 min) and console time (mean 62 min) mean blood loss was under 10 ml. mean hospital stay was 5.2 days after surgery. one patient underwent oral anticoagulation therapy only for portal vein thromobisis without any symptoms, and thromobisis was resolved at 1 month follow-up ct scan. there were no clavien-dindo class iii or above postoperative complication. conclusions: robotic reduced-port splenectomy using single-site platform seems to be feasible and effective. it seems to overcome certain limits of previous robotic or conventional single-site laparoscopic splenectomy and single-site only robotic splenectomy. we think 8 mm additional port allows to use endo-wrist da vinci instruments such as vessel sealer which enhances dissection efficiency andsafety of procedures. aims: inguinal lymph node dissection carries an important risk of post-operative complications, mainly related with wound complications and long term lymphedema. the minimally invasive approach aims to reduce the morbidity of this procedure, avoiding the traditional groin incision but still allowing a full access to the lymph node basin. the authors aimed to describe their videoassisted inguinal lymph node dissection (vilnd) cases, comparing the surgical outcomes with a sample of open inguinal lymph node dissection (oilnd) cases. methods: we performed a retrospective descriptive study that compared the data from patients submitted to vilnd since 2017 (the year in which this technique was first performed in our institution) with the patients submitted to oilnd in 2015 and 2016. gynaecologic and urologic malignancies were excluded. the statistical analysis was performed using spssv25ó, with a p value \ 0.05 indicating statistical significance. results: a total of 62 cases of inguinal lymph node dissection were analysed, 33.9% of which vilnd (none of them requiring conversion to the open approach). melanoma was the primary tumour in 87% of patients. the vilnd and oilnd groups had no statistically significant difference between them regarding age, body mass index, smoking status or the reason for lymph node dissection-clinically detected lymph node vs. positive sentinel node biopsy. the mean of isolated lymph nodes in the vilnd (7.71) and oilnd (9.63) groups was also not statistically different (p = 0.109). there was no difference in the rate of post-operative seroma, wound dehiscence or lymphedema. the rate of surgical site infections was higher in the oilnd group-34% vs. 9.5% during post-operative hospital admission (p = 0.045); 29.3% vs. 4.8% after discharge (p = 0.036). conclusions: in our population of patients we conclude that the main advantage of the videoassisted approach regarding surgical morbidity lies in the reduction of the infection rate, as the published literature also confirms. the equivalent number of lymph nodes retrieved in both groups points toward the oncological safety of the minimally invasive procedure, that we hope to study further in the future after a longer follow up period. objectives: to evaluate the clinical feasibility of tumor localization technique with radio-frequency identification (rfid) clip marker methods: we developed the proto-type rfid integrated endoscopic clip (rfid-clip) and probe to detect it on serosa surface during the laparoscopic surgery. a pig weighing 40 kg was used as the specimen for the in-vivo test. endoscopist performed the application of the rfid-clip on porcine gastric mucosa. after then, the surgeon tried to find the location of rfid-clip using the detection probe and marked with the electrocautery. after the gastrectomy with 3 cm margin (each to proximal and distal), we confirmed the prediction of rfid-clip location and accuracy of resection. results: rfid-clip location was detected and recorded on the exact site of clip application. detection range was very short and we confirmed there are almost no differences between actual clip location and our prediction. this result might arise from using the low-frequency rfid tag to increase the accuracy through reduction of the range. however, some rfid-clip were not detected because of the issue of clipping trouble, not rfid tag. conclusions: this is a basic study to evaluate the clinical usefulness and feasibility of the new localizing technique. we confirmed the possibilities of this system and it could be the helpful option to provide the information of exact location for the minimally invasive surgery or early gastrointestinal tumors. background: the advantages of laparoscopic posterior retroperitoneal adrenalectomy (lpra) have been described in the literature. the aim of this study was to compare the clinical outcomes of lpra and robotic posterior retroperitoneal adrenalectomy (rpra) and determine the differences that could affect the outcomes. methods: we retrospectively analyzed 253 adrenalectomy cases at asan medical center from 2014 to 2017. there were 190 lpra and 63 rpra cases, and their clinicopathological features and surgical outcomes were compared. results: in lpra, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. in rpra, adrenal tumor size and pheochromocytoma were the only factors affecting the operation time. when the adrenal tumor size was = 5.5 cm, the operation time of lpra was shorter than that of rpra (p = 0.001). when the tumor size was [ 5.5 cm, there was no significant difference in the operation time of lpra and rpra (p = 0.102). conclusions: rpra is a feasible and technically safe approach for benign adrenal diseases. the use of rpra could benefit patients with large tumors and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique. methods: twenty years experience at the american university of beirut medical center for laparoscopic adrenalectomy. a total of 65 cases were done laparoscopically with no conversion and minimal complication. the average operative time is 40 mins.the video will show the various steps used for lap redo (lt) adrenalectomy for a 15 cm pheochromocytoma using the lateral position and through 3 trocars. attempt to remove the pheochromocytoma in iraque was complicated by cardiac arrest treated successfully and patient referred to the american university of beirut medical center. results: patient had smooth postoperative course following laparoscopic adrenalectomy and patient discharged 3 days later with no complications. conclusions: even large adrenal masses can be completed laparoscopically in advanced experienced centers in laparoscopy. surg endosc (2019) aims: the adrenocortical of uncertain malignancy neoplasm is a spectrum of classification for adrenal tumors whose histopathological diagnosis is uncertain. clinical case: we present a 65 year old patient with constitutional syndrome and severe hypercortisolism and hypokalemia reason why she was admitted to icu for episodes of ventricular fibrillation. no other medical history of interest except refractory hypertension to treatment. the tc showed a left adrenal mass of 6.5 9 4.5 9 5 cm with microcalcifications, areas of necrosis and hemorrhage, no infiltrating, without disease to distance. the surgery was a laparoscopic left adrenalectomy with no evidence of infiltration and no lymph nodes. the histopathology lesion presented a dense proliferation cellular of cortical type, with incomplete fibrous, without vascular or capsular invasion, with a 30% ki67; positivity vimentin and cd56. all epithelial markers, were negative. all this leads to the diagnosis of a neoplasm of uncertain malignancy potential adrenocortical. during the postoperative period, the patient presents a crisis of adrenal insufficiency that was treated with intravenous replenishment corticoidea and later orally with good clinical response. discussion: the adrenal carcinoma has a low incidence (0.1%), incidence peak around the 50 years, the most frequent is the mixed secretory. they are 2-5% of the adrenal incidentalomas. it is usually presented to the diagnosis as a locally advanced tumor with metastases (to liver, lung, retroperitoneal ganglia and bone). may present clinically due to hormonal hyperproduction; or be non-functioning tumors. the adrenal carcinoma poses a great difficulty at the time of the diagnosis pathological, and includes as differential diagnosis to other abdominal tumors. the distinction between corticoadrenal adenoma and adrenal carcinoma is sometimes difficult, so it has been defined a spectrum of intermediate category called adrenocortical neoplasm of intermediate or uncertain malignancy. it is obtained with the weiss criteria, being necessary at least 3 of them for confirm the diagnosis of adrenal carcinoma. this category has a low risk of local recurrence or metastasis, but it needs a narrow follow-up. conclusion: adrenal carcinoma of uncertain malignancy implies a new category in those tumors of difficult classification. aims: multiple endocrine neoplasia type 2 (men2) is an autosomal dominant disorder with an estimated prevalence of 1 per 30,000 in the general population. among patients suspected to have a pheochromocytoma, the diagnosis is rarely confirmed and only 10% is presented bilaterally. we present bilateral laparoscopic adrenalectomy in patients with men2. method: a 77-year-old woman with a family history of medullary thyroid cancer and breast cancer. personal history: hypertension, medullary thyroid cancer, breast cancer, laparoscopic cholecystectomy. appendectomy. after a study by endocrinology and suspicion of bilateral pheochromocytoma, discussing the case in a multidisciplinary committee, bilateral adrenalectomy was decided by laparoscopic approach. selective alpha-1-adrenergic blocking agent (doxazosin) were utilized before surgery. under general anesthesia left adrenalectomy was performed first in right lateral decubitus position. 15 mmhg pneumoperitoneum was started with the verres needle and 3 trocars (11 mm umbilical, 5 mm subxifoid and 12 mm left subcostal).once dissection was completed the gland was placed in a plastic bag and extracted through one of the trocars incisions, then the position of the patient was changed to left lateral decubitus for the right adrenal approach. another right subcostal 5 mm trocar was used. adhesiolysis of previous cholecystectomy was performed to right adrenal approach. adrenal veins were divided between metallic clips.no drainage was employed. results: the procedures were successfully performed without conversion. surgical time was 150 min and hospital stay was 2 days. had a clinical reversion with control of blood pressure monitored by endocrinology conclusions: currently, the laparoscopic approach is the technique of choice for the management of adrenal pathology.lateral decubitus transperitoneal approach is the procedure of choice in most cases. bilateral laparoscopic synchronous adrenalectomy is feasible and safe with good results as in our patient. traditionally the treatment of hyperparathyroidism for patients with familial hyperparathyroidism was subtotal parathyroidectomy or total parathyroidectomy and auto transplantation. in the era of minimally invasive parathyroidectomy, the removal of only abnormal glands guided by preoperative localizing studies has been suggested. aims: this systematic review aimed to investigate the role of focused minimally invasive parathyroidectomy in the treatment of patients with familial hyperparathyroidism. methods: electronic databases were searched with the search terms 'men i', 'familial hyperparathyroidism', 'men2a','hyperparathyroidism-jaw tumor syndrome', 'parathyroidectomy', 'minimally invasive ', for the time period up to and including december 2018. full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria. results: thirty five possibly relevant studies were identified. abstracts were reviewed and fifteen articles were excluded. twenty studies, that met inclusion criteria were retrieved in full text and included in the systematic review, including three retrospective cohort studies i.e. two presenting data on meni associated hyperparathyroidism and the third study on familial hyperparathyroidism and seventeen small case series or case reports. the two retrospective studies on meni hyperparathyroidism included 125 patients treated either with focused minimally invasive parathyroidectomy or with the conventional approach. these studies presented conflicting data with one supporting and the other negating the focused minimally invasive parathyroidectomy due to the failure of localization studies to identify enlarged parathyroid glands in a great number of patients. conclusion: undoubtedly, the idea of minimally invasive parathyroidectomy in patients with hereditary and familial hyperparathyroidism is interesting. this idea is especially challenging in the case of meni. existing data suggest that focused mimimally invasive parathyroidectomy is feasible under the condition of exact preoperative localization studies. the main advantage of this approach is the minimization of the risk of postoperative hypoparathyroidism. however, data are limited and further research is needed before valid conclusions can be drawn on the suitability of this approach. objective: resection of pheochromocytomas is a challenging procedure due to hemodynamic lability, tumor vascularity and malignant potential.given the technical challenges for resection of large pheochromocytomas, there were hesitations about using the laparoscopic approach for these tumors during the first decade of laparoscopic surgery. however, improvement in imaging modalities,better pharmacological preparation,advances in anaesthesia and laparoscopic surgery rendered laparoscopic surgery for pheochromocytomas safe and efficient. our aim was to evaluate surgical outcomes in 86 patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. design: a total of 85 procedures for pheochromocytoma were performed between january 1998-september 2018. the preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow up were retrieved from the hospital records of 668 patients who underwent 686 adrenalectomies for benign and malignant adrenal tumors in the same period. preoperative localization was established in all patients with computerized tomography (ct) or magnetic resonance imaging (mri), while iodine -123-metaiodobenzyguanidine(mibg) scan was reserved for ambiguous cases where paraganglioma or metastatic disease was suspected. endocrinological evaluation and complete adrenal dynamic testing were performed to determine whether the tumor was functional or not. results: eighty-seven tumors were removed from 85 patients. one patient with meniia underwent bilateral resection of pheochromocytomas in two stages. tumor size in laparoscopic procedures ranged from 1.2 cm to 11.0 cm (mean 5.87 cm). forty-three patients had benign disease, 41 potentially malignant (based on pass), 1 malignant with metastasis. eight were in the context of a familial syndrome. sixty -eight patients underwent laparoscopic adrenalectomy, 8 patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, 1 patient had open approach due to inoperable malignant pheochromocytoma and 10 patients had conversions from laparoscopic to open procedure. nine patients received sodium nitroprusside intraoperatively to treat hypertension. one patient developed pulmonary embolism, and succumbed 1 month later. there were no recurrences for the benign tumors during the follow-up period. conclusions: laparoscopic resection of pheochromocytomas despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure. aim: the concept 'large' in transperitoneal lateral laparosopic adrenalectomy (tlla) has been evolving along time, ranging from 5 to 8-10 cm depending on different authors. on the other hand, some authors discourage laparoscopic surgery in larger tumors due to the increased risk of malignancy in those larger than 5-6 cm, referring to malignancy in 1 out of 3 or 4 cases. paragangliomas are rare tumors originated in extra-adrenal chromaffin cells, with an incidence of 2-8 cases per million inhabitants. they can appear in any location between neck and pelvis. sympathetic paragangliomas are usually functional and catecholamines producers. we present a movie of surgical intervention of a 22-year-old patient who, in study for refractory hypertension, presented paraganglioma producing norepinephrine, whose approach was performed laparoscopically. 22-year-old woman studied by nephrology for refractory hypertension. on physical examination, only obesity standed out. in blood exams, levels of normetanephrine were observed in plasma of 1950 pg/ml and aldosterone 832 pg/ml. abdominal scintigraphy was performed in which there was no evidence of increased activity at adrenal level. abdominal ct shows retroperitoneal extra-adrenal tumor of inter-aortocava location immediately below renal vessels with dimensions of 3.6 9 2.1 9 6 cm. after preparation, she was operated. laparoscopic access was performed under exhaustive monitoring. an heterogeneous, polylobulated tumor of 6 cm, located interaortocava, intimately adhered to left renal vascular pedicle, was observed. a cattell-braash and kocher maneuver was performed, with exposure of inferior cava and aorta to iliac bifurcation. complete tumor excision was performed after clipping arterial and venous tributary branches. after the operation, the pacient presented favorable evolution being discharge on the second postoperative day with good control of blood pressure levels. laparoscopic approach of retroperitoneal paragangliomas is a safe technique, which allows minimally invasive access, with consequent improvement in postoperative results. the exact location of lesions and their relationships with surrounding structures, as well as their functional behavior, are very important when considering the best therapeutic strategy for these patients. we present the case of a 50-year-old obese male patient referred for adrenalectomy after being diagnosed with left adrenal incidentaloma. abdominal mri showed a 4.7/4.1/3.9 left adrenal mass with normal hormonal levels. after preoperative workup, the patient underwent standard laparoscopic adrenalectomy. the lateral to medial dissection and mobilization of the spleen and pancreatic tail was difficult due to the abundance of peritoneal and pararenal fat. the anatomy was peculiar: the bulky pancreatic tail was located well inferior to the splenic hilum and was visible throughout the intervention and the spleen was quite elongated-long axis = 15 cm. the exposure of the adrenal gland was therefore cumbersome. the operating time was 128 min and blood loss 170 ml. the abdominal drainage was maintained for 48 h. before discharge the patient underwent a control abdominal us examination that only showed a thin line of left pleural fluid. the patient was readmitted 6 days after discharge for chest pain, fever (38.9°c) and malaise with no abdominal signs. the emergency ct scan diagnosed left basal pneumonia with minimal pleural effusion and a 7/1 cm fluid collection between the spleen and diaphragm while the blood test showed leukocytosis. the patient was treated for pneumonia with an apparent clinical benefit for three days and lowered white cell count but his condition worsened during the forth day. repeat abdominal us demonstrated that the abdominal collection increased in size therefore the patient underwent emergency surgery. during laparoscopic exploration, the collection was unveiled as being pancreatic juice (more than 7 times the normal serum levels of lipase and amylase). after thorough lavage, two drainage tubes were positioned in the left subphrenic space. the postoperative course was uneventful under antibiotic treatment for pneumonia and pancreatic antisecretory medication. the patient was discharged after 7 days with minimal pancreatic drainage and the drainage tube was extracted after 5 more days. the aim of the study was to develop the algorithm and the choice of the method of endoscopic treatment of a combined pathology of uterine leiomyoma and adenomyosis depending on the reproductive plans. methods: the study involved 60 patients with a combined pathology of uterine leiomyoma and adenomyosis. indications for conservative myomectomy were: the size of the uterus is more than 13 weeks. pregnancy; multiple leuomatous nodes and adenomyotic foci up to 5 cm in size; hemorrhagic and pain syndromes, anemia, compression of the adjacent organs; suspected node malfunction; submucous leiomyoma deforming the uterine cavity with foci of adenomyosis; subserous, cervical isthus nodes and foci of adenomyosis; the presence of endometrial hyperplasia, tumors of uterine appendages; growth rate of uterine leiomyoma more than 4 weeks pregnancy for the year; the growth of uterine leiomyoma on the background of drug treatment; infertility associated with leiomyoma and uterine adenomyosis.the laparoscopic myomectomy of the subserous node on the 'leg' with a size of more than 6 cm and nodes of more than 8 cm of intramural location is shown with an interest in preserving the organ.the hysterectomy is indicated for women after 43 years of age who insist on hysterectomy, with a combination of uterine leiomyoma with atypical endometrial hyperplasia. results: the conservative myomectomy and removal of adenomyotic foci were performed in 24 (40.5%) patients: from hysteroscopic access-4, vaginal access-3, laparoscopic access-13, abdominal access-5 in the presence of reproductive plans.the hysteroscopic myomectomy was performed in 8 (21.1%) patients, hysterectomy in 30 (78.9%) patients: from laparoscopic access-23, from vaginal access-3, from abdominal access-4 in the absence of reproductive plans. conclusions: the choice of surgical treatment of uterine leiomyoma and adenomyosis depends on the reproductive plans of the woman and the severity of the lesion.the laparoscopic method of treating a combined pathology of uterine leiomyoma and adenomyosis in the presence and absence of reproductive plans is a priority for women. surgery, policlinico ,,paolo giaccone,,, palermo, italy background: breast cancer in females represents the most frequent neoplasm in all age groups. the risk of getting breast cancer (mc) increases with age. the brca1 and the brca2 genes (tumor-suppressor genes, autosomal dominant transmission at high penetrance) alone justify from 30% to 70% of cases of hereditary breast cancer. methods: from 1 january 2011 to 1 june 2017 we have analyzed 18 patients with brca mutation. all 18 patients had in common a genetic mutation of brca1 or brca2 tumor suppressor genes. results: the frequency of germline mutation on brca1 (9 patients: 50%) was identical to brca2 gene (9 patients: 50%). 13 of the analyzed patients were women (72.2% of patients) 9 brca1 and 4 brca2, and 5 men (27.8%) all with brca2 mutation. conclusions: prophylactic surgery must be seen as a way to put the patient in the condition to implement the most appropriate treatment. further studies will be necessary to support the validity of prophylactic surgery in patients with mutations in brca1 and brca2 genes. introduction: laparoscopic hysterectomy is a safe surgical technique for removing the uterus with or without including the ovaries and fallopian tubes. laparoscopic surgery of endometrial cancer is a safe method, with the mean time of recovery being two days only. material-method: the case of a 55 yr old woman with metrorrhagia and anaemia (ht 24,5%) due to adenocarcinoma of the endometrius is presented. the patient underwent a laparoscopic hysterectomy and oophorectomy. 4 trocar ports were used during the procedure (a 10 mm transumbilical port, similar to the port used in single incision laparoscopic operations, two 5 mm ports at the level of the anterior superior iliac spines, and a 10 mm port in the middle of the imaginary line between the pubic symphisis and the umbilicus). the uterine vessels and the uterine ligaments were ligated and dissected by using a thermal energy source. the patient's postoperavite course was uneventful. the patient continues to be in good condition, 6 months post-surgery. conclusion: laparoscopic hysterectomy seems to be a safe method for addressing endometrial cancer, as it offers the surgeon a better surgical field, is tissue friendly and causes fewer postoperative complications. it is considered to be a less traumatic operative method, as due to zooming in the picture there is greater accuracy in handling the tissue, and blood loss is minimal. m. shahin background: hysterectomy is one of the most frequently performed surgical procedure. though there are three approaches in hysterectomy (open, vaginal and laparoscopic), still there are controversies regarding the optimal route for performing it. methods: this prospective comparative study included 42 obese patients subjected for panhysterectomy as a treatment. the forty-two patients were allocated into two groups: group (a) subjected to laparoscopic pan-hysterectomy, group (b) subjected to open pan-hysterectomy. results: there was significant difference between the two groups regarding mean operative time, blood loss, analgesic requirements and hospital stay, while no significant difference regarding intra-operative complications. conclusions: laparoscopic hysterectomy in obese patients has emerged as a viable, safe and better alternative to open hysterectomy amongst appropriately trained surgeons. general: endometriosis in the inguinal region is rare. the usual presentation is that of a woman in the reproductive age group. it accounts for 0.3-0.6% of patients affected by endometriosis. the groin swelling is usually slow growing, painful with exacerbations during menses. the incidence of inguinal endometriosis on the right side is 90-94% as compared to the left. aim: to present our laparoscopic approach for the treatment of the diagnostic dilemma. case presentation: a 40-year-old woman presented with a palpable mass in the right groin. the swelling was associated with a dull aching pain. the patient was suffering from increasing pain over the swelling during menstruation. she had undergone cesarean section some years ago and the scar had healed by primary intention. mri scan revealed a nodular hypoechoic lesion at the level of the internal inguinal ring with the absence of vascular flow around the lesion. results: since inguinal endometriosis was in the differential diagnosis and it may be associated with pelvic or intraperitoneal endometriosis, a laparoscopic approach was decided. the procedure was successfully completed laparoscopically following the transabdominal preperitoneal approach. the endometriosis was found, after dissecting the internal inguinal ring, firmly adhered to the round ligament. it was excised en bloc with the round ligament. a preperitoneal polypropylene mesh was inserted to protect for future inguinal hernias due to extensive dissection at the level of the internal inguinal ring. no intraperitoneal endometriosis was appreciated. histopathology revealed endometriosis of the round ligament. the patient was uneventfully discharged the next day. on follow up the patient was asymptomatic. conclusions: round ligament endometriosis is a rare entity. it is a disease of specific interest to the physician. it can be confused with an inguinal hernia and thereby pose a diagnostic dilemma. we recommend considering endometriosis in the differential diagnosis of groin swellings in women. the transabdominal preperitoneal approach is feasible and safe in the hands of an advanced laparoscopic surgeon. introduction: sentinel node biopsy is the newest accepted method for surgical staging of early stage endometrial and cervical cancer. aim: to evaluate the role of the technique of indocyanine green (icg) identification of the sentinel lymph nodes in cases of early endometrial cancer. material and method: five patients with early endometrial and cervical cancer were introduced in a prospective study. icg was locally injected during the laparoscopic exploration. novadac pinpoint near to red technology was used. guided biopsies were performed into the marked sentinel nodes and histological results were evaluated. results: sentinel lymph nodes were easily identified by using icg and near-infrared technology. technical details are described. no associated complication was encountered. conclusion: sln mapping using icg in uterine cancers is demonstrated as an effective and safe procedure. laparascopic extraction of an intraperitoneal gossypiboma following c/s and a retroperitoneal gossypiboma following pyeloplasty n. ozlem general surgery department, ahievran university, kirsehir, turkey gossypibomas are forgatten foreign bodies,iatrogenic.their symptoms are different where they are. they extracted with laparotomy in the past but now we can some article mentioned their extraction was made with laparoscopy. case 1: 33 y o female has abdominal pain after c/s for 2.5 years. a gossypiboma was extracted with laparoscopy above umblicus.a superficial surgical site infection existed,drained,subsided. case 2: 46yo m had a pyleoplasty operation 8 years ago.a gossypiboma was extracted with retroperitonescopy,no postoperative event. basibuyuk et al reported retroperionescopic extraction of a gossypiboma from single port in first time.althoug every effort taken the incidence of foreign body detected in the body is about 0.03-0.1%.they are most frequently localized in the intraabdominal cavity followed by tracheobronchial area,pleural cavity,pararenal area,vagina,spinal chord, neck, femur,breast,bladder,pancreas,and they may cause local irritation,and infection.tactile sense is absent in laparoscopy. all radiologic examinations(usg ct pet mri etc) be used to detect.we used usg ct.in the end laparoscopy make the diagnosis and remove gossypibomas in our cases with less postoperative pain and cosmosis. justo et al the computerized tomography (ct) scan is the most useful method for diagnosis; however, sometimes the preoperative diagnosis remains uncertain even after the imaging exam. in that case, laparoscopy arises as a valuable diagnostic tool, as well as a prompt treatment option. concerning gossypiboma, prevention is preferred rather than treatment. notwithstanding, there is no highly reliable prevention system. counting sponges is a method based on staff communication during the surgery with only 77% sensibility. routine surgical postoperative x-ray (spox) constitutes an early detection system, but the need to incorporate a radiopaque marker and to expose the whole surgical field to maximize its efficacy limits its use. more recently, electronic dispositives based on barcode detection and other technological adjuncts for counting sponges are being developed. none of these prevention systems are reliable when used alone. our education and research clinic was a state hospital before. no surgeon followed above instruction.but now we use all. multiple procedures and surgical teams, long operations and non-elective operations are the evidenced risk factors.c/s operation was learned full opened of ostium of cervix of the patient. urology, japan, nagoya, japan aims: some scoring systems have been suggested to standardize the renal tumor characteristics. among them, renal score is widely used in partial nephrectomy. whereas diameter-axis-polar (dap) score was developed to be more significantly related with postoperative renal function. our study compared dap score with renal score in robotic partial nephrectomy (rpn) outcomes. methods: records of patients who underwent rpn at nagoya daini red cross hospital between april 2016 to october 2018 were analyzed retrospectively. those include three oncocytomas. accordingly, we calculated the estimated glomerular filtration rate (egfr) just before rpn and 1 month postoperatively in 51 patients. we compared two nephrometry scores with warm ischemic time and change in egfr. results: in our institution, four surgeons performed rpn. according to dap score, 14 patients were high, 19 were middle and 18 were low. according to renal score, 1 were high, 26 were middle and 24 were low. the median warm ischemic time was 20 min (11-35). the median egfr decreased from 67.9 (23. 2-127.3) to 57.8 (10.7-116.9 ) ml/min/1.73 m 3 . there were no significant differences in warm ischemic time and percentage change in egfr between renal score groups (p = 0.38 and 0.87) but significant differences between dap score groups (p \ 0.05 and p \ 0.05). univariate and multivariate analyses were used to identify factors influencing postoperative renal function. that confirmed that dap score was independent poor predictors of change in egfr after rpn. conclusions: dap score is simpler estimate system than renal score. our study suggested that dap score is a useful scoring system for preoperative evaluation of renal tumor for rpn. further investigation is needed to better understand preoperative dap score. aims: retroperitoneal primary tumors comprise a great variety of neoplasm with different histological typologies, with insidious clinical symptoms and little specificity in most cases. its diagnosis is established through imaging tests and anatomopathological study is needed so complete surgical resection is the treatment of choice. the aim of the video is to demonstrate the safety and efficacy of the minimally invasive approach in patients with retroperitoneal lesions. methods: a 66-year-old female patient who, in the course of an abdominal pain at the right iliac fossa suspected of possible acute appendicitis, is diagnosed with a right retroperitoneal tumor, compatible with primary neurogenic tumor on a ct. radiographic imaging is a key component of the evaluation of a patient with a retroperitoneal mass, a ct scan is necessary to evaluate the primary site as well as to rule out metastatic disease. after complete biochemical study, nonfunctioning tumor is determined. the study is completed with mri where the lesion is located below the right kidney, in front of the right psoas muscle and lateral to the inferior vena cava, and without contact with these structures. ??it is in intimate contact with the ovarian vein. the complementary tests and iconography of interest of the case are exposed. surgical intervention is proposed with a laparoscopic approach. results: full minimally invasive approach in left lateral decubitus position: 4 trocars-lateral laparoscopic transabdominal approach. laparoscopic liberation of the right colon, kocher maneuver until the inferior vena cava is visualized, identification of a tumor of approximately 5 cm in the right infrarenal region, lateral to the right ureter, which includes the gonadal vessels. resection of the tumor in block with margins previous dissection and clipping of the proximal and distal gonadal vessels with ligasureò. the patient presented a successful postoperative recovery, being discharged 24 h after the intervention. definitive result of the specimen: leiomyosarcoma, grade 2 of the fnclcc with negative margin. the laparoscopic approach is a safe and effective technique in the approximation of retroperitoneal tumors, a radical oncological criterion is always needed with correct margins of resection especially in those of uncertain etiology. we started endoscopic thyroidectomy using the lifting method in 2001 and have developed single incision endoscopic thyroidectomy (siet) via chest (c-) or axillary incision (a-) by our original retractor since 2007. we created a new approach in 2010. recently, we have applied this method to parathyroid surgery. in this study, we present our method and results in parathyroid surgery with regard to surgical outcome and patients' complaints. method: endoscopic parathyroidectomy of c-siet was performed in 6 patients with hyperparathyroidism (primary 4, secondary 2) in new approach (mean age 69, male 1 female 5). single parathyroid adenoma was diagnosed using ultrasonic device, preoperatively. the patient is placed in a supine position with the neck extended. 30 mm vertical incision is made in anterior chest. flexible endoscope (olympus co. japan) is used through 5 mm trocar detached the retractor. in new approach, the parathyroid and thyroid are exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle. both of the skin and sternal head are lifted up by our original retractor (takasago medical co. japan). parathyroid adenoma behind the thyroid is resected using an ultrasonic scalpel. i would like to present our c-siet procedure. results: no scars in the neck were left in all cases. benign and hemi lateral parathyroid adenoma sized from 8 mm to 25 mm (mean:16.5 mm) were operated. mean operation time is 123 min. in new approach. there was no complication. parathyroid hormone levels decreased in all patients immediately after operation. conclusion: it is a little possible to make recurrent nerve palsy in this approach. new approach is useful to operate and make the working space wider without stress to find out of parathyroid adenoma. our original retractor can be introduced easily in most hospital, because it is not so expensive. most of women satisfied cosmetic results because of hidden scars. objectives: radiofrequency ablation (rfa) is a novel and developing technique for the treatment of parathyroid hyperplasia/adenoma in the context of secondary hyperparathyroidism (hpt) to chronic kidney disease (ckd) and there is little literature on the subject. the purpose of this study is to determine its usefulness by contributing a case carried out in our hospital. methods: we selected a case of secondary htp in a patient of 62 years old with ckd who presented a parathyroid adenoma detected clearly by ultrasound scanning. the patient was dismissed for surgery due to high surgical risk due to his comorbidities. rfa of a right inferior parathiroid adenoma was performed. intact parathyroid hormone (ipth) was measured before arf and 10 min after de procedure, calcium and phosphorus were measured the day after. the treatment was considered effective if ipth levels decreased at least 50% 10 min after rfa and calcium levels decreased the day after. results: ipth level before rfa was 1985 pg/ml. ipth level after 10 min of rfa was 835 pg/ ml, this meant a 58% reduction (normal values 15-65 pg/ml). calcium levels were from 10.2 at the baseline to 8.6 the day after (normal values 8.5-10.5 mg/dl) and phosphorus from 4.5 to 5.4 mg/dl (normal values 2.5-4.5 mg/dl). the patient presented dysphonia as a complication that improved with corticosteroid therapy. we are currently waiting for the next analytical controls at 3, 6 and 12 months after the proceidure. conclusions: rfa of parathiroid adenomas for treating secondary hpt in patients with ckd is feasible in selected patients. this treatment may reduce the morbidity that surgery supposes, it is developed in an outpatient regime avoiding hospital admission and this contributes to a reduction of health costs. however, a longer follow-up is necessary to verify the good results in our case. splenectomy is one of the treatment strategy for advanced portal hypertension due to liver cirrhosis. after splenectomy, thrombocytopenia is dramatically ameliorated, and liver function parameters have also been improved in several clinical settings. however, the mechanism underlying such a phenomenon remains unclear. the aims of the present study was to analyze histological changes of the liver after splenectomy in human, and to speculate the underlying mechanism. subjects and methods: cirrhotic patients with hepatocellular carcinoma (hcc) who had undergone laparoscopic splenectomy prior (4 weeks-52 months) to hepatic resection were analyzed (n = 15). non-tumorous liver specimens obtained at hepatectomy were histologically investigated. liver tissues from cirrhotic hcc patients who underwent only hepatectomy were used as controls (n = 15). results: after splenectomy, significant leukocytosis, especially increase in monocytes, was observed in addition to thrombocytosis. in the non-cancerous liver tissues, many round-shaped cd68-positive macrophages accumulated after splenectomy, while this phenomenon was merely observed in patients without splenectomy. the macrophages were cd163 ? (m2 marker) and cd14 -cd16 ? , suggesting their anti-fibrotic population. the accumulated macrophages existed around fibrous scar as well as ck19 ? epcam ? cells spreading out from the ductular reactions (dr). as a result, the number of ki67-positive hepatocytes significantly increased after splenectomy. the amount of platelets detected in the liver did not change even after splenectomy. finally, remarked attenuation of the established liver fibrosis was detected after relatively long duration. the accumulated macrophages expressed metalloproteinase (mmp)-1 and fibroblast growth factor (fgf)-7, suggesting these molecules may possibly participate in resolution of established fibrosis and hepatocyte proliferation. conclusion: splenectomy in cirrhotic patients with portal hypertension ameliorate liver fibrosis, and stimulate liver regeneration. the mechanism possibly include hepatic accumulation of anti-fibrotic cd163-positive macrophages and stimulation of dr-derived ck19 ? epcam ? progenitor-like cells. in patients with advanced splenic fibrosis, splenectomy could be a feasible therapeutic modality. the paper tries to establish the role and the opportunity of using laparoscopy in regard with abdominal contusions, as well as its indications or contraindications, combined in a therapeutic algorithm. we analyzed two groups of patients with abdominal contusions divided over two 5-year periods, 2008-2012 (51 patients) and 2013-2017 (60 patients) respectively. we have separated the two periods because starting from 2013 we have established a strategy for dealing with cases of abdominal contusions where we included diagnostic and / or therapeutic laparoscopy and nonoperative management. the investigation was done by fast echography, ct scan, simple abdominal radiography, peritoneal lavage puncture, and sometimes arteriography. in the second period we determined the diagnostic and therapeutic laparoscopy indications: suspicion of hollow or parenchymal organ injury, or mesentery injury, the presence of hemoperitoneum or fluid in the peritoneal cavity in a stable patient without major hemorrhage, apparent with unique injuries, without immediate vital risk and without other associated severe trauma. we have associated in this last period the nonoperative management for patients with grade 1 and 2 lesions of parenchymal organs that do not have fluid in the peritoneum, or only a very discreet quantity. in the first period, all 51 patients were treated by classic surgery, resulting in 4 unnecessary laparotomies where no visceral lesions were revealed. in the second period, we applied non-operative management to 8 patients out of 60, 2 patients with grade 1 and 2 splenic injuries, and 6 patients with grade 1 and 2 hepatic lesions. diagnostic laparoscopy was performed in 5 cases, in 2 of them without evidence of lesions, and in 3 other cases of grade 1 lesions no therapeutic action was required. therapeutic laparoscopy was required for one case of splenectomy and one of hepatorrhaphy. diagnostic laparoscopy is useful in abdominal contusions, if certain indications are followed and in selected patients. in our study, with the introduction of modern therapeutic strategies, unnecessary laparotomies were completely avoided, some lesions being even treated by laparoscopy. the new algorithm introduced allowed 23% of patients to avoid laparotomy. aims: about 150 cases of splenic hamartoma have been described in the literature since it was first described by rokitansky in 1861, it is a rare benign tumor. it is usually a casual finding in laparotomies or autopsies. they are usually asymptomatic, but there are few symptomatic splenic hamartomas and they can be associated with haematological alterations, being in some cases associated with spontaneous splenic rupture and acute abdomen, two thirds of them have multiple tumors. there are no specific data that allow the preoperative diagnosis of this entity, which is performed after the anatomopathological study of the surgical specimen, which must be extracted entirely, this together with the size of the spleen makes the laparoscopic approach difficult. the aim of this video is to demonstrate the surgical technique of a complete laparoscopic approach for this type of lesions, without the need for assistance laparotomies (handport). methods: clinical case: a 44-year-old man admitted to internal medicine due to fever and left lumbar pain. additional explorations of interest are discussed, including: thrombopenia of probable peripheral origin secondary hypersplenism (fna of bone marrow), ct: splenomegaly with 4 splenic masses, which deform the splenic contour, compatible with atypical hemangiomas, without being able to discard other vascular splenic tumors. results: complete semi-laparoscopic approach, 4 trocars, multilobulated splenomegaly (19x16 cm.), mechanical vascular section, complete bag extraction after minilaparotomy on the left flank. the patient presented a successful postoperative recovery, being discharged on the 4th po day. abdominal ultrasound at 1st week with portal vein thrombosis, which resolves after treatment with heparin. definitive result of the specimen: multiple splenic hamartoma. asymptomatic one year after surgery. the laparoscopic approach is a valid and effective alternative to splenic benign tumor lesions. the size does not contraindicate this type of approach, although the complete extraction of the spleen is recommended for its pathologic study. we recommend eco-doppler control per week, given the risk of portal thrombosis with an existing laparoscopic post-splenectomy. objectives: splenic cysts are a rare entity, currently described between 800-1000 cases in literature. a female patient's case is hereby presented, giant splenic cyst treated by conservative laparoscopic surgery obtaining good results. method: 30 years old female, without any relevant medical history, examined after abdominal pain on the left hypochondriac region, nausea, postprandial swelling and mass sensation. after exploration the presence of such mass was ratified, the rest of exploration found no relevant findings, no record of previous traumatism nor any other relevant incidence. diagnosis was made through ultrasound and computerized tomography, the existence of a big splenic cyst is confirmed, 19 cm by 14 cm, on the superior section of the spleen, negative results after parasitism test, normal haemogram, coagulation and biochemistry levels. patient was intervened using laparoscopic surgery, performing the deroofing technique on the cyst (two liters of orangey amber serous liquid that was sent for analysis) as well as extirpation of superior wall of the cyst, which was sent to pathological anatomy, a saline solution was used to cleanse the cavity, omentum and drainage were then set in place. results: patient evolved satisfactorily, hospital discharge and drainage withdrawal after 48 h. regular check-ups, after 12 and 24 months, patient presents no symptoms nor recurrence. pathological anatomy confirmed primary splenic cyst and the extracted liquid as cystic. conclusion: splenic cysts are primary (25%) or secondary (75%). diagnosis is performed through imagery tests, cat scan the being standard test used. regarding her treatment there is no clear consensus, due to the fact that up to a few years ago, complete splenectomy was the recommended treatment, techniques with preservation of the spleen are currently being widely recommended through laparoscopy in literature. among the conservative techniques percutaneous aspiration, with or without the injection of a sclerosing agent, partial splenectomy, marsupialisation, cystectomy, decapsulation, unroofing or fenestration can be found. the main issue is recurrence rates. few cases of primary giant splenic cysts treated by laparoscopic decapsulation can be found in literature, this treatment being simple and quick to perform, resenting a recurrence rate lower than other techniques such as aspiration and marsupialization. introduction: technology's progress and its application in the minimally invasive surgery of the thyroid gland offers us new surgical approache's like the transaxillary approach. this new technic still unusual in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary thyroidectomy and emphasize in the most relevant tips to take into account. also we going to review the main limitations we observed so far. statement of the case: we present the case of a 49-year-old woman referred for evaluation of a left thyroid nodule without associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a 3.5 cm single right nodule with welldefined edges and presence of peripheral vascularization . no other nodules are identified. fna of the nodule describes a bethesda iii. after evaluation we decide to perform a left transaxillary thyroidectomy. discussion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). surely, more evidence and experiencie is required to make a better assessment of minimally invasive approaches in thyroid surgery. surgery, taipi city hospital, yan-ming branch., taipei, taiwan; 2 surgery, taipei city hospital, taipei, taiwan the first endoscopic thyroidectomy was performed in 1997 using a cervical approach. since then, various remote-access method, have been developed for thyroid surgery to avoid scarring of the neck. trans axillary approach(taa),bilateral axillo-breast approach(baba),and retroauricular approach(raa) are common in use. the main benefit of these procedure is that there are no visible scar that is one of the drawbacks of conventional kocher's incision. however,these methods require more dissection and longer operation time than conventional thyroidectomy transoral thyroidectomy(tovet) is a new approach and has become popular in recent years, however,most surgeons peformed a single procedure because of the limited patients and the learning periods sine 2017,more than 100 cases were performed,patients received endoscopic thyroidectomy(et) procedure at our hospital. we compare the surgical procedure of bilateral axillo-breast approach(baba) with transoral vestiblar approach(tovet) in our hospital both performed by one single surgeon .the surgen has expended eaqual amounts of time with these two procedures. the patient seletion process,operation time, operation procedure and approach,learnig experience, consmetic effect,onaologic consideration and surgical outcome were discussed yhroughly. presenting a case of a thyroid metastasis from an ovarian carcinoma, we conducted a review of the literature without finding similar reported cases. case: a 43-year-old woman consults for progressive asthenia, weight loss and ascites. abdominal ct finds a conglomerate in the pelvis involving the ovaries and peritoneal implants, the largest up to 10 cm. an omental epigastric lesion biopsy and paracentesis is performed resulting in adenocarcinoma and omental metastasis from ovarian neoplasm, associated with ca125 of 4553. patient starts neoadjuvant therapy with carboplatin-paclitaxel. in image controls there is a favorable response. three months later, intervention was carried out; laparotomy hysterectomy ? double anexectomy ? omentectomy ? appendectomy ? pelvic and paraaortic lymphadenectomy.the anatomopathological study shows a low-differentiated endometrioid carcinoma, omentum infiltration and absence of metastatic lymphatic involvement. while getting the maintenance treatment with bevacizumab the patient presented symptoms of arthritis and hypercalcemia was detected (11.4) with pth 268. a gammagraphy was performed and an increased uptake area was detected in the lower pole of rtl, suggestive of a parathyroid adenoma. we initially proposed the possibility of performing radiofrequency ablation but in a previous thyroid ultrasound we visualize 3 nodular lesions in rtl compatible with adenoma and a mass in the superior mediastinum that seems to correspond the area of greatest uptake in the gammagraphy so finally the procedure is dismissed and surgery is proposed. during the intervention we found a hard consistency nodule in the inferior pole rtl and lymphadenopathies of hard consistency in right vi area that are sent for intraoperative anatomopathological study with the result of adenocarcinoma metastasis without identifying origin. a total thyroidectomy, parathyroidectomy and central ganglion drainage is performed with the result of a parathyroid adenoma, lymphatic invasion of ovarian-grade latent carcinoma and extensive vascular permeation by carcinoma of the thyroid. the patient maintains oncological treatment with carboplatin-caelix. in the last follow-up, the pth and calcemia remains normal. conclussion: although some cases of neoplasic thyroid involvement associated with struma ovarii have been published, no cases similar to the one described are found, neither in our experience, which is why it is an exceptional case. the aim of the study was to evaluate the effectiveness of the use of embolization of the splenic artery in order to prevent portal bleeding. methods: the study included 96 patients, who had esophageal varices bleeding, which developed as a result of decompensated cirrhosis of the liver of various etiologies of classes b and c according to child-pugh. patients were divided into 2 groups. the main group included 71 (73.95%) patients who underwent endoscopic ligating of bleeding varix and in order to prevent recurrence of bleedingembolization of the splenic artery with gianturco coils. the comparison group consisted of 25 (26.05%) patients who received only drug therapy. to assess the effectiveness of the treatment, the patient's condition was monitored for 6 months. results: the average age of patients in the comparison group was 56.8 ± 4.4 years. using only drug therapy, we stopped bleeding in 54 (76.1%) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. 17 (23.9%) patients died. the duration of treatment was 10.1 ± 2.4 days. the average age of patients in main group was 55.2 ± 5.6 years. performing endoscopic ligation of bleeding varices, we stopped bleeding in 23 (92.0%) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. 2 (8.0%) patients died. the duration of treatment was 6.5 ± 2.7 days. a statistical analysis of mortality and duration of treatment revealed a significant difference (p \ 0.01) between the groups in both indicators. after splenic artery embolization in all cases managed to achieve a reduction in blood flow of 60-80%. after 6 months among 54 patients in the comparison group, bleeding relapse occurred in 12 (22.2%) cases. in the main group, this indicator was 8.7% (2 patients). the indicator in the main group was significantly (p \ 0.01) different from the same indicator in the comparison group. conclusion: performing embolization of the splenic artery in patients after endoscopic hemostasis of variceal bleeding allows to reduce the pressure in the portal system, which in turn leads to a decrease in the frequency of bleeding recurrences. thoracoscopic esophagectomy for aortoesophageal fistula y. ebihara, t. shichinohe, y. kurashima, s. murakami, surgery ii, hokkaido university, sapporo, japan background: aortoesophageal fistula (aef) is an uncommon but one of highly fatal conditions. there are surgical, endoscopic and interventional radiological treatment options, however, definitive treatment is the surgical intervention. video-assisted thoracoscopic surgery (vats) has been gradually accepted as a substitution for thoracotomy to reduce the invasiveness of the surgery as radical surgery for esophageal cancer. we aimed to evaluate a feasibility of vatsesophagectomy (vats-e) for aef in this study. introduction: achalasia is the most common motility disorder of the esophagus. heller's cardiomyotomy associated with a antireflux technique is the treatment of choice in patients with this disease; however, a small group of patients could present a recurrence of the symptoms being necesary a new surgery, what is an important challenge for most of the surgeons. we report the case of recurrence after a laparoscopic miotomy and dor fundoplication as a paradigm for the appropiate management in this kind of patients. methods: a 63 years old female, who underwent a previous miotomy and a dor fundoplication in 2011 due to an achalasia.six years after surgery, the patient showed epigastric pain and dysphagia. the study of the patient was performed with: barium swalow, phmetry, manometry, ct-scan and mri showing a recurrence of her disease.the patient was transfered to our center where she underwent a new surgery.the key points of the new surgery includes the next steps: dissection of the previous adhesions, dissection of the dor's partial fundoplication, avoid dissection of the anterior esophageal wall at the leve lof the hiatus (the area of previous myotomy) in order to avoid perforation of the esophagus, lateral and posterior dissection of the distal esophagus, lateral myotomy at the rigth wall of the esophagus and a toupet's funduplicatury. all of thisis procedures are done under intraoperative endoscopy in order to confirm a good passage to the estmach and to identify a perforationic supervision. results: following theseis steps several patients have been operated in our center with excellent results. in all of these cases, including the patiente presented previously, the symptoms have dissapeared. conclusions: achalasia is a rare motility disorder of the esophagus, being recurrences an important challenge for surgeons. a great proper therapeutic strategy using the different diagnostic exams and the supervison by a group of experts in this kind of entity are the basis in order to obtain good results in these situations. aims: re-do fundoplication is usually performed for recurrent reflux symptoms due to wrap failure or recurrent hiatus hernia. conversely, persistent dysphagia may occur early due to tight wrap/crural repair which should be avoided by good surgical technique. a small group of patients however may suffer progressive dysphagia due to weakening motility (especially in older patients), fibrosis of the wrap or a combination of the two. this video demonstrates the successful treatment of this problem with a laparoscopic conversion from nissen to posterior toupet fundoplication. a 72 year old man underwent an uncomplicated laparoscopic nissen fundoplication in 2015 with complete resolution of reflux symptoms. he re-presented 2 years later, still free of reflux but suffering progressive dysphagia and troublesome regurgitation. investigations demonstrated intact wrap and no mechanical obstruction, but confirmed low-amplitude peristalsis. a trial endoscopic dilatation improved symptoms for 11 days before recurrence, suggesting likely wrap fibrosis (which would reduce elasticity and impede passage of food bolus), justifying consideration for a conversion from nissen to toupet. results: this video demonstrates the expected adhesions between fundoplication and inferior surface of left lobe liver, mobilisation and division of the nissen fundoplication, and reconstitution of a posterior toupet fundoplication. the patient made a good recovery and was discharged the following day. three-and six-month follow-up confirmed complete resolution of symptoms with no recurrence of reflux. conclusion: laparoscopic re-do surgery for late-onset progressive dysphagia is a safe and viable option. patients must be thoroughly investigated and carefully selected for an appropriately tailored procedure. they should also be advised of the increased risks associated with re-do surgery. the anatomy can be unpredictably distorted by variable adhesions and this operation should therefore only be performed by laparoscopic surgeons experienced in both primary and re-do fundoplication. methods: i report unusual iatrogenic injury of cervical esophagus that resulted with complete resection post total thyroidectomy for papillary ca of thyroid patient presented 4 days post surgery to our center. the video will show the steps used to treat this unusual complication by neck exploration, laparoscopic trans hiatal esophagectomy with creation of gastric tube with preservation of the right gastroepiploic artery and the neck anastomosis between the cervical esophagus and stomach. were open and 13 minimally invasive esophagectomies. of the 27 patients, 10 were for squamous cell carcinoma, 13 were adenocarcinoma and 3 were of other histological diagnosis such as gastrointestinal stromal tumor and schwannoma. the median length of stay for patients who underwent minimally invasive esophagectomies was 9 days (9 to 120 days) while the median length of stay for patients who underwent open esophagectomies was 15 days (9 to 45 days). the minimally invasive group had a shorter icu stay of 1 day. for 30 day morbidity, the minimally invasive esophagectomy group had 2 patients who encountered anastomotic leaks, 1 with post operative pneumonia while the open esophagectomy group had 1 patient with anastomotic leak, 1 patient with post operative stricture and 1 patient with delayed gastric emptying. there were 2 mortalities in the minimally invasive group while there were no mortalities in the open group. conclusion: our data show that patients who underwent minimally invasive esophagectomies had a shorter duration of hospitalization with similar perioperative morbidity rates. minimally invasive esophagectomy is a viable surgical option for a select group of patients. aims: there has been an increasing tendency towards minimally invasive surgery for esophageal cancer. our aim was to evaluate the results of the thoracoscopic approach (ta) and compare them with the ones of open approach (oa) at our institution. methods: retrospective review of all patients who underwent esophagectomy due to esophageal cancer (adenocarcinoma or squamous cell) between 2013 and 2017 were included. patients with siewert iii tumors and those who didn't need a thoracic approach were excluded. results: during the study period were performed 83 esophagectomies, 23 through ta. in 43.5% of these, the abdominal stage was done by laparoscopy. when comparing ta versus oa, there were no statistically significant differences in the baseline characteristics of the two groups (mean age, median body mass index, ecog performance status, asa score, smoking status, diabetes mellitus, pulmonary disease, histologic type, clinical staging and neoadjuvant chemo and radiotherapy). regarding outcomes, there were no significant differences in need of intraoperative transfusion, median intraoperative blood loss, operative time and length of stay. although not significant, in ta group there was a tendency for higher overall morbidity (69.6% versus 58.3%, p = 0.347); major morbidity-ctcae 3-5 (56.5% versus 38.3%, p = 0.135); anastomotic leak (34.8% versus 16.7%, p = 0.084) and re-intervention rate (17.4% versus 15%, p = 0.748). on the other hand, in ta group there was a tendency (although not significant) towards lower rate of respiratory complications (17.4% versus 33.3%, p = 0.152), lower rate of r1 margins (4.3% versus 13.3%, p = 0.433) and higher median of lymph nodes removed (22 versus 18, p = 0.083). conclusions: in our series, outcomes of ta were similar to oa, with a tendency towards lower respiratory complications, lower rate of r1 margins and higher number of lymph nodes removed in ta group. the impact of these findings in survival remains to be seen. the tendency towards higher morbidity may be related to the learning curve, since this were the first cases performed at our center. background: esophagectomy is a surgical procedureburdened by a high morbidity rate. the effect of minimally invasive (mi) approach on elderly patients is still not clear. aim: of this study was to analyze the impact of mi approach on post-operative course according to the patient age. methods: a consecutive series of 692 patients underwent to elective oncological esophagectomy between 1997 and 2017. all data were entered into a prospective database. patients submitted to 3-flield or trans-hiatal esophagectomywere excluded andonly ivor-lewisopen, hybrid or totally minimally invasive esophagectomywere. patients were stratified according to age in 3 groups:group a(= 50 years) 53 patients, group b ([ 51 and \ 70 years)269 and group c (were = 71 years)126.clinical and pathological factors influencing surgical outcome were evaluated. complications were classified according to clavien-dindo (cd). results: as expected outcomes worsened with patients age(cd = 3b: 7.5% group a, 13% group b and 21% group c. p = 0.001), mortality (0% group a, 3% group b and 5.5% group c. p = 0.035) and length of stay (10 days group a, 11 days group b and 13 days group c. p = 0.001).a statistically significant higher incidence of anastomosticleaks was observed among patients submitted to totally mi esophagectomy in group c vs a and b that were respectively 12,5%, 0% and 7%. major respiratory complications were not statistically different among these 3 three sub-group. conclusions: old age has a significant impact on outcomes afteresophagectomy. in this subset of patients a mi approachcould also increasepostoperative morbidity. elderly patients should be carefully selected before to be submitted to mi esophagectomy. introduction: esophagectomy is a major surgical procedure with morbidity and mortality related to the patient's condition, stage of the disease, complementary treatments, and surgical experience. minimally invasive esophagectomy (mie) may lead to a reduction in perioperative morbidity and mortality with very good quality of life. material and method: we present the experience of the center of excellence in esophageal surgery regarding totally mie through thoracolaparoscopic modified mckeown three-stage approach followed by esophageal reconstruction by gastric intrathoracic pull-up and cervical esophagogastric anastomosis used for the treatment of thoracic esophageal cancer. results: in the last 4 years, mie was performed initial, in our clinic with extracorporeal preparation of the gastric conduit with reduced lung complications and hospital stay. we introduced the totally minimally invasive esophagectomy with laparoscopic-assisted feeding jejunostomy using a 3d high definition camera. operative times were: thoracic-120 min, abdominal-130 min and cervical-50 min with a total of 300 min. the augmented 3d high definition image provided an excellent visual field, that allowed an accurate identification of dissection plans and extensive periesophageal and perigastric lymphadenectomy. the short-term outcomes of the totally minimally invasive esophagectomy procedure were very encouraging with early feeding on jejunostomy and the control of cervical anastomosis was usually performed in the 5th day postoperative and the patients were discharged in the 9th day postoperative without any symptomatology. at the first and third-month follow-up was not reported any major complications. the long-term oncological results are being evaluated. conclusions: the totally minimally invasive approach using advanced technology of endoscopic surgery allowed for these patients a simple postoperative evolution, no major complications, and a good recovery after an extensive surgery. the solid experience in open esophageal surgery of the upper gastrointestinal surgeons provides a fast learning curve of complex minimally invasive surgical procedures with reduced perioperative morbidity. long-term follow-up should confirm the results from the literature regarding the survival, which is expected to be for these patients at least equivalent with outcomes after open esophagectomy. introduction: esophageal fistulas, benign or malignant, represent a real challenge for the surgeons and gastroenterologists, regarding the treatment and the outcome. in these cases, endoscopic treatment is the first line approach, being less invasive and sometimes avoiding the need for surgery. this includes clips, stents, glue and even suture. material and method: we have analyzed 9 esophageal fistulas in patients with benign or malignant pathology, diagnosed and treated in the first 6 months of 2018. the management of this complication included a self-expandable esophageal metallic stent. we have evaluated the diagnosis, the surgical intervention, the timing until the development of the leak, the localization and management of the fistula. results: 5 were postoperative leaks and 4 spontaneous esophageal fistulas. the localization was cervical in one case, thoracic in 5 cases and abdominal in 3 cases. for the postoperative fistulas, in 4 patients the treatment included at least one surgical reintervention with lavage and drainage, beside the insertion of an esophageal metallic stent. in the other cases, endoscopic treatment and antibiotic therapy was enough. in 2 cases, the stent migrated needing repositioning. 30 days mortality was 22%, both patients from postoperative group. conclusions: esophageal fistulas represent a severe complication, usually in patients already immunocompromised. endoscopic management, including self expandable esophageal metallic stent, can be the main approach, by stopping the contamination and by permitting the early per oral feeding. disadvantages include the possibility of migration and the need of removal after 6-8 weeks. methods: five hundreds and one patients with esophageal cancer who underwent mie from 2010 to 2016 at our department were eligible. we considered the risk factors of complications of pneumonia, anastomotic leakage, and hoarseness after surgery, and the risk factors of difficulty of surgery. results: the risk factors of postoperative complications in univariate analysis were more than 75 years old (odds ratio: 2.1, p = 0.01), more than ii in asa-ps (odds: 3.1, p \ 0.01), more than 300 g of bleeding (odds: 2.1, p = 0.01), more than 450 min. of operation time (odds: 2.2, p \ 0.01), and colon reconstruction (odds: 3.2, p = 0.02). the one in multivatiate analysis was more than ii in asa-ps (odds: 3.2, p = 0.01). the risk factors of much bleeding were colon reconstruction (odds: 6.5, p \ 0.01), and more than 50 of lymph node dissection (odds: 1.5, p = 0.05). the risk factors of long operation time without cervical lymph node dissection were neo-adjuvant therapy (odds: 8.1, p \ 0.01), more than 60 of lymph node dissection (odds: 3.0, p = 0.01), and colon reconstruction (odds: 8.1, p \ 0.01). the ones with cervical lymph node dissection were more than pstage iii (odds: 2.4, p \ 0.01) and more than 60 of lymph node dissection (odds: 2.8, p = 0.03). conclusions: considering those risk factors, we should perform perioperative management more carefully. method: sa 74-year-old man with a tobacco and alcoholic habit was suspended for years, under treatment for arterial hypertension, who consults for a logical dysphagia of 4 months of evolution. he is diagnosed of stenosing esophageal distal third epidermoid carcinoma txn1m0. it is decided to place a prosthesis that is effective and subsequent neoadjuvant qt-rt, after 6 weeks of its completion the surgery is performed. results: the surgery is performed in 2 times, initially by laparoscopy. the esophageal hiatus and the greater curvature are dissected preserving the right gastroepiploic, and lymphadenectomy of the celiac trunk with pedicle section of the left gastric. gastric plasty is performed with a section of lesser curvature towards fundus. it is continued by thoracoscopy. a section of the azygos vein is performed, dissection of the esophageal middle and lower third and lymphadenectomy. gastric plasty is promoted, proximal esophagus section and latero-lateral intrathoracic gastro-oesophageal anastomosis. the anatomopathological study reports ypt3 and pn2 with 4/33 adenopathies, and disease-free surgical margins. he was discharged without complications on the 12th day and did not require re-entry. conclusions: ivor-lewis endoscopic surgery is safe and meets oncological criteria in selected patients with distal esophageal neoplasia and performed by an experienced esophagogastric unit. background: the rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in japan. we retrospectively reviewed short term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position under artificial pneumothorax by co2 insufflation in a single institution. this study aimed to evaluate the feasibility of applying this procedure. methods: between july 2013 and december 2017, 124 patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co2 insufflation. the thoracic procedure is performed as follows:the lymph nodes around the right recurrent laryngeal nerve are dissected. on the cranial side, the lymph node dissection is advanced to the level of the inferior thyroid artery. then, the assistant rotates the trachea toward the ventral side, and the lymph nodes around the left recurrent laryngeal nerve are dissected. the middle and inferior mediastinal lymph nodes are dissected including supradiaphragmatic lymph nodes and the dorsal lymph nodes around the thoracic descending aorta. then, the esophagus is transected using an automatic suture device. finally, the tracheal bifurcation area lymph nodes are dissected. we retrospectively analyzed these patients. results: the completion rate of thoracoscopic esophagectomy was 92.0%, and the procedure was converted to thoracotomy in five patients, due to hemorrhage,severe adhesion. the mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were 210.5 min, 120.5 ml, and 23.0, respectively. postoperative complications included pneumonia (13.7%), anastomotic leakage (16.9%), and recurrent nerve paralysis (16.1%). postoperative (30d) mortality was 2/124 (1.6%) due to ards and nomi, respectively. conclusions: standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co2 insufflation, with a standardized clinical pathway for perioperative care led to favorable surgical outcomes. introduction: recently thoracoscopic surgery has become widespread even in chest procedure in thoracic esophageal cancer surgery. as an advantage of minimally invasive esophagectomy, it is possible to perform sophisticated procedures due to its magnified visual effects. on the other hand, short-term perioperative safety and oncological safety are still unclear. in cases where abnormal anatomy or comorbidity in the thoracic cavity is observed, it is thought that it is necessary to carry out thoracic surgery which ensures safety while keeping in mind the transition to transthoracic surgery. here, we report on esophageal resection of the thoracic esophageal cancer accompanied by a 20 mm saccular aneurysm inside the aortic arch. patient: a 67-year-old man visited a nearby doctor with a chief complaint of discomfort during swallowing. upper gastrointestinal endoscopy examined middle cervical esophageal cancer and received referral to our hospital. ct revealed a 20 mm saccular aneurysm inside the descending aorta in contact with the thoracic esophagus. preoperative diagnosis was middle thoracic esophageal cancer; 0-iic ct1bn0m0 stageia (uicc 8th). we performed thoracoscopic esophagectomy and lymph node dissection as curative surgery. the anterior surface of the aorta was exposed from the lower mediastinum and descended ascendingly, reaching the lower end of the saccular anus at the head level of the lower pulmonary vein. peeling off the esophagus dorsal side along the margin of the saccular sac and performing esophageal resection. conclusion: we reported thoracoscopic esophageal resection for thoracic esophageal cancer with chest descending aortic saccular aneurysm. thoracoscopic surgery, which can fully exploit close magnification effect, seemed to be useful for anatomically disqualified cases. introduction: anastomotic leakage from oesophagojejunal (oj) anastomosis after total gastrectomy is associated with a high morbidity and mortality rate. leakage rates reported vary between 3?% and 11?% but lack of consensus in management. in the past, it often required surgical intervention or radiologically abscess drainage that will keep patients fasted with external drain for a long duration. recently, variable endoscopic options-oesophageal stents, clips, fibrin glue and endoluminal vacuum therapy had been introduced with variable outcomes. here, we presented a case of oj anastomotic leak management with combination innovative endoluminal and radiologically technique to insert double pig-tailed catheter. aim: to introduce the feasibility of double pig-tailed catheter for drainage and management of oj anastomosis leak. a 70 year old man presented with two months history of dysphagia. upper endoscopy (ogd) showed suspicious cardio-oesophageal lesion. histology biopsy confirmed with adenocarcinoma. ct-scan of thorax, abdomen and pelvic showed irregular thickening at cardiooesophageal junction with regional lymphadenopathy. no distant metastases. he underwent uneventful d2 total gastrectomy. on 5th post-operative day, patient had spike fever and newly developed atrial fibrillation. urgent ct-thorax, abdomen and pelvis with oral omnipaque. it showed lower mediastinal gas-containing fluid adjacent to oj anastomosis within the left retrocrural space suspicious for leak. ogd evaluation showed pin-hole oj leak. guidewire inserted via endoscopy into left retrocural space under radiologically guidance. double pig-tail 7fr 5 cm subsequently inserted via seldinger approach over guide wire. the proximal end of pig-tail pushed into left retrocural space and distal end positioned into efferent jejunal limb with crocodile jaw through endoscope. diluted contrast injected and passed down to efferent limb with minimal leak. outcome: after double pig-tail insertion, patient started on clear feed on 1st day post-insertion. one week later, he was started on full feed. repeat upper endoscopy and stent removal done two weeks later. contrast injection showed small blind ended sinus tract from anastomosis toward left pleural space without obvious leak. conclusion: radio-endoscopic is a novel minimally invasive technique that allows insertion of double pig-tailed internal drainage to control oj anastomosis leak. it allows early enteral nutritional feeding and avoid external drainage. background: the number of gastric cancer (gc) survivors, especially long-term survivors, is increasing. how best to evaluate the diseasespecific survival (dss) of gc survivors over time is unclear. we aimed to assess changes in the conditional survival of patients with gc after curative intend gastrectomy and the evolution of the impact of well-known risk factors. methods: clinicopathological data from 22,265 patients who underwent curative intend resection for gc at four specialized centres (three in china and one in italy) and from the surveillance, epidemiology, and end results (seer) database were retrospectively analysed. changes in the patients' 3-year conditional disease-specific survival (cs3) were analysed. we used time-dependent cox regression to analyse which variables had long-term effects on dss and devised an accurate, dynamic dss predictive model based on the length of survival. results: the median follow-up time was 74 months, and disease-specific death occurred in 9,927 cases (44.6%). the dss of the patients after surgery was dynamic, and most of the disease-specific deaths occurred within the first 3 years after surgery. based on 1-, 2-, 3-, 4-and 5-year survivorships, the cs3 of the population increased gradually from 62% to 68.1%, 77.3%, 83.7%, 87.6%, and 90.6%, respectively. subgroup analysis showed that the cs3 of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (e.g., n3b: 26.6%-84.1%, ?57.5% vs. n0: 84.1%-93.3%, ?9.2%). time-dependent cox regression analysis showed the following predictor variables constantly affecting dss: age, the number of examined lymph nodes, t stage, n stage and site (p all \ 0.05, 5 years after gastrectomy). the influence of prognostic factors on dss and cs3 changed dramatically over time. based on data from several large global centres, we developed an effective model for predicting the dss of gc patients based on the length of survival time. this model can provide personalized long-term follow-up strategies for patients. methods: we retrospectively analyzed clinicopathological data for 253 rgc patients who underwent radical gastrectomy from 6 centers. the prognosis prediction performances of the ajcc7th and ajcc8th tnm staging systems and the trm staging system for rgc patients were evaluated. web-based prediction models based on independent prognostic factors were developed to predict the survival of the rgc patients. external validation was performed using a cohort of 49 chinese patients. result: the mean number of retrieved lymph nodes was 16.1, and in 54.2% of patients, the number was = 15. the predictive abilities of the ajcc8th and trm staging systems were no better than those of the ajcc7th staging system (c-index: ajcc7th vs. ajcc8th vs. trm, 0.743 vs. 0.732 vs. 0.744; p [ 0.05). within each staging system, the survival of the two adjacent stages was not well discriminated (p [ 0.05). multivariate analysis showed that age, tumor size, t stage and n stage were independent prognostic factors for overall survival (os), disease-specific survival (dss) and disease-specific survival (dfs). based on the above variables, we developed 3 web-based prediction models, the huang os model, the huang dss model and the huang dfs model, which were superior to the ajcc7th staging system in their discriminatory ability (cindex), predictive homogeneity (likelihood ratio chi-square), predictive accuracy (aic, bic), and model stability (time-dependent roc curves). the stratified analysis showed that regardless of whether more or fewer than 15 lymph nodes were retrieved, the predictive performances of the web-based prediction models were still better than those of the other three staging systems. a decision curve analysis showed that the huang model provided better net benefits than the other three staging systems. external validation showed predictable accuracies of 0.780, 0.822 and 0.700, respectively, in predicting os, dss and dfs. conclusion: the ajcc tnm staging system and the trm staging system did not enable good distinction among the rgc patients. we have developed and validated visual web-based prediction models that are superior to these staging systems. objective: to perform competing risk analysis and evaluate cancer-and noncancer-specific mortality in patients with gastric cancer after radical surgery. methods: a total of 5051 patients from our department (as training set) and a total of 7123 patients from the surveillance, epidemiology, and end results (seer) database (as validation set) were enrolled in the study. the cumulative incidence of cancer and noncancer-specific mortality was determined by univariate and multivariate competing risk analysis. results: the five-year cancer-and noncancer-specific cumulative incidence of death (cid) in the training set were 36.9% and 2.5%, respectively, which were significantly lower than that in the validation set (48.2% and 8.6%, respectively). multivariable analysis showed that age, tumor site, tumor size and ptnm stage were independent predictors of gastric cancer-specific mortality and overall survival, whereas age was an independent predictor of gastric noncancer-specific mortality. noncancer-specific cid surpassed cancer-specific cid for ptnm stage i patients after approximately 8 years of surgery, but never for stage ii and iii patients. moreover, for stage i patients, the time point when noncancer-specific cid surpassed cancer-specific cid become earlier as age increasing, with only 3.5 years after surgery for patients more than 74 years of age. conclusions: age is an independent predictor of gastric cancer-and noncancer specific mortality and overall survival for patients after radical surgery. for patients with stage i gastric cancer, noncancer-specific mortality is a significant competing event, with an increasing impact as age increases. aim: of the study was to analyse the possibility of function preserving gastrectomy based on the sentinel lymph node (sln) concept. methods: during last 5 years in two clinics odessa national medical university we used mapping procedures in the 25 patients with early gastric cancer. there were 11 men and 14 women, age 52 to 85 years, mean age 56.8 ± 8.2 years. blue dye was injected into 4 quadrants of the submucosal layer surrounding the primary lesion using an endoscopic puncture needle in 16 patients. blue lymphatic vessels and blue-stained lymph nodes can be identified by laparoscopy within 15 min. of the blue dye injection. we used 0.5% indocyanine green in 9 patients, which we injected by intraoperative endoscopy. new technology indocyanine green (icg) fluorescent imaging was used for sln mapping in this 9 patients. results: amany 16 patients, in which we used blue dye for mapping sln, positive sln was in 5 patients, negative-in 11 patients. in all 16 patients distal gastrectomy (dg) was performed with d2 lymphdissection. from 11 patients with negative sln in 3 patients metastasis in other lymph nodes were detected.among 9 patients in whom we used icg fluorescent mapping positive sln were detected in 2 patients. laparoscopic-assisted distal gastrectomy with d2 lymph node dissection was performed in these patients. in 7 patients with negative sln partial wedge resection was performed in 2 patients, segmental pylorus preserving gastrectomy was performed in 5 patients. during follow-up period from 3 to 24 months no recurrences or metastasis were detected in these group of patients. qol in this group of patients was much better, than in patients with conventional distal gastrectomy. conclusions: icg fluorescent method is highly effective for detection of sln. in the patients with early gastric cancer function preserving gastrectomy based on sln navigation may be promising strategy to achieve better results. laparoscopic procedure taking advantage of robotic gastrectomy for gastric cancer to prevent pancreatic fistula gastrointestinal surgery and surgical oncology, ehime university, toon-city, japan backgrounds and aims: analysis of japanese national clinical database (ncd) showed that laparoscopic gastrectomy(lg) had rather increased pancreatic fistula (pf) compared with open gastrectomy. on the other hand, last year, multicenter collaborative research result of robotic gastric cancer surgery(rg)was shown that the complications including pf were significantly decreased as compared with lg. in this study, we have employed a new easy to use device in lg to minimize pf during suprapancreatic lymph nodes dissection requiring pancreatic retraction and compared with conventional lg and rg. materials and methods: internal organ retractor (aesculapò) to grasp the gastropancreatic fold and the suprapancreatic peritoneum to imitate davinci's forceps was guided with a thread outside the body. 104 patients(jan.2016 * nov.2018) were divided into three groups as follows, group lg-1(n = 40), lg using the standard devices, group lg-2(n = 40), lg using organ retractor, group rg (n = 24). amylase value in drain(d-amylase) and the volume in drainage, intraoperative bleeding, postoperative hospital stay, incidence of cd (] grade iii) were compared among three groups. results: data are indicated as lg-1/lg-2/rg(mean ± sd), respectively. on the day and third day after surgery, d-amylase were 1203 ± 260/645 ± 148/608 ± 285 and 383 ± 228/ 323 ± 136,176 ± 98(iu/l). d-amylase was significantly lower in lg-2 and rg group than in lg-1 the day after surgery. the operation time was significantly longer in rg, 318 ± 38/ 290 ± 64/396 ± 47 (min). bleeding volume and hospital stay did not differ among 3 groups. pancreatic fistula (cd ] grade iii)was observed only in lg-1 group at 5(%) . discussion: pf(grade]cdiii), which may lead to mortality, occurred in lg-1 group. a significant elevation of d-amylase on the 1st postoperative day was prevented in lg-2 just like rg, which seemed to lead to prevent pf afterwards. the multijoint forceps is known to be an advantage of rg but it cannot be reproduced by lg using a linear forceps. however, another advantage such as vertical grasping and lifting of the gastropancreatic fold at rest could be mimicked by lg using this device, which seemed to enable a safe lymph node dissection and lead to reduce the pancreatic damage. conclusion: this inexpensive and easy to use method taking the advantage of rg seems to reduce surgeon's fatigue and tissue damage(pf). the study presents comparison of perioperative outcome between different surgical approaches for gastric adenocarcinoma (ac). methods: retrospective cohort of 85 patients that underwent gastrectomy for (ac) at rambam hospital during 2012-2016. patients data was collected based on demographic characteristics, bmi, operating room time (ort), number of lymph nodes (ln), length of hospitalization (loh), and perioperative complications. results: study population included 55 patients after total gastrectomies, 10 of them robotic and 30 partial gastrectomies, 12 of them robotic. age, gender and bmi were similar between patients who underwent any type of procedures. median length of hospitalization (loh) for robotic total gastrectomy was 4.5 days and it was significantly shorter than both laparoscopic total gastrectomy (ltg) 7.0 days (p = 0.003) and open total gastrectomy (otg) 9.0 days (p \ 0.001). similar significant differences in (loh) between the groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of (lpg). median(ort) was significantly longer among robotic gastrectomies compared to open, the difference was 64 min in total gastrectomy group and 145 min in partial gastrectomy group (p \ 0.001 for both differences), but the difference in(ort) between laparoscopic and robotic procedures were smaller and non-significant. the number of dissected (ln) was similar between the 3 procedures in total gasrectomies. in partial gastrectomies, the number of dissected (ln) was even higher among both laparoscopic and robotic gastrectomies compared to open (p \ 0.001).) conclusions: robotic total and partial gastrectomies for gastric (ac) are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer ort. objectives: during esophagojejunostomy using a circular stapler after latg, placement of the anvil head via the transabdominal approach proved difficult. the authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head(orvil) via the transoral approach. methods: between january 2013 and november 2018, esophagojejunostomy was performed using orvil in 99 patients after latg. the anesthesiologist introduced the anvil while observing its passage through the pharynx. during the anastomosis, we kept the jejunum fixed in position with a silicone band lig-a-loops, thereby preventing the intestine from slipping off the shaft of the stapler. results: esophagojejunostomy using the orvil was achieved successfully in all patients. no other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. the postoperative complications of anastomosis were leakage in two patients and stenosis in 5 patients, in whom mild relief was achieved using a bougie. conclusions: esophagojejunostomy using the orvil is a simple and safe technique. gastrointestinal tract surgery, fukushima medical university, fukushima-shi, japan; 3 surgery, ohara general hospital, fukushima-shi, japan background: juvenile polyposis of the stomach is a very rare disease, and its malignant potential has been reported previously and total gastrectomy has been recommended as a standard treatment. recently, the usefulness of laparoscopic surgery for this case has been reported, however this type of surgery is thought that maintaining the surgical space is difficult because of distended and thickening stomach. case presentation: eight years ago, a 64-year-old woman who had no family history of gastrointestinal polyposis had been diagnosed with gastric polyposis and polyp-related anemia and received twice endoscopic submucosal dissection to early gastric cancer in another hospital. she had received an annual upper gastrointestinal endoscopy and she had taken iron supplements for anemia caused from the occasional bleeding from the polyps. however, the number of the polyps had increased over time. because she had a loss of appetite, she admitted to our hospital. enhanced computed tomography showed gastric wall thickening and multiple gastric polyps without lymphadenopathy or distant metastasis. colonoscopy showed no specific findings. she was diagnosed as the juvenile polyposis of the stomach, and she received laparoscopic total gastrectomy with roux-en y esophagojejunostomy. in operative findings, although there were the excessive distention and congestion of the stomach, standard laparoscopic surgery could be performed. the resected specimen revealed multiple variously sized polyps throughout the stomach except for lesser curvature and fundus and the histopathological examination revealed that all polyps were hyperplastic polyps without containing cancer. she was discharged on postoperative day 10. we successfully performed laparoscopic surgery to treat a rare case of juvenile gastric polyposis. introduction: we report a novel technique for combined use of laparo and thoracoscopy for faradvanced adenocarcinoma of esophagogastric junction (aeg). case presentation: a 50's years old man presented with far-advanced aeg. an esophagogastroduodenoscopy revealed a type 2 lesion with the entire circumference around esophagogastric junction (egj). contrast radiography revealed a severe stenosis in the egj and wall irregularity from egj to cardia. computed tomography revealed a stenosis of egj, suspected invasion into the left side diaphragm and some lymph nodes metastases at the abdomen. we diagnosed siewert type ii aeg (ct4an1m0, cstage iiia : japanese classification of gastric carcinoma ver.14). surgical technique :the patient was placed in the reverse-trendelenburg position with the left upper body lifted and legs spread, under general anesthesia. the tumor was huge, exposed from the serous membrane and invaded the left crus. first we performed from laparoscopic proximal gastrectomy using five ports. then, three ports were added in the 8th, 9th, and 11th intercostal spaces with the patient in the same body position, and performed thoracoscopic lower esophagectomy under artificial pneumothorax with intrathoracic pressure of 8-10 mmhg, which allows the ventilation of both lungs. the lower esophagus was resected under the thoracoscopic view to ensure an adequate margin. following this resection, intrathoracic esophagojejunostomy was performed by using the laparo-and thoracoscopic techniques. the operative time was 439 min, and the blood loss was 15 g. he was discharged on the 15th day after the operation without any postoperative morbidity. the histopathological diagnosis was pt4bn3am1, p1, pstage iv. after adjuvant chemotherapy with capecitabine and oxaliplatin, ramcilumab monotherapy is undertaken now. ct revealed solitary lung metastasis in 24 months after the operation. conclusion: malta for locally advanced aeg invading the surroundings could be performed safely. introduction: despite being the pioneer in laparoscopic surgery, europe did not have similar surgical experience compared to east asia due to decreased exposure to gastric cancer. several studies on minimally invasive gastrectomy for gastric cancer have been conducted in europe. however, some of them did not analyse total gastrectomy as a distinct entity combining both distal and total gastrectomies; moreover, most of them do not provide data on full five-year follow up for each patient. baltic countries stand in between east and west in terms of gastric cancer incidence: incidence rate per 100,000 is 10.6 in united kingdom, 26.3 in lithuania and 85.3 in japan. this exposure to gastric cancer provides unique opportunity to investigate the role of laparoscopic gastrectomy. therefore, a case-control study was designed to evaluate laparoscopic (ltg) versus open total gastrectomy (otg), comparing short-term surgical and long-term oncologic outcomes. surgery, jeju national university, school of medicine, jeju, korea; 2 surgery, chosun university, school of medicine, gwangju, korea objective: although mcv (mean corpuscular volume) levels are known to be associated with the prognosis of various diseases, few study investigated mcv as prognostic factor after gastric cancer surgery. the aim of this study is to address the prognostic value of mcv in gastric cancer who underwent curative gastric cancer surgery. methods: 286 patients (june 2009-december 2015) with stage i, ii, and iii cancer were consecutively included in this study. all patients underwent curative gastric cancer surgery including subtotal gastrectomy or total gastrectomy. overall survival (os), disease-free survival (dfs) and postoperative complications rate were compared between mcv [ 94 group and = 93 group. results: of all patients, the mean mcv was 89 fl (normal range, 80 to 100 fl). the dfs was significantly higher in the high-mcv ([ 94) than low-mcv group(= 93) (p \ 0.05) group. there was no significant difference in postoperative complications when compared with clavien-dindo scale. the survival rate of the high mcv group was higher but there was no significant difference. conclusions: mcv may be a predictive factor after gastric cancer surgery. unlike previous studies, patients with low mcv group showed lower dfs. more research is needed on the significance of mcv in variety of disease. methods: and materials. for 6 years we observed 11 cases with gist of stomach and duodenum. seven patients were brought to clinic with the bleeding and two patients were brought to clinic with vomiting and compensate stenosis. in all circumstances we done the ct, mrt and endoscopic examinations of stomach and duodenum with biopsy . in two circumstances we performed endoscopic operation. in one circumstance we successfully take off the gist from the duodenum endoscopically. during the operation we use the endoscopic instruments. in another circumstances,after endoscopic excision the tumor appear the bleeding which was stopped by endoscopic local heamostasis, by putting clipps on the vessels. in 9 circumstances the tumors were in stomach. in 4 circumstances we performed laparoscopic wedge resection the tumors by staplers. in 3 circumstances when the tumor was very big and situated in the fundus of stomach, we performed laparoscopic resection of the fundal part of stomach by using laparoscopic staplers and 'liga sure' sealing. in 2 circumstance we took off the tumor by putting laparoscopic trocars inside the stomach for instruments and for visualization tumor. after excision the tumor and took it of the stomach we sutured the holes in the stomach. we have no mortality after laparoscopic operation. there were no malignisation in all 9 circumstances. we have 3 cases morbidity. in 2 circumstance the bleeding from the stomach that was stopped endoscopically. in 1 circumstance there was wound infection. the aim of the study to decrease the morbidity in the patients with perforated ulcers of the stomach and duodenum. we observed 107 patients with perforated ulcers of stomach and duodenum. women were 45, men were 62. average age about 45 years. 91patients had perforation ulcer of stomach and duodenum. 26 patients had perforations with bleeding. all patients were divided in two groups. the first groups 59 patient operated laporocopically, in the second group 48 patients operated traditionally. results: there were no mortality in the group that operated laparoscopically. in the group that were operated traditionally one patient died after rebleeding. the average stay in hospital in the group that were operated laporoscopically about 2 days. in the groups with traditional operations, were about 8 days. the morbidity in the first group were in 5 cases. pneumonia in 2 cases, suppuration of the troacar points were in 3 cases. in the second group pneumonia were in 3 cases, suppuration of the operation wound were in 5 cases, subdiaphragmatic abscess was in 1 cases. conclusion: laporoscopic operation in during treatment decrease the mortality, morbidity and hospital staying in the patients the perforated ulcer of stomach and duodenum . of the 32 patients of the third group 22 (68.75%) were operated about ulcer rebleeding in the hospital, and 10 (31.25%)-about the profuse bleeding ulcer. noonr patient had recurrent bleeding. the average treatment time for patients in group 2 was 12.5 ± 3.2 days. conclusions: the development of hemorrhagic shock in patients with peptic ulcer bleeding significantly increases the risk of rebleeding and mortality. the application of endoscopic hemostasis allows to reduce the risk of rebleeding and mortality compared with conservative antiulcer therapy. surgical treatment can achieve reliable hemostasis, but accompanied by higher mortality and longer duration of hospital treatment. tan tock seng hospital is second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. minimally invasive surgery for both benign and malignant diseases of upper gastrointestinal tract becomes more and more popular nowadays. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them with better understanding of the procedures. the viewing of videos help them with the importance of steps, standardization of steps. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start doing the procedure themselves after the graduation from the residency programme. this is the step by step instructional video of laparoscopic repair of perforated duodena ulcer for surgeons-in-training rotated to our department. in general duplication cysts are rare developmental congenital disorders of the gi tract. three morphological criteria should be met in order to confirm the pathological diagnosis: 1. they should be attached to the stomach's wall and should be the continuation of it, 2. at least one of the muscle layers of the stomach's wall should be included and 3.it should have normal gastric mucosa. the treatment is either enucleation or partial gastrectomy. aim: present our minimally invasive approach to a rare prepyloric submucosal cystic lesion causing gastric outlet obstruction. case report: a 27-year-old female with vomiting, weight loss and in bad general condition was diagnosed after a full work-up (blood tests, endoscopies, eus, ct and mri) with a submucosal cystic tumor. this cyst first was thought to be a duplication cyst. since the patient was young, our intention was to offer the least invasive surgical technique in order to spare gastrectomy and billroth anastomosis. results: the procedure was completed laparoscopically with enucleation of the cyst through a gastrotomy on the anterior wall of the stomach. after the enucleation of the cyst the gastric mucosa was sutured back and then the gastrotomy was closed with continuous sutures. the result of the pathological report confirmed a rare case of a heterotopic pancreatic cystic lesion. the postoperative course of the patient was uneventful and was discharged with instruction for her diet the 4 th postoperative day. the patient 3 months post-operative has no symptoms. conclusion: in such benign conditions and especially in young patients, gastrectomies could be avoided if possible and give their place to less invasive approaches in order to reduce lifelong risks and morbidity. trangastric enucleation of the cyst although a demanding approach is safe and could be considered as a 'gentler' technique with reduced morbidity. background: pancreatoduodenectomy is considered to be very invasive for early superficial duodenal tumors (sdts), which have a lower risk of lymph node metastasis. partial duodenal resection with endoscopic submucosal dissection for sdts is an attractive technique but it is associated with a high risk of complications. the full-thickness resection of the duodenum wall including laparoscopic and endoscopic cooperative surgery has risk of spreading tumor cells and digestive juices into the abdominal cavity. we have developed novel technique for sdts to decrease the risk of exposure to abdominal cavity of tumor cells and digestive juices, called nonexposed duodenum laparoscopic and endoscopic cooperative surgery (neo-dlecs). aim: the aim of this study is to evaluate the feasibility and safety of neo-dlecs for sdts. surgical procedure: the attachment of the transverse mesocolon was freed from the head of the pancreas and retroperitoneal tissues under laparoscopy. the duodenum and the head of the pancreas were mobilized from the retroperitoneum using the kocher maneuver. a standard esd was performed for the sdt using endoscope. the serosa of the esd ulcer bed was reinforced using the laparoscopic hand-sewn suturing technique in the seromuscular layer around the resected area. after completing the procedure, the endoscope was inserted and passed over the resected area to confirm that there was no stenosis or leakage. methods: ten consecutive patients with sdt underwent neo-dlecs in our institute between march 2015 and march 2017. the clinicopathological features of the patients and surgical outcomes were prospectively collected and retrospectively analyzed. results: pathological diagnosis was adenocarcinoma for six patients, adenoma for three patients, and neuroendocrine tumor grade 1 for one patient. the median tumor size was 36 (20-54) mm. the median operative time was 227.5 (180-390) min. the median blood loss was 0 (0-175) g. there were no conversions to open surgery in this series. intraoperative perforation was found in two cases during the esd procedure. however, all perforations were closed and reinforced using hand-sewn sutures. no postoperative complications were above grade 2 in the clavien-dindo classification system. conclusions: neo-dlecs is safe and feasible and can be an option for surgical sdt resection. aims: wilkie's syndrome is caused by the entrapment of the 3 rd part of the duodenum between the aorta and the superior mesenteric artery (sma). surgery is indicated for chronic cases and failure of conservative management, being reported a laparoscopic duodenojejunostomy as a minimally invasive option. methods: all cases treated by laparoscopic duodenojejunostomy in our centre because of chronic wilkie's syndrome were recorded. results: 3 females and 1 male underwent a laparoscopic duodenojejunostomy, with a mean age of 32 years (range 19-47). all patients presented abdominal pain, and weight loss was identified in most of them. a reduced aortomesenteric angle measured by ct scan was the key for the diagnosis (mean angle 22.5 degrees, range 21-24). conventional laparoscopic approach was performed in two patients, the other two patients underwent a sils port approach. mean time of surgery was 62.5 min (range 35-100) and length of stay was 5 days (range 2-13). after a mean follow-up of 47.5 months (range 11-69), 3 patients improved their symptoms. conclusions: surgery is the mainstay in complicated or refractory cases of sma. laparoscopic duodenojejunostomy has the advantages of the laparoscopic approach (including rapid recovery time, reduced post-operative pain and shorter hospital stay) and it is feasible, safe and effective. in mexico in 2013, gastric cancer represented the 3rd cause of death; it may manifest in a variety of histologic, anatomic, and genetic patterns, which influences the surgical approach. until now gastrectomy with curative intent is the only treatment that offers potential cure in gastric cancer. in recent years, laparoscopy has emerged as an important modality in the surgical management. in multiple trials no significant difference in recurrence, long-term survival and disease-free survival was observed when compared to the standard open gastrectomy. we present the case of a 62 year old man. with a smoking history of 30 pack years, suspended 12 years earlier. he presented unspecific upper gastrointestinal symptoms; an upper endoscopy was made observing a suspicious depressed lesion of 3 cm located in the greater curvature between the body and the antrum, the biopsy resulted in a poorly diferentiated signet-ring cell carcinoma of the stomach. an endoscopic ultrasound and a thoracoabdominal ct scan showed no evidence of enlarged adenopaties or metastatic disease. initially a diagnostic laparoscopy was made, there was no evidence of carcinomatosis, nor free intraperitoneal fluid; so the greater omentum was dissected towards the splenic and hepatic flexure; a d2 lymph node dissection was performed, and a subtotal gastrectomy with reconstruction of roux en y was done; intraoperative endoscopy was done to identify the lesion, so adequate margins could be obtained. the patient had a good post operative evolution and was discharged home at 4th day tolerating oral intake. minimally invasive techniques have proved equivalency of oncologic results when compared to the conventional approach; these techniques are becoming the preferred approach in the treatment of well-selected patients with gastric cancer and have a role in definitive staging, curative resection, and lymphadenectomy. appropriate selection of patients and optimal technical approach are paramount for good outcomes. most data of laparoscopic gastrectomy come from eastern countries, where the prevalence is higher; however western experience is growing along with evolution and development in surgical instruments and new technology. wilkie syndrome is a rare cause of high intestinal obstruction, resulting from the compression of the duodenum between the abdominal aorta and the superior mesenteric artery. the main symptoms are nausea and vomiting, weight loss, early satiety, abdominal distension and epigastric pain. historically, the barium study and arteriography were the diagnostic tests used; more recently the angiotac has shown greater sensitivity. the diagnostic criteria are: dilated duodenum, duodenal compression by the superior mesenteric artery and aortomesenteric angle less than 20 degrees. patients with an acute condition usually respond to conservative treatment (decompression, correction of hydroelectrolyte alterations, nutritional support…). however, those with chronic symptoms usually require surgery preferably with laparoscopic approaches of duodenojejunostomy or the strong's procedure. the strong procedure mobilizes the duodenum by dividing the ligament of treitz. once the duodenal-jejunal junction is mobilized, the duodenum is positioned to the right of the superior mesenteric artery and it is preferred because it provides less morbidity due of the maintaining of the integrity of the gastrointestinal tract, but it has a failure rate of 25%. gastrojejunostomy allows gastric decompression, but does not relieve duodenal compression, so digestive symptoms may persist, leading to the appearance of a blind loop syndrome or recurrent peptic ulcers. on the other hand, the duodenojejunostomy, which according to some series may be the procedure of choice, may obtain a success rate higher than 90%. we advocate to initiate the surgical approach with the strong procedure and if it fails to perform to a duodenojejunostomy. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in 95 cases. the outcome was assessed by reflux test performed on 4-5 postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was 56 months (3-110 months) . in 11 cases (11.6%) ppi was restarted before 6 months after the anti-reflux surgery. in 25 cases (26.3%) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed 'the esophagitis score'. in this scoring method, a number from 0-5 was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p \ 0.001). discussion: to extract the gerd patients who really need anti-reflux surgery is important. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good. background: laparoscopic paraesophageal hernia repair with fundoplication has become more and more popular nowadays due to less morbdity and mortality with shorter length of hospital stay. discussion: tan tock seng hospital is the second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them understand the procedures better. the videos can also help them recognize the important steps and standardized safe approach. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start performing the procedure themselves during their training period. this is the step by step instructional video of laparoscopic paraesophageal hernia repair with fundoplication for surgeons-in-training who are posted to our department. conclusion: the step by step instructional video on laparoscopic paraesophageal hernia repair with fundoplication can help the surgeons in training reduce their learning curve and improve their surgical skills so that they can perform the procedure safely. the human immunodeficiency virus (hiv) is a neurotropic virus. there have been reports of patients with hiv who have esophageal motility problems, sometimes associated with opportunistic infections. the absence of contractility is defined as a major motility disorder according to the chicago v 3.0 classification, which is characterized by normal esophagogastric union relaxation and 100% peristalsis failure. we present the case of a 56-year-old male patient with a history of acquired immunodeficiency on treatment with efavirenz, emtricitabine and tenofovir. he presented progressive dysphagia, gastroesophageal reflux and pyrosis of 4 months of evolution. physical examination showed no alterations. upper endoscopy is done reporting a normal esophagus and diffuse chronic gastritis. the esophagogram reported inadequate esophageal motility with contrast stasis and a delayed emptying. the esophageal manometry reported an upper esophageal sphincter with high resting pressure. the middle and distal esophagus showed absence of peristalsis with a pan-esophageal pressurization pattern. the lower esophageal sphincter presented normal resting pressure and borderline relaxation (41%). the integrated relaxation pressure was less than 15 mmhg. the diagnostic impression was absence of contractility (chicago classification v 3.0).medical management was initiated with inhibitors of the proton pump, isosorbide dinitrate and injections of botulinum toxin without success. it was decided to program the patient for a heller myotomy with toupet fundoplication. a trans-surgical endoscopy revealed a complete myotomy with no leakage or obstruction. the patient went home on the second postoperative day tolerating a solid diet.heller myotomy by laparoscopy with partial fundoplication is safe in the treatment of patients with hiv and esophageal motility disorders, reporting a mortality of 0.1%. the effect of endoscopic treatments prior to surgery is controversy aims: epiphrenic diverticulum represents an infrequent entity and it is usually associated with esophageal motility disorders, such as achalasia, distal esophageal spasm, nutcracker esophagus or hypertensive lower esophageal sphincter. nowadays, epiphrenic diverticulectomy, esophageal myotomy and partial fundoplication is the gold standard technique; although it supposes a challenging procedure and it may provoke lots of complications. approach for diverticulectomy usually depends on the distance from the upper border of the diverticulum's neck to gastroesophageal junction, considering that thoracoscopy should be carried out when this distance is more than 5 cm. methods: we presentthecase of a 57-year-old male patient, with a bodymass index of 30anda medical history of diabetes, smoking and alcoholism. his symptoms were mainly regurgitation and dysphagia. upper endoscopy showed esophageal dilatation and the presence of a diverticulum with its neck 2 cm over the gastroesophageal junction. ct scan confirmed these findings and manometry showed achalasia. in the video we can see how we perform a laparoscopic diverticulectomy with esophageal myotomy and dor fundoplication. results: patient was discharged home on the second postoperative day with no complication. after more than two years of follow-up, he has not suffered regurgitation, heartburn, dysphagia or chest pain. conclusions: we present a case with an epiphrenic diverticulum secondary to achalasia in which we performed a laparoscopic diverticulectomy, esophageal myotomy and dor fundoplication. some authors suggest that the correction of the underlying motility disorder is the key in the management of these patients and they do not recommend concomitant diverticulectomy for all cases. however, we consider that the complete procedure, adding diverticulectomy, supposes the gold standard and it is feasible to perform for teams which are skilled in esophageal and gastric laparoscopic surgery, despite its high morbidity rates. purpose: a laparoscopic wedge resection for a gastric submucosal tumor closed to gastroesophageal junction or involved to gastroesophageal junction is technically challenging and more aggressive compared with tumors in other sites of the stomach. a gastroesophageal reflux disease would be more prevalent after laparoscopic wedge resection of a gastric submucosal tumor in gastroesophageal junction because of the destruction to low esophageal sphincter. we hypothesized that a prophylactic anti-reflux surgery after this surgery would be less prevalent the gastroesophageal reflux disease (gerd) and more improve the quality of life of the patients. the aim of this study is to analyze our experience with prophylactic anti-reflux surgery after laparoscopic wedge resection for a gastric submucosal tumor of gastroesophageal junction materials and methods: we retrospectively collected data from 51 patients who diagnosed with submucosal tumor of near the gastroesophageal junction underwent laparoscopic wedge resection between january 2000 and december 2017. the patients were divided into 2 groups according to operation with prophylactic anti-reflux surgery (group a) and without one (group b). results: there were no difference in the frequency of the preoperative gerd symptoms between the 2 groups, whereas postoperative gerd symptoms and postoperative use of acid suppressive medications were more frequent in the group b (p = 0.032, p = 0.036). however, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and hill's grade between the 2 groups. in group a, postoperative mean low esophageal sphincter (les) pressure was 22.0 ± 13.0. the les pressure was dropped until 15 mmhg in the only one patient. however, there was no reflux symptom in this patient. conclusions: the prophylactic anti-reflux surgery after laparoscopic gastric wedge resection of gastroesophageal junction is an effective method of prevent gastroesophageal reflux symptoms. background: the most critical obstacle is a pancreatic leakage(pl). the most cause of pl might be an activation of pancreatic juice by the mixing of pancreatic juice and intestinal fluid because of the anastomosis technique, the difference of anastomosis between pancreatic duct and caliber of jejunum, and the topple of jejunal mucosa. aim: in this study, we devised the new anastomotic method of pancreato-jejunostomy, so called ' pancreatic stent sliding guide' (pssg) method using a pancreatic duct stent. we would like to demonstrate its method and results. (operative procedure) the 10cases of hybrid laparoscopic pancreatico-duodenectomies (pd) were done by shuriken-shaped umbilicoplasty with pssg. the pancreatic duct stent, which is fit for a diameter of pancreatic duct, is used for the direct puncture without any incineration. the aims of direct puncture are both the avoidance of the enlargement of anastomotic opening and disturbance of blood flow. the contralateral of anastomotic opening is also punctured and the stent is pulled out of the jejunum. the 6-0 pds with the needles at both ends is used for anastomotic thread. firstly, the eversion anastomosis of posterior wall is done by sliding the needle on the stent. and then the anastomosis of anterior wall is done by the same way. the stent of contralateral side is cut and the hole is closed. materials and methods: the 10 cased of pancreato-jejunostomy by pssg method were done by february 2019. the average of patient's age was 72 y.o. the disease of patients were pancreatic cancer (n = 4), bile duct cancer (n = 5), and papilla vater cancer(n = 1). the pancreatic leakage by the isgpf were grade 0:10,a:0,b:0,c:0 respectively. in the same periods, we underwent the more ten cases of open pd by pssg method. the pl were only one case of grade a and there were none of clinical pl. conclusion: our new device of pancreato-jejunostomy by pssg might be very effective for the decrease of pl from the view point of machanisms of pl even for laparoscopic pd. year old, male patient presented with upper abdominal discomfort and pain, without nausea, vomiting or weight loss. an sub mucosal lesion was found on endoscopy examination in first part of the duodenum. endoscopic ultrasound has showed 2.5 cm sub mucosal lesion in first part of duodenum (anterior wall and close to pylorus). cytology examination from the lesion has showed neuroendocrine tumor. computed tomography of abdomen and chest were normal. his blood laboratory examinations were within normal limits. patient underwent da vinci robotic partial gastrectomy with intra corporeal billroth ii gastrojejunostomy. total operating time (ort) was 255 min. three day after operation patient started regular diet and was discharged home on day fife. final pathology report confirmed diagnosis of carcinoid tumor with ki67 less than 1%. surg endosc (2019) 33:s485-s781 p426-robotics & new techniques-education integrated education for colorectal disease-a digital solution for a digital age united kingdom aims: surgical plume has problem in poor visibility of the operative field, inclusion of harmful chemical substances, and biological risk. it is desirable that plume should be removed appropriately to minimize these risks. we assessed whether these problems can be solved by using commercialized evacuator semi-quantification of residual chemicals in the abdominal cavity: was performed using industrial smoke tester by aspirating the intra-abdominal plume onto filter papers and digitizing the stains. (3) detection of dna in the exhausted gas from the evacuator: the hepa filter, which was interposed at the inlet or outlet of the evacuator, was analyzed using pcr method to detect any dna derived from porcine tissues. results: (1) laparoscopic visualization: judgement score were 2.2 vs. 1.0 for ec and 3.8 vs. 1.8 for us (evacuator: on vs. off, both p \ 0.0001), indicating the visualization was significantly better in the use of the evacuator on both devices general surgery, royo villanova hospital general surgery minimally invasive surgery centre, jesús usón minimally invasive surgery centre methods: i report my experience at the american university of beirut medical center for laparoscopic adrenalectomy 65 cases, 35 left adrenalectomy and 30 cases for right adrenalectomy. three out of the series are large adrenal of 15 cm, and all of these were completed laparoscopically.the video will show the steps of this procedure.a large rt. adrenal mass measuring 15 cm, wt.750gm was removed laparoscopically using 4 trocar techniques. the lateral position facilitated the exposure and ease of dissection. the mass was removed by extending one of the trocar site with muscle splitting using endocatch 15 mm. results: patient was discharged home 3 days after surgery. the operative time was 1 hour. pathology revealed carcinoma with no involvement of the capsule or vascular invasion 163 patients (male: n = 39; female: n = 124) underwent minimally invasive adrenalectomy (tp: n = 135; rp: n = 28) at our institute. mean patient age was 53.8 years (21-82 years). besides comparing operative (intraoperative blood loss, previous abdominal surgeries, conversion rate, operative time, tumor size) and perioperative factors (time of hospitalization, time to oral intake, histology, postoperative complications) in each group, perioperative outcomes of a learning curve (lc)-the first 28 procedures in both groups-was also analyzed in terms of tumor size, significantly larger lesions were removed with tp (tp: 48.18 ± 22.8 mm vs rp: 34.8 ± 11.2 mm; p = 0.028). the number of asa (american society of anesthesiologists) ii patients were significantly higher in the tp group while there were significantly more asa iii patients in the rp group conversions 237) showed no significant difference. the analysis of lc showed a significant difference in previous abdominal surgeries min vs rp: 134.5 ± 12.4 min; p = 0.023] all favoring the tp approach. conclusion: both methods proved to be feasible and safe in terms of minimally invasive adrenalectomy. based on our own experience the tp approach resulted in improved operative time and conversion rates to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the face of a massive splenomegaly or neoplastic pathology. material and method: clinical case: a 38-year-old man followed in the dept. of internal medicine for a hepatosplenomegaly of probable lymphoproliferative origin. additional explorations of interest are provided. result: intervention: complete laparoscopic approach, right lateral partial decubitus, massive splenomegaly, ? 23 cm, splenuncle of 3-4 cm that is resected, section of short vessels, dissection of the splenic hilum, vascular section with endogias, splenectomy with full extraction in a pocket through reduced laparotomy in the left flank for anatomopathological study the aim of this video is to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the case of a massive splenomegaly or neoplastic pathology it can transform into adenocarcinoma. patients and methods: between 2001 and 2008 we performed laparoscopic nissen fundoplication (lars) in 254 cases of gerd. in 78 cases of gerd patients be was proved by endoscopy and histological examination. the demeester score was higher (18.9 versus 41.9, p \ 0.001), and bile re?ux was measured more frequently among the be patients on the other hand during the 8.5 years long endoscopic follow up early barrett carcinoma developed in 2 patients, 38.5 months after the lars. both patients underwent a limited surgical resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic jejunal segment. there were no complication. histological examination was shown pt1n0 stage disease in both cases. oncological follow up was 82 months long (6.8y) and both patients are still disease free. conclusions: although lars can affect regression in a part of be patients, progression to adenenocarcinoma can also occur. endoscopic surveillance is important in the case of be to recognize early cancer, to perform limited surgical resection with low morbidity and long overall-and disease free survival gastric cancer development a nomogram for predicting the conditional probability of survival after d2 lymphadenectomy for gastric cancer this study aimed to devise a nomogram to predict the conditional probability of cancer-specific survival (cpcs) in gastric cancer (gc) patients after gastrectomy with d2 lymphadenectomy. methods: clinicopathological data for 2,596 gc patients who underwent d2 lymphadenectomy in a large-volume eastern institution (the training cohort) were analysed. cancer-specific survival (css) was predicted using cox regression models. a conditional survival nomogram was constructed to predict cpcs at 3 and 5 years post-gastrectomy. two external validations were performed using a cohort of 2,198 chinese patients and a cohort of 504 italian patients. results: in the training cohort, the 5-year cpcs was 59.2% immediately post-gastrectomy and increased to 68.8%, 79.7%, 88.8% and 95.1% at 1, 2, 3 and 4 years post-gastrectomy, respectively. multivariate cox regression analyses showed that age; tumour site, size and invasion depth; numbers of examined and metastatic lymph nodes; and surgical margins were independent prognostic factors of cancer-specific survival (all p \ 0.05) and formed the nomogram predictor variables. internal validation showed that the conditional nomogram exhibited good discrimination ability at 3 and 5 years post-gastrectomy (concordance index, 0.794 and 0.789, respectively) gastric cancer does non-compliance in lymph node dissection affect oncological efficacy in gastric cancer patients undergoing radical gastrectomy? univariate and multivariate analyses revealed that non-compliance was an independent risk factor for os. logistic regression analysis demonstrated that the extent of gastrectomy, primary tumour site, history of intraperitoneal surgery, bmi and open gastrectomy were independent preoperative predictive factors for non-compliance. cox analysis demonstrated that age, pt, pn, and the extent of gastrectomy independently affected os in patients with noncomplaint lymphadenectomy. however, os was significantly better in the compliant group than in the non-compliant group regardless of the recommendation for chemotherapy. stratified analysis demonstrated that os was significantly better in chemotherapy patients than in patients without chemotherapy and stage ii patients (pt1n2/n3m0 and pt3n0m0) in whom chemotherapy was not recommended. conclusion: non-compliance is an independent risk factor after radical gastrectomy for gc we prospectively collected and retrospectively analysed the medical records of 398 patients with proximal gc who underwent lspsd. the data were split 75/25, with one group used for model development and the other for validation testing. results: of the 398 patients enrolled in this study, 174 (43.7%) required laparoscopic haemostasis treatment. a multivariate analysis determined the following preoperative adverse risk factors for the model group: gender, preoperative n stage, and terminal branches of the splenic artery (spa), and we developed a scoring system based on these findings. each of these factors contributed 1 point to the risk score. the intraoperative laparoscopy hemostasis rates were 11.5, 33.6, 58.5, and 73.5% for the low-, intermediate-, high-, and extremely high-risk categories, respectively. there were statistically significant differences among groups (p \ 0.001). with the increase in risk, both blood loss volume (blv) and operative time (min) of lspsd increased significantly (p \ 0.001).the area under the receiver operating characteristic curve for the score of intraoperative laparoscopic haemostasis was 0.700. the observed and predicted incidence rates for intraoperative laparoscopic haemostasis were parallel in the validation set. conclusions: this simple we compared the survival of src patients with that of tubular adenocarcinoma patients according to bmi. results: the 5-year survival of src was significantly worse than that of wmd (p \ 0.001) but superior to that of pd (p \ 0.001). bmi-stratified analysis showed that in the high-bmi group, the prognosis of src was similar to that of wmd (p [ 0.05) and better than that of pd (p \ 0.001). in normal-bmi patients, src had a worse prognosis than wmd (p \ 0.001) but a more favorable prognosis than pd (p \ 0.001). src among low-bmi patients displayed much poorer survival than did both wmd (p \ 0.001) and pd (p = 0.005). multivariate analysis indicated that the risk of death was lowest for src patients with a high bmi and highest for src patients with a low bmi baseline characteristics were compared in a 35-patient rspshl cohort and a 608-patient lspshl cohort. one-to-four propensity score matching was performed to determine between-group differences. result: in total, 175 patients were matched, including 35 patients who underwent rspshl and 140 who underwent lspshl. no significant differences in baseline characteristics were observed between these groups after matching. significant differences in total operative time, estimated blood loss (ebl), splenic hilar blood loss (shbl), splenic hilar dissection time (shdt), and splenic trunk dissection time were detected between these groups (all p \ 0.05). furthermore, no significant differences were evident between rspshl and lspshl in the overall noncompliance rate of lymph node (ln) dissection (62 the highest body temperature within 1 week after operation was used to establish diagnostic thresholds for high body temperature and low body temperature, which was obtained by x-tile software. the study used cox regression to analyze the influence of high body temperature on 5-year dfs. results: a total of 1396 patients were included in the analysis. the diagnostic threshold for high body temperature was defined as 38°c; 370 patients with a high postoperative body temperature were allocated to the high temperature group (htg), while another 1026 patients were allocated to the low temperature group (ltg) cao department of gastric surgery, fujian medical university union hospital, fuzhou, china background: laparoscopic surgery for remnant gastric cancer third step: baring of the right side of the esophagus. fourth step: exposure of left gastroepiploic vessels and lns dissection in the splenic hilar area. fifth step: baring of the left side of the esophagus. the above procedure was performed for 45 rgc patients with stage ct1-4an0/? disease. results: there was no conversion to open surgery. mean operation time was 195.0 ± 52.5 min, mean blood loss was 104.3 ± 90.4 ml, and mean times to first flatus p526-upper gi-gastric cancer a novel prognosis prediction model after gastrectomy for remnant gastric cancer: development and validation using international multicenter databases fuzhou, china; 2 department of gastrointestinal surgery the model calibration was accurate in predicting 5-year survival. dca showed that the model has a greater benefit. the results were also confirmed by bootstrap internal validation. in external validation, c-statistics and dca showed good prognostic performance in patient datasets from 2 participating institutions. moreover, we verified reliability of the model in an analysis of patients with different eln counts p527-upper gi-gastric cancer a novel abdominal negative pressure lavage-drainage system for anastomotic leakage after r0 resection for gastric cancer while risk of gastric cancer for ppi users was higher than non-ppi users when duration between 1-3 year, = 1 year, = 3 year and = 5 year. the risk of gastric cancer when duration = 5 year(rr = 2.03)and duration = 3 year(rr = 1.95)are higher than risk of gastric cancer when duration between 1-3 year (rr = 1.74). according to location subgroups meta-analysis,risk of non-cardiac gastric cancer for ppi users higher than non-ppi users conclusion: based on a systematic review with meta-analysis, we found the correlation between long-term use of ppi and the risk of gastric cancer and long-term use of ppi may increase the risk of non-cardiac gastric cancer when duration = 1 year p534-upper gi-gastric cancer age-adjusted charlson comorbidity index (acci) is a significant factor for predicting survival results: there were 1476 patients included in the analysis. the high-acci and low-acci groups had significant differences in preoperative abdominal surgery history, asa grade, tumor size, tumor stage, histologic type, age and comorbidity (all p \ 0.05). the incidence of postoperative complications was 17.9% in the high-acci group and was significantly higher than that in the low-acci group (p = 0.001). the overall survival rate (os) and cancer-specific survival (css) rate in the low-acci group were both higher than those in the high-acci group (p \ 0.05). univariate and multivariate analyses showed that the acci was an independent risk factor for os and css (p \ 0.05). furthermore, a combination of the tnm staging system and acci showed a trend toward higher prognostic value and higher auc for os and css than the tnm staging system alone (p \ 0.05). conclusions: the acci was an we aimed to investigate the clinicopathological features and prognosis of patients with mgc and the impact of postoperative adjuvant chemotherapy on long-term survival. methods: the clinical and pathological data of patients diagnosed with gastric adenocarcinoma and undergoing radical gastrectomy from stratified analysis showed that, in advanced gastric cancer (agc), the 5-year os rates of mgc without adjuvant chemotherapy and sgc without adjuvant chemotherapy were 34.0% and 46.1%, respectively, with a statistically significant difference (p = 0.025). the 5-year os rates of advanced mgc after adjuvant chemotherapy and of advanced sgc after adjuvant chemotherapy were 48.0% and 53.3%, respectively, and the difference was not statistically significant (p = 0.292). the 5-year os rate of advanced mgc after adjuvant chemotherapy was significantly higher than that of patients without adjuvant chemotherapy (48.0% vs. 34.0%, p = 0.026). conclusions: mgc is a poor prognostic factor after radical gastrectomy for gastric cancer background: whether the tumor-node-metastasis (tnm) staging system is suitable for patients with node-negative gc is still controversial. the modified staging system established by rpa showed good prognostic performance in a variety of cancers. the application of rpa has not been reported in the prognostic prediction of gc. methods: node-negative gc patients who underwent radical resection at fujian medical university union hospital (n = 862) and sun yat-sen university cancer center (n = 311) with an at least 5-year follow-up information were selected as the training set. rpa was used to develop a modified staging system. patients from the surveillance, epidemiology, and end results databases (n = 1415) were selected as the external validation set. results: the 5-year overall survival (os) rates of patients with 8th ajcc-tnm stage ia-iiia in the training set were ia 95%, ib 87%, iia 78%, iib 76% and iiia 73%. multivariate analysis (mva) showed that larger tumor size, older age, and deeper depth of invasion were independent risk factors for os in patients with node-negative gc (all p \ 0.05). patients were reclassified into rpa i, rpa ii, rpa iii, and rpa iv stage based on rpa, the 5-year os rates were 96%, 87%, 81%, and 64%, respectively, with significantly difference (p \ 0.05). two-step mva showed that the rpa staging system was an independent predictor for os (p \ 0.05) were retrospectively collected. patients were classified into two groups according to bmi of \ 25 kg/m 2 (332 patients; high bmi group) and = 25 kg/ m 2 (108 patients; low bmi group). for these 440 patients, clinicopathological variables were analyzed using propensity score matching to mitigate the selection bias: sex, age, asa physical states, clinical stage, laparoscopy-assisted total gastrectomy (latg) or totally laparoscopic total gastrectomy (tltg), d2 lymph node dissection, combined resection of other organs, method of anastomosis, jejunal pouch reconstruction. the surgical results and postoperative outcomes were compared and examined between the two groups. results: a total of 152 patients were matched for the analysis. contrary to our expectations, there were no differences in the surgical results about operative time and estimated blood loss (low bmi 336.3 ± 72.0 min, high bmi 354.5 ± 85.3 min; p = 0.479, low bmi 144.2 ± 300.8 g, high bmi 112.6 ± 155.8 g; p = 0.695, respectively). furthermore, there was no significant difference in postoperative outcome of complication (clavian-dindo [ iiia) and the length of postoperative hospital stays (low bmi 13 cases, high bmi 10 cases baiocchi general surgery, university of brescia-spedali civili, brescia, italy background and aim: recently indocyanine green (icg) was introduced in clinical practice as a fluorescent tracer. the use of icg for sentinel lymph node (ln) mapping was investigated in lots of fields such as breast methods: we conduced a single center prospective trial. we included patients with gastric cancer candidate to surgery. icg was injected intraoperative or the day before surgery, via submucosal or subserosal. total or subtotal gastrectomy was performed open, laparoscopic or video-assisted access. during gastric cancer standard lymphadenectomy we studied lymphatic flow and ln bright in vivo and ex vivo japan introduction: in japan, the number of elderly patients with gastric cancer has been increasing in correlation with the increase in average age of the population. the aim of this study is to assess the safety and efficacy of laparoscopic gastrectomy for cancer in elderly patients compared with the short-term outcome in the nonelderly. method: we reviewed 231 patients who underwent laparoscopic gastrectomy (dital gastrectomy,proximal gastrectomy,total gastrectomy)between 021).the incidence of advanced cancer(stageiior more)was higher in elderly patients there were no significant differences in the operating time,blood loss and postoperative hospital stay. there were no significant differences in the incidence of postoperative morbidity. conclusion: in elderly patients, there was a tendency of reduction surgery being selected according to individual condition, but there was no significant difference in the short-term outcome.hence,we conclude that laparoscopic gastrectomy is indicated even in elderly patients. p548-upper gi-gastric cancer improved technique of vacuum therapy and carried out ltg . a patient factor (the gender, the age and bmi), an operation factor (operation time, the bleeding amount, lymph node dissection and conjurer), a coincidence related complication (clavien dindo classification, sutural insufficiency of grade more than 2, anastomotic stricture, anastomotic region bleeding and reflux esophagitis) and the post-operatively length of stay were considered . result: cs crowd met 98 cases (85.2%) and ls cluster (14.8%) 17 cases. 70 years old of age medians (38-84), men and women were 93 examples (83.4%), 22 examples (16.6%) and bmi median 22.5 (16.2-31.1) by a patient factor, and a significant difference didn't admit by two groups for 13 days, the post-operatively average length of stay was 11 days by ls group by cs group. conclusion: operation time was short for a coincidence by linear stapler more than a coincidence by circular stapler in comparison of an esophagoenterostomy way in ltg on the day before the operation, we endoscopically clipped several points located 2 cm proximal to the tumor edge to cover about half of the tumor. after lymph node dissection, we incised the stomach with an endoscopic linear stapling device,including the previously placed clips. reconstruction was performed in all patients who underwent billroth i or roux-en-y procedures. result: no complications were observed during pre-operative endoscopic clipping or intraoperatively p558-upper gi-gastric cancer small intestinal tumors after laparoscopic surgery in our hospital small intestinal tumors are rarely observed, accounting for about 3-6% (malignant cases: 1-2%) of all gastrointestinal tumors. therefore, occasionally, their diagnoses can be difficult. however, recently, capsule and balloon endoscopes have been widely employed were examined regarding patient backgrounds, diagnostic methods, pathological findings, postoperative courses, and prognoses. results: the subjects consisted of 15 males and 5 females, with a mean age of 63 years. their chief complaints were black stools the median distance from the treitz ligament or bauhin valve was 50 cm (2-200) postoperative complications were abdominal abscess (2 cases; 10.0%) and surgical site infection (ssi), hemorrhage, and paralytic ileus (1 case each; 5.0%). pathological diagnoses were lymphoma metastatic small intestinal tumor (2 cases; 10.0%), and granuloma, lipoma, peutz-jeghers polyp, clear cell sarcoma, malignant mesothelioma, and ectopic pancreas most patients were diagnosed in bleeding, complicated by anemia and black stools. however, as most tumors were relatively close to the treitz ligament and bauhin valve, almost a half could be diagnosed with a small intestine endoscope before surgery patients were classified as popf and no-popf according to their grade b or c popf status. popf was diagnosed according to international study group of pancreatic fistula (isgpf) criteria or clinical findings. patient characteristics, intraoperative parameters, electrosurgical device type, pathological findings, and early postoperative outcomes were compared. electrosurgical devices were classified asthunderbeat (tb) or laparosonic coagulating shears (lcs) based on energy sources. results: eighteen patients developed grade b or c popf. among them, 12 (66.7%) and 6 (33.3%) were diagnosed with popf according to isgpf criteria and clinical findings 011), operation time (p = 0.03) and electrosurgical device type (p = 0.005) were significant risk factors for popf following lag 017) and tb device (or, 6.80; 95% ci 002) were independent risk factors for popf following lag. conclusions: operation time and tb use significantly affect the risk of popf and should be considered in future clinical studies. p560-upper gi-gastric cancer feasibility and nutritional benefits of double flap with no-knife stapler reconstruction after laparoscopic proximal gastrectomy for gastric cancer were analyzed. receiver operating characteristic curves were generated, and by calculating the areas under the curve(auc) and the c-index, the discriminative ability of crps during different periods were compared, including pre-crp, postoperative days 1, 3, 5 and postoperative maximum crp (post-crp max ). a decision curve analysis was performed to evaluate the clinical utility. result: ultimately, 401 patients were included this study and the median follow-up time was 29 (3-41) months. for postoperative recurrence, the auc and c-index of pre-crp were 0.692 and 0.678, respectively, significantly higher than the other crps, all p \ 0.05. among = ''''''the = '''' post-crps = '''' post-crp = '''' sub = similar findings were observed for overall survival. conclusion: both pre-crp and post-crp max , cheap and easily obtained, are independent predictors of recurrence for gc. act significantly prolonged the rfs for stage ii/iii gc patients with high-prep p566-upper gi-gastric cancer robot-assisted gastroduodenal surgery: a single center experience robot-assisted gastroduodenal surgery (ras) was introduced to overcome the technical limitations of conventional laparoscopy. it provides a 3d-amplified view to the surgeons and an increased ability to control the operative field by manipulating optics, as well as enhanced mobility and precision of instruments. the aim of the present study is to evaluate the main outcome of a single center experience in gastroduodenal robotic surgery. materials and methods: we report a case series of patients who underwent robot-assisted gastroduodenal surgery at sanchinarro university hospital between conclusions: robot-assisted gastroduodenal surgery is a safe and feasible technique in experienced centers with advanced robotic skills. in the literature, there are only few reports of robotic assisted gastroduodenal resection. further studies are necessary to better confirme our results. p567-upper gi-gastric cancer atypical methods: retrospective review of ogd reports before and after the introduction of the new guidelines. inclusion criteria: all elective ogds. exclusion criteria: emergency ogds and elective therapeutic ogds. data recorded: patient demographics, endoscopist, indication, number of photos, anatomical site photographed, pathology identified and whether pathology photographed or not. results: 1099 ogds reviewed, 790 before the guidelines (group 1) and 309 afterwards (group 2). the most common indication was reflux 166 (21%) in group 1 and anaemia 67 (22%) in group 2 clinical utility of systematic pre treatment staging laparoscopic exploration methods: all locally advanced gastric adenocarcinoma managed in surgical oncological unit between 1st january and 30th november were prospectively enrolled in the study. in the absence of emergency surgery or preoperative contraindications, all patients with curative intent underwent either preoperative chemotherapy followed by surgical exploration in the intent of curative gastrectomy (g)or systematic pretreatment laparoscopic exploration (l) benkabbou surgical department the patient background (age, gender, bmi) and c-stage of the preoperative factor were matched using propensity score matching method, and the surgical results were compared and examined. results: thirty rg groups matched rag 30 cases. the operation time (rag / lg) was significantly longer in the rag group as 309.2 ± 47.9 min / 220.6 ± 55.2 min (p \ 0.05). amount of blood loss was not significantly different each other; 10 ml / 9 ml (p = 0.693). pathologically t4a case was involved in 4 cases in rag and 5 cases in lg. the extent of lymph node dissection (d1 ? / d2) was 23/7 cases in both groups conclusions: rag in our clinical experiences can be safely introduced and short-term results are comparable to those of lg. verification of superiority of robotic surgery including long-term results seems to influence the future of robotic surgery conclusions: totally laparoscopic gastrectomy is feasible method in terms of surgical outcomes. furthermore, totally laparoscopic total gastrectomy is not technically difficult in advanced gastric cancer such as early gastric cancer and safety method. key words: gastrectomy, reconstruction, laparoscopic surgery, stomach neoplasm aims: meckel's diverticulum (md) is one of the most common congenital anomalies of the small intestine caused by an obliteration defect of omphalomesenteric duct. the objective of this study was to review surgical treatment and clinical outcomes of md, and evaluate the safety and feasibility of minimal invasive surgery (mis) in md. methods: we performed a retrospective analysis of medical record for patients who underwent meckel's diverticulectomy at six hallym-university-affiliated hospitals between 18 d), as well as the average of drainage stay. patients who underwent laparoscopic repair required significantly less parenteral analgesics than the open group.the mean postoperative stay was significantly shorter for laparoscopic group (mean, 5.48 d) than the open one.morbidity of medical and surgical complication was higher in open groups (23 vs 2). the most common complication in both groups was medical complication.more case of pneumonia was occurred in open groups compared to laparoscopic groups methods: a retrospective study using our prospective database was designed to analyse all the resected md in our centre. epidemiological data, clinical setting, diagnostic test and histological results were reported. results: md was resected in 112 patients, 80 males and 32 females, with a mean age of 13.00 years (3.25-59.50). in 35 cases, a laparoscopic approach was chosen. eighty-seven percent of the patients had a presurgical imaging test (ultrasounds, ct-scan or meckel's scan) background: perforated peptic ulcer (ppu) is a substantial health problem with significant postoperative morbidity up to 63% and mortality up to 40% worldwide. aims: this study aimed to estimate the sensitivity scoring systems for prognosis morbidity of patients operated for ppu with diffuse peritonitis. methods: a total of 153 patients were underwent emergency repair for ppu with diffuse peritonitis in pirogov russian national research medical university's surgical clinics during 2014-2016 years. different scoring systems used to predict outcome in ppu patients were identified: boey score, peptic ulcer perforation (pulp) score, asa, mannheim peritonitis index (mpi), world society of emergency surgery sepsis severity score (wses score). to quantify the strength of the concatenation of prognostic score and morbidity we use odds ratio (or) with 95% ci 05), respectively. pulp score and asa score have good prognostic value in relation to morbidity, but less than boey, mpi and wses sss. patients with pulp [ 7 had or 27 with 95% ci of p596-upper gi-gastroduodenal diseases gastrostomy tube placed by laparoscopy as a new therapeutic option for continuous intestinal infusion treatment with levodopa/ carbidopa we present 20 year outcomes of our initial consecutive patient cohort. methods: patients were identified in a prospectively maintained irb-approved database (1993-1998). post-operative eckardt scores and a 5-point validated system questionnaires were obtained via telephone interviews one patient required reoperation for failed myotomy. the mean eckardt score at 20 years was 0.81(± 0.21), with all fourteen patients having an eckardt score \ 3. all patients reported significant improvement in their quality of life. classic gerd symptoms (heartburn and regurgitation) were present in 3 (21.4%) patients. proton-pump inhibitors are being used by 35% of with patients with excellent symptom control. seven patients returned for a repeat egd (median 18.3yrs) with 5 patients having normal anatomy and 2 having la grade a esophagitis (1 patient on ppi). barrett's esophagus was not detected. conclusion: long-term results from our early experience with lhm are excellent and durable with only one patient requiring re-intervention in 20 years until recently the esophagectomy was the only choice in treatment of patients with end-stage achalasia. developing of minimally invasive techniques such as a laparoscopic heller miotomy and peroral endoscopic myotomy (poem) allowed to use them as a treatment options. aim: to present an experience of treatment of patents with end-stage cardiac achalasia. materials and methods: since 07.2013 till the 12 laparoscopic heller myotomy was performed in 3, and esophagectomies were performed in 3 patients with failed previously myotomy made in other clinics. gastric tube was used to replace the esophagus in patients underwent esophagectomy after skeletization of crura posteriorly to esophagus, two separated rectangular patches of parietene progrip mesh (covidien) measuring 1x2.5-3 cm were attached to the posterior surfaces of the crura. the patches were fixated themselves due to special hooks. than continious twodirections suture was placed through both crura along with the patches using self-gripping v-loc 2-0 suture (covidien). the same suture was used for construction of nissen fundoplication wrap 3.5 cm long. aditional anchoring stich through the wrap and esophageal wall was placed using ti-cron 2-0 suture (covidien). 3d laparoscopy was used while suturing using richard wolf epic system. results: all the procedures were performed successfully. there were no cases of bleeding from the suturing points either from the crura and the fundus wall. there were no crural dehiscence while suturing, even if the distance between crura was more than 4 cm. the mean duration of suturing facilitated by 3d laparoscopy was 15 min (range, 12-20 min) for crural repair, and 10 min (range, 8-25 min) for fundoplication. there were no excessive postoperative pain in all the patients. there were no disphagia 1 month postop in every patient. conclusions: 1. the new technique of posterior buttress of crural repair using small patches of parietene progrip mesh and v-loc suture showed feasibility and safety. 2. the use of 3d in such case most commonly manifested symptoms are cough, sore throat, hoarseness, dysphonia, globus and only 40% patients with lpr have typical gerd symptoms. also ppi therapy are less effective in patients with lpr in comparison with patients which have typical features of gerd. purpose: to compare the outcomes between surgical treatment and conservative therapy in patients with laryngopharyngeal reflux. materials and methods: for the period chesarev faculty surgery #1, federal state autonomous educational institution of higher education i.m. sechen, moscow, russia p614-upper gi-reflux-achalasia a case of a primary parahiatal hernia associated with a type i hiatal hernia emergency county hospital parahiatal hernia is a rare disease that occurs when an abdominal organ protrudes through an opening adjacent to an anatomically intact esophageal hiatus. the herniated organ is usually the stomach, although cases of omental and colonic herniation exist we report the case of a 60-year-old woman which accused epigastric pain, starting 2 years prior, pseudo-angina, heartburn and bloating. based on imagistic findings the patient was diagnosed with a parahiatal hernia and an associated type i hiatal hernia. patient underwent surgery and a 7 cm diameter defect in the diaphragm lateral to the left crus was discovered, through which 40-50% of the stomach had herniated. the hiatal orifice was slightly enlarged but anatomically intact, with an associated small sliding hiatal hernia. we performed closure of the defect, hiatoplasty and a floppy-nissen fundoplication pneumatic dilation with 30 mm balloon was performed under general anesthesia. radiological contrast control and endoscopy reevaluation revealed a perforation just above the squamo-columnar junction. a minimally invasive approach was decided. an fully covered esophageal stent was inserted. radiological control after 2 days reveals left pleurisy and migration of the stent. the same day was performed an endoscopic repositioning of the stent with clip fixation. left pleural puncture was performed and clear fluid was extracted. the condition of the patient got worse and she was transferred on icu (08.07). we performed left pleurostomy and initial exploratory laparoscopy-no intraperitoneal lesions. due to difficult transhiatal access to the inferior mediastinum the surgery was converted to open-perisophageal mediastinal abscess was found, evacuated and drainage and jejunostomy were performed. after a week, the patient presented progressive altered condition, febrile syndrome. thoraco-abdominal ct-scan showed left pleural effusions. left pleurostomy was performed, with extraction of fetid fluid. continuous lavage was instituted. on 1 st of august, the pleurostomy tube drained gastric content, and the clinical examination revealed signs of generalized peritonitis. laparotomy was performed with lavage, drainage and posterior decompression gastrostomy. results: postoperative evolution was favorable, with the suppression of pleural drainage in 13.08 and discharge in 29.08 with alimentation exclusive on jejunostomy. one month later, she had normal clinical and radiological examination evaluation of efficacy was performed with reflux symptom index (rsi) specific for extraesophageal symptoms, subjective satisfaction and occurrence of dysphagia and gas-bloat syndrome. a rsi score [ 12 was considered as pathological. results: rsi significantly decreased after surgery (14and msa as compared with total fundoplication; 83,3% of patients were satisfied with surgery: a comparison between techniques showed superiority of msa objective: to demonstrate the efficacy of hiatorraphy without the use of meshes in thegiant paraesophageal hiatus hernia, as well as the standardization of our technique, with thetechnical steps that we make successively. material and method: clinical cases: 68-year-old man,with symptomatic hiatal hernia with progressive intolerance and dysnea. egd: the stomach rotated in a giant hiatal hernia.gastroscopy not completed due to endoscope loop formation within giant hiatal hernia with gastric volvulation. ct: large hiatal hernia,combined volvulation (axial axial mesenteric organ), the stomach in a right subpulmonary situation. results: intervention: laparoscopic approach.hh of large paraesophageal size,double organoaxial-and-mesenteric volvular component,gastric walls very thickened and adhered to the mediastinum.reduction of all content and the sac,is adhered to the pleura, extended med-iastinal esophageal disection, up to vein pulmonary and get enough abdominal esophagus and rule out the presence of an short esophagus,posterior-anterior and left tutorized modified hiatorraphy with stitches in ''u'' with non-absorbable suture on teflon reinforcement patches.nissen fixed to both pillars, intramediastinal drainage.egd at the 1st day with esophageal stenosis due to inflamation of the nissen, resolved with medical treatment. dischage at 5 th day.asymptomatic and without radiological recurrence after 10 months of follow-up. conclusions: in giant and paraesophageal hiatus hernias, modified primary hiatorraphy together with mediastinal esophageal dissection extended can be an effective and safe alternative, and can be advised as a technical gesture prior to a collis nissen and-or placement of a hiatal-hiatoplasty mesh united states of america aim/background: prescribed opioids for pain control have been implicated as major contributors to addiction through their illicit use. efforts to reduce opioid prescriptions and measure their impact on outcomes are novel. we analyzed how patient outcomes are affected with reduced opioid prescriptions following laparoscopic foregut surgery narcr: 89%), length of hospital stay (narcs: 1.60 days vs. narcr: 1.62 days), 30-day readmission rates (narcs: 1% vs. narcr: 4%) and perioperative complication rates. additionally, no significant qol outcome differences between the groups were reported at one month postoperatively. conclusion: our study supports reducing opioid prescriptions as a strategy to counter illicit drug use and addiction 50 patients who underwent paraesophageal hernia repair at a tertiary referral center were analyzed retrospectively. demographic data, asa classification, characteristics of peh, onset of symptom, dysphagia severity score, characteristics of fundoplication (partial vs. total; laparotomy vs. laparoscopy; emergency vs. elective) and surgical outcome (length of stay, complication and 30-day mortality) were recorded and reviewed. results: 50 patients were included; 88% were female (mean age of 76.8 years old and mean body mass index of 21.5). mean onset of symptom was 2.0 weeks after peh repair, dysphagia severity scores were changed 1.8 from 3.7. conclusion: in our series, the dysphagia severity scores reduced after surgery upper gi surgery, the catholic university of korea mary's hospital, incheon city, korea p634-upper gi-gastric cancer general surgery biopsy from the mass has showed poorly differentiated signet ring cell adenocarcinoma. chest computed tomography revealed 38 mm thoracic aortic aneurism. abdominal computed tomography showed 43 mm infra renal aortic aneurism and no evidence of metastatic disease general surgery 70 year old, female patient presented with upper abdominal pain, weight loss (10 kg during last three month), without nausea or vomiting biopsy was done and pathology result showed intestinal type, her2-negative adenocarcinoma of the stomach. chest and abdominal computed tomography (ct) were normal. endoscopic ultrasound (eus) revealed 3 cm lesion with invasion to the muscularis propria (mp) she was treated by neo adjuvant chemotherapy (3 cycles carboplatine ? 5fu). patient underwent laparoscopic partial gastrectomy with modified d2 lymphadenectomy and billroth ii gastrojejunostomy. total operating time (ort) was 320 min. three day after operation patient started regular diet and was discharged home on day fife. final pathology result confirmed intestinal type, modified differentiated adenocarcinoma of the stomach economou 1st surgical department 1 general, visceral and transplant surgery, section minimally invasive surgery, heidelberg university hospital, heidelberg, germany; 2 department of surgery, iuliu hatieganu university, cluj-napoca, romania; 3 general and visceral surgery, klinikum mittelbaden, baden-baden, germany 1 surgery, toyonaka municipal hospital, toyonaka city, osaka, japan; 2 gastroenterological surgery, osaka university, osaka, japan; 3 next generation endoscopic intervention, osaka university, osaka, japan aims: uncomplicated healing of anastomoses in colorectal surgery is the basis for early adjuvant oncology therapy. the basis for proper healing is good blood flow. we use by robotic surgery foor control the firefly by intuitive. since january 2018, icg has used for blood flow in laparoscopic bowel surgery for the d-light system of storz. method: use of icg wants to accurately determine the resection line for free colon operations based on good blood circulation. we use icg pulse in two batches and color detection using d light from storz to verify blood flow. the first dose is given after the skeletalisation of the intestines intraabdominally and the second after the colic anastomosis to verify its vitality. results: in the period under review we performed 85 laparoscopic operations on the free colon, 82% of the operations were elective. we had 5.88% leakage across the set, however, in the subset of elective operations, we had only a leak of 0.142%. conclusion: in an unselected set of colorectal operations, leakage was 5.88%, but only 0.142 for elective operations. in our group there was a clear effect of using icg in elective laparoscopic resections with an intracorporal anastomosis, the effect was not shown in others, probably due to leakage were factors other than blood flow. objective: right hemicoloctomy (rhce) is the first choice in treating the right colon cancer. complete mesocolic excision with extended lymph node dissection at the roots of superior mesenteric artery (sma) branches enables removal of all lymphatic tissue and prevents local recurrence. previously variability of sma branches was demonstrated. the aim of presented study was to compare the distribution of sma branches in two ethnically different cohorts methods: preoperativect scans with vascular 3d reconstruction were assessed in 100 patients (28-93 years) from russia and 95 patients (24-88 years) from turkey with right colon cancer operated in 2015-2018. the distribution of ileocolic artery (ica), right colic artery (rca) and middle colic artery (mca) was investigated. results: ica and mca could be found on ct scans in all patients, whereas rca had significantly different distribution between patient cohorts: it was visible in 93 (98%) of turkish patients and only in 32 (32%) of russian patients (p = 0.001). conclusion: these results suggest that there might be ethnical differences in sma branches distribution. in turkish patients all named sma branches ate visible on ct scans in 98%, whereas in russian patients only in 32%. the majority of patients from russia don't have rca. ica and mca could be found in all patients regardless ethnicity. knowing the variant of sma branching before the operation can help plan extended lymph node dissection. the national training programme in laparoscopic colorectal surgery (s-micras-lapserb) in serbia was set up to introduce standardized and structured training in laparoscopic colorectal surgery. method: an assessment based structured training programme (lapserb) started in 2015. series of hands on supervised workshops were conducted for four different hospitals using the structured training by single trainer. this study aims at retrospective analysis of prospectively collected data for patients undergoing colorectal resections. we look at short-term clinical and pathological outcome of patients within laparoscopic colorectal resections performed in national training program. results: during the period november 2015 until november 2018, laparoscopic colorectal resection was performed in 746 (426 male and 320 female) patients. mean age of patients was 65.6 (21-88). the most common indication was colorectal cancer (645 patients, 86.4%), 80 (10.7%) patients were operated due to the colorectal polyps not suitable for endoscopic resection and 21(2.8%) was operated due to ibd. there were 174 (23.3%) right colonic, 557 (74.6%) left colonic /tme and 13 (1.7%) other resections. average number of lymph node harvested in patients with colorectal carcinoma was 16.5 . there were 6/645 (0.9%) r1 resections mean duration of hospital stay was 6.5 days (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) . postoperative complications were encountered in 103 /746 patients (13.8%). overall, mortality rate was 1.2% (9/ 746). conclusions: this study demonstrates successful and safe adoption of laparoscopic technique for colorectal resections. short term clinical and pathological outcomes are compared to published data and shows wider adoption at the national level. standardization of operative technique and structured training remains the key in success. introduction: femal adnexal tumor of probable wolffian origin (fatwo) was first described in 1973. it is a tumor of mesonephiris wolffian duct origin. fatwo is rare tumor which is usualle benign. in the literature has been reported 71 cases and only 8 cases of recurrent disease. next rare tumor in pelvic localisation is sex cord-gonadal stromal tumor of sertoli cells. methods: we present case report of women who presented metastatic fatwo with duplicity of sertoli tumor. results: 60-year old women underwent 15 years ago exstirpation of tumor in the left broad ligament. histologically there was rare benign fatwo. this year was indicated adnexectomy at gynecology department. during the operation was done bilateral adnexectomy and discovered tumor of anterior wall on upper rectum. microscopic examination showed sertoli tumor on the left ovary. afterward we completed next examinations. colonoscopy without any abnormality. on ct scan was tumor 7 cm without contact to rectum wall, without distant metastasis. the same was described on rectal ultrasonography-normal wall of rectum, tumor probably from uterus. at diagnostic laparoscopy was tumor mass 7 cm, with necrosis arising from anterior wall of the rectum. next small metastasis on pelvic peritoneum. we performed debulking of this big tumor and metastasectomy, there was no infiltration to muscularis propria of the rectum. patient did not have any postoperativ complications. microscopic examination of the rectal tumor and small peritoneal metastasis showed metastatic fatwo. after 6 weeks she underwent laparoscopic second look operation. there were small metastasis on pelvis peritoneum. we removed two biggest metastasis and the rest was destroyed wit j plazma. microscopic examination showed in this metastasis sertoli tumor. conclusion: our patient has metastatic fatwo and sertoli tumor. fatwo is so rare, that in the literaure is not enough information for observation or adjuvant therapy. in one case was described imatinib mesylae (gleevec) therapy with good results. surgeons must be ready to meet new diagnosis. bochdalek hernia is a type of congenital diaphragmatic hernia. in most cases, it is diagnosed during the neonatal period. we present a case of laparoscopically treated congenital bochdalek hernia that led to jejunal strangulation in an adult . case: an fifty eight year old obese(bmi = 38.3) female admitted for gradually worsening right flank pain, vomiting and respiratory distress for one day. there was no trauma history to chest or abdomen. the past medical history were old cva, well controlled hypertension and dm. she was hemodynamically stable. her right flank was very tender. there was no abdominal distension. initial cbc tests showed leukocytosis (15,200/ul) , but electrolytes were normal. chest pa revealed right side diaphragmatic hernia. there was poorly enhanced, herniated small bowel in the right hemithorax on chest ct scan. the patient was taken for emergency operation. on laparoscopy, the normal liver was displaced leftward because of herniated bowel. there was incarcerated jejunum and omentum which could not be reduced. so we widened a 3 cm sized posterolateral diaphragmatic defect first, and then we could reduce the strangulated jejunum(45 cm in length) and omentum. there was no hernial sac. the defect was closed with 2-o prolene. finally, the strangulated jejunum was resected and anastomosed extracorporeally. the hospital progress of the patient was not eventful. on post-operative day 4, the patient was allowed soft diet. the patient was discharged on post-operative day 8 without any complication. conclusion: congenital diaphragmatic hernia is an uncommon condition in adults, but you should keep in mind the diaphragmatic hernia as a cause of intestinal obstruction and respiratory distress in an adult. prompt surgical intervention is required to a favorable outcome. laparoscopic repair of bochdalek hernia is a good management option. aims: intestinal obstruction is one of the most frequent abdominal conditions in the emergency department (ed). up to 93% of patients having undergone a laparotomy will have an episode throughout their lives, of which 60% up to 70% will respond to conservative management. the laparoscopic approach is widely accepted and supported by the studies published up todate. it is recommended in patients with suspected single band, who have less than one previous laparotomy and less than 24 h of clinical evolution. our objective is to validate in our experience that these premises are the appropriate ones in the election of candidates for a minimally invasive approach. methods: we present a series of 26 cases admitted with symptoms compatible with adhesive intestinal obstruction in the ed of a third level hospital during 16 months. all patients underwent abdominal ct to rule out the possible causes of obstruction. emergency surgery was indicated because of failure of a conservative medical treatment or for the findings of the complementary tests. results: a initial laparoscopic approach was performed in the 26 patients, with a conversion rate of 38% of the cases (resection and anastomosis was required in 7 patients, due to loop suffering or intestinal tumor not seen in the ct). among the patients who required laparotomy, 80% had more han 24 h of clinical evolution before de surgery and 20% had free fluid in the tc. as surgical complications: 5 intestinal perforations were produced secondary to the manipulation. there was 3 recurrences of obstruction in the following 3 months. conclusion: the laparoscopic approach is feasible in selected cases and experienced hands. acording to our results it is recommended to perform it in only in patients with less than 24 h evolution and with a single band image in the ct without free fluid. the intestine should be explored avoiding the manipulation of the most extensive loops to prevent complications and keep in mind the possible conversion to laparotomy in case of complications. aim: the aim of the study was to evaluate whether physiologic and operative severity score for the enumeration of mortality and morbidity (possum) is useful to predict the risk of complications in patients older than 80 years. methods: we performed a retrospective study of 13 patients older than 80 years old diagnosed with acute abdomen who were admitted to the department of general, minimally invasive and elderly surgery in olsztyn between may and october 2017. results: the most common disagnosis was ileus. the mortality rate in surgery department was 31%.after relocation to the intensive care unit, the overall mortality rate was 53.9%. the patients who died a short time after surgery had mortality rates greater than 95% and morbidity rates greater than 60% according to possum. conclusions: this study shows that possum seems to be a valuable scale to predict the risk of death after surgery in older patients. patients with higher mortality and morbidity scores should be very carefully selected for surgery. aims: diaphragmatic hernia in adulthood is rare. the most common causes are blunt and penetrating trauma. we present an intraoperative video of the laparoscopic repair of an adult onset, non-traumatic, diaphragmatic hernia in a patient with splenomegaly. method: a 66 year old woman was referred to upper gastrointestinal surgery with epigastric burning and pain in the left side of her chest, radiating to the left shoulder, for one year. there was no recent or distant history of trauma. she has a past medical history of treated hepatitis c, cirrhotic liver disease, splenomegaly, thrombocytopenia and iron deficiency anaemia. gastroscopy was interpreted as a fundal diverticulum. ct abdomen/pelvis with intravenous (iv) contrast showed this to be a left diaphragmatic defect with herniated stomach causing a volvulus, which lay immediately above an enlarged spleen. a ct three years prior to this showed no diaphragmatic hernia. the patient had some symptomatic relief with a proton pump inhibitor and oral antacids, however due to her persistent symptoms surgery was undertaken. the patient had laparoscopic repair of the diaphragmatic hernia. ports were as follows: 10 mm umbilical, 12 mm left upper quadrant, 5 mm right upper quadrant, 5 mm left iliac fossa. a left posterior diaphragmatic defect was found, just above the enlarged spleen, containing the incarcerated fundus of the stomach. the hernia was reduced by gradual dissection of the sac. a 15 9 15 cm nonabsorbable polypropylene mesh (proceed) was used to cover the defect a 4 cm margin. this was tacked in place with protack. a single 16 french robinson drain was left in situ. results: the procedure was uncomplicated. oral diet was introduced on post-operative day 1 and the drain was removed and patient discharged on day 4. there were no post-operative complications. conclusions: the video shows an effective dissection of a left sided diaphragmatic hernia and mesh repair, overcoming multiple technical challenges secondary to splenomegaly and portal hypertension. aims: creating laparoscopic anastomosis is a challenging surgical skill with high clinical relevance. to assure efficient training and enhanced learning curves, constructive and objective feedback is essential. currently there is no appropriate instrument to assess the surgical performance while creating laparoscopic anastomosis. the aim of this study is to develop and validate the anastomosis-objective structured assessment of technical skill (a-osats) score. methods: to obtain an international expert consensus for a procedure specific checklist (psc) for laparoscopic anastomosis, a modified delphi survey with an integrated analytic hierarchy process is currently being performed. each a-osats sub step is assigned a specific weight to determine its importance to the final outcome of the anastomosis. to validate the a-osats score, a laparoscopic side-to-side small bowl anastomosis with a linear stapler and hand-sewn closure of the enterotomy was chosen and is performed by surgeons with varying degrees of laparoscopic experience on a live porcine model. all performances are recorded and rated twice using the a-osats by two blinded experts. results: the final a-osats score includes a weighted psc developed by the modified delphi survey and the already validated global rating scale of previously published osats scores. four key steps (bowel placement, creation of enterotomies, stapling, closure of enterotomy) and sub steps, as well as their definitions, were established during the delphi survey. to validate the a-osats, 16 surgeons (4 experts, 9 intermediates, 3 novices) have participated in the study so far. preliminary results showed significant differences between all three levels of laparoscopic experience (novices: 73.6 ± 8.9; intermediates: 89.1 ± 8.7, experts: 110.2 ± 5.6; p \ 0.001) for the overall a-osats score as well as the psc itself (novices: 52.0 ± 7.8, intermediates: 63.4 ± 6.2, experts: 76.5 ± 4.6; p = 0.001). conclusions: the a-osats is a weighted score that objectively assesses surgical skill during the creation of laparoscopic anastomosis. preliminary results confirm construct validity of the proposed score. furthermore, by offering the possibility to differentiate single aspects during the procedure, the a-osats allows focused feedback to enhance one's performance. minor changes in weights are expected after the last round of the delphi survey. interand intrarater reliability will be assessed after final inclusion of all participants.aims: to apply augmented reality technology from three-dimensional colon models as preoperative planning method in colorectal surgery. method: from three-dimensional anatomical models of the colon we have developed holograms of augmented reality. the models were obtained from ct images (siemens somatom perspective 64ò) with abdominal image cuts with 1 mm thick. the recovery of the images was in dicom format and the processing to achieve the three-dimensional reconstruction was performed with the programs osirixò and horosò, which made a complete segmentation of the colon surface, and a modification of the image density. in this way models 3d were obtained of the isolated colon, and in relationship with the bone structure. the application colon 3d ar was designed (increased hyper experience-visualizer with slam technology) creating a hologram of augmented reality to scale 1:1 from each three dimensional model to make a projection of it on the abdomen of the patient by modifying the position in height of the reconstruction, using the bone pelvis as anatomic reference point to calibrate the placement of the hologram. results: in the preliminary phase (from october to december 2018) holograms of augmented reality were developed in 6 patients with colorectal cancer (right colon, left colon, transverse colon and rectum) to complement the radiological reconstruction with the virtual model. in the application phase (from january 2019) the holograms developed are going to be applied as a method to improve preoperative study. conclusions: three dimensional reconstruction of the tumor in the preoperative plan of colorrectal surgery combined with hyperreality technology allows to develop models of augmented reality in order to improve colon anatomy knowledge and to plan the surgical technique.aims: laparoscopic adrenalectomy has become the standard of care for most adrenal masses. we report a case of laparoscopic adrenalectomy for left adrenal adenoma. methods: we present the case of a 72-year-old caucasian female patient with an asymptomatic, left-sided adenoma, that was incidentally detected during abdominal ultrasound. no headaches, palpitations, tachycardia, tremor, dizziness or vomiting were reported. pre-operative blood tests confirmed that the tumor was a non-secreting one and a ct-scan revealed a 2.9 9 2.2 cm left adrenal mass. laparoscopic surgical excision was proposed. the patient was placed in semilateral right-sided decubitus position. four trocars (1 epigastric-10 mm & 3 subcostals-10 mm & 2 5 mm) were used, without the use of a liver retractor. the adrenal vessels were clipped not only with the standard laparoscopic clips, but also with the hem-o-lok ligation system. results: the operation lasted for 2 h with minimal blood loss. the patient's post-operative course was uneventful and she was finally discharged four days post-operatively. histology report ensured that it was adenoma of the adrenal cortex. aims: since the first laparoscopic adrenalectomy in 1992 (gagner), the laparoscopic lateral transabdominal approach has proved to be the one of choice. it provides an easy anatomical orientation, overall the technique is similar to other traditional laparoscopic procedures. on the other hand, the posterior retroperitoneoscopic adrenalectomy (pra), described in 1995 (waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. the advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient. currently there is controversy about which is the approach of choice, having to take into account the learning curve necessary for the retroperitoneal approach and the reduced number of patients with adrenal pathology subsidiary of surgical management. the objetive is to demonstrate the safety and efficacy of the standardized laparoscopic approach of the left adrenal gland with 3 trocars for selected cases. methods: clinical case: 43-year-old man, resistant hypertension despite concurrent use of three antihypertensive agents, with biochemical and radiological diagnosis of left adrenal adenoma with primary hyperaldosteronism. demonstrative video of the technical steps in a standardized way that we propose for laparoscopic left adrenalectomy only using 3 trocars. results: full laparoscopic surgical approach in right lateral decubitus position: 3 trocars-lateral transabdominal approach. steps: 1. laparoscopic liberation of the splenic flexure of the colon for the colo-spleen-pancreato-gastric en block mobilization until identification of the left pillar, 2. dissection of the medial border of the gland, identification of left renal and diaphragmatic vein, as well as the adrenal vein which is dissected and clipped, 3. dissection of the lateral edge of the adrenal gland, 4. lower pole dissection of the gland completing the resection with ligasureò. the patient presented a successful postoperative recovery, being discharged 24 h after the intervention. asymptomatic, the patient does not need antihypertensive drugs at 1 year follow-up. conclusion(s): the standardization of the procedure allows reducing the number of trocars, maintaining the safety and effectiveness of the minimally invasive approach. aims: cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. the aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in singleadrenal patients or patients requiring bilateral adrenalectomy. methods: prospective study between january 2015 and october 2017 including pheochromocytoma patients diagnosed with low risk of malignant mutations. all patients agreed to be included in the study. experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. results: a total of eight patients were registered, five associated with men type 2 syndrome and three in the context of vhl syndrome. retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was 2.2 days. preservation of the functional cortex without corticosteroids was achieved in 7 (87.5%) of out 8 cases with a follow-up of 37.5 ± 4 months. today, these seven patients have a preserved adrenal function without hormone replacement. conclusions: cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases. biomedical sciences, university of west attica, athens, greece partial adrenalectomy has been suggested for patients benign adrenal tumors especially in the case of hereditary syndromes, like multiple endocrine neoplasia type 2, von hippel-lindau disease and neurofibromatosis type i. aims: this systematic review aimed to investigate the role of partial adrenalectomy in the treatment of hereditary pheochromocytoma. methods: electronic databases were searched with the search terms 'men ii', 'von hippel lindau', 'neurofibromatosis', 'laparoscopic partial adrenalectomy', 'robotic assisted partial adrenalectomy' for the time period up to and including december 2018. full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria results: thirty five possibly relevant studies were identified. abstracts were reviewed and fourteen articles were excluded as they were review articles or articles presenting data on open partial adrenalectomy. twenty one studies, that met inclusion criteria were retrieved in full text and included in the systematic review. eight studies presented data on partial adrenalectomy in patients with von hippel lindau including two case series with median follow up ranging from 5 to 7.2 years and six case reports. thirteen studies presented data on partial adrenalectomy in patients with men ii, including two case series and eleven case reports. recurrence rate was estimated at about 10% for pheochromocytoma. overall steroid dependence rate was estimated at 90%. conclusion: minimally invasive partial adrenalectomy is a therapeutic option especially in patients with heritable pheochromocytoma, given that tumors are often bilateral, tumors are commonly benign and severe morbidity and mortality may be associated with life-long steroid replacement therapy such as the possibly lethal addisonian crisis . however, data are limited, follow up is not standardized and not appropriately reported and rcts are difficult to be done due to the rarity of the disease. a multinational registry on the short term and long term outcomes of partial adrenalectomy in hereditary pheochromocytoma would be a significant source of knowledge. results: patients were operated on after an average of 31 months with complaints. in both groups, the leading symptoms were severe dysphagia and severe regurgitation. no intraoperative complication was detected. in the transoral group, one patient had to be reoperated on for bleeding, another patient developed pneumonia in the transcervical group. the average duration of the surgeries (42.5 vs. 98 min, p \ 0,001), the time to oral feeding (2.9 vs. 4.6 days, p \ 0,001) and the mean hospital stay (7.3 vs. 9.7 days, p \ 0,001) were significantly shorter in the transoral group than the transcervical group. 15 patients were completely symptomless postoperatively. after transcervical treatment, complaints were developed in 2 cases (moderate dysphagia and hoarseness). after transoral surgery, recurrent symptoms were observed in 6 patients, 4 had to be reoperated transcervically due to severe regurgitation. conclusion: transoral stapler diverticulostomy is a fast procedure and offers short hospital stay especially in comorbid, aged patients and intermedium diverticulum size. in the long term, some of the patients may require reintervention due to persistent regurgitation. the transcervical approach has higher perioperative morbidity, which can be performed in patients with less than 3 cm or large diverticulum size. aims: complex hiatal hernias, either implicating large hiatal defects or concerning cases of recurrence, often need apart from the primary closure of the hiatal gap, the re-enforcement of the crura with the use of meshes. our aim is to demonstrate the surgical technique for the on-lay placement of the absorbable mesh (phasix tm st mesh /bard) in challenging cases, presenting both the laparoscopic and the robotic approach. methods: we present video fragments from procedures of laparoscopic and robotic reconstruction of complex hiatal hernias, performed by our team, in which an absorbable mesh was utilized in an on-lay fashion. results: patients having undergone a minimally invasive surgical approach (laparoscopic or robotic) for the treatment of complex hiatal hernias with the use of an absorbable mesh, had an uneventful post-operative course and very short hospital stay and recovery time. the 6-month follow up revealed no recurrences or late complications. conclusions: treating complex cases of hiatal hernias with a minimally invasive approach can be proven quite challenging, with high recurrences and possible complications rate. a proper surgical technique, either laparoscopic or better (based in our primary experience) robotic, by experienced surgical teams and the use of meshes with the right strategy, minimizes the complications, offers all the benefits of minimally invasive surgery and reduces the recurrence rates. aims: several flexible endoscopic techniques for symptomatic zenker's diverticulum have been developed during the last decade. thulium laser has limited tissue penetration and may decrease the risk of perforation. this study reports the first use of thulium laser through flexible endoscopy for cricopharyngeal (cp) myotomy. aims were safety and efficacy of flexible endoscopic thulium laser myotomy and quality of life (qol) changes after treatment. methods: a retrospective review of a prospectively collected database of 19 patients who underwent thulium laser septum division for symptomatic zenker's diverticulum was done. demographic data, presenting symptoms, diverticulum characteristics, and intraoperative data were analyzed. functional outcome swallowing scale (foss) and m.d. anderson dysphagia inventory (mdadi) questionnaires were administered to determine severity of dysphagia and its effect on qol, both preoperatively and during follow-up visits. all the operations were carried out under general anesthesia. a continuous laser configuration and an emissionpower of 9 w was used in non-contact mode. once the mucosa was opened, the fibers of the cricopharyngeal muscle were divided until the buccopharyngeal fascia was visibile. results: between march 2017 and september 2018, 19 patients (12 males) underwent flexible endoscopic cp myotomy with thulium laser. mean age was 72 ± 10.6, mostly males (68.4%). seven patients (36.8%) presented with recurrent diverticulum after previous transoral or open treatment. mean diverticulum size was 2.5 ± 0.8 cm. preoperative main symptoms were dysphagia (94.7%), regurgitation (68.4%), and cough (47.3%). foss score was = 2 in 12 patients (66.7%). mean mdadi global and composite score were 47.8 ± 25.8 and 59.7 ± 9.4. complete division of the septum was achieved in all patients. mean hospital stay was 2.83 ± 1.62 days. there was only one perforation treated conservatively. no 90-days mortality was observed. at median follow-up of 7 months, foss was = 2 in 1 (5.6%) patient and mdadi global and composite score were 90.0 ± 12.4 and 89.5 ± 7.7. all main symptoms were significantly reduced and qol significantly increased. conclusions: flexible endoscopic approach with thulium laser is a safe and effective treatment option for zenker's diverticulum either as a primary treatment or as a rescue therapy. objective: this study sought to explore prognostic factors for patients with borrmann type iv gastric cancer and to establish a predictive model for survival benefit of postoperative adjuvant chemotherapy in such patients. method: this study reviewed the clinical data of patients who underwent curative surgery at fujian medical university union hospital from 2006 to 2014 for borrmann type iv gastric cancer using a prospective database. cox regression analyses were performed to identify prognostic factors that formed the basis for a nomogram and risk groups. establishment of risk groups to identify patients with borrmann type iv gastric cancer who would benefit from adjuvant chemotherapy. results: 265 patients who underwent r0 resection were included in this study.multivariate analysis showed that bmi, tumour differentiation, pt stage, pn stage, and asa score were independent prognostic factors. patients in the act-group had longer os than patients in the sagroup, although the p-value for this difference was marginally above the threshold for statistical significance (23.8% vs. 10.9%, p = 0.057). stratified analysis showed that there was no significant difference in os between the act-group and the sa-group for each ajcc stage (stage ii: 40.6% vs. 29.8%, p = 0.44; stage iii: 21.4% vs. 9.7%, p = 0.056).a nomogram was established based on these independent risk factors, and nomogram scores were used to divide all patients into a high-risk group (score [ 16), an intermediate-risk group (8 \ score = 16) and a low-risk group (score = 8).further stratified analysis based on ajcc stage showed that the 3-year survival rate was higher in the adjuvant chemotherapy group than in the surgery alone group for low-and intermediate-risk patients in each ajcc stage, while high-risk patients in stage iii did not significantly differ. objective: this study sought to explore the prognostic factors for smoking patients with gastric cancer and to establish a predictive model for the survival benefit of postoperative adjuvant chemotherapy in such patients. methods: we studied 2081 patients who were diagnosed from september 2009 to september 2014 at union hospital of fujian medical university. cox regression analyses were performed to identify prognostic factors. the kaplan-meier method was used to assess the effect of smoking history on the benefit of adjuvant chemotherapy after gastric cancer surgery. a decision tree algorithm was used to identify smoking patients who benefited from postoperative adjuvant chemotherapy. results: the median follow-up time for the whole group was 42.5 months, and the average age of all the included patients was 61.5 years.multivariate analysis showed that age (p \ 0.001), bmi (p \ 0.001), degree of tumor cell differentiation (p \ 0.01), and ajcc stage (p \ 0.001) were independent risk factors for the prognosis of smoking patients. based on these independent risk factors, a decision tree model for the benefit of adjuvant chemotherapy for smokers with gastric cancer was established, and the smoking patients were divided into the low-risk patients 78 .7%), medium-risk patients (3year os, 51.3%) and high-risk patients (3year os, 28.4%) (p \ 0.001). conclusion: cigarette smoking may reduce the efficacy of adjuvant chemotherapy after gastric cancer surgery. our decision tree model is simple and effective for identifying smokers who would benefit from adjuvant chemotherapy. objective: our study investigated the effect of lymph node (ln) noncompliance on the longterm prognosis of patients after laparoscopic total gastrectomy (ltg) and explored the risk factors of ln noncompliance. methods: the clinicopathological data of gastric cancer (gc) patients who underwent ltg with d2 lymphadenectomy from june 2007 to december 2014 were prospectively collected and retrospectively analyzed. the effects of ln noncompliance on the long-term prognosis of patients with gc after ltg were explored. results: the overall ln noncompliance rate was 51.9%. ln noncompliance was significantly correlated with age, bmi, asa score, tumor size, macroscopic tumor type and tnm staging (p values \ 0.05). the survival rate of patients after ltg with ln compliance was significantly superior to that of patients with ln noncompliance (p = 0.013). the stratified analysis of tnm stage indicated that there was no difference between the os of stage i patients with ln compliance and those with ln noncompliance; os of stage ii/iii patients with ln compliance was significantly better than that of those with ln noncompliance. cox regression analyses showed that ln noncompliance was an independent risk factor for os. logistic regression analysis showed that high bmi ([ 25 kg/m 2 ) was an independent risk factor for preoperative prediction of ln noncompliance in cstage ii/iii patients. compared with patients with a low bmi (bmi \ 25 kg/m 2 ), those with a high bmi were more likely to show ln noncompliance during surgery, especially during the dissections of #6, #8a and #12a ln stations. conclusion: ln noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (agc) after ltg. patients with high bmi were more likely to have ln noncompliance, especially during the dissections of #6, #8a and #12a ln stations. ln tracing was recommended for these patients to reduce the rate of ln noncompliance. aim: to study the differences in pathology, survival, and recurrence between special remnant gastric cancer (srgc) and nonspecial rgc (nrgc). method: a total of 366 rgc patients were analyzed in 7 hospitals in china from january 2003 to july 2015.we compared the 3-year overall survival (os) disease-free survival (dfs) rates and used two-step regression explore the influence of the rgc categories on patient outcomes. results: all of the patients divided into srgc group (group s) (n = 200) and nrgc group (group n) (n = 166). the r0 resection rate and lymph node (ln) dissection number of group s were significantly higher than group n (p \ 0.05). the difference in 3-year os was not significant (p = 0.282), but the 3-year dfs of group s was worse than group n (p = 0.042). twostep multivariate analyses showed nrgc was an independent risk factor for poor dfs. of the 225 patients who had undergone r0 resection, 74 patients (32.89%),suffered recurrence, and the recurrence rate of group s was significantly higher than group n (p = 0.039), moreover, the ln recurrence rate of group s was significantly higher than group n (p = 0.027). cox regression analysis showed that age, ca199 level, n stage and category of rgc were independent risk factors for rgc recurrence. conclusion: srgc has a higher r0 resection rate and ln dissection number than nrgc, but among patients who had undergone radical gastrectomy, srgc patients had worse dfs and a higher tendency for ln recurrence; thus, they should be treated differently in the clinic. objective: the aim of this study was to report our institution's experience with a novel abdominal negative pressure lavage-drainage system (anplds) for anastomotic leakage (al) after radical gastrectomy (rg) for gastric cancer (gc). background: al is a severe complication associated with high morbidity and mortality after rg for gc. the optimal creation of drainage in al patients after rg remains controversial. methods: the study enrolled 4173 patients who underwent r0 resection for gc at our institution between 2009 and 2016. anplds was routinely used for patients with al after january 2014. al rates and postoperative outcome were compared before and after the anplds therapy. we used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with al and failure-to-rescue (ftr) after al. results: al occurred in 83 patients (83/4173, 2%), leading to 7 deaths. the al rate was similar before (2009-2013, period 1) and after (2014-2016, period 2) the implementation of anplds (1.7% vs 2.3%, p = 0.121). age and malnourished were independently associated with al. the ftr rate and abdominal bleeding rate after al occurred were respectively 8.4% and 9.6% for the entire period, but compared with period 1, it significantly decreased at period 2 (16.2% vs 2.2%, p = 0.041; 18.9% vs 2.2%, p = 0.020, respectively). what's more, only anplds therapy was an independent protective factor for ftr after al. conclusion: our experience demonstrates that anplds is feasible and cost-effective for the management of al after rg for gc. objective: to apply the principles of the 'metro-ticket' paradigm to develop a novel tnm staging system (ntnm) for gastric cancer (gc). background: the 'metro-ticket' prognostic tool for hepatocellular carcinoma has been proven to predict outcome, but a similar concept has not been investigated for gc. methods: the ntnm considered the distance from the origin on a cartesian plane incorporating the pn (x-axis) and pt (y-axis) stages. gc patients undergoing radical resection at fujian medical university union hospital (fmuuh) (n = 4267) were included. the ntnm was validated using 2 external cohorts from the sun yat-sen university cancer center (sysucc) (n = 1800) and surveillance, epidemiology, and end results (seer) (n = 3227) databases. results: ntnm classes with the same distance from the origin have same stage; the stage increases with this distance. among all patients, 48.0% (n = 2049) were restaged in the ntnm compared with the 7th edition of the ajcc-tnm classification; 26.2% (n = 1116) were downstaged in the ntnm compared with the 8th edition. the ntnm provides significant survival differences between stages (all p \ 0.001). the survival difference between stages ib and iia was especially large for the ntnm (p \ 0.001) compared to the 7th and 8th editions (p = 0.073). the concordance index and hazard ratio increased successively with the ntnm stage. similar findings were observed in both external cohorts. conclusion: compared with the ajcc-tnm classification, the 'metro-ticket' ntnm for gc is easier to remember and provides some improvements; therefore, the ntnm may be considered for adoption in future editions of the ajcc-tnm classification. objective: to investigate the prognostic value of complete blood count (cbc)-based biomarkers for patients with resectable gastric cancer (gc). methods: patients with gc who underwent curative resection between december 2008 to december 2013 were included. estimated area under the curve (auc) and multivariate cox regression models were used to identify the best cbc-based biomarker. time-dependent receiver operating characteristics (t-roc) analysis was used to compare the prognostic impact. results: based on multivariate analysis, the lymphocyte-monocyte ratio (lmr) and hemoglobin (hb) level were the independent prognostic factors (both p \ 0.05). based on the lmr and hb level, we established the cbc-based inflammatory score (cbcs). higher cbcs was associated with older age, female sex, higher american society of anesthesiologists (asa) score, proximal tumor location, larger tumor size, later stage and vascular involvement (all p \ 0.05). univariate analyses showed that higher cbcs was also associated with poorer overall survival (os), which was consistent in each stage (all p \ 0.05). multivariate analysis revealed that the cbcs was a significant independent biomarker (p \ 0.05). furthermore, t-roc curve of the cbcs was superior to that of the prognostic nutritional index (pni), systemic immune-inflammation index (sii), modified glasgow prognostic score (mgps) and c-reactive protein/albumin ratio (crp/ alb) throughout the observation period. conclusion: preoperative lmr and hb were optimal cbc-based biomarkers for predicting os in gc patients after curative resection. based on the lmr and hb, we developed a novel and easily obtainable prognostic score called the cbcs, which may improve the prediction of clinical outcomes. purpose: the aim of this study was to evaluate the prognostic value of the eighth ajcc tnm staging classification for patients with gastric cancer who had already survived for 5 years. patients and methods: patients who underwent radical gastrectomy at a large eastern center were considered. the prognostic value of staging systems were assessed and compared. additional external validation was performed using a dataset from the surveillance, epidemiology, and end result (seer) database. results: the 5-year overall survival (os) rate for patients in the training set was 59.4%. with the prolongation of the survival time after surgery, the 5-year os improved significantly (p \ 0.05). however, there were no significant differences in survival curves among patients who have survived 5 years after surgery. the auc and c2 of the eighth ajcc classification for predicting of 5-year os decreased gradually after surgery and appeared stable after 5 years. for patients who survived 5 years after surgery, we constructed a new tnm staging system (ntnm) according to the survival curves of t stage and n stage. a 2-step multivariate analysis showed that ntnm, age and sex were independent prognostic factors. the ntnm demonstrated superior prognostic stratification, with higher c-statistic and likelihood ratio chi-square scores and lower aic values than those of the ajcc classification. similar results were observed in the external validation set. conclusion: the ntnm predicted an additional survival more accurately than did the ajcc classification for patients who have survived 5 years after surgery; this may guide decisions regarding surveillance. objective: to investigate the relationship between preoperative sarcopenia and systemic inflammation and evaluate the prognostic impact of these factors on patients with resectable gastric cancer (gc). methods: patients with gc who underwent radical gastrectomy between december 2009 and december 2013 were included. a multivariate cox regression analysis was performed to identify the prognostic factors. a novel prognostic score (slmr) was developed based on preoperative sarcopenia and the lymphocyte-monocyte ratio (lmr), and its prognostic value was evaluated. results: in total, 1167 patients with resectable gc were included in the study. on multivariate analysis, preoperative sarcopenia and the lmr were shown to be independent prognostic factors (both p \ 0.001). a low lmr was an independent predictor from sarcopenia (p \ 0.001). based on preoperative sarcopenia and the lmr, we established the slmr. an elevated slmr was associated with older age, higher asa scores, larger tumor size, advanced stages and vascular invasion (all p \ 0.05). multivariate analysis revealed that the slmr was a significant independent predictor (p \ 0.001). we incorporated the slmr into a prognostic model that included tumor size and tnm stage and generated a nomogram, which accurately predicted 3-and 5-year survival for gc patients. objective: to explore whether adjuvant chemotherapy is still needed in patients aged less than 50 years with pt1n0-3 and pt2/3n0 gastric cancer. methods: multi-center cohort data of patients with gastric cancer who underwent radical gastrectomy were analyzed. kaplan-meier curves and cox regression were used to analyze the relationships between chemotherapy and prognosis. additionally, nomograms to predict the benefit of chemotherapy were established. results: in total, 1,432 patients with pt1n0-3 and pt2/3n0 gastric cancer were included. 217 patients (15.2%) were aged \ 50 years. the 5-year overall survival (os) was not significantly different between the \ 50 years of age group and = 50 years of age group (92.6% vs. 90.4%, respectively; p = 0.249). lymph node (ln) metastases (hr 5.054; p = 0.002) and ln dissection number \ 15 (hr 6.944; p \ 0.001) were independent risk factors for the os of patients aged \ 50 years. adjuvant chemotherapy did not improve the 5-year os for patients aged \ 50 years with pt1n0-3 and pt2/3n0 gastric cancer (p = 0.218). however, chemotherapy showed a significant benefit (p = 0.042) when there were ln metastases and/or ln dissection number was \ 15. two nomograms were constructed, and the calculated difference was the potential benefit of adjuvant chemotherapy for the patients aged \ 50 years. conclusions: ln metastases and ln dissection number \ 15 were independent prognostic risk factors of patients aged \ 50 years with pt1n0-3 and pt2/3n0 gastric cancer. patients with these risk factors may benefit from the addition of adjuvant chemotherapy. objective: the choice of reconstruction after distal gastrectomy remains controversial. we have performed roux-en-y (r-y) method after laparoscopic distal gastrectomy(ldg) as a standard since 2008, but we have performed billroth ii (b-ii) method in an increasing number of cases, depending on the patient. we retrospectively investigated the outcomes of patients with b-ii method after laparoscopic distal gastrectomy in our hospital. methods: patients who underwent b-ii and r-y reconstruction after ldg from january 2008 to december 2015 were included. the patient characteristics, surgical outcomes, and postoperative outcomes between the 2 procedures were retrospectively analyzed. we also compared extend of gastritis on endoscopy and loss of body weight after surgery at 1 year. results: b-ii / r-y :110/307. b-ii was selected in the elderly patients with poor asa-ps (p \ 0.001). in surgical outcomes, operative time was shorter for b-ii than r-y (p \ 0.001), and blood loss was also smaller (p = 0.023). in postoperative outcomes, there were significant differences in complications (?grade3) (b-ii vs. r-y: 0.9 vs. 6.8%, p = 0.013) and length of stay (b-ii vs. r-y: median 10.5 vs. 14-day, p \ 0.001). there was significant difference in presence of gastritis between b-ii (35.4%) and r-y (11.0%) (p \ 0.001), but no significant difference in loss of body weight (p = 0.105). conclusion: b-ii reconstruction may be an adequate procedure for high-risk cases because of its shorter operative time and the absence of severe complications. background: numerous studies have shown that the short-term efficacy of three-dimensional (3d) laparoscopic radical gastrectomy (lg) is comparable to that of two-dimensional (2d)-lg. whether 3d-lg affects the recurrence pattern after surgery has not been investigated. using data from a prospective clinical trial, the present study compares the recurrence patterns between 2d-lg and 3d-lg. methods: from january 2015 to april 2016, a total of 419 patients were recruited for the clinical trial (nct02327481). the recurrence types, the first recurrence time and recurrence-free survival (rfs) were compared between the two groups. multivariate analyses of factors associated with rfs were performed to identify whether 3d-lg affects the recurrence patterns. results: ultimately, 401 patients were analyzed (197 in the 2d-lg group and 204 in the 3d-lg group), and there were no differences in the clinicopathological data between the two groups. distant metastasis was the most common type of recurrence. there were no significant differences between the two groups in the recurrence types, the first recurrence time or rfs (all p [ 0.05). according to the 7th american joint committee on cancer tumor-node-metastasis (tnm) staging system, both groups were stratified into pathological (p) i, ii, and iii stages. the stratified analysis showed that there were no statistically significant differences in rfs between the 2d group and the 3d group among patients in each subgroup (all p [ 0.05). the multivariate analysis of rfs showed that pathological tnm (ptnm) stage and lymphovascular invasion were independent risk factors (all p \ 0.05). the multivariate analysis of post-recurrence survival (prs) showed that adjuvant chemotherapy was an independent protective factor (p = 0.043). conclusions: distant metastasis was the most common type of recurrence after lg. the postoperative recurrence patterns, rfs and prs after 3d-lg were similar to those after 2d-lg. purpose: the aim of this study is to evaluate the efficacy of delta-shaped anastomosis compared to circular stapler anastomosis in laparoscopic distal gastrectomy with billroth i reconstruction (ladg-bi). method: this is a single-center randomized controlled study. eligibility criteria included histologically proven gastric adenocarcinoma in the lower third of the stomach, clinical stage i tumor. patients were preoperatively randomized to circular stapler anastomosis or delta-shaped anastomosis. the primary endpoint is the number of analgesics use during 3 days after surgery. we compared the surgical outcomes of the two groups. postoperative qol was evaluated using the postgastrectomy syndrome assessment scale-45. this trial was registered at the umin clinical trials registry as umin000016496. results: between december 2016 and september 2018, 39 patients (delta-shaped anastomosis 18, circular stapler anastomosis 21) were enrolled. there was no difference in the number of analgesics use during 3 day after surgery (median 9: delta-shaped anastomosis vs. 7: circular stapler anastomosis, p = 0.91). there was no difference in the overall proportion with in-hospital grade ii-iiib surgical complications (11%: delta-shaped anastomosis, 14%: circular stapler anastomosis). there was no operation-related death in either arm. regarding postoperative qol evaluated 1 month after surgery, diarrhea subscale was significantly worse in delta-shaped anastomosis than in circular stapler anastomosis. conclusion: we did not demonstrate the advantage of delta-shaped anastomosis in terms of postoperative pain. since delta-shaped anastomosis tended to cause postoperative abdominal symptoms related to diarrhea, we should carefully apply the delta-shaped anastomosis to ladg. introduction: the use of a three-dimensional(3d) camera for laparoscopic surgery has been reported in literature. however, there are only few comparative studies demonstrating its benefits, and no reports on the application of 3d vision to single-incision laparoscopic surgery. this study aims to compare 3d vision to the previous two-dimensional(2d) system in solo single-incision laparoscopic distal gastrectomy(sidg). methods: medical charts of 179 gastric cancer patients who underwent solo sidg from february 2014 to december 2017 were retrospectively reviewed. patients were grouped into either 2d group or 3d group depending on the type of camera used. all the operations were performed by a single surgeon using a flexible camera(olympus, japan), fixed onto a passive scope holder without the use of a scopist or an assistant. operative data, postoperative outcome, and early complication were analyzed. results: ninety had their operations under 2d vision and 89 used the 3d scope. in both groups, there was no difference in age, body mass index, staging, and other demographic or histopathologic criteria. operative time was significantly faster in the 3d group(115.6 ± 34.0 vs. 129.4 ± 38.5 mins., p = 0.012) and ebl was also less(20.7 ± 30.0 vs. 35.1 ± 56.0 ml, p = 0.034). patients in the 3d group started small fluid diet faster(2.5 ± 0.9 vs. 3.0 ± 1.1 postoperative days, p = 0.006), and were discharged faster(4.4 ± 1.7 vs. 5.2 ± 3.1 postoperative days, p = 0.024). early complication was also less in the 3d group(2.2% vs. 6.7%) but there was no statistical significance(p = 0.140). conclusion: the use of the 3d camera improves operative outcome and hospital stay in patients undergoing solo sidg. the frequency of anastomotic leakage after gastrectomyreaches 7-8%. at the same time, mortality in this group of patients reaches 30%, and the use of aggressive methods of surgical treatment for the treatment of anastomotic leakage increases the mortality rate from 20 to 64%. since 2006, vacuum-assisted closure has been used to treat anastomotic leakage of various localizations. the essence of this method is based on the creating a local negative pressure, which is transmitted to the drip cavity through a special porous spongy system. the negative pressure created in the closed cavity, allows you to remove exudate, helps to reduce tissue swelling, improvesmicrocirculation, which in turn contributes to the development of granulations and wound healing with separation of the fistulous course. failures in using the method of vacuum therapy in anastomotic leakage are associated with the great difficulty of delivering a polyurethane sponge with a drainage tube to the leakage zone. in this regard, we have developed an improved method of endoscopic local vacuum therapy, in which the delivery of a polyurethane sponge was carried out with the help of a thread through a pharyngeal ring, a leakage zone and brought out through a drainage tube. this technique has been successfully used in the treatment of four patients with anastomotic leakage after operations on the upper part of the digestive tract. for complete healing of the cavity of the leakage and defect of the organ wall, it took 6, 9, 10 and 5 sessions of replacing the vac system, respectively (average 7.5 ± 2.4). there were no complications during the endoscopic local vacuum therapy. when the control endoscopic studies after 3 months after the completion of the treatment at the site of defects of the seams of the anastomoses formed tender scar tissue without signs of narrowing of the organ. aims: enhanced recovery after surgery pathways are safe and effective for patients undergoing gastrectomy. this study aimed to identify perioperative factors influencing the adherence to the protocol, the postoperative course, and the consequent length of stay. methods: between 2014 and 2017, 201 patients were referred to our institution for gastric cancer. among these, 21 patients underwent atypical gastric resection and were excluded from this analysis. 187 were assigned to either total or distal gastrectomy and represent the study population. all patients were managed with a standardised perioperative pathway according to eras principles. according to data from the literature and based on our clinical experience, patients with optimal adherence to eras protocol may fit the criteria for discharge within ninth postoperative day, that was considered our ideal threshold for hospital discharge. data were retrospectively collected and analysed from a prospectively maintained database. statistical analyses were performed using spss version 24 for macintosh. the v 2 test, with a significance level of 0.05, was used to investigate the association between the outcome and perioperative categorical variables. when parametric assumptions were met, student's two-tailed t-test was used to compare the means of continuous variables; otherwise, the mann-whitney test was performed. a significance level of 0.05 was chosen. logistic binary regression with a backward selection procedure and selection criteria of p-value \ 0.05 were exploited to determine significant predictors. results: 44 preoperative, intraoperative and early postoperative variables were considered. among all, multivariate regression analysis revealed that incomplete preoperative immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids infusions [ 2150 ml and blood transfusion [ 268 ml, surgery duration [ 195 min, and failure to mobilise patients within 24 h from surgery were associated with delayed discharge. the logistic regression model was statistically significant (p \ 0.001) and correctly classified 73.6% of cases. sensitivity and specificity were 74.1% and 73.2%, respectively. conclusions: results seem to be clinically rational and focus the attention on the importance of some perioperative clinical issues for the management of postoperative course. these variables could be considered as clinical goals to be reached in order to get an early discharge. objectives: the purpose of this study is to confirm the safety of laparoscopic gastrectomy with intraperitoneal cisplatin administration as a treatment for advanced gastric cancer with potential for peritoneal seeding. methods: from july 2014 to august 2018, 56 patients with advanced gastric cancer who underwent ip chemotherapy after diagnostic laparoscopy were retrospectively studied. all patients underwent laparoscopic gastrectomy with ip chemotherapy or ip chemotherapy alone after a diagnostic laparoscopy. gastrectomy was performed for palliative purposes even with seeding. results: the average age of the patients was 56 years. eight patients (14.3%) had preop chemotherapy. curative resection (r0) was performed in 31 patients (55.4%). in diagnostic laparoscopy, cytology was performed in 38 patients (67.9%) and cy1 was 10 (26.3%). peritoneal metastasis was detected in 35 patients (62.5%). of the total cohort, the 2 year os rate was 54.5% and the median survival time was 19 months. in the case of stage iiib and below, the 2-year os rate was 83%, but it was 42% in stage iiic-iv group. when the r0 resection group and the r1-2 resection group were compared, the 2-year os rates were 70.7% and 26.7%, respectively. hematological toxicity such as neutropenia was not seen in all patients. the mean hospital stay was 8.2 days and adjuvant chemotherapy was performed in 35 patients (62.5%). background: radical proximal gastrectomy (pg) and lymph nodes dissection are indicated for selected gastric cancers at the upper third of the stomach. with the advent of laparoscopic surgeries, more and more pg were performed by laparoscopic apporaches. in the past 5 years, our team has accomplished and reported the oncological outcome of laparoscopic distal gastrectomies in 100 cases of clinical stage i gastric cancer in taiwan. through the evolution of surgical trechniques and team work, we have cruised the learning curve of laparoscopic gastrectomy and reconstruction. materials and methods: in this report,we would like to present our surgical experience of laparoscopic proximal gastrectomy for gastric cancer patients. from 2005 to 2018,192 pateints with gastric cancer underwent laparoscopic gastrectomies by the same surgical team at the national taiwan university. among them,six consecutive pateints (male:female = 3:3) with gastric adenocarcinoma of the upper stomach underwent laparoscopic pg in 2018. the demographics, dissection, reconstruction methods and peri-operative outcome are presented. all six patients tolerated the procedure well, onepatient had mild anastomotic stenosis and improved with one session of endoscopic dilatation. one patient needed temporary proton pump inhibitor for controlloing acid reflux. four of the 6 patients were pathological stage i, and the rest two pateint were stage iia and iiia disease. there was no tumor recurrence until now. summary: laparoscopic proximal gastrectomy is technically safe for treating upper third gastric cancers. the long term oncological outcome deserve further observation. introduction: open gastrectomy (og) has long been the preferred surgical approach worldwide for treatment of gastric cancer (gc). nowadays, several randomized, prospective trials have confirmed improvements in postoperative outcomes for laparoscopic gastrectomy (lg) compared to open procedures, with similar oncologic outcomes. however, most part of these studies comes from the eastern countries. material and methods: a prospective non randomized study was conducted with all patients operated of gc at ramón y cajal university hospital from january 2015 to december 2017. over 96 patients enrolled, 47 patients underwent lg and 49 og. textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. results: a textbook outcome was achieved in 51.04% of patients operated of gc. the outcome parameter 'no severe postoperative complication' had the greatest negative impact on the textbook outcome. a statistically higher number of patients with early cancer (40% vs. 16.3%) and subtotal gastrectomy (57.5% vs. 34.7%) were found in the laparoscopic group. no statistically differences were found between open and laparoscopic approach regarding operating time, rate of microscopic margin positivity, hospital stay, number of retrieved lymph nodes, complications, reinterventions, mortality and readmissions. no statistical differences in textbook outcome were found between both groups (57.14% vs. 45%; p = 0.25). conclusions: laparoscopic gastrectomy for treatment of gastric cancer seems to be safe and feasible with similar textbook outcomes compared to open gastrectomy. introduction: laparoscopic surgery has been increasing for treatment of gastric cancer. however, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. the aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. material and methods: the first consecutive 100 cases of laparoscopic gastrectomy (lg) performed at our hospital from november 2008 to february 2018 were enrolled. patients were divided into two groups based on the period they were operated. training phase (tp) was considered between 2008 and 2014 (46 cases) and more-developed phase (mdp) between 2015 and 2018 (54 cases). conversion, lymphadenectomy and retrieved lymph nodes (ln), hospital length of stay, mean operative time, complications, reintervention and mortality rates were compared between the two phases of learning curve. results: the number of retrieved ln was higher in the mdp (17 ± 8,6 vs. 23,3 ± 10,4; p = 0,004). furthermore, we have also found less complications (47,8% vs. 27,8%; p = 0,038), a decreased reintervention rate (15,2% vs. 1,85%; p = 0,023) and overall mortality (8,7% vs. 0%; p = 0,003) in the mdp. there were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. conclusion: although we consider that our learning curve is not completed yet because the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last two years have showed our results are near to the best results published in the literature. aims: lymph node (ln) dissection proves to be essential for oncological gastrectomy, given that the presence of ln metastases is very high, even for early gastric cancer (4.9% for t1a and 21.4% for t1b). this way, d2 dissection for advanced gastric cancer and d1 ? for early gastric cancer are the gold standard procedures. some teams are using indocyanine green (icg) lymphography to improve their ln dissections, claiming that this technique facilitates the harvesting of small fluorescent ln that, otherwise, would be difficult to identify by conventional laparoscopic methods. methods: we herein present the case of a 60-year-old man with a t1b distal gastric cancer. endoscopic ultrasound discarded the presence of metastatic ln and ct scan showed no distant metastases. icg was administrated endoscopically the day before the surgery, an amount of 6 mg was injected along the submucosal layer around the tumour. in the video we can see how we perform a laparoscopic distal gastrectomy with d1 ? ln dissection and roux-en-y reconstruction. icg lymphography helped us to complete our expected ln harvesting, especially for groups 6 (infrapyloric) and 7 (left gastric artery). thanks to this technique, we could resect ln that we might have obviate during a usual laparoscopic procedure. results: patient was discharged home on the sixth postoperative day without complications and with adequate oral tolerance. conclusions: we present a case in which we have performed a laparoscopic distal gastrectomy with d1 ? dissection and roux-en-y reconstruction. we used icg lymphography to help us to improve our ln harvesting. although it is soon to assess if this technique may increase the number of retrieved ln and in which stations might be more useful, we consider this is a harmless method that may help gastric teams to complete their expected ln dissections. introduction: gastrointestinal stromal tumor (gist) represents around 0.1% to 3% of gastrointestinal neoplasms, with the mesenchymal tumor being more frequent than the digestive one.the gist can be produced from the esophagus to the anus, at any point, being the stomach of (39 to 60%) and the small intestine (30 to 42%) more frequent sites.it is characterized by the expression of the tyrosine kinase growth factor receptor,cd117,differentiating it from other mesenchymal tumors,which do not express it.it is accepted that its origin corresponds to the interstitial cells of ramón y cajal,which act as a pacemaker for intestinal motility.they are very heterogeneous tumors, which vary in size,morphology and biological behavior,being neoplasms with uncertain malignant potential.the incidence is between the fourth and sixth decades,being the distribution by gender similar. clinical case: female patient of 70 years,who goes to the general surgery service,as interconsultation,after a veda,by dyspepsia.it is reported stomach:ceiling mucosa without alterations,at the level of the greater curvature is seen a tumor of 5 cm,hard to the touch with the biopsy forceps,slightly irregular covered with mucosa of normal appearance. computed tomography: stomach body:rounded image of nodular aspect which does not present heterogeneous enhancement after administration intravenous iodine contrast extending to peritoneal region, measures 44 x33x32 mm liver:hypodense image without heterogeneous enhancement adjacent to this,a 10 mm rounded image that is suggested to be studied with nmr. gadolinium nmr liver hypodense image with well-defined limits without heterogeneous enhancement of cystic aspect. gastric roof,heterogeneous formation,which enhances with gadolinium 37mmx38m-mx40 mm,having to discard a gist. surgical technique laparoscopic partial gastrectomy. pathological anatomy and immunohistochemistry 1.5 cm injury with net edges.uncertain malignant fusocellular nodule, cd117 ??? actin-dog1 ??? s100-no mitosis or invasion of the mucosa is observed. conclusion: a case of stomach gist is presented,which,the main symptom was dyspepsia,being the clinical presentation very variable,in relation to the place in which it is located. there is fletcher criteria for the risk of malignancy,this being less than 1.5 cm,very low risk,less than 2 cm, the patient evolved favorably,without surgical complications.aims: to present the surgical procedure of resection of the lesser gastric curvature and its pedicle with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: an 85-year-old man with prostate cancer treated with complete hormonal block and epoc, who consults for rectal bleeding of 1 week of evolution. it is diagnosed of gist in gastric lesser curvature, 9 x 8 x 11 cm, very vascularized and infiltrates the wall producing marked imprint on the fundus. it is tributary of left gastric artery. precise blood transfusion and presents hemodynamic stability, is decided surgical resection scheduled. results: the surgery is performed by laparoscopy, with a tumor of approximately 10 cm, which is dependent on the lesser curvature. the esophageal hiatus and the lesser curvature are dissected with section of the left gastric pedicle. atypical gastrectomy of the lesser curvature including gist, making a gastric sleeve dependent on the greater curvature. the anatomopathological study reports pt4 pn0 with 22 lymph nodes without adenopathies, and disease-free surgical margins. he was discharged without complications on the 6th day and did not require re-entry. conclusions: the laparoscopy surgery for atypical gastrectomy of lesser curvature is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. aims: to present the surgical procedure of total gastrectomy with d2 lymphadenectomy with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: a 35-year-old male with a tobacco habit who consults due to epigastric pain and constitutional syndrome of 6 months of evolution. it is diagnosed of gastric adenocarcinoma t3n2m0. neoadjuvant qt is decided, after 4 weeks of its completion, scheduled surgery is performed. results: the surgery is performed by laparoscopy, showing a stenosing tumor in at gastric antrum of approximately 8 cm. dissection of the greater curvature with section of the right gastroepiploic at its birth and duodenal section is performed. dissection of the lesser curvature with d2 lymphadenectomy, section of the pedicle of the left gastric and the distal esophagus. the transit is restored with latero-lateral esophageal-jejunal anastomosis and jejunojejunostomy. the anatomopathological study reports ypt4a and pn2 with 3/36 adenopathies, and disease-free surgical margins. he was discharged without complications on the 7th day and did not require reentry. conclusions: the laparoscopy surgery for total gastrectomy with complete d2 lymphadenectomy is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. background: in gastric cancer surgery, to secure surgical margin, it is necessary to accurately judge the position of the tumor. however, with conventional marking clips, it is difficult to identify the exact location of the tumor during laparoscopic surgery. purpose: we investigate whether icg (indocyanine green) fluorescence navigation method is effective and safe for determination of cutting line in laparoscopic gastrectomy. patients and methods: 428 subjects underwent laparoscopic gastrectomy (including robot-assisted surgery) based on the icg method for gastric cancer in the period from april 2017 to december 2018. the day before surgery, icg diluted 50 times (0.2 ml of reagent ? 9.8 ml of distilled water) was injected at 1 cm from the tumor edge and 0.5 ml at the four submucosal layers around. then clip to the same part. gastrectomy based on standard surgery is performed, and the position of the tumor and spread of icg are confirmed by icg fluorescence navigation during operation, and a cutting line is determined. the extent of icg from the tumor is again measured with the excised specimen and compared with the pathological margin. results: among the patients who underwent intraoperative pathological examination, they were negative in all cases except one. the spread of icg was 2.5 cm on average, and considering the marking position (1 cm) from the tumor edge, securing of 3.5 cm or more was possible. the operation time was 230.0 ± 92.7 min and the estimated bleeding loss was 24.6 ± 120.9 ml. conclusion: laparoscopic gastrectomy with icg method can evaluate tumor position and spread easily and in real time during operation and it was effective for determining the cutting line in laparoscopic gastrectomy. epstein-barr virus (ebv) has been known as one of causal virus of gastric cancer. ebv-related gastric cancer considered to be about 10% of the entire gastric cancer, and it is rare that ebvrelated gastric cancer has multiple lesions. the patient was 60 years old female. she was diagnosed with upper gastrointestinal endoscopy with lesion in the lower major stomach body, lower anterior wall of the stomach body, rear wall in the middle part of the stomach, rear wall in the middle part of the stomach, and lesser curvature of the stomach angle, as a result of biopsy, adenocarcinoma was observed from the former four. the patient underwent a robot-assisted total gastrectomy. adding a newly found lesion, the histopathological diagnosis was pt1b in the lower major stomach body, pt1b in the lower anterior wall of the stomach body, pt1b on rear wall in the middle part of the stomach, pt1b on rear wall in the middle part of the stomach, and pt1a in lesser stomach body, pn0, pstageia. pathological examination results showed that the four lesions were positive for tumor cells in eber in situ hybridization and were considered to be ebv-related gastric cancers. she was discharged on the 12th day after the operation without any postoperative morbidities.there has been no sign of recurrence without postoperative therapy for 12 months. results: a 35-year-old female with no medical history of interest or allergies to medications, who consulted for palpable mass at mesogastric level to the left of the midline associated with abdominal pain of 3-6 months of evolution, without concomitants or relationship with the intake, valsalva or physical efforts, without change in the depositional habit or toxic syndrome. the abdominal ct (computed tomography) revealed a cystic mass in jejunum mesentery, defined edges, about 6 cm in diameter and that does not capture contrast; likewise, there is no ascites, retroperitoneal adenopathies or other intra-abdominal or pelvic masses, radiology recommends completing the study with abdominal mri (magnetic resonance imaging) that informs of possible lymphangioma at the level of the jejune mesentery. surgical exeresis was decided, which was carried out by laparoscopic approach, with emptying of the lesion and enucleation of the lesion without incidents, the postoperative evolution was favorable being discharged at 48 h. the pathological anatomy reported fibro-adipose tissue with presence of lymphatic dilatations associated with a cystic lesion without epithelial lining, with serous fluid and abundant macrophagic reaction compatible with mesenteric lymphangioma. conclusions: the mesenteric cyst is a rare pathology with an incidence ranging from 1 / 27,000 to 1 / 250,000, predominating in the fourth decade of life. it is defined as any cystic lesion in the mesentery, and is subdivided according to its origin into lymphatic, mesothelial, urogenital, dermoid, and enteric and pseudocysts. most of the time they are asymptomatic although they can (as in our case) present with abdominal pain and even produce complications such as intestinal obstruction, volvulus, intracystic hemorrhage, infection, rupture, and even malignant transformation. for the diagnosis, the palpation can be of great help, showing mass of well-defined limits and partially mobile. the imaging test of choice is abdominal ultrasound / abdominal ct, supplemented by magnetic resonance imaging. the recommended treatment is surgical exeresis, considering laparoscopy as the first option; if it is complete, it can be considered as a curative treatment. purpose: gastrostomy(og) is an alternative method for nutrition support, especial for the patients with oral-esophagus route obstruction or dysfunction. the most operation were conducted by young surgeon or residents. laparoscopic gastrostomy(lg) was a new coming procedure and the skillful suture techniques were needed. the most the residents can't be qualified for this operation. we designed the method for laparoscopic gastrostomy to provide the traning opportunity of suture skill training and guarantee the patient's safety. material and method: laparoscopic gastrostomy procedure was done with two 5 mm trocar. the lower body of stomach was chose. four point around gastrostomy wound were chose for subcutaneous fixation. the straight needle with 2-0 prolene was inserted into peritoneal cavity from upper point, then punctured the sero-muscular layer of stomach. the needle was retrieved out from the same point by guidance of 18 gauge needle. the same way was used for other three points. one purse string around gastrostomy was created by one hand suture method and fastened by köckerling knot tier after insertion of 20 fr foley tube. finally, the peritonization was finished by hand tie externally and knot were keep in subcutaneous layer material-method: we present the case of a 85 year old woman who presented with melena, hematemesis, anemia (ht 12.5%) and being haemodynamically unstable. after the stabilization of the patient, a gastroscopic examination followed, where it revealed a tumor of the fundus (adenocarcinoma). the patient was submitted to laparoscopic total gastrectomy and oesophagojejunal anastomosis, omega type (o), and intestinal anastomosis braun, with the usage of 3 trocars (umbilical 10 mm as inserted in laparoscopic surgery of a single incision, and two 12 mm in the midclavicular line bilaterally). the oesophagojejunal anastomosis was conducted with the use of a linear stapler for the posterior wall and the convergence of the anterior wall with laparoscopic sutures in two layers. patient remains in well condition, 6 months after the operation. conclusion: laparoscopic approach seems to be safe for treatment of gastric cancer of the fundus and of the gastroesophangeal junction, as it offers better surgical field view and less postoperative complications. the restoration of the continuity of the gastrointestinal tube with anastomosis of w type is considered safe alternative to the classic roux-en-y anastomosis. git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; 2 git surgery, faculty of medicine, alexandria, egypt background: superior mesenteric artery syndrome is best described as compression of the third part of duodenum by the superior mesenteric artery, resulting in obstruction. the study of this rare medical condition was carried out since decades yet remain obscure. this study aimed to analyze different clinical presentations, diagnostic modalities, treatment approaches and outcomes, as well as to emphasize the importance of long term follow up. methods: thirty-five superior mesenteric artery syndrome cases were collected retrospectively from a facebook group called 'superior mesenteric artery syndrome awareness & support'. a questionnaire was designed using google form to obtain the demographics, presenting symptoms, risk factors and co-morbidities, investigations, means of treatment and the outcomes. data was entered into microsoft office excel for statistical analysis. results: the median age at diagnosis was 22 years. the median body mass index was 20.8 kg/ m 2 ;. the median time interval from symptom onset to initial diagnosis was 22 months. the major presenting symptoms were abdominal pain (82.86%), nausea (77.14%), and vomiting (65.71%). abdominal computed tomography scan with contrast (82.86%) was commonly used for confirmation of diagnosis. thirteen cases (37.14%) were congenital. thirty patients (85.71%) had received treatment. the overall management success was only 13.33%. surgical management (34.29%) was the most used regimen. conclusion: diagnosis of superior mesenteric artery syndrome is established after a thorough assessment of the clinical presentations and confirmation with suitable imaging modalities. the choice of treatment should be dependent on the causes and severity as different patients respond differently to therapy. recurrence is possible in all patients thus a long-term follow up is required. aims: in the last hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years. treatment for perforated ulcer can be performed laparoscopically in 85% of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late eventration. methods: a 77-year-old male presented to emergency room with a three-hour history of progressively worsening epigastric pain and nausea. physical examination revealed rebound tenderness compatible with an acute abdomen. a ct scan showed: important pneumoperitoneum unable to define the drilling point; distended stomach with plenty of fluid inside and dense content fundus / body suggestive of active arterial bleeding . results: the patient was emergently taken to the operating room for diagnostic laparoscopy . perforation shown in greater gastric curvature associated blood remnants. gastrotomy for clot removal is done without observing active bleeding. the gastrotomy was repaired using standard stitches. all exudate was aspirated and the peritoneal cavity was irrigated with warm saline solution the patient had an uncomplicated post-operative course. jp drain was removed and he was discharged one week after surgery. conclusion: the role of laparoscopic surgery in emergencies is well documented. laparoscopic approach is indicated in any case of suspected gastroduodenal perforation and seems to offer the same advantages as for the vast majority of laparoscopic procedures. laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer. the aim: of our study was to evaluate of effectiveness of local injection of platelet-rich plasma for treatment of peptic ulcer bleeding with hemorrhagic shock in experiment. methods: the study was performed on 60 wistar rats according to local and international rules for working with experimental animals. the average weight of animals was 183 ± 16 grams. in all animals our modification of type 2 acetic acid ulcer (susumu okabe, 2005) was modeled. we randomly divide all animals in 3 groups. 20 rats with only modeled ulcer were included in group 1. 20 rats with modeled ulcer and hemorrhagic shock after 3-3.5 ml blood sampling were included in group 2. in group 3 we included 20 rats with modeled ulcer and hemorrhagic shock and performed local injection of platelet-rich plasma (local periulcelar injection of 0.1 ml of autologous platelet-rich plasma). on 1st, 7th and 14th day measurement of the ulcers square and morphological study were performed. results: the data we have received demonstrate a tendency of decrease of ulcers' square in all groups with time flow. we also compared sizes of ulcerative defects in all groups at every point of the study. on the 1 st day of investigation there were no differences (p [ 0.05) between ulcers' square in all groups. on the 7 th day we found out more rapid decrease of size in group 3 (p [ 0.05). however, this tendency had no statistical significance. on the 14th day difference was larger and it was statistically significant this time (p \ 0.01). also the better ability to stimulate the activity of fibroblasts and revascularization in the young connective tissue with improving oxygenation in the ulcers and enhancing of cell proliferation, differentiation and accelerating of maturation of connective tissue and healing of ulcers was demonstrated in group 3. conclusion: platelet rich plasma reduces inflammatory response and stimulates proliferation of gastric epithelial cells on 7 th day with the restoration of secretory activity and epithelialization of ulcers in 71.4% of experimental animals on 14 th day, the activation of the fibroblastic reaction during the all experiment and decreasing of ulcers' square. h. fujii, depat. of surgery, japanese red cross fukui hospital, fukui, japan introduction: in conjunction with charmant, a local eyeglass frame manufacturer, we developed novel devices called the fj (free jaw) clip to grasp organs in the abdominal cavity and the f (free) loop plus to pull thread extracorporeally from within the abdominal cavity. product summary: the fj clip is used to grasp organs in the abdominal cavity, a stainless steel, removable forceps for use in laparoscopic surgery. it provides a strong grip but rarely crushes organ tissue. the clip comes in two sizes, one for use in a 5-mm port and the other for use in a 12-mm port, and in two lengths, 29.4 mm and 35.6 mm, respectively. to pull out thread tied to the fj clip, we developed the f loop plus, which is a 21g by 90-mm-long special stainless needle with f0.1-mm niti alloy thread which is used pull suture threads from inside the abdominal cavity to outside the body. case: we performed 9 cases of reduced port laparoscopic and endoscopic cooperative surgery (lecs). we performed reduced port surgery (rps) by making a 1.5-cm incision at the umbilicus, inserting 2 trocars (12 mm and 5 mm), and inserting another trocar (5 mm) at the left side of the abdomen. we expanded the left hepatic lobe with a 12-mm fj clip for penrose drain placement, grasped the front wall of the gastric body with a 12-mm fj clip, applying traction toward the legs to pull up the tissues around the tumor, and resected all layers of the tumor via oral endoscopic submucosal dissection technique. the resected area was closed with a suturing device or interrupted sutures in the abdominal cavity. a 75 year-old female was admitted to the emergency department with complaints of abdominal cramping pain, back pain and diarrhea for one day. she also had fever, ever up to 39°. in these two weeks, she felt occasionally epigastric pain. her past medical history included hypertension. on physical examination, she was conscious and alert. abdominal examination revealed diffuse tenderness and knocking pain over right flank. laboratory tests indicated an degraded white cell count of 2890/cumm with 22% band forms, c-reactive protein of 25 mg/dl and abdominal liver function tests (alanine aminotransferase: 149 u/l, alkaline phosphatase: 249 u/l, gammaglutamyl transferase: 175 u/l) without hyperbilirubinemia. abdominal x-ray showed paralytic ileus. our presumptive diagnosis was acute peritonitis, based on the patient's symptoms. empirical antibiotics were administered immediately, and a computed tomography (ct) imaging study was performed. the ct scan showed a stick like foreign body noted between ventral side of pylorus and smv lumen, about 1.5 cm in length and associated with perifocal infiltration and segmental smv thrombus formation. (fig. 1) however, there is no obvious pneumoperitoneum and no evident ascites is associated. an emergency exploratory laparotomy was performed, revealing stomach perforation at posterior wall with a 3 cm fish bone thourgh pancreas into smv. localized inflammation and fibrosis were identified without obvious fluid accumulation( fig. 2 -4) . removal of fish bone and simple closure of stomach perforation were performed. blood cultures revealed bacteroides thetaiotaomicron. three weeks later, she received a follow-up ct scan which showed smv obliteration with chronic pylephlebitis. aim: here we present a case report about the endoscopic treatment for iatrogenic gastric perforation secondary to a chest tube insertion. methods: a case report of a 24-year-old male with history of a road traffic accident. described injuries were severe brain injury with gcs \ 8 at pre-hospital care arrival, thoracic injury with several rib fractures on the left hemithorax and hypoventilation on the left side. prior to hospital transfer a chest drain was inserted on the left side, and the patient was intubated. results: at hospital admission, the patient was hemodynamically stable and connected to a mechanical ventilator. thoracic exam showed persistent hypoventilation on the left chest. no other abdominal or pelvic injuries were found in the physical exam. a frontal chest x-ray revealed pneumothorax and the chest tube was not viewable. a further ct scan showed the chest drain placed in the abdominal cavity, into the stomach, besides a subdural hematoma, comminuted pelvic fracture of the pubic rami and a left sacroiliac fracture. during the first 24 h in the icu, neurological worsening was observed, and a new cranial ct revealed enlargement of the subdural hematoma, for what the patient underwent decompressive craniectomy, with improvement thereafter. following a five-day period of stabilization after surgery, the patient was evolving satisfactorily, and the removal of the intragastric chest drain was considered. endoscopy was performed to confirm the placement of the drain, and it was removed under direct vision. approximately twenty five centimeters of the catheter were visualized in the gastric lumen, and then successfully removed. the patient recovered well and was discharged from icu to medical hospital ward after fourteen days, and a week later he was discharged home. conclusion: endoscopic management for gastric perforation after a chest drain insertion may result effective and can prevent open surgery morbidity. aims: intestinal infusion treatment with levodopa/carbidopa (duodopa) is a therapeutic option concerning the advanced parkinson disease cases with no response to the conventional treatment. the drug requires carrying out a gastrostomy either by percutaneous endoscopy way, or by laparoscopy -if the first one is not possible-. later, a duodenum-yeyunum tube is placed in order to infuse the duodopa gel continuously by a portable bomb. in this report, we explain the laparoscopic gastrostomy technique. method: sin this report, we include two patients with advanced parkinson disease: the first one is a 61 year-old female patient suffering from an important gait disorder; and the second one is a 71 year-old male patient with uncontrolled motor fluctuations. in both cases, a percutaneous endoscopic gastrostomy was proposed, but neither was feasible because of the non-traslumination between the gastric and the abdominal wall. under general anesthesia, neumoperitoneum by veress needle was performed. three main trocars and one accessory were placed. at the level of the gastric antrum, a 1 cm incision was conducted to insert a gastrostomy tube, to be the guide for the drug infusion catheter. next, the gastrostomy is fixed to the abdominal wall by the stamm technique, externalizing the catheter through the accessory trocar in the medial line. results: on the first post-operative day, a duodenum-yeyunum tube is placed by endoscopic control through the gastric device. both patients got well satisfactorily, and no complications were described; and they develop a total normal life within the limitations of their underlying disease. conclusions: the duodopa intestinal infusion shows a significative improvement for the advanced parkinson disease symptoms, compared with oral medication; appreciating positive results referring to life quality. when the catheter placement by endoscopy way does not seem posible, gastrostomy by laparoscopy constitutes a valuable surgical option for the treatment of this kind of patients. peptic perforated ulcus (ppu) is a common surgical emergency and laparoscopic repair has been introduced as an alternative to open repair. it has shown good results and allows closure and peritoneal lavage, just like the open repair does but with the advantages of a minimally invasive surgery. the objective is to report the outcome of laparoscopic ppu in our hospital. methods: from january 2015 to october 2018, 16 patients with a clinical diagnosis of ppu were assigned to undergo laparoscopic repair. this retrospective study included all husm patients who underwent laparoscopic ppu repair by emergency surgeons. minimum follow-up of 3 months is carried out. results: of the 16 patients in this series, 70% were men and 30% were women, between 15 and 80 years of age at the time of surgery, average of 48 years. the time between the manifestation of symptoms and surgery was [ to 24 h in 70% of patients. in 6 patients there was a history of previous ulcer or non-steroidal anti-inflammatories intake and up to 50% were smokers. a ct scan was performed in all cases to reach the diagnosis primary closure with simple suture plus omental patch was the elected technic (90%). the approach was performed with 3 trocars in 44%, 4 trocars in 50% and 5 in 1 case. 13 cases (81%) were gastric ulcer, 2 duodenal cases (13%) and in one case no perforation was found. the conversion rate was 19%, in two cases due to technical difficulty and in the other case because the level of the perforation was not found. the median postoperative stay was 7 days although there were 2 cases with intrabdominal complications. there was an exitus due to a metastasic pulmonary neoplasia diagnosed in the immediate postoperative period. there were no cases of recurrence in the follow-up time. conclusion: in most centers, including ours, the rate of laparoscopic management has gradually increased along with the improvement of technical skills. improvements in the outcome of laparoscopic ppu repair are to be expected with more experience surgeon and a good selection of the cases. general surgery, jzu hospital ,,sveti vracevi,, bijeljina, bosnia-herzegovina introduction: diverticulum is an outpouching of a hollow organ. gastric diverticulum is rare form od this disease. incidence of detection varies depending on investigation method. it has been reported in 0.02% cases of autopsies, 0.04% cases of gastroduodenal roentgenographies with contrast, and 0.01-0.11% cases of upper endoscopies.small diverticula are usually asimptomatic, but bigger diverticula can cause variable symptoms such as abdominal pain, feeling of epigastric fullness right after meal, feeling of discomfort in upper parts of abdomen, and severe 'foetor ex ore' .diagnosis is usually established in procedures such as gastroduodenal roentgenographies with contrast, upper endoscopies and abdominal ct scan. case report: a 57-year-old woman came to our hospital because of feeling of discomfort and mild pain in upper abdomen that lasted for last year. diagnosis is established after ct scan of abdomen and upper endoscopy procedure. initially she has been prescribed conservative therapy (proton pump inhibitors). since the symptoms persisted, laparoscopic resection of the gastric divertuculum was performed using endogia stapler. considering the feeling of discomfort and abdominal pain dissapeared, the patient was discharged from hospital on the fourth postoperative day. conclusion: asymptomatic gastric diverticula doesn't require treatment. since gastric diverticulum can have complications such as bleeding, perforation and neoplasia, patient without symptoms should be monitored. initial therapy for symptomatic diverticula is conservative therapy (proton pump inhibitors). if conserative therapy doesn't procude expected results, laparoscopic resection of the diverticulum should be considered. introduction: the acute perforation of a gastric ulcer is a serious entity that requires urgent surgical treatment in most of the occasions, it is increasingly accepted that the approach of choice is laparoscopic, depending, above all, on the time of evolution of the process. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the perforation of a pyloric peptic ulcer, even in cases of severe peritonitis, by means of a standardized procedure, insisting on the sequential thorough washing of the cavity.material and methods: we present a video of the surgical intervention of a patient with acute abdomen, with a history of nsaid ingestion, exploration and ct-analysis compatible with perforation of hollow viscus, probably of gastric origin. results: intervention: complete laparoscopic approach, 4 trocars. severe biliopurunitic peritonitis, by pyloric perforation 'acute', liquid culture, suture of the perforation, epipoplasty, sequential thorough washing of the cavity with physiological saline and placement of drainages.correct postoperative period, discharge from the hospital on the 7th day after completing antibiotic treatment. endoscopy and helycobacter test are performed on an outpatient basis with normal results. conclusion: the laparoscopic approach is safe and effective in acute and complicated gastric ulcer disease, even in cases of severe peritonitis. surgical procedure: the clean-net procedure involves the selective dissection of both the serosa and muscle layer using a laparoscopic monopolar endoscopic scissor. the preserved mucosal layer provides a mechanical barrier between the gastric lumen and peritoneal cavity that aids in the prevention of peritoneal cavity contamination with gastric contents. tumors are observed with an upper gastrointestinal endoscope with the injection of indocyanine green (icg) into peri-tumoral submucosal layers at 4 points. selective seromuscular dissection is performed using a laparoscopic electrocautery monopolar scissor. the mucosa surrounding the gist is then resected using a endoscopic mechanical stapler to prevent exposure of the gastric lumen to the peritoneal cavity and peritoneal tumor cell seeding. results: there were 5 males and 1 female, and the average age was 65 years. the operation time was 186 min, the average bleeding volume was 14.6 ml, the postoperative hospital stay was 7.8 days. the mean tumor diameter was 32.3 mm, the final histopathological diagnosis was 5 gist, 1 schwannoma. there were no postoperative complications of clavien-dindo classification 2 or more. conclusion: clean-net was found to be safe and useful for the treatment of gastric smt with ulceration. year outcomes: laparoscopic heller myotomy stands the test of time aims: laparoscopic cardiomyotomy leads to excellent relief of dysphagia in 95% of patients and avoids thoracotomy or laparotomy. methods: we present a video illustration of the procedure that was modified at the american university of beirut medical center. so far, 129 patients underwent laparoscopic cardiomyotomy, age range of 14 to 76 years, with 56 males and 73 females. most of them have had previous balloon dilatation. results: all cases were successfully completed laparoscopically without complications. followup of 2 months to 15 years revealed excellent results with complete resolution of symptoms and no need for further medications. this will result in minimal post-operative pain and very short recovery period and is associated with low complication rate. conclusion: cardiomyotomy for achalasia is ideal for laparoscopic approach. magnification allows for precise division of muscle fibers. the new technique of hydro dissection and enseal for division of esophageal muscle allows for completion of the procedure without injury of the mucosa. therefore, adequate release of the obstructing segment followed by anti reflux procedure toupet will lead to excellent results with minimal morbidity and no mortality. aims: laparoscopic repair of huge hiatus hernia methods: twenty two cases of huge hiatus hernia presented to the american university of beirut medical center. patients underwent through 5 trocars in the upper abdomen reduction of the hernial sac from the chest. special care was taken in the dissection of the mediastinum to keep the thoracic fascia and pleura intact. the defect was sutured primarily by 0-ethibond sutures reinforced by onlay prolene mesh u-shaped was fixed at the rt. and lt. crus and a floppy nissen fundoplication performed . results: the video presentation includes the technical aspects and the method of reducing and repair of huge hiatus hernia.aim: nowadays, there is little experience in the world of applying robotic surgical system (rss) in treatment of patients with hiatal hernia (hh) and reflux-esophagitis (re). the aim of study was to determine the possibility and feasibility of using rss in treatment of patients with hh. materials and methods: a total of 41 patients underwent robot-assisted hh repair without mesh, followed by fundoplication with our original method (360°full symmetric wrap). the clinical and technical analysis did not reveal any advantages over similar laparoscopic procedures, so we abandoned the use of rss for hh type i, and these 4 patients were excluded. there were 32(86%) patients with hh type iii and 5(14%) type iv. the surgeries were performed by experienced robotic upper gastrointestinal surgeon and conducted with the davinci si surgical system (intuitive surgical, sunnyvale, ca). results: average operation time was 118 ± 37 (62-173) min. the respondents' mean age was 56.2 ± 10.9 years (range 29-68) and bmi was 30.8 ± 7.1 (range 17.1-44.3) cm/kg 2 . average blood loss was 20 ± 9 (5-70) ml. average hospital stay was 5 ± 1.3 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) days. the average follow-up time was 14 ± 3.6 (6-24) months. postoperative x-ray imaging and upper gi endoscopy was conducted in all 37 (100%) patients. there was no hh recurrence diagnosed. we did not observe a relapse of hh or clinical manifestations of re in the early (less than 30 days) and long-term (more than 6 months) postoperative periods. conclusion: we can conclude that robot-assisted surgery is safe, appropriate and justified in patients with hh type iii and iv. all procedures performed to the patients with giant hh revealed clear technical advantages of rss over similar laparoscopic operations: an enlarged 3d hd image, bendable instruments with endowrist technology allowed for precise dissection of tissues (hernial sac, cicatricial adhesions) in a narrow anatomical space-posterior mediastinum without damage to pleura, pericardium and vagus nerves. we believe that use of rss in treatment of patients with reflux esophagitis and/or hh type i is unjustified, due to the lack of proven advantages over laparoscopy. introduction: the presence of major anatomical obstacles -such as massive caudate lobe-in the confined operative field of laparoscopic hiatal hernia repair (lhhr) poses significant challenge to the foregut surgeon. aim: to provide a safe alternative for lhhr using a laparoendoscopic approach. method: this patient is a 60 year old female, with bmi of 32.2. her past medical history includes diabetes, hypertension and hyperlipidemia. she had gerd for 20 years. her egd showed 5 x 4 cm hiatal hernia and class b esophagitis. manometry showed ineffective esophageal motility. we used the classic five ports approach for lhhr. we found a massive caudate lobe which was comparable to the size of an already enlarged left lobe of the liver. the operative strategies: terminating the procedure proceeding with the standard approach and taking the risk of bleeding from the caudate lobe itself or the inferior vena cava (ivc) with possible catastrophic outcome. using the laparoendoscopic approach. the following three steps facilitated the performance of safe and effective surgery. additional liver retractor this improved exposure and minimized manipulation of the caudate lobe. extracorporeal sliding arthroscopic knots (esak) esak are similar to the knots used in endoloop. they are tied extracorporeally and require a single insertion of the knot pusher as they do not unravel. transoral incisionless fundoplication (tif) we performed tif to avoid a limited operative field and to prevent excessive tissue manipulations associated with laparoscopic fundoplication. tif also preserves the angle of his and produces partial fundoplication which has less side effects of dysphagia and gas bloat syndrome. results: the operative time was 98 min (lhhr 78 min and tif 20 min). there were no complications. patient discontinued omeprazole which she used daily for 20 years. at 6 months follow up, her gerd related quality of life (hrql) and gerd symptom (gerss) scores were (30 vs 5) and (40 vs 8). conclusion: the laparoendoscopic repair of hiatal hernia in the presence of anatomical obstacles is safe and effective. longer follow up is needed to assess the durability of this repair. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. nowadays, some surgeons haddifficulties with the laparoscopic approach to treatment of recurrent hiatal hernias.patient was a 30-year-old man. he requested medical assistance with dysphagia, nausea after eatingand heartburn getting worse in a horizontal position. conservative treatment was not effective.transthoracic nissen fundoplication was performed in 2017. the main complaints of the patientpersisted during the postoperative period. the upper half of stomach and s-like curved esophagus werelocated in the mediastinum according to multislice computed tomography of the thorax in 2018 august.in our clinical center was performed laparoscopic cruroraphy, cardiomyotomy and nissen fundoplicationin 2018 november. during the surgery the normal anatomical position of stomach has been restored, s-like curve of esophagus has been removed; a gastric cuff (collis-nissen) has been created and anteriorand posterior cruroraphy has been performed. the patient was in intensive care during 8 h. anasogastric tube feeding was continued during the first 48 h. passage of the contrast through theesophagogastric junction was free within 72 h after surgery. patients had been discharged within 5 days after surgery.this case report shows that at the current stage of surgery laparoscopic approach can be useful not onlyfor treatment of primary hiatal hernias-but also for treatment of recurrent ones. aims: laparoscopic heller myotomy procedure, completed with an anti-reflux procedure is technically demanding. we report a case of laparoscopic heller myotomy followed by a dor anterior fundoplication. methods: this is the case of a 57-year-old caucasian woman with gradual dysphagia for solids and liquids, accompanied by severe regurgitation and chest pain. an initial diagnosis of achalasia was made in 2010, with the use of manometry and barium swallow. endoscopic dilatations were attempted pre-operatively with no clinical improvement. decision was made to perform a laparoscopic heller myotomy, combined with a standard dor anterior fundoplication. a 4-ports operation took place (one intra-umbilical 10 mm trocar-single incision laparoscopic surgery (sils) technique, two 5-mm subcostal trocars, and one another 10 mm subcostal trocar for the use of liver retractor). the operation lasted 2 h and 15 min. results: no post-operative complications were noted. the post-operative swallow test showed improvement of the esophageal patency. the patient started a liquid diet three days later and was discharged six days post-operatively. two months later the patient presented no complications. conclusions: heller's myotomy has demonstrated good long-term results in the treatment of esophageal achalasia and the laparoscopic approach has been well established in the last two decades. it is a very demanding operation to perform and the disease is relatively rare, making the learning curve difficult to achieve. aims: achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus. the association of a long-term achalasia and a large size hiatus hernia is an infrequent entity. among the therapeutic options is medical treatment, endoscopic treatment and surgical treatment associated with an antireflux procedure. the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences. the aim of the video is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure. methods: 73-year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. the complementary explorations and iconography of interest are exposed. results: intervention: complete endoscopic approach, 5 trocars. reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. extended mediastinal esophageal dissection. complete resection of both the sac and lipoma, respecting the posterior vagus. heller's myotomy of 10 cm, including 3 cm distal to the ueg, perforation of 3 mm of the mucosa at the ueg level, suture and blue methylene verification of the sealing. hiatorraphy and dor-type anterior fundoplication as antireflux technique. correct postoperative, with egd control on the 3rd po day and discharge on the 6th. asymptomatic at 24 months after surgery. conclusion(s): for achalasia laparoscopic heller myotomy with a partial fundoplication should be the treatment of choice in patients who are at low surgical risk. the length of the myotomy, especially distal to ueg is one of the most important aspects of the surgery, to achieve an effective disruption of the les. the presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, such as perforation. standardization is essential to increase safety and efficacy in these complex cases. purpose: there is evidence that the application of mesh-reinforced hiatal repair has resulted in a significant reduction in recurrence rates in comparison with primary suture repair, at least in short-term follow-up. however, and instead of this, the standard of care for repairing large paraesophageal hiatal hernias (lphh) remains controversial because no clear guidelines are given regarding indications, mesh type, shape and position. the aim of this study is to evaluate our short-term outcomes in management of lphh with a biosynthetic monofilament polypropylene mesh surrounded by a high-purity and adherent titanium dioxide surface coating to enhance the biocompatibility (tio 2 mesh tm ). methods: a retrospective study was conducted on our institution between december 2014 and october 2018. data were collected on 27 patients with lphh greater than 5 cm in which a laparoscopic repair was carried on by primary suture and additional reinforcement with a tio 2 mesh tm . clinical and radiological recurrences, dysphagia and mesh-related complications were investigated. results: there were 17 females and 10 males with a mean age of 73 years (range, 63-79 years). all operations were completed laparoscopically. median postoperative stay was 3 days. after a mean follow-up of 16 months, 3 patients developed clinical recurrence of reflux symptoms (11.1%) and 2 radiological recurrences (7.4%). there were no mesh-related complications. conclusions: the use of tio 2 mesh tm for laparoscopic repair of lphh is suited and with a reasonably low recurrence rate in this short-term study. additional long-term studies with enormous numbers carried out for years will be necessary to affirm whether this mesh is convenient in the prevention of recurrences and mesh related complications. background: surgery for refractory gastroesophageal reflux disease (gerd) has a satisfactory outcome, however sometimes fundoplication fails and redo surgery is required. several publications have investigated the feasibility of performing reoperative fundoplications using laparoscopic techniques. the aim of this study was to describe our experience in laparoscopic redo fundoplications in the last 4 years. material and methods: we retrospectively reviewed 26 consecutive patients who required laparoscopic redo fundoplication from january 2014 to august 2018.the indications were recurrent symptoms of gastroesophageal reflux disease (gerd) (15.4%), recurrent symptomatic paraesophageal hernia (42.3%), dysphagia (30.8%) and acute volvulus (11.5%). results: all redo fundoplications (basically toupet 69.2% and nissen 26.9%) were completed laparoscopically. the mean operative time was 120 min (range, 100-136.25 min). a mesh was placed in 31% of cases. intraoperative and postoperative complication rates were 23.1% and 3.8% respectively. the mean hospital stay was 4 days (range, 3-5 days). one patient (3.8%) from the laparoscopic group required a third operation-one for acute recurrent paraesophageal herniation of the redo wrap one month after surgery, which was repair laparoscopically again. symptomatic outcome was successful in 84.6% without any kind of proton bomb inhibitors therapy. conclusion: laparoscopic redo fundoplication is technically feasible and clinically effective with a reasonable low rate of postoperative complications p620-upper gi-reflux-achalasia objectives: in recent years, balloon dilatation (bd) for diseases requiring correction of the impaired patency of the sphincter zones of the esophagogastroduodenal region has become widespread. purpose: to assess the effectiveness of the use of the balloon dilatation in patients with impaired sphincter zones of the esophagogastroduodenal region. materials and methods: in the institute department of surgery for the period from 2006 to 2018, bd was performed in 245 patients. 210 of them diagnosed with achalasia of cardia (ac): 17-1 stage, 86-2 stage, 62-3 stage, 45-4 stage. 7 patients diagnosed with pylorospasm, 7 patients had compensated stenosis and 21 patients had subcompensated ulcerative pyloroduodenal stenosis. there were 87 males, 158 females, average age (45.3 ± 5.2). bd was performed under endoscopic and / or x-ray control by 'boston scientific' balloons with a diameter of 18-20 mm, 35 mm and 40 mm, a course of 3-6 sessions with an interval of 1-3 days and a cylinder exposure of 3-6 min. evaluation of bd was performed using esophagogastroscopy, balloon manometry and x-ray passage of barium. results: in the course of the study, the existing indications were refined and new indications were developed for performing an endoscopic bd in pyloroduodenal stenosis and in ac. in patients with stage 1-2 ac, a positive result was noted in 94.3% of cases already after the first session of bd. recurrences of ac after bd for up to 5 years were established in 49 (23.3%) patients: at stage 1-in 12.2%, at stage 2-in 16.3%, at stage 3-in 24.5% and at stage 4-in 47.0%. repeated bd courses in case of ac recurrence in 29 (13.8%) cases turned out to be ineffective. recurrence of pyloroduodenal subcompensated stenosis was diagnosed in 2.8% of cases in the period of 24 months after performing bd. conclusions: bd is an effective method for correcting the permeability of the sphincter zones caused by the pathology of the esophagogastroduodenal region. keywords: balloon dilatation, achalasia of cardia, pylorospasm, ulcerative pyloroduodenal stenosis, recurrences. introduction: the reoperation in antireflux surgery significantly increases morbidity and mortality up to 75-85%, reaching rates of 42% in patients undergoing 3 or more surgeries. the advantages of laparoscopic surgery used in this surgical technique have amplified its acceptance and use, resembling its results in terms of feasibility, safety and efficacy of laparoscopic surgery to open surgery.objective: :evaluate the currently literature about antireflux surgery reintervention, focusing on the main indications of re-intervention, type of approach and morbidity and mortality of laparoscopic antireflux surgery. material and methods: a literature search was conducted in two electronic databases, med-line and embase. the search was limited to the period 2009 to 2016. terms were used in relation to the procedure or intervention and the underlying disease. we chose observational studies (cohort, cases and controls and series of cases), where the main indication for antireflux surgery would have been gastroesophageal reflux disease. results: a total of 19 studies were selected, most of them were case series (57.9%), cohort studies (31%) and case-control studies (10.5%). a total of 1940 patients. the main indications were anatomical faults, of these failures, recurrent hiatus hernia and sliding occupy the highest percentage, while physiological failures, failure in esophageal and gastric motility occur more frequently. the main type of approach was laparoscopic in 85%, the conversion rate was 5.3% and the open approach was reserved for complex cases with more than one re-intervention 12.9%, for abdomen 8.6% and chest 3.5%, this last for cases with high esophageal lesions that can not be repaired via trans-abdominal.the main complications were injuries to hollow viscera, such as: esophagus and stomach among others. these complications are related to the complexity of the procedure. mortality has remained low up to 0.05%, however, the cause of death was due to medical complications and not related to the procedure. conclusions: this systematic review on reoperation in reflux surgery has confirmed that morbidity after reoperation surgery is higher than after primary surgery and reoperation indications increase with the use of new technologies (manometry) and the laparoscopic approach continues on the rise, with great adaptation to its use and improvement in results. aims: eras protocol is not commonly used in acute emergency procedures. elective lc is commonly performed as one day surgery, while in an emergency setting of acute cholecystitis, the in hospital stay averages 4, 5 days. the aim of this trial is the application of eras protocol in patients with acute cholecystitis, undergoing laparoscopic cholecystectomy. methods: a randomized prospective trial was conducted in first surgical department of sismanogleion g.h.a. the study included 96 patients, who were admitted with acute cholecystitis and underwent lc into 24 h from their admission. preoperatively, they all received crystalloid isotonic solutions and antibiotics. 5.3% were submitted to ercp, preoperatively, due to choledocholithiasis. the postoperative care included early mobilization into 2 h after surgery, early fluid intake (into 4 h) and early liquid food intake (into 6 h). they all received systematically antibiotics, analgesics and antiemetic on demand. asa score was not an exclusion criterion. results: conversion to open procedure was necessary in 6.5% of patients, whom were excluded from the study. all the rest were discharged into 24 h from the surgery with the guidance to receive oral antibiotics for 3 more days. readmission was necessary for 2 patients, one week after the operation. the first one presented with bile leak and submitted to ercp with stent placement and percutaneous drainage of the intrabdominal collection. the second one presented with choledocholithiasis and underwent ercp with balloon catheterization. conclusion: it is commonly accepted that eras protocol in elective procedure enhances the postoperative recovery while reduces the in hospital stay and cost. in emergency condition eras cannot be applicated preoperatively. however, a modified post surgery application seems to have advantages equal to those observed in elective procedures. aim: laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic cholelithiasis. administration of one single dose of chemoprophylaxis before an elective laparoscopic cholecystectomy is a broadly accepted practice. however, its value is currently questioned, especially in low risk patients. method: this study was conducted in a high volume surgical department. one hundred and twelve patients submitted to elective laparoscopic cholecystectomy were included in this research. a written consent was acquired after thorough patient briefing. half the patients that underwent surgical operation received one dose of antibiotics 30 min prior to the incision and the other half did not receive any chemoprophylaxis. results: the age ranges from 16 to 81 years old. commonest concomitant diseases were arterial hypertension, type ll diabetes, hypothyroidism and respiratory deficiency. approximately 30% of patients were smokers and 11% were obese (bmi [ 30). the duration of the operations was between 20 and 85 min. intra-operative gallbladder rupture was observed in 36 patients (rate 32%). all the patients were discharged the first post-operative day and their monitoring continued for 30 more days. in the chemoprophylaxis group, no surgical site infection or other major complication was observed. from the group that did not receive any antibiotics, one patient developed surgical site infection and specifically infection of the surgical port in the epigastrium, which was treated with drainage of the abscess and oral antibiotics administration. no other complications were recorded. conclusion: our study concluded no statistically significant difference between the two patient groups, which depicts that chemoprophylaxis may not be necessary in elective cholecystectomy operations. on the contrary, antibiotics increase the cost of hospital stay and are often accompanied by multiple mild or severe side effects. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.